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Wael Hassaneen, Nicholas B. Levine, Dima Suki, Abhijit L. Salaskar, Alessandra de Moura Lima, Ian E. McCutcheon, Sujit S. Prabhu, Frederick F. Lang, Franco DeMonte, Ganesh Rao, Jeffrey S. Weinberg, David M. Wildrick, Kenneth D. Aldape and Raymond Sawaya

association of the extent of resection and survival duration in patients with glioblastoma has been well described, 4 , 6 , 14 , 15 , 21 , 33 , 38 the role of surgical intervention in patients with multifocal or multicentric gliomas remains controversial. Some authors recommend aggressive surgical treatment, mostly resection of one tumor focus, 27 , 31 for longer and better survival, whereas others, such as Chadduck and colleagues, 7 believe that biopsy alone is preferable and can be followed by radio- and chemotherapy. The use of multiple craniotomies during a single

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Atom Sarkar and E. Antonio Chiocca

The submission, “Multiple craniotomies in the management of multifocal and multicentric glioblastoma” by Dr. Hassaneen and colleagues from The University of Texas M. D. Anderson Cancer Center 4 represents a unique contribution to the neurosurgical literature. To appreciate the authors' accomplishment, based on 2007–2008 Central Brain Tumor Registry of the United States report, an organization that gathers epidemiological data on primary brain tumors, 73,583 CNS neoplasms were tabulated. 2 Of that number, just a little over 20,000 lesions represented

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Rajesh K. Bindal, Raymond Sawaya, Milam E. Leavens and J. Jack Lee

death within 30 days, attributed to the infection. The two complications in Group C were both infections; there were no deaths within 30 days. Three complications were noted in patients undergoing multiple craniotomies: one pseudomeningocele and two hematomas; there were no deaths within 30 days among these patients. The median hospital stay after craniotomy for all 82 patients in this study was 3 days. TABLE 6 Complications and mortality related to patient group and multiple craniotomies * Category Group A Group B Group C

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Kevin A. Reinard, Hesham M. Zakaria, Ahmad Qatanani, Ian Y. Lee, Jack P. Rock and Herman P. Houin

satisfactory wound closure and cosmetic results ( Fig. 4 ). FIG. 4. Case 1. A 36-year-old female with recurrent glioma underwent multiple craniotomies and/or craniectomies, as well as EBRT, resulting in a large bony defect, scarring, and tissue retraction (A and B) . The DermaClose RC device was applied to the scalp outside the margins of the bony defect (C and D) . Postoperative images reveal good structural integrity and cosmetic results (E and F) . Figure is available in color online only. Case 2 A 63-year-old diabetic female with history of

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David H. Jho, Sergey Neckrysh, Julian Hardman, Fady T. Charbel and Sepideh Amin-Hanjani

flaps isodense with adjacent skull bone and a satisfactory contour. TABLE 2 Patients with bone flap infection following cranioplasty * Age (yrs), Sex Indication for Surgery Craniectomy Procedure Flap Preservation Interval (mos) Risk Factors Time to Removal of Infected Flap (mos) Culture Results 41, M blunt head trauma w/ SDH rt FTP w/ partial fronto-temporal lobectomy 11 preservation interval ≥10 mos 3 no growth 60, M ruptured dural AVF lt FTP w/ evacuation of ICH 0.5 multiple craniotomies 6

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Kingsley O. Abode-Iyamah, Hsiu-Yin Chiang, Nolan Winslow, Brian Park, Mario Zanaty, Brian J. Dlouhy, Oliver E. Flouty, Zachary D. Rasmussen, Loreen A. Herwaldt and Jeremy D. Greenlee

92 166 Patient factors  Age in yrs, mean 49.3 ± 16.1 48.5 ± 16.1 0.69 —  Male 59 (64.1) 100 (60.2) 0.54 1.18 (0.70–2.00)  Smoking history 43 (46.7) 75 (45.2) 0.81 1.06 (0.64–1.78)  Diabetes 13 (14.1) 13 (7.8) 0.11 1.94 (0.86–4.38)  BMI in kg/m 2   Median 26.7 36.2 0.50 —   Range 16.9–67.7 14.8–46.8  Multiple craniotomy procedures 13 (14.1) 25 (15.1) 0.84 0.93 (0.45–1.92)  Prior same-side craniotomy 13 (14.1) 23 (13.9) 0.95 1.02 (0.49–2.13)  Prior minor procedures 22 (23.9) 35 (21.1) 0.60 1.18 (0.64–2.16) Procedure factors  Indication for craniectomy   Hemorrhage 41

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Subdural sarcoma associated with chronic subdural hematoma

Report of two cases and review of the literature

Giuseppe Cinalli, Michel Zerah, Michel Carteret, François Doz, Laurent Vinikoff, Arielle Lellouch-Tubiana, Beatrice Husson and Alain Pierre-Kahn

