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STUDY DESIGN.: Review the presentation and diagnosis of a lumbar intradural varix. OBJECTIVE.: To report an innovative magnetic resonance imaging (MRI) technique that enabled radiographic diagnosis in a rare case of symptomatic lumbar intradural varix. SUMMARY OF BACKGROUND DATA.: Lumbar variceal veins rarely occur intradurally, and may radiographically mimic nerve-sheath tumors. These lesions are typically diagnosed at surgery performed due to suspicion of tumor. METHODS.: A 55-year-old man presented with radicular lower back pain and normal neurologic examination. MRI revealed an ellipsoid intradural enhancing mass at the L2 level. The patient refused to undergo the surgical procedure that was recommended. Over 2-year follow-up, symptoms resolved together with weight reduction. Repeat MRI revealed an unchanged lumbar lesion in addition to engorged epidural and intradural veins, thought to be related to outflow obstruction secondary to past right nephrectomy and obliterated inferior vena cava. Breath-holding and Valsalva maneuvers during MRI caused a change in the shape of the intradural lesion. RESULTS.: The patient's refusal to undergo surgery led to noninvasive assessment of his lumbar spinal pathology. Diagnosis of nonthrombosed intradural varix was established on MRI-based detection of a change in the shape of the lesion following breath-hold and Valsalva maneuvers. CONCLUSION.: We diagnosed a nonthrombosed intradural varix by demonstrating a change in the lesion's shape on MRI, following breath-hold and Valsalva maneuvers. This is the first report of nonpathologic, purely radiologic diagnosis of such a lesion. This is a relatively simple, noninvasive method of evaluating these patients. [ABSTRACT FROM AUTHOR]

Decompressive craniectomy is a procedure for managing elevated intracranial pressure (ICP). However, it carries a high morbidity and mortality toll. While there is relative consensus regarding the bony part of the decompression, the role of dura opening and the optimal technique to perform it are under debate. Here we compared the commonly used augmented duraplasty technique to an understudied technique of dura fenestrations in a single center, prospective, non-controlled randomized study. The study included 23 patients who underwent decompressive craniectomy. The lowering of ICP was significant in both methods when compared to preoperative values and compared to pre-duraplasty values. The ICP was similar in various postoperative time points between both techniques. The rate of complications was lower when the dura was fenestrated - brain herniation was over five time less common, infection was more than five times rarer. Contusion expansion, meningitis and contralateral subdural collection were all lower in fenestrated dura cases than in wide dura opening. These results hold promise for a superior surgical approach in duraplasty for intracranial pressure reduction., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 Elsevier Ltd. All rights reserved.)

Background: Intracranial pressure (ICP) is a well-established measure in managing not only traumatic brain injury but also nontraumatic intracranial bleeding or edema. When ICP increases despite nursing or medical management, ICP may be reduced via surgical measures. Deciding whether to perform a craniotomy vs. craniectomy (whether the bone flap is replaced or not, respectively) is commonly made intraoperatively following preoperative planning. While ICP monitoring (ICPm) is standard pre- and postoperatively, its intraoperative utility remains understudied., Methods: We conducted a study utilizing prospectively gathered and retrospectively analyzed data from 25 traumatic brain injury surgical decompression cases at a single center. All cases had intraoperative ICPm throughout surgery., Results: Our findings indicate that ICPm significantly influenced real-time intraoperative decision-making, diverging from preoperative., Conclusions: These results bring forward the potential pivotal role of intraoperative ICPm in guiding surgical strategies for elevated ICP, suggesting a novel data-driven approach to intraoperative management of decompression surgery., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Overexpression of the longevity gene Klotho prolongs lifespan, while its knockout shortens lifespan and impairs cognition via perturbation of myelination and synapse formation. However, comprehensive analysis of Klotho knockout effects on mammalian brain transcriptomics is lacking. Here, we report that Klotho knockout alters the levels of aging- and cognition related mRNAs, long non-coding RNAs, microRNAs and tRNA fragments. These include altered neuronal and glial regulators in murine models of aging and Alzheimer's disease and in human Alzheimer's disease post-mortem brains. We further demonstrate interaction of the knockout-elevated tRNA fragments with the spliceosome, possibly affecting RNA processing. Last, we present cell type-specific short RNA-seq datasets from FACS-sorted neurons and microglia of live human brain tissue demonstrating in-depth cell-type association of Klotho knockout-perturbed microRNAs. Together, our findings reveal multiple RNA transcripts in both neurons and glia from murine and human brain that are perturbed in Klotho deficiency and are aging- and neurodegeneration-related., (© 2024. The Author(s).)

Background: Between 2017 and 2021, the newly established Department of Neurosurgery at Shaare Zedek Medical Center in Jerusalem, a high volume metropolitan hospital, operated on 25 intradural lesions in 24 patients (one patient had multiple tumors). In this retrospective study, we review results and lessons learned as experienced surgeons opened a new service line., Methods: A multidisciplinary team was assembled and led by experienced neurosurgeons with skills in both microneurosurgery and complex spine care. Standard operative techniques were used. A chart review was done to assess complications and outcome., Results: 25 lesions were reviewed in 24 patients (14 female; 10 male) between the ages of 11-82 years of age. In 14 cases, gross total resection (GTR) was achieved; 11 cases underwent partial resection. Of the 11 non-GTR cases, 3 were initially planned as biopsies. In one case, there was a significant neurologic decline directly related to surgery. In a separate case, there was iatrogenic instability, necessitating further treatment., Conclusions: We identify six lessons learned in a nascent neurosurgical department, noting that surgical excellence is of paramount importance, but that the surgeon must also expand his/her role from master technician to team leader. Both microsurgical expertise for neural anatomy and understanding of spinal biomechanics for osseous anatomy is mandatory for surgery of SIDT. This retrospective analysis of our case series demonstrates experienced neurosurgeons can successfully deploy a new service line for challenging cases to the benefit of the hospital and local community., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Non-alcoholic fatty liver disease (NAFLD) involves hepatic accumulation of intracellular lipid droplets via incompletely understood processes. Here, we report distinct and cooperative NAFLD roles of LysTTT-5'tRF transfer RNA fragments and microRNA miR-194-5p., Methods: Combined use of diet induced obese mice with human-derived oleic acid-exposed Hep G2 cells revealed new NAFLD roles of LysTTT-5'tRF and miR-194-5p., Results: Unlike lean animals, dietary-induced NAFLD mice showed concurrent hepatic decrease of both LysTTT-5'tRF and miR-194-5p levels, which were restored following miR-132 antisense oligonucleotide treatment which suppresses hepatic steatosis. Moreover, exposing human-derived Hep G2 cells to oleic acid for 7 days co-suppressed miR-194-5p and LysTTT-5'tRF levels while increasing lipid accumulation. Inversely, transfecting fattened cells with a synthetic LysTTT-5'tRF mimic elevated mRNA levels of the metabolic regulator β-Klotho while decreasing triglyceride amounts by 30% within 24 h. In contradistinction, antisense suppression of miR-194-5p induced accumulation of its novel target, the NAFLD-implicated lipid droplet-coating PLIN2 protein. Further, two out of 15 steatosis-alleviating screened drug-repurposing compounds, Danazol and Latanoprost, elevated miR-194-5p or LysTTT-5'tRF levels., Conclusion: Our findings highlight the different yet complementary roles of miR-194-5p and LysTTT-5'tRF and offer new insights into the complex roles of small non-coding RNAs and the multiple pathways involved in NAFLD pathogenesis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier GmbH.. All rights reserved.)

