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BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has exerted a significant impact on health care workers. Recent studies have reported the detrimental effects of the pandemic on neurosurgery residents in North America, Asia, and Italy. However, the impact of the pandemic on neurosurgical training in Latin America and Spain has not yet been reported. In the present report, we describe effects of COVID-19 on training and working conditions of neurosurgery residents in these countries. METHODS: An electronic survey with 33 questions was sent to neurosurgery residents between September 7, 2020 and October 7, 2020. Statistical analysis was made in SPSS version 25. RESULTS: A total of 293 neurosurgery residents responded. The median age was 29.47 ± 2.6 years, and 79% (n = 231) were male. Of respondents, 36.5% (n = 107) were residents training from Mexico; 42% surveyed reported COVID symptoms and 2 (0.7%) received intensive care unit care; 61.4% of residents had been tested for COVID and 21.5% had a positive result; 84% of the respondents mentioned persisted with the same workload (≥70 hours per week) during the pandemic. Most residents from Mexico were assigned to management of patients with COVID compared with the rest of the countries (88% vs. 68.3%; P < 0.001), mainly in medical care (65.4% vs. 40.9%; P < 0.001), mechanical ventilators (16.8% vs. 5.9%; P = 0.003), and neurologic surgeries (94% vs. 83%; P = 0.006). CONCLUSIONS: Our results offer a first glimpse of the changes imposed by the COVID-19 pandemic on neurosurgical work and training in Latin America and Spain, where health systems rely strongly on a resident workforce.

Background Gangliogliomas (GGs) are extremely rare benign neoplasms frequently located within the temporal lobe that usually present with seizures. GGs growing predominantly within the ventricular system (VGGs) are even more infrequent, so definite conclusions concerning their diagnosis and therapeutic management are lacking. Methods A retrospective review of case reports of VGGs was performed from the introduction of modern imaging techniques, including 4 new illustrative cases treated in our department. Results Thirty-four cases were collected. Ages ranged from 10 to 71 years (mean, 26.62 years), and 55.9% were male. Most patients developed symptoms related to high intracranial pressure. The lateral ventricles were predominantly involved (58.8%). Obstructive hydrocephalus was observed in 54.5% of patients. Cystic degeneration and calcification were frequently observed. Surgical treatment was carried out in all cases. Morbidity and mortality were 17.6% and 2.9%, respectively. Gross total tumor resection was achieved in 64.5% of patients. Four patients experienced tumor dissemination along the neural axis. More than 90% of patients maintained a good functional status at last follow-up. Conclusions Despite their low incidence, a diagnosis of VGGs should be considered in young male adults who progressively develop intracranial hypertension, caused by a ventricular mass showing signs of cystic degeneration and calcification. Maximal and safe surgical resection represents the gold standard for the treatment of symptomatic VGGs, although total removal is frequently precluded by difficulties in defining appropriate tumor boundaries. Adjuvant radiotherapy should be considered if an incomplete resection was carried out, especially in World Health Organization grade III neoplasms.

Resumen Introduccion El tratamiento de los glioblastomas (GMB) comienza en la mayor parte de los pacientes con una cirugia, ya sea para la extirpacion tumoral, ya sea para la obtencion de tejido con el que determinar un diagnostico histologico. Con el fin de obtener el maximo beneficio de estos tratamientos cada paciente debe ser valorado de forma individualizada por un equipo multidisciplinar, constituido por aquellas especialidades involucradas tanto en el diagnostico como en el tratamiento. Material y metodos El objetivo de este trabajo es elaborar unas recomendaciones de tratamiento para los pacientes con GBM, para lo cual un experto en cada campo ha descrito lo mas relevante de dicha area basado tanto en su experiencia como en la literatura. Resultados Se han desarrollado los distintos apartados sobre el tratamiento de los GBM y al final de cada apartado se concluye la recomendacion del GTNO. Conclusiones A pesar de que los GBM son tumores agresivos y el pronostico es malo, los pacientes se pueden beneficiar de tratamientos que mejoren no solo la supervivencia global sino tambien la calidad de vida. El neurocirujano debe conocer las distintas opciones de tratamientos, sus indicaciones y riesgos para poder participar activamente en la toma de decisiones y ofrecer un tratamiento neuroquirurgico oportuno a cada situacion.

