OBJECTIVE: Deep-seated supratentorial tumors require surgical corridors that risk injury to eloquent white matter pathways. Tubular retractors may mitigate retraction-related injury, and patient-specific connectome mapping may further inform trajectory selection. We evaluated the feasibility of integrating connectome-based planning with tubular retractor surgery and explored associated clinical and tract asymmetry outcomes in a matched cohort. METHODS: We performed a single-center retrospective review of adult patients undergoing connectome-guided resection of deep-seated supratentorial tumors using tubular retractors and compared outcomes to manually matched controls undergoing resection with standard retraction techniques. Functional outcomes included Karnofsky Performance Status (KPS) and new postoperative neurologic deficits. In patients with available quantitative tractometry, pre- and postoperative fractional anisotropy (FA) derived values and associated asymmetry indices were assessed for six major white matter tracts. RESULTS: Twenty-three patients met inclusion criteria (tubular: n = 7 tubular; controls: n = 16). Median preoperative KPS was 90 in both groups. One tubular retractor patient developed a new postoperative neurologic deficit at first follow-up, compared with 11 controls (p = 0.027). Gross total resection rates were not significantly different (tubular: 57.1% vs. controls: 37.5%; p = 0.650). Quantitative tractometry was available in 5 patients. In this exploratory subset, controls with left-sided lesions demonstrated postoperative shifts in tract asymmetry toward relative right hemispheric dominance, most prominently in association pathways including the arcuate fasciculus and superior longitudinal fasciculus. Tubular retractor cases with left-sided lesions showed smaller postoperative changes in tract asymmetry. CONCLUSIONS: Integrating patient-specific connectome mapping into tubular retractor workflows is feasible in routine practice. In this small retrospective cohort, tubular retractor cases were associated with fewer new postoperative neurologic deficits, with exploratory tractometry suggesting smaller postoperative shifts in tract asymmetry among left-sided lesions. Larger prospective studies incorporating standardized neurocognitive outcomes and systematic perioperative imaging are needed to validate clinical benefit and clarify the relationship between tract asymmetry metrics and functional recovery.

Metabolic rewiring fuels tumorigenicity of cancer stem cells contributing to universal glioblastoma (GBM) recurrence. Invasive glioblastoma stem cells (GSCs), already unresectable, acquire tumorigenic properties that confer therapy resistance. Using samples from both recurrent and newly diagnosed GBM patients, we identified fatty acid oxidation (FAO) as a key pathway supporting GSC tumorigenicity. Transcriptomic profiling, compared against non-malignant human astrocytes from epilepsy patients, highlighted an FAO-enriched signature in GSCs. In vivo studies showed that tumor formation by these GSCs could be modulated by altering the availability of metabolizable lipids in the brain, with beneficial effects observed under a low carbohydrate high fat diet (LCHFD). The lipid metabolism contributing to GSC mediated tumor formation was confirmed using metabolomic and lipidomic analyses. Gut microbiome analyses revealed that LCHFD shapes the microbiome and modulates the circadian network. By targeting FAO in the postoperative period before chemoradiation, LCHFD offers a non-pharmacologic strategy to delay GBM recurrence. This study suggests a mechanistic framework for dietary modulation as a therapeutic approach to improve GBM outcomes. Low carbohydrate high fat diet restricts lipid availability and limits metabolic capabilities of glioblastoma stem cells to inhibit their contribution towards tumor recurrence.