Introduction: Females with Alzheimer's disease (AD) suffer accelerated dementia and loss of cholinergic neurons compared to males, but the underlying mechanisms are unknown. Seeking causal contributors to both these phenomena, we pursued changes in transfer RNS (tRNA) fragments (tRFs) targeting cholinergic transcripts (CholinotRFs)., Methods: We analyzed small RNA-sequencing (RNA-Seq) data from the nucleus accumbens (NAc) brain region which is enriched in cholinergic neurons, compared to hypothalamic or cortical tissues from AD brains; and explored small RNA expression in neuronal cell lines undergoing cholinergic differentiation., Results: NAc CholinotRFs of mitochondrial genome origin showed reduced levels that correlated with elevations in their predicted cholinergic-associated mRNA targets. Single-cell RNA seq from AD temporal cortices showed altered sex-specific levels of cholinergic transcripts in diverse cell types; inversely, human-originated neuroblastoma cells under cholinergic differentiation presented sex-specific CholinotRF elevations., Discussion: Our findings support CholinotRFs contributions to cholinergic regulation, predicting their involvement in AD sex-specific cholinergic loss and dementia., (© 2023 The Authors. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Overexpression of the longevity gene Klotho prolongs, while its knockout shortens lifespan and impairs cognition via altered fibroblast growth factor signaling that perturbs myelination and synapse formation; however, comprehensive analysis of Klotho's knockout consequences on mammalian brain transcriptomics is lacking. Here, we report the altered levels under Klotho knockout of 1059 long RNAs, 27 microRNAs (miRs) and 6 tRNA fragments (tRFs), reflecting effects upon aging and cognition. Perturbed transcripts included key neuronal and glial pathway regulators that are notably changed in murine models of aging and Alzheimer's Disease (AD) and in corresponding human post-mortem brain tissue. To seek cell type distributions of the affected short RNAs, we isolated and FACS-sorted neurons and microglia from live human brain tissue, yielding detailed cell type-specific short RNA-seq datasets. Together, our findings revealed multiple Klotho deficiency-perturbed aging- and neurodegeneration-related long and short RNA transcripts in both neurons and glia from murine and human brain.

Introduction: The 5-aminolevulinic acid (5-ALA) fluorescence-guided resection is an essential part of the current state-of-the-art treatment of primary malignant brain tumors. Metabolized by tumor cells, creating Protoporphyrin-IX, which is fluorescent under UV light emitted from the microscope, 5-ALA facilitates visual distinction between the tumor and the normal brain tissue surrounding it, coloring it pink. This real-time diagnostic feature was shown to lead to more complete removal of the tumor and confers a survival benefit. Nevertheless, despite the high sensitivity and specificity that was described using this method, there are other pathological processes in which 5-ALA is being metabolized that fluoresce similarly to a malignant glial tumor.

Transfer RNA fragments (tRFs) have recently been shown to be an important family of small regulatory RNAs with diverse functions. Recent reports have revealed modified tRF blood levels in a number of nervous system conditions including epilepsy, ischemic stroke, and neurodegenerative diseases, but little is known about tRF levels in the cerebrospinal fluid (CSF). To address this issue, we studied age, sex, and Parkinson's disease (PD) effects on the distributions of tRFs in the CSF and blood data of healthy controls and PD patients from the NIH and the Parkinson's Progression Markers Initiative (PPMI) small RNA-seq datasets. We discovered that long tRFs are expressed in higher levels in the CSF than in the blood. Furthermore, the CSF showed a pronounced age-associated decline in the level of tRFs cleaved from the 3'-end and anti-codon loop of the parental tRNA (3'-tRFs, i-tRFs), and more pronounced profile differences than the blood profiles between the sexes. In comparison, we observed moderate age-related elevation of blood 3'-tRF levels. In addition, distinct sets of tRFs in the CSF and in the blood segregated PD patients from controls. Finally, we found enrichment of tRFs predicted to target cholinergic mRNAs (Cholino-tRFs) among mitochondrial-originated tRFs, raising the possibility that the neurodegeneration-related mitochondrial impairment in PD patients may lead to deregulation of their cholinergic tone. Our findings demonstrate that the CSF and blood tRF profiles are distinct and that the CSF tRF profiles are modified in a sex-, age-, and disease-related manner, suggesting that they reflect the inter-individual cerebral differences and calling for incorporating this important subset of small RNA regulators into future studies., (© 2022 The Authors. Journal of Neurochemistry published by John Wiley & Sons Ltd on behalf of International Society for Neurochemistry.)

