Return to play following craniotomy for non-traumatic brain lesions.

Objective: Return to play (RTP) decisions after cranial surgery are important to patients. Most published data relate to RTP following sports-related brain injury. This study investigated factors that influence neurosurgical RTP decision-making following craniotomy for non-traumatic brain lesions. Methods: A patient scenario-based survey was distributed to U.S. and Europe-based neurosurgeons via the American Association of Neurological Surgeons/Congress of Neurological Surgeons Tumor Section and the European Association of Neuro-Oncology. From one core patient scenario, 5 further scenarios were developed involving patients of varying age, sport preference, tumor pathology, and craniotomy approach. Respondents provided RTP recommendations and factors important in forming these recommendations. Results: Forty-one responses were received; Europe (48%), U.S. (37%). The most commonly cited factors influencing RTP decision-making across scenarios were symptomatic recovery (85.4%), resolution of blood and/or air on imaging (43.4%), and patient demand (31.7%). The sports with the longest average RTP timeline were boxing (10.3 months), rugby (8.7 months), and American football (8.5 months) in the core patient scenario. Twenty-nine percent of neurosurgeons requested neuroimaging before determining RTP recommendations in this scenario, more commonly in America than Europe (46.7% and 5.0% respectively, p = .006). Conclusions: Although limited by sample size, the data provides a foundation to support development of a systematic approach to RTP decision-making following craniotomy for brain lesions of non-traumatic etiology. Future work to develop consensus guidelines will benefit from objective data about outcomes, particularly in relation to repeat imaging prior to RTP.

Landscape and impact of mind-body, cognitive-behavioral, and physical activity interventions in adolescent and adult brain tumor patients: A systematic review.

Background: The use of mind-body, cognitive-behavioral, and physical activity interventions have shown efficacy for improving symptom burden and functional limitations in other cancers; however, these strategies have not been widely implemented within neuro-oncology. This systematic review describes the current landscape and the impact of these interventions on adolescent and adult patients with brain tumors, which may guide the development of future interventions. Methods: A systematic search of PubMed, Embase, and Web of Science was performed using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines with predefined eligibility criteria. Twenty-nine studies met the inclusion criteria and were selected for review. Results: There was promising evidence for the feasibility and efficacy of mind-body and physical activity interventions for improving mood and quality of life, as well as enhanced physical functioning following aerobic and strength-based interventions. Results were mixed for cognitive-behavioral interventions, likely due to underpowered analyses. Interventions tested in pediatric patients also showed improvements in fatigue, mood, and quality of life, though these individuals represented a small proportion of the pooled sample. Conclusions: Findings suggest that mind-body and physical activity interventions can improve both physical and psychological health for patients with brain tumors, though additional well-designed clinical trials are needed to better establish efficacy.

Biophysical and Biological Mechanisms of Tumor Treating Fields in Glioblastoma.

Glioblastoma (GBM) is one of the most aggressive forms of brain cancer that presents with a median survival rate of 14-30 months and along with a discouraging five-year survival rate of 4-5%. Standard treatment of newly diagnosed GBM, also known as the Stupp protocol, includes a maximally safe surgical resection followed by radiation and chemotherapy. Despite these treatment regimens, recurrence is almost inevitable, emphasizing the need for new therapies to combat the aggressive nature of GBMs. Tumor Treating Fields (TTFs) are a relatively new application to the treatment of GBMs, and results have been promising with both progression-free survival and overall survival when TTFs have been used in combination with temozolomide. This article critically reviews the biophysical and biological mechanisms of TTFs, their clinical efficacy, and discusses the results in clinical trials, including EF-11 and EF-14. Both trials have demonstrated that TTFs can enhance progression free survival and overall survival without compromising quality of life or causing severe adverse effects. Despite the high cost associated with TTFs and the need for further analysis to determine the most effective ways to integrate TTFs into GBM treatments, TTFs represent a significant advancement in GBM therapy and offer hope for improved patient prognosis.

Elevated SH3 and Multiple Ankyrin Repeat Domains 2 Expression Correlates With Improved Glioma Prognosis.