BACKGROUND:Hypofractionated stereotactic radiosurgery (HF-SRS) has become a mainstay of treatment for patients with brain metastases (BM). However, HF-SRS schedules involving 3-5 fractions may not align with conventional 5-day clinical workflows due to interruptions over weekends or holidays. We seek to compare the rate of local failure (LF) and radiation necrosis (RN) in patients using HF-SRS for BM, treated on consecutive or non-consecutive days. METHODS:A retrospective review from 2018 to 2023 identified adult patients who underwent HF-SRS for lung and breast cancer BM with more than 3 months of radiological imaging follow-up at a single center. Demographic data, tumor and treatment characteristics including biologically equivalent dose with α/β of 10 (BED10), and imaging-based progression outcomes were collected; LF and RN were assessed via log-rank test. RESULTS:Of the 197 included lesions from 76 patients, 84 (42.6%) experienced interruptions (median: 3.0 days) in HF-SRS treatment. There were 49 (64.5%) lung and 27 (35.5%) breast cancer patients. Between consecutive and non-consecutively treated groups, the median radiological follow-up was 11 versus 14.5 months (p = 0.42), mean gross tumor volume (GTV) was 1.6 versus 2.8 cc (p = 0.30), and mean BED10 was 51.3 versus 51.3 Gy (p = 0.34). There was no significant difference between the interrupted and non-interrupted subgroups for the probability of LF (p = 0.620) nor probability of RN (p = 0.717). BED10 was inversely associated with LF on univariable (p = 0.005) and multivariable analysis (p = 0.003). GTV trended towards increased risk of RN on univariable analysis (p = 0.08). Sub-group analysis did not demonstrate an effect of treatment interruption on LF or RN in surgically resected lesions (p = 0.721, p = 0.509) or lesions treated with SRS only (p = 0.436, p = 0.790). CONCLUSIONS:Despite potential differences in radiobiological parameters, there was no significant difference in LF or RN in patients with BM from lung or breast carcinoma treated with consecutive versus nonconsecutive HF-SRS. Brief interruptions do not appear to need avoidance in patients undergoing HF-SRS when necessitated by workplace factors.

Brain and spine metastases are a major cause of morbidity and mortality in patients with malignancy. Aside from advancements in medical, surgical, and radiation therapies, patient workflow optimization augments care. Here, we present the first systematic review to identify opportunities in workflow optimization and use these findings to present guidelines for operational excellence. PubMed/MEDLINE, Embase, and Web of Science databases were searched for peer-reviewed studies evaluating optimization points within treatment workflows for brain and spinal metastases. Inclusion criteria encompassed rapid diagnostic models, expedited care pathways, and quality improvement interventions for metastatic disease, whereas non-English and case reports were excluded. Eligible studies were screened, and data such as study design, outcomes, and bias were recorded using Cochrane’s RoB-1 analysis. This protocol was prospectively registered in PROSPERO (CRD420251016218). 30 studies were included, with a total of 23,697 patient participants. These studies focused on patient education, referral to surgery, referral from surgery to radiation oncology, and referral from surgery to medical oncology. These studies highlighted the benefits of expediting triaging, referral speed, and treatment initiation in the context of valuable resources such as a comprehensive clinical team and artificial intelligence in radiology and cytopathology. Optimizing workflows around the current literature for metastatic brain and spine disease identifies critical areas of improvement to enhance outcomes. We draw from this literature to propose guidelines for delivering a comprehensive and standardized patient workflow. Future studies targeting these salient points will further improve quality and advance patient care.

