PURPOSE:Patients with large or symptomatic brain metastases typically have surgery followed by postoperative (post-op) stereotactic radiosurgery. However, post-op stereotactic radiosurgery leads to elevated rates of radiation necrosis (RN), nodular meningeal disease (nMD), and local failure (LF) when compared with whole brain radiation therapy. Fractionated stereotactic radiation therapy (FSRT) can deliver a higher biological effective dose and may reduce the risk of LF, and preoperative (pre-op) treatments may reduce the risk of RN and nMD through treating smaller volumes and tumor sterilization. METHODS AND MATERIALS:This single institution cohort study included patients who had surgical resection and FSRT to at least one brain metastasis. Pre-op or post-op FSRT was delivered with a dose of 27 Gy in 3 fractions or 30 Gy in 5 fractions. The primary endpoint was a composite endpoint defined by (1) LF, (2) nMD, and/or (3) grade 2 or higher (symptomatic) RN. RESULTS:Of the 534 resected brain metastases from 458 patients were eligible for analysis, 235 and 299 metastases received pre-op and post-op FSRT, respectively. Notably, 4 (1.7%) pre-op and 14 (4.7%) post-op metastases were diagnosed with nMD (P = .088). Notably, 28 (12%) and 59 (20%) metastases that received pre-op and post-op FSRT, respectively, experienced the composite endpoint (P = .018). The 3-year composite endpoint for pre-op and post-op FSRT was 15% (95% CI, 10%-20%) and 20% (95% CI, 15%-25%), respectively. CONCLUSIONS:In our study, pre-op FSRT compares favorably to post-op FSRT primarily because of a lower incidence of nMD. Differences between treatment groups for symptomatic RN or LF endpoints were comparatively smaller. Prospective validation of pre-op FSRT is needed.

Purpose/Objective(s) The treatment standard for patients with large or symptomatic brain metastases and limited intracranial disease is surgical resection followed by post-operative (post-op) stereotactic radiosurgery (SRS). The multicenter PROPS-BM cohort showed how pre-operative (pre-op) SRS may lead to a reduced incidence of radiation necrosis (RN), local failure (LF), and meningeal disease (MD) compared to historical controls. However, most patients in this cohort were treated with single fraction radiosurgery. Fractionated treatments can deliver a higher biological effective dose and may reduce the incidence of LF and MD. We hypothesize that pre-op fractionated stereotactic radiation therapy (FSRT) will reduce the incidence rate of RN, MD, and LF when compared to patients who receive pre-op SRS. Materials/Methods Patients who had surgical resection and radiation to at least one brain metastasis at a single institution were retrospectively analyzed. Only patients who received pre-op radiation were eligible for inclusion. Patients with multiple metastases resected pre-operatively, either during the same surgery or at different times in the disease course, were eligible for inclusion. Outcomes were evaluated on a per-lesion basis. Relevant demographic, clinical, radiation, surgical, and follow up data were collected for each patient. The primary outcome was a composite endpoint defined by 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. Results 260 patients with 299 resected brain metastases were eligible for analysis. The median follow up was 10 months. 64 metastases received SRS and 235 metastases received FSRT. 38 patients had multiple metastases resected pre-operatively. Resected metastases were commonly located in the frontal lobe (35%), parietal lobe (23%), and cerebellum (16%). The median gross tumor volume was 4 ccs for SRS and 10 ccs for FSRT (P<0.001). The median planning target volume was 6 ccs for SRS and 16 ccs for FSRT (P<0.0001). The median SRS dose was 18 Gy, and the median FSRT dose was 24 Gy. Overall, 4 (6.3%) SRS and 6 (2.6%) FSRT patients experienced LF. 4 (6%) SRS and 21 (8.9%) FSRT patients experienced Grade 2 or higher RN. 3 (4.7%) SRS and 11 (4.7%) FSRT patients were diagnosed with MD. 14% of both SRS and FSRT patients experienced the composite endpoint. There were no statistically significant differences in outcome between these two treatment groups. Conclusion In our study, pre-op SRS and FSRT both appear to be safe and effective options to treat resectable brain metastases. Comparing SRS and FSRT in our cohort is challenging due to differences in tumor size; larger tumors more frequently received FSRT, and these tumors may have a higher risk for adverse events. Therefore, the selection bias in this cohort may disguise any potential benefit of FSRT. It is important to prospectively compare pre-op SRS and FSRT in matched cohorts to assess any differences in treatment efficacy and toxicity.

