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Jesse Jones and John Ruge

✓Pituitary macroadenomas most frequently present with visual loss. Although transsphenoidal surgery remains the treatment of choice for patients with neurological manifestations, there have been several advances in its implementation over the last 5 years. Intraoperative magnetic resonance (MR) imaging has emerged as a novel quality control measure, with the potential to guide the surgeon to tumor remnants concealed from the operating microscope. Investigators have reported enhanced resections when using intraoperative MR imaging, leading to complete tumor removal in a larger proportion of cases. Further debulking of unresectable lesions may also prove beneficial in delaying symptom recurrence and facilitating radiotherapy, where distance between the tumor and optic chiasm is an important predictor of visual outcome. However, confirmation of such advantages is complicated by the fact that most macroadenomas are both indolent and hormonally silent, necessitating years of follow-up. Experienced pituitary surgeons will operate as safely with intraoperative MR imaging as without it, perhaps due to a balance between more elaborate resections and better visualization. Intraoperative MR imaging represents a new technique applied to an old problem in tumor surgery: complete, safe resection.

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Jesse Jones, Alexander Lerner, Paul E. Kim, Meng Law, and Patrick C. Hsieh

Cervical spondylotic myelopathy due to ossification of the posterior longitudinal ligament (OPLL) is a common neurosurgical disease that carries high morbidity. OPLL and other degenerative processes cause narrowing of the central canal, with subsequent spinal cord injury. Repeated minor trauma and vascular aberrations have been purported to underlie cervical spondylotic myelopathy, although the exact pathophysiological mechanism is unclear. Regardless, detection of early axonal damage may allow more timely surgical intervention and prediction of functional outcome. Diffusion tensor (DT) imaging of the cervical spine is a novel technique with improved sensitivity compared with conventional anatomical MR imaging that is currently available on most clinical scanners. This review describes the theoretical basis, application, and analysis of DT imaging as it pertains to neurosurgery. Particular emphasis is placed on OPLL.

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Jesse Jones, Sunyoung Jang, Christopher C. Getch, Alan G. Kepka, and Maryanne H. Marymont

✓ Radiosurgery has proven useful in the treatment of small arteriovenous malformations (AVMs) of the brain. However, the volume of healthy tissue irradiated around large lesions is rather significant, necessitating reduced radiation doses to avoid complications. As a consequence, this can produce poorer obliteration rates. Several strategies have been developed in the past decade to circumvent dose–volume problems with large AVMs, including repeated treatments as well as dose, and volume fractionation schemes. Although success on par with that achieved in lesions smaller than 3 ml remains elusive, improvements over the obliteration rate, the complication rate or both have been reported after conventional single-dose stereotactic radiosurgery (SRS). Radiosurgery with a marginal dose or peripheral dose < 15 Gy rarely obliterates AVMs, yet most lesions diminish in size posttreatment. Higher doses may then be reapplied to any residual nidi after an appropriate follow-up period. Volume fractionation divides AVMs into smaller segments to be treated on separate occasions. Doses > 15 Gy irradiate target volumes of only 5–15 ml, thereby minimizing the radiation delivered to the surrounding brain tissue. Fewer adverse radiological effects with the use of fractionated radiosurgery over standard radiosurgery have been reported. Advances in AVM localization, dose delivery, and dosimetry have revived interest in hypofractionated SRS. Investigators dispensing ≥ 7 Gy per fraction minimum doses have achieved occlusion with an acceptable number of complications in 53–70% of patients. The extended latency period between treatment and occlusion, about 5 years for emerging techniques (such as salvage, staged volume, and hypofractionated radiotherapy), exposes the patient to the risk of hemorrhage during that period. Nevertheless, improvements in dose planning and target delineation will continue to improve the prognosis in patients harboring inoperable AVMs.