Deep-seated tumors present a significant surgical challenge due to the risk of damaging critical brain networks. Minimally invasive approaches using tubular retractors aim to reduce collateral damage by displacing rather than transecting tissue. Connectomic-guided surgical planning has the potential to optimize these approaches by preserving critical fiber tracts and improving functional outcomes. To evaluate this potential, we investigated the impact of minimally invasive tubular retractor-assisted tumor resections on structural network integrity and clinical outcomes, using individualized, AI-powered connectomic analysis. We retrospectively reviewed patients who underwent minimally invasive tumor resection using tubular access, with pre- and postoperative connectomic assessment performed via Quicktome v2.1.0 and Cleartome when available. The platform reparcellates HCP-MMP templates to reflect patient-specific connectivity and identify at-risk regions. Tractometry included Asymmetry Index (AI), and percent asymmetry (%Asym) for key tracts: CST, AF, ILF, IFOF, SLF, and UF. Functional outcomes were measured using Karnofsky Performance Status (KPS) scores and compared to matched controls undergoing conventional resections without tubular access. Seven patients (mean age 61.3 years; 3M/4F) were included, most with left-hemispheric tumors (n=5), including high-grade gliomas and one metastasis. Functional independence was preserved across the cohort (median KPS: 90 both pre- and postoperatively). In a tractometry subcohort (n=4), postoperative AI and %Asym values showed favorable trends, particularly in the uncinate fasciculus and IFOF, suggesting relative preservation or rebalancing of ventral semantic pathways. These improvements were more favorable than in matched controls, though statistical power was limited by sample size. Minimally invasive, tubular retractor-assisted resections guided by individualized connectomic analysis appear to preserve functional status and support postoperative structural network integrity. AI-powered tractometry highlights potential preservation or adaptive reorganization of language-associated tracts, underscoring the importance of personalized connectomic planning in deep tumor surgery.

Contemporary brain tumor surgery increasingly prioritizes a network-based view of cerebral function, shifting from localizationist models toward a meta-network framework that recognizes the brain as an interconnected system. We hypothesize that tumor resection can improve global network organization by alleviating peritumoral hyperexcitability and microenvironmental disruption. Within this framework, structural and functional connectomics provide a promising framework for surgical planning and postoperative assessment. To assess the feasibility of incorporating AI-based connectomic software into clinical workflows and to quantitatively assess changes in large-scale brain network connectivity following tumor resection. We retrospectively analyzed all patients undergoing brain tumor surgery with preoperative connectome imaging processed via Quicktome v2.1.0. Demographic, tumor, and cognitive data were collected. A subcohort of patients with both pre- and postoperative connectome imaging—without intervening adjuvant therapy—was analyzed to assess structural connectomic changes. Quantitative metrics included fractional anisotropy (FA), asymmetry index (AI), and percentage asymmetry (%Asym) across key white matter tracts, including the CST, AF, ILF, IFOF, UF, and SLF. Special focus was placed on the dorsal and ventral semantic pathways due to their relevance in language and executive functions. The full cohort included 200 patients (mean age 57.8 ± 16.0 years), 85.5% with intra-axial tumors, predominantly left-sided (53.4%) and medial (60.1%). Of the 113 gliomas, 64.6% were WHO grade 4. In the quantitative subcohort (n=19), tumor resection resulted in measurable improvements in network asymmetry and FA, particularly in the ventral semantic pathway (IFOF and ILF). These changes were most prominent in left-hemispheric tumors patients. Functional outcomes were preserved, with a median postoperative KPS of 80, and 64.5% of patients discharged home. AI-guided connectomics can be feasibly integrated into clinical workflows and may offer quantitative insight into postoperative network reorganization. Improvements in tract-level symmetry and FA—especially in ventral semantic pathways—suggest potential for not only preserving but enhancing global network integrity. This approach supports a personalized, connectome-informed definition of eloquence, advancing the principles of cognitive-preserving neurosurgery.

Maximal tumor resection with neurological preservation is central to brain tumor surgery. This study evaluates the integration of an artificial intelligence-based connectomics platform for surgical planning, with exploratory tractometry analysis of postoperative white matter changes. We retrospectively reviewed 192 consecutive brain tumor surgeries performed between April 2023 and April 2025 using preoperative connectomic mapping (Quicktome, Omniscient Neurotechnology). Functional outcomes were assessed with Karnofsky Performance Status (KPS). In an opportunistic subgroup (n = 13), paired pre- and postoperative imaging enabled tractometry (Cleartome). Fractional anisotropy (FA) was measured across six major tracts, and three hemispheric FA asymmetry indices were calculated: difference in average FA (Diff FA), asymmetry index (AI), and percentage asymmetry (

