Brachytherapy in Brain Metastasis Treatment: A Scoping Review of Advances in Techniques and Clinical Outcomes.

Brain metastases pose a significant therapeutic challenge in the field of oncology, necessitating treatments that effectively control disease progression while preserving neurological and cognitive functions. Among various interventions, brachytherapy, which involves the direct placement of radioactive sources into or near tumors or into the resected cavity, can play an important role in treatment. Current literature describes brachytherapy's capacity to deliver targeted, high-dose radiation while minimizing damage to adjacent healthy tissues-a crucial consideration in the choice of treatment modality. Furthermore, advancements in implantation techniques as well as in the development of different isotopes have expanded its efficacy and safety profile. This review delineates the contemporary applications of brachytherapy in managing brain metastases, examining its advantages, constraints, and associated clinical outcomes, and provides a comprehensive understanding of advances in the use of brachytherapy for brain metastasis treatment, with implications for improved patient outcomes and enhanced quality of life.

Comparing surgical clipping with endovascular treatment for unruptured middle cerebral artery aneurysms: a systematic review and updated meta-analysis.

OBJECTIVE: Unruptured middle cerebral artery aneurysm (uMCAA) has traditionally been treated with open surgical clipping (SC). Endovascular treatments (EVTs) were designed to reduce surgical risks in these cases. Nevertheless, despite its potential benefits, many surgeons favor SC for uMCAA. This updated meta-analysis aimed to compare the safety, efficacy, and clinical outcomes of SC and EVT for uMCAA. METHODS: The authors searched the Medline, Embase, and Cochrane Library databases according to the Cochrane and PRISMA guidelines. Eligible studies included those with ≥ 4 patients with uMCAA reporting comparative data of SC and EVT. The endpoints were the complete occlusion rate (Raymond class I and II), good clinical outcomes (modified Rankin Scale score ≤ 2 or Glasgow Outcome Scale score ≥ 4), procedure-related complications (further divided into major and minor), and mortality. The authors pooled OR with 95% CI values with a random-effects model. I2 statistics were used to assess heterogeneity, and sensitivity analysis was conducted to address high heterogeneity. Publication bias was assessed with funnel plot analysis and the Egger's test. RESULTS: The analysis included data from 10 studies. Regarding the complete occlusion assessment, the comparative analysis revealed OR 0.17 (95% CI 0.08-0.40, p < 0.01), favoring SC. In terms of achieving good clinical outcomes, OR 0.44 (95% CI 0.20-0.97, p < 0.05) was determined, favoring SC. No differences regarding total procedure-related complications, major complications, or mortality were identified. However, a higher likelihood of minor complications was identified for EVT, with OR 4.68 (95% CI 2.01-10.92, p < 0.01). CONCLUSIONS: This systematic review and meta-analysis identified a lower likelihood of complete occlusion at last follow-up and lower likelihood of good clinical outcomes in patients treated with EVT when compared with SC. Furthermore, a higher likelihood of minor complications was identified in patients who underwent EVT when compared with SC. The findings reinforce that, based on the currently available data, SC should be considered the primary approach for treating uMCAA. However, EVT is an evolving approach, and this study's findings represent a synthesis of observational studies. Randomized trials are warranted to elucidate which approach should be the mainstay for uMCAA and to identify the nuances that determine whether SC or EVT is more or less indicated for addressing uMCAA with consideration of the individuality of each patient and aneurysm.

Staged cerebral and brachiocephalic bypass in a patient with MCA and brachiocephalic steno-occlusion.

Background: Brachiocephalic steal is a rare phenomenon that may lead to hemodynamic abnormalities in the ipsilateral vertebral and carotid arteries. Current treatment includes management of vascular risk factors, endovascular stenting, and surgical management depending on the severity of symptoms. Case Information: We describe a patient with multiple vascular risk factors who presented with mild neurological symptoms and chronic right arm weakness associated with concurrent brachiocephalic steal and right MCA M1 stenosis on neuroimaging. Use of right superficial temporal artery to middle cerebral artery bypass and aorta-right subclavian bypass resulted in improved flow to the right hemisphere on quantitative magnetic resonance angiography and single-photon emission computed tomography, significantly lowering the risk of catastrophic ischemic stroke. Conclusion: Complex steal phenomena increase stroke risk. In cases of high-grade occlusion or advanced symptoms, endovascular or surgical management should be considered for optimal stroke prevention.

