Incorporation of intraoperative confocal laser endomicroscopy into the routine workflow of brain surgery.

A high preoperative prognostic nutritional index is associated with improved overall survival in patients undergoing brain tumor resection.

The genetic diagnosis of brain tumors necessitates the direct collection of tumor tissue. Recently, genetic diagnosis using cell-free DNA (cfDNA) from plasma has been clinically applied to some somatic cancers, but it has not been established for brain tumors. This study conducted a genetic diagnosis via liquid biopsy (LB) using cfDNA extracted from the plasma and cerebrospinal fluid (CSF) of pediatric brain tumor patients. The study included children who underwent surgical resection or biopsy for brain tumors between January 2019 and December 2020. Tumor-specific variants were identified using whole-exome sequencing of genomic DNA from tumor samples and normal blood cells. Subsequently, CSF and plasma collected during surgery were analyzed for these specific variants using droplet digital PCR. Tumor-specific variants were detected in six of 13 (46.2%) CSF samples. In contrast, no tumor-specific variants were detected in plasma in any patient. Among the six CSF-positive cases, two had negative or inconclusive CSF cytology (Class I or II), and one was a case of low-grade pilocytic astrocytoma. The median variant allele frequency in the positive CSF samples was 16.0% (range: 0.6%-86.1%). In certain pediatric brain tumors, genetic diagnosis using cfDNA from CSF demonstrated promising potential. This approach has the potential for diagnosis in cases with negative cytology or low-grade tumors. However, several issues must be addressed before this method can achieve clinical utility, including its low sensitivity and the extended turnaround time for analysis.

Dear Editor, This letter explores the considerations involved in performing an Awake craniotomy (AC) on a patient with a history of long-standing goiter, highlighting the utility of AC after careful patient selection, multidisciplinary collaboration, and prevention of potential complications. AC is a specialized surgical procedure that allows resection of brain tumors while patient remains conscious. It facilitates in intraoperative neurological monitoring of motor, sensory and speech functions. The potential benefits are maximizing tumor resection, minimizing post-operative neurological defects and better recovery profile 2. However, potential complications require careful consideration and anticipation. Amongst them, airway related events are at the top and, commonly associated with failure of technique and conversion to general anaesthesia3. Our patient was elderly female with history of Diabetes, Hypertension, and Hypothyroidism. She presented with a frontal lobe space occupying lesion. Physical examination revealed, swelling in front of neck because of large goiter predominantly on the left side, but showed no signs of respiratory distress. A thorough examination, including Pemberton's sign, was negative for thoracic inlet obstruction. Chest X-ray confirmed the presence of a large thyroid gland. ENT consultation was done revealed no airway involvement a part from having tracheal deviation. There was no airway obstruction and patient were able to lie supine without any signs & symptoms of respiratory distress. We opted for awake throughout approach. A regional scalp block was performed for perioperative analgesia. To mitigate the associated risks, surgical position was modified so that patient remained. comfortable in terms of breathing. Supplemental oxygen was also given via nasal prong. Close communication was maintained throughout the procedure and conscious sedation was maintained with low dose of Dexmedetomidine infusion (0.1-0.2mcg/Kg/hr.). Procedure was done successfully and patient was shifted to recovery unit. In conclusion, AC presents unique challenges in patients with history of goiter and neck swelling. Through careful patient selection, preoperative evaluation, and a multidisciplinary approach, it is possible to achieve successful outcomes while minimizing risks associated with general anaesthesia.

Orienting visuospatial attention towards relevant stimuli is vital for effective environmental interactions. Current attentional control models rely on functional neuroimaging, which is correlational, and lesion studies in stroke patients, affected by localization bias. Studying patients undergoing awake neurosurgery for brain tumour resection offers a unique chance to overcome these limitations and possibly enhance current neurofunctional models. We combined Lesion-Symptom-Mapping (LSM) in 163 brain tumour patients and Direct Electrical Stimulation (DES) in 47 patients during awake neurosurgery to unveil the network causally associated with visuospatial exploratory/selective attention. LSM and DES convergently identified a right dorsomedial frontal region linked to visuospatial neglect, potentially functioning as a pre-oculomotor hub for contralateral attentional deployment. Moreover, stimulation of right ventrolateral white matter was associated with visuospatial errors in both hemifields. Finally, we provided a tool that effectively detects and preserves frontal connectivity for visuospatial exploratory/selective attention in neurosurgical settings.

