Vascular anomalies in patients with growth hormone-secreting pituitary adenomas: illustrative case report and systematic review of the literature.

PURPOSE: Endonasal resection is the first-line treatment for patients harboring growth hormone (GH)-secreting pituitary adenomas. The complexity of the parasellar neurovascular structures makes pre-operative diagnostic imaging essential to understanding the anatomy of this region. We aimed to describe vascular anomalies in acromegalic patients and emphasize their relevance for surgery and preoperative planning. METHODS: A systematic review following the PRISMA statement was performed in July 2021. RESULTS: Thirty-three studies were evaluated. Elevated GH and insulin-like growth factor-1 (IGF-1) levels are linked to the occurrence of cardiovascular risk factors. This is attributed to endothelial dysfunction, mainly caused by changes in flow-mediated dilatation (FMD), which is probably the main cause of vascular anomalies in acromegaly. The occurrence of protrusions of the internal carotid artery (ICA) (35-53%), a narrow intercarotid distance, and an asymmetrical course was described. In 13-18% of acromegalic patients, the presence of an intracerebral aneurysm could be reported (incidence in the general population:0.8-1.3%). The selected studies were however performed with a small patient sample (range:1-257). We present a case report of a 57y/o male patient with anomalies of the ICA ("kissing carotid arteries") harboring a GH-secreting adenoma, which was resected via an endoscopic endonasal approach. CONCLUSIONS: There is an association between acromegaly and endothelial dysfunction, which increases cardiovascular risk factors and vascular anomalies. Preoperative vascular imaging, e.g., CT angiography, should be implemented as a standard to identify patients at risk and estimate surgical morbidity. However, no evidence-based recommendations exist so far, so future studies are necessary.

Iatrogenic lumbosacral infiltration with petroleum (hydrodesulfurized heavy) with secondary intrathecal distribution-a case report.

Petroleum is commonly used as a solvent, and primary intrathecal administration or secondary diffusion and subsequent clinical management has not been reported. We report the case of a male patient with intrathecal petroleum diffusion following accidental lumbar infiltration. After the onset of secondary myeloencephalopathy with coma and tetraparesis, continuous cranio-lumbar irrigation using an external ventricular and a lumbar drain was established. Cranial imaging revealed distinct supra- and infratentorial alterations. The patient improved slowly and was referred to rehabilitation. Intrathecal petroleum leads to myeloencephalopathy and continuous cranio-lumbar irrigation might be a safe treatment option.

Mixed Reality as a Teaching Tool for Medical Students in Neurosurgery.

Background and Objectives: Simulation-based learning within neurosurgery provides valuable and realistic educational experiences in a safe environment, enhancing the current teaching model. Mixed reality (MR) simulation can deliver a highly immersive experience through head-mounted displays and has become one of the most promising teaching tools in medical education. We aimed to identify whether an MR neurosurgical simulation module within the setting of an undergraduate neurosurgical hands-on course could improve the satisfaction of medical students. Materials and Methods: The quasi-experimental study with 223 medical students [120 in the conventional group (CG) and 103 in the MR-group (MRG)] was conducted at the University Hospital Münster, Münster, Germany. An MR simulation module was presented to the intervention group during an undergraduate neurosurgical hands-on course. Images of a skull fracture were reconstructed into 3D formats compatible with the MR-Viewer (Brainlab, Munich, Germany). Participants could interact virtually with the model and plan a surgical strategy using Magic Leap goggles. The experience was assessed by rating the course on a visual analog scale ranging from 1 (very poor) to 100 (very good) and an additional Likert-scale questionnaire. Results: The satisfaction score for CG and MRG were 89.3 ± 13.3 and 94.2 ± 7.5, respectively. The Wilcoxon rank-sum test showed that MR users (Mdn = 97.0, IQR = 4, n = 103) were significantly more satisfied than CG users (Mdn = 93.0, IQR = 10, n = 120; ln(W) = 8.99, p < 0.001) with moderate effect size (r^biserial = 0.30, CI95 [0.15, 0.43]), thus indicating that the utilization of MR-simulation is associated with greater satisfaction. Conclusions: This study reports a positive response from medical students towards MR as an educational tool. Feedback from the medical students encourages the adoption of disruptive technologies into medical school curricula.

Resection of Intramedullary Hemangioblastoma: Timing of Surgery and Its Impact on Neurological Outcome and Quality of Life.

