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BACKGROUND: Diffusion tensor imaging (DTI) can characterize eloquent white matter tracts affected by brain arteriovenous malformations (AVMs). However, DTI interpretation can be difficult in ruptured cases due to the presence of blood products. The authors present the case of a ruptured pediatric AVM in the corticospinal tract (CST) and discuss how DTI at different time points informed the treatment. OBSERVATIONS: A 9-year-old female presented with a sudden headache and left hemiparesis. She was found to have a Spetzler-Martin grade III, Supplementary grade I AVM in the right caudate and centrum semiovale, with obliteration and corresponding reduced fractional anisotropy (FA), fiber density (FD), and tract count (TC) of the adjacent CST on DTI. The patient remained stable and was scheduled for elective resection following a 6-week period to facilitate hematoma resorption. After 6 weeks, repeat DTI showed part of the nidus within intact CST fibers with concordant improvement in FA, FD, and TC. Considering the nidus location, CST integrity, and motor function recovery, surgery was deferred in favor of stereotactic radiosurgery. LESSONS: In ruptured AVMs, DTI may initially create an incomplete picture and false assumptions about white matter tract integrity. DTI should be repeated if delayed treatment is appropriate to ensure informed decision-making and prevent avoidable permanent neurological deficits. https://thejns.org/doi/10.3171/CASE24225.

PURPOSE: This study investigated whether Ki-67 labeling index (LI) correlated with clinical outcomes after SRS for atypical meningiomas. METHODS: This retrospective study examined 39 patients with atypical meningiomas who underwent SRS over a 10-year study period. Ki-67 LI was categorized into 3 groups: low ( 10%). Local tumor control rates (LCRs), progression-free rates (PFRs), disease-specific survival (DSS) rates, and adverse radiation-induced events (AREs) were evaluated. RESULTS: The median follow-up periods were 26 months. SRS was performed at a median prescription dose of 18 Gy for tumors with a median Ki-67 LI of 9.6%. The 3-year LCRs were 100%, 74%, and 25% in the low, intermediate, and high LI groups, respectively (p = 0.011). The 3-year PFRs were 100%, 40%, and 0% in the low, intermediate, and high LI groups (p = 0.003). The 5-year DSS rates were 100%, 89%, and 50% in the low, intermediate, and high LI groups (p = 0.019). Multivariable Cox proportional hazard analysis showed a significant correlation of high LI with lower LCR (hazard ratio [HR], 3.92; 95% confidence interval [CI] 1.18-13.04, p = 0.026), lower PFR (HR 3.80; 95% CI 1.46-9.88, p = 0.006), and shorter DSS (HR 6.55; 95% CI 1.19-35.95, p = 0.031) compared with intermediate LI. The ARE rates were minimal (8%) in the entire group. CONCLUSION: Patients with high Ki-67 LI showed significantly more tumor progression and tumor-related death. Ki-67 LI might offer valuable predictive insights for the post-SRS management of atypical meningiomas.

Introduction: Management for elderly patients (> 65yo) with incidental meningiomas remains unclear. This study aims to characterize the functional and tumor outcomes of expectant and stereotactic radiosurgery (SRS) management of asymptomatic meningioma elderly patients. Methods: Using retrospectively collected data from 14 centers, SRS outcomes were compared to radiographic and clinical observation of asymptomatic meningiomas in elderly patients following propensity score matching. Results: Following propensity score matching, 114 patients were in each cohort. Tumor control was achieved at 97.37% in the SRS cohort, and no meningioma growth was seen 71.93% of the observation cohorts (p < 0.01; OR 14.44 [95% CI 4.27–48.78]). New neurological deficits developed in 1.39% of the SRS cohort but in none of the patients managed conservatively. 3.5% of patients underwent resection in the active surveillance matched cohort compared to 0.9% of patients in the SRS cohort (p = 0.063; OR 0.135 [95% CI 0.163–1.117]). The all-cause mortality rate was almost half in the SRS group (9.65%) compared to the observation group (18.42%) (p = 0.06; OR 0.47 [95% CI.22–1.03]). Conclusion: SRS achieves superior radiological tumor control compared to surveillance but with a slightly increased the risk of new SRS-related neurological deficits in elderly patients with asymptomatic meningiomas. Although SRS reduces meningioma progression, the need for of an open neurosurgical procedure and mortality were not significantly reduced. Furthermore, mortality in the observation group was not directly related to the meningioma in any of the patients. [ABSTRACT FROM AUTHOR]

Background: Neurofibromatosis type 2 (NF2)-related schwannomatosis is a rare genetic disorder associated with meningiomas. Stereotactic radiosurgery (SRS) has emerged as a potential non-invasive method. This study aims to synthesize the available evidence on using SRS to treat these tumors. Methods: PubMed/Medline, Embase, Scopus, and Web of Science were searched until March 21, 2024. This study was prepared by adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Results: Four studies were included comprising 101 patients with NF2-associated meningiomas treated with SRS. All included studies used gamma knife stereotactic radiosurgery (GKRS) as treatment modality. Overall survival rates remained high (100%) up to 3 years post-treatment, with slight declines at five years of 98% (95% CI: 0.95–1.01) and ten years of 68% (95% CI: 0.48–0.87). Progression-free survival rates were similarly favorable, with 95% (95% CI: 89-101%) at three years, 93% (95% CI: 86-99%) at five years, and 81% (95% CI: 51-111%) at ten years. The pooled radiation necrosis rate was 5% (95% CI: 3-7%), while the overall radiation toxicity rate was 16% (95% CI: 11-21%). Local tumor control rates were high at six months, and at 12 months, they were 100% (95% CI: 1.00–1.00). Conclusion: GKRS demonstrates high efficacy and a favorable safety profile for NF2-associated meningiomas, offering a valuable treatment option for this challenging patient population. [ABSTRACT FROM AUTHOR]

