Journal of Neurosurgery
Volume 140: Issue 2 (Feb 2024)
Illustration from Martini et al. (pp 386–392). Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.

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In Brief

Given the emergence of oncolytic viruses (OVs) as novel therapeutic agents, this review provides an overview of OV therapy thus far, exploring the pathophysiology, advantages/disadvantages, challenges, and therapeutic uses of several OVs. Most importantly, this review seeks to further clinical application of OVs by proposing intrathecal delivery by adapting the IRRAflow catheter—a novel method—to overcome one of the main obstacles of OV therapy: the lack of an optimal delivery method.

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OBJECTIVE

The relationship between brain metastasis resection and risk of nodular leptomeningeal disease (nLMD) is unclear. This study examined genomic alterations found in brain metastases with the aim of identifying alterations associated with postoperative nLMD in the context of clinical and treatment factors.

METHODS

A retrospective, single-center study was conducted on patients who underwent resection of brain metastases between 2014 and 2022 and had clinical and genomic data available. Postoperative nLMD was the primary endpoint of interest. Targeted next-generation sequencing of > 500 oncogenes was performed in brain metastases. Cox proportional hazards analyses were performed to identify clinical features and genomic alterations associated with nLMD.

RESULTS

The cohort comprised 101 patients with tumors originating from multiple cancer types. There were 15 patients with nLMD (14.9% of the cohort) with a median time from surgery to nLMD diagnosis of 8.2 months. Two supervised machine learning algorithms consistently identified CDKN2A/B codeletion and ERBB2 amplification as the top predictors associated with postoperative nLMD across all cancer types. In a multivariate Cox proportional hazards analysis including clinical factors and genomic alterations observed in the cohort, tumor volume (× 10 cm3; HR 1.2, 95% CI 1.01–1.5; p = 0.04), CDKN2A/B codeletion (HR 5.3, 95% CI 1.7–16.9; p = 0.004), and ERBB2 amplification (HR 3.9, 95% CI 1.1–14.4; p = 0.04) were associated with a decreased time to postoperative nLMD.

CONCLUSIONS

In addition to increased resected tumor volume, ERBB2 amplification and CDKN2A/B deletion were independently associated with an increased risk of postoperative nLMD across multiple cancer types. Additional work is needed to determine if targeted therapy decreases this risk in the postoperative setting.

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In Brief

This study assessed the pretreatment characteristics of brain metastases receiving laser interstitial thermal therapy (LITT) and demonstrated that small-sized and spherical lesions are the ideal candidates for this therapy. Lesions meeting cutoffs of < 2.5 cm3 of enhancing volume and sphericity ≥ 0.705 showed a significantly higher probability of progression-free survival after treatment. These findings will aid future patient selection for LITT by highlighting the key radiologic features for treatment success.

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In Brief

Researchers investigated the relationship between facility type (academic centers vs nonacademic centers) and surgical outcomes in patients with intracranial meningioma. Patients treated at academic centers had a higher median overall survival at 10 years than patients treated at nonacademic centers, even after adjusting for other variables. This finding highlights the association between facility type and survival outcomes in the treatment of intracranial meningiomas, emphasizing the importance of addressing healthcare disparities and biases in treatment recommendations.

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In Brief

This study represents the first attempt to analyze the performance of in vivo confocal laser endomicroscopy (CLE) imaging at the infiltrating margins of gliomas. After correlating CLE images acquired at glioma margins with corresponding permanent pathology, blinded neuropathologists found that CLE has limited dependability, especially in scenarios where a low probability of tumor infiltration is expected. These results suggest that CLE requires further exploration as a method for consistent, actionable intraoperative guidance.

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OBJECTIVE

Isocitrate dehydrogenase (IDH) mutations in both high- and low-grade gliomas are associated with an increase in survival compared with IDH–wild-type (IDHwt) tumors. A rare and understudied population is elderly individuals, ≥ 65 years of age, who have IDH1-R132H–mutant (IDHmt) gliomas. The objective of this paper was to characterize the institutions’ experience with IDHmt gliomas in a patient population ≥ 65 years of age over the last 10 years.