There is a lack of evidence on timing, frequency, and duration of postoperative endocrine, radiologic, and ophthalmologic assessments that should be performed after pituitary surgery (PS). However, it is known that careful optimization of treatment and follow-up strategies as well as a multidisciplinary approach may have a significant impact on long-term outcomes, improving surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological, and radiological reassessment throughout the follow-up. Considering that there are no specific guidelines on the postoperative management of patients with pituitary tumors (PT), we present our protocol for the postoperative management of patients with PT. It has been elaborated by the multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the management of PT thereby facilitating the postoperative management of patients submitted to PS.

Granulocytic sarcomas are solid, extramedullary-located neoplasms composed of immature myeloid cells, associated with myeloproliferative syndromes. Central nervous system involvement is very rare and may develop either after complete remission, coexist with or precede the systemic disease, being the last one that guides the radiological diagnosis and marks the prognosis. In this work, we report 2 pathologically-verified cases of intracranial granulocytic sarcoma treated by surgical means. Their clinical, diagnostic, therapeutic and prognostic features are discussed in the light of the most relevant scientific literature published to date.

To investigate the status of preoperative anterior pituitary function in patients undergoing pituitary adenoma (PA) resection and to identify factors associated with preoperative anterior pituitary dysfunction (APD). Patients with functioning and nonfunctioning PAs who underwent pituitary adenoma resection for first time, from January 2009 to December 2019 were analyzed. Total sample included 232 patients; 123 (53.2%) females, mean age at diagnosis was 53.3 years. Sixty-three percent presented as nonfunctioning PAs and 37.1% as functioning PAs. Eighty-eight percent were macroadenomas and 34.9% had cavernous sinus invasion. APD was demonstrated in 36.2% (n = 84) of the patients. The FSH/LH deficit was the most frequent anterior pituitary deficit (31.9%); followed by ACTH (18.1%); TSH (16.4%) and GH (13.8%). We identified as independent risk factors of APD, male sex (OR = 6.1, 95% CI = 3.3–11.0); age (OR = 1.03 for each year, 95% CI = 1.01–1.04), diabetes mellitus (OR = 3.5, 95% CI = 1.63–7.69), pituitary apoplexy presentation (OR = 4.3, 95% CI = 1.3–14.5) and tumor size (OR = 1.06 for each mm, 95% CI = 1.04–1.09). Nonfunctioning PAs (NFPA) had higher risk of APD than functioning PAs (FPA) (OR = 2.8 (95% CI = 1.5–5.0), but these differences disappeared after adjusted by tumor size (OR adjusted by tumor size = 1.7, 95% CI = 0.9–3.3). The tumor size with the highest diagnostic accuracy to predict hypopituitarism was 22 mm (sensitivity of 61.9% and specificity of 70.1%). More than one third of PAs candidates for surgery had APD. The male sex, diabetes, an older age, pituitary apoplexy, and larger PAs were risk factors of APD. Hence, in these patients, the hormonal study should be prioritized and the need for dynamic tests must be carefully assessed.

The optimal planning of preoperative diagnosis, management and treatment of pituitary tumors (PT) candidates to pituitary surgery (PS) requires a multidisciplinary approach involving a team of endocrinologists, neurosurgeons, ENT, neuro-ophthalmologists and neuroradiologists with experience in pituitary diseases. Such teams improve surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological and radiological preoperative and follow-up evaluation. We have developed a clinical practice protocol for patients with PT who are candidates to PS based on the most recent national and international guidelines and the relevant literature regarding PT published in the last years. The protocol has been elaborated by a multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the perioperative and surgical management of PT thereby facilitating the management of patients undergoing PS.

