The implications of antithrombotic agents on subdural hematoma evacuation: what does "reversal" truly entail?

OBJECTIVE: The optimal perioperative management of antithrombotic therapy (ATT) in patients requiring urgent neurosurgical intervention for subdural hematoma (SDH) is poorly understood. The delicate equilibrium of effective hemostasis while preventing thrombosis is complex and relies on numerous factors such as indication for and type of ATT, medical comorbidities, and extent of neurological injury. This study aimed to analyze the impact of ATT and reversal strategies on surgical outcomes to highlight current challenges in the management of these high-risk patients. METHODS: The authors performed a retrospective surgical cohort analysis of 100 patients undergoing urgent SDH evacuation at a level I trauma center between March 2020 and May 2021. The patients were first stratified into two cohorts based on preoperative ATT use and then further segregated by receipt of reversal agents. Statistical analysis included the chi-square test, Welch two-sample t-test, and multivariate logistic regression. The primary outcome was mortality. Secondary endpoints included radiographic SDH reexpansion, revision surgery, improvement in preoperative neurological deficits, and incidence of thromboembolism. A crossover cohort was secondarily analyzed in patients for whom ATT was interrupted for a minimum duration equal to effective drug metabolism. Finally, ATT reinitiation patterns were examined. RESULTS: Of 100 patients, 48% received ATT, 54.2% of whom were given reversal agents. ATT use was significantly associated with decreased rates of postoperative neurological improvement (p = 0.023) with trends toward increased mortality (p = 0.078), SDH reexpansion (p = 0.12), and need for revision surgery (p = 0.10). Patient crossover revealed a 4 times greater likelihood of death in patients without ATT interruption prior to surgery (p = 0.040) without an observable impact on secondary outcomes. ATT reversal contributed no improvement in outcomes other than a decreased intensive care unit length of stay when adjusted for in-hospital mortality (p = 0.014). The rate of postoperative thromboembolism following ATT reversal was 11.5%. ATT reinitiation was highly variable, occurring in 59.5% of patients, with median times of 17 and 15 days for antiplatelets and anticoagulants, respectively. CONCLUSIONS: Use of preoperative ATT portends poor clinical outcomes following nonelective SDH evacuation regardless of attempts to reverse these medications with replacement blood products. This study further reinforces the critical need for judicious use of ATT and optimization of reversal strategies in high-risk patient populations as best guided by multidisciplinary teams and evolving clinical practice guidelines.

Congress of Neurological Surgeons systematic review and evidence-based guidelines update on the role of radiation therapy in the management of progressive and recurrent glioblastoma in adults.

TARGET POPULATION: These recommendations apply to adult patients (18 years of age and above) with progressive/recurrent glioblastoma multiforme (pGBM) after first line combined multimodality treatment. QUESTION: Can re-irradiation (by using conventional radiotherapy, fractionated radiosurgery, or single fraction radiosurgery) be used in patients with pGBM after the first adjuvant combined multimodality treatment with radiation and chemotherapy? RECOMMENDATION: Level III: When the target tumor is amenable for additional radiation, re-irradiation is recommended as it provides improved local tumor control, as measured by best imaging response. Such re-irradiation can take the form of conventional fractionation radiotherapy, fractionated radiosurgery, or single fraction radiosurgery. LEVEL III: Re-Irradiation is recommended in order to maintain or improve a patient's neurological status and quality of life prior to any further tumor progression.

Congress of Neurological Surgeons systematic review and evidence-based guidelines update on the role of cytotoxic chemotherapy and other cytotoxic therapies in the management of progressive glioblastoma in adults.