METHODS

A retrospective study of individuals ≥ 65 years of age with IDHmt gliomas treated between 2010 and 2020 at Memorial Sloan Kettering was performed.

RESULTS

Twenty-five patients ≥ 65 years of age underwent resection or biopsy with a diagnosis of IDHmt glioma (52% WHO grade II, 32% WHO grade III, and 16% WHO grade IV). The most common presenting symptoms were seizure (28%) and motor or sensory deficits (24%). On preoperative MRI, 56% of tumors demonstrated contrast enhancement and 44% had no enhancement. Most patients underwent craniotomy for resection (n = 23, 92%), with subtotal resection achieved in the majority (16/23, 69.6%). Postoperative discharge location included home (64%), acute rehabilitation (16%), subacute rehabilitation (8%), and unknown (12%). Most patients received postoperative chemotherapy (72%) and radiation therapy (68%). The 2- and 5-year survival rates for the overall cohort were 83.1% (95% CI 69.3%–99.7%) and 69.7% (95% CI 53.2%–91.3%), respectively, with gross-total resection or near-total resection, contrast enhancement, and WHO grade significantly associated with survival. From the clinical sequencing data, no significant differences were identified between younger and older IDHmt cohorts.

CONCLUSIONS

While IDH mutation in elderly patients may be rare, these patients have favorable survival relative to their IDHwt counterparts. Age at diagnosis should not be used in isolation to suggest a molecular IDHwt status or poor prognosis when guiding patient treatment decisions.

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In Brief

The general trend in meningioma treatment is shifting from surgery to active surveillance. Researchers herein used diffusion-weighted imaging to predict the growth pattern of asymptomatic meningiomas. Meningiomas with low relative apparent diffusion coefficient (rADC) values at baseline were more likely to grow than tumors with high rADC values, whereas lower rADC values in growing meningiomas were associated with a faster growth rate and shorter tumor doubling time. This study provides a new strategy for the follow-up of meningiomas.

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In Brief

Inferior petrosal sinus (IPS) sampling (IPSS) can help determine pituitary tumor laterality but may be confounded by the presence of multiple collateral channels connecting the IPSs bilaterally. The authors retrospectively reviewed cases of histopathologically confirmed pituitary microadenomas that had previously undergone IPSS and found that angiographic cross-filling through collateral channels significantly impacted adrenocorticotropic hormone laterality measurements. These findings suggest that angiographic cross-filling may be an important factor to consider when pursuing IPSS to understand microadenoma laterality.

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OBJECTIVE

Grade 3 meningioma represents a rare meningioma subtype, for which limited natural history data are available. The objective of this study was to identify demographics and pathologic characteristics, clinical and functional status outcomes, and prognostic factors in an international cohort of grade 3 meningioma patients.

METHODS

Clinical and histopathological data were collected for patients treated at 7 sites across North America and Europe between 1991 and 2022.

RESULTS

A total of 103 patients (54% female, median age 65 [IQR 52, 72] years) were included. Sixty-seven (65%) patients had de novo grade 3 lesions, whereas 29 (28%) had malignant transformations of lower-grade meningiomas. All patients underwent initial resection of their tumor. Patients were followed for a median of 46 (IQR 24, 108) months, during which time there were 65 (73%) recurrences and 50 (49%) deaths. The 5-year overall survival (OS) and progression-free survival (PFS) rates were 66% (95% CI 56%–77%) and 37% (95% CI 28%–48%), respectively. Age ≥ 65 years and male sex were independent predictors of worse OS and PFS in multivariate regression analysis, while postoperative radiotherapy was independently associated with improved OS. Karnofsky Performance Status (KPS) remained stable relative to baseline over 5 years postdiagnosis among participants who were alive at the end of the follow-up period.

CONCLUSIONS

This large multicenter study provides insight into the longitudinal outcomes of grade 3 meningioma, with respect to recurrence, survival, and functional status. This study affirms the survival benefit conferred by radiotherapy in this population and suggests good functional status outcomes for patients surviving to 5 years postoperatively.