✓ The authors report the cases of two children who presented in the first months of life with progressive macrocrania related to chronic pericerebral fluid collection. This condition resolved spontaneously without treatment after a few months in the first case, whereas it required several aspirations of blood-stained fluid via the fontanel in the second case. Both patients developed normally without evidence of disease in the earliest years of life and presented at the ages of 3 1/2 and 4 1/2 years, respectively, with symptoms and signs of rapidly progressing intracranial hypertension. In both cases contrast-enhanced computerized tomography and magnetic resonance imaging revealed masses in the subdural space of the skull base and the cranial vault associated with significant subdural fluid collections. In the first case the lesion was misdiagnosed in the initial phase and treated, by means of multiple craniotomies, as an organized subdural hematoma. After a diagnosis of liposarcoma had been made, the patient was treated with chemotherapy, which resulted in a good resolution of the lesions at 3-month follow-up review. In the second case a biopsy allowed the diagnosis of fibrohistiocytic sarcoma and the patient was treated with chemotherapy. The authors review the literature of the few reported cases and discuss the possible pathophysiological association between pericerebral fluid collection and the subsequent development of a subdural sarcoma.

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Robert J. Coffey, Terrence L. Cascino and Edward G. Shaw

✓ Hemangiopericytomas of the meninges, classified previously as angioblastic meningiomas, have a propensity to recur either locally or at distant sites within the nervous system after surgical resection. Visceral metastases also develop much more commonly in these lesions than in other types of histologically benign meningiomas. The radiosurgical gamma knife was used to treat five patients with 11 meningeal hemangiopericytomas (seven new, two recurrent, and two residual tumors) after surgical resection of an initially solitary intracranial lesion. Three patients had undergone multiple craniotomies and radiation therapy before referral, and two patients underwent a second radiosurgical procedure for lesions that appeared between 5 and 13 months after the first treatment session. Dramatic tumor shrinkage occurred in most patients within 6 to 10 months after treatment. The only treatment-related morbidity in this series was a partial visual-field defect in one patient with a large falx-tentorial junction hemangiopericytoma who had previously undergone radiation therapy. Radiosurgery appears to cause dramatic early shrinkage of small and medium-sized intracranial hemangiopericytomas that have recurred or developed after previous surgery and/or radiation therapy.

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Yuhao Huang, Derek Yecies, Lisa Bruckert, Jonathon J. Parker, Allen L. Ho, Lily H. Kim, Linden Fornoff, Max Wintermark, Brenda Porter, Kristen W. Yeom, Casey H. Halpern and Gerald A. Grant


Completion corpus callosotomy can offer further remission from disabling seizures when a prior partial corpus callosotomy has failed and residual callosal tissue is identified on imaging. Traditional microsurgical approaches to section residual fibers carry risks associated with multiple craniotomies and the proximity to the medially oriented motor cortices. Laser interstitial thermal therapy (LITT) represents a minimally invasive approach for the ablation of residual fibers following a prior partial corpus callosotomy. Here, the authors report clinical outcomes of 6 patients undergoing LITT for completion corpus callosotomy and characterize the radiological effects of ablation.


A retrospective clinical review was performed on a series of 6 patients who underwent LITT completion corpus callosotomy for medically intractable epilepsy at Stanford University Medical Center and Lucile Packard Children’s Hospital at Stanford between January 2015 and January 2018. Detailed structural and diffusion-weighted MR images were obtained prior to and at multiple time points after LITT. In 4 patients who underwent diffusion tensor imaging (DTI), streamline tractography was used to reconstruct and evaluate tract projections crossing the anterior (genu and rostrum) and posterior (splenium) parts of the corpus callosum. Multiple diffusion parameters were evaluated at baseline and at each follow-up.


Three pediatric (age 8–18 years) and 3 adult patients (age 30–40 years) who underwent completion corpus callosotomy by LITT were identified. Mean length of follow-up postoperatively was 21.2 (range 12–34) months. Two patients had residual splenium, rostrum, and genu of the corpus callosum, while 4 patients had residual splenium only. Postoperative complications included asymptomatic extension of ablation into the left thalamus and transient disconnection syndrome. Ablation of the targeted area was confirmed on immediate postoperative diffusion-weighted MRI in all patients. Engel class I–II outcomes were achieved in 3 adult patients, whereas all 3 pediatric patients had Engel class III–IV outcomes. Tractography in 2 adult and 2 pediatric patients revealed time-dependent reduction of fractional anisotropy after LITT.


LITT is a safe, minimally invasive approach for completion corpus callosotomy. Engel outcomes for completion corpus callosotomy by LITT were similar to reported outcomes of open completion callosotomy, with seizure reduction primarily observed in adult patients. Serial DTI can be used to assess the presence of tract projections over time but does not classify treatment responders or nonresponders.

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two metastatic tumors when they were in the same operative field but have never considered multiple craniotomies as described in their article. I have a question for the authors which I think is of considerable importance and could improve the information for other surgeons interested in this topic. It would appear from the paper that Group A patients (with one or more lesions left unresected after surgery) were operated on with the intent of removing all lesions, but this proved to be impossible. Group B appeared initially to include the same patients but were