OBJECTIVE:Intraoperative confocal laser endomicroscopy (CLE) offers neurosurgeons a real-time, high-resolution imaging tool to differentiate tumor tissue from normal brain parenchyma during brain tumor resection. This study aims to evaluate the feasibility of incorporating CLE into the routine workflow of brain tumor surgeries. METHODS:A prospective study was conducted to evaluate the integration of CLE in brain tumor surgeries. In all cases, the CLE probe (CONVIVO, Carl Zeiss Meditec AG) was introduced into the surgical field to acquire images at various stages of resection. This was followed by a real-time neuropathology assessment of tissue characteristics using a telepathology software platform (TSP; Zeiss CONVIVO In Vivo Pathology Suite, Carl Zeiss Meditec AG). CLE/TSP was employed in conjunction with the planned surgical technique and tools. RESULTS:The CLE system was used as a co-diagnostic tool in seven consecutive cases at our institution. Recurrent glioblastoma was the most common histopathological diagnosis. Two cases were performed using minimally invasive approaches: one via an endoscopic transsphenoidal route for a sellar lesion, and another with a tubular retractor for a periventricular WHO grade 4 glioblastoma. Intraoperative ultrasound was employed in all transcranial cases. The surgical microscope was used in four procedures, the exoscope in two, and 5-ALA fluorescence-guided resection was combined with CLE in two cases. No modifications were required to the planned surgical workflow in any of the cases, and integration of CLE technology alongside standard operating procedures and tools was seamless. CONCLUSION:CLE can be successfully integrated into the standard neurosurgical workflow for patients with brain tumors without the need for major procedural modifications, including in microscopic, endoscopic, and minimally invasive tubular approaches. With its seamless integration, CLE holds potential to improve surgical precision, enhance intraoperative decision-making, and contribute to better surgical outcomes.

- BACKGROUND: Giant falcine meningiomas are surgically complex as they are deep in location, concealed by normal brain parenchyma, in close proximity to various neurovascular structures, and frequently involve the falx bilaterally. Although classically accessed using a bifrontal craniotomy and interhemispheric approach, little data exist on alternative operative corridors for these challenging tumors. We evaluated perioperative and long-term outcomes in patients undergoing transcortical resection of giant bilateral falcine meningiomas. - METHODS: From 2013 to 2022, fourteen patients with giant bilateral falcine meningiomas treated via a transcortical approach at our institution were identified. Perioperative and long-term outcomes were evaluated to determine predictors of adverse events. Corticectomy depth was also analyzed to determine if it correlated with increased postoperative seizure rates. - RESULTS: 57.1% of cases were WHO grade 2 meningiomas. Average tumor volume was 77.8 +/- 46.5 cm3 and near/ gross total resection was achieved in 78.6% of patients. No patient developed a venous infarct or had seizures in the 6 months after surgery. Average corticectomy depth was 0.83 +/- 0.71 cm and increasing corticectomy depth did not correlate with higher risk of postoperative seizures (P = 0.44). Increasing extent of tumor resection correlated with lower tumor grade (P = 0.011) and only 1 patient required repeat resection during a median follow -period of 24.9 months. - CONCLUSIONS: The transcortical approach is a safe alternative corridor for accessing giant, falcine meningiomas, and postoperative seizures were not found to correlate with increasing corticectomy depth. Further prospective studies are necessary to determine the best approach to these surgically complex lesions.