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In Brief

This study examined risk factors for local progression after treatment of cerebellar hemangioblastomas and assessed outcomes after salvage treatment for recurrences. In the upfront stereotactic radiosurgery (SRS) group, an older patient age and a cystic tumor component were associated with recurrence. Salvage SRS was typically used for smaller recurrences, and no recurrences smaller than 1.0 cm3 required additional surgery after salvage SRS. In cases of recurrence, salvage surgery and repeat SRS treatment are both valid options for achieving local control.

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In Brief

The objective of this paper was to analyze the feasibility and efficacy of endoscopic transorbital decompression of the optic canal through anterior clinoidectomy for compressive optic neuropathic lesions. The study adds value to the field by providing a less invasive and potentially safer alternative to traditional surgical approaches for treating these conditions. This study expands the available treatment options for neurosurgeons and provides evidence to support the adoption of this procedure in clinical practice.

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In Brief

Petroclival meningiomas are challenging lesions to treat because of their deep location and proximity to critical neurovascular structures. A symptom that proves challenging to manage is trigeminal neuralgia, which occurs in about 5% of cases. In this systematic review and meta-analysis, the authors concluded that microsurgical resection is associated with higher rates of pain resolution and lower rates of pain persistence and exacerbation as compared with rates following stereotactic radiosurgery (SRS) treatment. SRS with further trigeminal neuralgia management is a viable alternative in patients who are not good candidates for microsurgical resection.

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In Brief

Same-day outpatient surgical procedures have been adopted by several specialties, but patient admission after elective brain aneurysm treatment remains common practice. The necessity of such monitoring has not been well characterized. The authors utilized imaging studies during posttreatment hospitalization to infer the value of inpatient monitoring after endovascular aneurysm treatment. They found that more than 1 in 8 patients required imaging during posttreatment hospitalization, mostly during the first 24 hours, and 1 in 20 had significant clinical findings. These findings suggest that short-term hospitalization after elective aneurysm treatment remains important to monitoring for potential complications.

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The authors aimed to study the effect on clinical outcomes of the Pipeline embolization device (PED) surface modification introduced with the Shield Technology. Complication rates, especially those that were thrombogenic in nature, were lower in the PED Shield cohort, but the difference did not reach significance. This study shows that the Shield Technology seemed to affect (nonsignificantly) complication rates. Larger studies are essential to answer the question of whether the Shield Technology is effective, and this third-generation device should be taken into consideration when searching for the best treatment modality.

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In Brief

This study aimed to identify the potential risk factors that can influence the rupture of choroidal anastomosis (ChA). A larger lumen area of the ChA and the angiographic presence of ChA alone are independent risk factors for a ruptured ChA. These characteristics can help to determine treatment strategies for patients with unruptured ChA.

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In Brief

Many parameters determine the success of a cerebral bypass, but rarely does one see data on troubleshooting the bypass once it is recirculated and it does not work. That is the point at which difficulties begin. In this work, the authors review causes and strategies to troubleshoot an initially nonworking anastomosis and create a decision-making flowchart based on their experience to serve as a tool for novice vascular neurosurgeons. Importantly, the authors show that by using a stepwise, less invasive to a more invasive approach for bypass interrogation, successfully troubleshooted bypasses maintain a high patency rate.

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In Brief

A historical perspective is presented on the first aneurysm clipping performed in Iceland. The details of how an aneurysm clip was flown from the US on a large military transport are provided. The implications of this event for the balance of power in the Cold War are discussed.

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In Brief

The researchers reported on endoscopic endonasal surgery for brainstem cavernomas. This technique was safe and effective for cavernomas located on the anterior surface of the brainstem. This technique is expected to be expanded as a safe alternative for brainstem cavernomas.

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Peripheral nerve sheath tumors encompass a full spectrum of pathologies that range from benign (schwannoma neurofibromas) to premalignant (atypical neurofibromas) to malignant peripheral nerve sheath tumors (MPNSTs). Advances in imaging techniques in ultrasound, MRI, and MRI tractography have improved our ability to understand the tumor’s relationship to normal nerve fibers running on or through the capsule, as well as surrounding anatomical structures. However, imaging techniques have not advanced enough for us to reliably distinguish between benign and malignant tumors.