TARGET POPULATION: These recommendations apply to adult patients diagnosed with progressive glioblastoma (pGBM). QUESTION (Q1): In adult patients with pGBM does the use of temozolomide (TMZ) with alternative dosing or the use of TMZ in combination with other cytotoxic treatments result in increased overall survival compared to other chemotherapy? RECOMMENDATION: Level III: Adult patients with pGBM might derive benefit in treatment with TMZ, especially those who progress after more than 5 months of TMZ-treatment free interval. LEVEL III: Combination of TMZ with other cytotoxic agents such as nitrosourea, cisplatin, electrohyperthermia, or tamoxifen is not suggested in adult patients with pGBM as a stand-alone therapy. There is insufficient data to make a recommendation about which alternative TMZ dosing provides the best benefits. QUESTION (Q2): In adult patients with pGBM does the use of systemic or in situ nitrosourea result in increased overall survival compared to other chemotherapy? RECOMMENDATION: Level III: In the setting of pGBM, fotemustine is suggested in elderly patients with methylated MGMT promoter status. There is insufficient evidence to compare fotemustine to other nitrosoureas. There is insufficient evidence to make a recommendation about the use of in situ nitrosourea in patients with pGBM who underwent the Stupp regimen. QUESTION (Q3): In adult patients with pGBM does the use of platinum compounds and topoisomerase result in increased survival compared to other chemotherapy? RECOMMENDATION: Level III: Other chemotherapy including platinum compounds and topoisomerase inhibitors are not suggested to be used in adult patients with pGBM. LEVEL III: Other cytotoxic therapies like perillyl acohol or ketogenic diet are not suggested for use in adult patients with pGBM as a stand-alone therapy. QUESTION (Q4): In adult patients with pGBM does the use of tumor treating field (TTF) result in increased overall survival compared to chemotherapy? RECOMMENDATION: Level III: The use of TTF with other chemotherapy may be considered when treating adult patients with pGBM. There is insufficient evidence to recommend TTF to increase overall survival in adult patients with pGBM. QUESTION (Q5): In adult patients with pGBM does the use of oncolytic virotherapy result in increased survival compared to chemotherapy? RECOMMENDATION: Level III: Oncolytic virotherapy is not suggested in patients with pGBM.

Guidelines in the management of CNS tumors.

INTRODUCTION: Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS). METHODS: The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice. CONCLUSION: This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low grade gliomas, vestibular schwannomas, and metastatic brain tumors.

The role of radiation therapy in treatment of adults with newly diagnosed glioblastoma multiforme: a systematic review and evidence-based clinical practice guideline update.