Shared Decision-Making with Latinx Caregivers During Community Implemented Evidence-Based Practices: Determinants and Associations with Alliance.

OBJECTIVE: The current observational study examined shared decision-making (SDM) with caregivers of Latinx youth within the delivery of multiple evidence-based practices (EBPs) in community mental health services. The aims of the study were to (1) Identify therapist and client factors associated with increased SDM within EBP sessions and (2) Examine the association between SDM and therapeutic alliance between community therapists and Latinx caregivers. METHOD: The Observing Patient Involvement in Decision-Making (OPTION) instrument measured SDM in 210 audio-recorded therapy sessions with 62 community therapists (91.94% female; 69.35% Latinx) and 109 Latinx caregivers (91.43% female) of youth who were an average age of 8.26 years (SD = 3.59). We used the Therapy Process Observational Coding System for Child Psychotherapy-Alliance scale to measure the caregiver-therapist alliance observationally. Multilevel linear regressions were conducted to examine research questions. RESULTS: Greater SDM was observed within sessions where therapists targeted conduct problems versus trauma (B = -8.79, 95% CI[-14.09, -3.49], p = .001). There was a trend that SDM was higher in English-language sessions compared to Spanish. We found that the global measurement of SDM (B = .04, 95% CI[.01, .08], p = .03) and the OPTION item Integrate Preferences (B = .69, 95% CI[.07, 1.32], p = .03) were positively associated with alliance. CONCLUSIONS: SDM may help foster Latinx caregiver engagement within EBP delivery. Provider training in SDM may be warranted with consideration of the specific clinical contexts (e.g., by presenting problem) that are appropriate for collaborative treatment planning. More research is needed to further establish the benefits of SDM in youth psychotherapy.

Reckoning With Our Past and Righting Our Future: Report From the Behavior Therapy Task Force on Sexual Orientation and Gender Identity/Expression Change Efforts (SOGIECEs).

Sexual orientation and gender identity/expression change efforts (SOGIECEs) are discredited practices that are associated with serious negative effects and incompatible with modern standards for clinical practice. Despite evidence linking SOGIECEs with serious iatrogenic effects, and despite support for LGBTQ+-affirmative care alternatives, SOGIECE practices persist. In the 1970s and 1980s, Behavior Therapy published articles testing and/or endorsing SOGIECEs, thereby contributing to their overall development, acceptance, and use. The Behavior Therapy Task Force on SOGIECEs was assembled to conduct a rigorous review of the SOGIECE articles published in Behavior Therapy and to decide whether, and what, formal action(s) should be taken on these articles. This report provides a detailed review of the historic SOGIECE literature published in Behavior Therapy and outlines the Task Force's deliberative and democratic processes resulting in actions to: (1) add prominent advisory information to k = 24 SOGIECE papers in the form of digital "black box" disclaimers that caution readers that the SOGIECE practices tested or described in these papers are inconsistent with modern standards, (2) offset organizational financial benefits from the publication of these papers, and (3) promote LGBTQ+-affirmative practices. SOGIECEs are not the only concerning practices across the field's history, and the pages of today's scientific journals include practices that will be at odds with tomorrow's moral standards and ethical guidelines. This report calls for precautionary measures and editorial safeguards to minimize the future likelihood and impact of problematic published scholarship, including the need to fully include those with relevant lived experiences in all aspects of clinical science and peer review.

Ethical Incorporation of Artificial Intelligence into Neurosurgery: A Generative Pretrained Transformer Chatbot-Based, Human-Modified Approach.

