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Nader Sanai and Michael W. McDermott

postoperative pseudomeningocele. The galea and skin were each closed separately with running suture. Results Patient and Tumor Demographics Eight tumors (67%) were right-sided and 4 (33%) were left-sided. The most common location was along the posterior fossa convexity (in 5 patients [42%]), followed by the CPA (in 4 [33%]) and the petrous face (in 3 [25%]). The mean tumor volume was 72.6 cm 3 (range 8–131 cm 3 ), and the median maximal tumor diameter was 4.9 cm. Microsurgical and Clinical Outcome Three patients (25%) underwent preoperative embolization, and

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Nader Sanai and Mitchel S. Berger

resection. Emerging imaging technologies, as well as state-of-the-art intraoperative techniques, can facilitate a greater extent of resection while minimizing the associated morbidity profile. Specifically, the value of mapping motor and language pathways is well established for the safe resection of intrinsic tumors. Interestingly, controversy persists regarding prognostic factors and treatment options for both low- and high-grade hemispheric gliomas. Among the various tumor- and treatment-related parameters—including tumor volume, neurological status, timing of

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Robert F. Spetzler and Nader Sanai

retract the brain. Used with permission from Barrow Neurological Institute. Electroencephalographic burst suppression with thiopental was routinely used to provide additional protection in case temporary vessel occlusion was inadvertently needed and to decrease the intracranial blood volume, which further increased the working space. Mannitol was not routinely administered before surgery, but it was used when significant tumor mass effect, brain edema, or both were present. Lumbar drains were not routinely placed. The choice of operative corridor was dictated by

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Nader Sanai, Juan Martino and Mitchel S. Berger

neurosurgeon (M.S.B.) conducted volumetric measurements of pre- and postoperative imaging. For low-grade gliomas, manual segmentation was performed with region-of-interest analysis to measure tumor volumes (cm 3 ) on the basis of FLAIR or T2 axial slices, as previously described. Extent of resection was calculated as (preoperative tumor volume − postoperative tumor volume)/preoperative tumor volume. For high-grade gliomas, a similar calculation was made using the volume of contrast-enhancing tissue seen on T1-weighted MR imaging. The determination of volumes was made without

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Laura B. Ngwenya and E. Antonio Chiocca

overall predictors of GBM survival (p < 0.0001 and p = 0.001, respectively) compared to EOR (p = 0.004). Their recursive partitioning analysis defined EOR ≥ 95% as providing the largest impact on survival, and included age and preoperative tumor volume in defining risk groups. However, it was unclear if those patients with low KPS scores were included in the ≥ 95% EOR group, and we thus do not know if this study includes an ill-defined bias toward larger EOR in patients with better KPS scores. Granted, this bias is somewhat unavoidable, because older patients with

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Nader Sanai, Mei-Yin Polley and Mitchel S. Berger

follow-up imaging and/or a higher-grade lesion on a subsequent biopsy procedure. Patients with no known progression/malignant progression were censored as of their last imaging date. Volumetric Analyses Volumetric measurement of pre- and postoperative imaging was conducted by the primary neurosurgeon (M.S.B.). For LGGs, manual segmentation was performed with region-of-interest analysis to measure tumor volumes (cm 3 ) on the basis of FLAIR or T2 axial slices, as previously described. 17 The EOR was calculated as follows: (preoperative tumor volume

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Nader Sanai, Susan Chang and Mitchel S. Berger

some instances, MR spectroscopy can also be used to discriminate radiation necrosis from tumor progression, as well as to monitor treatment progress. 125 Among low-grade astrocytomas, measurement of relative cerebral blood volume (rCBV) derived from dynamic susceptibility-weighted perfusion contrast-enhanced MR imaging (DSC-MR imaging) correlates well with tumor behavior and patient survival. 78 For these tumors, rCBV specifies regional tumor vascularity and correlates with expression of vascular endothelial growth factor, 2 critical factors driving tumor growth

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Nader Sanai, Susan Chang and Mitchel S. Berger

Among low-grade astrocytomas, measurement of relative cerebral blood volume (rCBV) derived from dynamic susceptibility-weighted perfusion contrast-enhanced MR imaging (DSC-MR imaging) correlates well with tumor behavior and patient survival. 78 For these tumors, rCBV specifies regional tumor vascularity and correlates with expression of vascular endothelial growth factor, 2 critical factors driving tumor growth. 84 Most low-grade astrocytomas demonstrate slightly higher rCBV than normal tissue (1.5), with an increase in rCBV (1.75–2.0) indicating the evolution of a

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Ian F. Dunn and E. Antonio Chiocca

our current attempts to decipher the response of atypical variants to postoperative radiation. While variability in patient selection may also be considered a weakness of the study, one may consider it a strength as well, because it likely simulates how radiation is incorporated into the management strategy of atypical meningiomas across many large-volume centers. 13 This factor certainly mirrors treatment selection at our center, where the decision to administer postoperative radiation is made on a case-by-case basis after discussions with a multidisciplinary

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Zaman Mirzadeh, Nader Sanai and Michael T. Lawton

mass, relatively small luminal volume of the ACoA aneurysm, and filling of the left pericallosal and callosomarginal arteries. B: Lateral view in the late arterial phase (left ICA injection) showing the separate origins of the PcaA and CmaA at the aneurysm base. C: An AP view (right ICA injection) demonstrating that the aneurysm did not fill from the right A 1 segment. The aneurysm was deemed unclippable. The azygos ACA bypass was performed, revascularizing the distal left PcaA and CmaA with the bypass, and the aneurysm was trapped ( Fig. 3 ). Postoperative