Preoperative tractography algorithm for safe resection of tumors located in the descending motor pathways zone.

Background: Diffusion tensor imaging (DTI) tractography facilitates maximal safe resection and optimizes planning to avoid injury during subcortical dissection along descending motor pathways (DMPs). We provide an affordable, safe, and timely algorithm for preoperative DTI motor reconstruction for gliomas adjacent to DMPs. Methods: Preoperative DTI reconstructions were extracted from a prospectively acquired registry of glioma resections adjacent to DMPs. The surgeries were performed over a 7-year period. Demographic, clinical, and radiographic data were extracted from patients' electronic medical records. Results: Nineteen patients (12 male) underwent preoperative tractography between January 1, 2013, and May 31, 2020. The average age was 44.5 years (range, 19-81 years). A complete radiological resection was achieved in nine patients, a subtotal resection in five, a partial resection in three, and a biopsy in two. Histopathological diagnoses included 10 patients with high-grade glioma and nine with low-grade glioma. A total of 16 perirolandic locations (10 frontal and six frontoparietal) were recorded, as well as two in the insula and one in the basal ganglia. In 9 patients (47.3%), the lesion was in the dominant hemisphere. The median preoperative and postoperative Karnofsky Performance Scores were 78 and 80, respectively. Motor function was unchanged or improved over time in 15 cases (78.9%). Conclusion: This protocol of DTI reconstruction for glioma removal near the DMP shows good results in low-term neurological functional outcomes.

The reverse question mark and L.G. Kempe incisions for decompressive craniectomy: A case series and narrative review of the literature.

Background: Decompressive craniectomy (DC) is a lifesaving procedure, relieving intracranial hypertension. Conventionally, DCs are performed by a reverse question mark (RQM) incision. However, the use of the L. G. Kempe's (LGK) incision has increased in the last decade. We aim to describe the surgical nuances of the LGK and the standard RQM incisions to treat patients with severe traumatic brain injury (TBI), intracranial hemorrhage (ICH), empyema, and malignant ischemic stroke. Furthermore, to describe, surgical limitations, wound healing, and neurological outcomes related to each technique. Methods: To describe a prospective acquired, case series including patients who underwent a DC using either an RQM or an LGK incision in our institution between 2019 and 2020. Results: A total of 27 patients underwent DC. Of those, ten patients were enrolled. The mean age was 42.1 years (26-71), and 60% were male. Five patients underwent DC using a large RQM incision; three had severe TBI, one ICH, and one ischemic stroke. The other five patients underwent DC using an LGK incision (one ICH, one subdural empyema, and one ischemic stroke). About 50% of patients presented severe headaches associated with vomiting, and six presented altered mental status (drowsy or stuporous). Motor deficits were present in four cases. In patients with ischemic or hemorrhagic stroke, symptoms were directly related to the stroke location. Hospital stays varied between 13 and 22 days. No readmissions were recorded, and no fatal outcome was documented during the follow-up. Conclusion: The utility of the LGK incision is comparable with the classic RQM incision to treat acute brain injuries, where an urgent decompression must be performed. Some of these cases include malignant ischemic strokes, ICH, and empyema. No differences were observed between both techniques in terms of prevention of scalp necrosis and general cosmetic outcomes.

Resección Tubular Microquirúrgica de un Subependimoma Extenso del Ventrículo Lateral Izquierdo: Video Operatorio en 2D / Microsurgical Tubular Resection of an Extensive Subependymoma of the Left Lateral Ventricle: Operative Video in 2D

