The state of art of awake craniotomy in Latin American countries: a scoping review.

BACKGROUND AND OBJECTIVE: Awake craniotomy (AC) is a valuable technique for surgical interventions in eloquent areas, but its adoption in low- and middle-income countries faces challenges like limited infrastructure, trained personnel shortage, and inadequate funding. This scoping review explores AC techniques in Latin American countries, focusing on patient characteristics, tumor location, symptomatology, and outcomes. METHODS: A scoping review followed PRISMA guidelines, searching five databases in English, Spanish, and Portuguese. We included 28 studies with 258 patients (mean age: 43, range: 11-92). Patterns in AC use in Latin America were analyzed. RESULTS: Most studies were from Brazil and Mexico (53.6%) and public institutions (70%). Low-grade gliomas were the most common lesions (55%), most of them located in the left hemisphere (52.3%) and frontal lobe (52.3%). Gross-total resection was achieved in 34.3% of cases. 62.9% used an Asleep-Awake-Asleep protocol, and 14.8% used Awake-Awake-Awake. The main complication was seizures (14.6%). Mean post-surgery discharge time was 68 h. Challenges included limited training, infrastructure, and instrumentation availability. Strategies discussed involve training in specialized centers, seeking sponsorships, applying for awards, and multidisciplinary collaborations with neuropsychology. CONCLUSION: Improved accessibility to resources, infrastructure, and adequate instrumentation is crucial for wider AC availability in Latin America. Despite disparities, AC implementation with proper training and teamwork yields favorable outcomes in resource-limited centers. Efforts should focus on addressing challenges and promoting equitable access to this valuable surgical technique in the region.

Supervised machine learning to validate a novel scoring system for the prediction of disease remission of functional pituitary adenomas following transsphenoidal surgery.

Functional pituitary adenomas (FPAs) are associated with hormonal hypersecretion resulting in systemic endocrinopathies and increased mortality. The heterogenous composition of the FPA population has made modeling predictive factors of postoperative disease remission a challenge. Here, we aim to define a novel scoring system predictive of disease remission following transsphenoidal surgery (TSS) for FPAs and validate our process using supervised machine learning (SML). 392 patients with FPAs treated at one of the three Mayo Clinic campuses were retrospectively reviewed. Variables found significant on multivariate analysis were incorporated into our novel Pit-SCHEME score. The Pit-SCHEME score with a cut-off value ≥ 6 achieved a sensitivity of 86% and positive likelihood ratio of 2.88. In SML models, without the Pit-SCHEME score, the k-nearest neighbor (KNN) model achieved the highest accuracy at 75.6%. An increase in model sensitivity was achieved with inclusion of the Pit-SCHEME score with the linear discriminant analysis (LDA) model achieving an accuracy of 86.9%, which suggests the Pit-SCHEME score is the variable of most importance for prediction of postoperative disease remission. Ultimately, these results support the potential clinical utility of the Pit-SCHEME score and its prospective future for aiding in the perioperative decision making in patients with FPAs.

Endoscopic Endonasal Approach for Resection of a Recurrent Craniopharyngioma: Techniques to Maximize Surgical Exposure and Extent of Resection.

Craniopharyngiomas are challenging tumors of the central nervous system that originate from epithelial remnants of the Rathke pouch.1-3 Despite maximum safe resection, these tumors present a high tendency to recur (∼20%-40%), even after apparent gross total resection.1,2 The management of recurrent craniopharyngiomas is more challenging, associated with a higher risk of permanent morbidity and complications.1,3 The endoscopic endonasal approach is an option for recurrent tumors, especially in the presence of a previous transcranial approach.1,3-7 In Video 1, we present a case of a 63-year-old man with a recurrent craniopharyngioma with a 2-month history of visual decline, confusion, impaired memory, and episodes of urinary incontinence. On physical examination, he presented slow speech, word-finding difficulties, and left homonymous hemianopsia. Magnetic resonance imaging evidenced a large suprasellar, retrochiasmatic mass with solid (calcified) and cystic components with interval progression compared with previous scans. Treatment options were discussed, and the patient consented to undergo maximum safe resection through an extended endoscopic endonasal approach. Surgical techniques are presented side by side with anatomic dissections to illustrate key steps of the procedure. The patient tolerated the procedure well, with gross total resection of the tumor and without complications or postoperative cerebrospinal fluid leaks. He was subsequently discharged home on postoperative day 5 with continued hormonal replacement therapy. On follow-up, the patient presented marked improvement in his cognitive function. The patient gave informed consent for the use of their images.

Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach.

In recent years, the endoscopic endonasal approach (EEA) for craniopharyngiomas has proven to be a safe option for extensive tumor resection, with minimal or no manipulation of the optic nerves and excellent visualization of the superior hypophyseal branches when compared to the Transcranial Approach (TCA). However, there is an ongoing debate regarding the criteria for selecting different approaches. To explore the current results of EEA and discuss its role in the management of craniopharyngiomas, we performed MEDLINE, Embase, and LILACS searches from 2012 to 2022. Baseline characteristics, the extent of resection, and clinical outcomes were evaluated. Statistical analysis was performed through an X2 and Fisher exact test, and a comparison between quantitative variables through a Kruskal-Wallis and verified with post hoc Bonferroni. The tumor volume was similar in both groups (EEA 11.92 cm3, -TCA 13.23 cm3). The mean follow-up in months was 39.9 for EEA and 43.94 for TCA, p = 0.76). The EEA group presented a higher visual improvement rate (41.96% vs. 25% for TCA, p < 0.0001, OR 7.7). Permanent DI was less frequent with EEA (29.20% vs. 67.40% for TCA, p < 0.0001, OR 0.2). CSF Leaks occurred more frequently with EEA (9.94% vs. 0.70% for TCA, p < 0.0001, OR 15.8). Recurrence rates were lower in the EEA group (EEA 15.50% vs. for TCA 21.20%, p = 0.04, OR 0.7). Our results demonstrate that, in selected cases, EEA for resection of craniopharyngiomas is associated with better results regarding visual preservation and extent of tumor resection. Postoperative CSF leak rates associated with EEA have improved compared to the historical series. The decision-making process should consider each person's characteristics; however, it is noticeable that recent data regarding EEA justify its widespread application as a first-line approach in centers of excellence for skull base surgery.

Management of Intraventricular Meningiomas.

Intraventricular meningiomas (IVM) are intracranial tumors that originate from collections of arachnoid cells within the choroid plexus. The incidence of meningiomas is estimated to be about 97.5 per 100,000 individuals in the United States with IVMs constituting 0.7% to 3%. Positive outcomes have been observed with surgical treatment of intraventricular meningiomas. This review explores elements of surgical care and management of patients with IVM, highlighting nuances in surgical approaches, their indications, and considerations.

Predictive factors for post operative seizures following meningioma resection in patients without preoperative seizures: a multicenter retrospective analysis.

PURPOSE: Meningiomas are the most common primary brain tumor and represent 35% of all intracranial neoplasms. However, in the early post-operative period approximate 3-5% of patients experience an acute symptomatic seizure. Establishing risk factors for postoperative seizures will identify those patients without preoperative seizures at greatest risk of postoperative seizures and may guide antiseizure medications (ASMs) management. METHODS: Adult seizure naïve patients who underwent primary resection of a World Health Organization (WHO) Grade 1-3 meningioma at the three Mayo Clinic Campuses between 2012-2022 were retrospectively reviewed. Multivariate regression analyses were used to identify radiological, surgical, and management features with the development of new-onset seizures in patients undergoing meningioma resection. RESULTS: Of 113 seizure naïve patients undergoing meningioma resection 11 (9.7%) experienced a new-onset post-operative seizure. Tumor volume ≥ 25 cm3 (Odds Ratio (OR) 5.223, 95% Confidence Interval (CI) 1.546 - 17.650, p = 0.008) and cerebral convexity meningiomas (OR 4.742, 95% CI 1.255 - 14.336, p = 0.016) were most associated with new onset postoperative seizures in multivariate analysis. ASMs and corticosteroid therapies did not display a significant difference among those with and without a new onset postoperative seizure. CONCLUSION: In the current study, a larger tumor volume (≥ 25 cm3) and/or convexity meningiomas predicted the development of new onset post-operative seizures. Those who present with these factors should be counseled for their increased risk of new onset post-operative seizures and may benefit from prophylactic ASMs therapy.