Background and Objectives: Spinal intramedullary hemangioblastomas (SIMH) are benign vascular lesions that are pathological hallmarks of von Hippel-Lindau disease (vHL) and constitute the third most common intramedullary neoplasm in adults. So far, maximal and safe resection is the first choice of treatment. However, as SIMH show no malignant transformation, it remains unclear whether surgical resection is beneficial for all patients. Materials and Methods: We retrospectively analyzed the surgical outcomes of 27 patients who were treated between 2014 and 2022 at our neurosurgical department and investigated potential risk factors that influence the surgical outcome. Pre- and postoperative neurological status were classified according to the McCormick scale. Furthermore, surgical quality indicators, such as length of hospital stay (LOS; days), 90-day readmissions, nosocomial infections, and potential risk factors that might influence the surgical outcome, such as tumor size and surgical approach, have been analyzed. In addition to that, patients were asked to fill out the EQ-5D-3L questionnaire to assess their quality of life after surgery. Results: Surgery on SIMH patients that display no or minor neurological deficits (McCormick scale I or II) is associated with a favorable postoperative outcome and overall higher quality of life compared to those patients that already suffer from severe neurological deficits (McCormick scale III or IV). Conclusion: Early surgical intervention prior to the development of severe neurological deficits may offer a better neurological outcome and quality of life.

Andexanet-Alfa-Associated Heparin Resistance in the Context of Hemorrhagic Stroke.

BACKGROUND: With a growing number of patients on new oral anticoagulants, interest in reversal agents is rising. Andexanet alfa is used for reversal of factor Xa inhibitors in intracranial hemorrhage. METHODS: We provide a brief review on andexanet-alfa-associated heparin resistance and discuss potentially critical situations from different clinical perspectives. RESULTS: Case reports point out that andexanet alfa can cause unresponsiveness to heparin, leading to catastrophic events. As a result, regulatory bodies have issued warning notices to avoid heparinization parallel to the use of andexanet alfa. CONCLUSIONS: Although well known to hematologists, the phenomenon is underrecognized among stroke clinicians. However, patients with intracranial hemorrhage frequently undergo endovascular or surgical interventions that require periprocedural administration of heparin.

Brain invasion in meningiomas: does surgical sampling impact specimen characteristics and histology?

Brain invasion (BI) is a new criterion for atypia in meningiomas and therefore potentially impacts adjuvant treatment. However, it remains unclear whether surgical practice and specimen characteristics influence histopathological analyses and the accuracy of detecting BI. Tumor location, specimen characteristics, and rates of BI were compared in meningioma samples obtained from 2938 surgeries in different neurosurgical departments but diagnosed in a single neuropathological institute. Non-skull base tumor location was associated with CNS tissue on the microscopic slides (OR 1.45; p < .001), increasing specimen weight (OR 1.01; p < .001), and remaining tissue not subjected to neuropathological analyses (OR 2.18; p < .001) but not with BI (OR 1.29; p = .199). Specimen weight, rates of residual tissue not subjected to histopathological analyses, of BI and of brain tissue, on the microscopic slides differed among the neurosurgical centers (p < .001, each). Frequency of BI was increased in one department (OR 2.07; p = .002) and tended to be lower in another (OR .61; p = .088). The same centers displayed the highest and lowest rates of brain tissue in the specimen, respectively (p < .001). Moreover, the correlation of BI with the neurosurgical center was not confirmed when only analyzing specimen with evidence of brain tissue in microscopic analyses (p = .223). Detection of BI was not correlated with the intraoperative use of CUSA in subgroup analyses. Rates of brain invasion in neuropathological analyses are not associated with tumor location but differ among some neurosurgical centers. Evidence raises that surgical nuances impact specimen characteristics and therefore the accuracy of the detection of BI.

Real-time in vivo kinetics of protoporphyrin IX after administration of 5-aminolevulinic acid in meningiomas and comparative analyses with glioblastomas.