Introducción: Los subependimomas intracraneales son raros, representan el 0.2-0.7% de todos los tumores del sistema nervioso central1,2 y se originan en los ventrículos laterales en el 30-40% de los casos.3 Los síntomas usualmente se asocian a hipertensión endocraneana secundaria a hidrocefalia obstructiva.4 La resección completa del tumor es curativa en esta patología.5 El abordaje trans-surcal es seguro para lesiones ventriculares profundas y el uso de los retractores tubulares minimizan la retracción del parénquima cerebral evitando la compresión directa con valvas. Esto permite disminuir la presión del tejido cerebral que puede ocluir los vasos y producir isquemia local generando una lesión neurológica permanente. Descripción del caso: Se presenta el caso de una paciente de 66 años, diestra, con cefalea crónica que aumenta en frecuencia en el último mes. La resonancia cerebral contrastada muestra un tumor extenso en el ventrículo lateral izquierdo con signos de hidrocefalia obstructiva. Intervención: Se coloca la paciente en posición supina. Se hace una incisión bicoronal y se hace un abordaje trans-surcal F1/F2 izquierdo. Se coloca un retractor tubular guiado con el puntero de neuronavegación, introduciéndolo directamente en el parénquima cerebral y fijándolo al soporte de Leyla. Se colocó un catéter de ventriculostomía contralateral y se retira a las 48 horas sin complicaciones asociadas. La resonancia contrastada postoperatoria demuestra una resección completa del tumor. El análisis de patología reveló un subependimoma grado I de la clasificación de la Organización Mundial de la Salud. La paciente presentó transitoriamente apatía y pérdida del control del esfínter urinario que resolvieron completamente a las 3 semanas después de la cirugía. Se firmó un consentimiento firmado para la publicación de la información utilizada en este trabajo. Conclusión: La resección completa microscópica de un subependimoma extenso del ventrículo lateral izquierdo es factible a través de un abordaje tubular transulcal.

Introduction: Intracranial subependymomas are rare, representing only 0.2-0.7% of all central nervous system tumors1,2 and arise in the lateral ventricles in 30-40% of the cases.3 Symptoms depend on tumor location and usually arise when the cerebrospinal fluid (CSF) is blocked, generating a consequent intracranial hypertension.4 Microsurgical gross-total resection is possible and curative for these tumors.5 The transcortical/trans-sulcal approach is a safe approach for the access of deep-seated intraventricular lesions. The use of tubular retractor systems minimizes retraction injury when passing through the cortex and deep white matter tracts. This allows a decrease in the pressure on brain tissue that can occlude the brain vessels and produce local ischemia and a consequent permanent neurological injury. Case description: This is a case of a 66-year-old woman who presented chronic headaches that increased in frequency in the last month. Enhanced-brain MRI demonstrated a large left ventricular lesion with signs of obstructive hydrocephalus. Procedure: Patient was positioned supine. A bicoronal incision was used to perform a left frontal craniotomy. An F1/F2 transcortical/trans-sulcal approach was used. A guided tubular retractor is placed with the neuronavigation pointer, inserting it directly into the brain parenchyma and fixing it to the Leyla support. Postoperative postcontrast MRI demonstrated a complete resection of the tumor. Histopathological analysis revealed a subependymoma (World Health Organization Grade I). The patient presented transient apathy and loss of urinary sphincter control that completely resolved 3 weeks after surgery. Written informed consent was obtained for publication of information used for this work. Conclusions: A complete microsurgical resection of a large left ventricular subependymoma is feasible through a trans-sulcal tubular approach.

Utilidad de la estimulación continua del núcleo pedunculopontino para el tratamiento de la enfermedad de Parkinson / Utility Continuous Stimulation of Pedunculopontine Nucleus for treating Parkinson's Disease

El núcleo pedunculopontmo contiene gran cantidad de conexiones que modulan la actividad motora en los humanos; por este motivo, se ha planteado que su estimulación profunda tendría beneficios significativos en el tratamiento de la enfermedad de Parkinson. Con una carga orgánica y social significativa, la enfermedad de Parkinson reúne una serie de signos y síntomas, principalmente motores, que afectan significativamente la calidad de vida de los pacientes que la padecen. Actualmente, se encuentran dentro de un área de investigación con gran potencial para dar manejo a los síntomas de esta enfermedad, y se desconoce si su estimulación cerebral profunda podría orientar futuras intervenciones con resultados óptimos. Por esta razón, la revisión busca esclarecer la utilidad de este procedimiento; sin embargo, es bastante controvertido y su evidencia escasa, además de que es difícil centrarse únicamente en un núcleo para resolver los problemas relacionados con dicha enfermedad.