The Evolving Landscape of Leptomeningeal Cancer from Solid Tumors: A Systematic Review of Clinical Trials.

Leptomeningeal carcinomatosis (LMC) is a fatal but uncommon complication occurring in 5-15% of patients with stage IV cancer. Current treatment options are ineffective at managing leptomeningeal spread, with a median overall survival (mOS) of 2-6 months. We aimed to conduct a systematic review of the literature to identify past and future therapies for LMC from solid tumors. Forty-three clinical trials (CTs) published between 1982-2022 were identified. Of these, 35 (81.4%) were non-randomized CTs and 8 (18.6%) were randomized CTs. The majority consisted of phase I (16.3%) and phase II CTs (65.1%). Trials enrolled patients with LMC from various primary histology (n = 23, 57.5%), with one CT evaluating LCM from melanoma (2.4%). A total of 21 trials evaluated a single modality treatment. Among CTs, 23.7% closed due to low accrual. Intraventricular (ITV)/intrathecal (IT) drug delivery was the most common route of administration (n = 22, 51.2%) vs. systemic drug delivery (n = 13, 30.3%). Two clinical trials evaluated the use of craniospinal irradiation for LMC with favorable results. LMC continues to carry a dismal prognosis, and over the years, increments in survival have remained stagnant. A paradigm shift towards targeted systemic therapy with continued standardization of efficacy endpoints will help to shed light on promising treatments.

Unilateral Supraorbital Keyhole Craniotomy Avoiding the Frontal Sinus for Large and Giant Olfactory-Groove Meningiomas: A Case Series.

OBJECTIVE: There are several different approaches to large and giant olfactory-groove meningiomas (OGMs). Each approach has advantages and disadvantages. We present our series using a unilateral supraorbital keyhole approach avoiding the frontal sinus for the resection of large and giant OGMs without the use of fixed brain retractors or orbital rim removal. MATERIALS AND METHODS: All consecutive patients operated on for large (>3 cm in largest diameter) and giant (>5 cm) OGMs by the senior author from 2016 to 2021 were prospectively identified and retrospectively reviewed. Patients who were operated on using an endoscopic endonasal approach were excluded. No fixed retraction was used. RESULTS: In total, 14 consecutive patients (11 with large, 3 with giant) were included. All patients were female, with an average age ± standard deviation of 59.7 ± 11.5 years. The median [interquartile range] preoperative Karnofsky Performance Status score was 80 [80-88]. The median preoperative tumor diameter and volume were 3.8 [3.2-4.2] cm and 22.2 [10.5-25.2] cm3, respectively. All patients underwent gross total resection. The median hospital stay was 2.7 [2-3] days, with all patients being discharged to home. No patients incurred any postoperative medical and/or surgical complications. Of the 9 patients who had subjective smell preoperatively, 5 stated they had subjective olfaction after surgery. CONCLUSIONS: We demonstrate the utility of a unilateral supraorbital keyhole approach avoiding the frontal sinus for large and giant OGMs. The potential advantages of this approach are minimizing bilateral brain manipulation, avoiding the frontal sinus and potential mucoceles, and reducing the risk of cerebrospinal fluid leaks.

Surgical resection of gliomas in the dominant inferior frontal gyrus: Consecutive case series and anatomy review of Broca's area.

