Intracranial Tumor Resection Research Articles

Predicting Outcomes After Glioma Surgery: Model Behavior

The ability to predict outcomes for individual patients undergoing craniotomy for resection of gliomas would be of great value to physicians, patients, families, and thirdparty payers. For instance, having precise knowledge of the personal potential for complications as well as the relative frequency of these unanticipated outcomes could help prepare patients and their loved ones for appropriate postoperative recovery. At present, of course, this is not a reality; however, neurosurgical oncologists are well versed in using molecular biomarkers such as isodehydrogenase-1 or methylguanine methyltransferase methylation status as well as histologic grade to help predict patient overall survival. They also have convincing evidence of the influence of their surgical efforts and patient demographics on overall survival. It is understood that overall survival and progression-free survival can be predicted by age, preoperative Karnofsky Performance Score, and extent of resection (8, 12). Nevertheless, it has not been possible to provide a patient with an individualized expectation of risk for postoperative complications. In a paper recently published in WORLD NEUROSURGERY, Missios et al. have attempted the task of determining preoperative predictive indicators of potential postoperative complications for patients undergoing craniotomy for glioma resection. They have a track record of doing similar analysis for other intracranial tumors: In a study similar to this, they described a predictive model of unfavorable outcomes for patients undergoing resection of benign intracranial tumors (2). Using multivariate analysis of a national database, they identified the effect of various risk factors on the incidence of death (1.3%), unfavorable discharge (22.7%), hydrocephalus (4.2%), cardiac (1.1%) or respiratory (0.9%) complications, deep venous thrombosis (DVT) (0.5%), pulmonary embolus (2.3%), and acute renal failure (1.5%). In their article in this month’s issue, they evaluated the records of over 20,000 patients with glioma included in a national database who underwent craniotomy and identified similar inpatient postoperative risks, including a 1.6% risk of mortality, and morbidity risk of 25.8% for discharge to rehabilitation, 4.0% for treated hydrocephalus, 0.7% for cardiac complications, 0.5% for respiratory complications, 0.8% for deep wound infection, 0.6% for DVT, 3.1% for pulmonary embolus, and 1.3% for acute renal failure. These numbers proved to be very similar for benign and malignant intracranial disease. Mortality is almost identical in both studies, as is true of most of the other postoperative complications. Discharge to rehabilitation is slightly higher for the glioma group but the difference is small and it is unclear whether it would be of statistical significance.

Perioperative predictive factors of intracranial meningioma recurrence following surgical resection

Background: Meningiomas represent the commonest benign intracranial tumor and surgical resection is the first line treatment. Tumor recurrence after surgical resection is common. The aim of this study is to identify peri-operative predictors of meningioma recurrence following surgical resection Methods: This was a retrospective hospital-based study of all surgical cases between January 1990 and June 2014. Information regarding age, gender, peri-operative imaging parameters such as peri-tumoral edema or post-operative hemorrhage or residual, and grade were collected. Linear and volumetric measurements (of both tumor volume and volume of edema) were collected as well. Results: Overall, 464 patients were reviewed; n=154(34%) percent of patients were male. The grade distribution was: 296 (74.6%) were Grade I, 78 (19.6%) Grade II, and 23 (5.8%) Grade III. Post-operative tumor bed hemorrhage, noted in 119 (29.9%) of cases, and preoperative peri-tumoral edema volume were significant predictors of tumor recurrence following resection (P= 0.002 and 0.037, respectively). These parameters did not correlate with the MIB-1 index, tumour residual, grade of the tumour, or primary versus recurrent presentation. Conclusions: Pre-operative peri-tumoral edema and post-operative tumor bed hemorrhage are independent predictive of tumor recurrence. Identification of other molecular and/or radiological predictive of recurrence factors could add in our understanding of meningioma behavior.