The pendunculopontine nucleus contains many connections responsible or modulate motor activity. It has been suggested that deep stimulation would have significant benefits in the treatment of Parldnson's disease, intervention that could improve the patient5s quality of life and generare a positive impact in public health due Parkmson's disease has important organic and social burden. There is a growmg area of research in this fíeld, however is still uncertain if deep brain stimulation could guide future interventíons with optimal results. For this reason, we pretend to darify the existing knowledge of this procedure, nevertheless, it is quite controversial, we consider that it is difficult to focusing on a unique nucleus to solve the problems associated with this disease.

Economic Analysis of Deep Brain Stimulation in Parkinson Disease: Systematic Review of the Literature.

BACKGROUND: Parkinson disease (PD) is a chronic multifaceted neurodegenerative disorder of adult onset that affects quality of life and places a burden on patients, caregivers, and society. In early disease, dopaminergic therapy improves motor symptoms, but as the disease progresses, symptoms tend to increase in frequency and severity, even with best medical treatment (BMT). Deep brain stimulation (DBS) becomes an option for certain patients, but cost becomes an important issue. OBJECTIVE: We performed a systematic review of the literature of economic studies of the use of DBS in patients with PD, including costs studies or economic evaluations expressed as cost per improvement in quality life, decrease in dose of pharmacological treatments, and the decrease of caregiver burden. METHODS: We reviewed the following databases: Medline/PubMed, Embase, Cochrane Database of Systematic Reviews, LILACS, Cochrane Central Register of Controlled Trials, WHO International Clinical Trials Registry Platform ICTRP portal and ClinicalTrials.gov from 1980 to 2015. Costs have been converted or adjusted to 2016 US dollars (US$). RESULTS: Nine studies were identified. The average cost of DBS for a patient with PD in 5 years is US$186,244. The quality-adjusted life year was higher in DBS compared with BMT after at least 2 years of treatment, with an average incremental cost utility ratio of US$41,932 per additional quality-adjusted life year gained. Costs in the first year are higher with DBS because of direct costs related to the surgical procedure, the device, and the more frequent controls. Studies show better results with a longer time horizon (up to 5 years). CONCLUSION: DBS is a cost-effective intervention for patients with advanced PD, but it has a high initial cost compared with BMT. However, DBS reduces pharmacologic treatment costs and should also reduce direct, indirect, and social costs of PD on the long term.

Craniocervical junction diseases treatment with a minimally invasive approach / Abordagem minimamente invasiva para tratamento de lesões da união craniocervical / Abordaje minimamente invasivo para tratamiento de lesiones de la union craneocervical

Objective: To introduce a new minimally invasive surgical approach to anterior and lateral craniocervical junction diseases, preserving the midline posterior cervical spine stabilizing elements and reducing the inherent morbidity risk associated with traditional approaches. Methods: We describe a novel surgical technique in four cases of extra-medullary anterolateral compressive lesions located in the occipito-cervical junction, including infections and intra- and/or extradural tumor lesions. We used a paramedian trasmuscular approach through an anatomical muscle corridor using a micro MaXcess® surgical expandable retractor, with the purpose of reducing morbidity and preserving the posterior muscle and ligamentous tension band. Results: This type of surgical approach provides adequate visualization and microsurgical resection of lesions and reduces muscle manipulation and devascularisation, preserving the tension of the ligament complex. There was minimal blood loss and a decrease in postoperative pain, with rapid start of rehabilitation and shorter hospitalization times. There were no intraoperative complications, and all patients recovered from their pre-operative symptoms. Conclusions: This novel surgical technique is feasible and adequate for the occipito-atlanto-axial complex, with better results than traditional procedures.