The distinction between benign and malignant tumors is very important for surgical planning because the approach to tumor resection

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In Brief

In this paper, the authors describe clinical and diagnostic complications that can occur in the biopsy of masses involving the peripheral nerves. Therefore, it is extremely important to evaluate criteria for indications of biopsy of these masses. Criteria are provided in this study to help clinicians determine whether a biopsy is indicated. A biopsy should only be performed if a tumor is likely malignant. In cases of peripheral nerve tumors, an experienced pathologist should be present in order to increase the patient's chances of attaining an optimal outcome.

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In Brief

The objective was to utilize a modified Delphi method to develop a core outcome set for ulnar neuropathy at the elbow (COS-UNE). The final COS-UNE consisted of 22 data points/outcomes covering domains of demographic characteristics, diagnostics, patient-reported outcomes, motor/sensory outcomes, and complications. The consensus minimum duration of follow-up was 6 months. This COS should serve as a minimum set of data to be collected in all future neurosurgical studies on ulnar neuropathy at the elbow.

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In Brief

Researchers used diffusion kurtosis imaging (DKI) to investigate brain microstructural alterations and compare the bilateral hemispheres in patients with unilateral classic trigeminal neuralgia. Asymmetric microstructural alterations in white and gray matter of bilateral hemispheres were revealed, probably caused by the compromised fiber tract integrity and abnormalities of the neurons and synapses. The thalamus could be an important structure in the pain conduction and modulation pathway. DKI can quantify microstructural alterations and help to evaluate the therapeutic effects longitudinally.

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In Brief

Researchers aimed to assess the impact of alexithymia and depression on Gamma Knife radiosurgery (GKRS) outcomes, as well as the potential role of colored pain drawings (CPDs) in identifying patients who require additional psychological support. The presence of alexithymia, depression, and unexpected CPDs was predictive of treatment failure in trigeminal neuralgia patients. This study highlights the importance of considering psychological factors and utilizing CPDs as a screening tool before GKRS.

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In Brief

The authors aimed to elucidate the management outcomes of patients presenting with trigeminal neuralgia (TN) with ipsilateral peripontine brain arteriovenous malformations (bAVMs) as the culprit lesion. Radiosurgery is a promising modality with a high chance of controlling the TN symptom while obliterating the AVM. This is the largest series to date describing radiosurgery outcomes of TN-associated bAVMs.

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OBJECTIVE

Vertebral artery injury (VAI), a complication of blunt trauma, may cause posterior circulation stroke. An association of disease severity, classified in Denver grades, with stroke risk has not been shown. Using a literature-based analysis, the authors estimated the incidence of VAI following blunt trauma with the aim to investigate the impact of Denver grade and bilateral VAI on stroke occurrence.

METHODS

A systematic review of the literature on VAI following blunt trauma was conducted, and data on its incidence, the severity per Denver grade, and stroke occurrence were collected. The incidence of VAI and stroke occurrence were analyzed cumulatively and between Denver grades. A meta-analysis with random-effects models was performed.

RESULTS

Fifty-six studies including 2563 patients were identified. The overall incidence of VAI was 0.49% among blunt trauma cases and 14.5% among patients screened via any type of angiography. The incidence rates of bilateral VAI and concurrent carotid injury among all VAIs were 12.3% and 19.2%, respectively. VAI severity by Denver grade was as follows: grade I, 23.4%; grade II, 28.2%; grade III, 5.8%; grade IV, 42.1%; and grade V, 0.5%. The overall stroke risk was 5.32%, differing significantly among lesions of different Denver grades (p = 0.02). Grade III and IV lesions had the highest stroke prevalence (9.8% and 10.9% respectively), while strokes occurred significantly less frequently in patients with grade I and II lesions (1.9% and 3.0%, respectively). Denver grade V cases were too rare for meaningful analysis. Bilateral VAI was associated with a 33.2% stroke prevalence. The association between Denver grade and stroke occurrence persisted in a sensitivity subanalysis including only unilateral cases (p = 0.03).

CONCLUSIONS

VAI complicates a small yet nontrivial fraction of blunt trauma cases, with Denver grade IV lesions being the most common. This is the first study to document a significantly higher stroke prevalence among grade III and IV VAIs compared with grade I and II VAIs independently from bilaterality. Bilateral VAIs carry a significantly higher stroke rate.