A Predictive Model of Unfavorable Outcomes After Benign Intracranial Tumor Resection

Benchmarking of outcomes and individualized risk prediction are central in patient-oriented shared decision making. We attempted to create a predictive model of complications in patients undergoing benign intracranial tumor resection. We performed a retrospective cohort study involving patients who underwent craniotomies for benign intracranial tumor resection during the period 2005-2011 and were registered in the National (Nationwide) Inpatient Sample database. A model for outcome prediction based on individual patient characteristics was developed. There were 19,894 patients who underwent benign tumor resection. The respective inpatient postoperative incidences were 1.3% for death, 22.7% for unfavorable discharge, 4.2% for treated hydrocephalus, 1.1% for cardiac complications, 0.9% for respiratory complications, 0.5% for wound infection, 0.5% for deep venous thrombosis, 2.3% for pulmonary embolus, and 1.5% for acute renal failure. Multivariable analysis identified risk factors independently associated with the above-mentioned outcomes. A model for outcome prediction based on patient and hospital characteristics was developed and subsequently validated in a bootstrap sample. The models demonstrated good discrimination with areas under the curve of 0.85, 0.76, 0.72, 0.74, 0.72, 0.74, 0.76, 0.68, and 0.86 for postoperative risk of death, unfavorable discharge, hydrocephalus, cardiac complications, respiratory complications, wound infection, deep venous thrombosis, pulmonary embolus, and acute renal failure. The models also had good calibration, as assessed by the Hosmer-Lemeshow test. Our models can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and potentially can be used as an adjunct for decision making in benign intracranial tumor surgery.

The structure of activation of the language zone in patients with intracerebral tumors according to fMRI with respect to tumor location and the functional asymmetry profile

A total of 50 patients were examined prior to surgical resection of intracranial tumors of the temporal and frontal lobes. Left-sided tumors were observed in 33 patients and right-sided tumors were observed in 17 patients. The functional asymmetry profile was determined using self-assessment, the Annet questionnaire, and the dichotic listening task. Twelve patients were left-handers or retrained left-handers and the remaining 38 patients were right-handers. FMRI examination was carried out on a 3.0 T SignaHDxt magnetic resonance tomograph (GE). The standard language block design paradigm was used in the study. We used the following tests: 1) recitation of months in reverse order; 2) generation of nouns according to the initial letters shown on the screen (K, M, L, N, P, C); 3) generation of verbs according to simple actions shown on the screen; 4) producing sentences using nouns shown on the screen; 5) listening to text through headphones. Data were processed using the standard BrainWave PA software (General Electric). Z-test was used in the range from 6 to 9. In all the studies, p<0.001. Statistical data processing included the nonparametric Spearman's test to determine the correlation between lateralization of the detected activation zone under speech load and tumor location (tumor is adjacent to the language zone, invades the language zone, or is located far from the language zone), as well as left- or right-handedness. Among 16 patients (right-handers and 2 left-handers) the activation of language zones was observed only on the left side; in one left-handed patient, Broca's area was detected only on the right side. In other patients (including right-handers with right-sided tumors), lateralization of language zones was different, including bilateral. Statistical processing revealed that bilateral activation of both Broca's and Wernicke's areas was more frequently observed in left-handers. Broca's area was more frequently detected on the left side in the presence of a distant tumor, while this trend did not apply for Wernicke's area. Localization of activation of Broca's area is more dependent on tumor location, while it depends on personal characteristics of an individual in the case of Wernicke's area.

Bone-anchored hearing device placement with translabyrinthine tumor removal.

