Correlation of CT-based bone mineralization with drilling-force measurements in anatomical specimens is suitable to investigate planning of trans-pedicular spine interventions.

This interdisciplinary study examined the relationship between bone density and drilling forces required during trans-pedicular access to the vertebra using fresh-frozen thoraco-lumbar vertebrae from two female body donors (A, B). Before and after biomechanical examination, samples underwent high-resolution CT-quantification of total bone density followed by software-based evaluation and processing. CT density measurements (n = 4818) were calculated as gray values (GV), which were highest in T12 for both subjects (GVmaxA = 3483.24, GVmaxB = 3160.33). Trans-pedicular drilling forces F (Newton N) were highest in L3 (FmaxB = 5.67 N) and L4 (FmaxA = 5.65 N). In 12 out of 13 specimens, GVs significantly (p < 0.001) correlated with force measurements. Among these, Spearman correlations r were poor in two lumbar vertebrae, fair in five specimens, and moderately strong in another five specimens, and highest for T11 (rA = 0.721) and L5 (rB = 0.690). Our results indicate that CT-based analysis of vertebral bone density acquired in anatomical specimens is a promising approach to predict the drilling force appearance as surrogate parameter of its biomechanical properties by e.g., linear regression analysis. The study may be of value as basis for biomechanical investigations to improve planning of the optimal trajectory and to define safety margins for drilling forces during robotic-assisted trans-pedicular interventions on the spine in the future.

Diffusion Weighted Imaging in Gliomas: A Histogram-Based Approach for Tumor Characterization.

(1) Background: Astrocytic gliomas present overlapping appearances in conventional MRI. Supplementary techniques are necessary to improve preoperative diagnostics. Quantitative DWI via the computation of apparent diffusion coefficient (ADC) histograms has proven valuable for tumor characterization and prognosis in this regard. Thus, this study aimed to investigate (I) the potential of ADC histogram analysis (HA) for distinguishing low-grade gliomas (LGG) and high-grade gliomas (HGG) and (II) whether those parameters are associated with Ki-67 immunolabelling, the isocitrate-dehydrogenase-1 (IDH1) mutation profile and the methylguanine-DNA-methyl-transferase (MGMT) promoter methylation profile; (2) Methods: The ADC-histograms of 82 gliomas were computed. Statistical analysis was performed to elucidate associations between histogram features and WHO grade, Ki-67 immunolabelling, IDH1 and MGMT profile; (3) Results: Minimum, lower percentiles (10th and 25th), median, modus and entropy of the ADC histogram were significantly lower in HGG. Significant differences between IDH1-mutated and IDH1-wildtype gliomas were revealed for maximum, lower percentiles, modus, standard deviation (SD), entropy and skewness. No differences were found concerning the MGMT status. Significant correlations with Ki-67 immunolabelling were demonstrated for minimum, maximum, lower percentiles, median, modus, SD and skewness; (4) Conclusions: ADC HA facilitates non-invasive prediction of the WHO grade, tumor-proliferation rate and clinically significant mutations in case of astrocytic gliomas.

Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it?

There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.

Resolution of Brainstem Edema after Neurosurgical Occlusion of Dural Arteriovenous Fistulas of the Craniocervical Junction: Report of Three Cases and Review.

OBJECTIVE: Dural arteriovenous fistulas of the craniocervical junction are rare but the most dangerous of spinal fistulas. The concurrent brainstem edema has been attributed to increased pressure within the venous outflow of the brainstem and upper cord, but the differential diagnosis of brainstem edema is demanding. This report presents the details of clinical findings, magnetic resonance imaging (MRI) , surgical techniques, and follow-up of these fistulas. METHODS: Three cases with dural arteriovenous fistulas and edema of the brainstem and upper cord are described plus a review of the literature. Clinical presentation, radiologic findings, and a follow-up of outcomes are presented. RESULTS: All three cases with misleading diagnoses at the time of referral experienced variable degrees of tetraparesis with brainstem edema on MRI. Congested veins on MRI raised the suspicion of a vascular origin of the edema. The diagnosis was established with highly specific angiography with microcatheters identifying a feeder from the ascending pharyngeal artery in two cases and a tentorial feeder from the carotid artery in one case. The operation included temporary clipping of the fistula and neuromonitoring. Follow-up confirmed improvement of clinical signs and resolution of the brainstem edema on MRI. CONCLUSION: Edema of the brainstem and cervical cord may be caused by a dural arteriovenous fistula of the craniocervical junction. Surgical occlusion may be an efficient option for the complete resolution of radiologic and clinical symptoms.