Factors affecting postoperative seizure risk and perioperative outcomes in pediatric brain tumor resections.

DMP-Net: Deep semantic prior compressed spectral reconstruction method towards intraoperative imaging of brain tissue.

Clinical features of paroxysmal sympathetic hyperactivity in brain tumor: a retrospective case series study and literature review.

Impact of Intraoperative, Ultrasound Guidance on the Extent of Surgical Resection of Intra-Axial Brain Tumors

Evaluation of Presurgical Outcome Predictors in Oncological Neurosurgery.

Thirty-day readmission rates are commonly used as quality indicators (QIs) due to their feasibility and financial impact on healthcare systems. However, their validity in neurosurgical oncology remains uncertain. This study evaluates 30-day readmission rates following craniotomies for brain tumor resection, focusing on causes, predictors, and their impact on overall survival (OS).A systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed, Cochrane, Scopus, and Web of Science databases were queried for studies reporting 30-day readmission rates in craniotomies for brain tumors. Meta-analysis with random-effects modeling was performed for pooled readmission rates, causes, predictors, and survival outcomes. Individual patient data (IPD) for overall survival were available for glioblastoma patients from four studies and were reconstructed from Kaplan-Meier curves to assess the association between readmission and survival.Eleven studies involving 132,791 patients yielded a pooled 30-day readmission rate of 13% (95% CI: 11%-16%). Neurological (50%) and infectious (25%) causes were the most common readmission indications. Surgical site infections accounted for 11% (7%-16%) and thromboembolic events for 12% (9%-16%) of all readmissions. Preoperative characteristics, including functional status, were consistent predictors of readmission. Among glioblastoma patients, reconstructed IPD from four studies demonstrated that readmitted patients had significantly shorter median overall survival compared with non-readmitted patients (6.4 vs. 8.7 months, p < 0.0001).Thirty-day readmission rates provide insights into neurosurgical oncology care but have limitations as standalone QIs. A combination of QIs would offer a more comprehensive and accurate assessment of care quality. Efforts to reduce readmissions should address modifiable risk factors, such as preventing SSIs and thromboembolic events, and optimizing perioperative care.

Acute kidney injury (AKI) is a major perioperative complication following brain tumor resection, yet multi-center studies on this topic remain scarce. This study aimed to determine the incidence, risk factors, and clinical outcomes associated with AKI in patients undergoing brain tumor resection, utilizing a nationally representative dataset. We analyzed brain tumor resection admissions from the United States’ National Inpatient Sample database (2010–2019), identifying hospitalizations with and without AKI using International Classification of Diseases, Ninth Revision, Clinical Modification and International Classification of Diseases, Tenth Revision, Clinical Modification codes. Multivariable logistic regression analyses were performed to evaluate the associations between patient/hospital characteristics, comorbidities, complications and AKI. Among more than 40,000 brain tumor resection admissions, AKI occurred in 3.1% of hospitalizations, with prevalence rising from 1.8% in 2010 to 4.4% in 2019. AKI-associated admissions had higher costs (median $171,904 vs. $99,821, p < .001), longer hospital stays (median 11 vs. 5 days), increased mortality (8.3% vs. 1.2%, p < .001), higher dialysis requirement (1.1% vs. 0.01%, p < .001), and mechanical ventilation (12.1% vs. 3.0%, p < .001). Associated risk factors for AKI included: age ≥65 years, Black/Hispanic race, congestive heart failure, diabetes, fluid and electrolyte disorders, other neurological disorders, obesity, and chronic kidney disease excluding end-stage renal disease. Medical complications associated with increased AKI risk included septicemia, deep vein thrombosis, urinary tract infection, pneumonia, and cerebral edema. Female sex and elective admission were protective factors. Prompt identification of these risk factors is crucial for optimizing perioperative management and improving clinical outcomes.