Translabyrinthine resection of intracranial tumors results in single-sided deafness, which can be treated by surgical and nonsurgical means. Here we describe the first series examining complication and device usage rates among patients receiving a surgically implanted bone-anchored hearing device (BAHD) at the time of translabyrinthine tumor removal. Case series with chart review. Private tertiary neurotologic referral center. Patients (N = 154) undergoing concurrent BAHD placement and translabyrinthine tumor resection. Concurrent BAHD placement and translabyrinthine tumor removal. Postoperative complication rates and BAHD usage. Of the 154 patients, 121 (78.6%) had no device-related complications. The most common device-related complications were skin overgrowth (8.4%), acute infection (5.2%), and chronic infection (3.2%). The overall and specific complication rates did not differ from published BAHD complication rates. One patient (0.6%) developed a cerebrospinal leak through the surgical site for the device. At the time of last follow-up (mean, 39.8 months), 151 patients (95.0%) were still using their devices. Patients undergoing concurrent translabyrinthine tumor removal and BAHD placement exhibit similar device-related complication profiles as patients undergoing standard device placement. Based on these outcomes and the high long-term usage rates, BAHD insertion at the time of translabyrinthine intracranial surgery can be considered a safe and useful procedure.

Impact of Orbitofrontal Lesions on Electrophysiological Signals in a Stop Signal Task

Behavioral inhibition and performance monitoring are critical cognitive functions supported by distributed neural networks including the pFC. We examined neurophysiological correlates of motor response inhibition and action monitoring in patients with focal orbitofrontal (OFC) lesions (n = 12) after resection of a primary intracranial tumor or contusion because of traumatic brain injury. Healthy participants served as controls (n = 14). Participants performed a visual stop signal task. We analyzed behavioral performance as well as event-related brain potentials and oscillations. Inhibition difficulty was adjusted individually to yield an equal amount of successful inhibitions across participants. RTs of patients and controls did not differ significantly in go trials or in failed stop trials, and no differences were observed in estimated stop signal RT. However, electrophysiological response patterns during task performance distinguished the groups. Patients with OFC lesions had enhanced P3 amplitudes to congruent condition go signals and to stop signals. In stop trials, patients had attenuated N2 and error-related negativity, but enhanced error positivity. Patients also showed enhanced and prolonged post-error beta band increases for stop errors. This effect was particularly evident in patients whose lesion extended to the subgenual cingulate cortex. In summary, although response inhibition was not impaired, the diminished stop N2 and ERN support a critical role of the OFC in action monitoring. Moreover, the increased stop P3, error positivity, and post-error beta response indicate that OFC injury affected action outcome evaluation and support the notion that the OFC is relevant for the processing of abstract reinforcers such as performing correctly in the task.

Infratentorial Neurosurgery Is an Independent Risk Factor for Respiratory Failure and Death in Patients Undergoing Intracranial Tumor Resection

Respiratory failure and death are devastating outcomes in the postoperative period. Patients undergoing neurosurgical procedures experience a greater frequency of respiratory failure compared with other surgical specialties. Resection of infratentorial mass lesions may be associated with an even higher risk because of several unique factors. Our objectives were: (1) to determine the incidence of postoperative respiratory failure and death in the neurosurgical population; and (2) to determine whether infratentorial procedures are associated with a higher risk compared with supratentorial procedures. We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing intracranial tumor resection. The primary outcome was a composite of reintubation within 30 days, failure to wean from mechanical ventilation within 48 hours, and death within 30 days after surgery. We examined the association between the surgical site and the outcomes using multivariate logistic regression. A total of 1699 patients met inclusion criteria (79% supratentorial and 21% infratentorial). The primary outcome occurred in 3.8% of supratentorial procedures and 6.6% of infratentorial procedures (P=0.02). Infratentorial tumor resection was independently associated with the composite outcome in the final model (odds ratio, 1.75; 95% confidence interval, 1.03-2.99; P=0.04) with the strongest association seen between infratentorial site and death (odds ratio, 2.44; 95% confidence interval, 1.23-4.87; P=0.01). Infratentorial neurosurgery is an independent risk factor for respiratory failure and death in patients undergoing intracranial tumor resection. Mortality is an important contributor to this risk and should be a focus for future research.