Glioblastoma stem cells (GSCs) reside close to blood vessels (BVs) but vascular cues contributing to GSC stemness and the nature of GSC-BVs cross talk are not fully understood. Here, we dissected vascular cues influencing GSC gene expression and function to perfusion-based vascular cues, as well as to those requiring direct GSC-endothelial cell (EC) contacts. In light of our previous finding that perivascular tumor cells are metabolically different from tumor cells residing further downstream, cancer cells residing within a narrow, < 60 µm wide perivascular niche were isolated and confirmed to possess a superior tumor-initiation potential compared with those residing further downstream. To circumvent reliance on marker expression, perivascular GSCs were isolated from the respective locales based on their relative state of quiescence. Combined use of these procedures uncovered a large number of previously unrecognized differentially expressed GSC genes. We show that the unique metabolic milieu of the perivascular niche dominated by the highly restricted zone of mTOR activity is conducive for acquisition of GSC properties, primarily in the regulation of genes implicated in cell cycle control. A complementary role of vascular cues including those requiring direct glioma/EC contacts was revealed using glioma/EC co-cultures. Outstanding in the group of glioma cells impacted by nearby ECs were multiple genes responsible for maintaining GSCs in an undifferentiated state, a large fraction of which also relied on Notch-mediated signaling. Glioma-EC communication was found to be bidirectional, evidenced by extensive Notch-mediated EC reprogramming by contacting tumor cells, primarily metabolic EC reprogramming., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: Resection of meningiomas adjacent to the central sulcus entails a high rate of morbidity. Explored for intra-axial lesion resection, intraoperative neuromonitoring intraoperative neuromonitoring (IONM) has been shown to decrease neurological deficits. The use of IONM is relatively uncommon and is not considered routine practice in the removal of extra-axial lesions. We sought to characterize IONM's impact on the surgical workflow in supratentorial meningiomas., Methods: We retrospectively analyzed a prospectively collected database, searching cases in which IONM was used for resection of meningioma between 2017 and 2020. We classified the IONM effect on surgical workflow into 5 distinct categories of workflow changes (WFC)., Results: Forty cases of meningiomas with IONM use were identified. In 1 case (class 1 WFC), the operation was stopped due to IONM input. In 5 cases (class 2 WFC), the tumor was incompletely resected due to input from the IONM. In 14 cases (35%), IONM leads to an alteration of the resection process (alteration of approach, class 3 WFC). In 4 cases (10%), anesthesia care was modified based on IONM input (class 4 WFC). In 16 cases, no changes were made (class 5 WFC). In all patients in whom a change was made (24 cases, WFC 1-4), only 8.3% suffered a temporary deficit, and there were no permanent deficits, whereas when no change was made, there were 18.75% temporary deficit and 6.25% permanent deficit., Conclusion: IONM has an impact during resection of meningiomas in eloquent areas and may guide the surgical technique, approach to tumor resection, and extent of resection., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Stereotactic needle brain biopsy is a commonly used neurosurgical procedure. However, up to 15% of biopsies result in undiagnostic pathology reports. Repeat biopsy or continued management without a diagnosis are often considered after undiagnostic biopsies. There have been no reports about the role of postoperative imaging in predicting the diagnostic yield of stereotactic biopsies., Methods: We retrospectively assessed all stereotactic biopsies performed over an 11-year period. We performed fusion of immediate postoperative computed tomography (CT) with preoperative MRI, to document whether the air bubble in the postoperative CT was located within the targeted lesion. We then evaluated the association of this fusion-based accuracy assessment with the diagnostic yield of the biopsy., Results: Fewer than 5% of biopsies did not have an air bubble on postoperative CT. A total of 226 biopsies were performed for 219 patients. In our sample, 213 of 226 biopsies were accurate (94.2% accuracy rate), and 203 of 226 biopsies gave a definitive diagnosis (89.8% diagnostic rate). In those cases where the fusion was accurate, the diagnostic rate was 93.9%. When the fusion was inaccurate, the diagnostic rate was only 23.1% (odds ratio 51.5, 95% confidence interval 12.6-210.44, P < 0.001). Of all patient, imaging, surgical, and admission parameters, the only parameter that correlated with diagnostic outcome of the biopsy was the fusion construct accuracy., Conclusions: Fusion of immediate postoperative CT with preoperative imaging is predictive of the diagnostic rate. In cases where the pathology report following a biopsy is not diagnostic, this fusion may be useful in making decisions regarding repeat biopsy or considering other diagnostic options., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Captopril is a well-characterized, FDA-approved drug that has demonstrated promise as a repurposed oncology therapeutic. Captopril's known anti-cancer effects include inhibition of Matrix Metalloproteinase-2 (MMP-2), an endopeptidase which selectively breaks down the extracellular matrix to promote cell migration. MMP-2 is a known therapeutic target in gliomas, tumors with significant clinical need. Using an aggressive gliosarcoma model, we assessed captopril's effects on MMP-2 expression in vitro and in vivo as well as its efficacy as an adjuvant in combination therapy regimens in vivo., Methods: Following captopril treatment, MMP-2 protein expression and migratory capabilities of 9 L gliosarcoma cells were assessed in vitro via western blots and scratch wound assays, respectively. Rats were intracranially implanted with 9 L gliosarcoma tumors, and survival was assessed in the following groups: control; captopril (30 mg/kg/day); temozolomide (TMZ) (50 mg/kg/day), and captopril+TMZ. In vivo experiments were accompanied by immunohistochemistry for MMP-2 from brain tissue., Results: In vitro, captopril decreased MMP-2 protein expression and reduced migratory capacity in 9 L gliosarcoma cells. In a gliosarcoma animal model, captopril decreased MMP-2 protein expression and extended survival as a TMZ adjuvant relative to untreated controls, captopril monotherapy, and TMZ monotherapy groups (27.5 versus 14 (p < 0.001), 16 (p < 0.001), and 23 (p = 0.018) days, respectively)., Conclusions: Captopril decreases gliosarcoma cell migration, which may be mediated by reduction in MMP-2 protein expression. Captopril provided a survival advantage as a TMZ adjuvant in a rat intracranial gliosarcoma model. Captopril may represent a promising potential adjuvant to TMZ therapy in gliosarcoma as a modulator of the MMP-2 pathway., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Attainment of micro-neurosurgical skills is a challenge in teaching hospitals throughout training. Models that mimic the workflow as well as haptics are time-consuming, expensive, and unsuitable to serve as a routine platform. Our objective was to present a model and a set of tasks, based on a hard-boiled egg, microscope, and a Cavitron ultrasonic aspirator (CUSA; Integra Lifesciences Corp., Tullamore, Ireland), which is cheap, easy to setup and can be used for training microsurgery and CUSA skills, required for removal of deep-seated tumors., Methods: The goal was to remove the egg yolk from within a hard-boiled egg, representing an intrinsic brain tumor, surrounded by the egg's white, representing adjacent brain tissue, while preserving it. Assessment was based on the yolk's exposure, completeness of removal, and collateral damage and task completion duration, with repeated trials (n = 4), for validation purposes, for 6 operators with different experience levels., Results: Improvement in overall score (mean of 47.5 ± 19 in the first trial vs. 80.0 ± 12 in the fourth trial, P < 0.01), and task duration completion (mean initial duration of 21:25 ± 4:52 minutes to 15:30 ± 5:17 minutes, P < 0.01) was observed. Parameters gradually improved on repeated attempts, and experience level of the operators correlated with scores., Conclusions: The egg model is an easy-to-handle, cheap model that enables the acquisition of basic micro-neurosurgical skills and basic workflow required for removing of intrinsic brain tumors. This study has validated and defined reproducible tasks that can be scored, correlated with performance. This model can be incorporated into a resident's routine and potentially provide an accessible training platform for neurosurgical trainees., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Meningiomas are a common tumor within the cranial cavity. They may be a target for metastatic spread of cancer elsewhere in the body. We analyzed all the data in the literature about tumor-to-meningioma metastasis (TTMM)., Methods: We performed a meta-analysis using the PRISMA checklist to locate all cases of TTMM in the PubMed and Medline databases. We collected patient and cancer parameters, meningioma parameters, and clinical factors., Results: We located 124 articles, describing 152 cases of patients with TTMM. The mean (± SD) age of all patients was 62.21 ± 10.8 years, with even distribution above and below the mean. Of the cases, 65.9% were reported in women. The most common cancer origins of TTMM were breast and lung carcinoma, followed by kidney, prostate, and GI tract carcinoma. Cancer status is not a good marker of TTMM when managing a meningioma. In 36.69% of cases, TTMM was the presentation of an unknown cancer. In nearly 60% of the known cases, cancer was considered in remission for at least 1 year. Meningioma parameters are unhelpful when considering a TTMM. The distribution of meningioma location is similar to other series of meningioma reported in the literature. Meningioma grade is similar to meningiomas without TTMM. In 57.89%, the patient presented with a focal deficit. Presenting factors were seizures, elevated ICP, and others. Over 95% of cases were symptomatic at presentation., Conclusion: TTMM should be suspected in cases of meningioma in a patient with background cancer, regardless of meningioma parameters or cancer status.