INTRODUCTION: There is a general lack of consensus on both anatomic definition and function of Broca's area, often localized to the pars triangularis (pT) and pars opercularis (pOp) of the left inferior frontal gyrus (IFG). Given the belief that this region plays a critical role in expressive language functions, resective surgery is often avoided to preserve function. However, the putative role of Broca's area in speech production has been recently challenged. The current study aims to investigate the plausibility of glioma resection and neurological outcomes in "Broca's area". METHODS: We report a single-surgeon, consecutive case series feasibility study describing the resection of gliomas within the IFG. Presentation, mapping, functional outcome, and extent of resection variables were considered for analysis. RESULTS: All included patients had tumors located in the traditional "Broca's area", eight (53.33 %) additionally extending into the insular and subinsular regions. All patients except for one, presented with speech-language deficits preoperatively. Awake brain surgery for tumor resection with direct cortical and subcortical stimulation and intraoperative neuropsychological evaluation was carried out in all individuals. During stimulation, positive speech-language sites within the IFG were identified in ten patients. Two patients (13.33 %) experienced a decline in naming during intraoperative cognitive monitoring and thirteen (86.66 %) had a stable performance throughout surgery. At two-week follow-up, all patients had recovery of language functions compared to initial presentation. Overall extent of resection (EOR) was 60.35 % ( ± 29.60) with residual tumor being the greatest within the insular and subinsular areas. EOR was stratified in anatomical regions within the IFG, being the pOr the area with the greatest EOR (97.4 %), followed by the pT (84.1 %), pOp (83.8 %), and vPMC (80 %). CONCLUSION: The belief that Broca's area is not safe to resect is challenged. Adequate mapping and careful patient selection allow maximum safe resection of tumors located in the traditional "Broca's area", with low risk of postoperative morbidity.

Disease characteristics and patterns of familial colloid cyst of the third ventricle: An international survey of the Colloid Cyst Survivors Group.

BACKGROUND: Colloid cysts of the third ventricle are rare benign tumors, accounting for approximately 1% of all intracranial tumors. Familial colloid cysts are less common, only 25 cases have been previously reported in the literature. We aim to describe demographic and disease-specific characteristics to reduce the knowledge gap with this potentially life-threatening tumor. METHODS: We conducted a retrospective cohort study of 211 colloid cyst patients from the Colloid Cyst Survivors Group who completed a survey that included demographicandclinical data andinquired aboutfamily members diagnosed with a colloid cyst. Datawascollected from October 14th, 2021 to October 27th, 2021. We compared our data with previously published cases from the literature. RESULTS: A total of 211 responses from patients with a previous diagnosis of a colloid cyst completed our survey. 11.8 % were familial colloid cysts, of this group 60.8 % were symptomatic and 39.2 % incidental. We observed significant difference between symptom incidence between reports from the literature and our cohort: headache 75.5 % versus 49 % (p = 0.005); imbalance 13.2 % versus 31.4 % (p = 0.03); nausea 11.3 % versus 29.4 % (p = 0.02), and difficulty walking 1.9 % versus 19.6 % (p = 0.003). Additionally, we found first degree family member as the most frequent relative diagnosed with this disease. CONCLUSION: Our study involved the largestcohortof patients with familial colloid cysts. According to previous literature, siblings are the most prevalent family member affected by this disease, specifically among monozygotic twins. This suggests strong inheritance patterns and even genetic mechanism underlying the development of this disease.

Neuro-oncologic Emergencies.

PURPOSE OF REVIEW: Patients with brain and spine tumors are at high risk of presenting cancer-related complications at disease presentation or during active treatment and are usually related to the type and location of the lesion. Here, we discuss presentation and management of the most common emergencies affecting patients with central nervous system neoplastic lesions. RECENT FINDINGS: Tumor-related emergencies encompass complications in patients with central nervous system neoplasms, as well as neurologic complications in patients with systemic malignancies. Brain tumor patients are at high risk of developing multiple complications such as intracranial hypertension, brain herniation, intracranial bleeding, spinal cord compression, and others. Neuro-oncologic emergencies require immediate attention and multi-disciplinary care. These emergent situations usually need rapid decision-making and management on an inpatient basis.