Comparison of dexmedetomidine versus propofol combined anesthesia for brain protection in patients undergoing intracranial tumor resection

Objective To compare dexmedetomidine versus propofol combined anesthesia for brain protection in the patients undergoing intracranial tumor resection.Methods Forty patients of both sexes,aged 18-60 yr,of ASA physical status Ⅰ or Ⅱ,scheduled for elective cerebral glioma or meningioma resection under general anesthesia,were randomly divided into 2 groups (n =20 each) using a random number table:dexmedetomidine combined anesthesia group (group D) and propofol combined anesthesia group (group P).Before induction of anesthesia,dexmedetomidine 1 μg/kg (4 μg/ml) was infused over 10 min in group D,while the equal volume of normal saline was infused over 10 min in group P.Anesthesia was induced with midazolam,fentanyl,cisatracurium and etomidate and maintained with remifentanil,isoflurane,cisatracurium and dexmedetomidine (0.2-1.0 μg·kg-1 ·h-1,group D) or propofol (3-10 mg·kg-1 ·h-1,group P).The patients were endotracheally intubated and mechanically ventilated.The doses of dexmedetomidine and propofol were adjusted to maintain BIS value at 40-50.Before induction of anesthesia (baseline),when the dura of brain was opened,at the end of tumor removal,at the end of operation,and at 24 h after operation (T0-4),venous blood samples were taken to determine the concentrations of serum neuron-specific enolase (NSE) and S100β.The emergence time and extubation time were recorded.Results Compared with the baseline value at T0,no significant changes were found in the concentrations of serum NSE and S100β at T1,and the concentrations of serum NSE and S100β were significantly increased at T2-4 in the two groups.Compared with group P,the concentrations of serum NSE and S100β were significantly decreased at T3,4,and the emergence time and extubation time were shortened in group D.Conclusion Dexmedetomidine combined anesthesia provides better efficacy than propofol combined anesthesia for brain protection in the patients undergoing intracranial tumor resection. Key words: Dexmedetomidine; Propofol; Anesthesia; Brain tumor; Brain injuries

Use of thrombin-based hemostatic matrix during meningioma resection: A potential risk factor for perioperative thromboembolic events

ObjectiveHemostatic agents are widely used in patients undergoing intracranial tumor resection to facilitate local hemostasis. We hypothesized that systemic activation of the clotting cascade after local application of hemostatic agents may result in unintended thromboembolic events, including deep venous thrombosis (DVT) and pulmonary embolism (PE). We performed a retrospective analysis to identify potential associations between hemostatic agent use and DVT/PE. MethodsA single-institution review of patients undergoing surgical resection of cranial meningiomas was performed. Patient demographics including gender and BMI, procedure duration, estimated blood loss (EBL), tumor pathology, use of hemostatic matrix, and the presence of DVT/PE within 14 days of surgery were collected from the medical record. ResultsA total of 467 patients underwent a craniotomy for meningioma from 2009 to 2012. There were 331 women and 136 men with a mean age of 58±14 years (range 18–92) and mean BMI of 28±6. Tumor pathology included 359 grade I, 77 grade II, and 31 grade III tumors. There were 12 patients (2.6%) with thromboembolic events. Age (p=0.66), gender (p=0.33), EBL (p=0.99), and procedure duration (p=0.17) were not associated with an increased incidence of DVT/PE. Use of DVT prophylaxis initiated 72h after surgery did not significantly alter the incidence of DVT/PE (p=0.20). Body mass index (p=0.04) and tumor grade (p=0.05) were associated with increased incidence of DVT/PE. Patients receiving greater than 10ml of a hemostatic agent intraoperatively had an increased incidence of DVT/PE (p=0.02). In a multivariate model, both BMI (OR=1.07, 95% CI: 1.00–1.15, p=0.048) and use of more than 10ml of hemostatic agent (OR=8.03, CI: 1.02–63.40, p=0.048) were found to be significantly associated with the risk of DVT/PE. ConclusionHemostatic agents are valuable tools in modern neurosurgery, however their use may be associated with an increased risk of DVT/PE in patients undergoing meningioma resection. This finding provides the impetus for more definitive clinical and laboratory studies to characterize the biology of this association and helps identify patients at increased risk for thromboembolism. This study also affirms the association between high BMI and the risk of thromboembolism. Interestingly the use of prophylactic anticoagulation after surgery did not decrease the incidence of DVT/PE.