BACKGROUND: The usefulness of 5-aminolevulinic acid (5-ALA)-mediated fluorescence-guided surgery (FGS) in meningiomas is intensely discussed. However, data about kinetics of 5-ALA and protoporphyrin (Pp) IX in meningiomas are lacking. METHODS: As the first study so far, we performed longitudinal intraoperative real-time ex situ measurements of fluorescence intensity and PpIX concentrations during FGS of ten benign and two atypical meningiomas. Kinetics were subsequently compared with data from 229 glioblastomas. RESULTS: Spectroscopy revealed fluorescence (median 2945.65 a.u.) and PpIX accumulation (median 18.31 µg/ml) in all 43 analyzed samples. Fluorescence intensity (2961.50 a.u. vs 118.41 a.u.; p < .001) and PpIX concentrations (18.72 µg/ml vs .98 µg/ml; p < .001) were higher in samples with (N = 30) than without (N = 2) visible intraoperative tumor fluorescence. ROC curve analyses revealed a PpIX cut-off concentration of 3.85 µg/ml (AUC = .992, p = .005) and a quantitative fluorescence cut-off intensity of 286.73 a.u. (AUC = .983, p = .006) for intraoperative visible tumor fluorescence. Neither fluorescence intensity (p = .356) nor PpIX (p = .631) differed between atypical and benign meningiomas. Fluorescence and PpIX peaked 7-8 h following administration of 5-ALA. Meningiomas displayed a higher fluorescence intensity (p = .012) and PpIX concentration (p = .005) than glioblastomas 5-6 h after administration of 5-ALA. Although fluorescence was basically maintained, PpIX appeared to be cleared faster in meningiomas than in glioblastomas. CONCLUSIONS: Kinetics of PpIX and fluorescence intensity differ between meningiomas and glioblastomas in the early phase after 5-ALA administration. Modification of the timing of drug administration might impact visibility of intraoperative fluorescence and helpfulness of FGS and should be investigated in future analyses.

Clinical, radiological, and histopathological predictors for long-term prognosis after surgery for atypical meningiomas.

BACKGROUND: Despite considerable rates of recurrence and mortality in atypical meningiomas, reliable predictors for estimating postoperative long-term prognosis remain elusive. METHODS: Clinical, histopathological, and radiological variables from 138 patients, including 64 females and 74 males (46% and 54%, median age 62 years), who underwent surgery for intracranial atypical meningioma were retrospectively analyzed. Associations between variables and recurrence and mortality were investigated using uni- and multivariate analyses. RESULTS: Gross total (GTR) and subtotal resection (STR) was achieved in 81% and 19% of cases, respectively. Within a median follow-up of 62 months, recurrence occurred in 52 (38%) and mortality in 22 (16%) cases. In patients who did not receive adjuvant irradiation, recurrence rates were higher after STR than after GTR (32% vs 63%, p = 0.025). In univariate analyses, only intratumoral calcifications on preoperative MRI (p = 0.012) and the presence of brain invasion in the absence of other histological grading criteria (p = 0.010) were correlated with longer progression-free intervals (PFI). In multivariate analyses, patient age was positively (HR 1.03, 95%CI 1.04-1.05; p = 0.018) and the presence of brain invasion as the only grading criterion (HR 0.37, 95%CI 0.19-0.74; p = 0.005) was negatively related with progression, while rising age at the time of surgery (HR 1.07, 95%CI 1.03-1.12; p = 0.001) was prognostic for mortality. CONCLUSIONS: PFI was longer in brain invasive but otherwise histological benign meningiomas and in tumors displaying calcifications on preoperative MRI. Advancing patient age and lower Karnofsky Performance Score were associated with higher overall mortality.

Gadolinium-based contrast agents induce gadolinium deposits in cerebral vessel walls, while the neuropil is not affected: an autopsy study.

Recent studies showed gadolinium depositions following serial administrations of gadolinium-based contrast agents (GBCAs) for magnetic resonance imaging examinations in various parts of the brain with the dentate nucleus (DN) being most affected. Even though no clinical correlates of the deposits are known yet, an intensive debate developed if this might be harmful. The aim of the current study was to specify the gadolinium distribution in brain tissue of patients who received serial injections of GBCAs in the low-µm range and to explore any potential pathological tissue changes caused by gadolinium deposits. Thirteen autopsy cases-eight receiving GBCA administrations, five serving as controls-were identified and analyzed. For all patients, total gadolinium quantification after acidic digestion by means of inductively coupled plasma-mass spectrometry (ICP-MS) was performed. Six cases were utilized for the spatially resolved quantification of gadolinium within the cerebellum and the basal ganglia by means of high-resolution laser ablation (LA)-ICP-MS. Histopathological and immunohistochemical examinations were performed to determine tissue reactions. LA-ICP-MS revealed gadolinium depositions in the walls of small blood vessels of the DN in all GBCA exposed patients, while no gadolinium was found in the control group. Additionally, the detection of phosphorus and metals like copper, zinc and iron provides evidence that transmetalation reactions might have occurred. No significant pathological changes of the brain tissue in the vicinity of the DN with respect to micro-/astrogliosis and neuronal loss were found in any of the patients. This notably holds true even for a patient who died from nephrogenic systemic fibrosis exhibiting extremely high gadolinium concentrations within the DN. The findings show that gadolinium depositions in the brain are restricted to blood vessel walls, while the neuropil is spared and apparent cellular reactions are absent.