Cavernous malformations (CM) of the brain are vascular abnormalities that carry a risk of bleeding, posing significant neurological and life-threatening challenges, particularly in posterior fossa. The efficacy of radiosurgery for cavernomas still remains a matter of debate, largely due to technical and statistical limitations. In this study, we present a series of posterior fossa cavernomas treated using CyberKnife radiosurgery, employing an innovative approach that integrates both technical and statistical advancements. Patients and methods: We conducted a prospective series involving 35 posterior fossa cavernomas in 33 patients treated with low-dose radiosurgery protocols (12 Gy in a single fraction or 18 Gy in 3 fractions). Compared to previously published series, our approach targeted a larger treatment volume, encompassing the entire hemosiderin ring surrounding the cavernoma. Radiosurgery was indicated for cases of hemorrhage or progressive neurological deficits in anatomically challenging, nonsurgical areas. The statistical analysis was designed to address the unknown onset time of cavernoma prior to radiosurgery, enabling a more accurate calculation of the hemorrhage incidence rate before treatment. Follow-up evaluations, including clinical assessments and MRI, were conducted at 3-6-9-12-18-24 months and subsequently on an annual basis. Results: With a mean follow-up duration of 26 months, exceeding the previously described latency period, and a median [IQR] follow-up of 13 months [8.7-30.4] which represents approximately half the latency period, only one patient experienced a recurrence of hemorrhage, occurring 20 months post-treatment and remaining asymptomatic. No patients exhibited radio-induced parenchymal changes or clinical deterioration following radiosurgery. Conclusions: These preliminary results support the strategy of increasing the target volume while reducing the radiation dose for cavernous malformations. We further recommend incorporating sensitivity analyses to evaluate the robustness of results, particularly in the context of uncertainties surrounding the time of onset of cavernomas. [ABSTRACT FROM AUTHOR]

Purpose: Existing literature on adjuvant radiation after subtotal resection (STR) of WHO II meningiomas is limited by heterogenous patient cohorts, combining adjuvant and salvage radiation, gross total resection (GTR) and STR, primary radiation treatment vs. re-treatment, or grade II and III meningiomas, all of which have different expected outcomes. Tumor control estimates in a large homogenous patient cohort are needed to accurately counsel patients. Methods: A retrospective review of patients that had immediate post-operative imaging-confirmed residual WHO grade II meningioma followed by either adjuvant intensity-modulated radiation therapy (IMRT) or stereotactic radiosurgery (SRS) between 1996 and 2020 was conducted. Kaplan-Meier survival analysis and log-rank test was used to assess progression-free survival (PFS). Results: Thirty-nine patients met inclusion criteria (IMRT = 32; SRS = 7). Overall, the 3-, 5-, and 10-year PFS was 81.1%, 61.2%, and 44.6%, respectively. Median follow-up time was 37 months. When comparing IMRT and SRS cohorts, baseline characteristics did not differ significantly between groups, but significantly larger residual tumor volumes were treated with IMRT (22.2 cm3 vs. 6.3 cm3, p = 0.004). PFS was not significantly different between IMRT and SRS at 3 years (81.1% vs. 80.0%) or 5 years (65.5% vs. 40%) (p = 0.19). There was no significant difference in radiation necrosis between groups (IMRT = 3/32 patients vs. SRS = 0/7 patients, p = 0.32). Conclusion: Our homogenous patient cohort displayed acceptable control rates at 3 years using SRS or IMRT as adjuvant therapy. No significant difference in PFS or radiation necrosis was noted between patients treated with adjuvant IMRT versus SRS. [ABSTRACT FROM AUTHOR]

Purpose: Meningiomas are the most frequent primary intracranial malignancy. While surgical resection can confer long term tumor control, stereotactic radiosurgery (SRS) is often used for small, asymptomatic tumors in the adjuvant setting. Frailty has been associated with increased rates of peri-operative morbidity but has yet to be defined in the setting of SRS for meningiomas. We therefore sought to examine the relationship between frailty and clinical/radiographic outcomes of patients with meningiomas who have undergone SRS. Methods: A single-center, retrospective cohort study classified patients by their 5-factor modified frailty index (mFI-5) score into pre-frail (0–1) and frail (2–5) at the time of SRS treatment. Evaluations of overall survival (OS), progression free survival (PFS), local control (LC), and distant control (DC) were performed using Kaplan–Meier analysis. Cox proportional hazards regression analysis was used to further define factors associated with OS/PFS. Results: 94 patients met inclusion criteria and underwent SRS for meningioma treatment from 2019 to 2023. Analyses compared prefrail (0–1) and frail (2–5) individuals. Kaplan–Meier analysis demonstrated a near significant association between frailty and OS (HR 3.66, 95% CI 0.49–26.8 p = 0.05) with 3-year OS rates of 75.4% in the pre-frail versus 36.6% in the frail group. However, a significant relationship was demonstrated between frailty and PFS (HR: 2.95 95% CI 1.12–7.81, p = 0.02) with 3-year PFS rates of 90.5% in the pre-frail group versus 49.2% in the frail group. Univariable regression analysis demonstrated that frailty, prior surgical excision, and cumulative tumor volume predicted PFS. Conclusion: Frailty, as assessed by the mFI-5, did not independently predict OS but did predict PFS in individuals with meningioma undergoing SRS. [ABSTRACT FROM AUTHOR]

Introduction: Craniopharyngiomas are challenging benign tumors arising from Rathke's pouch remnants, often requiring multidisciplinary management due to their proximity to critical neurovascular structures. This meta-analysis systematically compares conventional radiation therapy (RT) and stereotactic radiosurgery (RS) in treating residual or recurrent craniopharyngiomas. Method: A comprehensive literature search identified 44 studies, including 46 reports, meeting inclusion criteria such as progression-free survival (PFS) and post-radiotherapy complications. Data extraction followed PRISMA guidelines. Results: The pooled 5-year PFS favored RT (0.843; 95% CI: 0.767–0.898) over RS (0.680; 95% CI: 0.631–0.727), as did 10-year PFS (RT: 0.813; 95% CI: 0.683–0.888; RS: 0.553; 95% CI: 0.470–0.634). RT demonstrated mitigating tumor recurrence risks. Visual and hormonal complication rates between the modalities were comparable (visual: ~4%; hormonal: ~6%). Conclusion: RT consistently achieved superior long-term PFS compared to RS, reaffirming its role as the standard for adjuvant therapy in craniopharyngiomas. This analysis highlights the need for tailored treatment strategies balancing efficacy and safety, ultimately enhancing patient outcomes. [ABSTRACT FROM AUTHOR]

The impact of three-dimensional (3D) dose delivery accuracy of C-arm linacs on the planning target volume (PTV) margin was evaluated for non-coplanar intracranial stereotactic radiosurgery (SRS). A multi-institutional 3D starshot test using beams from seven directions was conducted at 22 clinics using Varian and Elekta linacs with X-ray CT-based polymer gel dosimeters. Variability in dose delivery accuracy was observed, with the distance between the imaging isocenter and each beam exceeding 1 mm at one institution for Varian and nine institutions for Elekta. The calculated PTV margins for Varian and Elekta linacs that could cover the gross tumor volume with 95% probability at 95% of the institutions were 2.3 and 3.5 mm, respectively, in the superior–inferior direction. However, with multifactorial system management (i.e., high-accuracy 3D dose delivery with rigorous linac quality assurance, strict patient immobilization, and high intra-fractional positioning accuracy), these margins could be reduced to 1.0 mm and 1.5 mm, respectively. The findings indicate significant millimeter-level variability in 3D dose delivery accuracy among linacs installed in clinical settings. Thus, maximizing a linac's 3D dose delivery accuracy is essential to achieve the required PTV margin in intracranial SRS. [ABSTRACT FROM AUTHOR]

