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Background Brain metastases (BM) frequently cause focal neurological deficits leading to a reduced Karnofsky performance score (KPS). Since KPS is routinely used to guide the choice of adjuvant therapy, we hypothesized that improving KPS by surgical resection may improve the chance for adjuvant treatment and ultimately result in better survival. We therefore analyzed the course of a large cohort undergoing resection of symptomatic brain metastases in the context of further treatment and clinical outcome. Patients and methods In a bi‐centric retrospective analysis we retrieved baseline, clinical, and treatment‐related parameters of patients operated on BM between 2010 and 2019. Survival was calculated using Kaplan‐Meier estimates; prognostic factors for survival were analyzed by Log‐rank test and Cox proportional hazards. Results We included 750 patients with a median age of 61 (19‐87) years. The functional status was significantly improved by surgical resection, with a median preoperative (KPS) of 80 (10‐100) increasing to 90 (0‐100) after surgery (P < .0001). Moreover, surgery improved the RTOG recursive partitioning analysis (RPA) class from III to I/II in 82 patients. Postoperative local radiotherapy and systemic treatment were associated with significantly longer survival (P < .0001 for each). Systemic treatment was provided significantly more frequently in patients with a fair postoperative clinical status (KPS ≥ 70; P < .0001). The postoperative clinical status, postoperative radiotherapy, systemic treatment, controlled systemic disease and < 4 BM were independent predictors for survival. Conclusion The resection of symptomatic BM may restore clinical status, so enhancing the likelihood of receiving adjuvant treatment, and therefore leading to improved overall survival. In patients with symptomatic brain metastases systemic oncological treatment is the strongest factor for further survival. Resection of a symptomatic brain metastasis results in an improved clinical status which facilitates further treatment.

Background Tractography has been used in various studies with respect to the improvement of patient-specific DBS targeting. Nevertheless, methodological influences of the chosen parameters and associated errors are often neglected. The aim of this study was to estimate concrete errors associated with specific image processing steps when using measurements of distances to specific subcortical fiber tracts to predict optimal stimulation sites for DBS targeting. Method Probabilistic tractography of the crossing and non-decussating part of the dentato-rubro-thalamic-tract (c-/ nd-DRTT) was performed using FSL 6.0.3 in 40 PD- and ET-patients having received bilateral DBS surgery. DBS-electrodes were reconstructed using LeadDBS. The influence of (1) the choice of threshold for binarization of fiber tracts, (2) manual measurements compared to measurements using automized distance maps and (3) normalization into the MNI standard space on measured distances were investigated. Results Different thresholds for binarization resulted in non-linear and unpredictable variations of measured distances up to 1.72 ± 1.49 mm (mean value ± standard deviation). Manual measurements on the axial slice of the electrode contact showed a mean error of 0.91 ± 1.36 mm (maximum 14.9 mm) compared to automated measurements. Regarding normalization, a mean error of 0.82 ± 0.50 mm (maximum 2.34 mm) was found compared to measurements in native space. Conclusion Measured maximum errors reach up to several millimeters, which might have significant impact on clinical targeting in DBS. Researchers should be aware of these errors and define individual standards for specific studies.

