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BACKGROUND Gross total resection (GTR) of contrast-enhancing tumor is associated with increased survival in primary glioblastoma. Recently, there has been increasing interest in performing supratotal resections (SpTRs) for glioblastoma. OBJECTIVE To address the published results, which have varied in part due to lack of consensus on the definition and appropriate use of SpTR. METHODS A crowdsourcing approach was used to survey 21 neurosurgical oncologists representing 14 health systems nationwide. Participants were presented with 11 definitions of SpTR and asked to rate the appropriateness of each definition. Participants reviewed T1-weighed postcontrast and fluid-attenuated inversion-recovery magnetic resonance imaging for 22 anatomically distinct glioblastomas. Participants were asked to assess the tumor location's eloquence, the perceived equipoise of enrolling patients in a randomized trial comparing gross total to SpTR, and their personal treatment plans. RESULTS Most neurosurgeons surveyed (n = 18, 85.7%) agree that GTR plus resection of some noncontrast enhancement is an appropriate definition for SpTR. Overall, moderate inter-rater agreement existed regarding eloquence, equipoise, and personal treatment plans. The 4 neurosurgeons who had performed >10 SpTRs for glioblastomas in the past year were more likely to recommend it as their treatment plan (P

Background Sport-related structural brain injury (SRSBI) is intracranial pathology incurred during sport. Management mirrors that of non-sport-related brain injury. An empirical vacuum exists regarding return to play (RTP) following SRSBI. Objective To provide key insight for operative management and RTP following SRSBI using a (1) focused systematic review and (2) survey of expert opinions. Methods A systematic literature review of SRSBI from 2012 to present in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a cross-sectional survey of RTP in SRSBI by 31 international neurosurgeons was conducted. Results Of 27 included articles out of 241 systematically reviewed, 9 (33.0%) case reports provided RTP information for 12 athletes. To assess expert opinion, 31 of 32 neurosurgeons (96.9%) provided survey responses. For acute, asymptomatic SRSBI, 12 (38.7%) would not operate. Of the 19 (61.3%) who would operate, midline shift (63.2%) and hemorrhage size > 10 mm (52.6%) were the most common indications. Following SRSBI with resolved hemorrhage, with or without burr holes, the majority of experts (>75%) allowed RTP to high-contact/collision sports at 6 to 12 mo. Approximately 80% of experts did not endorse RTP to high-contact/collision sports for athletes with persistent hemorrhage. Following craniotomy for SRSBI, 40% to 50% of experts considered RTP at 6 to 12 mo. Linear regression revealed that experts allowed earlier RTP at higher levels of play (β = -0.58, 95% CI -0.111, -0.005, P = .033). Conclusion RTP decisions following structural brain injury in athletes are markedly heterogeneous. While individualized RTP decisions are critical, aggregated expert opinions from 31 international sports neurosurgeons provide key insight. Level of play was found to be an important consideration in RTP determinations.

Please see the full-text version of this guideline https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_2) for the target population of each recommendation listed below. SURGERY FOR METASTATIC BRAIN TUMORS AT NEW DIAGNOSIS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgery, stereotactic radiosurgery (SRS), or whole brain radiotherapy (WBRT)? Recommendations Level 1: Surgery + WBRT is recommended as first-line treatment in patients with single brain metastases with favorable performance status and limited extracranial disease to extend overall survival, median survival, and local control. Level 3: Surgery plus SRS is recommended to provide survival benefit in patients with metastatic brain tumors Level 3: Multimodal treatments including either surgery + WBRT + SRS boost or surgery + WBRT are recommended as alternatives to WBRT + SRS in terms of providing overall survival and local control benefits. SURGERY AND RADIATION FOR METASTATIC BRAIN TUMORS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgical resection followed by WBRT, SRS, or another combination of these modalities? Recommendations Level 1: Surgery + WBRT is recommended as superior treatment to WBRT alone in patients with single brain metastases. Level 3: Surgery + SRS is recommended as an alternative to treatment with SRS alone to benefit overall survival. Level 3: It is recommended that SRS alone be considered equivalent to surgery + WBRT. SURGERY FOR RECURRENT METASTATIC BRAIN TUMORS QUESTION: Should patients with recurrent metastatic brain tumors undergo surgical resection? Recommendations Level 3: Craniotomy is recommended as a treatment for intracranial recurrence after initial surgery or SRS. SURGICAL TECHNIQUE AND RECURRENCE QUESTION A: Does the surgical technique (en bloc resection or piecemeal resection) affect recurrence? Recommendation Level 3: En bloc tumor resection, as opposed to piecemeal resection, is recommended to decrease the risk of postoperative leptomeningeal disease when resecting single brain metastases. Question b Does the extent of surgical resection (gross total resection or subtotal resection) affect recurrence? Recommendation Level 3: Gross total resection is recommended over subtotal resection in recursive partitioning analysis class I patients to improve overall survival and prolong time to recurrence. The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_2.

