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.

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.

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.

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.

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.

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.

Case report: a troublesome ophthalmic artery aneurysm.

Objective and Importance When treating large unruptured ophthalmic artery (OA) aneurysms causing progressive blindness, surgical clipping is still the preferred method because aneurysm sac decompression may relieve optic nerve compression. However, endovascular treatment of OA aneurysms has made important progress with the introduction of stents. Although this development is welcomed, it also makes the choice of treatment strategy less straightforward than in the past, with the potential of missteps. Clinical Presentation A 56-year-old woman presented with a long history of progressive unilateral visual loss and magnetic resonance imaging showing a 20-mm left-sided OA aneurysm. Intervention Because of her long history of very poor visual acuity, we considered her left eye to be irredeemable and opted for endovascular therapy. The OA aneurysms was treated with stent and coils but continued to grow, threatening the contralateral eye. Because she failed internal carotid artery (ICA) balloon test occlusion, we performed a high-flow extracranial-intracranial bypass with proximal ICA occlusion in the neck. However, aneurysm growth continued due to persistent circulation through reversed blood flow in distal ICA down to the OA and the cavernous portion of the ICA. Due to progressive loss of her right eye vision, we surgically occluded the ICA proximal to the posterior communicating artery and excised the coiled, now giant, OA aneurysm. This improved her right eye vision, but her left eye was permanently blind. Conclusion This case report illustrates complications of the endovascular and surgical treatment of a large unruptured OA aneurysm.

Atypical femoral fractures in elderly women: a fracture registry-based cohort study.

An atypical femoral fracture (AFF), with a transverse fracture radiologically through the lateral cortex is a rare but serious condition. In order to improve our ability to identify patients with this condition, we retrospectively surveyed all subtrochanteric, peri-implant and diaphyseal femoral fractures in patients aged ≥ 65 years who underwent surgical treatment at our hospital between 2004 and 2011. We describe the incidence of atypical fractures and their characteristics, with observational data including a review of the hospital and general practitioner records. Clinical outcomes were evaluated using the Harris hip score (HHS) and the timed up-and-go (TUG) test. Atypical fractures only occurred in women with an incidence of 9.8 per 100,000 person-years. The incidence in those who were treated with bisphosphonates was 79.0 per 100,000 person-years; eight of 17 fractures occurred around metal implants. There was a high incidence of delayed union and revision surgery. A total of nine patients (ten AFFs) were available for review at a mean follow-up of 36.5 months (10 to 104). The clinical outcome was poor with a mean HHS of 58.9 (95% CI 47.4 to 70.4) and a mean TUG test of 25.7 s (95% CI 12.7 to 38.8). The delay in diagnosis and treatment of AFF may result from a lack of knowledge of this condition.

Treatment of esthesioneuroblastomas.

OBJECTIVE: To analyze the clinical features, treatment outcomes, pattern of failures, and course of the disease of a cohort of patients treated for esthesioneuroblastoma (ENB) with craniofacial resection (CFR) at a single institution during a 12-year period. MATERIAL AND METHODS: Retrospective analysis of 11 patients with ENB treated with CFR in a tertiary care academic medical center from 1998 to 2009. RESULTS: Median age at diagnosis was 51 years (range 41-67 years). The most common presenting symptom was nasal obstruction (91%). Four patients (36%) presented with Kadish stage B, six patients (55%) with Kadish stage C, and one patient (9%) with Kadish stage D. The initial treatment was craniofacial resection (CFR) alone for three patients (23%), CFR followed by postoperative radiation therapy (RT) in seven patients (64%), while one patient (9%) received both neoadjuvant and adjuvant RT in addition to surgery. The mean and median follow-up times were 66 and 58 months, respectively (range 23-158 months). Seven patients are currently alive with no evidence of disease (64%), while two patients are alive with disease (18%). Overall survival was 100% at one year postoperatively and 80% five years after the primary treatment. The progression free survival was calculated to 73% at one year and 64% at five years. CONCLUSIONS: ENB is an uncommon diagnosis with an incidence of 0.037/100,000 persons/year in the catchment area of our institution. Treatment can be challenging, especially with advanced disease. CFR with RT offers good oncologic disease control with minimal morbidity.

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.

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.

Anterior cingulate cortex and cognitive control: neuropsychological and electrophysiological findings in two patients with lesions to dorsomedial prefrontal cortex.

Whereas neuroimaging studies of healthy subjects have demonstrated an association between the anterior cingulate cortex (ACC) and cognitive control functions, including response monitoring and error detection, lesion studies are sparse and have produced mixed results. Due to largely normal behavioral test results in two patients with medial prefrontal lesions, a hypothesis has been advanced claiming that the ACC is not involved in cognitive operations. In the current study, two comparably rare patients with unilateral lesions to dorsal medial prefrontal cortex (MPFC) encompassing the ACC were assessed with neuropsychological tests as well as Event-Related Potentials in two experimental paradigms known to engage prefrontal cortex (PFC). These included an auditory Novelty Oddball task and a visual Stop-signal task. Both patients performed normally on the Stroop test but showed reduced performance on tests of learning and memory. Moreover, altered attentional control was reflected in a diminished Novelty P3, whereas the posterior P3b to target stimuli was present in both patients. The error-related negativity, which has been hypothesized to be generated in the ACC, was present in both patients, but alterations of inhibitory behavior were observed. Although interpretative caution is generally called for in single case studies, and the fact that the lesions extended outside the ACC, the findings nevertheless suggest a role for MPFC in cognitive control that is not restricted to error monitoring.

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.

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.

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).