Abstract INTRODUCTION Surgically targeted radiation therapy (STaRT) using Cesium-131 collagen tile brain brachytherapy (GammaTile®, GT Medical Technologies, Tempe, Arizona, USA) is FDA cleared for operable newly diagnosed intracranial malignant neoplasms and recurrent intracranial neoplasms. OBJECTIVE To assess the rate of infection after brain tumor resection (R) and permanent implantation of STaRT on a prospective, multi-institutional observational study. METHODS The prospective, observational registry (NCT04427384) evaluates clinical outcomes that measure the effectiveness and safety of R+STaRT. As a secondary endpoint of the registry, wound infections are pre-specified as an adverse event (AE) of particular focus and are tracked and attributed using Common Terminology for Adverse Events version 5. The first 250 consecutive patients undergoing R+STaRT from 30 centers were chosen for evaluation to help ensure adequate follow up, and these patients were treated with brain tumor resection and STaRT between 11/2020 and 10/2023. RESULTS 73.6% of cases were for recurrent tumors and 26.4% were for newly diagnosed tumors. 46.3% were glioblastomas, 34.3% were brain metastases, 12.4% were meningiomas, and 7.0% were “other.” Median follow-up was 11.9 months (range 0-36.3 months). There were surgical wound infections among 5 patients, four Grade 3 and one Grade 4. From the day of surgery, 4 infections were noted within the first 30 days, none occurred between 31-90 days, and 1 was noted 117 days after surgery. CONCLUSION This interim data analysis of the first 250 consecutive patients from 30 centers show an infection rate (Grade 3 or 4) of 2%, which is consistent with what would be expected with craniotomy without STaRT. This data supports the safety of STaRT in a wide variety of clinical scenarios.

Abstract BACKGROUND Gliomas and brain metastases represent the most prevalent malignant brain tumors, yet data on surgical outcomes and survival predictors in low- and middle-income countries remain limited. This study aimed to characterize clinical, surgical, and prognostic variables associated with outcomes following resection of primary and metastatic brain tumors in a large tertiary center in Brazil. METHODS A retrospective cohort study was conducted including 902 adult patients who underwent craniotomy for resection of primary or metastatic brain tumors between June 2018 and December 2022. Demographic, clinical, surgical, and molecular data were collected. Outcomes included in-hospital mortality, prolonged hospitalization, and overall survival. Multivariate logistic regression and Cox proportional hazards models were used to identify independent predictors. RESULTS Of 902 patients, 388 (51.9%) had gliomas and 322 (35.7%) had brain metastases. Prolonged hospitalization (&amp;gt;5 days) occurred in 30.5% of cases, and 14.2% developed postoperative neurological or surgical complications. In patients with primary brain tumors, older age (OR = 1.051; p = 0.006) and longer preoperative stay (OR = 1.262; p = 0.031) were associated with increased in-hospital mortality, while IDH mutation was protective (OR = 0.196; p = 0.002). Emergency surgeries and older age were also associated with prolonged hospitalization. Age was the only independent predictor of decreased survival (HR = 1.016; p = 0.004). In the metastatic tumor cohort, awake surgery and resection of a single brain metastasis reduced the risk of death, whereas emergency surgery and motor area involvement increased mortality risk. CONCLUSIONS In this Brazilian cohort, older age and emergency surgical indication were consistently associated with worse short-term and long-term outcomes. IDH mutation status and surgical variables such as approach and tumor location may serve as important predictors in neuro- oncologic care. These findings support the integration of clinical, surgical, and molecular data in guiding brain tumor management in resource-constrained settings.