This study investigates the prognostic significance of SH3 and multiple ankyrin repeat domains 2 (SHANK2) gene expression in glioma patients, using data from The Cancer Genome Atlas (TCGA), the Genotype-Tissue Expression (GTEx) project, and the Gene Expression Omnibus (GEO). Through comprehensive analysis, we found a significant association between higher SHANK2 expression and improved survival outcomes across various glioma subtypes. To further validate the clinical relevance of SHANK2, we conducted cellular experiments involving siRNA-mediated knockdown of SHANK2 in U87 and A172 glioma cell lines. Quantitative real-time PCR (qPCR) and Western blot analyses confirmed the successful knockdown of SHANK2, and subsequent MTT assays revealed that silencing SHANK2 significantly promoted glioma cell proliferation. These findings underscore the potential role of SHANK2 as a tumor suppressor in glioma. The study also introduces a multivariate prognostic model incorporating SHANK2, providing a novel perspective on glioma prognosis. While the retrospective nature of the study presents limitations, our results suggest that SHANK2 expression could serve as a valuable biomarker for glioma prognosis and inform future therapeutic strategies.

Social media "SoMe" in neuro-oncology: a review of the literature.

PURPOSE: This article examines the current state of social media (SoMe) in neuro-oncology and neurosurgical oncology. The goal of this paper is to provide thorough discourse regarding benefits and disadvantages of being a neurosurgical oncologist on SoMe, while discussing the place SoMe will have in cranial tumor-based practices going forward. METHODS: The author's performed a rigorous literature review on the topic. Included information was pertinent to the history of SoMe in neurosurgical oncology and its impact on the field of neuro-oncology. Incorporated as well are the benefits of being a neurosurgical oncologist on SoMe, the drawbacks of participation on SoMe platforms, and knowledge that facilitates discussion about the future of SoMe in neurosurgical oncology. RESULTS: SoMe plays an important role in neuro-oncology and neurosurgical oncology. SoMe continues to exponentially grow in the healthcare sphere as more providers utilize SoMe platforms. We report objective negative and positive outcomes of SoMe in neurosurgical oncology and neuro-oncology. Here, we summarize these results and provide dialogue describing the effect SoMe is having on the many different aspects of neurosurgical oncology and neuro-oncology. CONCLUSION: Although SoMe platforms improve social presence and patient outreach, the use of SoMe can also adversely affect one's career by exposing clinicians to unchecked societal, legal and professional consequences. While using SoMe as a vessel to propagate career initiatives, neurosurgical oncologists should exercise caution with the content they choose to circulate.

Financial toxicity in patients with glioblastoma.

PURPOSE: There has been mounting interest in understanding the impact of financial toxicity (FT) in various cancer types; however, it remains poorly understood and understudied within neuro-oncology-especially as it relates to neurosurgical components of patient care. METHODS: Retrospective, single-center study of patients who underwent craniotomy for resection of glioblastoma from 2020 to 2022. OIBEE™ (Austin, Texas) software was queried to identify the subset of these patients who had a bad debt charged to their account. These patients were deemed to qualify as experiencing FT. Chi Square analysis was conducted between FT and non-FT patient groups. Additionally, survival analyses were performed to determine predictors of progression free and overall survival. RESULTS: 74 patients were included in this sample. 33/74 (44%) met criteria for FT. The average bad debt amount was $7,476.76 and the median debt amount was $2,015.96, with the average time to financial toxicity after surgery being approximately 127 days. FT patients were significantly younger at diagnosis than those who were not FT (64.6 years- non-FT vs. 59.0 years- FT, p = 0.0344). FT patients were more likely to have undergone subtotal resections rather than a gross total resection compared to non-FT patients (FT GTR 27.3%, non-FT GTR 52.4%, p = 0.028). Hospital length of stay was significantly longer for FT patients compared to non-FT patients (LOS FT 9.5 days, non-FT 6.5 days, p = 0.0312). CONCLUSION: Glioblastoma patients are at high risk of experiencing FT with our series showing no significant impact on overall survival. Larger studies are needed to understand the impact of FT on patient outcomes.

3D ultrasound-augmented image guidance for surgery of high-grade gliomas - A quantitative analysis focused on the extent of resection.

