Headache in patients with non-functioning pituitary adenoma before and after transsphenoidal surgery - a prospective study.

PURPOSE: To study the long-term effect of transsphenoidal surgery (TSS) on headache in patients with non-functioning pituitary adenoma (NFPA) and identify factors predicting headache relief following TSS. METHODS: We evaluated headache in 101 consecutive patients with NFPA who underwent TSS from September 2015 to December 2021, preoperatively and 12-months post-surgery, by using the Migraine Disability Assessment (MIDAS) questionnaire. Health-related quality of life (QoL) was assessed using the EQ-5D visual analogue scale (EQ-VAS). RESULTS: Of 101 patients, 27 (27%) experienced disabling preoperative headache. Among these, the median total MIDAS score improved from 60 (interquartile range (IQR): 19-140) to 10 (IQR: 0-49) (P = 0.004). Additionally, headache frequency over a 90-day period decreased from 45 (IQR: 25-83) to 6 (IQR: 3-36) days (P = 0.002), and headache intensity decreased from 5 (IQR: 4-7) to 4 (IQR: 2-7) (P = 0.016) at 12-months post-surgery. At 12 months post-surgery, 18 (67%) of 27 patients with preoperatively disabling headache showed clinically relevant improvement of their headache, 4 (15%) showed deterioration, and 5 (19%) remained unchanged. In patients with clinically relevant improvement of their headache, the EQ-VAS score improved from 50 (IQR: 30 - 7) to 80 (IQR: 65-86) (P < 0.001). Of the 74 patients with no preoperative headache, 11 (15%) developed postoperative headache. We identified no clinical factors predicting postoperative headache relief. CONCLUSION: The study supports that clinically significant and long-lasting improvements of disabling headache and QoL can be achieved with TSS in a substantial number of patients with NFPA.

The glymphatic system for neurosurgeons: a scoping review.

The discovery of the glymphatic system has revolutionized our understanding of cerebrospinal fluid (CSF) circulation and interstitial waste clearance in the brain. This scoping review aims to synthesize the current literature on the glymphatic system's role in neurosurgical conditions and its potential as a therapeutic target. We conducted a comprehensive search in PubMed and Scopus databases for studies published between January 1, 2012, and October 31, 2023. Studies were selected based on their relevance to neurosurgical conditions and glymphatic function, with both animal and human studies included. Data extraction focused on the methods for quantifying glymphatic function and the main results. A total of 67 articles were included, covering conditions such as idiopathic normal pressure hydrocephalus (iNPH), idiopathic intracranial hypertension (IIH), subarachnoid hemorrhage (SAH), stroke, intracranial tumors, and traumatic brain injury (TBI). Significant glymphatic dysregulation was noted in iNPH and IIH, with evidence of impaired CSF dynamics and delayed clearance. SAH studies indicated glymphatic dysfunction with the potential therapeutic effects of nimodipine and tissue plasminogen activator. In stroke, alterations in glymphatic activity correlated with the extent of edema and neurological recovery. TBI studies highlighted the role of the glymphatic system in post-injury cognitive outcomes. Results indicate that the regulation of aquaporin-4 (AQP4) channels is a critical target for therapeutic intervention. The glymphatic system plays a critical role in the pathophysiology of various neurosurgical conditions, influencing brain edema and CSF dynamics. Targeting the regulation of AQP4 channels presents as a significant therapeutic strategy. Although promising, the translation of these findings into clinical practice requires further human studies. Future research should focus on establishing non-invasive biomarkers for glymphatic function and exploring the long-term effects of glymphatic dysfunction.

Observations from the first 100 cases of intraoperative MRI - experiences, trends and short-term outcomes.