INTRODUCTION: Artificial intelligence (AI) has become increasingly used in neurosurgery. Generative pretrained transformers (GPTs) have been of particular interest. However, ethical concerns regarding the incorporation of AI into the field remain underexplored. We delineate key ethical considerations using a novel GPT-based, human-modified approach, synthesize the most common considerations, and present an ethical framework for the involvement of AI in neurosurgery. METHODS: GPT-4, ChatGPT, Bing Chat/Copilot, You, Perplexity.ai, and Google Bard were queried with the prompt "How can artificial intelligence be ethically incorporated into neurosurgery?". Then, a layered GPT-based thematic analysis was performed. The authors synthesized the results into considerations for the ethical incorporation of AI into neurosurgery. Separate Pareto analyses with 20% threshold and 10% threshold were conducted to determine salient themes. The authors refined these salient themes. RESULTS: Twelve key ethical considerations focusing on stakeholders, clinical implementation, and governance were identified. Refinement of the Pareto analysis of the top 20% most salient themes in the aggregated GPT outputs yielded 10 key considerations. Additionally, from the top 10% most salient themes, 5 considerations were retrieved. An ethical framework for the use of AI in neurosurgery was developed. CONCLUSIONS: It is critical to address the ethical considerations associated with the use of AI in neurosurgery. The framework described in this manuscript may facilitate the integration of AI into neurosurgery, benefitting both patients and neurosurgeons alike. We urge neurosurgeons to use AI only for validated purposes and caution against automatic adoption of its outputs without neurosurgeon interpretation.

Feasibility, safety, and efficacy of endovascular treatment of anterior cranial fossa dural arteriovenous fistulas: a systematic review and meta-analysis with a subanalysis for Onyx.

Dural Arteriovenous Fistulas (dAVFs) of the anterior cranial fossa (ACF) are uncommon but carry a high risk of hemorrhage and pose substantial treatment challenges. Recent advancements in endovascular treatment (EVT), including the introduction of novel liquid embolic agents, have markedly bolstered EVT's role in managing ACF-dAVFs, with notable series published in the last five years. We aimed to assess the feasibility, safety, and efficacy of EVT for ACF-dAVFs. We searched Medline, Scopus, Web of Science, and Cochrane Library databases following PRISMA guidelines. Eligible studies included those with ≥ 5 patients undergoing embolization of ACF-dAVFs, detailing both angiographic and clinical outcomes. We used single proportion analysis with 95% confidence intervals under a random-effects model, I2 to assess heterogeneity, and Baujat and sensitivity analysis to address high heterogeneity. Publication bias was assessed by funnel-plot analysis and Egger's test. Outcomes included complete occlusion following embolization, unsuccessful endovascular embolization attempts, incomplete occlusion following embolization, symptom resolution or clinical improvement following embolization, recurrence; procedure-related complications, morbidity, and mortality. Additionally, a subanalysis for studies exclusively utilizing Onyx™ embolic system was done. Eighteen studies comprising 231 ACF-dAVF were included. Unsuccessful endovascular embolization attempts rate was 2%. Complete occlusion rate was 85%, with 4% of complications. Incomplete occlusion rate was 10%. Successfully embolized patients experienced either symptom resolution or clinical improvement in 94% of cases. Morbidity and mortality rates were 1% and 0%, respectively. Onyx subanalyses showed an overall rate of 0% for unsuccessful attempts, 95% for complete occlusion, and 5% for incomplete occlusion. Symptom resolution or clinical improvement was 98% and recurrence rate was 0%. EVT for ACF-dAVF is highly feasible, effective, and safe, with a low rate of complications, morbidity, and mortality. The subanalyses focusing on Onyx embolizations revealed superior efficacy and safety outcomes compared to the findings of the primary analyses involving all included studies.

Results from a first-in-human phase I safety trial to evaluate the use of a vascularized pericranial/temporoparietal fascial flap to line the resection cavity following resection of newly diagnosed glioblastoma.