Objetivo: Realizamos esforços para desenvolver novas técnicas cirúrgicas para reduzir a morbidade e a mortalidade. Métodos: Descrevemos uma técnica cirúrgica nova em quatro casos de lesões extramedulares compressivas anterolaterais da junção occipitocervical, que incluem infecções e lesões tumorais intra e extradurais. As lesões foram excisadas por uma nova técnica cirúrgica minimamente invasiva, por meio de um corredor anatômico muscular, utilizando-se o afastador expansível MaXcess® (Nuvasive Inc., San Diego, CA, EUA) visando reduzir a morbidade e preservar a banda de tensão músculo-ligamentar. Resultados: Esse tipo de abordagem proporcionou visualização e excisão microcirúrgica adequada das lesões, com redução da manipulação muscular, preservando a tensão do complexo ligamentar nucal. Houve perda de sangue mínima, além da redução da dor pós-operatória, início rápido da reabilitação e pequena estadia hospitalar. Não foram observadas complicações intraoperatórias e os pacientes não tiveram mais os sintomas apresentados no pré-operatório. Conclusões: Essa nova técnica cirúrgica é uma opção de tratamento na região do complexo occipito-atlanto-axial anterolateral, com resultados superiores aos dos procedimentos tradicionais.

Objetivo: Se han realizado esfuerzos por desarrollar nuevas técnicas quirúrgicas que reduzcan morbimortalidad. Métodos: Describimos una novedosa técnica quirúrgica de tratamiento en cuatro casos de lesiones extramedulares compresivas anterolaterales de la unión occipitocervical que incluyen infecciones y lesiones tumorales intra y extradurales. Las lesiones fueron extirpadas por una nueva técnica quirúrgica mínimamente invasiva a través de un corredor anatómico muscular, utilizándose el retractor expansible MaXcess® (Nuvasive Inc., San Diego, CA, EEUU) con el objetivo de reducir la morbilidad y preservar la banda de tensión músculo-ligamentaria. Resultados: Este tipo de abordaje aportó adecuada visualización y resección microquirúrgica de las lesiones, con reducción de la manipulación muscular, preservando la tensión del complejo ligamentario nucal. Hubo mínima pérdida sanguínea además de disminución de dolor post-operatorio, rápido inicio de rehabilitación y corta estancia hospitalaria. No se presentaron complicaciones intraoperatorias y los pacientes se recuperaron de la sintomatología preoperatoria. Conclusiones: Esta nueva técnica quirúrgica se perfila como una opción de tratamiento a nivel del complejo occipito-atlanto-axial anterolateral con resultados superiores a los procedimientos tradicionales.

Procedimientos neuroquirúrgicoscerebrales guiados por estereotaxiarealizados en el Hospital Universitario de San Ignacio (HUSI): evolución a corto y mediano plazo / Neurosurgical Brain Estereotactic- Guided Procedures Performed at Hospital Universitario San Ignacio (HUSI): Development in the Short and Medium Term

Objetivo: Describir los resultados postoperatorios de los pacientes a los que se lesrealizaron procedimientos neuroquirúrgicos cerebrales guiados por estereotaxia enel Hospital Universitario de San Ignacio durante el periodo julio del 2009-julio del2011. Materiales y métodos: Se revisaron las historias clínicas de 78 pacientes,sus características clínicas, la localización de las lesiones en las neuroimágenes,el tipo de procedimiento, los resultados funcionales y los desenlaces a corto ymediano plazo. Resultados: 78 pacientes tuvieron procedimientos neuroquirúrgicosguiados por estereotaxia entre julio del 2009 y julio del 2011. El 64,1 % (n = 50)eran hombres. La localización de las lesiones fue en orden de frecuencia: gangliossubtalámicos, lóbulo frontal, lóbulo temporal, tálamo, unión córtico-subcortical, tallocerebral, ubicación frontotemporal, lóbulo occipital, ubicación parieto-occipital ybase del cráneo. Discusión: La implementación de procedimientos neuroquirúrgicosguiados por estereotaxia sigue siendo una de las mejores opciones en el abordaje depatologías cerebrales profundas o de difícil acceso. Tanto en Colombia como en elresto del mundo son procedimientos con una baja tasa de morbilidad y mortalidad.Conclusiones: Independientemente del tipo de procedimiento guiado por estereotaxiala tasa de complicaciones no excede el 5 %, tasas similares a las obtenidas en laliteratura mundial...