Surgical treatment of intradiploic epidermoid cyst treated as depression

Extradural intradiploic epidermoid cysts are rare, representing less than 0.25% of all primary intracranial tumors. They can be neurologically silent and can only present psychiatric symptoms like depression, cognitive or personality changes. A 68-year-old male with two year long history of depressive mood, lack of motivation, helplessness, hopelessness and poor response to antidepressive drug therapy was described. CT scan showed a well-defined mass in the parietal scalp with destruction of the scull. He underwent intracranial tumor resection. Surgical resection and cranioplasty were performed. Pathology confirmed intradiploic epidermoid cyst. Total removal of these cysts and repeated washing of the cavity with 0.9% saline may prevent recurrence and aseptic meningitis and may improve mental state of the patient. We also emphasize the need for neuroimaging studies in a patient with atypical changes in mental status, even without neurological signs or symptoms.

Delayed post-operative haemorrhage after carmustine wafer implantation: A case series from two UK centres

Object. Significant haemorrhage following intracranial tumour resection may occur in 1–2% of cases and the majority occur within the first few hours post-operatively. Implantation of carmustine wafers has been associated with increased operative site complications in some series, but post-operative haematoma is not routinely reported. We analyzed the characteristics of post-operative haemorrhage after carmustine wafer insertion. Methods. We performed a retrospective audit of surgical site haematoma after tumour resection and insertion of carmustine wafers in two neurosurgical units in the UK (University Hospital of North Staffordshire, Stoke-on-Trent, March 2003 – July 2012; Wessex Neurological Centre, Southampton, October 2005 – January 2013). Results. During the specified time periods, carmustine wafers were inserted in 181 operations in 177 patients. We identified acute operative site haematomas after carmustine wafer insertion in 8 (4.4%) patients. All presented in a delayed fashion on or after Day 2 post-operatively. In contrast, acute operative site haematoma was present in 4/491 (0.81%) of patients who underwent resection without gliadel wafer insertion. Conclusions. In contrast to the expected timing of bleeding following intracranial tumour resection, all carmustine wafer patients who experienced haemorrhage presented in a delayed fashion on or after Day 2 post-operatively. The causative factors for universally delayed post-operative haematoma after carmustine wafer insertion are unclear and further studies are required to characterize this phenomenon.

Subdural hemorrhage from a hepatoma due to metastasis

Dural metastasis with subdural hemorrhage is very rare. We report a 69-year-old woman who visited our emergency department with a history of nausea and vomiting for 6 days. Computed tomography of the brain with enhancement showed a space-occupying lesion over temporal skull with subdural hematoma. Abdominal sonography revealed a liver tumor. Emergent craniotomy and resection of intracranial tumor were performed because of impaired consciousness on the 4 th day after admission. A pathological analysis of the cranial lesion later confirmed the diagnosis of metastatic hepatocellular carcinoma with skull involvement. After a complete survey of her hepatoma, she received tumor embolization and was discharged. However, 6 months later, she died because of multiple brain metastases, leading to subdural hemorrhage and intracranial hemorrhage. Although intracranial metastatic lesions are rare, they are life-threatening because of the lack of obvious history that usually leads to delayed diagnosis. A literature review was performed to shed light on the frequency and importance of this rare but important clinical entity.