TARGET POPULATION: These recommendations apply to adult patients diagnosed with newly diagnosed glioblastoma. QUESTION 1 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is the addition of radiation therapy (RT) more beneficial than management without RT in improving survival? RECOMMENDATIONS: Level I: Radiation therapy (RT) is recommended for the treatment of newly diagnosed malignant glioblastoma in adults. QUESTION 2 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is the RT regimen of 60 Gy given in 2 Gy daily fractions more beneficial than alternative regimens in providing survival benefit while minimizing toxicity? RECOMMENDATIONS: Level I: Treatment schemes should include dosage of up to 60 Gy given in 2 Gy daily fractions that includes the enhancing area. QUESTION 3 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, is a tailored target volume superior to regional RT for reduction of radiation-induced toxicity while maintaining efficacy? RECOMMENDATION: Level II: It is recommended that radiation therapy planning include 1-2 cm margin around the radiographically T1 weighted contrast-enhancing tumor volume or the T2 weighted abnormality on MRI. Level III: Recalculation of the radiation volume during RT treatment may be necessary to reduce the radiated volume of normal brain since the volume of surgical defect will change during the long period of RT. QUESTION 4 : In adult patients (aged 65 and under) with newly diagnosed glioblastoma, does the addition of RT of the subventricular zone to standard tumor volume treatment improve tumor control and overall survival? RECOMMENDATION: No recommendation can be formulated as there is contradictory evidence in favor of and against intentional radiation of the subventricular zone (SVZ) QUESTION 5 : In elderly (age > 65 years) and/or frail patients with newly diagnosed glioblastoma, does the addition of RT to surgical intervention improve disease control and overall survival? RECOMMENDATION: Level I: Radiation therapy is recommended for treatment of elderly and frail patients with newly diagnosed glioblastoma to improve overall survival. QUESTION 6 : In elderly (age > 65 years) and/or frail patients with newly diagnosed glioblastoma, does modification of RT dose and fractionation scheme from standard regimens decrease toxicity and improve disease control and survival? RECOMMENDATION: Level II: Short RT treatment schemes are recommended in frail and elderly patients as compared to conventional 60 Gy given in 2 daily fractions because overall survival is not different while RT risk profile is better for the short RT scheme. Level II: The 40.05 Gy dose given in 15 fractions or 25 Gy dose given in 5 fractions or 34 Gy dose given in 10 fractions should be considered as appropriate doses for Short RT treatments in elderly and/or frail patients. QUESTION 7 : In adult patients with newly diagnosed glioblastoma is there advantage to delaying the initiation of RT instead of starting it 2 weeks after surgical intervention in decreasing radiation-induced toxicity and improving disease control and survival? RECOMMENDATION: Level III: It is suggested that RT for patients with newly diagnosed GBM starts within 6 weeks of surgical intervention as compared to later times. There is insufficient evidence to recommend the optimal specific post-operative day within the 6 weeks interval to start RT for adult patients with newly diagnosed glioblastoma that have undergone surgical resection. QUESTION 8 : In adult patients with newly diagnosed supratentorial glioblastoma is Image-Modulated RT (IMRT) or similar techniques as effective as standard regional RT in providing tumor control and improve survival? RECOMMENDATION: Level III: There is no evidence that IMRT is a better RT delivering modality when compared to conventional RT in improving overall survival in adult patients with newly diagnosed glioblastoma. Hence, IMRT should not be preferred over the Conventional RT delivery modality. QUESTION 9 : In adult patients with newly diagnosed glioblastoma does the use of radiosensitizers with RT improve the efficacy of RT as determined by disease control and overall survival? RECOMMENDATION: Level III: Iododeoxyuridine is not recommended to be used as radiosensitizer during RT treatment for patients with newly diagnosed GBM QUESTION 10 : In adult patients with newly diagnosed glioblastoma is the use of Ultrafractionated RT superior to standard fractionation regimens in improving disease control and survival? RECOMMENDATION: There is insufficient evidence to formulate a recommendation regarding the use of ultrafractionated RT schemes and patient population that could benefit from it. QUESTION 11 : In patients with poor prognosis with newly diagnosed glioblastoma is hypofractionated RT indicated instead of a standard fractionation regimen as measured by extent of toxicity, disease control and survival? RECOMMENDATION: Level I: Hypofractionated RT schemes may be used for patients with poor prognosis and limited survival without compromising response. There is insufficient evidence in the literature for us to be able to recommend the optimal hypofractionated RT scheme that will confer longest overall survival and/or confer the same overall survival with less toxicities and shorter treatment time. QUESTION 12 : In adult patients with newly diagnosed glioblastoma is the addition of brachytherapy to standard fractionated RT indicated to improve disease control and survival? RECOMMENDATION: Level I: Brachytherapy as a boost to external beam RT has not been shown to be beneficial and is not recommended in the routine management of patients with newly diagnosed GBM. QUESTION 13 : In elderly patients (> 65 year old) with newly diagnosed glioblastoma under what circumstances is accelerated hyperfractionated RT indicated instead of a standard fractionation regimen as measured by extent of toxicity, disease control and survival? RECOMMENDATION: Level III: Accelerated Hyperfractionated RT with a total RT dose of 45 Gy or 48 Gy has been shown to shorten the treatment time without detriment in survival when compared to conventional external beam RT and should be considered as an option for treatment of elderly patients with newly diagnosed GBM. QUESTION 14 : In adult patients with newly diagnosed glioblastoma is the addition of Stereotactic Radiosurgery (SRS) boost to conventional standard fractionated RT indicated to improve disease control and survival? RECOMMENDATION: Level I: Stereotactic Radiosurgery boost to external beam RT has not been shown to be beneficial and is not recommended in patients undergoing routine management of newly diagnosed malignant glioma.

Neurocognitive functioning in patients with glioma of the left and right temporal lobes.