Background Spinal arachnoiditis is an arachnoid inflammatory process frequently caused by infection or spinal surgery; there are different degrees of severity, including arachnoid thickening and severe adhesive lesions that can lead to the development of arachnoid cysts. Non-traumatic subarachnoid haemorrhage (ntSAH) is a relatively uncommon cause of arachnoiditis; further complication with spinal cord compression (SCC) is even more unusual. Method we describe a 70-year-old female, with SCC caused by arachnoid cysts. Her medical past history was relevant for an episode of ntSAH after rupture of a posterior communicating artery aneurysm, eight months prior to the onset of symptoms. We also present a literature review of previous published cases. Results we selected 23 articles with 24 case reports. A noticeable female predominance (11:1) was observed. It is more common between the fourth and fifth decades. The majority of cases (58 %) were secondary to aneurysmal SAH due to rupture of a posterior circulation aneurysm. The most common location of the cyst is in the cervicothoracic spine. The average time between the initial bleeding and symptom development is 3–6 months. The most frequently described treatment is laminectomy and marsupialization of the cyst, but reports show a high recurrence rate. Conclusions ntSAH is an uncommon aetiology of arachnoiditis and arachnoid cysts. SCC from arachnoid cysts secondary to ntSAH is exceptional. Treatment through laminectomy has a relatively high recurrence rate (33 %). We present different hypotheses to try to explain how the alteration of cerebrospinal fluid (CSF) dynamics after ntSAH can lead to arachnoid cyst development and SCC. Although the small number of cases included in the present series precludes us to draw definite conclusions, ventriculoperitoneal shunt (VPS) placement can be considered as an alternative treatment in the management of known ntSAH patients that present recurrent symptomatic arachnoid cysts.

Introduction Glioblastoma (GBM) treatment starts in most patients with surgery, either resection surgery or biopsy, to reach a histology diagnose. Multidisciplinar team, including specialists in brain tumours diagnose and treatment, must make an individualize assessment to get the maximum benefit of the available treatments. Material and methods Experts in each GBM treatment field have briefly described it based in their experience and the reviewed of the literature. Results Each area has been summarised and the consensus of the brain tumour group has been included at the end. Conclusions GBM are aggressive tumours with a dismal prognosis, however accurate treatments can improve overall survival and quality of life. Neurosurgeons must know treatment options, indications and risks to participate actively in the decision making and to offer the best surgical treatment in every case.

Pituicytomas (PTs) are extremely rare, low-grade glial tumors closely related to the neurohypophyseal axis. Definite conclusions concerning the optimal diagnostic and therapeutic approach to these neoplasms are lacking to date, as most of this information has been presented as case reports. Retrospective review of case reports published in the scientific literature to date, including a new illustrative example treated in our department. 116 cases were collected. PTs had a higher prevalence in the fifth and sixth decades of life, with a slight male predominance. Main symptoms, which tended to be progressive, included visual field defects and pituitary–hypothalamic dysfunction. Radiologically, PTs were found anywhere along the hypothalamic–pituitary axis mimicking other, more frequent tumors growing in this anatomical region. Surgical treatment included both transcranial or transsphenoidal approaches, and resulted in gross total resection and morbidity rates of 46.8 and 59%, respectively; the latter essentially consisted in anterior and posterior pituitary dysfunction, with limited impact on daily quality of life. Due to both low frequency and the absence of pathognomonic clinical and/or radiological features, formulating a suspicion diagnosis of PT represents a considerable challenge even for experienced professionals. The indication for treatment should be made on an individual basis, but it is inescapable in the presence of a visual field defect. The surgical approach has to be tailored according to the topography of the tumor and preoperative symptoms; the greatest challenges in accomplishing a gross total removal are represented by the degree of adherence and vascularization of the PT.

The use of antithrombotic medication (antiplatelet and/or anticoagulant therapy) is widespread. Currently, the management of neurosurgical patients receiving this type of therapy continues to be a problem of special importance. Patients receiving antithrombotic treatment may need neurosurgical care because of bleeding secondary to such treatment, non-haemorrhagic neurosurgical lesions requiring urgent attention, or simply elective neurosurgical procedures. In addition, the consequences of reintroducing early (bleeding or rebleeding) or late (thrombotic or thromboembolic) anticoagulation can be devastating. In this paper we present the antithrombotic treatment consensus protocol during the perioperative and periprocedural period, both in emergent surgery and in elective neurosurgical procedures.