Background Patients with glioblastoma (GB) not only suffer from a life-threatening oncological disease but also present with severe neurological symptoms and high psychosocial distress. The unfavorable prognosis and the early decline in neurological functions and activities of daily living, such as mobility, lead to a significant deterioration in quality of life aspects. The need for palliative care (PC) therefore arises at an early stage and increases as the disease progresses but is often inadequately assessed and treated. Methods In this single-center, retrospective study, we investigated prognostic factors, survival outcomes and neuro-oncologically focused primary palliative care (nPPC) as well as specialized palliative care (SPC) interventions. Pearson’s Chi-square test and an univariable and multivariable binary logistic regression analysis were used to test the independence between categorical variables and the correlation between SPC and tumor-specific therapy prior to death. The Kaplan-Meier method and a multivariable Cox regression analysis were performed to estimate the impact of SPC on survival. Results A cohort of 274 patients with GB was investigated, of whom 251 (91.6%) received nPPC and 210 (76.6%) SPC. Patients with SPC ( p  < 0.001; OR: 0.302; 95% CI: 0.157–0.584) and patients with methylation of the MGMT promoter region ( p  = 0.005; OR: 0.375; 95% CI: 0.190–0.739) were less likely to receive a tumor-specific therapy in the 30 days prior to death. Median overall survival was 16.9 months (95% CI: 14.5–19.3 months) for patients with SPC ( n  = 210) vs. 12.9 months (95% CI: 10.8–15.1 months) for patients without ( n  = 64) ( p  = 0.100; not significant). The Cox proportional hazards model demonstrated that SPC significantly correlates with longer overall survival ( p  = 0.017; HR: 0.707; 95% CI: 0.532–0.939). Conclusion This study revealed a broad availability of PC interventions for patients with GB. After adjustment of known prognostic factors, an association between SPC supply and prolonged OS was observed. Utmost efforts should be made to incorporate PC into the care of every patient within a standardized framework. Data on PC in patients with GB is still rare; therefore, further research should be made to improve PC in this highly burdened patient group.

Background Thyrotropin-producing adenomas (TSHomas) account for approximately 1–2% of all pituitary tumors. Recently, there has been debate on primary treatment as some studies suggest a high rate of hypopituitarism after transsphenoidal surgery and therefore suggest primary use of somatostatin analogs (SSA) instead. We would like to challenge this assumption by presenting our single-center experience with transsphenoidal surgery for TSHoma. Methods Fifteen patients treated consecutively between May 2010 and December 2016 were analyzed for long-term postoperative remission and pituitary function. Results Data on the development of TSH, fT3 and fT4 were available for 12 of 15 patients (mean follow-up was 18 months, 8 patients >12 months), showing mean TSH levels of 1.289 mU/l (0.02–2.04, SD 0.66), mean fT3 levels of 3.76 pmol/l (0.5–6.16, SD 1.8) and mean fT4 levels of 16.5 pmol/l (11.7–21.9, SD 3.66). Six of those patients were substituted with a mean of 85.4 μg L-thyroxine after a median follow-up of 20.7 months. The other six patients did not receive L-thyroxine at a median follow-up of 15.5 months. One patient with a known tumor remnant on MRI stayed euthyreotic with cabergoline at the timepoint of follow-up 22 months after the operation. Control of the corticotrop axis was also available in 12 of 15 with no patient showing a corticotroph insufficiency in the long term. Conclusions We argue that transsphenoidal surgery for TSHoma should be considered as the treatment of choice as remission following surgery is highly probable and postoperative hypopituitarism is very unlikely if patients are referred to centers with high pituitary surgery case loads.

Background A widely accepted tool to assess hemodynamics, one of the most important factors in aneurysm pathophysiology, is Computational Fluid Dynamics (CFD). As current workflows are still time consuming and difficult to operate, CFD is not yet a standard tool in the clinical setting. There it could provide valuable information on aneurysm treatment, especially regarding local risks of rupture, which might help to optimize the individualized strategy of neurosurgical dissection during microsurgical aneurysm clipping. Method We established and validated a semi-automated workflow using 3D rotational angiographies of 24 intracranial aneurysms from patients having received aneurysm treatment at our centre. Reconstruction of vessel geometry and generation of volume meshes was performed using AMIRA 6.2.0 and ICEM 17.1. For solving ANSYS CFX was used. For validational checks, tests regarding the volumetric impact of smoothing operations, the impact of mesh sizes on the results (grid convergence), geometric mesh quality and time tests for the time needed to perform the workflow were conducted in subgroups. Results Most of the steps of the workflow were performed directly on the 3D images requiring no programming experience. The workflow led to final CFD results in a mean time of 22 min 51.4 s (95%-CI 20 min 51.562 s–24 min 51.238 s, n  = 5). Volume of the geometries after pre-processing was in mean 4.46% higher than before in the analysed subgroup (95%-CI 3.43–5.50%). Regarding mesh sizes, mean relative aberrations of 2.30% (95%-CI 1.51–3.09%) were found for surface meshes and between 1.40% (95%-CI 1.07–1.72%) and 2.61% (95%-CI 1.93–3.29%) for volume meshes. Acceptable geometric mesh quality of volume meshes was found. Conclusions We developed a semi-automated workflow for aneurysm CFD to benefit from hemodynamic data in the clinical setting. The ease of handling opens the workflow to clinicians untrained in programming. As previous studies have found that the distribution of hemodynamic parameters correlates with thin-walled aneurysm areas susceptible to rupture, these data might be beneficial for the operating neurosurgeon during aneurysm surgery, even in acute cases.

