Surgical management of anterior clinoidal meningiomas: consensus statement on behalf of the EANS skull base section.

BACKGROUND: The optimal management of clinoidal meningiomas (CMs) continues to be debated. METHODS: We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of these tumors. The data from the literature along with contemporary practice patterns were discussed within the task force to generate consensual recommendations. RESULTS AND CONCLUSION: This article represents the consensus opinion of the task force regarding pre-operative evaluations, patient's counselling, surgical classification, and optimal surgical strategy. Although this analysis yielded only Class B evidence and expert opinions, it should guide practitioners in the management of patients with clinoidal meningiomas and might form the basis for future clinical trials.

Petroclival meningiomas: update of current treatment and consensus by the EANS skull base section.

BACKGROUND: The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist. METHODS: A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group. RESULTS: The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient's counselling. CONCLUSION: This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

Imaging of the spine and spinal cord: An overview of magnetic resonance imaging (MRI) techniques.

This review will discuss conventional and advanced magnetic resonance (MRI) imaging techniques used to study the spine and spinal cord according to the anatomical structures and clinical indications. Clinical challenges that neuroradiologists may face are also discussed, such as the "when" and "where" concerning the use of each technique, and in which pathology or clinical scenario each technique is useful. Finally, some "tips and tricks" to overcome the challenges are provided with clinical examples.

Surgical management of colloid cyst of the third ventricle.

BACKGROUND: The aim of this study of third ventricular colloid cysts (TVCC) from a defined population was to estimate the incidence, the presenting features, the surgical treatment, the treatment related complications, and the clinical and surgical outcomes. METHODS: A reprospective study of 32 consecutive primary surgeries for TVCC was performed at Oslo University Hospital in the time period 2002-2015. RESULTS: The estimated incidence rate for TVCC was 0.9 per million. Mean age was 41 years and the male-to-female ratio was 1:1.5. The most common presenting symptoms were headache (100%), ataxia (25%), reduced level of consciousness (22%), and impaired vision (19%). The surgical mortality was 0%. Gross total resection (GTR) was achieved in 69% based on intraoperative findings and in 81% based on postoperative imaging. The rate of surgery-related complications was 13%. There was no statistically significant difference between microsurgery and endoscopic surgery with respect to surgery-related complications and grade of resection. At time of follow-up, all patients were able to care for themselves. CONCLUSIONS: Due to the risk of acute neurological deterioration and sudden death, surgical treatment is recommended for patients with symptomatic TVCC. This study shows that surgical resection can be performed with a fairly low risk and with a good long-term outcome.

Are melanomas averse to cerebellum? Cerebellar metastases in a surgical series.

OBJECTIVES: To study the propensity of different cancers to metastasize to the cerebrum and cerebellum, and to study overall survival (OS) and prognostic factors for patients after surgical resection for cerebellar metastases. MATERIALS AND METHODS: From a prospectively collected tumor database, all patients that underwent a craniotomy for intracranial metastases between 2003 and 2011 at Oslo University Hospital were included. RESULTS: One hundred and forty patients underwent resection for cerebellar metastases. Most common primary tumor sites were lung, colon/rectum, and breast in 45%, 19%, and 14%, respectively. None were prostate cancers. Melanoma metastases were significantly underrepresented, and colorectal cancer metastases significantly overrepresented in cerebellum, compared to the overall proportion of cerebellar/supratentorial metastases surgically resected (P < 0.05). Thirty-day post-operative mortality rate was 4.3%. Median OS was 7.7 months (95% CI 6.0-9.5 months) irrespective of post-operative adjuvant therapy. Median OS was 51.8, 8.4, and 3.4 months, respectively, for recursive partitioning analysis class 1(n = 11), 2 (n = 78) and 3 (n = 34). Significant negative prognostic factors were age ≥65 years, Karnofsky performance score (KPS) <70, extracranial metastases and uncontrolled systemic disease. CONCLUSIONS: Melanoma metastases were significantly underrepresented in cerebellum, whereas colorectal cancer metastases were significantly overrepresented. Surgical mortality and OS after surgical treatment of cerebellar metastases were similar to the results of supratentorial metastases.

Non-technical skills for neurosurgeons: An international survey.