Epilepsy is a common neurological disease that is treated with medications; however, patients with drug-resistant epilepsy, commonly intractable temporal lobe epilepsy, tend to have better control with surgical treatment. While the mainstay of surgical treatment is anterior temporal lobectomy, it carries risk of potential adverse effects hence minimally invasive techniques are now being used as an alternative to open surgery. This systematic review and meta-analysis compare the efficacy and safety of three of the most used techniques: laser interstitial thermal therapy (LITT), radiofrequency ablation (RFA) and stereotactic radiosurgery (SRS). Multiple databases were searched and PRISMA guidelines were followed to make an indirect meta-analysis using the currently available studies for the three techniques in terms of seizure freedom, risk of major complications and reoperations. Further subgroup analyses were carried out for LITT in terms of follow up periods and seizure freedom in patients with or without hippocampal sclerosis. A total of 42 papers were included in this study with a total of 1675 patients (1303 treated by LITT, 188 treated by RFA and 184 treated by SRS). LITT had the highest rate of seizure freedom (55.0%, CI 51.5 − 58.5%, P = 0.148), and the lowest rates of major complications (2.3%, CI 1.2 − 3.5%, P = 0.070), and reoperations (14.3%, CI 10.4 − 18.3%, P = 0.042) compared to RFA and SRS which had seizure freedom of 46.3% (CI 18.8 − 73.7%, P = 0.000) and 53.8% (CI 44.4 − 63.3%; I^2 = 40.4%, P = 0.098), major complication rate of 3.9% (CI 0.7 − 7.0%; I^2 = 0%, P = 0.458) and 14.3% (CI 3.1 − 25.5%, P = 0.000) and reoperation rate of 28.6% (CI -4.3 − 61.5%, P = 0.000) and 15.4% (CI 6.1 − 24.8%; I^2 = 0%, P = 0.392) respectively. In conclusion, LITT showed the highest rate of seizure freedom and the lowest rate of major complications and reoperations compared to RFA and SRS in single-arm studies of intractable mesial temporal lobe epilepsy. However, the lack of direct comparisons between treatment modalities limits definitive conclusions. Despite this, LITT appears to offer a favorable safety profile, warranting further prospective, comparative studies to validate these findings. [ABSTRACT FROM AUTHOR]

Background: Vestibular symptoms can severely affect patients with vestibular schwannomas (VSs). Studies assessing vestibular symptoms beyond clinical routine assessment in patients with VS treated by stereotactic radiosurgery (SRS) are scarce. Therefore, we employed the standardized questionnaire Dizziness Handicap Inventory (DHI) to systematically evaluate vestibular symptoms prior to and after SRS. Methods: For this retrospective single center study, we included patients who received Cyberknife® SRS for newly diagnosed unilateral VS between 2012 and 2022, and who had a minimum of two follow-up (FU) visits. Besides clinical assessment, the presence and severeness of vestibular symptoms before and after treatment was recorded by using the DHI. Overall DHI symptom scores (1–100) were classified into four grades (0 = "none", 1 = "mild", 2 = "moderate" and 3 = "severe"). The results were correlated with tumor-, patient-, and treatment-related characteristics. Results: We analyzed 128 patients with a median age of 60 years (range: 20–82) and a median FU of 36 months (range: 11–106 months). The median tumor volume was 0.99 cm3 (range: 0.04–7.1 cm3). A median marginal dose of 13 Gy (range: 12–14 Gy) was administered. The crude rate of local tumor control was 99.2%. The mean DHI total score at last follow-up (LFU, 25.5 ± 24.7; range 0–92) was significantly lower than before SRS (29.4 ± 25.3; range:0–92, p = 0.026), which was reflected in a higher proportion of patients with DHI grade "none" and a lower proportion of patients with DHI grade "severe" at LFU. Chi-square tests showed a significant correlation of the DHI grades (DHI 0–1 vs. DHI 2–3) with the absence or presence of vestibular symptoms both before SRS (p < 0.001, CI 95%) and at LFU (p = 0.038). Conclusions: The DHI is a feasible and valid instrument for measuring vestibular symptoms after SRS. In addition, the DHI enables the quantification of symptoms and can therefore serve as an important tool for outcome assessment after SRS of VS. In the present cohort, DHI scores improved significantly during FU. [ABSTRACT FROM AUTHOR]

Purpose: Toxicities associated with stereotactic radiosurgery (SRS) are important when considering treatment and supportive management for patients with brain metastases. We herein assessed the association between brain metastasis location and risk of toxicity after SRS. Methods: We conducted a retrospective institutional review of patients treated with SRS for brain metastases between 2008 and 2023. Outcomes included radiation necrosis, seizure, local failure, and overall survival (OS). Results: We reviewed 215 patients treated to 605 metastases (median diameter 10 mm, IQR 5–17 mm), in the frontal (34%), cerebellar (19%), parietal (16%), temporal (13%), and occipital (13%) regions. Median follow-up was 16 months (IQR 7–36). New-onset seizures developed in 11% (19/174) of patients without prior seizure and was higher in patients with motor or sensory cortex lesions (12/48, 25%) on multivariate analysis (MVA, P = 0.02). SRS-related grade ≥ 2 symptomatic radionecrosis occurred in 6% (33/605) of lesions and correlated with larger metastasis volume (P < 0.001) and renal cell carcinoma histology (P < 0.05), while supratentorial location was nearly significant (MVA, P = 0.06). Median OS across all patients was 16 months (95% CI 12–20). Patients with symptomatic radiation necrosis had a longer median survival compared to those who did not (43 vs. 14 months, P = 0.002), which remained significant alongside Karnofsky performance status and extracranial disease on MVA. Conclusion: Brain metastasis location in the motor or sensory cortex is associated with increased risk of new-onset seizure following SRS and may warrant consideration of steroid and/or anti-epileptic prophylaxis. Symptomatic radiation necrosis is uncommon in the cerebellum and may be increasing with improvements in survival. [ABSTRACT FROM AUTHOR]