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In Brief

The authors studied the correlation between patient age and midline shift (MLS) caused by chronic subdural hematoma (CSDH). For a fixed CSDH volume, older age correlates with decreased MLS with every 10 years by 1 mm. Similarly, 10-ml increments in CSDH volume correlate with a 1-mm increase in MLS in patients aged < 60 years compared to a 0.5-mm increase in patients aged > 75 years. Younger patients may need earlier intervention for CSDH of similar volumes. As automated calculation of CSDH and MLS becomes established with artificial intelligence algorithms, this relationship will have increased importance for treatment and prognosis.

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In Brief

In this two-center retrospective series, the authors sought to assess the outcome of patients with intracranial mass lesions, transtentorial brain herniation, and nonreactive mydriasis, following emergency surgical decompression. Nearly a third of patients, many of whom had bilaterally fixed and dilated pupils, survived with a satisfactory functional outcome at 3 months. In addition to younger age and a smaller midline shift, improved pupillary response following osmotherapy or surgery was found to be a favorable prognosticator.

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In Brief

Researchers analyzed one of the largest trauma databases of the United States, describing outcomes after surgical intervention in severe traumatic brain injury (TBI) in the form of discharge disposition outcomes. There were racial and ethnic differences in disposition outcomes, and regardless of age, transfer to a skilled nursing facility was the most common outcome. The study provides neurosurgeons quantitative and tangible outcome predictions to assist in patient-care discussions in these life-changing situations.

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In Brief

The objective of this study was to assess various methods for the diagnosis of concussion and which methods were most effective. These methods were evaluated via a systematic review as well as a network meta-analysis.

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In Brief

The researchers performed a nationwide survey of neurosurgical residency programs aiming to study the factors that impact residents' case volume at time of graduation. The study showed that the program faculty size and total cases had no impact on residents' case volume. The number of cases performed per faculty was the only factor that significantly correlated with residents' case volume.

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In Brief

This paper aimed to evaluate the current status of neurosurgical training in Ethiopia (began in 2006), provide a historical prospective, and propose future educational opportunities using a survey of all neurosurgery residents. The survey response rate was 86% and showed that approximately 50% of trainees log > 100 cases/year. In addition to affirming the positive impact of previous and current international collaborations focused on resident training, the results demonstrated significant interest in subspecialty training in primarily spine, tumor, and vascular subspecialties. Educational opportunities include initiatives promoting a subspecialized, diverse workforce that attains both the clinical and academic proficiency necessary for advancing neurosurgical care locally and globally.

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In Brief

Given the high variability in nomenclature of the craniocervical junction, a high-volume, institutional experience was used to identify and standardize classes of disease causing ventral compression. The authors identified basilar invagination with anterior subluxation and a retroflexed dens as two separate causes of compression that are often confused. A retroflexed dens often appears in tandem with platybasia and Chiari malformation. This report helps reclassify and standardize the diagnosis and management of these disease processes.

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In Brief

Researchers conducted extensive contemporary interviews and corresponded with the Raney family to fill in the gaps in neurosurgical history regarding the invention of the Raney clip. Aidan and Rupert Raney were early neurosurgical inventors who inherited their zest for tinkering from their father and passed it down to their children/nieces and nephews and grandchildren/grandnieces and -nephews. The Raney clip is now the quintessential tool for achieving scalp hemostasis in cranial neurosurgery.

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Following a hiatus of 3 years, given the COVID-19 pandemic and the Russian invasion of Ukraine on February 24, 2022, a team of 6 clinicians including 2 neurosurgeons, 1 neurologist, 1 neonatologist, 1 neonatal critical care nurse practitioner, and 1 psychiatrist returned to Ukraine to reinitiate our capacity-building program, which had begun in 2012. The Ukraine Paediatric Fellowship Program (UPFP), which started as a neurosurgery and psychiatry initiative, has since expanded to include neurology, neonatology, oncology, anesthesiology, radiology, and pediatric surgery. It is a bi-directional program with Ukrainian fellows and observers travelling to the Hospital for Sick Children