Background: Attainment of basic microsurgical skills in neurosurgery presents a departmental challenge worldwide. Models for teaching are either not readily available or expensive and are incompatible with a resident's busy schedule, requiring lengthy and proper setup. We present a model and a set of measurable tasks, based on a fruit (orange) that is cheap, easy to set up instantly when desired, and useful for training of basic microsurgical skills., Methods: Basic microsurgical skills were identified, necessitating hand-eye coordination working with the microscope. The goal was to dissect an orange segment while preserving adjacent segments. Assessment was based on the number of side tears and task completion duration. The task was repeated in a sequential manner (n = 10), for validation purposes, for 3 operators at different seniority levels., Results: An improvement in the number of side tears (mean of 12.66 ± 9.01 in the first trial vs. 4 ± 4.35 in the 10th trial, P < 0.01), as well as duration of time required for task completion (mean initial duration of 28:16 ± 19:00 minutes to a duration of 16:33 ± 10:50 minutes in the last attempt, P < 0.01), was observed. Daily practice scores and time gradually improved, and the seniority level of operators was correlated with scoring between individuals., Conclusions: The orange model is an easily accessible, cheap model that enables the acquisition of basic microneurosurgical skills. In this work, we validated and defined reproducible tasks that can be scored and tracked, correlated with operator's proficiency and experience. This model can be incorporated into a resident's workflow environment and provides a platform for attainment of elementary microsurgical skills for neurosurgical residents., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: G lioblastoma (GBM) is associated with poor overall survival. Recently, we showed that androgen receptor (AR) protein is overexpressed in 56% of GBM specimens and AR antagonists induced dose-dependent death in several GBM cell lines and significantly reduced tumor growth and prolonged the lifespan of mice implanted with human GBM. 16β-18F-fluoro-5α-dihydrotestosterone ([ 18 F]-FDHT) is a positron emission tomography (PET) tracer used to detect AR expression in prostate and breast cancers. This study was aimed at exploring the ability of [ 18 F]-FDHT-PET to detect AR expression in high-grade gliomas., Methods: Twelve patients with suspected high-grade glioma underwent a regular workup and additional dynamic and static [ 18 F]-FDHT-PET/CT. Visual and quantitative analyses of [ 18 F]-FDHT kinetics in the tumor and normal brain were performed. Mean and maximum (max) standardized uptake values (SUVs) were determined in selected volumes of interest. The patients had surgery or biopsy after PET/CT. AR protein was analyzed in the tumor samples by western blot. Fold change in AR expression was calculated by densitometry analysis. Correlation between imaging and AR protein samples was determined., Results: In six of the 12 patients, [ 18 F]-FDHT uptake was significantly higher in the tumor than in the normal brain. These patients also had increased AR protein expression within the tumor. Pearson correlation coefficient analysis for the tumor-to-control normal brain uptake ratio in terms of SUV mean versus AR protein expression was positive and significant (R = 0.84; P = .002)., Conclusion: [ 18 F]-FDHT-PET/CT could identify increased AR expression in high-grade glioma., (© The Author(s) 2021. Published by Oxford University Press, the Society for Neuro-Oncology and the European Association of Neuro-Oncology.)