BackgroundGiant intracranial aneurysms of the posterior circulation (GPCirA) are rare entities compressing the brainstem and adjacent structures. Previous evidence has shown that the amount of brainstem shift away from the cranial base is not associated with neurological deficits. This raises the question whether other factors may be associated with neurological deficits.MethodsAll data were extracted from the Giant Intracranial Aneurysm Registry, an international multicenter prospective study on giant intracranial aneurysms. We grouped GPCirA according to the mass effect on the brainstem (lateral versus medial). Brainstem compression was evaluated with two indices: (a) brainstem compression ratio (BCR) or diameter of the compressed brainstem to the assumed normal diameter of the brainstem and (b) aneurysm to brainstem ratio (ABR) or diameter of the aneurysm to the diameter of the compressed brainstem. We examined associations between neurological deficits and GPCirA characteristics using binary regression analysis.ResultsTwenty-eight GPCirA were included. Twenty GPCirA showed medial (71.4%) and 8 lateral compression of the brainstem (28.6%). Baseline characteristics did not differ between the groups for patient age, aneurysm diameter, aneurysm volume, modified Rankin Scale (mRS), motor deficit (MD), or cranial nerve deficits (CND). Mean BCR was 53.0 in the medial and 54.0 in the lateral group (p = 0.92). The mean ABR was 2.9 in the medial and 2.3 in the lateral group (p = 0.96).In the entire cohort, neither BCR nor ABR nor GPCirA volumes were associated with the occurrence of CND or MD. In contrast, disability (mRS) was significantly associated with ABR (OR 1.94 (95% CI 1.01–3.70; p = 0.045) and GPCirA volumes (OR 1.21 (95% CI 1.01–1.44); p = 0.035), but not with BCR.ConclusionIn this cohort of patients with GPCirA, neither the degree of lateral projection nor the amount of brainstem compression predicted neurological deficits. Disability was associated only with aneurysm volume. When designing treatment strategies for GPCirA, aneurysm laterality or the amount of brainstem compression should be viewed as less relevant while the high risk of rupture of such giant lesions should be emphasized.Trial registrationThe registry is listed at clinicaltrials.gov under the registration no. NCT02066493.

In patients with brain metastases (BM), advanced age is considered a negative prognostic factor. To address the potential reasons for that, we assessed 807 patients who had undergone BM resection; 315 patients aged at least 65 years (group A) were compared with 492 younger patients (group B). We analyzed the impact of the pre- and postoperative Karnofsky performance status (KPS), postoperative treatment structure and post-treatment survival. BM resection significantly improved KPS scores in both groups (p = 0.0001). Median survival after BM resection differed significantly between the groups (A: 5.81 vs. B: 8.12 months; p = 0.0015). In both groups, patients who received postoperative systemic treatment showed significantly longer overall survival (p = 0.00001). However, elderly patients less frequently received systemic treatment (p = 0.0001) and the subgroup of elderly patients receiving such therapies had a significantly higher postsurgical KPS score (p = 0.0007). In all patients receiving systemic treatment, age was no longer a negative prognostic factor. Resection of BM improves the functional status of elderly patients, thus enhancing the likeliness to receive systemic treatment, which, in turn, leads to longer overall survival. In the context of such a treatment structure, age alone is no longer a prognostic factor for survival.