The Dilemma of Early Postoperative Magnetic Resonance Imaging

Postoperative magnetic resonance imaging (MRI) is critical to the clinical decision-making process for patients undergoing resection of intracranial tumors. The accuracy of immediate postoperative MRI in determining the presence of residual disease following intracranial tumor resection, however, has not been studied. A 57-year-old man underwent an uncomplicated retrosigmoid craniotomy for the resection of a cystic vestibular schwannoma. Immediate gadolinium-enhanced postoperative MRI, performed within 1.5 hours of surgery, was notable for a plaquelike, lobular, avidly enhancing collection with MRI characteristics consistent with fluid density extending from the porus acusticus into the cerebellopontine angle. This anomalous lesion disappeared upon repeat imaging 48 hours later, and the patient had no attributable clinical sequelae. He was discharged home without issues within 12 hours of repeat imaging. We demonstrate here that immediate postoperative, gadolinium-enhanced MRI scans after tumor resection may result in avid enhancement in the region of surgical manipulation, likely due to leakage of gadolinium chelates into the subarachnoid space from residual compromise of the blood-brain barrier immediately following surgical manipulation. Early imaging is no longer routinely performed at our institution unless otherwise clinically indicated. FLAIR, fluid-attenuated inversion recoveryIAC, internal auditory canal.

Rosai‐dorfman disease with extranodal involvement

Rosai-Dorfman disease is a rare condition of marrow hematopoietic stem-cell origin. Patients can show extranodal involvement as well as lymphatic involvement, but only about 5% of extranodal cases involve intracranial lesions. A 53-year-old male was admitted to our hospital with bilateral cervical lymphadenopathy. Intracranial tumors and bone lesions were also detected. Cervical lymph node biopsy and intracranial tumor resection were performed, and histopathological examination revealed Rosai-Dorfman disease. The patient showed good clinical course without significant enlargement of the tumor. This study describes the case of a patient with Rosai-Dorfman disease presenting with massive cervical lymphadenopathy mimicking malignant neoplasm.

Scleral Contact Lenses as an Alternative to Tarsorrhaphy for the Long-Term Management of Combined Exposure and Neurotrophic Keratopathy

Most ophthalmologists are unaware of the therapeutic applications of gas-permeable scleral contact lenses for the prevention and treatment of ocular complications in patients with facial nerve palsy and concomitant neuroparalysis. The case reports refer to 3 patients who developed unilateral lagophthalmos and corneal anesthesia after an acoustic neuroma or intracranial tumor resection. Two patients explicitly requested a tarsorrhaphy to be opened because they were incapacitated by the limited visual acuity and visual field. Tarsorrhaphy was not an acceptable aesthetic solution for the third patient. Fluid-ventilated scleral lenses were fitted because they protect the cornea by creating a precorneal fluid reservoir while optimizing visual acuity. The follow-up periods were 3, 17, and 18 years. Two patients wear the contact lenses full time, but the wearing time is limited to 10 hours per day for the third patient. All patients were instructed not to wear their lenses while sleeping. Two eyes required a corneal transplant, but lens wear could be resumed 4 to 6 weeks after transplantation. The learning curve for the insertion and removal of this large-diameter lens is the main obstacle for a patient, especially when there is loss of corneal sensation. Scleral lens wear is a valid long-term alternative to standard treatment options such as tarsorrhaphy for patients with corneal exposure and corneal anesthesia as a consequence of postsurgery facial nerve paralysis. Scleral contact lenses provide these patients with effective protection of the ocular surface in an aesthetically acceptable way while optimizing visual function.

Predictive Value of Somatosensory Evoked Potential Monitoring during Resection of Intraparenchymal and Intraventricular Tumors Using an Endoscopic Port