Our study aim is to evaluate the accuracy of freehand external ventricular drain (EVD) placement, without the use of adjuncts to placement, immediately following a large decompressive hemicraniectomy (DC). We performed a retrospective cohort analysis comparing patients who underwent freehand EVD placement immediately after a DC, to those who underwent freehand EVD placement without DC. Computed tomography (CT) studies were used to assess accuracy based on catheter tip location. Intracranial catheter length, pre- and post-operative Evan's Index, and midline shift pre- and post-operatively were analysed as separate variables in each group. A previously described grading system was used to assess the accuracy of free hand EVD placement. There were a total 110 patients overall; DC group, n = 50; non-DC group, n = 60. There was a significant reduction from pre-operative midline shift to post-operative midline shift in the DC group (9.13 vs 6.02 mm; p = 0.0064). There was no significant difference in accuracy between the two groups (p = 0.8917), and similar rates of Grade 1 - i.e. optimal - catheter tip location (DC = 78% vs non-DC = 81%) were found. All analysed variables comparing both Grade 1 subgroups (pre- and postoperative Evan's Index, and midline shift) showed significant differences between them. Mean catheter length in Grade 1 EVD placement showed a statistically significant difference between the DC and non-DC groups (63.78 vs 59.96 mm, respectively; p = 0.009). An EVD, after DC for traumatic and non-traumatic intracranial pathologies, can be accurately placed by freehand., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: A circulating biomarker has potential to provide more accurate information for glioma progression post treatment, however no such biomarker is currently available. We aimed to discover a microRNA serum biomarker for longitudinal monitoring of glioma patients., Methods: A prospectively collected cohort of 91 glioma patients and 17 healthy controls underwent pre and post-operative serum miRNA profiling using Nanostring®. Differentially expressed miRNAs were discovered using a machine learning random forest analysis. Candidate miRNAs were then assessed by droplet digital PCR in 11 patients with multiple follow up samples and compared to tumor volume based on magnetic resonance imaging., Results: A 9-gene miRNA signature was identified that could distinguish between glioma and healthy controls with 99.8% accuracy. Two miRNAs miR-223 and miR-320e, best demonstrated dynamic changes that correlated closely with tumor volume in LGG and GBM respectively. Importantly, miRNA levels did not increase in two cases of pseudo-progression, indicating the potential utility of this test in guiding treatment decisions., Conclusions: We identified a highly accurate 9-miRNA signature associated with glioma serum. Additionally, we observed dynamic changes in specific miRNAs correlating with tumor volume over long-term follow up. These results support a large prospective validation study of serum miRNA biomarkers in glioma.

Management of spontaneous cerebellar hemorrhage (SCH) has been scarcely reported, and controversies still exist regarding their surgical management., Methods: We performed a retrospective review of the Rambam Medical Center registry. All cases with a SCH, operated or not, were reviewed. Basic patient parameters, clinical status on admission and imaging results, management and outcome measures were evaluated. Parameters were compared between the operated and unoperated groups, and assessed for their correlation to patient death within 12 months. When operated, patients underwent Suboccipital craniectomy (SOC), insertion of an external ventricular drain (EVD) or both., Results: 57 patients were treated for SCH in the years 2005-2017. 20 patients (35.09%) died during their original admission. 16 were discharged in non-functional status. In total, 36 patients died within 12 months of their admission. Only 21 patients (36.84%) were alive one year after their bleed. The following parameters were correlated to death in the entire cohort: older age, larger hematoma size, hydrocephalus, brainstem compression by the bleed and outcome status. The unoperated patients were younger, and had a lower Glasgow Coma Scale (GCS) on admission. Death within 12 months occurred in 69.77% of the operated patients, but only 42.86% of the unoperated patients, p = 0.10. Unfavorable outcome was found in 36% of the unoperated group and 72% of the operated group, p = 0.024., Conclusion: SCH carries a grim prognosis in both operated and unoperated patients. Roughly one third of patients in our series died during their admission and another third were either vegetative or severely disabled on discharge., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Differential exposure of tumor cells to blood-borne and angiocrine factors results in diverse metabolic microenvironments conducive for non-genetic tumor cell diversification. Here, we harnessed a methodology for retrospective sorting of fully functional, stroma-free cancer cells solely on the basis of their relative distance from blood vessels (BVs) to unveil the whole spectrum of genes, metabolites, and biological traits impacted by BV proximity. In both grafted mouse tumors and natural human glioblastoma (GBM), mTOR activity was confined to few cell layers from the nearest perfused vessel. Cancer cells within this perivascular tier are distinguished by intense anabolic metabolism and defy the Warburg principle through exercising extensive oxidative phosphorylation. Functional traits acquired by perivascular cancer cells, namely, enhanced tumorigenicity, superior migratory or invasive capabilities, and, unexpectedly, exceptional chemo- and radioresistance, are all mTOR dependent. Taken together, the study revealed a previously unappreciated graded metabolic zonation directly impacting the acquisition of multiple aggressive tumor traits., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Intracranial dural arteriovenous fistulae (DAVF) are complex vascular malformations consisting of a pathological shunt located between meningeal arteries and drainage to dural venous sinuses and/or cerebral veins. We report an unusual anatomical variation, resulting in a DAVF forming between the superior sagittal sinus and an anomalous origin of the middle meningeal artery (MMA) arising from the left ophthalmic artery. We present an atypical case requiring mini-craniotomy for catheter access, as well as cannulation of extracranial arterial supply prior to embolization of a Cognard type IIa+b fistula. Due to structural variation, transarterial endovascular embolization was deemed too high risk owing to risk of permanent blindness. We present a technical note and literature review on the first documented case of combined endovascular and surgical intervention as first line treatment for embolization of an anomalous middle meningeal artery related fistula. Our approach provided adequate obliteration of the DAVF and may be an alternative way to treat DAVF, when traditional transarterial or transvenous approaches are deemed high risk for neurological deficit., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Systemic chemotherapy of malignant brain tumors has failed to achieve sufficient drug concentrations at the neoplasm site and frequently results in severe toxicities. Therefore, the local application of several anticancer agents, oncolytic viruses and vectors for gene therapy, immune-modifying preparations, and angiogenesis inhibitors has been investigated widely. Various modes of their administration were introduced, including intratumoral injections, implantation of reservoirs or pumps, convection-enhanced delivery, and use of nanocarriers, thermoreversible gels, microchips, and drug-loaded polymers. Many of these therapeutic approaches have shown promising results in management of high-grade gliomas., (© 2018 S. Karger AG, Basel.)