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TO THE EDITOR: I read the article by Christian et al. with interest from the perspective of a physician in a leadership position in a hospital in Lviv, Ukraine (Christian E, Romach M, Rutka JT. Assistance amidst air alerts and angst: Ukraine unbroken. J Neurosurg. Published online September 29, 2023. doi:10.3171/2023.8.JNS231781). When the COVID-19 pandemic struck, the whole world stopped; we were all victims of this hidden assailant. How so? How was it possible that we were all prisoners within our own homes? We were unable to fly to distant places. Even buying food

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TO THE EDITOR: In their thought-provoking study on the influence of craniopharyngioma (CP) topography on surgical outcome, Sadhasivam et al. demonstrated that the retrochiasmatic location is associated with a significantly higher risk of hypothalamic morbidity (Sadhasivam S, Menon G, Abraham M, et al. The influence of tumor topography on the surgical outcome of craniopharyngiomas. J Neurosurg. 2023;139[5]:1247-1257). This informative result underscores the need to accurately define CP topography preoperatively and to stratify patients into different risk categories. What struck us most was the topographical scheme chosen, which differentiated prechiasmatic and retrochiasmatic CPs. These two

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TO THE EDITOR: It was our pleasure to read the article by Pangal and Donoho, encouraging neurosurgeons to incorporate artificial intelligence (AI) and machine learning (ML) into the operating room (OR) and drawing parallels to the benefits of "film study" in professional sports (Pangal DJ, Donoho DA. "Are we recording this?" Surgeons deserve next-generation analytics. J Neurosurg. 2023;139[6]:1792-1795). Here, we propose an adjacent discussion on the ethical and legal considerations in recording OR activity. The recording of visual, audio, and physical data points in the OR setting is achieved using a medical data recorder

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In Brief

The authors examined the area deprivation index as an indicator of socioeconomic status (SES) in the prognosis of patients with unruptured brain arteriovenous malformations (bAVMs). The results showed that along with older age, worse baseline functional status, high-grade bAVM, and non-obliteration, patients without an advantaged SES are prone to nonindependence at the last follow-up. This is the first United States–based study to explore SES and bAVM outcome, but more studies should follow to affirm the current findings and guide social interventions for patients with disadvantaged SESs.

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In Brief

The authors' goal was to improve the endoscopic endonasal lateral approach for the removal of Knosp grade 4 pituitary adenomas. This study revealed that the lateral compartment of the cavernous sinus is divided by the abducens nerve?internal carotid artery complex into the superolateral and inferolateral compartments. Accordingly, the lateral approach was subclassified into the lateral superior and anterior inferior approaches, which allowed a high gross-total resection rate with acceptable safety in the surgical treatment of Knosp grade 4 pituitary adenomas.

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TO THE EDITOR: Glioblastoma multiforme (GBM) is the most common histological subtype of glioma and gives rise to high morbidity and mortality. The standard of care involves initial resection followed by a combination of chemotherapy and radiotherapy. A well-established prognostic factor is the extent of resection (EOR). 5-Aminolevulinic acid (5-ALA) fluorescence–guided surgery (FGS) has been shown to improve tumor visualization and therefore EOR. In their study, Picart et al. (Picart T, Pallud J, Berthiller J, et al. Use of 5-ALA fluorescence–guided surgery versus white-light conventional microsurgery for the resection of newly diagnosed glioblastomas [RESECT study]: a French

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TO THE EDITOR: We read with keen interest the article by Cohen-Cohen et al. (Cohen-Cohen S, Graffeo CS, Botello-Hernandez E, et al. Anterior clinoid meningiomas: surgical results and proposed scoring system to predict visual outcomes. J Neurosurg. Published online November 3, 2023. doi:10.3171/2023.8.JNS23894). The study offers important insights into surgical trends and outcomes for these complex tumors. However, we wish to highlight the significance of stereotactic radiosurgery (SRS) as a viable alternative treatment approach.