Abstract BACKGROUND Cognitive reserve (CR) is recognized as a protective factor against cognitive decline in neurodegenerative diseases. However, its role in modulating cognitive outcomes after brain tumor resection remains unclear. This study investigated the association between CR, particularly derived from leisure activities, and postoperative cognitive function, in the context of white matter network disruption. METHODS We retrospectively analyzed 40 patients in the chronic phase following resection of brain tumors: CNS WHO grade 1 (n = 4), 2 (n = 16), 3 (n = 8), 4 (n = 10), and metastases (n = 2). Cognitive function was assessed using the Mini-Mental State Examination (MMSE) and the Japanese Adult Reading Test (JART) as a proxy for premorbid intelligence. CR was evaluated using a culturally adapted version of the Cognitive Reserve Index (CRI), developed for the Japanese population and comprising education, occupational attainment, and leisure activities. Postoperative 3D T1-weighted MR images were normalized to the MNI152 template. Resection cavities were delineated and overlaid onto normative white matter tracts using the BCB Toolkit® and TRACTOTRON®. Disconnection ratios were calculated for major fiber pathways. RESULTS JART and MMSE scores were moderately correlated (r = 0.43). Among CRI subdomains, only CRI-leisure was significantly associated with both JART (p = 0.034) and MMSE (p &amp;lt; 0.001) scores. Disconnection analysis identified the corpus callosum, anterior commissure, right cingulum, and right superior longitudinal fasciculus (SLF) as frequently affected tracts. Multiple regression analysis revealed that disruptions in the left inferior fronto-occipital fasciculus (IFOF) (p = 0.0127) and right posterior SLF (p = 0.0051) significantly contributed to lower JART scores. CONCLUSIONS CR derived from leisure activities may confer resilience against cognitive decline after brain tumor resection. Preservation of the left IFOF and right posterior SLF is essential for cognitive integrity, supporting the integration of lifestyle-based CR into surgical planning and rehabilitation.

Abstract BACKGROUND Awake surgery (AS) has demonstrated utility in the resection of brain tumors and in epilepsy surgery. However, due to risks such as intraoperative seizures and difficulties in securing the airway, it is desirable to avoid unnecessary AS in cases where poor intraoperative awakening is anticipated, as this may result in insufficient neurological monitoring (AS failure). In the present study, we retrospectively analyzed predictive factors for AS failure. METHODS A total of 78 consecutive cases of AS performed for brain tumors and epilepsy at our institution between January 2021 and December 2024 were retrospectively reviewed. We evaluated previously reported predictive factors and contraindications for AS, as well as the presence or absence of basal ganglionic involvement. RESULTS The mean age was 45.4 years, and 46 patients were male. The median MoCA-J score was 26. Preoperative aphasia was present in 26 cases, and the median preoperative KPS was 90. Left hemisphere lesions were present in 52 cases. Diagnoses included high-grade glioma (47), low-grade glioma (17), and epilepsy (11). Repeated surgeries were performed in 30 cases, midline shift was observed in 19, and basal ganglionic involvement in 18. Successful AS, defined as sufficient intraoperative neurological monitoring under awake conditions, was achieved in 65 cases (83.3%). Failed AS, defined as insufficient monitoring due to poor awakening, occurred in 13 cases (16.7%). A comparison between the two groups revealed the following: left hemisphere lesions were present in 60% of the successful group and 100% of the failure group (p=0.0035); midline shift was observed in 16.9% vs. 61.5% (p=0.0019); and basal ganglionic involvement in 9.2% vs. 92.3% (p&amp;lt;0.0001), respectively. CONCLUSIONS Left hemisphere involvement, midline shift, and basal ganglionic involvement were significantly more frequent in the AS failure group. Among these, basal ganglionic involvement may serve as a novel predictive factor for AS failure.