OBJECTIVE:As the coronavirus disease 2019 (COVID-19) pandemic spread to the United States in 2020, there was an impetus toward postponing or ceasing nonurgent transsphenoidal pituitary surgeries to prevent the spread of the virus. Some centers encouraged transcranial approaches for patients with declining neurologic function. However, no large-scale data exist evaluating the effects that this situation had on national pituitary practice patterns. METHODS:Pituitary surgeries in the National Inpatient Sample were identified from 2017 to 2020. Surgeries in 2020 were compared with the 3 years previously to determine any differences in demographics, surgical trends/approaches, and perioperative outcomes. RESULTS:In 2020, there was a decline in overall pituitary surgeries (34.2 vs. 36.3%; odds ratio (OR), 0.88; P < 0.001) yet transsphenoidal approaches represented a higher proportion of interventions (69.0 vs. 64.9%; P < 0.001). Neurosurgical complications were higher (51.9 vs. 47.4%; OR, 1.13; P < 0.001) and patients were less likely to be discharged home (86.4 vs. 88.5%; OR, 0.84; P < 0.001). This finding was especially true in April 2020 during the first peak in COVID-19 cases, when transcranial approaches and odds of mortality/complications were highest. CONCLUSIONS:In 2020, transsphenoidal surgery remained the preferred approach for pituitary tumor resection despite initial recommendations against the approach to prevent COVID-19 spread. Pituitary surgeries had a higher risk of periprocedural complications despite accounting for preoperative comorbidities, COVID-19 infection status, and surgical approach, suggesting that an overwhelmed hospital system can negatively influence surgical outcomes in noninfected patients.

Abstract BACKGROUND Low-grade IDH-mutant astrocytomas are rare primary brain tumors that typically affect young adults and slowly progress to more aggressive lesions when untreated. Since lengthy follow-up is required to identify high-risk subgroups and useful therapeutic strategies, consensus recommendations after maximal safe resection are still based on low-level evidence and remain unclear. METHODS Retrospective chart review of all adult patients with a pathological diagnosis of low-grade (grade 2) IDH-mutant astrocytoma from 2013–2023 at a multi-site tertiary care center was performed. Cases without confirmatory IDH-mutation testing or at least 6-month follow-up imaging were excluded. RESULTS A total of 32 patients were included with a mean age of 35.6 years (range: 18–69) and 15 (46.9%) females. Mean follow-up was 40.3 months (range: 8.1–120.7). Preoperative average maximal tumor diameter was 4.1cm (range: 1.4–7cm) with 18 (56.3%) cases involving eloquent cortex. Gross total resection (GTR) was achieved in 12 (37.5%) cases. Observation was the most prevalent postoperative management strategy (n=21, 65.6%), followed by temozolomide-based chemoradiation (n=5, 15.6%), temozolomide alone (n=2, 6.3%), PCV (n=2, 6.3%), radiation alone (n=1, 3.1%), and carboplatin (n=1, 3.1%). Progression of disease (POD) was eventually seen in 17 (53.1%) cases with a median progression-free survival (PFS) of 41.9 months. While GTR was protective against POD (OR:0.14, p=0.019*), initial postoperative management with adjuvant chemotherapy and/or radiation was not (OR:1.09, p=0.907). Additionally, seizures during the follow-up period were significantly associated with POD and a reduced PFS (median 32.5 versus 71.7 months, HR:3.88, p=0.013*). There were no differences in EOR or tumor localization between patients who did and did not have seizures during follow-up. CONCLUSIONS Although limited by sample size, this 10-year series confirms the importance of maximizing EOR for low-grade IDH-mutant astrocytoma and suggests that seizures during follow-up can identify high-risk cases that may benefit from more aggressive treatment.

BACKGROUND:Postoperative hemiparesis following frontal lobe lesion resection is alarming, and predicting motor function recovery is challenging. Supplementary motor area (SMA) syndrome following resection of frontal lobe lesions is often indistinguishable from postoperative motor deficit due to surgical injury of motor tracts. We aimed to describe the use of intraoperative transcranial electrical stimulation (TES) with motor evoked potential monitoring data as a diagnostic tool to distinguish between SMA syndrome and permanent motor deficit (PMD). METHODS:A retrospective analysis of 235 patients undergoing craniotomy and resection with TES-MEP monitoring for a frontal lobe lesion was performed. Patients who developed immediate postoperative motor deficit were included. Motor deficit and TES-MEP findings were categorized by muscle group as left upper extremity, left lower extremity, right upper extremity, or right lower extremity. Statistical analysis was performed to determine the predictive value of stable TES-MEP for SMA syndrome versus PMD. RESULTS:This study included 20 patients comprising 29 cases of immediate postoperative motor deficit by muscle group. Of these, 27 cases resolved and were diagnosed as SMA syndrome, and 2 cases progressed to PMD. TES-MEP stability was significantly associated with diagnosis of SMA syndrome (P = 0.015). TES-MEP showed excellent diagnostic utility with a sensitivity and positive predictive value of 100% and 92.6%, respectively. Negative predictive value was 100%. CONCLUSIONS:Temporary SMA syndrome is difficult to distinguish from PMD immediately postoperatively. TES-MEP may be a useful intraoperative adjunct that may aid in distinguishing SMA syndrome from PMD secondary to surgical injury.