Introduction: Neurosurgery is considered a technically demanding specialty; nonetheless, it also requires non-technical skills (NTSs) to reach mastery. Research question: This study seeks to understand how important NTSs are perceived by neurosurgeons across diverse roles and socio-economic backgrounds. The objective is to identify key NTSs and explore their role in surgical precision, teamwork, and collaboration. Material and method: An international survey involving 372 neurosurgeons from various socio-economic and cultural contexts was conducted. The extensive sample and inclusive methodology provide a comprehensive perspective on the perceived importance of NTSs in neurosurgery. Results: The survey results highlight the universal significance of NTSs among neurosurgeons. Attention to detail, humility, and self-awareness are considered essential for surgical precision, effective teamwork, and collaboration. The findings underscore the necessity for integrated training programs that combine NTSs with technical skills. Discussion and conclusion: The study emphasizes the importance of effective training methods such as simulations, mentorship, and role-playing in equipping neurosurgeons to navigate the complexities of their profession. Future research should focus on optimizing teaching methods for NTSs, comparing traditional courses, online modules, and hybrid training programs. Addressing the global disparity in neurosurgical care, particularly in low- and middle-income countries, is crucial for improving patient outcomes worldwide.

Surgery for high-grade gliomas in the aging.

OBJECTIVE: High-grade glioma (HGG) is the commonest primary brain tumor in adults. We prospectively assessed outcome following surgery and adjuvant treatment for HGG in older patients. MATERIALS AND METHODS: Patients ≥ 60 years undergoing craniotomies for gliomas WHO grade 3 and 4 at Oslo and Haukeland University Hospitals 2008-2009 were included (n = 80). Outcome was assessed at six months, and overall mortality evaluated at two years. RESULTS: Forty-two males and 38 females of median age 68.5 (60-83) years were included, 35% attended a follow-up appointment at six months. Surgical mortality was 1.3%. Surgical morbidity included neurological sequela (10%), post-operative hematomas (3.8%) and hydrocephalus (1.3%). Median overall survival was 8.4 months and significantly increased by adjuvant radiochemotherapy. In univariate survival analyses, age ≥ 80 years, subtotal resection, American Society of Anesthesiology (ASA) scores 3-4, Karnofsky performance scale (KPS) < 70, and mini-mental state examination (MMSE) score < 25 significantly reduced survival. CONCLUSIONS: Surgical treatment of HGG carries low mortality and acceptable morbidity in patients aged ≥ 60 years. There is improved survival following bimodal adjuvant treatment. Maximum tumor resection should be attempted. Treatment might be less beneficial in patients aged ≥ 80 years and in those with poor pre-operative function.

Outcome following surgery for intracranial meningiomas in the aging.

OBJECTIVE: To prospectively assess mortality, morbidity and the functional and symptomatic outcome following intracranial surgery for meningiomas in elderly patients at two neurosurgical institutions in Norway. METHODS: Patients ≥60 years who underwent craniotomies for intracranial meningiomas at Oslo University Hospital and Haukeland University Hospital in 2008 and 2009 were included (n = 54). Outcome was assessed at 6 months. RESULTS: Thirty-five females and 19 males of median age 70 (60-84) years were assessed pre- and post-operatively, 87% attended follow-up at 6 months. The surgical mortality rate was 5.6% at 30 days and 7.4% at 3 and 6 months. The rates of complications were: post-operative hematomas 5.6%, deep venous thrombosis 1.9%, osteitis 1.9%, cerebrospinal fluid disturbances 13.0% and neurological sequelae 13.0%. Surgery resulted in a significant improvement in the MMSE score, with a further 14.9% obtaining scores of ≥25 without a significant change in the level of independence according to the Karnofsky performance scale. QoL assessments showed good functioning post-operatively compared to other cancer patient groups, yet slightly reduced when compared to data from the general population. CONCLUSION: In our series, we found that meningioma surgery in the aging patient carries a higher risk of mortality and morbidity compared to intracranial tumor surgery in general. Our findings indicate, however, that the survivors have improved cognitive function and acceptable QoL, and we did not see any significant decrease in the proportion of independent patients according to the KPS.

Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section.

Introduction: Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery. Research question: Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection. Material and methods: A PRISMA based literature search was performed to select the most relevant papers on the topic. Results: Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery. Discussion and conclusion: This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.

Craniotomy for brain metastases: a consecutive series of 316 patients.