Patients with glioma frequently suffer from deficits of neurocognitive functioning (NCF), though few studies have assessed NCF in localized glioma patients prior to surgery. One hundred and three patients (M age = 52.0; M education = 14.6 years) with histologically confirmed glioma in the right (RTL: n = 30; 57 % glioblastoma) or left temporal lobe (LTL: n = 73; 49 % glioblastoma) completed presurgical neuropsychological assessment. Impairment of NCF was identified in 75 % of all patients. Notably, patients with RTL glioma were most frequently impaired on measures of verbal memory and executive functioning, and at similar rates as the LTL group. Nonetheless, χ(2) tests revealed that impairment rates were significantly higher in the LTL group on attention and object naming tests (p ≤ .05). Independent-samples t-tests revealed that mean performances of patients with LTL glioma were also significantly below RTL patients on measures of attention (p = .01), verbal learning and memory (p = .05), and language (p < .03). A trend was observed in which anterior LTL tumors were associated with reduced verbal learning and medial LTL lesions with delayed recall problems, though patients with lesions involving multiple LTL regions exhibited the greatest difficulty across all verbal memory measures. Significant group differences in NCF performances remained so after controlling for FLAIR volume and tumor histology. These findings indicate that temporal lobe glioma frequently present with impaired NCF, though impairments are often milder in RTL compared to LTL patients. Nonetheless, the relatively frequent verbal memory impairment in the RTL group underscores the bilaterality of verbal memory processes.

The role of initial chemotherapy for the treatment of adults with diffuse low grade glioma : A systematic review and evidence-based clinical practice guideline.

TARGET POPULATION: Adult patients (older than 18 years of age) with newly diagnosed World Health Organization (WHO) Grade II gliomas (Oligodendroglioma, astrocytoma, mixed oligoastrocytoma). QUESTION: Is there a role for chemotherapy as adjuvant therapy of choice in treatment of patients with newly diagnosed low-grade gliomas? LEVEL III: Chemotherapy is recommended as a treatment option to postpone the use of radiotherapy, to slow tumor growth and to improve progression free survival (PFS), overall survival (OS) and clinical symptoms in adult patients with newly diagnosed LGG. QUESTION: Who are the patients with newly diagnosed LGG that would benefit the most from chemotherapy? LEVEL III: Chemotherapy is recommended as an optional component alone or in combination with radiation as the initial adjuvant therapy for all patients who cannot undergo gross total resection (GTR) of a newly diagnosed LGG. Patient with residual tumor >1 cm on post-operative MRI, presenting diameter of >4 cm or older than 40 years of age should be considered for adjuvant therapy as well. QUESTION: Are there tumor markers that can predict which patients can benefit the most from initial treatment with chemotherapy? LEVEL III: The addition of chemotherapy to standard RT is recommended in LGG patients that carry IDH mutation. In addition, temozolomide (TMZ) is recommended as a treatment option to slow tumor growth in patients who harbor the 1p/19q co-deletion. QUESTION: How soon should the chemotherapy be started once the diagnosis of LGG is confirmed? RECOMMENDATION: There is insufficient evidence to make a definitive recommendation on the timing of starting chemotherapy after surgical/pathological diagnosis of LGG has been made. However, using the 12 weeks mark as the latest timeframe to start adjuvant chemotherapy is suggested. It is recommended that patients be enrolled in properly designed clinical trials to assess the timing of chemotherapy initiation once diagnosis is confirmed for this target population. QUESTION: What chemotherapeutic agents should be used for treatment of newly diagnosed LGG? RECOMMENDATION: There is insufficient evidence to make a recommendation of one particular regimen. Enrollment of subjects in properly designed trials comparing the efficacy of these or other agents is recommended so as to determine which of these regimens is superior. QUESTION: What is the optimal duration and dosing of chemotherapy as initial treatment for LGG? RECOMMENDATION: Insufficient evidence exists regarding the duration of any specific cytotoxic drug regimen for treatment of newly diagnosed LGG. Enrollment of subjects in properly designed clinical investigations assessing the optimal duration of this therapy is recommended. QUESTION: Should chemotherapy be given alone or in conjunction with RT as initial therapy for LGG? RECOMMENDATION: Insufficient evidence exists to make recommendations in this regard. Hence, enrollment of patients in properly designed clinical trials assessing the difference between chemotherapy alone, RT alone or a combination of them is recommended. QUESTION: Should chemotherapy be given in addition to other type of adjuvant therapy to patients with newly diagnosed LGG? RECOMMENDATION: Level II: It is recommended that chemotherapy be added to the RT in patients with unfavorable LGG to improve their progression free survival.

The role of biopsy in the management of patients with presumed diffuse low grade glioma: A systematic review and evidence-based clinical practice guideline.