BACKGROUND: We sought to analyze, in well-defined clinical setting, the first 100 patients treated at the intraoperative MRI (iMRI) hybrid surgical theatre at our facility in a population-based setting to evaluate which pathologies are best approached with iMRI assisted surgeries, as this is not yet clearly defined. METHODS: Patients undergoing surgery in the 3T iMRI hybrid surgical theatre at our neurosurgical department between December 2017 to May 2021 were included after informed consent. Demographic, clinical, surgical, histological, radiological and outcome parameters, as well as variables related to iMRI, were retrospectively collected and analyzed. Patients were subdivided into adult and pediatric cohorts. RESULTS: Various neurosurgical procedures were performed; resection of tumors and epileptic foci, endoscopic skull base procedures including pituitary lesions, deep brain stimulation (DBS) and laser interstitial thermal therapy (LITT). In total, 41 patients were pediatric. An iMRI scan was carried out in 96% of cases and led to continuation of surgery in 50% of cases, mainly due to visualized remaining pathological tissue (95.2%). Median time to iMRI from intubation was 280 min and median total duration of surgery was 445 min. The majority of patients experienced no postoperative complications (70%), 13 patients suffered permanent postoperative deficits, predominantly visual. CONCLUSION: Herein, we demonstrate the first 100 patients undergoing neurosurgery aided by iMRI at our facility since introduction. Indications for surgery differed between pediatric and adult patients. The iMRI was utilized for tumor surgeries, particularly adult low-grade gliomas and pediatric tumors, as well as for epilepsy surgery and DBS. In this heterogenous population, iMRI led to continuation of surgery in 50%. To establish the benefit in maximizing the extent of resection in these brain pathologies future studies are recommended. CLINICAL TRIAL NUMBER: Not applicable.

Hypotension during transsphenoidal pituitary surgery associated with increase in plasma levels of brain injury markers.

BACKGROUND: Patients undergoing pituitary surgery may experience short- and long-term postoperative morbidity. Intraoperative factors such as hypotension might be a contributing factor. Our aim was to investigate the association between intraoperative hypotension and postoperative plasma levels of tau, neurofilament light (NfL), and glial fibrillary acidic protein (GFAP) as markers of perioperative brain injury. METHODS: Between June 2016 and October 2017, 35 patients from the Gothenburg Pituitary Tumor Study were included. For tau, NfL, and GFAP, concentrations were measured in plasma samples collected before and immediately following surgery, and on postoperative days 1 and 5. The difference between the highest postoperative value and the value before surgery was used for analysis (∆taupeak , ∆NfLpeak , ∆GFAPpeak ). Intraoperative hypotension was defined as the area under the curve of an absolute threshold below 70 mmHg (AUC70) and a relative threshold below 20% (AUC20%) of the baseline mean arterial blood pressure. RESULTS: Plasma tau and GFAP were highest immediately following surgery and on day 1, while NfL was highest on day 5. There was a positive correlation between AUC20% and both ∆taupeak (r2 = .20, p < .001) and ∆NfLpeak (r2 = .26, p < .001). No association was found between AUC20% and GFAP or between AUC70 and ∆taupeak , ∆NfLpeak or ∆GFAPpeak . CONCLUSION: Intraoperative relative, but not absolute, hypotension was associated with increased postoperative plasma tau and NfL concentrations. Patients undergoing pituitary surgery may be vulnerable to relative hypotension, but this needs to be validated in future prospective studies.

A single-centre study of frame-based stereotactic brain biopsies.

OBJECTIVE: We aimed to evaluate the concordance between the image-based and the tissue-based diagnosis using frame-based stereotactic biopsy. MATERIALS AND METHODS: Medical records of biopsy procedures from 2000 to 2017 were reviewed. The radiologists' preoperative reports, biopsy procedures and postoperative histopathological diagnoses were retrieved. We compared the preoperative image-based diagnosis with the final histopathological diagnosis. RESULTS: We identified 125 biopsy procedures performed in 123 patients. The concordance between image-based and histopathological diagnoses varied between 53.3% and 87.5%. The concordance of diagnosis concerning both tumor entity (i.e. cell type) and WHO grade was 54.6%. The diagnostic yield was 95.2%. There was overall morbidity of 10.4%, and a mortality rate of 0.8%. Minor complications occurred in 4.0% of the cases, while clinically significant complications occurred in 6.4% of the cases. CONCLUSIONS: There was suboptimal concordance between radiological and histopathological diagnosis. Also, there was a tendency of histopathological undergrading. We confirm that frame-based stereotactic biopsies have a high diagnostic yield and a low rate of clinically significant complications and mortality.