Neurofibromatosis type 2 (NF2), a neurogenetic condition manifest by peripheral nerve sheath tumors (PNST) throughout the neuroaxis for which there are no approved therapies. In vitro and in vivo studies presented here examine agents targeting signaling pathways, angiogenesis, and DNA repair mechanisms. In vitro dose response assays demonstrated potent activity of lapatinib and nilotinib against the mouse schwannoma SC4 (Nf2 -/- ) cell line. We then examined the efficacy of everolimus, nilotinib, lapatinib, bevacizumab and radiation (RT) as mono- and combination therapies in flank and sciatic nerve in vivo NF2-PNST models. Data were analyzed using generalized linear models, two sample T-tests and paired T-tests, and linear regression models. SC4(Nf2 -/- ) cells implanted in the flank or sciatic nerve showed similar rates of growth (p = 0.9748). Lapatinib, nilotinib and RT significantly reduced tumor growth rate versus controls in the in vivo flank model (p = 0.0025, 0.0062, and 0.009, respectively) whereas bevacizumab and everolimus did not. The best performers were tested in the in vivo sciatic nerve model of NF2 associated PNST, where chemoradiation outperformed nilotinib or lapatinib as single agents (nilotinib vs. nilotinib + RT, p = 0.0001; lapatinib versus lapatinib + RT, p < 0.0001) with no observed toxicity. There was no re-growth of tumors even 14 days after treatment was stopped. The combination of either lapatinib or nilotinib with RT resulted in greater delays in tumor growth rate than any modality alone. This data suggest that concurrent low dose RT and targeted therapy may have a role in addressing progressive PNST in patients with NF2.

Background: Galenic dural arteriovenous fistulas (DAVF) are rare; however, they are the most frequent type of DAVF to manifest aggressive clinical behavior and usually represent a diagnostic and therapeutic challenge for clinicians., Methods: We retrospectively reviewed clinical and imaging data of patients managed with neuroendovascular techniques for the treatment of galenic DAVFs from 2000 to 2016. We searched the 2000-2016 English-language literature for papers discussing neuroendovascular management of galenic DAVFs, with or without companion surgical procedures., Results: Five patients were treated for galenic DAVFs during the study period (four males; mean age, 61 years). Three presented with progressive neurological deterioration due to venous congestion, two with acute intracranial hemorrhage. Three were treated by staged transarterial embolization procedures (three procedures in two, four procedures in one); two underwent a single transvenous embolization procedure. Four out of five fistulas were completely occluded. All patients improved clinically; the patient whose fistula was partially occluded remains angiographically stable at 2-year follow-up. Six reports describing 17 patients are reviewed. Embolization was performed via transvenous approach in 1/17 and transarterial approach in 16/17 with additional open surgery in 9/16. The trend toward the use of transarterial approaches is based primarily on advances on embolization techniques that allow better and more controllable penetration of the embolizing agents with improved clinical and angiographic results, as well as the technical complexity of the transvenous approach., Conclusions: Although transarterial embolization is the preferred endovascular route for the management of most galenic DAVFs, selected cases can be successfully treated by transvenous approach.

Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults and carries a grim prognosis. Lobar GBM, notably those localized to the frontal lobe, are generally more amenable to complete surgical resection, and may carry a better prognosis. The biology of differently localized GBM has been reported scarcely in terms of prognostic markers, including isocitrate dehydrogenase 1 (IDH1) mutation and O(6)-methylguanine-methyltransferase (MGMT) methylation. To our knowledge, there has been no evaluation in the literature of different proliferation indexes in different GBM locations in the brain. We performed a retrospective evaluation of our prospectively collected database to assess the rate of IDH1 positivity, MGMT methylation and Ki67 index for GBM located in the frontal lobes alone, lobar GBM in other supra-tentorial lobes and multilobar GBM. IDH1 mutated tumors were localized in the frontal lobes in 50.0%, whereas only 20.3% of IDH1 wild-type tumors were localized in the frontal lobe (p=0.006); MGMT methylated tumors were localized in the frontal lobe in 32.0% of the cases. Only 13.75% of the MGMT unmethylated tumors were localized to the frontal lobe (p=0.005); Tumors with higher Ki67 proliferation index were more likely to be localized in the frontal lobe (40.6% vs. 19.5%, p=0.019). This is the largest cohort of GBM assessed for these purposes in the literature. Frontal lobe GBMs may be intrinsically biologically distinct from GBM in other lobes and from multilobar tumors., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Isocitrate dehydrogenase 1 (IDH1) mutation is a known prognostic factor in glioblastoma multiforme (GBM). It has been well documented that patients with IDH1 mutant (IDH1-mu) GBM have a better outcome compared to patients with IDH1 wild-type (IDH1-WT) GBM. IDH1-mu tumors have been shown to be more commonly located in the frontal lobe, and less likely to be in multiple lobes. It is unclear whether differential location is part of the prognostically favorable profile of these tumors. We performed a case-control study, matching IDH1-mu GBMs to IDH1-WT GBMs that are controlled for age, sex and tumor location. There were 21 IDH1-mu tumors and 21 matched IDH1-WT tumors. Age, sex and tumor location were matched between the two groups. After controlling for the factors described, the IDH1-mu tumors were more likely to be secondary GBM (61.9% secondary vs. 14.3%, p=0.004). There was an insignificant trend towards smaller tumor volume in the IDH1-mu group (28.13±6.56 vs. 41.8±7.33 cm 3 , p=0.173). Extent of surgical resection was similar in both groups (mean 84.49% vs. 89.89%, p=0.419). There was no survival advantage for IDH1-mu tumors when controlled for location: 25.2months overall survival for IDH1-mu patients and 23.6 for IDH1-WT patients, p=0.794. IDH1 mutation may provide part of its prognostic significance by differential localization of tumor, both making IDH1-mu tumors more amenable to gross total resection and placing these tumors in less eloquent areas, thereby lowering neurological morbidity., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Although common after subarachnoid haemorrhage, cerebral vasospasm (CVS) and delayed ischaemic neurological deficit (DIND) rarely occur following elective clipping of unruptured aneurysms. The onset of this complication is variable and its pathophysiology is poorly understood. We report two patients with CVS associated with DIND following unruptured aneurysmal clipping. The literature is reviewed and the potential mechanisms in the context of patient presentations are discussed. A woman aged 53 and a man aged 70 were treated with elective clipping of unruptured middle cerebral artery aneurysms, the older patient also having an anterior communicating artery aneurysm clipped. The operations were uncomplicated with no intra-operative bleeding, no retraction, no contusion, no middle cerebral artery (MCA) temporary clipping, and no intra-operative rupture. Routine post-operative CT scan and CT angiogram showed that in both patients the aneurysms were excluded from the circulation and there was no perioperative subarachnoid blood. Both patients had no neurological deficit post-operatively, but on day 2 developed DIND and vasospasm of the MCA. Both patients had angiographic improvement with intra-arterial verapamil treatment. In one patient, this was done promptly and the patient made a complete recovery, but in the other, the diagnosis was delayed for more than 24hours and the patient had residual hemiparesis and dysphasia due to MCA territory infarction. CVS and DIND following treatment of unruptured aneurysms is a very rare event. However, clinicians should be vigilant as prompt diagnosis and management is required to minimise the risk of cerebral infarction and poor outcome., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Meningiomas are a common central nervous system tumour and radiation is a known risk factor for their development. In utero radiation exposure correlates to developmental abnormalities and carcinogenesis in a dose- and gestational age-related manner. Radiation induced meningioma has been reported in detail in the literature in patients who had been irradiated earlier in life. At the time of publication, there was no data on radiation exposure whilst in utero and meningioma. We report on a 42-year-old woman with multiple intracranial meningiomas and no other risk factors except a history of in utero exposure to low dose X-ray radiation at 12weeks gestational age., (Copyright © 2016. Published by Elsevier Ltd.)

