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Sarel J. Vorster and Gene H. Barnett

Although surgical resection of brain tumors has been performed for over a century, complications still occur with distressing frequency.

The authors propose a simple preoperative grading scheme to assess surgical risk for resection of primary and secondary intraaxial supratentorial brain tumors.

The authors retrospectively reviewed the clinical records, neuroimaging studies, and outcomes of 224 surgeries performed in 207 patients from January 1993 to December 1995 at the Cleveland Clinic Foundation Brain Tumor Center. Subsequently, they considered and statistically analyzed multiple variables related to the patients and their lesions. Surgical risk was defined as any complication occurring within 30 days postoperatively, and was divided into transient operative complications, transient medical complications, and new sustained neurological deficits. Length of stay was also recorded. The overall incidence of complications was 10.6% and the mortality rate was 2.7%, with a median hospital stay of 3 days. Patient age greater than 60 years (p < 0.001), preoperative Karnofsky Performance Scale scores of 50 or less (p < 0.03), previous irradiation (p < 0.001), tumor location in eloquent regions (p < 0.03), and depth of tumor invasion (p < 0.001) independently predicted complicated outcome or increased length of stay. Finally, the authors derived a simple five-tier grading scheme in which these patient risk factors are added together to obtain a grade of I to V that corresponds to outcome and length of hospital stay.

This grading scheme may be used to identify patients at higher risk and facilitate comparison of results between institutions and individual surgeons.

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John A. Anson and Robert F. Spetzler

. All patients underwent surgical resection of their lesions. Although complete resection was thought to have been achieved in all cases, one patient developed a recurrent cavernous malformation 21 months later. The recurrent lesion was removed and has not subsequently recurred during 4 years of follow-up monitoring. All patients had an excellent outcome after surgery; the symptoms completely resolved in two patients and were markedly reduced in four. The two most recent cases and the case with recurrence are described below. Illustrative Cases Case 1 This

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Frederick F. Lang, Nancy E. Olansen, Franco DeMonte, Ziya L. Gokaslan, Eric C. Holland, Christopher Kalhorn and Raymond Sawaya

the anterior insula during tumor surgery. Discussion Surgical resection of insular tumors remains a challenge. In a recently published pilot study, Ebeling and Kothbauer 3 concluded that the risk associated with operating on insular tumors outweighed the potential for radical resection and suggested that these tumors are best treated using biopsy and nonsurgical therapy. Although there is much debate about the role of radical resection in the treatment of gliomas, authors of several studies have suggested that aggressive surgery is important for their

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Jafar J. Jafar, Adam J. Davis, Alejandro Berenstein, In Sup Choi and Mark J. Kupersmith

T his study was undertaken to evaluate the usefulness of preoperative embolization in patients undergoing surgical resection of cerebral arteriovenous malformations (AVM's). The advent of microsurgical techniques has allowed neurosurgeons to undertake the resection of more formidable cerebrovascular malformations and has fostered the evolution of preoperative endovascular therapy. Endovascular embolization of cerebral AVM's is now an accepted adjunct to surgical therapy. However, the indications for endovascular therapy are still being clarified. The

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Friedrich W. Kreth, Peter C. Warnke, Rudolf Scheremet and Christoph B. Ostertag

) with those of surgical resection plus irradiation performed between 1986 and 1988 (resection group). Clinical Material and Methods The pathohistological diagnosis of glioblastoma was established using the criteria defined by Burger and colleagues. 4–7 The criteria for complete irradiation were: 1) beginning radiation therapy within 3 weeks after surgery; and 2) application of a conventionally fractionated radiation dose (1.7 to 2.0 Gy/day) to a total dose of 50 to 60 Gy. Therefore, in most cases whole-brain irradiation was combined with a tumor “boost.” There

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Eveline Teresa Hidalgo, Svetlana Kvint, Cordelia Orillac, Emily North, Yosef Dastagirzada, Jamie Chiapei Chang, Gifty Addae, Tara S. Jennings, Matija Snuderl and Jeffrey H. Wisoff

OBJECTIVE

The choice of treatment modality for optic pathway gliomas (OPGs) is controversial. Chemotherapy is widely regarded as first-line therapy; however, subtotal resections have been reported for decompression or salvage therapy as first- and second-line treatment. The goal of this study was to further investigate the role and efficacy of resection for OPGs.