QUESTION: What is the optimal role of biopsy in the initial management of presumptive low-grade glioma in adults? TARGET POPULATION: Adult patients with imaging suggestive of a low-grade glioma. LEVEL III: Stereotactic biopsy is recommended when definitive surgical resection is limited by lesions that are deep-seated, not resectable, and/or located within eloquent cortex, or in patients unable to undergo craniotomy due to medical co-morbidities to obtain the critical tissue diagnosis needed for targeted treatment planning for patients with low-grade gliomas. QUESTION: What is the best technique for brain biopsy? TARGET POPULATION: Adult patients with imaging suggestive of a low-grade glioma. LEVEL III: Frameless and frame-based stereotactic brain biopsy for low-grade gliomas are recommended based on clinical circumstances as they provide similar diagnostic yield, diagnostic accuracy, morbidity, and mortality. It is recommended the surgeon consider advanced imaging techniques (e.g., perfusion, spectroscopy, metabolic studies) to target specific regions of interest to potentially improve diagnostic accuracy.

Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users.

OBJECT: Primary spine infection secondary to intravenous drug abuse (IVDA) is a difficult clinical entity encountered by spine surgeons and infectious disease specialists. Patients tend to be noncompliant with the treatment and follow-up, and some continue to use IV recreational drugs even after the diagnosis of spine infection. The authors undertook this study to analyze the presentation, etiology, demographic characteristics, treatment, and outcome of primary pyogenic spinal infection in patients with IVDA as the major risk factor. METHODS: The medical records, radiology imaging, and laboratory results (white blood cell count, inflammatory markers, bacteriology cultures) of all patients with pyogenic spine infection and history of IVDA presenting to a tertiary care center from August 2005 through December 2013 were retrospectively reviewed. The department of neurosurgery database and the hospital electronic medical records of University Hospital in San Antonio were used to identify the cohort for our study. RESULTS: A total of 164 patients with spinal infection were evaluated during the study period; 102 of these patients had a history of IVDA. Their average age was 45.4 years, and only 14 (13.7%) were women. The mean laboratory values at presentation included a white blood cell count of 11.1 × 10(3) cells/µl (range 0.5-32 × 10(3) cells/µl), erythrocyte sedimentation rate (ESR) of 74 mm/hr (range 9.9-140 mm/hr), and C-reactive protein (CRP) level of 67 mg/L (range 0.1-327 mg/L). Twenty-six patients (25.4%) had an associated epidural abscess. The most common organism isolated from cultures of the bone and/or blood was methicillin-sensitive Staphylococcus aureus (MSSA), which was found in 37 cases. A close second was methicillin-resistant S. aureus (MRSA), found in 23 cases. The most commonly involved region was the lumbar spine (24 cases [57.8%]), and most patients (69.6%) had involvement of only a single level. Eighty patients were initially treated with long-term IV antibiotic therapy, and only 22 underwent surgical intervention (24 procedures). Of the latter group, 8 patients underwent laminectomy alone while 16 required some type of instrumented stabilization. Of the patients requiring stabilization procedures, 2 (12.5%) required reoperation with extension of their surgical constructs to other levels. The average follow-up was 29.7 weeks (range 6 weeks to 3 years). CONCLUSIONS: Diagnosis and management of spinal infection in patients with a history of IVDA is challenging. The data from this study show that initial laboratory values are difficult to interpret given that only a minority of these patients present with leukocytosis. Back pain was the only reliable predictor of spine infection. The authors' experience indicates that the majority of patients with spine infection and a history of IVDA can be successfully treated with IV antibiotic therapy alone.

Intraoperative Stereotactic Arteriography in Complex Cervical Spine Surgery.