Objective: Retrospective description of postoperativeoutcomes of patients who underwentneurosurgical brain stereotactic guided proceduresat the Hospital Universitario San Ignacioduring the period July 2009-July 2011. Materialsand Methods: A review of medical recordsof 78 patients who were taken to neurosurgicalstereotactic guided procedures at the HospitalUniversitario San Ignaci. We reviewed the clinicalcharacteristics of patients, the location of thelesions on neuroimaging, management, type ofprocedure of each patient, functional results andoutcomes in the short and medium term. Results:78 patients who underwent neurosurgical brainstereotactic guided procedures between July2009 to July 2011 at the Hospital UniversitarioSan Ignacio. The 64.1 % (n = 50) were men. Thelocation of the lesions were in order of frequencysub-thalamic ganglia, frontal lobe, temporallobe, thalamus, cortico-subcortical junction, brainstem,fronto-temporal location, occipital lobe,parieto-occipital location, and at the skull’s base.Discussion: Implementing guided stereotacticneurosurgical procedures remains one of the bestoptions in dealing with deep brain pathologies ordifficult access. In both Colombia and the rest ofthe world, these are procedures with low morbidityand mortality. It must, however, developmulticenter studies that allow us to observe thedevelopment of stereotactic neurosurgery in ourcountry, also develop studies with a larger continuityto assess the long-term outcomes. Conclusions:Whatever type of stereotactic guidedprocedure the rate of complications does not exceed5 %, similar rates to those obtained from theglobal literature...

Outcome predictors after gamma knife radiosurgery for recurrent trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) that recurs after surgery can be difficult to manage. OBJECTIVE: To define management outcomes in patients who underwent gamma knife stereotactic radiosurgery (GKSR) after failing 1 or more previous surgical procedures. METHODS: We retrospectively reviewed outcomes after GKSR in 193 patients with TN after failed surgery. The median patient age was 70 years (range, 26-93 years). Seventy-five patients had a single operation (microvascular decompression, n=40; glycerol rhizotomy, n=24; radiofrequency rhizotomy, n=11). One hundred eighteen patients underwent multiple operations before GKSR. Patients were evaluated up to 14 years after GKSR. RESULTS: After GKSR, 85% of patients achieved pain relief or improvement (Barrow Neurological Institute grade I-IIIb). Pain recurrence was observed in 73 of 168 patients 6 to 144 months after GKSR (median, 6 years). Factors associated with better long-term pain relief included no relief from the surgical procedure preceding GKSR, pain in a single branch, typical TN, and a single previous failed surgical procedure. Eighteen patients (9.3%) developed new or increased trigeminal sensory dysfunction, and 1 developed deafferentation pain. Patients who developed sensory loss after GKSR had better long-term pain control (Barrow Neurological Institute grade I-IIIb: 86% at 5 years). CONCLUSION: GKSR proved to be safe and moderately effective in the management of TN that recurs after surgery. Development of sensory loss may predict better long-term pain control. The best candidates for GKSR were patients with recurrence after a single failed previous operation and those with typical TN in a single trigeminal nerve distribution.

T1/T2 matching to differentiate tumor growth from radiation effects after stereotactic radiosurgery.