OBJECTIVE: To assess the incidence of craniotomy for brain metastases, overall survival (OS), surgical mortality, and prognostic factors in a large, contemporary, consecutive series from a well-defined catchment area. MATERIAL AND METHODS: All patients ≥ 18 years who underwent craniotomies for intracranial metastases at Oslo University Hospital, Rikshospitalet and Ullevål, between 2005 and June 30, 2009 were included (n = 316). Patients were identified from our prospectively collected database and a thorough review of all charts to validate the entered data was performed. RESULTS: The annual incidence of first-time craniotomy for a brain metastasis was 2.6/100,000 inhabitants. Patient age ranged from 25 to 87 years (median 64 years). The 30-day mortality rate was 3.8%. Median OS was 9.2 months. Recursive partitioning analysis was class I in 19.6%, class II in 59.2%, and class III in 21.2% with median OS of 16.2, 8.9, and 5.6 months, respectively (P < 0.001). Lung cancer and melanoma were associated with a higher risk (>1% per year) of developing brain metastases. Significant negative prognostic factors were age ≥ 65, a poor performance score, unstable extracranial disease, presence of extracranial metastases, multiplicity, metastasis in eloquent area, and no post-operative radiotherapy. CONCLUSIONS: In this population study, the annual incidence of a first-time craniotomy for a brain metastasis was 2.6/100,000, the 30-day mortality rate was 3.8%, and median OS was 9.2 months. The well-known prognostic factors were confirmed.

Executive functions after orbital or lateral prefrontal lesions: neuropsychological profiles and self-reported executive functions in everyday living.

OBJECTIVE: This study examined the effects of chronic focal lesions to the lateral prefrontal cortex (LPFC) or orbitofrontal cortex (OFC) on neuropsychological test performance and self-reported executive functioning in everyday living. METHODS: Fourteen adults with OFC lesions were compared to 10 patients with LPFC injuries and 21 healthy controls. Neuropsychological tests with emphasis on measures of cognitive executive function were administered along with the Behavior Rating Inventory of Executive Functions (BRIEF-A) and a psychiatric screening instrument. RESULTS: The LPFC group differed from healthy controls on neuropsychological tests of sustained mental effort, response inhibition, working memory and mental switching, while the BRIEF-A provided more clinically important information on deficits in everyday life in the OFC group compared to the LPFC group. Correlations between neuropsychological test results and BRIEF-A were weak, while the BRIEF-A correlated strongly with emotional distress. CONCLUSIONS: It was demonstrated that LPFC damage is particularly prone to cause cognitive executive deficit, while OFC injury is more strongly associated with self-reported dysexecutive symptoms in everyday living. The study illustrates the challenge of identifying executive deficit in individual patients and the lack of strong anatomical specificity of the currently employed methods. There is a need for an integrative methodological approach where standard testing batteries are supplemented with neuropsychiatric and frontal-specific rating scales.

Molecular cytogenetic analysis of a gliosarcoma with osseous metaplasia.

Gliosarcoma, a rare glioblastoma variant, is composed of a glial and a mesenchymal component. Though the mesenchymal portion most commonly resembles a fibrosarcoma, other differentiation patterns have been observed. We present the first genomic characterisation (karyotyping followed by FISH and array comparative genomic hybridisation analysis) of a gliosarcoma with osseous metaplasia. In addition to chromosomal changes often found in gliomas (+7, -10, -13, and -22), the tumour cells also harboured a hitherto unknown t(3;21)(q13∼21;q21∼22).

Is Contrast Medium Really Needed for Follow-up MRI of Untreated Intracranial Meningiomas?