Intra-operative navigation has revolutionized spinal instrumentation. The O-arm (a mobile X-ray system; Medtronic, Minneapolis, MN) is uniquely capable of enabling visualization of the spine in axial planes. The application of this technology is wide yet underutilized in terms of its capacity to image spinal vascular anatomy. We completed a retrospective chart review of the following case studies. A 24-year-old neurologically intact female presented with a Jefferson fracture without vertebral artery dissection after a motor vehicle accident. After the failure of conservative management due to pseudoarthrosis, the patient opted for fusion. Prior to the procedure, bilateral 5 French femoral sheaths were placed. After exposure, intraarterial (IA) contrast was injected prior to the O-arm spin to visualize both vertebral arteries, which were stretched and adjacent to a mobile boney segment. In the second case, a 71-year-old male presented with right shoulder pain and a flaccid left deltoid secondary to a large enhancing epidural lesion spanning C4-C7. Further work-up confirmed a diagnosis of metastatic intrahepatic cholangiocarcinoma. Prior to resection with cervical spinal stabilization, a right radial artery 4 French Glidesheath was placed. Prior to the O-arm spin, the right vertebral artery was selected, and intravenous contrast was injected to permit visualization of the vertebral artery, which was encased within the tumor and at significant risk for iatrogenic injury. Both patients tolerated the endovascular and spinal procedures well without vertebral artery injury. This is the first series to report the effective use of the O-arm for improved visualization of vascular anatomy during surgery for cervical spinal trauma and oncology.

Systematic Review of WHO Grade 4 Astrocytoma in the Cerebellopontine Angle: The Impact of Anatomic Corridor on Treatment Options and Outcomes.

Background Despite advances in multimodal oncologic therapies and molecular genetics, overall survival (OS) in patients with high-grade astrocytomas remains poor. We present an illustrative case and systematic review of rare, predominantly extra-axial World Health Organization (WHO) grade 4 astrocytomas located within the cerebellopontine angle (CPA) and explore the impact of anatomic location on diagnosis, management, and outcomes. Methods A systematic review of adult patients with predominantly extra-axial WHO grade 4 CPA astrocytomas was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines through December 2022. Results Eighteen articles were included comprising 21 astrocytomas: 13 exophytic tumors arising from the cerebellopontine parenchyma and 8 tumors originating from a cranial nerve root entry zone. The median OS was 15 months with one-third of cases demonstrating delayed diagnosis. Gross total resection, molecular genetic profiling, and use of ancillary treatment were low. We report the only patient with an integrated isocitrate dehydrogenase 1 (IDH-1) mutant diagnosis, who, after subtotal resection and chemoradiation, remains alive at 40 months without progression. Conclusion The deep conical-shaped corridor and abundance of eloquent tissue of the CPA significantly limits both surgical resection and utility of device-based therapies in this region. Prompt diagnosis, molecular characterization, and systemic therapeutic advances serve as the predominant means to optimize survival for patients with rare skull base astrocytomas.

Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures.

Cerebrospinal fluid rhinorrhea is a serious and potentially fatal condition because of an increased risk of meningitis and brain abscess. Approximately 80% of all cases occur in patients with head injuries and craniofacial fractures. Despite technical advances in the diagnosis and management of CSF rhinorrhea caused by craniofacial injury through the introduction of MRI and endoscopic extracranial surgical approaches, difficulties remain. The authors review here the pathophysiology, diagnosis, and management of CSF rhinorrhea relevant exclusively to traumatic anterior skull base injuries and attempt to identify areas in which further work is needed.

Intradural Extramedullary Hemangioblastoma of the Cervical Spine: Case Report and Literature Review.

Hemangioblastomas are uncommon in the spine, accounting for less than 3% of all spinal cord tumors and occurring even more rarely in the intradural extramedullary vicinity. We present a unique case report of an intradural extramedullary hemangioblastoma. A 62-year-old man presented with a five-month history of neck pain radiating to the left arm. A magnetic resonance imaging (MRI) of the cervical spine revealed a left paracentral contrast-enhancing intradural extramedullary lesion at the C4-C5 level. Surgical options were discussed, and surgery was performed via a posterolateral approach. The lateral masses and facets at the C4 and C5 levels were drilled and the tumor was encountered ventral to the spinal cord. There were multiple nerve roots adherent to the tumor capsule. The tumor was highly vascularized. Analysis revealed a highly vascular lesion with vacuolated tumor cells, positive for inhibin and S100 stains, consistent with a diagnosis of hemangioblastoma. The patient remains intact throughout the post-operative period. Few studies have reported intradural extramedullary spinal hemangioblastomas and purely extramedullary spinal hemangioblastomas of the neuraxis are far less common. Most cases occur in the Japanese population and in patients over the age of 50. By location, extramedullary hemangioblastomas involving the thoracic spine occur in women, while those occurring in men are restricted to the cervical spine or conus medullaris. Complete resection remains the treatment of choice.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Management of Progressive Glioblastoma in Adults: Update of the 2014 Guidelines.