Virtual magnetic resonance elastography has the feasibility to evaluate preoperative pituitary adenoma consistency.

PURPOSE: To evaluate the use of preoperative virtual Magnetic Resonance Elastography (vMRE) for patients undergoing transsphenoidal resection of pituitary adenomas (PA). METHODS: Ten patients (60.2 ± 19.6 years; 8 males) were prospectively examined with the vMRE-method prior to transsphenoidal surgery. vMRE-images, reflecting tissue stiffness were reconstructed. From these images, histograms as well as the mean stiffness values over the tumor body were extracted. Finally, vMRE-data was compared with the PA consistency at surgery blinded to vMRE. RESULTS: In all patients, successful vMRE-examination was performed enabling evaluation of even small PAs. For tumors with homogenous tissue, the mean stiffness value increased with surgical consistency grading. For heterogenous tumors, however, the mean stiffness value did not consistently reflect the grading at surgery. On the other hand, the vMRE-images and histograms were found to be able to characterize the tumor heterogeneity and display focal regions of high stiffness that were found to affect the surgery outcome in these PAs. The vMRE-images and histograms showed great promise in characterizing the consistency at surgery for these PAs. CONCLUSION: Evaluation of PA consistency in preparation for surgery seems to be feasible using the vMRE-method. Our findings also address the need for high resolution diagnostic methods that can non-invasively display focal regions of increased stiffness, as such regions may increase the difficulty of transsphenoidal PA-resection.

Indications and outcome in surgically treated asymptomatic meningiomas: a single-center case-control study.

BACKGROUND: Many meningiomas are detected incidentally and remain asymptomatic until intervention. The goal of this study was to describe the management and outcome in this group of surgically treated asymptomatic meningiomas. METHODS: From 2004 to 2017, 45 patients with asymptomatic meningioma were surgically treated at Sahlgrenska University Hospital, and their medical records and imaging data were analyzed. The asymptomatic cases were matched with symptomatic ones with respect to age at diagnosis, location, WHO (World Health Organization) grade, and Simpson grade. RESULTS: Time from diagnosis to surgery differed between the asymptomatic and symptomatic patients (8.6 vs. 1.3 months; p < 0.001). Of symptomatic patients, 32.6% still used anti-epileptic drugs > 1 year after surgery, compared with 7.7% of the asymptomatic (p = 0.003). Thirty-day complication rate was significantly higher among the asymptomatic cases (35.6% vs. 24.4%; 0.001), as well as the proportion of older asymptomatic individuals (> 70 years) experiencing postoperative complication compared with symptomatic patients of the same age group. CONCLUSION: As expected, asymptomatic cases had smaller tumors and waited longer for surgery. Surprisingly, complication rate was significantly higher among asymptomatic cases compared with their symptomatic control. Taken into account that many asymptomatic tumors are removed surgically due to patient's wish, one might suggest a more restrictive approach, especially in the elderly.

Chiari I malformation-neuropsychological functions and quality of life.

OBJECTIVE: To assess the neuropsychological (NP) functioning and quality of life (QOL) before and 3 months after surgery on adults with Chiari I malformation (CMI). PATIENTS AND METHODS: All adult patients who had been diagnosed with CMI were invited to participate. Those who participated were assessed using a Hospital Anxiety and Depression scale (HAD) and NP examinations. Their QOL was assessed using the self-reported life satisfaction checklist, LiSat-11 and the five-dimensional EuroQol measurement of health outcome, EQ-5D-5L. All assessments were carried out both before and 3 months after surgery was performed. Demographic data and comorbidities were also registered. RESULTS: Of the 11 patients who underwent NP assessment, the majority demonstrated cognitive functioning within the normal range. However, postoperatively, their performance in verbal learning, psychomotor speed, colour naming speed and the ability to manage interference through response selection and inhibition (aspects of executive functioning) was significantly improved. Thirteen patients completed QOL assessments. When LiSat-11 item domains were compared with those of healthy subjects, patients reported a lower level of satisfaction with their life quality both before and after surgery. However, the EQ-5D-5L measurements, i.e., the descriptive system and the visual analogue, indicated that their QOL of life was significantly improved after surgery. CONCLUSION: There is scarcely any literature documenting effects of surgery on the QOL of CMI patients. The study we present here breaks new ground by comparing pre- and postoperative NP functions in CMI. We also examine the value of surgery for improving both NP functions and QOL in CMI.

Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management.

PURPOSE: Non-functioning pituitary adenomas (NFPAs) are associated with impaired well-being, increased comorbidities, and reduced long-term survival. Data on optimal management of NFPAs around surgical treatment are scarce, and postoperative treatment and follow-up strategies have not been evaluated in prospective trials. Here, we review the preoperative, perioperative, and early postoperative management of patients with NFPAs. METHODS: We searched Medline and the Cochrane Library for articles published in English with the following items "Pituitary neoplasms AND Surgery" and "Surgery AND Hypopituitarism". Studies containing detailed analyses of the management of NFPAs in adult patients, including pituitary surgery, endocrine care, imaging, ophthalmologic assessment and long-term outcome were reviewed. RESULTS: Treatment options for NFPAs include active surveillance, surgical resection, and radiotherapy. Pituitary surgery is currently recommended as first-line treatment in patients with visual impairment due to adenomas compressing the optic nerves or chiasma. Radiotherapy is reserved for large tumor remnants or tumor recurrence following one or more surgical attempts. There is no consensus of optimal pre-, peri-, and postoperative management such as timing, frequency, and duration of endocrine, radiologic, and ophthalmologic assessments as well as management of smaller tumor remnants or tumor recurrence. CONCLUSIONS: In clinical practice, there is a great variation in the treatment and follow-up of patients with NFPAs. We have, based on available data, suggested an optimal management strategy for patients with NFPAs in relation to pituitary surgery. Prospective trials oriented at drawing up strategies for the management of NFPAs are needed.

Neurosurgical treatment and outcome patterns of meningioma in Sweden: a nationwide registry-based study.

BACKGROUND: Surgery is the main treatment modality for intracranial meningiomas, but data on short-term surgical outcome are limited. The aim of this Swedish nationwide registry-based study was to benchmark the 30-day complication rate in a cohort of meningioma patients using data from the Swedish brain tumor registry (SBTR). Furthermore, we investigated outcomes for asymptomatic patients. METHODS: Data were collected from the SBTR for all adults with histopathologically verified intracranial meningioma between 2009 and 2015. Patient symptoms, tumor characteristics, and complications within 30 days postoperatively were analyzed. RESULTS: In total, 2324 patients, with a mean age of 58.7 years (SD 13.5), underwent surgery for intracranial meningioma and 14.1% of the patients were asymptomatic before the intervention. The most common symptom prior to treatment was focal deficit, which occurred in 1450 patients (62.4%). Moreover, within 30 days after surgery, 344 patients (14.8%) developed new neurological deficits and new-onset seizures occurred in 105 patients (4.5%), while 8.3% of asymptomatic patients developed neurological deficit and 3.7% new-onset seizures. Due to complications, reoperations were performed in 120 patients (5.2%). The postoperative 30-day mortality in the whole cohort was 1.5%. CONCLUSION: This study benchmarks the 30-day complication rate after meningioma surgery and provides outcome data in the highly relevant group of asymptomatic patients using data from the Swedish brain tumor registry. Since surgical decision-making is a careful consideration of short-term risk versus long-term benefit, this information may be useful for both caregivers and patients.

Longitudinal changes in diffusion tensor imaging parameters of the corpus callosum between 6 and 12 months after diffuse axonal injury.