Interactive exploration of a 3D intracranial aneurysm wall model extracted from histologic slices.

PURPOSE: Currently no detailed in vivo imaging of the intracranial vessel wall exists. Ex vivo histologic images can provide information about the intracranial aneurysm (IA) wall composition that is useful for the understanding of IA development and rupture risk. For a 3D analysis, the 2D histologic slices must be incorporated in a 3D model which can be used for a spatial evaluation of the IA's morphology, including analysis of the IA neck. METHODS: In 2D images of histologic slices, different wall layers were manually segmented and a 3D model was generated. The nuclei were automatically detected and classified as round or elongated, and a neural network-based wall type classification was performed. The information was combined in a software prototype visualization providing a unique view of the wall characteristics of an IA and allowing interactive exploration. Furthermore, the heterogeneity (as variance of the wall thickness) of the wall was evaluated. RESULT: A 3D model correctly representing the histologic data was reconstructed. The visualization integrating wall information was perceived as useful by a medical expert. The classification produces a plausible result. CONCLUSION: The usage of histologic images allows to create a 3D model with new information about the aneurysm wall. The model provides information about the wall thickness, its heterogeneity and, when performed on cadaveric samples, includes information about the transition between IA neck and sac.

HoloInjection: augmented reality support for CT-guided spinal needle injections.

The correct placement of needles is decisive for the success of many minimally-invasive interventions and therapies. These needle insertions are usually only guided by radiological imaging and can benefit from additional navigation support. Augmented reality (AR) is a promising tool to conveniently provide needed information and may thus overcome the limitations of existing approaches. To this end, a prototypical AR application was developed to guide the insertion of needles to spinal targets using the mixed reality glasses Microsoft HoloLens. The system's registration accuracy was attempted to measure and three guidance visualisation concepts were evaluated concerning achievable in-plane and out-of-plane needle orientation errors in a comparison study. Results suggested high registration accuracy and showed that the AR prototype is suitable for reducing out-of-plane orientation errors. Limitations, like comparatively high in-plane orientation errors, effects of the viewing position and missing image slices indicate potential for improvement that needs to be addressed before transferring the application to clinical trials.

Comparison of gesture and conventional interaction techniques for interventional neuroradiology.

PURPOSE: Interaction with radiological image data and volume renderings within a sterile environment is a challenging task. Clinically established methods such as joystick control and task delegation can be time-consuming and error-prone and interrupt the workflow. New touchless input modalities may have the potential to overcome these limitations, but their value compared to established methods is unclear. METHODS: We present a comparative evaluation to analyze the value of two gesture input modalities (Myo Gesture Control Armband and Leap Motion Controller) versus two clinically established methods (task delegation and joystick control). A user study was conducted with ten experienced radiologists by simulating a diagnostic neuroradiological vascular treatment with two frequently used interaction tasks in an experimental operating room. The input modalities were assessed using task completion time, perceived task difficulty, and subjective workload. RESULTS: Overall, the clinically established method of task delegation performed best under the study conditions. In general, gesture control failed to exceed the clinical input approach. However, the Myo Gesture Control Armband showed a potential for simple image selection task. CONCLUSION: Novel input modalities have the potential to take over single tasks more efficiently than clinically established methods. The results of our user study show the relevance of task characteristics such as task complexity on performance with specific input modalities. Accordingly, future work should consider task characteristics to provide a useful gesture interface for a specific use case instead of an all-in-one solution.