The survival outcomes of molecular glioblastoma IDH-wildtype: a multicenter study.

PURPOSE: Histological diagnosis of glioblastoma (GBM) was determined by the presence of necrosis or microvascular proliferation (histGBM). The 2021 WHO classification now considers IDH-wildtype diffuse astrocytic tumors without the histological features of glioblastoma (that would have otherwise been classified as grade 2 or 3) as molecular GBM (molGBM, WHO grade 4) if they harbor any of the following molecular abnormalities: TERT promoter mutation, EGFR amplification, or chromosomal + 7/- 10 copy changes. The objective of this study was to explore and compare the survival outcomes between histGBM and molGBM. METHODS: Medical records for patients diagnosed with GBM at the three tertiary care academic centers of our institution from November 2017 to October 2021. Only patients who underwent adjuvant chemoradiation were included. Patients without molecular feature testing or with an IDH mutation were excluded. Univariable and multivariable analyses were performed to evaluate progression-free (PFS) and overall- survival (OS). RESULTS: 708 consecutive patients were included; 643 with histGBM and 65 with molGBM. Median PFS was 8 months (histGBM) and 13 months (molGBM) (p = 0.0237) and median OS was 21 months (histGBM) versus 26 months (molGBM) (p = 0.435). Multivariable analysis on the molGBM sub-group showed a worse PFS if there was contrast enhancement on MRI (HR 6.224 [CI 95% 2.187-17.714], p < 0.001) and a superior PFS on patients with MGMT methylation (HR 0.026 [CI 95% 0.065-0.655], p = 0.007). CONCLUSIONS: molGBM has a similar OS but significantly longer PFS when compared to histGBM. The presence of contrast enhancement and MGMT methylation seem to affect the clinical behavior of this subset of tumors.

Pattern of changes in cross sectional area of arterial branches after jailing with pipeline embolization device: beyond parent neck artery patency.

OBJECTIVE: The Pipeline-Embolization-Device (PED) has been used increasingly for intracranial-aneurysms. Despite the high-patency-rate of jailed branches following PED deployment, little is known about changes in these vessels size. This study measured change in size after PED. METHODS: This retrospective-study screened a database of 183-consecutive-patients treated with PED (07/2011-07/2017) across inclusion criteria. We included patients in whom the ophthalmic artery (OA) and/or the posterior communicating artery (PComA) were jailed by the PED. MRA was used to calculate change in cross-sectional-area (CSA) of these vessels. 29 patients who had MRA before and after treatment were included in the study. The CSA was measured automatically using Syngo®.via-software at fixed points along the analyzed vessels. After exclusion of low-quality and software non-capturable MRA-images, 16 OA and 23 PComA were included in the final analysis. Statistical Package for Social Sciences was used for analysis. RESULTS: The mean CSA of PComA, P1-segement of posteriror-cerebral-artery (P1-PCA), and OA was 3.3 ± 1.3, 4.1 ± 1.2, and 3.2 ± 0.9 mm2 at baseline and 1.9 ± 1.4, 4.3 ± 1.2, and 3.1 ± 0.7 mm2 at follow-up, respectively. The average follow-up was approximately 26 months. While the decrease in CSA of PComA was statistically significant, the increase in P1-PCA CSA was not. The change in OA CSA was not statistically significant. CONCLUSION: Jailing PComA with a PED resulted in a statistically significant decrease in PComA CSA and a statistically non-significant increase in ipsilateral P1 CSA. No statistically significant change in the CSA of OA was noted. Changes might be due to a balance between flow demand through the jailed ostium and presence of collateral flow.

Smell Outcomes in Olfactory Groove Meningioma Resection Through Unilateral versus Bilateral Transcranial Approaches: A Systematic Review and Meta-analysis.