Purpose: Stereotactic radiosurgery (SRS) is frequently used in the management of brain metastasis patients. However, there is an urgent need to evaluate post-treatment outcomes and quality of life metrics for patients undergoing SRS for brain metastases. Methods: The NeuroPoint Alliance (NPA) SRS Quality Registry conducted prospective enrollment of patients undergoing SRS from 2017 to 2024. Patients with brain metastases from lung cancer, breast cancer, and melanoma were included in the analysis. Outcomes of interest included quality of life metrics, as captured by the five-dimension Euro-QOL (EQ-5D) at 6–12 months and last record follow-up, overall survival, local progression, out-of-field progression, and overall intracranial progression. Results: 522 patients comprised our analytic cohort, and 315 patients had available EQ-5D data at the time of SRS and final follow-up. 264 (47.8%), 197 (35.7%), and 91 (16.5%) patients had 1, 2–4, and 5–14 lesions pre-SRS, respectively. The median overall survival time from diagnosis was 27.3 months. The median time-to-local progression was not reached. At final follow-up, 107 (34.0%) patients had improvement, 51 (16.2%) patients had stable, and 113 patients (35.9%) had worsening EQ-5D scores when compared to baseline. For 44 (13.9%) patients mixed responses across the EQ-5D indices were reported. Linear regression analysis showed that male sex, smoking status, primary tumor type, time-to-overall progression, cumulative intracranial tumor volume (CITV), and baseline EQ-5D were statistically significantly associated with EQ-5D single index at the final follow-up. Conclusion: Real-world data from the SRS NPA Registry demonstrated that most patients with brain metastasis had no change or improvement in quality of life after SRS. Baseline EQ-5D was predictive of EQ-5D single index at final follow-up, and, as such, EQ-5D at baseline would be a valuable assessment measure for brain metastasis patients undergoing SRS. [ABSTRACT FROM AUTHOR]

Background: Delayed radiation-induced complications after stereotactic radiosurgery (SRS) for arteriovenous malformations (AVM) have scarcely been described in the literature, and their incidence, pathophysiology, and treatment remain unclear. Additionally, the literature regarding these complications is confusing. The authors present a well-documented case report describing these late complications, adding evidence to the possible common pathophysiological mechanism underlying them, and illustrating an effective treatment modality when they occur. Case presentation: A case of a 28-year-old male with an increasing cyst formation (CF) appearing 10 years after SRS for AVM is presented. Despite surgical treatment, due to the incomplete resection of the angiomatous nodule, recurrence as a chronic encapsulated expanding hematoma (CEEH) occurred. This relapse required a second treatment, which could have been avoided if aggressive surgical treatment had been performed initially. Conclusions: This case highlights the continuum between CF and CEEH, challenging existing confusion in the literature. Complete resection of the angiomatous nodule associated with CF is imperative for achieving resolution and preventing recurrence. [ABSTRACT FROM AUTHOR]

Introduction: Pediatric hemifacial spasm (HFS) is rare, presenting early in infancy, and often fraught with subsequent psychomotor and intellectual deficits. Fourth ventricular hamartoma (FVH) is a rare cause of HFS with only 5 cases reported in literature. While gamma knife radiosurgery (GKRS) has been used to treat hypothalamic hamartomas, this is the first case of FVH treated with primary GKRS. Case Presentation: A two-year-old female presented with persistent episodes of HFSs and dystonic posturing with an early resistance to medication. Thorough radiological profiling of the fourth ventricular tumor is the suggested tentative diagnosis of FVH. The patient’s guardians refused surgical intervention and gave consent for GKRS aware of the lack of literature on its use in FVH. She underwent frame-based GKRS covering a total target volume of 0.986 cc with 13 Gy@50% with Leksell Perfexion. The patient showed a phasic response to GKRS with remarkable seizure control at a 1.5-year follow-up. Conclusion: Previous studies have suggested that gelastic seizures of hypothalamic hamartoma are comparable to HFSs of FVH. Our case exemplifies another key similarity between the two, i.e., a near-congruent phasic response to GKRS. This hints at the underlying pathophysiology of HFS in similar pathologies and GKRS as a treatment option in select patients. [ABSTRACT FROM AUTHOR]

Purpose: Stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) are increasingly used as initial therapies for brain metastases (BM). We aimed to assess the outcomes of SRS/FSRT in patients aged ≥ 65 years who had 1-10 BM from non–small cell lung cancer (NSCLC). Materials and Methods: We retrospectively reviewed 91 elderly NSCLC patients with 222 BM who were treated with SRS/FSRT at two institutions between 2010 and 2020. The primary endpoint was overall survival (OS) after SRS/FSRT. In addition, in-field local control (IFLC) within the treated field was evaluated. Statistical analysis was performed to identify the prognostic factors affecting OS and IFLC. Results: During a median follow-up of 18 months, the median OS was 32 months. The 1- and 2-year survival rates were 69.8% and 56.1%, respectively. In multivariate analysis, the NSCLC-specific graded prognostic assessment (GPA) score (p=0.007) and administration of systemic therapy (p=0.039) were defined as prognosticators affecting OS. The median IFLC period was 31 months, and the 1- and 2-year IFLC rates were 75.9% and 57.6%, respectively. The total BM volume (p=0.042) significantly affected IFLC. No severe adverse events were reported after SRS/FSRT. Conclusion: SRS/FSRT is an effective upfront treatment option for BM arising from NSCLC in elderly patients, with a good OS without severe side effects. Higher GPA score and active systemic treatment were associated with improved OS, indicating that elderly patients are significant candidates for SRS/FSRT. [ABSTRACT FROM AUTHOR]