BACKGROUND AND PURPOSE: Recent concerns relating to tissue deposition of gadolinium are favoring the use of noncontrast MR imaging whenever possible. The purpose of this study was to assess the necessity of gadolinium contrast for follow-up MR imaging of untreated intracranial meningiomas. MATERIALS AND METHODS: One-hundred twenty-two patients (35 men, 87 women) with meningiomas who underwent brain MR imaging between May 2007 and May 2019 in our institution were included in this retrospective cohort study. We analyzed 132 meningiomas: 73 non-skull base (55%) versus 59 skull base (45%), 93 symptomatic (70%) versus 39 asymptomatic (30%). Fifty-nine meningiomas underwent an operation: 54 World Health Organization grade I (92%) and 5 World Health Organization grade II (8%). All meningiomas were segmented on T1 3D-gadolinium and 2D-T2WI. Agreement between T1 3D-gadolinium and 2D-T2WI segmentations was assessed by the intraclass correlation coefficient. RESULTS: The mean time between MR images was 1485 days (range, 760-3810 days). There was excellent agreement between T1 3D-gadolinium and T2WI segmentations (P < .001): mean tumor volume (T1 3D-gadolinium: 9012.15 [SD, 19,223.03] mm3; T2WI: 8528.45 [SD, 18,368.18 ] mm3; intraclass correlation coefficient = 0.996), surface area (intraclass correlation coefficient = 0.989), surface/volume ratio (intraclass correlation coefficient = 0.924), maximum 3D diameter (intraclass correlation coefficient = 0.986), maximum 2D diameter in the axial (intraclass correlation coefficient = 0.990), coronal (intraclass correlation coefficient = 0.982), and sagittal planes (intraclass correlation coefficient = 0.985), major axis length (intraclass correlation coefficient = 0.989), minor axis length (intraclass correlation coefficient = 0.992), and least axis length (intraclass correlation coefficient = 0.988). Tumor growth also showed good agreement (P < .001), estimated as a mean of 461.87 [SD, 2704.1] mm3/year on T1 3D-gadolinium and 556.64 [SD, 2624.02 ] mm3/year on T2WI. CONCLUSIONS: Our results show excellent agreement between the size and growth of meningiomas derived from T1 3D-gadolinium and 2D-T2WI, suggesting that the use of noncontrast MR imaging may be appropriate for the follow-up of untreated meningiomas, which would be cost-effective and avert risks associated with contrast media.

Overall survival, prognostic factors, and repeated surgery in a consecutive series of 516 patients with glioblastoma multiforme.

OBJECTIVES: To study overall survival (OS), prognostic factors, and repeated surgery in glioblastoma multiforme (GBM). MATERIAL AND METHODS: Retrospective study of 516 consecutive adult patients who underwent primary surgery for a GBM in year 2003-2008. RESULTS: Median age at primary surgery was 63.7 years (range 18.0-88.0). Median OS was 9.9 months. Age > 60 years, poor preoperative ECOG score, bilateral tumor, biopsy rather than resection, and no temozolomide chemoradiotherapy were negative risk factors. Repeat surgery was performed in 65 patients (13%). Median time between first and second surgery was 7 months. Indications for second surgery were increasing neurological deficits (35.4%), raised ICP (33.8%), asymptomatic but reoperated because of tumor progression verified on MRI (20.0%), and epileptic seizures (11%). Patients who underwent repeated surgery had longer OS; 18.4 months vs 8.6 months (P < 0.001). CONCLUSIONS: OS for adult GBM patients was 9.9 months. Negative prognostic factors were increasing age, poor neurological function, bilateral tumor involvement, biopsy instead of resection, and RT alone compared to temozolomide chemoradiotherapy. Our rate of repeated surgery for GBM was 13% and the main indications for second surgery were raised ICP and increasing neurological deficits. In a carefully selected group of patients, repeat surgery significantly prolongs OS.

The Perplexity Surrounding Chiari Malformations - Are We Any Wiser Now?

Chiari malformations are a diverse group of abnormalities of the brain, craniovertebral junction, and the spine. Chiari 0, I, and 1.5 malformations, likely a spectrum of the same malformation with increasing severity, are due to the inadequacy of the para-axial mesoderm, which leads to insufficient development of occipital somites. Chiari II malformation is possibly due to nonclosure of the caudal end of the neuropore, with similar pathogenesis in the rostral end, which causes a Chiari III malformation. There have been significant developments in the understanding of this complex entity owing to insights into the pathogenesis and advancements in imaging modalities and neurosurgical techniques. This article aims to review the different types and pathophysiology of the Chiari malformations, along with a description of the various associated abnormalities. We also highlight the role of ante- and postnatal imaging, with a focus on the newer techniques in the presurgical evaluation, with a brief mention of the surgical procedures and the associated postsurgical complications.

Intracranial tumor surgery in patients >70 years of age: is clinical practice worthwhile or futile?