The use of antithrombotic medication (antiplatelet and/or anticoagulant therapy) is widespread. Currently, the management of neurosurgical patients receiving this type of therapy continues to be a problem of special importance. Patients receiving antithrombotic treatment may need neurosurgical care because of bleeding secondary to such treatment, non-haemorrhagic neurosurgical lesions requiring urgent attention, or simply elective neurosurgical procedures. In addition, the consequences of reintroducing early (bleeding or rebleeding) or late (thrombotic or thromboembolic) anticoagulation can be devastating. In this paper we present the antithrombotic treatment consensus protocol during the perioperative and periprocedural period, both in emergent surgery and in elective neurosurgical procedures.

OBJECTIVES: Since the introduction of endovascular treatment for cerebral aneurysms, hospitals in which subarachnoid hemorrhage is treated show different availability and/or preferences towards both treatment modalities. The main aim is to evaluate the clinical and angiographic results according to the hospital's treatment preferences applied. METHODS: This study was conducted based on use of the subarachnoid hemorrhage database of the Vascular Pathology Group of the Spanish Neurosurgery Society. Centers were classified into 3 subtypes according to an index in the relationship between endovascular and surgical treatment as: endovascular preference, high endovascular preference, and elevated surgical preference. The clinical results and angiographic results were evaluated among the 3 treatment strategies. RESULTS: From November 2004 to December 2017, 4282 subarachnoid hemorrhage patients were selected for the study: 630 (14.7%) patients from centers with surgical preference, 2766 (64.6%) from centers with endovascular preference, and 886 (20.7%) from centers with high endovascular preference. The surgical preference group obtained the best angiographic results associated with a greater complete exclusion (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). The surgical preference subgroup obtained the best outcome at discharge (65.45%), followed by the high endovascular preference group (61.5%) and the endovascular preference group (57.8%) (odds ratio: 1.359; 95% confidence interval: 1.025-1.801; P = 0.033). CONCLUSIONS: In Spain, there is significant variability in aneurysm exclusion treatment in aneurysmal subarachnoid hemorrhage. Surgical centers offer better results for both surgical and endovascular patients. A multidisciplinary approach and the maintenance of an elevated quality of surgical competence could be responsible for these results.

Granulocytic sarcomas are solid, extramedullary-located neoplasms composed of immature myeloid cells, associated with myeloproliferative syndromes. Central nervous system involvement is very rare and may develop either after complete remission, coexist with or precede the systemic disease, being the last one that guides the radiological diagnosis and marks the prognosis. In this work, we report 2 pathologically-verified cases of intracranial granulocytic sarcoma treated by surgical means. Their clinical, diagnostic, therapeutic and prognostic features are discussed in the light of the most relevant scientific literature published to date.

Background Ossifying fibroma is a rare benign bone tumor that occurs mostly in the jaw, but also affects paranasal sinuses and fronto-ethmoidal complex. Occipital bone is an extremely rare location for these tumors; only two cases have been reported. Methods We present the first case reported as psammomatoid subtype of ossifying fibroma, according to the 2005 WHO classification. An 18 years old male patient with infratentorial tumor, in the occipital bone, that produces mass effect over the cerebellum. Conclusions This case may provide a guide to consider these lesions for a more rapid and precise diagnostic in future cases.