Background and PurposeIntraoperative neurophysiological monitoring (IONM) using upper and lower somatosensory evoked potentials (SSEPs) is an established technique used to predict and prevent neurologic injury during intracranial tumor resections. Endoscopic port surgery (EPS) is a minimally-invasive approach to deep intraparenchymal and intraventricular brain tumors. The authors intended to evaluate the predictive value of SSEP monitoring during resection of intracranial brain tumors using a parallel endoscopic technique.MethodsA retrospective review was conducted of patients operated on from 2007-2010 utilizing IONM in whom endoscopic ports were used to remove either intraparenchymal or intraventricular tumors. Cases were eligible for review if an endoscopic port was used to resect an intracranial tumor and the electronic chart included all intraoperative monitoring data as well as pre- and post-operative neurologic exams.Results139 EPS cases met criteria for inclusion. Eighty five patients (61%) had intraparenchymal and fifty four (39%) had intraventricular tumors or colloid cysts. SSEP changes were seen in eleven cases (7.9%), being irreversible in three (2.2%) and reversible in eight cases (5.8%). Seven patients (5.0%) with intraparenchymal tumors had SSEP changes which met our criterea for significant changes while there were four (2.9%) with intraventricular (p-value=0.25). Five patients suffered post operative deficits, two reversible and two irreversible SSEP changes. Only one case exhibited post operative hemiparesis with no SSEP changes. The positive predictive value of SSEP was 45.4% and the negative predictive value was 99.2%.ConclusionsBased on the high negative and low positive predictive values, the utility of SSEP monitoring for cylindrical port resections may be limited. However, the use of SSEP monitoring can be helpful in reducing the impact of endoscopic port manipulation when the tumor is closer to the somatosensory pathway.

Innovative Neurosurgery: the first year

The first year is coming to an end. As expected, there have been skeptical people. Fortunately, there has been also an at least equally big group of active supporters of the journal. Many high-quality reviews, original articles, and technical notes have been submitted despite the awareness of a lacking impact factor or MEDLINE listing in this critical first year. Thank you authors for your trust. Based on your great work we will soon be able to apply for it. As expected, there have been some technical problems at the beginning. Fortunately, all could be solved immediately. Currently, all processes are running as designed and smoothly. Concerning the editorial board, none of the associated editors were really experienced in that field but all took up their duties right away without muttering but with great motivation, confidence, and success. Thank you editors for your invaluable work. You gave the journal a face. As expected, the advisory board performed really well and quick. No buts! Since the peer review process is the heart of any scientific journal and sentence over success or failure, this distinct group of people all over the world really pushed the journal forward. Thank you reviewers for your great contribution. Last but not least, the publishers need to be mentioned. All of us were really pleased by your competence, unlimited support, and generosity. One example is to enable open access to the full text articles within the first 2 years. This really helps and makes the difference. Thank you publisher for the opportunity. Innovative Neurosurgery surely has proven to be innovative by many outstanding articles such as the unique and new description of intracranial arachnoid membranes based on endoscopic anatomy or first experiences with a true optical 3D HD endoscope in Neurosurgery or near-infrared fluorescence image-guided intracranial tumor resection. In addition, comprehensive reviews on minimal-invasive and endoscopic Neurosurgery have been published by worldwide recognized opinion leaders. Examples are contributions on – transcranial endoscope-assisted skull base surgery, transsphenoidal endoscopic skull base surgery, and innovations in surgical treatment of gliomas. But Innovative Neurosurgery also wants to become innovative in terms of new publication formats. Therefore, we are currently working on a format that is supposed to demonstrate innovative management strategies for standard care in a variety of neurosurgical indications in an educative way. For next year we are currently planning a special issue on “Innovative Young Scientists in Neurosurgery”. This shall serve the purpose to give outstanding young scientists in the field of Neurosurgery a forum to be recognized as such, to create a platform for exchanging knowledge and building up cooperation as well as motivating others to follow in their footsteps. A subsequent column on “Innovative Young Scientists in Neurosurgery” will keep to the journal’s vanguard target. Being involved in many teaching courses for minimalinvasive and endoscopic techniques as well as in numerous meetings focused on the future of Neurosurgery, I have to presume that we still have a long way to go for these techniques becoming the standard of care in Neurosurgery. But I strongly believe, that we only reach that goal by scientifically proving the superiority or at least equality of minimal-invasive strategies compared with current microsurgical techniques. With the introduction of 3D-HD endoscopes into Neurosurgery we are for the first time able to come close to the image quality of current operating microscopes, the gold standard for visualization of the last and present century. However, launching a new technique is much more than presenting a new visualization tool. It includes instrumentation, compatibility with other important innovative technologies, comprehensible concepts, and of course clinical experience. Only then it will find acceptance in the majority of the Neurosurgical community and finally will be successful. Innovative Neurosurgery wants to be part of this process by motivating all of you to submit your innovative work with the goal to build up an appropriate body of knowledge in the best of scientific means. Join in!