Background: We have retrospectively reviewed our series of brain tumor patients operated on using 3D IntraOperative UltraSound (IOUS) to report technical advantages and areas of improvement. Methods: Clinical and radiological data of patients with a diagnosis of high-grade glioma IV operated with and without IOUS were retrieved and analyzed. Results: We have found 391 patients operated using IOUS coupled with neuronavigation and 257 using neuronavigation standalone. We have selected a pool of 60 patients with a diagnosis of GlioBlastoma (GB), comparing two equally sized groups operated with and without IOUS, respectively. The average extent of resection (EOR) in the IOUS group was 93%, while in the control group, it was 80%. IOUS was significantly associated with improved EOR (P < 0.0004), even when accounting for other factors affecting EOR. The average overall survival (OS) was 13.4 months, and the average progression-free survival (PFS) was 7.4 months. The Cox proportional hazard model showed an advantage in OS on patients operated using the IOUS. No statistically significant effect was observed on PFS. Conclusion: Intraoperative ultrasound coupled with image guidance is associated with an improved EOR and possibly an improved OS. While we are aware of several limitations related to the present analysis, these data support the routine use of IOUS as a safe and reliable technology. Larger, prospective series with updated IOUS technology are desirable to verify the accuracy of these results.

The surgical management of third ventricle region tumors.

OBJECTIVES: The goal of this study was to characterize the largest known cohort of patients presenting with different tumor pathologies in the third ventricle region to better understand outcomes of surgical management. METHODS: All patients undergoing surgical intervention on tumors in or encroaching upon the third ventricle at Loyola University Medical Center between the years 1986-2021 were reviewed. Information recorded included presenting symptoms, pre- and post-operative interventions, tumor pathology, operative technique, extent of resection (EOR), and approach of operation. The primary clinical outcome was Karnofsky Performance Status (KPS) score. RESULTS: Ninety-seven patients underwent 123 operations. Forty-six (47.4 %) patients were female, and the median age at operation was 39 years. Eighty-seven (70.7 %) operations were open, and 36 (29.3 %) were endoscopic. Gross total resection (GTR) was achieved in 34.4 % of operations, near-total resection (NTR) in 31.5 %, subtotal resection in 25.0 %, and biopsy alone in 9.3 %. Median KPS increased pre- to postoperatively, regardless of surgical technique. Adjusting for preoperative KPS, age, and operation number, regression analysis demonstrated a trend that lesser EOR is associated with lower KPS at most recent follow-up (p=0.031 for NTR vs GTR, p=0.022 for biopsy vs GTR). There was no statistically significant association between the most recent KPS and either open or endoscopic surgical technique, with or without adjusting for the previously stated factors (p=0.26). There was no association between postoperative complication rates or age with either surgical technique. CONCLUSIONS: Here, we characterize a large cohort of patients presenting for neurosurgical evaluation of tumors in the region of the third ventricle. Our results demonstrate a trend that a more aggressive resection may yield better KPS outcomes. Additionally, both open and endoscopic techniques lead to a similar improvement in clinical outcome and rates of complication. While ultimate surgical approach and technique is determined by individual tumor characteristics, patient health status, and surgeon expertise, ability to resect the tumor in its entirety should be taken into consideration.

Endovascular surgical neuro-oncology: advancing a new subspecialty.

Endovascular surgical neuro-oncology is a relatively new subspecialty which uses endovascular neuro-interventional techniques for the management of nervous system tumors and tumor-related vascular conditions. Although there are several endovascular procedures that are widely available as standard-of-care diagnostic and treatment adjuncts, there has been a renewed interest to explore endovascular approaches as a means for selective intra-arterial delivery of therapeutic agents to nervous system tumors, including methods for opening the blood brain and blood tumor barriers. In this review, we discuss the historical development of various forms of endovascular intra-arterial treatment for tumors over the past 40 years, summarize endovascular approaches that are currently being employed, and highlight current clinical trials.

Endoscopic transorbital approach for recurrent spheno-orbital meningiomas: single center case series.