METHODS

A retrospective chart review was performed on 83 children who underwent surgical treatment for OPGs between 1986 and 2014. Pathology was reviewed by a neuropathologist. Clinical outcomes, including progression-free survival (PFS), overall survival (OS), and complications, were analyzed.

RESULTS

The 5- and 10-year PFS rates were 55% and 46%, respectively. The 5- and 10-year OS rates were 87% and 78%, respectively. The median extent of resection was 80% (range 30%–98%). Age less than 2 years at surgery and pilomyxoid features of the tumor were found to be associated with significantly lower 5-year OS. No difference was seen in PFS or OS of children treated with surgery as a first-line treatment compared with children with surgery as a second- or third-line treatment. Severe complications included new disabling visual deficit in 5%, focal neurological deficit in 8%, and infection in 2%. New hormone deficiency occurred in 22% of the children.

CONCLUSIONS

Approximately half of all children experience a long-term benefit from resection both as primary treatment and as a second-line therapy after failure of primary treatment. Primary surgery does not appear to have a significant benefit for children younger than 2 years or tumors with pilomyxoid features. Given the risks associated with surgery, an interdisciplinary approach is needed to tailor the treatment plan to the individual characteristics of each child.

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Hiroki Morisako, Takeo Goto, Christian A. Bohoun, Hironori Arima, Tsutomu Ichinose and Kenji Ohata

Transcript 0:35 We report here our experiences in treating patients with pontine cavernous malformation via an anterior transpetrosal approach. 0:56 Surgical resection of pontine cavernous malformation remains a particularly formidable challenge in the neurosurgical field because of their deep-seated and eloquent locations. A small cortical incision with multidirectional dissection is the most important factor for minimizing postoperative neurological deficits. 0:56 Three entry zones can be used via an anterior transpetrosal approach to excise pontine lesions. On

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Narayan Sundaresan, Gerald Rosen, Joseph G. Fortner, Joseph M. Lane and Basil S. Hilaris

✓ Three patients with posterior paravertebral tumors are presented to illustrate the value of preoperative chemotherapy prior to surgical resection. All three had massive tumors adjacent to the spine, extending over several vertebral segments, with myelographic evidence of epidural involvement in one patient. Tissue diagnosis by incisional biopsy confirmed the diagnosis of extraosseous osteogenic sarcoma in one, extraosseous Ewing's sarcoma in the second, and embryonal rhabdomyosarcoma in the third. All patients were treated with chemotherapy preoperatively. Marked regression in tumor size was noted, and surgical excision of the tumor along with involved segments of spine was easily accomplished. Histological examination following surgery revealed completely necrotic tumor in two patients. Preoperative chemotherapy for fully malignant tumors offers the following advantages: 1) extremely bulky and otherwise unresectable tumors can be reduced in size to enable complete surgical resection; 2) systemic chemotherapy is instituted earlier in the course of disease to prevent more effectively the appearance of metastases; and 3) the information gained regarding the sensitivity of the tumor to a particular chemotherapy regimen allows postoperative adjuvant chemotherapy to be used on a more rational basis.

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Toru Iwama, Nobuo Hashimoto, Tatemi Todaka, Yoshikado Sasako, Syuji Inamori and Masakazu Kuro

L arge , high-flow arteriovenous malformations (AVMs) are among the most challenging lesions in neurological disorders. The key to successful surgical resection of AVMs is control of bleeding and cerebral swelling. 4, 10 To control intraoperative bleeding, surgical strategies, such as selection of the optimum operative approach and prior embolization, are as important as the surgical technique. 2, 8, 9, 11, 12 In addition, induced hypotension is one of the most valuable means of controlling bleeding and swelling. 10, 13 In patients who harbor large, high

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Laura Stewart, Paul Steinbok and Jorge Daaboul

techniques have made the resection of HHs a viable and relatively safe option to consider in the treatment of precocious puberty when such an associated hypothalamic lesion is present. 1 In this report, the current role of surgical resection of hypothalamic lesions for treatment of precocious puberty caused by HHs is reviewed in light of our long-term experience with two children treated with surgical resection and a somewhat shorter experience with four children treated only with GnRHas. Patients and Materials Six patients (five girls and one boy) who presented