PURPOSE: The efficacy of systemic therapies for glioblastoma (GBM) remains limited due to the constraints of systemic toxicity and blood-brain barrier (BBB) permeability. Temporoparietal fascial flaps (TPFFs) and vascularized peri cranial flaps (PCF) are not restricted by the blood-brain barrier (BBB), as they derive their vascular supply from branches of the external carotid artery. Transposition of a vascularized TPFF or PCF along a GBM resection cavity may bring autologous tissue not restricted by the BBB in close vicinity to the tumor bed microenvironment, permit ingrowth of vascular channels fed by the external circulation, and offer a mechanism of bypassing the BBB. In addition, circulating immune cells in the vascularized flap may have better access to tumor-associated antigens (TAA) within the tumor microenvironment. We conducted a first-in-human Phase I trial assessing the safety of lining the resection cavity with autologous TPFF/PCF of newly diagnosed patients with GBM. METHODS: 12 patients underwent safe, maximal surgical resection of newly diagnosed GBMs, followed by lining of the resection cavity with a pedicled, autologous TPFF or PCF. Safety was assessed by monitoring adverse events. Secondary analysis of efficacy was examined as the proportion of patients experiencing progression-free disease (PFS) as indicated by response assessment in neuro-oncology (RANO) criteria and overall survival (OS). The study was powered to determine whether a Phase II study was warranted based on these early results. For this analysis, subjects who were alive and had not progressed as of the date of the last follow-up were considered censored and all living patients who were alive as of the date of last follow-up were considered censored for overall survival. For simplicity, we assumed that a 70% PFS rate at 6 months would be considered an encouraging response and would make an argument for further investigation of the procedure. RESULTS: Median age of included patients was 57 years (range 46-69 years). All patients were Isocitrate dehydrogenase (IDH) wildtype. Average tumor volume was 56.6 cm3 (range 14-145 cm3). Resection was qualified as gross total resection (GTR) of all of the enhancing diseases in all patients. Grade III or above adverse events were encountered in 3 patients. No Grade IV or V serious adverse events occurred in the immediate post-operative period including seizure, infection, stroke, or tumor growing along the flap. Disease progression at the site of the original tumor was identified in only 4 (33%) patients (median 23 months, range 8-25 months), 3 of whom underwent re-operation. Histopathological analyses of those implanted flaps and tumor bed biopsy at repeat surgery demonstrated robust immune infiltrates within the transplanted flap. Importantly, no patient demonstrated evidence of tumor infiltration into the implanted flap. At the time of this manuscript preparation, only 4/12 (33%) of patients have died. Based on the statistical considerations above and including all 12 patients 10/12 (83.3%) had 6-month PFS. The median PFS was 9.10 months, and the OS was 17.6 months. 4/12 (33%) of patients have been alive for more than two years and our longest surviving patient currently is alive at 60 months. CONCLUSIONS: This pilot study suggests that insertion of pedicled autologous TPFF/PCF along a GBM resection cavity is safe and feasible. Based on the encouraging response rate in 6-month PFS and OS, larger phase II studies are warranted to assess and reproduce safety, feasibility, and efficacy. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: ClinicalTrials.gov ID NCT03630289, dated: 08/02/2018.

Impact of Cerebral Revascularization on Pial Collateral Flow in Patients With Unilateral Moyamoya Disease Using Quantitative Magnetic Resonance Angiography.

BACKGROUND AND OBJECTIVES: Moyamoya disease (MMD) is a chronic steno-occlusive disease of the intracranial circulation that depends on neoangiogenesis of collateral vessels to maintain cerebral perfusion and is primarily managed with cerebral revascularization surgery. A quantitative assessment of preoperative and postoperative collateral flow using quantitative magnetic resonance angiography with noninvasive optimal vessel analysis (NOVA) was used to illustrate the impact of revascularization on cerebral flow distribution. METHODS: A retrospective review of patients with unilateral MMD who underwent direct, indirect, or combined direct/indirect cerebral revascularization surgery was conducted between 2011 and 2020. Using NOVA, flow was measured at the anterior cerebral artery (ACA), ACA distal to the anterior communicating artery (A2), middle cerebral artery (MCA), posterior cerebral artery (PCA), and PCA distal to the posterior communicating artery (P2). Pial flow (A2 + P2) and collateral flow (ipsilateral [A2 + P2])-(contralateral [A2 + P2]) were measured and compared before and after revascularization surgery. Total hemispheric flow (MCA + A2 + P2) with the addition of the bypass graft flow postoperatively was likewise measured. RESULTS: Thirty-four patients with unilateral MMD underwent cerebral revascularization. Median collateral flow significantly decreased from 68 to 39.5 mL/min ( P = .007) after bypass. Hemispheres with maintained measurable bypass signal on postoperative NOVA demonstrated significant reduction in median collateral flow after bypass ( P = .002). Median total hemispheric flow significantly increased from 227 mL/min to 247 mL/min ( P = .007) after bypass. Only one patient suffered an ipsilateral ischemic stroke, and no patients suffered a hemorrhage during follow-up. CONCLUSION: NOVA measurements demonstrate a reduction in pial collateral flow and an increase in total hemispheric flow after bypass for MMD, likely representing a decrease in leptomeningeal collateral stress on the distal ACA and PCA territories. Further studies with these measures in larger cohorts may elucidate a role for NOVA in predicting the risk of ischemic and hemorrhagic events in MMD.