Abstract BACKGROUND The optimal management of previously irradiated recurrent brain metastases is a challenging clinical scenario and despite several salvage strategies, to date no prospective, multi-institutional outcomes for surgically targeted radiation therapy (STaRT) have been reported. OBJECTIVE We sought to assess the efficacy of STaRT for the management of patients with recurrent brain metastases enrolled onto a prospective, multi-institutional study. METHODS A prospective, multi-institutional observational registry (NCT04427384) was created to capture clinical outcomes following brain tumor resection and STaRT using collagen-tile Cesium-131 brachytherapy (GammaTile®, GT Medical Technologies, Tempe, Arizona, USA). Herein, the first 50 consecutive patients with recurrent, previously irradiated brain metastases were assessed for patient demographics, tumor characteristics, and cumulative incidence rates of local failure. RESULTS: 50 consecutive patients with 56 recurrent brain metastases underwent resection (94.6% gross total resection) and STaRT at 19 separate centers. The median age was 60 (Range [R]: 28-81) years; the Male:Female ratio was 1:1; and 50%, 14%, 18%, and 18% of patients had tumors of lung, breast, melanoma, or other, respectively. Median follow up was 12.7 months, and median maximum tumor diameter was 3.0 cm (R: 0.4-5.7). The median time to recurrence after prior radiotherapy was 11.0 months (R: 2.5-44.9) (n=26), with the median time from last radiotherapy treatment to STaRT being 14.1 months (R: 3.5-56.3). After STaRT, cumulative incidences of local failure per-patient at 6, 12, and 15 months were 11.7%, 18.4%, and 22.5%, respectively. Survival probabilities at 6, 12, and 15 months were 79.0%, 65.4%, and 62.4%, respectively. Median overall survival was 22.0 months. Symptomatic adverse radiation effects (AREs) occurred in 3 patients (6%). CONCLUSION This analysis demonstrates encouraging outcomes with STaRT for salvaging previously irradiated, recurrent brain metastases after prior radiotherapy across 19 different centers with a low cumulative incidence rate of local failure and AREs.

Abstract Radiation-induced organizing hematomas (RIOHs) are delayed complication of brain irradiation, particularly in long-term survivors of brain tumors. Although often asymptomatic, RIOHs may enlarge leading to clinical deterioration that mimics tumor progression. However, comprehensive evaluations using advanced multimodal imaging remain limited. We retrospectively analyzed five patients (3 males, 2 females; median age 52 years) with histopathologically confirmed RIOHs. All had undergone surgical resection and radiotherapy for primary brain tumors (glioblastoma, n=3; oligodendroglioma, n=1; atypical meningioma, n=1), with cumulative radiation doses ranging from 60—122 Gy (median: 105G y). Presenting symptoms included nausea, cognitive decline, headache, seizure, and vomiting. Imaging assessments included brain computed tomography (CT) and multimodal magnetic resonance imaging (MRI), incorporating diffusion-weighted imaging (DW), susceptibility-weighted imaging (SWI), and dynamic susceptibility contrast (DSC) perfusion. Lesions were evaluated for morphology, signal profile, and perfusion characteristics. All RIOHs developed within prior irradiation fields, with a latency of 5—10 years. CT showed subtle hyperdensities indicative of chronic hemorrhage. On MRI, lesions were characterized by marked T2 hypointensity with relatively well-defined spherical margins, wide perilesional edema, and internal heterogeneity. Contrast-enhanced T1-weighted images revealed inner solid or fuzzy rim enhancement, often localized to T2 hyperintense, pre-contrast T1-isointense regions. Lesion margins were often obscured by adjacent post-treatment parenchymal changes on enhanced images. SWI consistently showed exaggerated blooming from hemosiderin. Signal dropout on DWI and CBV was observed in all cases, likely reflecting susceptibility effects from hemorrhagic byproducts. Notably, peripheral CBV elevation was seen in all cases, potentially mimicking recurrent high-grade tumor. Symptomatic or enlarging RIOHs can closely mimic tumor recurrence in both clinically and radiologically. However, RIOHs demonstrate characteristic imaging findings—including T2 hypointensity with SWI blooming, solid or fuzzy rim enhancement, and peripheral CBV elevation—that may aid in accurate diagnosis. Recognizing these imaging patterns is essential to prevent misdiagnosis and guide appropriate management.