Resection is often the primary treatment for large brain tumors but is less practical for multiple brain metastases (BM). Current guidelines recommend stereotactic radiosurgery (SRS) for untreated BMs or following the surgical removal of a solitary BM to reduce the risk of local tumor recurrence. Preoperative SRS (pre-SRS) shows promise with fewer complications and more precise targeting, but it lacks tissue diagnosis and may hinder wound healing. This study aims to compare the safety and efficacy of pre-SRS and postoperative SRS (post-SRS) for BM treatment. A comprehensive literature search was conducted in PubMed, Embase, Scopus, and Cochrane Library. Studies were selected based on PICO criteria, including patients with metastatic intracranial lesions undergoing preoperative or postoperative radiosurgery. Data related to outcomes and complications were extracted. Meta-analysis was performed, employing the fixed effect model due to study design similarities and limited patient numbers. Four studies encompassing 616 BM patients (221 preoperative, 405 postoperative) were included. Patient characteristics, including age, gender, cancer source, and lesion location, were similar between groups. Radiosurgery modalities included LINAC and Gamma Knife, with hypofractionated treatments more common postoperatively. Outcomes showed comparable overall survival (p = 0.07), local failure (p = 0.26), and distant failure rates (p = 0.84) between groups. The preoperative group had lower risks of radiation necrosis (p = 0.02) and leptomeningeal disease (p = 0.03) in 1-year follow-up, with significantly better composite outcomes (p = 0.04). No significant difference in wound issues was observed (p = 0.98). This review reveals pre- and post-SRS for BM have similar outcomes for LF, DF, and OS. Pre-SRS potentially lowers RN and LMD risks, with better tumor targeting and less radiation to healthy tissue, while post-SRS targets residual disease but with higher complication risks. Future research should optimize SRS protocols. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate an extended self-adapting nnU-Net framework for detecting and segmenting brain metastases (BM) on magnetic resonance imaging (MRI). Six different nnU-Net systems with adaptive data sampling, adaptive Dice loss, or different patch/batch sizes were trained and tested for detecting and segmenting intraparenchymal BM with a size ≥2 mm on 3 Dimensional (3D) post-Gd T1-weighted MRI volumes using 2092 patients from 7 institutions (1712, 195, and 185 patients for training, validation, and testing, respectively). Gross tumor volumes of BM delineated by physicians for stereotactic radiosurgery were collected retrospectively and curated at each institute. Additional centralized data curation was carried out to create gross tumor volumes of uncontoured BM by 2 radiologists to improve the accuracy of ground truth. The training data set was augmented with synthetic BMs of 1025 MRI volumes using a 3D generative pipeline. BM detection was evaluated by lesion-level sensitivity and false-positive (FP) rate. BM segmentation was assessed by lesion-level Dice similarity coefficient, 95-percentile Hausdorff distance, and average Hausdorff distance (HD). The performances were assessed across different BM sizes. Additional testing was performed using a second data set of 206 patients. Of the 6 nnU-Net systems, the nnU-Net with adaptive Dice loss achieved the best detection and segmentation performance on the first testing data set. At an FP rate of 0.65 ± 1.17, overall sensitivity was 0.904 for all sizes of BM, 0.966 for BM ≥0.1 cm3, and 0.824 for BM <0.1 cm3. Mean values of Dice similarity coefficient, 95-percentile Hausdorff distance, and average HD of all detected BMs were 0.758, 1.45, and 0.23 mm, respectively. Performances on the second testing data set achieved a sensitivity of 0.907 at an FP rate of 0.57 ± 0.85 for all BM sizes, and an average HD of 0.33 mm for all detected BM. Our proposed extension of the self-configuring nnU-Net framework substantially improved small BM detection sensitivity while maintaining a controlled FP rate. Clinical utility of the extended nnU-Net model for assisting early BM detection and stereotactic radiosurgery planning will be investigated. [ABSTRACT FROM AUTHOR]

Objective: This review aims to formulate the most current, evidence-based recommendations regarding radiation therapy, radiosurgery, and chemotherapy for patients with metastatic spine tumors. Methods: A systematic literature using PRISMA methodology was performed from 2010–2023 using the search terms "radiosurgery," "radiation therapy," "external beam radiation therapy," or "stereotactic body radiation therapy" in conjunction with "spinal," "spine," "metastasis," "metastases," or "metastatic." Results: Spinal metastases should be managed in a multidisciplinary team consisting of spine surgeons, radiation oncologists, radiologists and oncologists. Patients identified as potential candidates for SRS/EBRT using internationally recognized frameworks and criteria should be assessed by surgeons to see if surgical cyto-reduction/ separation surgery can be achieved. Choices for treatment of recurrence include re-irradiation with SBRT vs EBRT, surgical debulking, additional chemotherapy or palliative care. There is a lack of current clinical evidence to support the routine use of targeted therapies in the management of metastatic spinal tumors. Conclusions: Improving the management of spinal metastasis will lead to increased quality of life and improved survival. This review provides current, evidence-based guidelines on radiation therapy, radiosurgery, and chemotherapy for patients with metastatic spine tumors. [ABSTRACT FROM AUTHOR]

This study aimed to explore the effect of observation, microsurgery, and radiotherapy for patients with vestibular schwannoma (VS). We searched PubMed, Medline, Embase, Web of Science, and Cochrane library from their establishment to July 31, 2024. 34 non-RCTs and 1 RCT that included 6 interventions were analyzed. We found the MS, and different SRS all had better tumor local control rates. Regarding preserved hearing, the order from the highest to the lowest was FSRT 5 fractions, FSRT 3 fractions, SRS, ConFSRT, Observation, and MS. Regarding improvement in the rate of tinnitus, the order from the highest to the lowest was ConFSRT, FSRT 3 fractions, SRS, Observation, MS, and FSRT 5 fractions. In terms of improving the rate of disequilibrium/vertigo, the order from the highest to the lowest was SRS, Observation, FSRT 3 fractions, FSRT 5 fractions, MS, and ConFSRT. In terms of protection of the trigeminal nerve, the order from the highest to lowest was observation, SRS, ConFSRT, FSRT 3 fractions, FSRT 5 fractions, and MS. Lastly, in terms of protection of the facial nerve, the order from the highest to lowest was SRS, ConFSRT, Observation, FSRT 3 fractions, FSRT 5 fractions, and MS. In patients with VS, MS and radiosurgery showed better local tumor control rates; however, compared with MS, different SRS all provided better protection of nerve function and improved the symptoms of vestibular function and tinnitus, among which the best was SRS. Therefore, in these patients, SRS may be a promising alternative treatment. [ABSTRACT FROM AUTHOR]

Simple Summary: Immune checkpoint inhibitors (ICIs) have become an important treatment for patients with brain metastases from cancers like lung cancer, melanoma, and breast cancer. While ICIs can improve survival, they can also cause immune-related adverse events (irAEs), affecting various organs, including the brain. This review discusses the safety of ICIs when used alone or in combination with other treatments like chemotherapy and radiosurgery. We explain how irAEs occur, their effects on different parts of the body, and how to manage them. Careful monitoring and treatment planning are essential to ensure the best outcomes for patients with brain metastases. Brain metastases (BM) are a frequent and severe complication in patients with lung cancer, breast cancer, and melanoma. Immune checkpoint inhibitors (ICIs) have become a crucial treatment option for BM, whether used alone or in combination with chemotherapy and stereotactic radiosurgery (SRS). However, ICIs are associated with immune-related adverse events (irAEs) that can affect multiple organ systems, complicating their use in BM patients. This review examines the mechanisms of irAEs and their effects on different organs and evaluates the safety of ICIs across various treatment strategies for BM. Our analysis indicates that ICIs significantly improve survival and disease control in BM patients, but their use increases the risk of irAEs, including dermatologic, gastrointestinal, endocrine, pulmonary, and neurologic toxicities. Neurotoxic events, particularly treatment-associated brain necrosis (TABN) and encephalitis, are more common in BM patients. While the overall incidence of irAEs is similar between patients with and without BM, the neurotoxicity risk is higher in the BM population. Combining ICIs with chemotherapy and SRS enhances efficacy but also heightens the risk of adverse events across organ systems. ICIs offer substantial benefits for BM patients but require careful management to mitigate the risks of irAEs. Close patient monitoring, individualized treatment protocols, and prompt intervention are essential for optimizing the outcomes. Future research should focus on refining combination strategies and improving the management of irAEs, particularly neurotoxicity, to maximize therapeutic benefits for BM patients. [ABSTRACT FROM AUTHOR]