As the COVID-19 pandemic spread to the United States in 2020, there was an impetus towards postponing or ceasing non-urgent transsphenoidal pituitary surgeries to prevent spread of the virus. Some centers encouraged transcranial approaches for patients with declining neurologic function. However, no large-scale data exists evaluating the effects this had on national pituitary practice patterns. Pituitary surgeries in the National Inpatient Sample were identified from 2017-2020. Surgeries in 2020 were compared to the three years prior to determine any differences in demographics, surgical trends/approaches and perioperative outcomes. In 2020, there was a decline in overall pituitary surgeries (34.2 vs. 36.3%, odds ratio (OR) 0.88, p<0.001) yet transsphenoidal approaches represented a higher proportion of interventions (69.0 vs. 64.9%, p<0.001). Neurosurgical complications were higher (51.9 vs. 47.4%, OR 1.13, p<0.001) and patients were less likely to be discharged home (86.4 vs. 88.5%, OR 0.84, p<0.001). This was especially true in April 2020 during the first peak in COVID-19 cases when transcranial approaches and odds of mortality/complications were highest. In 2020, transsphenoidal surgery remained the preferred approach for pituitary tumor resection despite initial recommendations against the approach to prevent COVID-19 spread. Pituitary surgeries had a higher risk of periprocedural complications despite accounting for preoperative comorbidities, COVID-19 infection status, and surgical approach, suggesting that an overwhelmed hospital system can negatively influence surgical outcomes in non-infected patients.

BACKGROUND:Craniopharyngiomas are benign tumors of the anterior skull base arising from epithelial remnants of Rathke pouch. They mainly occur in the suprasellar space, can be incredibly debilitating, and remain difficult to resect as they frequently involve critical neurovascular structures. Although it is embryologically possible for craniopharyngiomas to arise extracranially along the entire migrational path of Rathke pouch, these remain exceedingly rare, especially among adults, and can be mistaken for nasopharyngeal cancer. As such, minimal data exist evaluating the management and outcomes of such lesions. We evaluated our institutional experience with purely infrasellar nasopharyngeal craniopharyngiomas and obtained individual patient data reported in the contemporary literature to better characterize the demographics, presentation, surgical management, and long-term outcomes of these lesions. METHODS:A systematic review of the literature was performed to identify previously published cases of purely infrasellar nasopharyngeal craniopharyngioma in 3 electronic databases: MEDLINE (PubMed), Embase, and Scopus. Search terms were "infrasellar craniopharyngioma" and "nasopharyngeal craniopharyngioma." RESULTS:We identified 25 cases, in which 72% of patients presented with symptoms of nasal obstruction, epistaxis, or headache. An endoscopic approach was performed in 40% of cases; 83.3% of all patients had gross total resection, with 60% having no recurrence at a median follow-up of 13 months. No postoperative complications were reported. Tumor location involving the cavernous sinus was associated with incomplete resection (100%) compared with tumors not involving the cavernous sinus (87%) (P = 0.033). CONCLUSIONS:While uncommon, infrasellar nasopharyngeal craniopharyngiomas appear to have better perioperative and long-term surgical outcomes than their suprasellar counterparts.