Background Current pathophysiological models of Parkinson’s disease (PD) assume a malfunctioning network being adjusted by the DBS signal. As various authors showed a main involvement of the cerebellum within this network, cerebello-cerebral fiber tracts are gaining special interest regarding the mediation of DBS effects. Objectives The crossing and non-decussating fibers of the dentato-rubro-thalamic tract (c-DRTT/nd-DRTT) and the subthalamo-ponto-cerebellar tract (SPCT) are thought to build up an integrated network enabling a bidimensional communication between the cerebellum and the basal ganglia. The aim of this study was to investigate the influence of these tracts on clinical control of Parkinsonian tremor evoked by DBS. Methods We analyzed 120 electrode contacts from a cohort of 14 patients with tremor-dominant or equivalence-type PD having received bilateral STN-DBS. Probabilistic tractography was performed to depict the c-DRTT, nd-DRTT, and SPCT. Distance maps were calculated for the tracts and correlated to clinical tremor control for each electrode pole. Results A significant difference between “effective” and “less-effective” contacts was only found for the c-DRTT ( p  = 0.039), but not for the SPCT, nor the nd-DRTT. In logistic and linear regressions, significant results were also found for the c-DRTT only ( p model logistic  = 0.035, p tract logistic  = 0,044; p linear  = 0.027). Conclusions We found a significant correlation between the distance of the DBS electrode pole to the c-DRTT and the clinical efficacy regarding tremor reduction. The c-DRTT might therefore play a major role in the mechanisms of alleviation of Parkinsonian tremor and could eventually serve as a possible DBS target for tremor-dominant PD in future.

Several research has underlined the multi-system character of COVID-19. Though effects on the Central Nervous System are mainly discussed as disease-specific affections due to the virus' neurotropism, no comprehensive disease model of COVID-19 exists on a neurofunctional base by now. We aimed to investigate neuroplastic grey- and white matter changes related to COVID-19 and to link these changes to neurocognitive testings leading towards a multi-dimensional disease model. Groups of acutely ill COVID-19 patients (n = 16), recovered COVID-19 patients (n = 21) and healthy controls (n = 13) were prospectively included into this study. MR-imaging included T1-weighted sequences for analysis of grey matter using voxel-based morphometry and diffusion-weighted sequences to investigate white matter tracts using probabilistic tractography. Comprehensive neurocognitive testing for verbal and non-verbal domains was performed. Alterations strongly focused on grey matter of the frontal-basal ganglia-thalamus network and temporal areas, as well as fiber tracts connecting these areas. In acute COVID-19 patients, a decline of grey matter volume was found with an accompanying diminution of white matter tracts. A decline in executive function and especially verbal fluency was found in acute patients, partially persisting in recovered. Changes in gray matter volume and white matter tracts included mainly areas involved in networks of executive control and language. Deeper understanding of these alterations is necessary especially with respect to long-term impairments, often referred to as 'Post-COVID'.

Purpose This study aimed to verify the feasibility, safety, and benefit of using fluorescein sodium (FL) and a YELLOW 560 nm filter in posterior fossa tumors in children. Methods All cases of pediatric posterior fossa tumors that have undergone surgery using fluorescein (2018–2022) have been included and were examined retrospectively. In those cases where resection of the tumor was planned, a blinded neuroradiologist distinguished gross total resection and subtotal resection according to the postoperative MRI findings. The surgical report and medical files were reviewed regarding the intraoperative staining grade and adverse events. The grade of fluorescent staining of the targeted lesion was assessed as described in the surgical reports. The screening was conducted for any reference to the degree of fluorescent staining: “intense,” “medium,” “slight,” and “no staining.” Results 19 cases have been included. In 14 cases, a complete resection was initially intended. In 11 of these cases, a gross total resection could be achieved (78.6%). Staining was described as intense in most cases (58.8%). Except for yellow-colored urine, no side effects obviously related to FL were found throughout the observation period. Conclusion In combination with a specific filter, FL is a reliable, safe, and feasible tool in posterior fossa surgery in children.