Malignant melanoma is third most common cause of brain metastasis after lung and breast cancer. Most patients with brain metastases from malignant melanoma are diagnosed after treatment for known extracranial metastases and have a poor outcome despite various local and systemic therapeutic approaches. Here we discuss an unusual case of a 61-year-old male patient who presented with a brain metastasis as the initial disease presentation and the presumed primary lesion was later found in the gastrointestinal tract and the scalp. Treatment consisted of a surgical removal of the large intracranial lesion. Further evaluation for primary lesion was done by general physical examination, contrast-enhanced computed tomography (CECT) of the chest and whole abdomen. Apart from that, colonoscopy was done, and a biopsy was taken from a suspicious colonic lesion. The scalp pigmented lesion was also evaluated. Both biopsies were in favor of melanoma. Recently, management of metastatic melanoma of the brain is decided according to the number of lesions, accessibility, visceral metastasis, and resectability of the lesion. Various treatment options are surgical resection, whole brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS). Malignant melanoma is relatively radioresistant, so the results are debatable. In conclusion, the prognosis of intracranial malignant melanoma is determined by the following factors: (1) the type of lesion; (2) the involvement of the leptomeninges; (3) the extent of tumor excised; and (4) the molecular immunology borstel number 1 (MIB 1) antibody index, which is the most relevant factor for prognosis in this type of cancer. [ABSTRACT FROM AUTHOR]

Ventricular arrhythmias (VA) can be life‐threatening arrhythmias that result in significant morbidity and mortality. Catheter ablation (CA) is an invasive treatment modality that can be effective in the treatment of VA where medications fail. Recurrence occurs commonly following CA due to an inability to deliver lesions of adequate depth to cauterise the electrical circuits that drive VA or reach areas of scar responsible for VA. Stereotactic body radiotherapy is a non‐invasive treatment modality that allows volumetric delivery of energy to treat circuits that cannot be reached by CA. It overcomes the weaknesses of CA and has been successfully utilised in small clinical trials to treat refractory VA. This article summarises the current evidence for this novel treatment modality and the steps that will be required to bring it to the forefront of VA treatment. [ABSTRACT FROM AUTHOR]

The International Stereotactic Radiosurgery Society aims to establish evidence-based guidelines for single-fraction stereotactic radiosurgery (SRS) in treating intracranial cavernous malformations. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines, searching electronic databases up to January 2024 to assess SRS's impact on post-treatment hemorrhage rates. Pooled risk ratios (RRs) and confidence intervals were used to quantify this effect, along with assessments of lesion volume changes, seizure outcomes, and SRS-related adverse effects. Our meta-analysis included 32 studies with 2672 patients. A significant decrease in annual hemorrhage rates was observed post-treatment (RR = 0.17), with rates of RR = 0.29 in the first 2 years and RR = 0.11 thereafter. Hemorrhage rates significantly differed before and after 2 years post-SRS (RR = 0.36). Among epileptic patients, 20.2% had epilepsy pretreatment, and 49.9% were seizure-free post-SRS, while 30.6% experienced reduced seizure frequency. Lesion volume changes showed a reduction in 46.9%, stability in 47.1%, and an increase in 6.7%. Symptomatic radiation effects affected 8% of patients. Subgroup analysis revealed symptomatic change rates of 6% at doses ≤13 Gy compared to 9% at doses >13 Gy. Permanent clinical deficits were rare (2%). This meta-analysis suggests SRS is an effective intervention for intracranial cavernous malformations, significantly reducing hemorrhage rates and improving seizure outcomes. International Stereotactic Radiosurgery Society practice guidelines are provided. [ABSTRACT FROM AUTHOR]

Introduction Research furthering treatment efficacy for microsurgical resection and stereotactic radiosurgery for vestibular schwannoma (VS) is ever-growing; however, there remains a paucity of research addressing treatment costs. Our aim is to define the reported costs of different treatment modalities used for VS. Methods A systematic review of the literature for VS treatment cost was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed and Web of Science databases. Literature that presented cost of VS treatment specific to the modality was included. Articles from 1990 to present day in English were considered. Cost was corrected for inflation to April 2022 dollars using the US Bureau of Labor Statistics Inflation Calculator. Results A total of 407 articles were included in the analysis. After review, eight articles provided data on cost of treatment. In total, 687 patients were included across seven studies, with study dates ranging from 1997 to 2020. The average cost of resection was $54,321.99 (range = $10,243–95,590, n = 8), radiosurgery $27,837.92 (range = $6,281–51,676, n = 6), and observation $6,304.88 (range = $2,149–11,886, n = 3). Conclusion Our findings describe the limited and significant variability of data on published costs for the treatment of VS. Given the relative clinical equipoise between treatment modalities in some scenarios, better understanding of this end-point will help physicians make more responsible recommendations in the resource-constrained environment of modern healthcare and this analysis should serve as a starting point for more robust analysis into cost-effectiveness of treatment for VS. [ABSTRACT FROM AUTHOR]

Introduction Cavernous sinus meningiomas (CSMs) are challenging given their proximity to neurovascular structures. Treatments include surgery, radiation, or observation. There are little data comparing outcomes based on treatment. This study presents the radiographic and functional outcomes of patients with CSMs treated with either radiation, surgical resection ± radiation, or radiographic surveillance. Methods This is a retrospective review of adults diagnosed with CSMs between 2009 and 2016. Patient and tumor characteristics and outcomes were obtained from chart review. Categorical and continuous variables were compared via nonparametric tests. Results Sixty-four patients were diagnosed with CSMs between 2009 and 2016. Thirty-four had radiation. Thirteen had surgical resection with adjuvant radiation and 14 underwent observation. Fifty-four patients had a pretreatment deficit (84.4%). Radiographic control rates were 100% in the surgery group, 97.1% in the radiation group, 69.2% in the surgery + adjuvant radiation, and 90.9% in the observation group (p = 0.035). The radiotherapy group had complete improvement of symptoms in 32.4% and partial improvement in 23.1% (p = 0.022). In the surgery group, one patient had complete resolution of symptoms (6.3%), eight had partial improvement (50.0%), and seven patients had no improvement (p = 0.002). Surgery was more likely to lead to progression of symptoms posttreatment (odds ratio: 5.16, confidence interval: 1.309–20.34) (p = 0.019). Conclusion Radiation has an excellent rate of radiographic control. Surgery is an option for large or symptomatic lesions. The role of surgery is primarily for vision preservation, decompression of cranial nerves, and tumor debulking and patients should be counseled extensively regarding treatment goals and expectations prior to surgery. [ABSTRACT FROM AUTHOR]