BACKGROUND: The Institute of Medicine best practice recommendation to review guidelines every 5 years is followed by the Congress of Neurological Surgeons Guidelines Committee. The aim of this work was to provide an updated literature review and evidence-based recommendations on the topic of diagnosis and treatment of patients with progressive glioblastoma (pGBM). OBJECTIVE: To review the literature published since the last guidelines on pGBM dated 2014, with literature search ending in June 2012. METHODS: PubMed, Embase, and Cochrane were searched for the period July 1, 2012, to March 31, 2019, using search terms and search strategies to identify pertinent abstracts. These were then screened using published exclusion/inclusion criteria to identify full-text review articles. Evidence tables were constructed using data derived from full-text reviews and recommendations made from the evidence derived. RESULTS: From the total 8786 abstracts identified by the search, 237 full-text articles met inclusion/exclusion criteria and were included in this update. Two new level II recommendations derived from this work. For the diagnosis of patients with GBM, the use of diffusion-weighted images is recommended to be included in the magnetic resonance images with and without contrast used for surveillance to detect pGBM. For the treatment of patients with pGBM, repeat cytoreductive surgery is recommended to improve overall survival. An additional 21 level III recommendations were provided. CONCLUSION: Recent published literature provides new recommendations for the diagnosis and treatment of pGBM. The Central Nervous System Guidelines Committee will continue to pursue timely updates to further improve the care of patients with diagnosis.https://www.cns.org/guidelines/browse-guidelines-detail/guidelines-management-of-progressive-glioblastoma.

Therapy for Diffuse Astrocytic and Oligodendroglial Tumors in Adults: ASCO-SNO Guideline.

PURPOSE: To provide guidance to clinicians regarding therapy for diffuse astrocytic and oligodendroglial tumors in adults. METHODS: ASCO and the Society for Neuro-Oncology convened an Expert Panel and conducted a systematic review of the literature. RESULTS: Fifty-nine randomized trials focusing on therapeutic management were identified. RECOMMENDATIONS: Adults with newly diagnosed oligodendroglioma, isocitrate dehydrogenase (IDH)-mutant, 1p19q codeleted CNS WHO grade 2 and 3 should be offered radiation therapy (RT) and procarbazine, lomustine, and vincristine (PCV). Temozolomide (TMZ) is a reasonable alternative for patients who may not tolerate PCV, but no high-level evidence supports upfront TMZ in this setting. People with newly diagnosed astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 2 should be offered RT with adjuvant chemotherapy (TMZ or PCV). People with astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 should be offered RT and adjuvant TMZ. People with astrocytoma, IDH-mutant, CNS WHO grade 4 may follow recommendations for either astrocytoma, IDH-mutant, 1p19q non-codeleted CNS WHO grade 3 or glioblastoma, IDH-wildtype, CNS WHO grade 4. Concurrent TMZ and RT should be offered to patients with newly diagnosed glioblastoma, IDH-wildtype, CNS WHO grade 4 followed by 6 months of adjuvant TMZ. Alternating electric field therapy, approved by the US Food and Drug Administration, should be considered for these patients. Bevacizumab is not recommended. In situations in which the benefits of 6-week RT plus TMZ may not outweigh the harms, hypofractionated RT plus TMZ is reasonable. In patients age ≥ 60 to ≥ 70 years, with poor performance status or for whom toxicity or prognosis are concerns, best supportive care alone, RT alone (for MGMT promoter unmethylated tumors), or TMZ alone (for MGMT promoter methylated tumors) are reasonable treatment options. Additional information is available at www.asco.org/neurooncology-guidelines.

Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline.