The evolution of cranial meningioma surgery-a single-center 25-year experience.

BACKGROUND: There have been major developments in diagnostic and surgical and non-surgical techniques used in the management of meningiomas over last three decades. We set out to describe these changes in a systematic manner. METHOD: Clinical and radiological data, surgical procedures, complications, and outcome of 817 patients who underwent surgery for primarily diagnosed meningioma between 1991 and 2015 were investigated. RESULTS: Median age at diagnosis increased significantly from 56 to 59 years (p = .042), while tumor location and preoperative Karnofsky performance status did not change during the observation period. Availability of preoperative MRI increased, and rates of angiography and tumor embolization decreased (p < .001, each). Median duration of total, pre-, and postoperative stay was 13, 2, and 9 days, respectively, and decreased between 1991 and 2015 (p < .001, each). Median incision-suture time varied annually (p < .001) but without becoming clearly longer or shorter during the entire observation period. The use of intraoperative neuronavigation and neuromonitoring increased, while the rates of Simpson grade I and III surgeries decreased (p < .001). Rates of postoperative hemorrhage (p = .997), hydrocephalus (p = .632), and wound infection (p = .126) did not change, while the frequency of early postoperative neurological deficits decreased from 21% between 1991 and 1995 to 13% between 2011 and 2015 (p = .003). During the same time, the rate of surgeries for postoperative cerebrospinal fluid leakage slightly increased from 2 to 3% (p = .049). Within a median follow-up of 62 months, progression was observed in 114 individuals (14%). Progression-free interval did not significantly change during observation period (p > .05). Multivariate analyses confirmed the lack of correlation between year of surgery and tumor relapse (HR: 1.1, p > .05). CONCLUSIONS: Preoperative diagnosis and surgery of meningiomas have been substantially evolved. Although early neurological outcome has improved, long-term prognosis remains unchanged.

The Simpson grading in meningioma surgery: does the tumor location influence the prognostic value?

In meningiomas, location-specific differences of the prognostic value of the Simpson classification are sparsely investigated but can influence strategy of surgery. We therefore compared the prognostic value of the Simpson classification in different tumor locations. Progression was compared with Simpson grade in 826 meningioma patients (median age 58 years, female:male ratio 2.4) in location-specific uni- and multivariate analyses. Simpson grade strongly correlated with tumor location (p < .001). Within a median follow-up of 50 months, recurrence was observed in 107 of 803 patients (13%). In general, increasing Simpson grade (p = .002) and subtotal resection (STR, ≥grade III) were correlated with tumor recurrence [hazard ratio (HR): 1.87; p = .004]. In 268 convexity meningiomas, frequency of tumor recurrence correlated with Simpson grade (p = .034). Risk of recurrence was similar after grade I and II resections, tended to increase after grade III (HR: 2.35; p = .087) but was higher after grade IV resections (HR: 7.35; p = .003). Risk of recurrence was higher after STR (HR: 4.21; p = .001) than after gross total resection (GTR, ≤grade II). Contrarily, increasing Simpson grade and STR were not correlated with progression in 102 falx, 38 posterior fossa and nine intraventricular meningiomas. In 325 skull base lesions, risk of recurrence was similar after GTR and STR (p = .198) and was only increased after grade IV resections (HR: 3.26; p = .017). Simpson grading and extent of resection were not equally prognostic in all locations. Lower impact of extent of resection should be considered during surgery for skull base, posterior fossa and falx meningiomas.

Glioma tissue obtained by modern ultrasonic aspiration with a simple sterile suction trap for primary cell culture and pathological evaluation.