Abstract INTRODUCTION Brain metastases effect approximately 30-40% of patients with solid tumor malignancies. Treatments include surgery, radiosurgery, whole brain radiotherapy, and CNS-penetrating systemic therapies. Despite expanding treatment options, overall survival (OS) remains poor. Patients with local recurrence after radiosurgery or tumors too large for radiosurgery are particularly challenging. GLIADEL implant, a biodegradable carmustine chemotherapy wafer that delivers high dose carmustine within a tumor, shows efficacy in malignant glioma treatment, while limited data exists in brain metastasis. The VIGILANT (Vigilant Observation of Gliadel Wafer Implant) registry examines use and efficacy of GLIADEL, including in patients with brain metastases. Here we present results of patients with brain metastasis from the VIGILANT registry. METHODS 48 patients underwent surgical resection of metastatic brain tumors with GLIADEL implantation at Wake Forest Baptist Medical Center starting in 2017. 33 were treated due to local recurrence despite radiosurgery. 15 had lesions deemed too large for successful radiosurgery. Patients were evaluated primarily for OS and progression free survival (PFS) from date of surgery, and secondarily for adverse events and local progression. RESULTS Median OS was 14.9 months (95% CI 8.3, 26.0). Of 25 deaths, 7 (28%) met criteria for neurological etiology. 27 (56%) patients had progression during follow up, 6 (12.5%) had local progression. 2 (4%) had local progression that required additional neurosurgical treatment. Median PFS when considering death censored was 4.9 months (95% CI 3.6, 11.4). Of 15 patients not previously treated with radiosurgery, 8 (53%) had no progression. 43 total patients had adverse events; two considered possibly GLIADEL related. CONCLUSIONS Placing GLIADEL wafers for treatment of brain metastases may favorably increase OS (14.9 months vs. 7.9-24 months) and decrease 1 year local progression rates (12% vs up to 39%) compared to the literature and was well tolerated in this population, the majority whom failed initial radiosurgical management.

Abstract PURPOSE Postoperative hemorrhage is a serious complication following elective craniotomy for intraparenchymal brain tumors and can significantly impair neurological outcomes. Elevated postoperative blood pressure is a known risk factor. This study aimed to evaluate the relationship between blood pressure and other clinical or radiological factors in relation to postoperative hemorrhage. MATERIALS AND METHODS We retrospectively analyzed all patients who underwent surgery for intraparenchymal brain tumors at our institution between 2016 and 2023. Intraoperative and postoperative blood pressure, as well as heart rate during the first 12 postoperative hours, were recorded. Patients who developed postoperative hemorrhage requiring surgical revision or intravenous antihypertensive therapy were compared with those without complications. ROC analysis was performed to identify blood pressure thresholds associated with increased risk. RESULTS A total of 453 patients (median age: 59 years) were included. Postoperative hemorrhage requiring intervention occurred in 35 patients (7.7%); 9 required surgical revision, and 26 were treated conservatively. Male sex (p = 0.008), pre-existing hypertension (p = 0.039), and residual tumor volume (p = 0.031) were significantly associated with hemorrhage. Both intraoperative (p &amp;lt; 0.05) and postoperative (p &amp;lt; 0.001) systolic blood pressure were strongly correlated with hemorrhage risk. ROC analysis identified a threshold of 140 mmHg systolic pressure. Patients with hemorrhage had significantly longer durations of elevated systolic pressure (&amp;gt;140 mmHg for 62 minutes, &amp;gt;160 mmHg for 17 minutes). Hemorrhage requiring revision surgery in the context of mass effect was associated with worse overall survival (p = 0.004). No significant differences were observed in postoperative ischemia between groups. CONCLUSION Postoperative systolic blood pressure should be strictly controlled below 140 mmHg following craniotomy for intraparenchymal tumors. Sustained elevations significantly increase the risk of hemorrhage and may impact overall survival.