The authors advocate for microsurgical resection in treating anterior clinoid meningiomas (ACMs), aiming to decompress the optic apparatus, preserve or

Open access

In Brief

Is biologically effective dose (BED) superior to prescription dose in predicting pain relief and facial numbness in trigeminal neuralgia patients undergoing Gamma Knife radiosurgery as a first procedure? No. Instead, the authors found an interplay of factors: 1) a distal target may be optimal, 2) BED was predictive for the distal target, 3) the physical dose was predictive for the proximal target, and 4) the maximum brainstem dose was associated with sensory dysfunction.

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In Brief

This study investigated the association between head impact exposure and short-term changes in cortical excitability using transcranial magnetic stimulation. Athletes who had played a full-contact football game exhibited significant intracortical disinhibition within hours following the game. Exposure to ≥ 40g hits positively correlated with short-interval intracortical inhibition disinhibition. Given the deleterious effects of decreased inhibition on motor control and balance, tracking head impact forces at each game and practice with contacts could prove useful for injury prevention.

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In Brief

The angle of exposure (AnE) represents a metric particularly useful for analyzing circular bony structures during skull base dissections. This study proposes a new formula based on vectorial geometry and the coordinates of three points collected with a neuronavigation system to measure the AnE. This formula represents a new method to accurately acquire objective measurements during skull base dissections. Researchers also provide a user-friendly interface to facilitate its wider application.

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In Brief

The objective of this study was to use a modified Delphi method to develop a core outcome set for brachial plexus and upper extremity nerve injuries (COS-BPUE). The final COS-BPUE consisted of 36 data points/outcomes covering demographic, diagnostic, patient-reported outcome, motor/sensory outcome, and complication domains. The consensus minimum duration of follow-up was 24 months. This COS should serve as a minimum set of data to be collected in all future neurosurgical studies on BPUE.

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In Brief

This study aimed to assess the relationship between arteriovenous malformation (AVM) blood flow (measured by quantitative MR angiography) in nonruptured AVMs and MR-detected microhemorrhage. Patients with unruptured AVMs with higher AVM flow have an increased likelihood of an AVM microhemorrhage being detected on MRI. This finding offers a potential strategy to risk-stratify patients with unruptured AVMs via microhemorrhage on MRI, a finding related to high AVM flow and other high-risk angioarchitectural features of AVMs.

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In Brief

This study was performed to compare ketorolac- with fentanyl-based patient-controlled analgesia (PCA) in terms of postoperative nausea and vomiting (PONV) and analgesia after microvascular decompression (MVD). Ketorolac-based PCA decreased PONV incidence and severity compared with those for fentanyl-based PCA, while exerting analgesic effects similar to those of fentanyl-based PCA. This study provides clinical evidence that ketorolac-based PCA may be a valid alternative to fentanyl-based PCA in the postoperative care of patients with MVD.

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In Brief

Researchers evaluated changes in cognitive symptoms following deep brain stimulation (DBS) for Parkinson's disease. In patients who underwent subthalamic nucleus (STN) DBS, more medial electrode position was associated with postoperative cognitive decline, while this relationship was not found for DBS of the globus pallidus internus. These findings suggest that nonmotor areas of the STN may contribute to cognitive changes following DBS.

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In Brief

Researchers investigated the association between CD44 expression and clinical factors of meningiomas. Extent of CD44 gene expression was positively correlated with the severity of peritumoral brain edema (PTBE) in meningiomas. Multivariate analysis revealed that overexpression of CD44 was an independent factor of severe PTBE development in meningiomas. Since PTBE is associated with epilepsy or cognitive dysfunction in patients with meningioma, CD44 would be a potential therapeutic target for reducing these symptoms.

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TO THE EDITOR: We are writing to express our appreciation for the study by Liu et al. (Liu Z, Mela A, Argenziano MG, et al. Single-cell analysis of 5-aminolevulinic acid intraoperative labeling specificity for glioblastoma. Published online September 22, 2023. J Neurosurg. doi:10.3171/2023.7.JNS23122). This research investigates the fluorescence specificity of 5-aminolevulinic acid (5-ALA) in neoplastic glioma cells, utilizing single-cell analysis techniques.

The study addresses the critical question of whether the fluorescence induced by 5-ALA is specific to neoplastic glioma cells at the single-cell level. By using SCOPE-seq2 (single-cell optical phenotyping and expression sequencing–version 2)