Background: Posttraumatic tremor (PTT) is the most frequent movement disorder secondary to cranioencephalic trauma and can be persistent and disabling. Objectives: We review and assess the efficacy of deep brain stimulation (DBS) at the VIM/VOP/ZI (ventralis intermedius/ventrooralis posterior/zona incerta) complex level for the treatment of PTT. Methods: During the period from 1999 to 2014, 5 patients diagnosed with PTT were selected who had experienced a major deterioration in their quality of life without improvement during medical treatment for more than 1 year. They underwent surgery for DBS at the VIM/VOP/ZI complex level, and the modified tremor scale before and after surgery was used for their follow-up. Results: Each patient showed improvements in their symptoms after DBS compared with baseline, which was moderate (II) in 2 cases and marked (III) in the other cases. All of the improvements were maintained with chronic DBS, without tremor rebound. Conclusions: Stimulation of the contralateral VIM/VOP/ZI complex resulted in a noticeable improvement in tremor and recovery of independence in basic daily activities in patients with PTT.

Objective The importance of visual evoked potentials (VEPs) in the field of Neurosurgery has been documented previously, but their use is not standardized due to their limitations (high sensibility to the anaesthetics and low reproducibility). In those surgical interventions that imply a possible damage to the optical nerve, VEPs may have an impact in the surgical decisions. Methods There have reviewed 6 cases from the Neurosurgery Department (Ramon y Cajal Hospital) which underwent surgery of tumours next to the visual pathway (in orbital cavity, occipito-parietal glioma, craniopharyngioma and at sphenoid bone’s sellar region). The visual function was monitored by VEPs with goggles stimulation and recording with the following electrode placing: Oz, O1, O2, lateral O1 and lateral O2. In two cases, responses were recorded with subdural electrodes. Results With the use of goggles with a stimulation frequency of 2.1 Hz, the placement of additional electrodes (lateral O1 and lateral O2), and the filters settings (low-pass filter: 1 Hz; high-pass filter: 1KHz), we have obtained reproducible VEPs in all the surgeries, with a higher amplitude with subdural recording. Discussion With these modifications in the neurophysiological technique, we have avoided one of the major difficulties using VEPs in the workaday monitoring, improving their reproducibility.

BACKGROUND: The management of glioblastoma (GB) in elderly patients is not well established, since until recently they have been excluded from randomized trials and there are concerns about the toxicity. METHODS: The authors retrospectively reviewed 53 patients at a single institution from 2005 to 2013. Patients were 70 years of age and older with histologically confirmed GB. RESULTS: Median age was 75 years (70-88y). Fifty-six percent men, 43% women. Majority had some kind of minor morbidity (89%), mainly arterial hypertension (55%). Complete resection was performed in 52%. Biopsy in 8%. 90% had presurgical KPS >70. Seven (14%) had worse KPS after surgery. 71% received radiotherapy, in 45% 60 Gy and in 26% 30 Gy. Nearly 40% were treated with concomitant and adjuvant temozolomide. The median number of cycles was 4,43 (1-14). 6% had grade 3 or 4 neutropenia or trombocitopenia. 24% had grade 1 asthenia or nausea and vomits. Median overall survival (OS) for the whole cohort was 7,36 m (95% CI 4,8-9,8). Median progression free survival was 5.9 m (3-8.7m). Treatment with temozolomide concomitant and adjuvant (Stupp regimen) was associated with longer OS (11,16 vs 4,1m p = 0.008 ). The median OS was 8,3 m. for those who received radiotherapy and 1,5m for those who did not (p = 0,046). No statistical differences were found between those treated with 60 or 30 Gy (p = 0.143). Nearly 10% was older than 80. Median OS in these patients was 4,2m even though 71% had a complete resection. CONCLUSION: In our experience, in selected patients with newly diagnosed glioblastoma over the age of 70, more intensive treatment was associated with prolonged OS, and results are close to those obtained in younger patients. Nevertheless these are retrospective data, selection bias should be considerer. Further randomized trial should be conducted to investigate this topic.