OBJECTIVES: Ultrasonic aspiration is widely used in the resection of brain tumors. Nevertheless, tumor tissue fragments obtained by ultrasonic aspiration are usually discarded. In this study, we demonstrate that these fragments are possible sources of material for histopathological study and tissue culture and compare their microscopic features and viability in tissue culture of cavitron ultrasonic surgical aspirator tissue fragments. METHODS: Brain tumor tissue collected by ultrasonic aspiration (CUSA EXcel®; Integra Radionics Inc.) in a simple sterile suction trap during resection was processed for primary cell culture. Cell viability and immunohistological markers were measured by the WST-1 test, microscopy and immunofluorescent evaluation. RESULTS: Six gliomas are presented to demonstrate that these tissue fragments show good preservation of histological detail and tissue viability in culture. CONCLUSION: Utilization of this material may facilitate pathological interpretation by providing a more representative sample of tumor histology as well as an adequate and sterile biosource of material for tissue culture studies.

A ten-year retrospective analysis of decompressive craniectomy or craniotomy after severe brain injury and its implications for donation after brain death.

Craniotomy or decompressive craniectomy are among the therapeutic options to prevent or treat secondary damage after severe brain injury. The choice of procedure depends, among other things, on the type and severity of the initial injury. It remains controversial whether both procedures influence the neurological outcome differently. Thus, estimating the risk of brain herniation and death and consequently potential organ donation remains difficult. All patients at the University Hospital Münster for whom an isolated craniotomy or decompressive craniectomy was performed as a treatment after severe brain injury between 2013 and 2022 were retrospectively included. Proportion of survivors and deceased were evaluated. Deceased were further analyzed regarding anticoagulants, comorbidities, type of brain injury, potential and utilized donation after brain death. 595 patients were identified, 296 patients survived, and 299 deceased. Proportion of decompressive craniectomy was higher than craniotomy in survivors (89% vs. 11%, p < 0.001). Brain death was diagnosed in 12 deceased and 10 donations were utilized. Utilized donations were comparable after both procedures (5% vs. 2%, p = 0.194). Preserved brain stem reflexes as a reason against donation did not differ between decompressive craniectomy or craniotomy (32% vs. 29%, p = 0.470). Patients with severe brain injury were more likely to survive after decompressive craniectomy than craniotomy. Among the deceased, potential and utilized donations did not differ between both procedures. This suggests that brain death can occur independent of the previous neurosurgical procedure and that organ donation should always be considered in end-of-life decisions for patients with a fatal prognosis.

[Organ donation after determination of brain death : Legal aspects and practical approach]. / Organspende nach irreversiblem Hirnfunktionsausfall : Rechtliche Aspekte und praktisches Vorgehen.

The prerequisites for post-mortem organ donation in Germany include the determination of irreversible loss of brain function, consent to organ donation, and the exclusion of medical contraindications. In addition, mainly because of the shortage of donor organs in Germany and the sometimes controversial social and media discussions on the topic of organ donation, all physicians involved in the donation process must be familiar with the relevant laws, guidelines, and procedural instructions. This applies especially to those who are to carry out the verification of irreversible brain death. Only then, can they act safely in this challenging situation and serve as competent consultants for all involved.

Risk factors associated with vasospasm after non-traumatic subarachnoid hemorrhage: a retrospective analysis of 456 patients.

BACKGROUND: The pathophysiology of vasospasm (VS) after non-traumatic subarachnoid hemorrhage is not completely understood. Several risk factors associated with VS were previously reported, partially with conflicting results. The aim of this study was to identify patients at increased risk for VS. METHODS: Retrospective analysis of data from all patients treated in our institutional intensive care unit (ICU) between 2010 and 2016 after non-traumatic subarachnoid hemorrhage. Possible contributing factors for VS studied were: age, sex, aneurysm-localization, treatment option, ICU-stay, ICU mortality, pre-existing condition, medication history, World Federation of Neurosurgical Societies (WFNS) grading system, modified Fisher scale. RESULTS: We obtained data from 456 patients. 184 were male and 272 female patients, respectively. Mean age was 57.7±13.9 and was not different between sexes. In 119 patients, VS was diagnosed after subarachnoid hemorrhage. Incidence of VS was not different between sexes (male: 22.3%, female: 28.7%, P=0.127). Patients with VS were significantly younger (mean age 52.2 vs. 59.7, P<0.001), meanwhile patients aged 36-40 yrs. had the highest incidence of VS. Most VS were found after rupture of middle cerebral artery-aneurysms. Higher incidence of VS was found after aneurysm clipping compared to coiling. VS developed more often in patients with more severe WFNS grade and Fisher scale. In multivariate analysis, age, previous drug abuse and history of anticoagulants were associated with the incidence of VS. CONCLUSIONS: Younger age, middle cerebral artery-aneurysms, aneurysm clipping, previous drug abuse and history of anticoagulants were associated with a higher incidence of VS after non-traumatic subarachnoid hemorrhage. No gender difference was found.