Background Cavernous sinus cavernous malformations (CSCMs) is a vascular malformation of the cavernous sinus. Nowadays, there is an increasing preference to withhold using the terms cavernoma or cavernous hemangioma in order to stop considering these lesions as vascular neoplasms. These lesions are highly vascularized making surgical resection a challenge, mainly in endoscopic approaches. We present a case of this tumor treated in our institution with an endoscopic endonasal approach and incomplete resection. Because of the strenuous resection through this approach, we systematically reviewed the reported endoscopic cases of CSCMs to determine their intraoperative complications, results and tumor features. Methods Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, one database (PubMed) and crossed references were queried for CSCMs from 1948 to 2020. Data regarding demographic features, clinical presentation, MRI features, surgical results and overall pathology features extracted. Results Eighteen patients were selected (including our case). The mean age was 50.4 +/- 14 years. Pituitary dysfunction and cavernous sinus nerve compression were the most reported symptoms. Only five cases (27%) reported a gross total resection (GTR) through endoscopic endonasal approach. Intraoperative bleeding was the most frequent intraoperative complication. Conclusion We present a comprehensive analysis of every reported CSCM treated through endoscopic approach. Partial or subtotal resection are the most used techniques because of the intraoperative bleeding and the adherence to surrounding structures. Radiotherapy is a very good option for patients with incomplete resections.

OBJECTIVE:Increasing centralization of high-level neurosurgical practice at academic centers has increased the need for academic neurosurgeons. The lack of systematic metrics-based analyses among neurosurgery trainees and the recent pass/fail U.S. Medical Licensing Examination system necessitates a multiparametric approach to assess academic success among trainees. METHODS:We conducted a comprehensive analysis of the University of Miami residency program using 2 data sets, one containing applicants' pre-residency metrics and a second containing trainees' intra-residency metrics. Intra-residency metrics were subjectively and anonymously assessed by faculty. Univariate and multivariate logistic regression analyses were performed to determine differences among academic and non-academic neurosurgeons and identify predictors of academic careers. RESULTS:Academic neurosurgeons had a significantly higher median Step 1 percentile relative to non-academic neurosurgeons (P = 0.015), and medical school ranking had no significant impact on career (P > 0.05). Among intra-residency metrics, academic neurosurgeons demonstrated higher mean rating of leadership skills (mean difference [MD] 0.46, P = 0.0011), technical skill (MD 0.42, P = 0.006), and other intra-residency metrics. Higher administrative and leadership skills were significantly associated with increased likelihood of pursuing an academic career (odds ratio [OR] 9.03, 95% CI [2.296 to 49.88], P = 0.0044). Clinical judgment and clinical knowledge were strongly associated with pursuit of an academic career (OR 9.33 and OR 9.32, respectively, with P = 0.0060 and P = 0.0010, respectively). CONCLUSIONS:Pre-residency metrics had little predictive value in determining academic careers. Furthermore, medical school ranking does not play a significant role in determining a career in academic neurosurgery. Intra-residency judgment appears to play a significant role in career placement, as academic neurosurgeons were rated consistently higher than their non-academic peers in multiple key parameters by their attending physicians.

OBJECTIVE The authors aimed to review the frontal lobe’s surgical anatomy, describe their keyhole frontal lobectomy technique, and analyze the surgical results. METHODS Patients with newly diagnosed frontal gliomas treated using a keyhole approach with supramaximal resection (SMR) from 2016 to 2022 were retrospectively reviewed. Surgeries were performed on patients asleep and awake. A human donor head was dissected to demonstrate the surgical anatomy. Kaplan-Meier curves were used for survival analysis. RESULTS Of the 790 craniotomies performed during the study period, those in 47 patients met our inclusion criteria. The minimally invasive approach involved four steps: 1) debulking the frontal pole; 2) subpial dissection identifying the sphenoid ridge, olfactory nerve, and optic nerve; 3) medial dissection to expose the falx cerebri and interhemispheric structures; and 4) posterior dissection guided by motor mapping, avoiding crossing the inferior plane defined by the corpus callosum. A fifth step could be added for nondominant lesions by resecting the inferior frontal gyrus. Perioperative complications were recorded in 5 cases (10.6%). The average hospital length of stay was 3.3 days. High-grade gliomas had a median progression-free survival of 14.8 months and overall survival of 23.9 months. CONCLUSIONS Keyhole approaches enabled successful SMR of frontal gliomas without added risks. Robust anatomical knowledge and meticulous surgical technique are paramount for obtaining successful resections.