Mathematical 3D modelling and sensitivity analysis of multipolar radiofrequency ablation in the spine.

Radiofrequency ablation is a valuable tool in the treatment of many diseases, especially cancer. However, controlled heating up to apoptosis of the desired target tissue in complex situations, e.g. in the spine, is challenging and requires experienced interventionalists. For such challenging situations a mathematical model of radiofrequency ablation allows to understand, improve and optimise the outcome of the medical therapy. The main contribution of this work is the derivation of a tailored, yet expandable mathematical model, for the simulation, analysis, planning and control of radiofrequency ablation in complex situations. The dynamic model consists of partial differential equations that describe the potential and temperature distribution during intervention. To account for multipolar operation, time-dependent boundary conditions are introduced. Spatially distributed parameters, like tissue conductivity and blood perfusion, allow to describe the complex 3D environment representing diverse involved tissue types in the spine. To identify the key parameters affecting the prediction quality of the model, the influence of the parameters on the temperature distribution is investigated via a sensitivity analysis. Simulations underpin the quality of the derived model and the analysis approach. The proposed modelling and analysis schemes set the basis for intervention planning, state- and parameter estimation, and control.

Experimental investigation of intravascular OCT for imaging of intracranial aneurysms.

PURPOSE: Rupture risk assessment of an intracranial aneurysm (IA) is an important factor for indication of therapy. Until today, there is no suitable objective prediction method. Conventional imaging modalities cannot assess the IA's vessel wall. We investigated the ability of intravascular optical coherence tomography (OCT) as a new tool for the characterization and evaluation of IAs. MATERIALS AND METHODS: An experimental setup for acquisition of geometrical aneurysm parameters was developed. Object of basic investigation was a silicone phantom with six IAs from patient data. For structural information, three circle of Willis were dissected and imaged postmortem. All image data were postprocessed by medical imaging software. RESULTS: Geometrical image data of a phantom with six different IAs were acquired. The geometrical image data showed a signal loss, e.g., in aneurysms with a high bottleneck ratio. Imaging data of vessel specimens were evaluated with respect to structural information that is valuable for the characterization of IAs. Those included thin structures (intimal flaps), changes of the vessel wall morphology (intimal thickening, layers), adjacent vessels, small vessel outlets, arterial branches and histological information. CONCLUSION: Intravascular OCT provides new possibilities for diagnosis and rupture assessment of IAs. However, currently used imaging system parameters have to be adapted and new catheter techniques have to be developed for a complete assessment of the morphology of IAs.

Clinical, Radiologic, and Legal Significance of "Extensor Response" in Posttraumatic Coma.

OBJECTIVE: The timely detection of neurologic deterioration can be critical for the survival of a neurosurgical patient following head injury. Because little reliable evidence is available on the prognostic value of the clinical sign "extensor response" in comatose posttraumatic patients, we investigated the correlation of this clinical sign with outcome and with early radiologic findings from magnetic resonance imaging (MRI). METHODS: This retrospective analysis of prospectively obtained data included 157 patients who had remained in a coma for a minimum of 24 hours after traumatic brain injury. All patients received a 1.5-T MRI within 10 days (median: 2 days) of the injury. The correlations between clinical findings 12 and 24 hours after the injury-in particular, extensor response and pupillary function, MRI findings, and outcome after 1 year-were investigated. Statistical analysis included contingency tables, Fisher exact test, odds ratios (ORs) with confidence intervals (CIs), and weighted κ values. RESULTS: There were 48 patients with extensor response within the first 24 hours after the injury. Patients with extensor response (World Federation of Neurosurgical Societies coma grade III) statistically were significantly more likely to harbor MRI lesions in the brainstem when compared with patients in a coma who had no further deficiencies (coma grade I; p = 0.0004 by Fisher exact test, OR 10.8 with 95% CI, 2.7-42.5) and patients with unilateral loss of pupil function (coma grade II; p = 0.0187, OR 2.8 with 95% CI, 1.2-6.5). The correlation of brainstem lesions as found by MRI and outcome according to the Glasgow Outcome Scale after 1 year was also highly significant (p ≤ 0.016). CONCLUSION: The correlation of extensor response and loss of pupil function with an unfavorable outcome and with brainstem lesions revealed by MRI is highly significant. Their sudden onset may be associated with the sudden onset of brainstem dysfunction and should therefore be regarded as one of the most fundamental warning signs in the clinical monitoring of comatose patients.