Which risk factors significantly influence the outcome of traumatic brain injured patients with alcohol use disorder?

PURPOSE: Every year, approximately 10 million people worldwide suffer a traumatic brain injury that leads to hospitalization or mortality. Chronic and acute alcohol intoxication increase the risk of developing traumatic brain injury. Alcohol use disorder (AUD) as a predictor of outcome in neurosurgical patients and the definition of risk factors have been sparsely addressed so far. This study aims to improve the understanding of the effects of alcohol use disorder in the context of neurosurgical therapy. METHODS: This study included patients admitted to Münster University Hospital with a traumatic brain injury and alcohol use disorder from January 1, 2010, to December 31, 2018. Univariate and multivariate analyses were performed to identify risk factors for a poorer outcome, assessed by the Glasgow Outcome Score. RESULTS: Of the 197 patients included, 156 (79%) were male, and 41 (21%) were female, with a median age of 49 years (IQR 38-58 years). In multivariate analyses, age (p < 0.001), the occurrence of a new neurologic deficit (p < 0.001), the development of hydrocephalus (p = 0.005), and CT-graphic midline shift due to intracerebral hemorrhage (p = 0.008) emerged as significant predictors of a worse outcome (GOS 1-3). In addition, the level of blood alcohol concentration correlated significantly with the occurrence of seizures (p = 0.009). CONCLUSIONS: Early identification of risk factors in patients with alcohol use disorder and traumatic brain injury is crucial to improve the outcome. In this regard, the occurrence of hydrocephalus or seizures during the inpatient stay should be considered as cause of neurological deterioration in this patient group.

Postoperative surveillance in cranial and spinal tumor neurosurgery: when is this warranted?

OBJECTIVE: The outbreak of COVID-19 and the sudden increase in the number of patients requiring mechanical ventilation significantly affected the management of neurooncological patients. Hospitals were forced to reallocate already scarce human resources to maximize intensive care unit (ICU) capacities, resulting in a significant postponement of elective procedures for patients with brain and spinal tumors, who traditionally require elective postoperative surveillance on ICU or intermediate care wards. This study aimed to characterize those patients in whom postoperative monitoring is required by analyzing early postoperative complications and associated risk factors. METHODS: All patients included in the analysis experienced benign or malignant cerebral or intradural tumors and underwent surgery between September 2017 and May 2019 at University Hospital Münster, Germany. Patient data were generated from a semiautomatic, prospectively designed database. The occurrence of adverse events within 24 hours and 30 days postoperatively-including unplanned reoperation, postoperative hemorrhage, CSF leakage, and pulmonary embolism-was chosen as the primary outcome measure. Furthermore, reasons and risk factors that led to a prolonged stay on the ICU were investigated. By performing multivariable logistic regression modeling, a risk score for early postoperative adverse events was calculated by assigning points based on beta coefficients. RESULTS: Eight hundred eleven patients were included in the study. Eleven patients (1.4%) had an early adverse event within 24 hours, which was either an unplanned reoperation (0.9%, n = 7) or a pulmonary embolism (0.5%, n = 4) within 24 hours. To predict the incidence of early postoperative complications, a score was developed including the number of secondary diagnoses, BMI, and incision closure time, termed the SOS score. According to this score, 0.3% of the patients were at low risk, 2.5% at intermediate risk, and 12% at high risk (p < 0.001). CONCLUSIONS: Postoperative surveillance in cranial and spinal tumor neurosurgery might only be required in a distinct patient collective. In this study, the authors present a new score allowing efficient prediction of the likelihood of early adverse events in patients undergoing neurooncological procedures, thus helping to stratify the necessity for ICU or intermediate care unit beds. Nevertheless, validation of the score in a multicenter prospective setting is needed.

Histopathological analysis of intracerebral hemorrhage: implications for clinical management.