OBJECTIVE: We define magnetic resonance imaging (MRI) and clinical criteria that differentiate radiation effect (RE) from tumor progression after stereotactic radiosurgery (SRS). METHODS: We correlated postoperative imaging and histopathological data in 68 patients who underwent delayed resection of a brain metastasis after SRS. Surgical resection was required in these patients because of clinical and imaging evidence of lesion progression 0.3 to 27.7 months after SRS. At the time of SRS, the median target volume was 7.1 mL (range, 0.5-26 mL), which increased to 14 mL (range, 1.3-81 mL) at the time of surgery. After initial SRS, routine contrast-enhanced MRI was used to assess tumor response and to detect potential adverse radiation effects. We retrospectively correlated these serial MRIs with the postoperative histopathology to determine if any routine MRI features might differentiate tumor progression from RE. RESULTS: The median time from SRS to surgical resection was 6.9 months (range, 0.3-27.7 months). A shorter interval from SRS to resection was associated with a higher rate of tumor recurrence (P = .014). A correspondence between the contrast-enhanced volume on T1-weighted images and the low signal-defined lesion margin on T2-weighted images ("T1/T2 match") was associated with tumor progression at histopathology (P < .0001). Lack of a clear and defined lesion margin on T2-weighted images compared to the margin of contrast uptake on T1-weighted images ("T1/T2 mismatch") was significantly associated with a higher rate of RE in pathological specimens (P < .0001). The sensitivity of the T1/T2 mismatch in identifying RE was 83.3%, and the specificity was 91.1%. CONCLUSIONS: We found that time to progression and T1/T2 mismatch were able to differentiate tumor progression from RE in most patients. When REs are suspected, surgery may not be necessary if patients respond to conservative measures. When tumor progression is suspected, resection or repeat radiosurgery can be effective, depending on the degree of mass effect.

Gamma Knife stereotactic radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Trigeminal neuralgia pain causes severe disability. Stereotactic radiosurgery is the least invasive surgical option for patients with trigeminal neuralgia. Since different medical and surgical options have different rates of pain relief and morbidity, it is important to evaluate longer-term outcomes. METHODS: The authors retrospectively reviewed outcomes in 503 medically refractory patients with trigeminal neuralgia who underwent Gamma Knife surgery (GKS). The median patient age was 72 years (range 26-95 years). Prior surgery had failed in 205 patients (43%). The GKS typically was performed using MR imaging guidance, a single 4-mm isocenter, and a maximum dose of 80 Gy. RESULTS: Patients were evaluated for up to 16 years after GKS; 107 patients had > 5 years of follow-up. Eighty-nine percent of patients achieved initial pain relief that was adequate or better, with or without medications (Barrow Neurological Institute [BNI] Scores I-IIIb). Significant pain relief (BNI Scores I-IIIa) was achieved in 73% at 1 year, 65% at 2 years, and 41% at 5 years. Including Score IIIb (pain adequately controlled with medication), a BNI score of I-IIIb was found in 80% at 1 year, 71% at 3 years, 46% at 5 years, and 30% at 10 years. A faster initial pain response including adequate and some pain relief was seen in patients with trigeminal neuralgia without additional symptoms, patients without prior surgery, and patients with a pain duration of < or = 3 years. One hundred ninety-three (43%) of 450 patients who achieved initial pain relief reported some recurrent pain 3-144 months after initial relief (median 50 months). Factors associated with earlier pain recurrence that failed to maintain adequate or some pain relief were trigeminal neuralgia with additional symptoms and > or = 3 prior failed surgical procedures. Fifty-three patients (10.5%) developed new or increased subjective facial paresthesias or numbness and 1 developed deafferentation pain; these symptoms resolved in 17 patients. Those who developed sensory loss had better long-term pain control (78% at 5 years). CONCLUSIONS: Gamma Knife surgery proved to be safe and effective in the treatment of medically refractory trigeminal neuralgia and is of value for initial or recurrent pain management. Despite the goal of minimizing sensory loss with this procedure, some sensory loss may improve long-term outcomes. Pain relapse is amenable to additional GKS or another procedure.