Endoscopic transorbital approaches (ETOAs) are finding wide application for skull base lesions, particularly for spheno-orbital meningiomas (SOMs). These tumors have high recurrence rates, and second surgery can often represent a challenge. In this study we analyze our experience of management of recurrent SOMs through a slightly modified eyelid crease approach. Between May 2016 and September 2023, in the Department of Neurosurgery of Fondazione IRCCS Policlinico San Matteo (Pavia, Italy), five consecutive recurrent SOMs have been treated using an endoscopic transorbital approach. Demographic data, preoperatory deficits, lesions characteristics, histology, grade of resection, eventual adjuvant treatments, complications, outcome in terms of symptoms improvement and cosmesis, and hospitalization are described. One patient maintained a right lateral rectus muscle palsy that was already present in the preoperatory, no cerebrospinal fluid (CSF) leaks were reported. All patients had postoperative periorbital edema, but no other systemic complication was found. All patients had proptosis improvement, two had visual acuity improvement, and best cosmetic outcome was obtained in all cases. Hospitalization varied between 4 and 6 days. ETOAs in the management of recurrent SOMs are safe and have good outcome. Right selection of patients is mandatory, but when feasible, endoscopic surgery can allow a virgin route to a previously operated tumor, guaranteeing a good strategic option.

Consensus guidelines for the management of posterior fossa tumour for low- and middle-income countries.

The posterior fossa is a limited compartment therefore lesions compressing its structures can result in devastating outcomes. It can cause significant neurological deficit due to mass effect on critical structures and hydrocephalus. Due to the nature of the infratentorial region, urgent surgical intervention is often the first-line option. Surgical neuro-oncologists guide patients and caregivers through the course of this disease and to inform them about the various options for management and long-term outcome optimisation. There is currently conflicting data; however, institutional experiences can guide us towards achieving improvements in surgical outcomes and quality of life. Advances in molecular classifications coupled with highdose radiation treatment improve our capacity for improving overall survival in these patients. Common childhood tumours are ependymomas, medulloblastomas, and juvenile pilocytic astrocytomas, while adults often present with metastases, and less commonly, cerebellar haemangioblastomas and gliomas. This paper outlines management strategies with consideration for multidisciplinary care and resourcelimited settings.

Contribution of [18F]FET PET in the Management of Gliomas, from Diagnosis to Follow-Up: A Review.

Gliomas, the most common type of primary malignant brain tumors in adults, pose significant challenges in diagnosis and management due to their heterogeneity and potential aggressiveness. This review evaluates the utility of O-(2-[18F]fluoroethyl)-L-tyrosine ([18F]FET) positron emission tomography (PET), a promising imaging modality, to enhance the clinical management of gliomas. We reviewed 82 studies involving 4657 patients, focusing on the application of [18F]FET in several key areas: diagnosis, grading, identification of IDH status and presence of oligodendroglial component, guided resection or biopsy, detection of residual tumor, guided radiotherapy, detection of malignant transformation in low-grade glioma, differentiation of recurrence versus treatment-related changes and prognostic factors, and treatment response evaluation. Our findings confirm that [18F]FET helps delineate tumor tissue, improves diagnostic accuracy, and aids in therapeutic decision-making by providing crucial insights into tumor metabolism. This review underscores the need for standardized parameters and further multicentric studies to solidify the role of [18F]FET PET in routine clinical practice. By offering a comprehensive overview of current research and practical implications, this paper highlights the added value of [18F]FET PET in improving management of glioma patients from diagnosis to follow-up.

AB006. The use of magnetic resonance spectroscopy in the differential diagnosis of paediatric intracranial tumours.