BACKGROUND: Magnetic resonance diffusion tensor imaging (MR-DTI) is used increasingly to detect diffuse axonal injury (DAI) after traumatic brain injury (TBI). PRIMARY OBJECTIVE: To investigate changes in the diffusion tensor imaging parameters of the corpus callosum 6 and 12 months after TBI, to optimize the timing of follow-up DTI investigations. A secondary goal was to study the relationship between DTI parameters and outcome. RESEARCH DESIGN: Longitudinal prospective study. METHODS AND PROCEDURES: MR-DTI was performed in 15 patients with suspected DAI, 6 and 12 months post-injury. Sixteen controls were also examined. Fractional anisotropy (FA) and diffusivity (trace) in the corpus callosum were analysed. The outcome measures were the extended Glasgow Outcome Scale and the Barrow Neurological Institute Screen for Higher Cerebral Functions, assessed at 6 and 12 months. MAIN OUTCOMES AND RESULTS: FA decreased and trace increased at 6 and 12 months compared to controls. Trace continued to increase even further between 6 and 12 months, while FA remained unchanged. Patients with the worst outcomes had lower FA and higher trace compared to patients with better outcomes. CONCLUSIONS: DTI parameters have not reached a stable level at 6 months after DAI, but continue to change, probably reflecting an incessant microstructural alteration of the white matter.

Surgical Replacement of Implantable Pulse Generators in Deep Brain Stimulation: Adverse Events and Risk Factors in a Multicenter Cohort.

BACKGROUND: Deep brain stimulation (DBS) is a growing treatment modality, and most DBS systems require replacement of the implantable pulse generator (IPG) every few years. The literature regarding the potential impact of adverse events of IPG replacement on the longevity of DBS treatments is rather scarce. OBJECTIVE: To investigate the incidence of adverse events, including postoperative infections, associated with IPG replacements in a multicenter cohort. METHODS: The medical records of 808 patients from one Australian and five Swedish DBS centers with a total of 1,293 IPG replacements were audited. A logistic regression model was used to ascertain the influence of possible predictors on the incidence of adverse events. RESULTS: The overall incidence of major infections was 2.3% per procedure, 3.7% per patient and 1.7% per replaced IPG. For 28 of 30 patients this resulted in partial or complete DBS system removal. There was an increased risk of infection for males (OR 3.6, p = 0.026), and the risk of infection increased with the number of prior IPG replacements (OR 1.6, p < 0.005). CONCLUSIONS: The risk of postoperative infection with DBS IPG replacement increases with the number of previous procedures. There is a need to reduce the frequency of IPG replacements.

Circulating Brain Injury Biomarkers for Predicting Outcomes Following Elective Neurosurgery: A Scoping Review.

OBJECTIVE: There is a need for refined methods to detect and quantify brain injuries that may be undetectable by magnetic resonance imaging and neurologic examination. This review evaluates the potential efficacy of circulating brain injury biomarkers for predicting outcomes following elective neurosurgical procedures. METHODS: A comprehensive search was conducted using the Cochrane, PubMed, and Scopus databases. RESULTS: Analysis of 23 relevant studies revealed that specific biomarkers, including glial fibrillary acidic protein, neurofilament light chain, neuron-specific enolase, S100B, and tau, are significantly associated with the extent of brain injury and could potentially predict postsurgical outcomes. The evaluated studies described intracranial tumor surgeries and miscellaneous neurosurgical interventions and demonstrated the complex relationship between biomarker levels and patient outcomes. CONCLUSIONS: Circulating brain injury biomarkers show promise for providing objective insights into the extent of perioperative brain injury and improving prognostication of postsurgical outcomes. However, the heterogeneity in study designs and outcomes along with the lack of standardized biomarker thresholds underscore the need for further research.

Cognitive function in pituitary adenoma patients: A cross-sectional study.