Gamma knife radiosurgery in younger patients with vestibular schwannomas.

OBJECTIVE: Management options for patients with vestibular schwannoma include observation, surgical resection, stereotactic radiosurgery (SRS), and stereotactic radiation therapy. In younger patients, resection is often advocated because of concern regarding the long-term effects of radiation. We studied tumor response and clinical outcomes after SRS in such patients. METHODS: We reviewed long-term outcomes in 55 patients with vestibular schwannomas. Patients were 40 years of age or younger, underwent gamma knife (GK) SRS between 1987 and 2003, and were followed up for a minimum of 4 years. The median patient age was 35 years (range, 13-40 years). Forty-one patients had Gardner-Robertson class 1 to 4 hearing. Thirteen patients (24%) had undergone surgical removal. The median tumor volume was 1.7 mm. The median tumor margin dose was 13.0 Gy (range, 11-20 Gy). RESULTS: At a median of 5.3 years, (range, 4-20 years), 2 of 55 patients underwent GK SRS for a second time; 1 of these patients had had a recurrence after initial resection. The 5-year rate of freedom from additional management was 96%. Hearing preservation rates (i.e., remaining within the same Gardner-Robertson hearing class) were 93%, 87%, and 87% at 3, 5, and 10 years, respectively. In patients with serviceable hearing before SRS, it was maintained in 100%, 93%, and 93% of patients at 3, 5, and 10 years, respectively. Hearing preservation was related to a margin dose lower than 13 Gy (P = 0.017). At the last assessment, facial and trigeminal nerve function was preserved in 98.2% and 96.4% of patients, respectively; the only facial deficit (House-Brackmann grade III) occurred in a patient who received a tumor dose of 20 Gy early in our experience (1988). None of the patients treated with doses lower than 13 Gy experienced facial or trigeminal neuropathy. All patients continued their previous level of activity or employment after GK SRS. No patient developed a secondary radiation-related tumor. CONCLUSION: Our experience indicates that GK SRS is an effective management strategy for younger patients with vestibular schwannoma, most of whom have no additional cranial nerve dysfunction.

The results of resection after stereotactic radiosurgery for brain metastases.

OBJECT: Radiosurgery for brain metastasis fails in some patients, who require further surgical care. In this paper the authors' goal was to evaluate prognostic factors that correlate with the survival of patients who require a resection of a brain metastasis after stereotactic radiosurgery (SRS). METHODS: During the last 14 years when surgical navigation systems were routinely available, the authors identified 58 patients who required resection for various brain metastases after SRS. The median patient age was 54 years. Prior adjuvant treatment included whole-brain radiation therapy alone (17 patients), chemotherapy alone (9 patients), both radiotherapy and chemotherapy (10 patients), and prior resection before SRS (8 patients). The median target volumes at the time of SRS and resection were 7.7 cm(3) (range 0.5-24.9 cm(3)) and 15.5 cm(3) (range 1.3-81.2 cm(3)), respectively. RESULTS: At a median follow-up of 7.6 months, 8 patients (14%) were living and 50 patients (86%) had died. The survival after surgical removal was 65, 30, and 16% at 6, 12, and 24 months, respectively (median survival after resection 7.7 months). The local tumor control rate after resection was 71, 62, and 43% at 6, 12, and 24 months, respectively. A univariate analysis revealed that patient preoperative recursive partitioning analysis classification, Karnofsky Performance Scale status, systemic disease status, and the interval between SRS and resection were factors associated with patient survival. The mortality and morbidity rates of resection were 1.7 and 6.9%, respectively. CONCLUSIONS: In patients with symptomatic mass effect after radiosurgery, resection may be warranted. Patients who had delayed local progression after SRS (> 3 months) had the best outcomes after resection.