Glioblastoma multiforme (GBM) are the most common and among the deadliest brain tumors in adults. Current mainstay treatments are insufficient to treat this tumor, and therefore, more effective therapies are desperately needed. Immunotherapy, which takes advantage of the body's natural defense mechanism, is an exciting emerging field in neuro-oncology. Adoptive cell therapy with chimeric antigen receptor (CAR) T cells provides a treatment strategy based on using patients’ own selected and genetically engineered cells that target tumor-associated antigens. These cells are harvested from patients, modified to target specific proteins expressed by the tumor, and re-introduced into the patient with the goal of destroying tumor cells. Here, we review the history of CAR T-cell therapy, and describe the characteristics of various generations of CAR T therapies, and the challenges inherent to treatment of GBM. Finally, we describe recent and current CAR T clinical trials designed to combat GBM.

Background The Open Payments Database (OPD) was launched by the Centers for Medicare & Medicaid Services in 2014. Through this online searchable database, the public can explore physician-industry interactions. To date, there is no published literature on the accuracy of the database for neurosurgeons or any physician specialty. Objective To study the accuracy of published records and scope of industry-neurosurgeon relationships between neurosurgeons and industry within the OPD. Methods We searched 4.3 million records in 2013 and 11.41 million records in 2014 in the OPD for board-certified neurosurgeons verified by the American Board of Neurological Surgery. Delimit software was used to condense these data, Microsoft Access for database queries, and STATA to perform descriptive analyses. Results Of the 3240 neurosurgeons in the OPD in 2013, 2020 were identified correctly as neurosurgeons within the database (62%). Of the 3593 neurosurgeons in the OPD in 2014, 2433 were identified correctly as neurosurgeons (68%). Within the OPD in 2013, there were 72 066 attributed records for neurosurgeons; within the 2014 OPD, there were 160 563 attributed records for neurosurgeons. Total payments to neurosurgeons in 2013 (for the 9 months published in OPD): $61 802 659.37; in 2014: $117 127 824.00. Conclusion The OPD details physician interactions with industry and has multiple inaccuracies. Publicly availing inaccurate information through a searchable governmental website that can be accessed by patients and journalists alike has the potential to tarnish individual neurosurgeons and undermine professional credibility. Abbreviations CMS, Centers for Medicare & Medicaid ServicesOPD, Open Payments Database.

Laser-induced thermal therapy has become a powerful tool in the neurosurgical armamentarium. The physics of laser therapy are complex, but a sound understanding of this topic is clinically relevant, as many centers have incorporated it into their treatment algorithm, and educated patients are demanding consideration of its use for their disease. Laser ablation has been used for a wide array of intracranial lesions. Laser catheter placement is guided by stereotactic planning; however, as the procedure has popularized, the number of ways in which the catheter can be inserted has also increased. There are many technical nuances for laser placement, and, to date, there is not a clear understanding of whether any one technique is better than the other. In this review, we describe the basic physics of magnetic resonance-guided laser-induced thermal therapy and describe the several common techniques for accurate Visualase laser catheter placement in a stepwise fashion. ABBREVIATIONS MRg-LITT, magnetic resonance-guided laser-induced thermal therapyPAD, precision aiming device.

Innovation in medicine has led to advances directly benefitting patients. Yet recent legislation has created intense scrutiny of the relationship between surgeons and industry. Critics argue that surgeon-held patents and royalties incentivize surgeon loyalty, influencing decision making as to which devices are used intraoperatively. We explored the potential for inventor-related conflicts of interest. We searched patent records from the United States Patent and Trademark Office for every diplomate recognized by the American Board of Neurological Surgeons (4868 neurosurgeons). We also searched physician payment registries of the 5 largest device makers; of these, Medtronic, DePuy, and Zimmer were the only companies with available registries. A total of 147 neurosurgeons (3.0%) hold a total of 582 patents; the number of patents held per neurosurgeon ranges from 1 to 53. The fields in which patents are held include tumor (125), spine (98), vascular (54), trauma (27), stereotaxy/image guidance (88), pain (19), peripheral nerve (2), electrical stimulation (63), and pediatrics (9); surgical instruments (59), drug delivery (17), and other (21) account for the remainder. The total amount of royalties received by neurosurgeons in 2010 is expected to be $13,223,000 (minimum: $7K, maximum: $8.261M). Despite public and legislative perceptions of widespread conflicts of interest, there are relatively few neurosurgeons who hold patents and receive significant royalties.

BACKGROUND The Emergency Medical Treatment and Active Labor Act was meant to provide access to emergency medical care irrespective of financial resources. Yet, many Level I trauma Centers have raised concerns about the financial drivers influencing transfer. OBJECTIVE : To study the relationship between insurance status and transfer, we focused on patients with mild head injury to tease apart the medical necessity for transfer from other potential drivers, such as financial factors. METHODS Using the 2002 to 2006 American College of Surgeons National Trauma Databank and Massachusetts General Hospital's Trauma Databank from 1993 to 2009, we conducted a retrospective study and limited our population to patients with mild head injuries and mild to moderate systemic injuries as determined by the Glasgow Coma Scale, Abbreviated Injury Scale, or Injury Severity Score. Statistical analyses were conducted with STATA software. RESULTS In a nationalized database, (1) uninsured patients with mild head injury are more likely to be transferred out of a Level II or III facility (adjusted odds ratio [OR]: 2.07; P = .000) compared with privately insured patients and (2) uninsured patients are less likely to be accepted by a Level II or III facility for transfer compared with privately insured patients (adjusted OR: = .143; P = .000l). For transfers received by 1 Level I trauma center (Massachusetts General Hospital), uninsured patients are more likely to be transferred to (1) Massachusetts General Hospital between midnight and 6 am (adjusted OR: 5.201; P = .000) compared with other time periods throughout the day and (2) Massachusetts General Hospital on Sunday (adjusted OR: 1.09; P = .000) compared with other days of the week. CONCLUSION Insurance status appears to influence transfer patterns.