Objectives Paragangliomas of the lateral skull base are rare, largely benign, neuroendocrine tumors. Little evidence exists to support clinicians in the management of these tumors. The present study evaluates considerations in the multidisciplinary workup and management of paragangliomas affecting the lateral skull base. Methods A STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist compliant retrospective review of adult patients with lateral skull base paragangliomas over 20 years (2002–2021) was performed. Patient and tumor data were collected from patient health care records. Results Seventy patients were identified including 21 (30.0%) males and 49 (70.0%) females. The mean length of follow-up was 87.3 months (range: 12–239 months). Twenty-nine (41.4%) patients had Fisch A or B tumors. Overall, 57 patients (81.4%) were offered treatment upfront, with 13 patients (18.6%) initially undergoing active surveillance. Younger age and reduced American Society of Anesthesiologists (ASA) grade was significantly associated with a decision to offer treatment at presentation (both p = 0.03), while all patients with succinate dehydrogenase (SDH) mutations (n = 10) and tumor secretion (n = 4) were offered treatment. Patients with Fisch A/B tumors (p = 0.01), cranial neuropathies (p = 0.01), and smaller tumors (p = 0.01) were more likely to undergo surgical resection. At the time of the last follow-up, the proportion of patients with a cranial neuropathy was notably lower in the observation (3/12, 25.0%) and radiotherapy (1/6, 16.7%) groups. Conclusion In our series, younger, fitter patients with SDH mutations, cranial neuropathies, or tumor secretion were more likely to be offered upfront treatment. There was a low incidence of new cranial neuropathy in the patients selected for observation during long-term follow-up. [ABSTRACT FROM AUTHOR]

The current standard of care for brain tumor management includes maximal safe surgical resection followed by concurrent chemotherapy and radiation therapy. Recent advances in image-guided surgical techniques have enhanced the precision of tumor resections, yet there remains a critical need for innovative technologies to further improve patient outcomes. Techniques such as fluorescence image-guided neurosurgery in combination with stereotactic radiosurgery have improved outcomes for patients with brain tumors. In this article for Brain Science's Special Issue Recent Advances in Translational Neuro-Oncology, we review the use of image-guided neurosurgery and stereotactic radiosurgery for the treatment of brain tumors. In addition, we summarize the emerging use of theranostic nanoparticles for the delivery of diagnostic and therapeutic technologies to enable the neurosurgeon to perform more precise surgical resections in the operating room, to specifically target the delivery of existing and novel treatments to tumor cells, and to augment the efficacy of stereotactic radiosurgery. These innovative translational tools will allow neurosurgeons, neuro-oncologists, and radiation oncologists to go "beyond the knife" to improve the survival of brain tumor patients. [ABSTRACT FROM AUTHOR]

Purpose We present the profile of first 1,000 cases of intracranial radiosurgery (IRS) treated with Gamma Knife system at a government-funded tertiary care hospital in India. In addition to the information on the indications treated, this study provides an idea of the relevance of the Gamma Knife Radiosurgery (GKRS) for IRS in the fast-changing technological scenario. This study also shows the disease indications for which GKRS was the primary treatment preference. Materials and Methods Leksell Gamma Knife model 4C was used for GKRS. Leksell G-frame-based stereotactic localization was used for all patients. Axial magnetic resonance imaging scans were used for treatment planning with additional two-dimensional angiography images for patients treated for arteriovenus malformations (AVM). The patient population treated with GKRS at our center mainly comprised of patients referred from across the country. Results Acoustic schwannoma formed the largest group of patients (27%) followed by meningioma (21%), AVM (18%), pituitary adenoma (16%), brain metastasis (5.3%), trigeminal neuralgia (3%), cavernoma (2.4%), glomus jugulare (1.8%), craniopharyngioma (1.1%) and "others" (5%). Conclusion The case mix at our center is similar to the overall Indian case mix. However, it is different from the Asian data of 2018 but interestingly similar to the data from Middle East and Africa for 2018. Among the various categories of cranial disorders treated by us, pituitary adenoma tumors had minimum (14/161) and cavernoma tumors had maximum (24/24) proportion of cases managed with GKRS as primary treatment modality. [ABSTRACT FROM AUTHOR]

Introduction Pituitary adenoma is the most common disease that affects the gland and may be classified as functional/nonsecretory tumors. Inflammatory/infective causes may also affect the pituitary gland. The 18F-fluorodeoxyglucose positron emission tomography/computed tomography (F18-FDG PET/CT) may have an incremental value in assessing these lesions and in determining their clinical significance. Aim This article assesses the utility of F18-FDG PET/CT in detecting and determining clinical profile of pituitary lesions with abnormal uptake. Methodology Retrospective analysis of all patients who underwent F18-FDG PET/CT from January 2015 to January 2023 was done. Those with abnormal pituitary uptake (standardized uptake value [SUV] > 2.5) were included in the study. SUV value along with relevant anatomical details, biochemical parameters, histopathological details, and follow-up imaging were analyzed. Results Among 15,085 studies, a total of 36 patients (21 males/15 females, average age 47.36 years, range: 17–75 years) with pituitary uptake (0.23%) were included. Out of 36 patients, causes are primary pituitary tumor (21/36, 58%), tubercular hypophysitis (3/36, 8%), lymphocytic hypophysitis (2/36, 6%), lymphomatous involvement (2/36, 6%), autoimmune hypophysitis (1/36, 3%), questionable significance/incidental (4/36, 11%), and metastasis (3/36, 8%)—one each from neuroendocrine tumor ileum, chondrosarcoma, and adenocarcinoma lung. There was no difference in the SUV range between the different etiologies. Among 21 patients with pituitary tumor, biochemical evaluation was done in 19 patients. Two patients were lost to follow-up and did not have biochemical evaluation. Among them, 8 underwent endoscopic transsphenoidal radical excision and 1 patient had PET-CT-guided stereotactic radiosurgery alone. In another 8 patients who had prior endoscopic transsphenoidal radical excision, uptake was noted as residual lesion on PET-CT. Of them, 3 underwent subtotal excision and 5 had PET-CT-guided stereotactic radiosurgery. Biopsy was done in 14 patients, of which 11 were macroadenoma and 3 were microadenoma. Overall, magnetic resonance imaging (MRI) brain was performed in 22 of them and the findings were concordant with F18-FDG PET/CT. Conclusion F18-FDG PET/CT is a useful modality in the evaluation of pituitary uptake. It has an incremental value along with MRI brain and biochemical parameters and is useful for follow-up. Due to its high diagnostic accuracy, it is particularly useful in those with suspected residual/recurrent adenomas. [ABSTRACT FROM AUTHOR]