Various factors may affect cognition in patients with pituitary adenoma, including size and extension of the tumor, degree of pituitary hormone deficiencies, and treatment of the tumor, most often being transsphenoidal surgery (TSS). The aim of this cross-sectional study was to evaluate cognitive function in patients with clinically significant pituitary adenoma and to identify factors influencing cognition. Sixty-eight patients with pituitary adenoma were included. Of these, 31 patients were evaluated before TSS and 37 patients 12 months following TSS. Cognitive function was evaluated by using the Repeatable Battery for the Assessment of Neuropsychological Status. Patients had lower mean scores on cognitive assessment compared to age-adjusted normative data. Variability in cognition, analyzed by linear regression analysis, was explained by sex, educational level, and self-perceived fatigue, but not by pituitary hormone deficiencies, diabetes insipidus, or surgical treatment. Our results are in line with previous findings, namely that pituitary adenoma affects cognition. To better evaluate the factors affecting cognition, longitudinal studies are recommended. Such studies would allow for within-individual comparisons, effectively controlling for the considerable influence of sex and education on test results.

Proteomic Profiles Associated With Postsurgical Progression in Nonfunctioning Pituitary Adenomas.

CONTEXT: There is a lack of reliable biomarkers capable of predicting postoperative tumor progression of nonfunctioning pituitary adenomas (NFPAs). OBJECTIVE: To discover proteomic profiles associated with postoperative tumor progression in patients with NFPAs. This was a case-controlled exploratory study at a tertiary university hospital. Tissue samples were obtained from 46 patients with residual tumor following surgery for NFPAs of gonadotroph lineage. Two patient groups were compared: patients requiring reintervention due to residual tumor progression (cases; reintervention group, n = 29) and patients with a residual tumor showing no progression for a minimum of 5 years (controls; radiologically stable group, n = 17). Differentially expressed proteins (DEPs) between patient groups were measured. RESULTS: Global quantitative proteomic analysis identified 4074 proteins, of which 550 were differentially expressed between the 2 groups (fold change >80%, false discovery rate-adjusted P ≤ .05). Principal component analysis showed good separation between the 2 groups. Functional enrichment analysis of the DEPs indicated processes involving translation, ROBO-receptor signaling, energy metabolism, mRNA metabolism, and RNA splicing. Several upregulated proteins in the reintervention group, including SNRPD1, SRSF10, SWAP-70, and PSMB1, are associated with tumor progression in other cancer types. CONCLUSION: This is the first exploratory study analyzing proteomic profiles as markers of postoperative tumor progression in NFPAs. The findings clearly showed different profiles between tumors with indolent postoperative behavior and those with postoperative tumor progression. Both enriched pathways involving DEPs and specific upregulated proteins have previously been associated with tumor aggressiveness. These results suggest the value of proteomic profiling for predicting tumor progression in patients with NFPAs.

Cognitive impact of traumatic axonal injury (TAI) and return to work.

OBJECTIVE: Axonal injury (AI) after traumatic brain injury (TBI) is often overlooked as an explanation for cognitive complaints when no damage is detected by computed tomography. The purpose was to assess cognition during the 12 months following a TBI and suspected traumatic axonal injury (TAI). METHODS: The sample included 17 patients younger than 65 years old, however one died. In the acute phase and at 6 and 12 months, cognition, reaction time, psychomotor performance and finger tapping speed were assessed. Working memory and work status were added at 12 months. Acute MRI findings were recorded. RESULTS: After 1 year, all patients still showed cognitive dysfunction. A recovery had been noted at 6 months, but a cognitive decline was indicated for the majority at 12 months. The sick-listed patients had TAI located in the corpus callosum and the brainstem. They were cognitively more impaired and in more areas than the four patients who had returned to work. CONCLUSION: Cognitive screening can identify the long-term impact of TAI identified by conventional MRI, used as a routine clinical technique. For rehabilitation and for insurance-related matters, these injuries must be taken seriously, as a deterioration over time might occur. Further research is needed.

[The glymphatic system - an overview]. / Glymfatiska systemet ­ renar hjärnan från slaggprodukter.