Despite advances in the treatment of intracranial aneurysms (IA) in recent years, the overall outcome of patients with aneurysmal subarachnoid hemorrhage has shown only modest improvement. Given this poor prognosis, diagnosis of IA before rupture is of paramount importance. Currently, there are no reliable methods other than screening imaging studies of high-risk individuals to diagnose asymptomatic patients. Multiple levels of evidence suggest that environmental factors acting in concert with genetic susceptibilities lead to the formation, growth, and rupture of aneurysms in these patients. Epidemiological studies have already identified aneurysm-specific risk factors such as size and location, as well as patient-specific risk factors, such as age, sex, and presence of medical comorbidities, such as hypertension. In addition, exposure to certain environmental factors such as smoking have been shown to be important in the formation of IA. Furthermore, substantial evidence proves that certain loci contribute genetically to IA pathogenesis. Genome-wide linkage studies using relative pairs or rare families that are affected with the Mendelian forms of IA have already shown genetic heterogeneity of IA, suggesting that multiple genes, alone or in combination, are important in the disease pathophysiology. The linkage results, along with association studies, will ultimately lead to the identification of IA susceptibility genes. Identification of the genes important in IA pathogenesis will not only provide novel insights into the primary determinants of IA, but will also result in new opportunities for early diagnosis in the preclinical setting. Ultimately, novel therapeutic strategies based on biology will be developed, which will target these newly elucidated genetic susceptibilities.

BACKGROUND Although current guidelines for the management of unruptured intracranial aneurysms (IAs) suggest aneurysms larger than 7 mm should be considered for treatment, a significant number of subarachnoid hemorrhages are caused by IAs 7 mm or smaller. Thus, we sought to identify risk factors associated with the rupture of IAs 7 mm or smaller. METHODS We identified 100 patients with subarachnoid hemorrhage resulting from IAs 7 mm or smaller between January 2001 and 2004. Patients were compared with controls (n = 51) with unruptured IAs 7 mm or smaller, diagnosed by conventional angiography or three-dimensional computerized angiography, with respect to aneurysm characteristics (size, location, and age of presentation) and risk factors (hypertension, smoking, cocaine use, and family history). RESULTS Hypertensive patients with IAs 7 mm or smaller were 2.6 times more likely to experience rupture (P = 0.01; 95% confidence interval, 1.21-5.53) than patients with normal blood pressure. Posterior circulation aneurysms were 3.5 times more likely to rupture than anterior circulation aneurysms (P = 0.048; 95% confidence interval, 0.95-19.4). After adjustment for location and hypertension, the age of patient on presentation was associated with a trend toward inverse correlation with aneurysmal rupture risk (P = 0.07). Hypertension and posterior location remained significant independent predictors in the logistic regression model. CONCLUSION Among patients with small aneurysms (< or = 7 mm), hypertension, relatively young age, and posterior circulation were significant risk factors for rupture. Given the minimal long-term morbidity and mortality of treatment of unruptured aneurysms in large, tertiary medical centers, management of unruptured aneurysms 7 mm or smaller should be governed by factors other than size, specifically age, history of hypertension, and location.

INTRODUCTION:Gliomas are among the most lethal malignancies and their histogenesis in humans remains unresolved. IDH1 mutational status and co-occurring genetic alterations define major clinical and prognostic classes of gliomas that closely mirror their histologic classification into astrocytic or

BACKGROUND Postoperative hydrocephalus is common in patients after resection of a posterior fossa tumor, with as many as 25% of patients requiring permanent cerebrospinal fluid diversion in the form of ventricular shunting or ventriculocisternostomy in some series. Prophylactic ventriculocisternostomy has been described with success in this patient population to prevent postoperative hydrocephalus. OBJECTIVE To define the technique of microsurgical retrograde third ventriculostomy from the posterior fossa. METHODS The operative technique is described and a single patient with 4-year follow-up is reported. RESULTS We describe the case of a 32-year-old woman who presented with a large cerebellopontine angle epidermoid tumor. She underwent a simultaneous lesion resection and third ventriculocisternostomy by accessing the interpeduncular cistern via a suboccipital posterior fossa approach and then making an incision through the tuber cinereum to access the third ventricle under direct vision. CONCLUSION Retrograde third ventriculostomy may be useful in the surgical treatment of patients already undergoing operations for large posterior fossa lesions who have a high likelihood of requiring permanent cerebrospinal fluid diversion and in whom exposure of the interpeduncular cistern is available.