Frameless Stereotactic Biopsy of Brainstem Tumors Using the Stealth Autoguide: A Technical Note.

BACKGROUND AND OBJECTIVES: In the molecular era of neuro-oncology, it is increasingly necessary to obtain tissue for next-generation sequencing and methylome profile for prognosis and targeted oncological management. Brainstem tumors can be technically challenging to biopsy in the pediatric population. Frame-based and frameless techniques have previously been described and proven to be safe and efficacious in children. Recent cranial robotic guidance platforms have augmented the fluency of frameless stereotactic approaches, but the technical nuances of these procedures in children are not often discussed. We present a technical workflow for frameless stereotactic biopsy of brainstem tumors in children using the Medtronic Stealth Autoguide cranial robotic guidance platform and examine safety and efficacy of this surgical approach. METHODS: A minimally invasive, frameless, transcerebellar approach is described, including operative steps and workflow. We assessed operative times, diagnostic accuracy and yield, and complication rates. RESULTS: Five patients underwent biopsy with the technique described. The youngest patient in our series was of 2 years. The intended target was achieved on postoperative imaging in all cases, and diagnostic tissue was obtained in all 5 patients. One patient had a clinically insignificant hemorrhage. CONCLUSION: Frameless stereotactic biopsy of the brainstem can be performed safely, efficiently, and accurately using the Medtronic Stealth Autoguide robotic platform in children as young as 2 years.

Blood-Brain Barrier Disruption for the Treatment of Primary Brain Tumors: Advances in the Past Half-Decade.

PURPOSE OF REVIEW: To review relevant advances in the past half-decade in the treatment of primary brain tumors via modification of blood-brain barrier (BBB) permeability. RECENT FINDINGS: BBB disruption is becoming increasingly common in the treatment of primary brain tumors. Use of mannitol in BBB disruption for targeted delivery of chemotherapeutics via superselective intra-arterial cerebral infusion (SIACI) is the most utilized strategy to modify the BBB. Mannitol is used in conjunction with chemotherapeutics, oligonucleotides, and other active agents. Convection-enhanced delivery has become an attractive option for therapeutic delivery while bypassing the BBB. Other technologic innovations include laser interstitial thermal therapy (LITT) and focused ultrasound (FUS) which have emerged as prime modalities to directly target tumors and cause significant local BBB disruption. In the past 5 years, interest has significantly increased in studying modalities to disrupt the BBB in primary brain tumors to enhance treatment responses and improve clinical outcomes.

A Well-Being Well-Check for Neurosurgery: Evidence-Based Suggestions for Our Specialty Based on a Systematic Review.

BACKGROUND: The path through neurosurgery is rigorous. Many neurosurgeons may experience burnout, depression, or suicide throughout training and practice. We review the literature to help foster a culture of awareness and self-care and arm trainees with coping skills to reduce burnout and, thus, suicidality during all phases of their medical careers. METHODS: A systematic search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using 4 databases. 7 studies were included. RESULTS: Overlying themes of interventions were to increase balance, mindfulness, and physical fitness. The most common interventions included in programs were educational and physical activity. We suggest a comprehensive wellness program emphasizing interventions from 4 wellness dimensions-physical, spiritual, mental, and emotional. CONCLUSIONS: Many neurosurgeons experience burnout, leading to a lack of satisfaction and early retirement; this necessitates a discipline-wide acknowledgment of endemic burnout among neurosurgeons. Systemic changes are needed to refine the training process and prioritize physician well-being- this cannot be left to chance.

Concomitant brain abscess and spinal cord abscess in an immunocompetent teenage male: illustrative case.

BACKGROUND: Multiple bilateral brain abscesses occur rarely in immunocompetent patients. Hematogenous spread to the central nervous system (CNS) allows suppuration and abscess formation in the privileged immune environment of the CNS; hematogenous spread to the spinal cord is extremely rare and the combination of multifocal brain abscesses and intramedullary abscesses has not been reported. This report presents a rare presentation and diagrams a treatment algorithm involving iterative minimal access surgeries and prolonged medical management. OBSERVATIONS: The authors present a case of an 18-year-old male with numerous multifocal and bilateral intraparenchymal abscesses and a medically resistant C5 intramedullary spinal cord abscess. The symptomatic patient had a left oculomotor palsy and left hemiparesis, ultimately undergoing ultrasound-guided aspiration of abscesses in the left frontal and left cerebral peduncle. Following transient motor improvement, he evolved tetraparesis prompting spinal cord imaging and emergent ultrasound-guided needle aspiration of an occult C5 intramedullary spinal cord abscess. The patient received appropriate medical therapy, completed inpatient rehabilitation, and made a full recovery. LESSONS: Needle- and ultrasound-guided catheter drainage of CNS abscesses should be considered for symptomatic lesions. Following the neurological examination closely is extremely important; if the expected neurological improvement is delayed or regresses, then expanded imaging is warranted.