DOCK6 mutations are responsible for a distinct autosomal-recessive variant of Adams-Oliver syndrome associated with brain and eye anomalies.

Adams-Oliver syndrome (AOS) is characterized by the association of aplasia cutis congenita with terminal transverse limb defects, often accompanied by additional cardiovascular or neurological features. Both autosomal-dominant and autosomal-recessive disease transmission have been observed, with recent gene discoveries indicating extensive genetic heterogeneity. Mutations of the DOCK6 gene were first described in autosomal-recessive cases of AOS and only five DOCK6-related families have been reported to date. Recently, a second type of autosomal-recessive AOS has been attributed to EOGT mutations in three consanguineous families. Here, we describe the identification of 13 DOCK6 mutations, the majority of which are novel, across 10 unrelated individuals from a large cohort comprising 47 sporadic cases and 31 AOS pedigrees suggestive of autosomal-recessive inheritance. DOCK6 mutations were strongly associated with structural brain abnormalities, ocular anomalies, and intellectual disability, thus suggesting that DOCK6-linked disease represents a variant of AOS with a particularly poor prognosis.

Bipolar radiofrequency ablation of spinal tumors: predictability, safety and outcome.

BACKGROUND: Bone metastases are often the cause of tumor-associated pain and reduction of quality of life. For patients that cannot be treated by surgery, a local minimally invasive therapy such as radiofrequency ablation can be a useful option. In cases in which tumorous masses are adjacent to vulnerable structures, the monopolar radiofrequency can cause severe neuronal damage because of the unpredictability of current flow. PURPOSE: The aim of this study is to show that the bipolar radiofrequency ablation provides an opportunity to safely treat such spinal lesions because of precise predictability of the emerging ablation zone. STUDY DESIGN: Prospective cohort study of 36 patients undergoing treatment at a single institution. PATIENT SAMPLE: Thirty-six patients in advanced tumor stage with primary or secondary tumor involvement of spine undergoing radiofrequency ablation. OUTCOME MEASURES: Prediction of emerging ablation zone. Clinical outcome of treated patients. METHODS: X-ray-controlled treatment of 39 lesions by bipolar radiofrequency ablation. Magnetic resonance imaging was performed pre- and postinterventionally. Patients were observed clinically during their postinterventional stay. RESULTS: The extent of the ablation zones was predictable to the millimeter because it did not cross the peri-interventional planned dorsal and ventral boundaries in any case. No complications were observed. CONCLUSIONS: Ablation of tumorous masses adjacent to vulnerable structures is feasible and predictable by using the bipolar radiofrequency ablation. Damage of neuronal structures can be avoided through precise prediction of the ablation area.

Recommendations for accurate numerical blood flow simulations of stented intracranial aneurysms.

The number of scientific publications dealing with stented intracranial aneurysms is rapidly increasing. Powerful computational facilities are now available; an accurate computational modeling of hemodynamics in patient-specific configurations is, however, still being sought. Furthermore, there is still no general agreement on the quantities that should be computed and on the most adequate analysis for intervention support. In this article, the accurate representation of patient geometry is first discussed, involving successive improvements. Concerning the second step, the mesh required for the numerical simulation is especially challenging when deploying a stent with very fine wire structures. Third, the description of the fluid properties is a major challenge. Finally, a founded quantitative analysis of the simulation results is obviously needed to support interventional decisions. In the present work, an attempt has been made to review the most important steps for a high-quality computational fluid dynamics computation of virtually stented intracranial aneurysms. In consequence, this leads to concrete recommendations, whereby the obtained results are not discussed for their medical relevance but for the evaluation of their quality. This investigation might hopefully be helpful for further studies considering stent deployment in patient-specific geometries, in particular regarding the generation of the most appropriate computational model.