BACKGROUND: The clinical impact of routine neuropathologic examination of samples from patients with intracerebral hemorrhage (ICH) is unclear. METHODS: Therefore, we evaluated a consecutive series of 378 surgical specimens from patients with ICH concerning demographic data, localization of hemorrhage, preoperative clinical diagnosis and neuropathological diagnosis. RESULTS: Histological examination revealed the putative origin of ICH in 143 cases (37.8%). Vascular pathologies were detected in 127 patients (33.6%), while tumors were identified in 9 patients (2.4%), infarction in 6 patients (1.6%) and abscess in 1 patient (0.3%). Preoperatively, tumor was considered in 65 patients (17.2%), while vascular malformations were supposed in 94 patients (24.9%), infarction in 18 cases (4.8%) and abscess in 3 cases (0.8%). In 198 patients (52.4%) no specific assumption was made. CONCLUSIONS: Comparing preoperative assumptions and histological diagnoses, tumor, vascular malformations and infarctions were clinically overestimated, while arteriolosclerosis and amyloid angiopathy were underestimated. In conclusion, we found that histological findings potentially affecting clinical management and prognosis were obtained in 37.8% of cases. Our data suggest that histopathological examination of intracerebral hemorrhage provides important information for patient management and should be routinely performed.

How Should We Treat Meningeal Melanocytoma? A Retrospective Analysis of Potential Treatment Strategies.

BACKGROUND: Meningeal melanocytomas (MM) are rare primary melanocytic tumors of the leptomeninges with an incidence of 1:10,000,000. Until now, there has been only sparse information about this tumor entity. Here, we provide a meta-analysis of all cases published in the English language since 1972. METHODS: A literature review was performed using PubMed and Web of Science. All published cases were evaluated for location, sex, age, therapeutic approach, and outcome. In total, we included 201 patient cases in our meta-analysis. RESULTS: The majority of MM was diagnosed more frequently in men between the third and fifth decade of life. Surgery is the preferred therapeutic approach, and total resection is associated with the best outcome. Patients with partial resection or tumor recurrence benefit from adjuvant radiotherapy, whereas chemo- or immunotherapies do not improve the disease course. Malignant transformation was described in 18 patients. Of these, 11 patients developed metastasis. CONCLUSIONS: We present the first retrospective meta-analysis of all MM cases published in the English language, including an evaluation of different treatment strategies allowing us to suggest a novel treatment guideline highlighting the importance of total resection for recurrence-free survival and characterizing those cases which benefit from adjuvant radiotherapy.

A Cohort Analysis of Truly Incidental Low-Grade Gliomas.

BACKGROUND: Management of low-grade gliomas (LGGs) is controversial. Incidental LGGs are thought to represent an earlier stage in the disease process compared with symptomatic LGGs. With advanced imaging techniques, the discovery of these lesions is expected to increase, resulting in clinical need for further understanding of these tumors. This study aimed to identify the incidence of incidental LGGs across 2 large European neurosurgical centers and review management and survival of tumors compared with symptomatic cranial LGGs over a 5-year period. METHODS: LGGs managed during 2015-2019 at the Royal Victoria Infirmary and Münster University Hospital were retrospectively reviewed. An incidental finding was strictly defined as one discovered secondary to routine clinical or research imaging, not associated with investigation for a space-occupying lesion, with no associated symptoms. All histomolecular pathology reports were reviewed. RESULTS: Of 150 cases of World Health Organization grade II tumors identified at both centers, 82 were symptomatic, diffuse LGGs, with 20 discovered incidentally. There were 48 nondiffuse and/or pediatric tumors, which were excluded. Incidental LGGs were mostly IDH mutated and oligodendroglial with a trend toward improved overall survival and significantly increased progression-free survival compared with symptomatic LGGs (P = 0.024). In all cases, regardless of presentation, progression-free survival and overall survival were significantly improved following gross total resection versus biopsy (hazard ratio 0.45 [95% confidence interval 0.21-0.95], P = 0.037 vs. hazard ratio 0.10 [95% confidence interval 0.02-0.44], P = 0.003). CONCLUSIONS: In this study, differences in characteristics and survival between incidental and symptomatic LGGs were present, yet not significant owing to the rarity, and therefore small sample size, of incidental LGGs. Further global collaboration and development of an international glioma registry with a focus on symptoms, imaging indications (if incidental), histomolecular data, and management are needed.