BACKGROUND: Despite different intracranial tumour subtypes varying largely in their prognoses and recommended treatment regimens, they can have markedly similar appearances on standard radiology, especially in paediatric patients where they tend to occur in the midline. There is a need for a non-invasive, accurate method of determining tumour diagnosis to help expedite treatment planning. Existing studies have found magnetic resonance spectroscopy (MRS) to have value in diagnosing intracranial tumours in adults. The aim of this study was to investigate whether MRS could be accurate in diagnosing and grading paediatric intracranial tumours. METHODS: The hospital database was retrospectively searched for paediatric intracranial tumour patients ≤18 years that had 1.5 T MRS data available. Medical and demographic data were collected from existing records including MRS metabolites N-acetylaspartate (NAA), creatine (Cr), and choline (Cho), and final histopathologic diagnosis. MRS metabolites were then statistically compared against final histopathologic diagnosis. RESULTS: In total, 166 patients were included. In the overall cohort, the tumour to control tissue Cr ratio was significantly higher in grade 1 than grade 4 tumours (P=0.03), and tumour Cho/Cr was significantly higher in grade 4 than grade 1 tumours (P=0.004). When analyzing tumour subtypes, control tissue Cr was significantly higher in embryonal/germ cell tumours than glial tumours (P=0.044). Binary logistic regression models including MRS metabolite ratios and age, sex, and tumour location covariates could diagnose grade 4 tumours [area under the curve (AUC) =0.857], and grade 1 tumours (AUC =0.766) with reasonable accuracy. CONCLUSIONS: This study suggests that MRS has benefits in the non-invasive diagnosis of paediatric intracranial tumours, in particular, identifying low- and high-grade tumours. Future advances in MRS technology, and larger cross-sectional studies will be necessary to improve the clinical integration of MRS for accurate non-invasive paediatric intracranial tumour diagnosis.

AB010. Analyzing Response Assessment in Neuro-Oncology (RANO) response criteria in WHO grade III anaplastic astrocytomas in comparison to clinician evaluation: a case report.

BACKGROUND: Anaplastic astrocytoma [AA; World Health Organization (WHO) grade III] is a diffusely infiltrative astrocytic brain tumor with anaplasia and represents 3.3% of primary brain tumors. Overall, 5-year median survival can range from 22% to 50%, depending on various prognostic features, including the patient's age, tumor location and genetics, resection, etc. Given the higher grade and increased likelihood of transformation to WHO-grade IV tumors (glioblastomas), these tumors are generally treated aggressively upfront. Headache and seizures are the most common symptoms, occurring in about 50% of the cases. Other symptoms, including memory loss, motor weakness, language deficit, and cognitive and personality changes, occur in 20% of cases. Standard treatment involves surgical resection, radiotherapy, and chemotherapy, but treatment options are greatly limited for progression and recurrence. This paper highlights the case of a 48-year-old male who presents with chronic progressive cephalgia and a new-onset seizure. We review the diagnostic and therapeutic challenges associated with the treatment of AA. CASE DESCRIPTION: We describe a patient who presented with chronic progressive cephalgia, gradual right-sided weakness, an asymmetrical face, slurred speech, and a new-onset focal-to-bilateral seizure. A cranial magnetic resonance imaging revealed a mass in the left frontoparietal region, causing herniation of the cerebri to the right. The patient had a maximal tumor resection, and the histopathology showed tissue sections containing tumors that were infiltrative in the stroma, forming a diffuse pattern consisting of proliferation of oval, round, polygonal, spindle, pleomorphic oval nucleated cells, hyperchromatic, some nucleoli appearing prominent, and cytoplasmaeosinophilic. There were areas of stromal necrosis and mitosis [3/10 high power field (HPF)]. The pathology result was reported with AA. The patient underwent concomitant chemoradiation and followed oral chemotherapy with temozolomid. Subsequent imaging revealed a significant decrease in the tumor's size and a resolution of the compression of the brain parenchyma underneath. The Response Assessment in Neuro-Oncology (RANO) evaluation showed partial responses with good clinical improvement. CONCLUSIONS: The case presented an AA that was responsive to radiotherapy and temozolomid chemotherapy. Despite being rare, knowledge of this malignant tumor type and a multidisciplinary approach to case management are essential to optimizing treatment results.

AB059. Molecular signatures for survival prediction in glioma: a prospective, real-world data analysis.