OBJECTIVE Bevacizumab is an antiangiogenic agent under investigation for use in patients with high-grade glioma. It produces a high rate of radiological response; however, this response should be interpreted with caution because it may reflect normalization of the tumor vasculature and not necessarily a true antitumor effect. The authors previously demonstrated that 4 hypoxia-mediated microRNAs (miRNA)-miR-210, miR-21, miR-10b, and miR-196b-are upregulated in glioma as compared with normal brain tissue. The authors hypothesized that the regulation and expression of these miRNAs would be altered in response to bevacizumab treatment. The object of this study was to perform longitudinal monitoring of circulating miRNA levels in patients undergoing bevacizumab treatment and to correlate it with tumor response. METHODS A total of 120 serum samples from 28 patients with high-grade glioma were prospectively collected prior to bevacizumab (n = 15) or temozolomide (TMZ; n = 13) treatment and then longitudinally during treatment. Quantification of the 4 miRNAs was evaluated by real-time polymerase chain reaction using total RNA extracted from the serum. At each time point, tumor response was assessed by Response Assessment in Neuro-Oncology criteria and by performing MRI using fluid attenuated inversion recovery (FLAIR) and contrast-enhanced images. RESULTS As compared with pretreatment levels, high levels of miR-10b and miR-21 were observed in the majority of patients throughout the bevacizumab treatment period. miR-10b and miR-21 levels correlated negatively and significantly with changes in enhancing tumor diameters (r = -0.648, p < 0.0001) in the bevacizumab group but not in the TMZ group. FLAIR images and the RANO assessment did not correlate with the sum quantification of these miRNAs in either group. CONCLUSIONS Circulating levels of miR-10b and miR-21 probably reflect the antiangiogenic effect of therapy, but their role as biomarkers for tumor response remains uncertain and requires further investigation.

Vestibular schwannoma (VS) is the most common tumor in the extra-axial posterior fossa compartment in adults. Growth rate is paramount to decision making regarding treatment and follow up of these tumors. We conducted a comprehensive review of the literature to answer four questions: What percentage of newly diagnosed VS will grow on follow-up? What factors correlate to tumor growth? What is the "normal" growth rate for sporadic VS? What factors characterize VS with rapid growth? Thirty-seven reports, with more than 4000 patients, fit our review criteria. One third of newly diagnosed VS will grow on follow-up of 1-3years. However, after 5years, up to one half will grow. Patient age and sex do not influence growth of VS. Hearing loss and vertigo at presentation do not predict tumor growth. It is unclear whether balance disturbance or tinnitus predict tumor growth. Tumor size and location do not predict tumor growth. Growth in the first year of observation is a strong predictor of tumor growth. The average growth rate of a VS is 0.99-1.11mm/year. However, the expected growth rate for VS that have been shown to grow at first follow-up is 3mm/year. Factors that may predict tumor growth of above 4mm/year are cystic and hemorrhagic features in the tumor, and hormonal treatment. VS grow at an average 1mm/year. VS that have been shown to grow at first follow-up should be considered for treatment, unless contraindicated. Long term follow-up is recommended for VS., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Meningiomas are one of the most common brain tumors. World Health Organisation (WHO) Grade II and Grade III meningiomas are grouped together as non-benign meningioma (NBM). There are several controversies surrounding NBM management, including the significance of extent of resection and the efficacy of post-operative radiation and drug treatment. We reviewed the literature to develop recommendations for management of NBM. The questions we sought to answer were: Does gross total resection (GTR) improve patient outcome? Is radiation therapy (RT) warranted after complete or after incomplete resection of NBM? What drug therapies have been proven to improve outcome in patients with NBM? We found that GTR improves outcome in WHO Grade II meningioma, and should be attempted whenever considered safe. GTR correlates less closely to outcome in Grade III meningioma compared to subtotal resection (STR). Extreme measures to completely resect Grade III meningioma are not warranted. RT following GTR of Grade II meningioma does not improve patient outcome, and may be reserved for recurrence. RT improves outcome following STR of Grade II meningioma. RT improves outcome after resection of Grade III meningioma. No drug therapy has been shown to improve outcome in NBM. This review elucidates recommendations for some of the controversies involving NBM., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Pilomyxoid astrocytoma (PMA) is a recently recognised World Health Organization (WHO) Grade II tumour that was previously characterised as a subtype of the WHO Grade I pilocytic astrocytoma (PA). PMA has a histological appearance distinct from PA and a poorer prognosis due to its greater propensity for local recurrence and cerebrospinal dissemination. Although originally considered a paediatric tumour involving mainly the hypothalamic and chiasmatic region, reports of the lesion occurring in the adult population and other areas of the neuroaxis are emerging. We review the literature on PMA within the adult population and present the first case of PMA in the cerebellum of an adult female., (Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.)