Performance evaluation of a C-Arm CT perfusion phantom.

PURPOSE: Brain perfusion measurement in stroke patients provides important information on the infarct area and state of involved tissue. Interventional C-Arm angiography systems can provide perfusion measurements. A CT perfusion phantom was developed for C-Arm perfusion imaging to test and evaluate this method and to aid in the design and validation of scan protocols. METHODS: A phantom test device was designed based on the anatomy of the human head. Four feeding arteries divided into sixteen sub-branches that lead into a sintered board simulating brain parenchyma. Perfusion measurements were performed using two conventional clinical CT scanners as the gold standard and with a C-Arm CT system to test and compare the implementations. The phantom's input parameters, contrast medium and flow properties were varied. A cerebral perfusion deficit was simulated by occlusion of a feeding artery tube. RESULTS: CT perfusion maps of the sintered board brain tissue surrogate were computed and qualitatively compared for both conventional CT and C-Arm CT systems. A characteristic flow pattern of the tissue board was identifiable in both modalities. The characteristic flow pattern of the resulting perfusion maps is reproducible. The calculated flow and volume were directly related. CONCLUSIONS: A new CT perfusion phantom was developed and tested. This phantom is an appropriate model for CT-based tissue perfusion measurements in both conventional CT scanners and C-Arm CT scanners. The influence of input parameter changes can be visualized. Perfusion deficits after occlusion of a feeding artery are readily simulated and identified with CT.

Early survival of comatose patients after severe traumatic brain injury with the dual cannabinoid CB1/CB2 receptor agonist KN38-7271: a randomized, double-blind, placebo-controlled phase II trial.

UNLABELLED: BACKGROUND AND STUDY OBJECT: Despite many drug trials, no substance has yet been identified that improves the outcome of severe head injury. The dual cannabinoid CB1/CB2 receptor agonist KN38-7271 mediates potent neuroprotection in animal models. We describe here the first randomized, double-blind, prospective, placebo-controlled clinical phase IIa proof-of-concept trial to investigate the safety, pharmacokinetics, and potential efficacy of a cannabinoid receptor agonist in humans. PATIENTS AND METHODS: Out of the 439, 97 comatose patients at 14 European neurosurgical centers met the inclusion criteria. KN38-7271 was administered within 4.5 hours of the injury, and the patients received 1000, 500 µg, or placebo. The primary analysis was pharmacokinetic; efficacy was measured by survival and by neurological improvement or deterioration 7 and 14 days and 1, 3, and 6 months after the injury. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were analyzed from start of treatment to end of day 7. RESULTS: Survival rates within 1 month of the injury were significantly better in the treatment groups than in the placebo group (high-dose, Kaplan-Meier difference on day 30 + 0.12 with p = 0.043; low-dose, difference +0.15 with p = 0.011) but this effect was not seen after 6 months. Critical ICP and CPP were less extreme and less frequent in the treatment group. There were no severe and no serious adverse effects that could be attributed to KN38-7271. CONCLUSIONS: KN38-7271 appeared beneficial in the acute early phase of the comatose patient after a head injury. Its use was safe and well tolerated by patients. These results may provide the basis for further phase II/III trials in larger study populations.

Bipolar radio frequency ablation of spinal neoplasms in late stage cancer disease: a report of three cases.

STUDY DESIGN: Case report. OBJECTIVE: To avoid neuronal damage by using the bipolar radio frequency ablation of spinal tumors. SUMMARY OF BACKGROUND DATA: Radio frequency ablation of tumorous masses is an established procedure and is increasingly used as pain therapy of unresectable spine tumors. Ablation of lesions adjacent to vulnerable structures remains a challenging task because flow of current is insufficiently controlled by monopolar probes. Using this technique, a prediction of the induced necrosis accurate to the millimeter is not feasible. METHODS: Three patients with metastases of the spine were treated using the bipolar radio frequency ablation. RESULTS: In all 3 cases collateral damage of neuronal structures could be avoided even though tumorous masses touched the cauda equina or were very close to vulnerable structures, respectively. The induction of necrosis was predictable to the millimeter. CONCLUSION: Ablation of tumorous masses adjacent to neural structures by bipolar technique, is feasible and predictable. Spinal cord damage can be avoided by exact planning of the induced necrosis.