Reconstruction of the Anterior Skull Base Using the Nasoseptal Flap: A Review.

The nasoseptal flap is a workhorse reconstructive option for anterior skull base defects during endonasal surgery. This paper highlights the versatility of the nasoseptal flap. After providing a brief historical perspective, this review will focus on the relevant primary literature published in the last ten years. We will touch upon new applications of the flap, how the flap has been modified to expand its reach and robustness, and some of the current limitations. We will conclude by discussing what the future holds for improving upon the design and use of the nasoseptal flap in anterior skull base reconstruction.

Stroke mechanisms in adult moyamoya disease: The association between infarction patterns and quantitative magnetic resonance angiography flow state.

INTRODUCTION: Flow augmentation is the mainstay treatment for moyamoya disease as hemodynamic failure is believed to be the dominant mechanism. We aimed to investigate the mechanisms of stroke in moyamoya disease by assessing the relationship between infarction patterns and quantitative magnetic resonance angiography flow state. METHODS: A retrospective study of adult patients with suspected MMD who presented with MRI confirmed acute ischemic stroke predating or following QMRA by a maximum of six months between 2009 and 2021 was conducted. Of the 177 consecutive patients with MMD who received QMRA, 35 patients, consisting of 41 hemispheres, met inclusion criteria. Flow-status was dichotomized into low-flow and normal-flow state based on previously established criteria. RESULTS: Mixed infarction pattern was the most frequent finding (70.7 %), followed by embolic (17.1 %), perforator (7.3 %), and internal borderzone (IBZ) (4.9 %). Infarction patterns were further dichotomized into IBZ+ (internal borderzone alone or mixed) and IBZ- (no internal borderzone constituent). Low-flow states were not significantly more frequent in the IBZ+ compared to IBZ- population (48.4 % vs. 20.0 %, p = 0.14). Ipsilateral posterior cerebral artery fractional flow was significantly higher with IBZ+ compared to IBZ- (345.0 % vs. 214.7 %, p = 0.04). CONCLUSION: Mixed infarction pattern was the most common pattern of infarction in patients with moyamoya disease, implying hypoperfusion and thromboembolism are codominant stroke mechanisms. An association between ICA flow status and infarction pattern was not found, although QMRA evidence of more robust posterior cerebral artery leptomeningeal collaterals was found in patients with a hypoperfusion contribution to their stroke mechanism.

Finding meaning in times of family stress: A mixed methods study of benefits and challenges amongst home-front parents in military families.

Family stress theory explains how demands placed on the family system interact with capabilities to influence family adaptation. One capability that some military families may use naturalistically is that of benefit-finding, the recognition of value and benefit after a stressful or traumatic experience. In this mixed methods study, authors explore the perception of benefits associated with military service amongst 26 home-front mothers. Methods incorporate a self-report questionnaire adapted for this population and a qualitative interview aimed at understanding challenges and benefits associated with these women's experiences as members of a military family. Results revealed that more women than not endorsed meaningful changes that they have experienced as a result of their family's military service, despite a wide range of challenges and negative experiences. Four themes of benefits emerged from analyses: (a) financial, educational and career benefits; (b) cultivating strength; (c) friendships and community; and (d) pride. These findings illuminate the diverse ways in which women find meaning in their family's military service and upon replication and elaboration of these results, have clinical implications for the development of future prevention and intervention work with military families.