OBJECTIVE: Olfactory disturbance is a common complication that occurs following the surgical resection of olfactory groove meningiomas (OGMs). There is little evidence on the best transcranial approach that minimizes rates of postoperative olfactory disturbance. The objective of this systematic review and meta-analysis is to compare smell outcomes after OGM resection in unilateral versus bilateral transcranial approaches. METHODS: A systematic review of the literature and meta-analysis was conducted using PUBMED, SCOPUS, and EMBASE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The primary endpoint was incidence of new olfactory disturbance defined as anosmia or hyposmia, or both. Patients were classified as undergoing either a unilateral or bilateral approach. Data on presence of new postoperative olfactory deficits were used to generate standardized mean differences and 95% confidence intervals. RESULTS: Ten studies met the inclusion criteria for quantitative analysis, comprising 342 patients. A total of 216 patients underwent unilateral approaches while 126 underwent resection via bilateral approach. In the unilateral approach cohort, 17.1% experienced new postoperative olfactory disturbance following resection, compared with 19.2% of patients in the bilateral approach cohort. Forest plot did not reveal any significant difference in the incidence of new olfactory disturbance following either unilateral or bilateral approaches. CONCLUSIONS: Our data suggest that there is no significant difference between the investigated transcranial approaches and postoperative olfactory disturbances. Accordingly, our study suggests that further investigation with introduced experimental control could provide more insight into the capabilities and drawbacks of each route in relation to olfactory outcomes.

Outcomes and Surgical Considerations for Neurosurgical Patients Hospitalized with COVID-19-A Multicenter Case Series.

OBJECTIVE: Neurosurgical patients are at a higher risk of having a severe course of coronavirus disease 2019 (COVID-19). The objective of this study was to determine morbidity, hospital course, and mortality of neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic in a multicenter health care system. METHODS: A retrospective observational study was conducted to identify all hospitalized neurosurgical patients positive for COVID-19 from March 11, 2020 to November 2, 2020 at Mayo Clinic and the Mayo Clinic Health System. RESULTS: Eleven hospitalized neurosurgical patients (0.68%) were positive for COVID-19. Four patients (36.6%) were men and 7 (63.3%) were women. The mean age was 65.7 years (range, 35-81 years). All patients had comorbidities. The mean length of stay was 13.4 days (range, 4-30 days). Seven patients had a central nervous system malignancy (4 metastases, 1 meningioma, 1 glioblastoma, and 1 schwannoma). Three patients presented with cerebrovascular complications, comprising 2 spontaneous intraparenchymal hemorrhages and 1 ischemic large-vessel stroke. One patient presented with an unstable traumatic spinal burst fracture. Four patients underwent neurosurgical/neuroendovascular interventions. Discharge disposition was to home in 5 patients, rehabilitation facility in 3, and hospice in 3. Five patients had died at follow-up, 3 within 30 days from COVID-19 complications and 2 from progression of their metastatic cancer. CONCLUSIONS: COVID-19 is rare among the inpatient neurosurgical population. In all cases, patients had multiple comorbidities. All symptomatic patients from the respiratory standpoint had complications during their hospitalization. Deaths of 3 patients who died within 30 days of hospitalization were all related to COVID-19 complications. Neurosurgical procedures were performed only if deemed emergent.

Circulatory shear stress induces molecular changes and side population enrichment in primary tumor-derived lung cancer cells with higher metastatic potential.