BACKGROUND: The management of glioblastoma (GB) in elderly patients is not well established. The incidence is higher in this population and is expected to increase over the next decades in relation with an aging population in western countries. Otherwise GB is the most life-threatening primary brain tumor especially in elderly patients and survival is significantly less than seen in younger patients. Until recently, this patients have been excluded from randomized trials and the effectiveness of the conventional active treatment has been controversial, since benefit was attenuated in older and there are concerns about mental deterioration. Different treatment approaches have been proposed. Here we review our experience in this population. METHODS: The authors retrospectively reviewed 53 patients at a single institution from February 2005 to March 2013. Patients were 70 years of age and older with histologically confirmed GB. RESULTS: Median age was 75 years (range 70-88). Fifty-six percent were men and 43% women. Most had frontal lobe location (37.7%) followed by temporal lobe (32%). Majority of patients had some kind of morbidity (89%), mainly arterial hypertension (55%) diabetes (13%) and thyroid function alteration (17%). Partial resection was planned in 49% of cases and a complete resection in 45%. After surgery, 71% received radiotherapy, in 45% of cases the dose was 60 Gy and in 26% was 30 Gy. Nearly 40% were treated with concomitant and adjuvant temozolomide. The median umber of cycles was 4,43 (range 1-14). Median survival for the whole cohort was 7,36 m (95% CI 4,8-9,8) and 8,3m for those who received some kind of treatment after surgery. Treatment with temozolomide concomitant and adjuvant (Stupp regimen) was associated with longer overall survival ( 11,16 months vs 4,1m p = 0.008 ). The median overall survival was 8,3 months for those who received radiotherapy and 1,5m for those who did not (p = 0,046). Differences were found between those treated with 30 or 60 Gy in terms of overall survival in favor of 60Gy treatment ( 6,3 vs 11,1 m) but didńt reach the statistical significance level (p = 0.143). Compared with temporal location, patients with tumor located in parietal lobe had a better overall survival. In 10% of cases received a second line treatment after progression and median survival was 4,8 months. CONCLUSION: Elderly patients diagnosed with GB had worst prognosis. In our experience, in patients with newly diagnosed glioblastoma over the age of 70, more intensive treatment was associated with prolonged OS, and results are close to those obtained from younger patients. Nevertheless these are retrospective data and a selection bias may be the explanation. Further randomized trial should be conducted to investigate this topic.

Aim: The management of glioblastoma (GB) in elderly patients is not well established. The incidence is higher in this population and is expected to increase over the next decades in relation with an aging population. Until recently, these patients have been excluded from randomized trials. The effectiveness of the conventional active treatment has been controversial, since benefit was attenuated in older and there are concerns about mental deterioration. Methods: The authors retrospectively reviewed 53 patients at a single institution (2005-2013). Patients were 70 years or older with histologically confirmed GB. Results: Median age was 75 years (y) (range 70-88), and nearly 60% of population was between 70-80 y. Gender: 56% men. Location: frontal lobe (37.7%), temporal (32%). Most had any morbidity (89%), mainly arterial hypertension (55%), diabetes (13%). Partial resection was planned in 49% of cases, and complete resection in 45%. After surgery 71% received radiotherapy(RT) (45% 60 Gy and 26% 30Gy). Nearly 40% were treated with concomitant and adyuvant Temozolamide (Stupp regimen). The median number of cycles was 4.43 (range 1-14). With regard to toxicity only 3 patients reached grade 4 (neutropenia and trombopenia). Median survival for the whole cohort was 7,36 m (95% CI 4,8-9,8). Median progression free survival (PFS) was 5.9 m (3-8.7m). Treatment with Stupp regimen was associated with longer overall survival (11.16 months vs 4.1 months; p= 0.008). Median overall survival in the cohort of patients who received or not RT was 8.3 months vs 1.5 months respectively (p = 0.046). Differences were found between the subgroup treated with 30 Gy vs 60 Gy in terms of overall survival in favor to the second one, but didnt reach statistical significance (6,3 vs 11,1; p = 0.143). Only 10% of patients could receive a second line treatment and median survival was 4.8 months. Conclusions: Elderly patients diagnosed with GB had worst prognosis. In our experience, in patients with newly diagnosed glioblastoma over the age of 70, more intensive treatment was associated with prolonged OS, and results are close to those obtained from younger patients. Nevertheless these are retrospective data and a selection bias may be the explanation. Further randomized trial should be conducted to investigate this topic. Disclosure: All authors have declared no conflicts of interest.