(1) Background: The objectives of this study were to assess survival of patients with a diagnosis of brain metastases secondary to gynaecologic malignancy and the impact of clinicopathological factors on prognosis in this population. (2) Methods: A retrospective cohort of patients with gynaecologic cancers diagnosed with brain metastases treated with radiation at a tertiary care centre from 1 January 2004 until 30 September 2023 was studied. Kaplan–Meier method and log-rank test were used to evaluate survival, and cox regression was used to identify significant predictive factors of survival. (3) Results: In total, 103 patients were included in this study. Median age at diagnosis of brain metastases was 59 (range 30–94). Median survival time following diagnosis of brain metastases was 3.6 months (range 0.4–183.8). Survival was significantly longer for patients treated with surgery combined with radiation compared to radiation alone and with stereotactic radiosurgery (SRS) compared to whole brain radiation therapy (WBRT). Cox regression revealed that primary ovarian malignancy, extracranial disease at diagnosis, and ≥3 brain metastases were associated with poorer prognosis, and complete response to prior treatment was associated with more favourable prognosis. (4) Conclusions: Data from this study will assist in providing evidence-based prognostic information to patients with gynaecologic malignancy diagnosed with brain metastases. [ABSTRACT FROM AUTHOR]

Background and Objectives: This study aims to evaluate and compare the safety and efficacy of the da Vinci® Xi and hinotori™ SRS robot-assisted surgical systems for gynecologic disorders. Materials and Methods: We conducted a retrospective study of 401 cases (43 benign uterine tumors; 88 pelvic organ prolapses; 270 low-risk endometrial cancers) of robot-assisted surgery performed at Kagoshima University Hospital between January 2017 and October 2024. Surgical factors such as the operative time, blood loss, and complication rates were analyzed and compared between the da Vinci® Xi (332 cases) and hinotori™ SRS (69 cases) systems. Complications were classified according to the Clavien–Dindo classification, with Grade 2 or higher considered significant. Results: Significant differences were observed between the two groups in terms of age, body mass index, cockpit/console time, and median time from roll-in to cockpit/console start. The cockpit/console time was significantly longer for the hinotori™ SRS system (173 min) compared to the da Vinci® Xi (156 min; p = 0.047). No significant differences were observed in the total operative time, blood loss, or length of hospital stay. Intraoperative complications were minimal, with one case of bladder injury and one case of vascular injury recorded for the da Vinci® Xi. The overall postoperative complication rate was approximately 4%. Conclusions: Robot-assisted surgery using both the da Vinci® Xi and hinotori™ SRS systems was found to be safe, with minimal blood loss and a low complication rate. The hinotori™ SRS system demonstrated operative outcomes comparable to those of the da Vinci Xi® system, suggesting that it may serve as a viable alternative. Further prospective studies are warranted to evaluate the efficacy and safety of these systems. [ABSTRACT FROM AUTHOR]

Purpose: Spinal metastases may result in intractable pain, neurological deficit, and vertebral body collapse. There are only a few studies describing outcomes following spine stereotactic radiosurgery (SRS) specifically for prostate cancer metastases. Methods: A prospectively collected database of patients with prostate cancer spinal metastases treated at the University of Pittsburgh Medical Center from 2003 to 2023 was analyzed. The primary outcome was local control (LC). Secondary outcomes were overall survival (OS), pain resolution, and adverse radiation effects (AREs). Results: Thirty-seven patients and 51 lesions were identified. Fifteen lesions (29%) were previously resected and 34 lesions (67%) were previously irradiated. The median tumor volume was 37.0 cc (range: 2.9-263.3). A majority of lesions (71%) were treated in a single fraction (median 20 Gy, range: 14-22.5); multi-fractionated treatment consisted of 21–30 Gy in 2–5 fractions. Median follow-up was 12 months (range: 1-146). The 6-month, 1-year, and 2-year LC rates were 97%, 91%, and 91%, respectively. No tested prognostic factors were associated with LC, including hormone sensitivity. The 6-month, 1-year, and 2-year OS rates were 71%, 56%, and 32%; age > 70 years (p = 0.048) and tumor volume > 30 cc (p = 0.03) were associated with inferior rates of OS. Complete or partial pain response was observed in 58% of patients. There were 8 instances (16%) of AREs, 2 of which were vertebral compression fractures (4%). Conclusion: Radiosurgery as a primary or adjuvant treatment modality for prostate cancer spinal metastases confers durable LC and moderate pain relief with minimal toxicity. Further studies are warranted to optimize management in this patient population. [ABSTRACT FROM AUTHOR]

Brain metastasis in the motor cortex is a challenging condition to treat. Surgical resection or stereotactic radiosurgery (SRS)/hypofractionated stereotactic radiotherapy (hypoSRT) are valuable options up to now. Due to its unique location and potential for neurologic deficits, neither treatment is entirely satisfactory. There is still a lack of data on the treatment result of motor cortex metastasis. This study provides a comprehensive review and meta-analysis comparing surgery and SRS/hypoSRT for treating brain metastasis in the motor cortex. Core databases, including PubMed, Embase, and the Cochrane Library, were systematically searched for brain metastasis in the motor cortex, demonstrating the clinical outcomes of both surgery and SRS/hypoSRT. Motor power outcome and treatment-associated complication rates were thoroughly evaluated. Twenty-five articles were listed for full-text review. Among them, 13 articles were eligible for inclusion criteria: retrospective cohort studies comparing surgery and SRS/hypoSRT. There are 323 patients in the surgery group and 220 in the SRS/hypoSRT group. The motor outcome is better in surgery group, but without statistical significance (0.49 vs 0.37, p = 0.3937) and treatment-related complication is lower in surgery group with statistical significance (0.09 vs 0.26, p = 0.0218). Treatment modality should be tailored by the patient's performance status, history of radiation, presence of ongoing chemotherapy, or extracranial progression status. [ABSTRACT FROM AUTHOR]