Cancer is a leading cause of death and disease worldwide. However, while the survival for patients with primary cancers is improving, the ability to prevent metastatic cancer has not. Once patients develop metastases, their prognosis is dismal. A critical step in metastasis is the transit of cancer cells in the circulatory system. In this hostile microenvironment, variations in pressure and flow can change cellular behavior. However, the effects that circulation has on cancer cells and the metastatic process remain unclear. To further understand this process, we engineered a closed-loop fluidic system to analyze molecular changes induced by variations in flow rate and pressure on primary tumor-derived lung adenocarcinoma cells. We found that cancer cells overexpress epithelial-to-mesenchymal transition markers TWIST1 and SNAI2, as well as stem-like marker CD44 (but not CD133, SOX2 and/or NANOG). Moreover, these cells display a fourfold increased percentage of side population cells and have an increased propensity for migration. In vivo, surviving circulatory cells lead to decreased survival in rodents. These results suggest that cancer cells that express a specific circulatory transition phenotype and are enriched in side population cells are able to survive prolonged circulatory stress and lead to increased metastatic disease and shorter survival.

Bur Hole-Based Resections of Intrinsic Brain Tumors with Exoscopic Visualization.

BACKGROUND: The primary goal of brain tumor surgery is maximal safe resection while avoiding iatrogenic injury. As surgical technology increases, it is becoming more possible to resect these lesions using minimally invasive approaches. While keyhole surgeries are being advocated, the lower limit of these approaches is unclear. Bur hole-based approaches may represent a standardized minimally invasive approach. The exoscope may provide increased visualization over standard microscopic visualization, making this approach possible. This approach has yet to be described strictly for intra-axial brain tumors. MATERIAL AND METHODS: All patients who underwent a bur hole-based surgery of an intra-axial tumor with exoscopic visualization by the senior author from January 2018 to December 2019 were prospectively identified and patient information and outcomes were collected. RESULTS: Fifteen consecutive patients underwent surgical resection of an intrinsic brain tumor using a bur hole-based approach with exoscopic visualization. The average ± standard deviation age was 57.9 ± 24.2 years. The pathology was a metastatic brain tumor in eight patients (53%), low-grade glioma in four patients (27%), and high-grade glioma in three patients (20%). The average percent resection was 100 ± 1%, where 14 (93%) underwent gross total resection. Following surgery, the median (interquartile range) Karnofsky performance scale (KPS) score was 90 (90-90), where 11 (73%) and four patients (27%) had improved and stable KPS, respectively. Zero patients had complications. The average length of stay following surgery was 1.4 ± 0.5 days, where nine patients (60%) were discharged on postoperative day 1. CONCLUSION: This study shows that intra-axial tumors can be resected through a bur hole-based approach with exoscopic visualization with extensive resection, minimal morbidity, and early discharge rates.

Mapping angiography and transarterial technetium macroaggregated albumin particle simulation of recurrent atypical intracranial meningioma: feasibility for potential vascular brachytherapy.

Atypical meningioma (AM) (WHO-II) has a recurrence rate of 28% after gross total resection (GTR) with limited salvage options. Transarterial therapies may provide treatment opportunities in AM patients who exhausted standard-of-care therapy. In cases where favorable tumor vasculature and particle simulation demonstrate acceptable target dose, Yttrium-90 trans-arterial radioemobilization (TARE) could theoretically provide salvage therapy. A 67-year-old man presented with recurrent AM post gross total resection with adjuvant radiotherapy in 2012, 2014, and 2016. The patient was deemed a poor candidate for additional therapies. Tumor vasculature mapping was performed to determine TARE candidacy. Super-selective angiography and contrast-enhanced cone-beam computed tomography angiosomes demonstrated predominant pial collaterals and minor supply from a middle meningeal artery branch. Particle simulation was performed by infusing 0.3 mCi of 99mTc-macroaggregated albumin (99mTc-MAA). SPECT/CT-MRI fusion demonstrated conformal activity solely within the tumor volume perfused by the middle meningeal artery branch with a lung shunt fraction of 54.7%. The patient subsequently received off-label Nivolumab (PD-1 inhibitor). Mapping angiography for AM using 99mTc-MAA is feasible. It may identify candidates for TARE and potential AM patients with favorable blood supply. The potential for conformal intracranial vascular brachytherapy is intriguing, however, altered arterial supply in recurrent tumors is challenging.