BACKGROUND: Glioma characterization and follow-up are underreported from low-and-middle-income country centers within the literature. With the recent emphasis on molecular markers for survival prediction, there is a need for robust data exploring molecular epidemiology in these countries. In Pakistan particularly, there is a significant gap in glioma outcomes reporting and survival analysis. METHODS: One hundred and sixty-five consecutive glioma patients were enrolled from 2019 onwards; histopathological and molecular analysis was performed on archived formalin-fixed paraffin-embedded (FFPE) blocks for isocitrate dehydrogenase (IDH), P53, α-thalassemia retardation X-linked (ATRX) and Ki-67 immunohistochemical (IHC) markers. Survival analysis was calculated using the Kaplan-Meier method; hazard ratios are reported through a multivariate Cox regression model. RESULTS: Fifty-seven (35%) histopathological diagnoses were revised according to the updated criteria; 30% (n=16) glioblastoma were converted to a new category on re-analysis. IDH wild type (IDH-WT) gliomas had a significantly worse overall survival (log-rank =0.002), with a 2-year survival rate of 60% for IDH-mutant (IDH-M) and 38% for IDH-WT. Significant survival differences were seen for the Ki-67 index (log-rank =0.001) and methylguanine methyltransferase (MGMT) promotor methylation [log-rank =0.027, 2-year survival rate: 100% (methylation detected), 33% (methylation not detected)]. On Cox proportional hazards regression, gross total resection (P<0.001), IDH mutation (P<0.001), and updated histopathological diagnosis (P<0.001) were significant predictors of survival, with good sensitivity and specificity as seen on receiver operating characteristic (ROC) analysis [area under the curve (AUC) =0.86]. CONCLUSIONS: In our cohort, the revised World Health Organization (WHO) classification shows significant implications on prognosis and implications for treatment. Although these markers are not commonly used in low-and-middle-income country centers, our results strongly support their greater implementation for improved prognostication and reclassification.

The Role of Neuropsychology in Neurosurgical Care: A Review of the Literature.

In this review article, the authors describe the invaluable role that neuropsychology plays in neurosurgical care for a broad range of pathologies. As our understanding of cognitive and behavioral implications of diseases and surgical management of the brain has deepened, so has the need to preserve the quality of life for patients undergoing surgery to optimize well-being and overall survival. This article recounts the history of neuropsychology, details tools and techniques used by neuropsychologists including the neuropsychological assessment, fMRI, tractography, and awake surgery, and discusses the practical applications of neuropsychological evaluation in tumor surgery, epilepsy, deep brain modulation, and beyond.

Central nervous system pediatric multi-disciplinary tumor board: a single center experience.

BACKGROUND: The Multidisciplinary Tumor Board (MTB) is a collaborative platform involving specialists in oncology, surgery, radiology, pathology, and radiotherapy, and aims to optimize diagnostics and treatments. Despite MTB's widespread benefits, limited literature addresses its application in pediatric neuro-oncology. After a literature revision on pediatric neuro-oncology MTB, our study describes our institute's pediatric neuro-oncology MTB, focuses on evaluating its impact and the neuroradiologist's role in patient-centric approaches, considering recent genetic insights into pediatric brain tumors. MATERIALS AND METHODS: Literature Review concerning pediatric neuro-oncology MTB from January 2002 to June 2024. CLINICAL DATA: retrospective study of all patient files presented in the pediatric neuro-oncology MTB (pnMTB) between 2019 and 2022. Statistical analysis was mainly carried out by directly comparing the absolute or relative values of the respective parameters examined; qualitative variables compared mainly with the chi-square test, quantitative variables mainly with the t-test. RESULTS: Literature Review: 7 papers encompass a multidisciplinary approach for the pediatric CNS tumors. CLINICAL DATA: A total of 236 discussions were analyzed representing 107 patients. Median age was 14,3 years (range: 6 months - 17 years). The requests for case evaluations primarily came from the pediatric oncologists (83%) and neurosurgeons (14.8%), and they were mainly addressed to the neuroradiologists (70.3%). Proposals during pnMTB mainly involved imaging follow-up (47.8%) and management with chemotherapy (34.7%). Changes in patient treatment (CPT) occurred in 115 cases, and pediatric neuroradiologist intervention contributed to 72.4% of these changes. CONCLUSION: Thanks to their multidisciplinarity, high number of cases discussed, and usual respect for their proposals, the pnMTB has made it possible to improve the coordination among specialties involved in patient management, to apply the recent protocols, and to exchange knowledge among teams managing pediatric CNS tumors.