Efficacy and Safety of Dexmedetomidine during Anesthesia Induction of Patients with Intracranial Tumor: A Preliminary Observational Trial

Background: The efficacy and safety of dexmedetomidine during the anesthesia induction of intracranial tumor patients remain unknown. We wondered whether loading infusion of dexmedetomidine 1 μg/kg over 10 min to intracranial tumor patients was as efficient and safe as to those abdominal disease patients. Methods: Patients aged 18-60 years, male or female, ASA I or II, scheduled for intracranial tumor resection (Group N, n = 30) or abdominal operation (Group A, n = 30) were enrolled in this observational trial. Dexmedetomidine was administrated with a loading dosage of 1 μg/kg over 10 min following with continuous infusing of 0.5 μg/kg/h. Fentanyl, propofol and rocuronium were sequentially administered for anesthesia induction. Heart rate (HR), blood pressure (BP), pulse oxygen saturation (SpO2), bispectral index (BIS) and other adverse effects were recorded from the beginning of loading infusion of dexmedetomidine to the end of endotracheal intubation. Results: Among with loading infusion, HR and BIS value decreased and were significantly lower at the end of infusion than before infusion (P P > 0.05). One patient of Group N dropped out from this trial because of a serious headache. 14 of 29 patients during dexmedetomidine loading infusion suffered hypoxemia (SpO2 P Conclusion: A loading dosage of 1 μg/kg of dexmedetomidine was not suitable for the anesthesia induction of intracranial tumor patients as compared to patients undergoing abdominal operation.

Short‐term outcomes of craniotomy for malignant brain tumors in the elderly

Disparity in resection rates for malignant brain tumors in elderly patients is partially attributed to a belief that advanced age is associated with an increased risk of postoperative morbidity and mortality. The objective of this study was to investigate the effect of advanced age (≥75 years) on 30-day outcomes in patients with primary and metastatic brain tumors who underwent craniotomy for definitive resection of a malignant brain tumor. The authors conducted prospective analyses of the American College of Surgeons' National Surgical Quality-Improvement Project (NSQIP) database from 2006 to 2010 of 970 patients aged ≥40 years who underwent craniotomy for definitive resection of neoplasm. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by age. By using propensity scores, 134 patients (aged ≥75 years) were matched to 134 patients ages 40 to 74 years. Logistic regression was used to predict adverse postoperative outcomes. The median length of hospital stay was 5 days; the rate of minor and major complications were 5.9% and 13.1%, respectively; 5.7% of patients returned to the operating room; and 4.3% of patients died within 30 days. Advanced age did not increase the odds for poorer short-term outcomes. Advanced age did not increase the risk of poor outcomes after surgical resection of primary or metastatic intracranial tumors when analyses were controlled for other risk factors. These results suggest that age should not be used, in isolation, as an a priori factor to discourage pursuing craniotomy.

Symptomatic Cerebral Vasospasm Following Resection of a Medulloblastoma in a Child

Vasospasm may occur following intracranial tumor resection but is uncommon following resection of tumors in the posterior fossa. Case report. Here, we report an unusual pediatric case of symptomatic cerebral vasospasm following resection of a posterior fossa medulloblastoma in a 10-year-old child. CT angiogram and serial Transcranial Doppler (TCD) studies confirmed the presence of vasospasm and response to hemodynamic augmentation therapy, resulting in favorable outcome. This case illustrates an unusual complication of posterior fossa tumor resection, and the potential utility of TCD studies in the detection and management of vasospasm in pediatric neurocritical care.