Spinal angiolipomas are uncommon benign tumours composed of mature fatty tissue and abnormal vascular elements, most commonly found within the posterior spinal epidural space. Most tumours are located within the mid-thoracic spine; in contrast thoracolumbar junction and purely lumbar angiolipomas are rare. We report a case series of four spinal angiolipomas, including a thoracolumbar junction and a purely lumbar tumour., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Awake craniotomy (AC) has been used in increasing frequency in the past few decades. It has mainly been used for resection of intrinsic tumors, but also, rarely, for other pathologies. The vast majority of reports specific to one pathology, however, have focused on resection of low grade glioma in the awake setting. Tumors in eloquent areas have mainly been resected when the patient is awake for the purpose of preservation of function. Motor function is the most documented, and most successfully preserved function. Other functions are harder to localize with direct electrical stimulation (DES), and thus more difficult to preserve. The success rate of DES localization correlates to the rate of function preservation. The effect of AC on extent of resection is inconsistent in the literature. Other functions, such as sensory and visuospatial recognition, have been protected during AC, but this is best performed in large, referral centers that have experience with the procedure. Other benefits to AC, such as cost-effectiveness and reduction in patient pain and anxiety, have also been reported., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: The objectives of this study were to examine the presence of β-2 transferrin (β2TRNSF) in cerebrospinal fluid (CSF) contaminated in vitro by various bacteria and explore the mechanism (passive or active) responsible for β2TRNSF elimination. Early diagnosis of CSF leakage may change treatment decisions and minimize the risk of meningitis and encephalitis. β2TRNSF is a protein present exclusively in CSF. Its detection is highly useful in cases of CSF leakage, although it has never been examined in the presence of central nervous system infection., Study Design: Prospective patient analysis., Methods: Sterile CSF drawn from patients was contaminated in vitro with several microorganisms chosen for their ability to cause neurosurgical-related infections: Streptococcus pneumoniae, methicillin-sensitive Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa. β2TRNSF was examined at two time points: following immediate inoculation (t0) and following an overnight incubation (t18) over various bacterial concentrations. Samples of CSF inoculated with S pneumoniae were also examined in the presence of ciprofloxacin. For β2TRNSF analysis we used immunoblotting electrophoresis and enzyme-linked immunosorbent assay (ELISA)., Results: CSF samples collected from nine patients were analyzed. β2TRNSF was not detected following S pneumoniae inoculation at both time points when immunoblotting electrophoresis was used. Quantitative analysis using ELISA demonstrated significant β2TRNSF concentration decrease. The addition of ciprofloxacin led to the same results., Conclusions: CSF leak detection using β2TRNSF may be deceiving in the presence of a S pneumoniae cerebral nervous system infection. A passive process is suggested, as β2TRNSF disappeared either immediately or following incubation with inactive bacteria., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Randomized controlled trials have demonstrated the efficacy of decompressive craniectomy in substantially decreasing mortality and improving functional outcome in middle cerebral artery infarction. The role of intracranial pressure (ICP) monitoring following decompressive craniectomy for stroke has not been well studied. We present a retrospective review of our experience with postoperative ICP monitoring in 12 stroke patients who underwent decompressive craniectomy. All elevations of ICP above a 20 mm Hg threshold were noted. ICP was recorded for 1417 hours during which 68 ICP elevations were seen. Nine out of 12 patients had events of raised ICP, including eight with more than three elevations. A total of 81 interventions were employed to treat elevated ICP; 71 were effective in reducing ICP below the 20 mm Hg threshold. The most frequent intervention was cerebrospinal fluid drainage via an external ventricular drain, which was effective in 85.4% of cases. Eleven out of 12 patients survived (92%) and attained a median modified Rankin Scale score of 4 (interquartile range 4-5) at a mean 15 month follow-up. In our experience, elevated ICP may commonly occur following decompressive craniectomy for stroke. Monitoring ICP influenced postoperative management and standard measures for reducing ICP were usually effective in the current series., (Copyright © 2014. Published by Elsevier Ltd.)

Object: Surgery for giant anterior clinoidal meningiomas that invade vital neurovascular structures surrounding the anterior clinoid process is challenging. The authors present their skull base technique for the treatment of giant anterior clinoidal meningiomas, defined here as globular tumors with a maximum diameter of 5 cm or larger, centered around the anterior clinoid process, which is usually hyperostotic., Methods: Between 2000 and 2010, the authors performed 23 surgeries in 22 patients with giant anterior clinoidal meningiomas. They used a skull base approach with extradural unroofing of the optic canal, extradural clinoidectomy (Dolenc technique), transdural debulking of the tumor, early optic nerve decompression, and early identification and control of key neurovascular structures., Results: The mean age at surgery was 53.8 years. The mean tumor diameter was 59.2 mm (range 50-85 mm) with cavernous sinus involvement in 59.1% (13 of 22 patients). The tumor involved the prechiasmatic segment of the optic nerve in all patients, invaded the optic canal in 77.3% (17 of 22 patients), and caused visual impairment in 86.4% (19 of 22 patients). Total resection (Simpson Grade I or II) was achieved in 30.4% of surgeries (7 of 23); subtotal and partial resections were each achieved in 34.8% of surgeries (8 of 23). The main factor precluding total removal was cavernous sinus involvement. There were no deaths. The mean Glasgow Outcome Scale score was 4.8 (median 5) at a mean of 56 months of follow-up. Vision improved in 66.7% (12 of 18 patients) with consecutive neuroophthalmological examinations, was stable in 22.2% (4 of 18), and deteriorated in 11.1% (2 of 18). New deficits in cranial nerve III or IV remained after 8.7% of surgeries (2 of 23)., Conclusions: This modified surgical protocol has provided both a good extent of resection and a good neurological and visual outcome in patients with giant anterior clinoidal meningiomas.

Background: Tracheoinnominate artery fistula is a relatively rare but life-threatening complication of tracheostomy. Peristomal bleed or hemoptysis may be massive and usually fatal if treatment is not instituted immediately., Case Description: We report the case of a 40-year-old woman who sustained surgical evacuation of a brainstem cavernoma and developed a massive hemoptysis 13 days after a percutaneous tracheostomy. Because of the patient's poor clinical condition, endovascular repair of the arterial injury was decided. The innominate artery was successfully repaired by means of urgent stent-graft placement., Conclusions: We believe that, if technically feasible, stent-graft placement can be a valuable therapeutic alternative for this dramatic condition. Physicians in charge of tracheostomized patients and neurointerventionalists should be familiar with this management strategy.