The glymphatic system as a concept was introduced a decade ago and the knowledge regarding the circulation of the cerebrospinal fluid has since been revised. The research of the glymphatic system is extensive today, but there are many knowledge gaps. The glymphatic system was first investigated in animal experiments, but with the MR techniques available today the glymphatic system has also been shown to exist in humans. Studies suggest that the glymphatic system may be involved in the pathophysiological processes of neurological pathologies, such as degenerative brain disorders and normal pressure hydrocephalus (NPH), but also in the aftermath of ischemic stroke, subarachnoidal hemorrhage and traumatic brain injury. It is believed that the glymphatic system with its cleansing capabilities is upregulated during sleep, and interestingly studies show association between lack of sleep and neurodegenerative diseases. In this article, we present an overview of the glymphatic system and its possible role in intracranial pathologies.

Prestroke physical activity is associated with admission haematoma volume and the clinical outcome of intracerebral haemorrhage.

BACKGROUND: Prestroke physical activity (PA) has been linked to improved outcomes after intracerebral haemorrhage (ICH), but its association with ICH volume is unknown. We aimed to investigate associations of prestroke PA with location-specific haematoma volume and the clinical outcome of ICH. METHODS: All patients with primary ICH, admitted to three hospitals between 2014 and 2019, were included. Patients performing light PA ≥4 hour/week the year before stroke were considered physically active. Haematoma volumes were assessed from admission brain imaging. Adjusted associations were estimated using multivariate linear and logistic regression models. Haematoma volume was explored as mediator to the relationship between prestroke PA and mild stroke severity (0-4 points on the National Institutes of Health Stroke Scale), a good 1-week functional status (0-3 points on the modified Rankin Scale) and 90-day survival. Average direct effects (ADE) and average causal mediation effects (ACME) were computed. RESULTS: Of 686 primary ICH cases, 349 were deep, 240 lobar and 97 infratentorial. Prestroke PA predicted smaller haematoma volumes in deep ICH (ß=-0.36, SE=0.09, p<0.001) and lobar ICH (ß=-0.23, SE=0.09, p=0.016). Prestroke PA was also associated with mild stroke severity (OR 2.53, 95% CI 1.59 to 4.01), a good 1-week functional status (OR 2.12, 95% CI 1.37 to 3.30) and 90-day survival (OR 3.48, 95% CI 2.06 to 5.91). Haematoma volume partly mediated the relationships between PA and stroke severity (ADE 0.08, p=0.004; ACME 0.10, p<0.001), 1-week functional status (ADE 0.07, p=0.03; ACME 0.10, p<0.001) and 90-day survival (ADE 0.14, p<0.001; ACME 0.05, p<0.001). CONCLUSIONS: Light PA ≥4 hour/week prior to ICH was associated with smaller haematoma volumes in deep and lobar locations. Physically active patients with ICH had a higher likelihood of mild stroke, a good 1-week functional status and 90-day survival, in part mediated by smaller haematoma volumes on admission.

Overview and recent advances in incidental meningioma.

INTRODUCTION: Meningioma has a prevalence around 1% in the population, and with the increasing use and availability of diagnostic imaging modalities, incidental meningiomas are increasingly detected. There is no clear consensus on their management, although several guidelines suggest firsthand active monitoring if no aggravating factors emerge. However, no collective guidelines on follow-up interval exist. AREAS COVERED: This narrative review covers the epidemiology, diagnosis, growth prediction, and management strategies of incidental meningioma. EXPERT OPINION: Overdiagnosis and excessive follow-up are potential pitfalls in the management of incidental meningioma. An MRI after 6-12 months could be reasonable to rule out rapid growth and differential diagnoses. Using the available prognostic models, one might later suggest more active monitoring for certain patient groups harboring specific radiological features predictive of growth. However, detecting growth may not necessarily be clinically significant as all larger non-growing meningiomas have at one point been small. Too much follow-up may place an unnecessary burden on patients and the health-care system and could be a driver toward overtreatment. It must be contemplated whether growth is an acceptable primary outcome measure or if there are other factors more relevant to consider in this often benign tumor entity.