Gliomas in adults.

BACKGROUND: Primary brain tumors are among the ten most common causes of cancer-related death. There is no screening test for them, but timely diagnosis and treatment improve the outcome. Ideally, treatment should be provided in a highly specialized center, but patients reach such centers only on the referral of their primary care physicians or other medical specialists from a wide variety of fields. An up-to-date account of basic knowledge in this area would thus seem desirable, as recent years have seen major developments both in the scientific understanding of these tumors and in clinical methods of diagnosis and treatment. METHODS: Selective search of the pertinent literature (PubMed and Cochrane Library), including the guidelines of the German Societies of Neurosurgery, Neurology, and Radiotherapy. RESULTS AND CONCLUSION: Modern neuroradiological imaging, in particular magnetic resonance imaging, can show structural lesions at high resolution and provide a variety of biological and functional information, yet it is still no substitute for histological diagnosis. Gross total resection of gliomas significantly improves overall survival. New molecular markers can be used for prognostication. Chemotherapy plays a major role in the treatment of various different kinds of glioma. The median survival, however, generally remains poor, e.g., 14.6 months for glio-blastoma.

[Interventional radiology - Image-guided minimal invasive procedures for treatment of neurological diseases]. / Bildgestützte minimal-invasive Therapie neurologischer Erkrankungen.

Neurological diseases can be treated more and more by minimal-invasive procedures. Most of them are performed under X-ray control in general anesthesia. In some diseases the minimal-invasive therapy is superior to medical or surgical therapy. In other cases final evaluation can not be made so far. For a successful minimal-invasive treatment a working communication between the involved persons is essential. At least basic knowledge about the underlying disease and the used techniques should be present.

Intraventricular meningioma with fatal haemorrhage: clinical and autopsy findings.

Only a few cases of intraventricular meningioma have been reported and the association with intracranial haemorrhage is even rarer. More than ever, autopsy findings are scarce. Here, we report a case of primary intraventricular meningioma with intraventricular haemorrhage in a 57-year-old woman. A CT scan of the head initially suggested a malignant brain tumour as the lesion was quite inhomogeneous with hyper- and hypodense sections accompanied by fresh haemorrhage. At autopsy, the tumour was histologically diagnosed as a fibroblastic meningioma WHO-Grade I. The source of haemorrhage was most likely the tumour itself as it contained focally rather large angiomatous and additionally small cavernous vessels and acute haemorrhage in various sections. The assumptive adherence of the tumour to the choroid plexus was probably disrupted by the haematoma.

Novel chromosomal aberrations in a recurrent malignant meningioma.

The molecular basis of tumorigenesis and tumor progression in meningiomas is not fully understood. Here we present results of conventional cytogenetic, fluorescence in situ hybridization (FISH), and comparative genetic hybridization (CGH) analyses in a patient with recurrent anaplastic meningioma. We found complex aberrant karyotype alterations previously described in anaplastic meningiomas, such as 1p, 14q aberration, and a possibly tetraploid karyotype. Loss of chromosome 22q was detected by conventional cytogenetic analysis. Additional chromosomal aberrations not previously reported included a near-triploid karyotype and alterations such as 4p+, 5p-, 7p+, 8q+, and gain of chromosome 19. FISH with LSI 9p21, CEP9, LSI PML/RARA, and CGH confirmed the karyotype complexity in this case. Our findings of several previously unreported cytogenetic alterations suggest that complex karyotype alterations are a characteristic feature in anaplastic meningiomas. High chromosomal complexity might be associated with a highly aggressive meningioma phenotype.