OBJECTIVES: To study survival and functional outcome after intracranial tumor surgery in elderly patients. MATERIALS AND METHODS: This is a retrospective study of 289 consecutive patients of age > or =70 years, who underwent primary surgery (resection or biopsy) in the time period 2003-2007 for an intracranial tumor (87 astrocytomas, 79 meningiomas, 62 brain metastases, 33 pituitary adenomas and 28 other tumors). RESULTS: The surgical mortality was 2.8%. Overall survival at 6 months, 1, 2 and 5 years was 73%, 57%, 46% and 38% respectively. Histology, pre-operative Eastern Cooperative Oncology Group (ECOG) performance score and resection, as opposed to biopsy, were significantly associated with survival. Gender, age and American Association of Anaesthetists (ASA) score were not significantly related to survival. One-year survival after surgery for astrocytoma, meningioma, brain metastases and pituitary adenoma were 24%, 94%, 31% and 96% respectively. More than 85% of the patients who were alive 6 months after surgery had a stable or improved ECOG score compared with their pre-operative score. CONCLUSIONS: Surgery for intracranial tumors in selected elderly patients is worthwhile, not futile. Age alone should not be used as a selection criterion for treatment.

Malignant granular cell tumor of the skull base.

OBJECTIVE AND IMPORTANCE: Malignant granular cell tumors (MGCTs) are extremely rare, high-grade sarcomas of Schwann cell origin. They often metastasize and are associated with short survival. We describe a patient with a large MGCT arising from the suboccipital nerve that eroded the posterior skull base, invaded the perifocal neck muscles, demonstrated perineural extension, and metastasized to regional lymph nodes. CLINICAL PRESENTATION: A 60-year-old woman with several years' history of neck pain noticed a right-sided suboccipital swelling 4 months prior to seeking medical attention. Magnetic resonance imaging (MRI) showed a 5-cm bone-eroding suboccipital tumor and a second tumor, anterocaudal to this, 4 cm in diameter. INTERVENTION: The patient underwent surgery. A 4-cm multinodular tumor was removed, freeing it from the internal jugular vein. A 5-cm suboccipital tumor infiltrated the trapezius, semispinalis capitis, and longissimus capitis muscles. The major and minor rectus capitis muscles were completely engulfed by tumor and their attachments to the occipital bone completely eroded. The oblique capitis muscle was infiltrated at its attachment to the C1 transverse process. These muscles were resected with a free margin to remove all tumor tissue. We then removed tumor encasing the right vertebral artery, the medial mastoid process up to the transverse sinus and anteriorly to the stylomastoid foramen, and lastly, the posterior third of the occipital condyle, achieving a gross total removal and no visible residual on postoperative contrast-enhanced MRI. CONCLUSION: This case represents the first report of resected primary MGCT involving the posterior fossa and arising from the suboccipital nerve.

Growth hormone deficiency in adults: the role of replacement therapy.

Although growth hormone has been in clinical use for almost 40 years to promote linear growth in children with growth hormone deficiency, replacement therapy in adults was previously not deemed clinically indicated. However, intensive research over the past decade has led to important advances in our medical knowledge and improvements in the care for patients with growth hormone deficiency. Well-controlled clinical trials have demonstrated beneficial effects of replacement therapy with recombinant human prion-free growth hormone (rhGH; somatropin). The most important restoration parameters include reduction of cardiovascular risk factors and improved lipid profile, normalised body composition, improved exercise capacity and bone mass, as well as enhanced psychological well-being. Some important issues regarding growth hormone deficiency and long term somatropin treatment are unresolved, such as diagnostic criteria and the potential for malignancy and impaired glucose tolerance. Furthermore, the effect on hard end-points such as life expectancy or vertebral fracture rate is unknown, but is expected to emerge from physician-managed, multinational databases. Consequently, at this point somatropin therapy should be given in conjunction with clinical trials.

Growth hormone deficiency in adults: a review.

For more than 35 years, growth hormone (GH) has been used to promote linear growth in GH-deficient children. Previously, GH replacement in adults was limited to the supply of human pituitary-derived GH. In addition, until recently, GH replacement was not deemed clinically indicated. With the introduction of recombinant human prion-free GH, replacement therapy in GH-deficient adults has become feasible, and its use has burgeoned. In this review, recent studies on GH therapy in healthy and GH-deficient adults are evaluated to provide a rational basis for the widened scope of its clinical application.