CD97, an adhesion G-protein coupled receptor highly expressed in glioblastoma (GBM), consists of two noncovalently bound domains: the N-terminal fragment (NTF) and C-terminal fragment. The C-terminal fragment contains a GPCR domain that couples to Gα12/13, while the NTF interacts with extracellular matrix components and other receptors. We investigated the effects of changing CD97 levels and its function on primary patient-derived GBM stem cells (pdGSCs) in vitro and in vivo. We created two functional mutants: a constitutively active ΔNTF and the noncleavable dominant-negative H436A mutant. The CD97 knockdown in pdGSCs decreased, while overexpression of CD97 increased tumor size. Unlike other constructs, the ΔNTF mutant promoted tumor cell proliferation, but the tumors were comparable in size to those with CD97 overexpression. As expected, the GBM tumors overexpressing CD97 were very invasive, but surprisingly, the knockdown did not inhibit invasiveness and even induced it in noninvasive U87 tumors. Importantly, our results indicate that NTF was present in the tumor core cells but absent in the pdGSCs invading the brain. Furthermore, the expression of noncleavable H436A mutant led to large tumors that invade by sending massive protrusions, but the invasion of individual tumor cells was substantially reduced. These data suggest that NTF association with CD97 GPCR domain inhibits individual cell dissemination but not overall tumor invasion. However, NTF dissociation facilitates pdGSCs brain infiltration and may promote tumor proliferation. Thus, the interplay between two functional domains regulates CD97 activity resulting in either enhanced cell adhesion or stimulation of tumor cell invasion and proliferation.

Background and purpose The goal of this study was to systematically review the metabolic profile of meningiomas using magnetic resonance spectroscopy in comparison to gliomas, as measured by mean metabolite ratios. Methods Following the PRISMA guidelines, a systematic literature review was performed using the PubMed, Ovid Embase, Web of Science, and the Cochrane databases from inception to May 2021. Studies were selected based on predetermined inclusion and exclusion criteria. Results Eight studies were ultimately selected with 207 patients included. Fifty-nine patients were diagnosed with meningioma (age = 48.4, 66.7% female) and 148 patients diagnosed with glioma (age = 56.4, 49.2% female). Three studies reported elevated Cho/Cr in meningiomas compared to gliomas (5.71 vs. 1.46, p < 0.05, 7.02 vs. 2.62, p < 0.05, and 4.64 vs. 2.52, p = 0.001). One study reported Ala/Cr to be significantly elevated in meningiomas compared to gliomas (1.30 vs. undetectable, p < 0.001). One study reported myo-Inositol/Cr to be significantly elevated in meningiomas in comparison to gliomas (1.44 vs. 1.08, p < 0.05). One study reported Glu/Cr to be significantly elevated in meningiomas in comparison to gliomas (3.47 vs. 0.89, p = 0.002). Two studies reported Cho/NAA to be significantly elevated in meningiomas in comparison to gliomas (4.46 vs. 2.6, p = 0.004, and 5.8 vs. 2.55, p < 0.05). Two studies reported NAA/Cr was significantly elevated in gliomas compared to meningiomas (undetectable vs. 1.54, p < 0.001 and undetectable vs. 0.58, p < 0.05). Conclusions Significant differences in metabolite ratios between tumor types were reported in Cho/Cr, Ala/Cr, Glu/Cr, Cho/NAA, myoI/Cr and NAA/Cr between meningiomas and gliomas.