PURPOSE: This guideline provides updated evidence-based recommendations addressing recent developments in the management of patients with brain metastases, including advanced radiation therapy techniques such as stereotactic radiosurgery (SRS) and hippocampal avoidance whole brain radiation therapy and the emergence of systemic therapies with central nervous system activity. METHODS: The American Society for Radiation Oncology convened a task force to address 4 key questions focused on the radiotherapeutic management of intact and resected brain metastases from nonhematologic solid tumors. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS: Strong recommendations are made for SRS for patients with limited brain metastases and Eastern Cooperative Oncology Group performance status 0 to 2. Multidisciplinary discussion with neurosurgery is conditionally recommended to consider surgical resection for all tumors causing mass effect and/or that are greater than 4 cm. For patients with symptomatic brain metastases, upfront local therapy is strongly recommended. For patients with asymptomatic brain metastases eligible for central nervous system-active systemic therapy, multidisciplinary and patient-centered decision-making to determine whether local therapy may be safely deferred is conditionally recommended. For patients with resected brain metastases, SRS is strongly recommended to improve local control. For patients with favorable prognosis and brain metastases receiving whole brain radiation therapy, hippocampal avoidance and memantine are strongly recommended. For patients with poor prognosis, early introduction of palliative care for symptom management and caregiver support are strongly recommended. CONCLUSIONS: The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care.

A Crowdsourced Consensus on Supratotal Resection Versus Gross Total Resection for Anatomically Distinct Primary Glioblastoma.

BACKGROUND: Gross total resection (GTR) of contrast-enhancing tumor is associated with increased survival in primary glioblastoma. Recently, there has been increasing interest in performing supratotal resections (SpTRs) for glioblastoma. OBJECTIVE: To address the published results, which have varied in part due to lack of consensus on the definition and appropriate use of SpTR. METHODS: A crowdsourcing approach was used to survey 21 neurosurgical oncologists representing 14 health systems nationwide. Participants were presented with 11 definitions of SpTR and asked to rate the appropriateness of each definition. Participants reviewed T1-weighed postcontrast and fluid-attenuated inversion-recovery magnetic resonance imaging for 22 anatomically distinct glioblastomas. Participants were asked to assess the tumor location's eloquence, the perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans. RESULTS: Most neurosurgeons surveyed (n = 18, 85.7%) agree that GTR plus resection of some noncontrast enhancement is an appropriate definition for SpTR. Overall, moderate inter-rater agreement existed regarding eloquence, equipoise, and personal treatment plans. The 4 neurosurgeons who had performed >10 SpTRs for glioblastomas in the past year were more likely to recommend it as their treatment plan (P < .005). Cases were divided into 3 anatomically distinct groups based upon perceived eloquence. Anterior temporal and right frontal glioblastomas were considered the best randomization candidates. CONCLUSION: We established a consensus definition for SpTR of glioblastoma and identified anatomically distinct locations deemed most amenable to SpTR. These results may be used to plan prospective trials investigating the potential clinical utility of SpTR for glioblastoma.

Isolated spinal neurenteric cyst presenting as intramedullary calcified cystic mass on imaging studies: case report and review of literature.

Intramedullary neurenteric cysts (NEC) without associated malformations are extremely rare and, to our knowledge, have never been reported in association with calcification. We report a unique imaging presentation as a partially calcified mass of an isolated intramedullary neuroenteric cyst of the lower thoracic spinal cord with pathologic correlation. The literature for isolated forms of intramedullary NEC since the advent of magnetic resonance imaging is also reviewed.

Contract Negotiation for Neurosurgeons: A Practical Guide.

Contract negotiation is a reality in the career of any neurosurgeon. However, little formal training exists for physicians - including neurosurgeons - on potential techniques and strategies for conducting meaningful contract negotiation. Increasing numbers of neurosurgeons seek hospital employment for which an employment contract will be provided. During contract negotiation, it is likely that a young neurosurgeon will be in discussion with an experienced negotiator acting on behalf of a hospital, practice, or department. Understanding and adapting to this imbalance in experience and using basic negotiating techniques as a means of approaching and resolving key contract issues is critical for the neurosurgeon to maximize his or her value in the course of contract negotiation. Even without formal training in negotiation in residency, negotiation skills can be taught, practiced, and improved. In affiliation with the Medical Director's Ad-Hoc Representational Section of Council of State Neurosurgical Societies (CSNS) this article is intended to serve as a practical guide for contract negotiation. Contract basics, negotiation terms, strategies, unique neurosurgical issues, and value creation are explored.