Purpose/Objective(s) The standard treatment for patients with large or symptomatic brain metastases and limited intracranial disease is surgical resection followed by post-operative (post-op) stereotactic radiosurgery (SRS). However, SRS can lead to elevated rates of radiation necrosis (RN), meningeal disease (MD), and local failure (LF). Fractionated treatments can deliver a higher biological effective dose and may reduce the risk of LF, and pre-operative (pre-op) treatments may reduce the risk of RN and MD through treating smaller volumes and tumor sterilization. We hypothesize that pre-op fractionated stereotactic radiation therapy (FSRT) will reduce the incidence rate of RN, MD, and LF when compared to patients who receive post-op FSRT. Materials/Methods A retrospective analysis was performed at a single institution and included patients who had surgical resection and radiation to at least one brain metastasis. Patients who received pre-op or post-op radiation were eligible for inclusion. Patients with multiple metastases resected, either during the same surgery or at different times in the disease course, were eligible for inclusion. All included patients received FSRT. Outcomes were evaluated on a per-lesion basis. Relevant demographic, clinical, radiation, surgical, and follow up data were collected for each patient. The primary outcome was a composite endpoint defined by 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. Results 458 patients with 534 resected brain metastases were eligible for analysis. The median follow up was 11 months. 235 metastases received pre-op FSRT, and 299 metastases received post-op FSRT. Overall, 15% of patients had multiple brain metastases resected. The most common metastasis locations were frontal (33%), parietal (22%), and cerebellar (19%) with no significant differences between groups. The median planning target volumes were 16 ccs and 36ccs for pre-op and post-op FSRT, respectively (p <0.001). Overall, 6 (2.6%) pre-op and 13 (4.3%) post-op patients experienced LF. 21 (8.9%) pre-op and 38 (12.7%) post-op patients experienced symptomatic RN. 11 (4.7%) pre-op and 29 (9.7%) post-op patients were diagnosed with MD (p=0.031). Overall, 14% of metastases that received pre-op FSRT experienced the composite endpoint, and 24% of metastases receiving post-op FSRT experienced the composite endpoint (p=0.005). Conclusion In our study, pre-op FSRT compares favorably to post-op FSRT primarily due to a 50% reduction in the incidence of MD. Differences in symptomatic RN or LF were small on adjusted analyses. Prospective validation of pre-op FSRT is needed.

Abstract The treatment standard for patients with large or symptomatic brain metastases and limited intracranial disease is surgical resection followed by post-operative (post-op) stereotactic radiosurgery (SRS). The multicenter PROPS-BM cohort showed how pre-operative (pre-op) SRS may lead to a reduced incidence of radiation necrosis (RN), local failure (LF), and meningeal disease (MD) compared to historical controls. Fractionated treatments can deliver a higher biological effective dose and may reduce the incidence of LF and MD. We hypothesize that pre-op fractionated stereotactic radiation therapy (FSRT) will reduce the incidence rate of RN, MD, and LF when compared to patients who receive pre-op SRS. Patients who had surgical resection and pre-operative radiation to at least one brain metastasis at a single institution were retrospectively analyzed. Outcomes were evaluated on a per-lesion basis. The primary outcome was a composite endpoint defined by 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. 260 patients with 299 resected brain metastases were eligible for analysis. 64 metastases received SRS and 235 metastases received FSRT. 38 patients had multiple metastases resected pre-operatively. The median gross tumor volume was 4 ccs for SRS and 10 ccs for FSRT (p<0.001). Overall, 4 (6.3%) SRS and 6 (2.6%) FSRT patients experienced LF. 4 (6%) SRS and 21 (8.9%) FSRT patients experienced Grade 2 or higher RN. 3 (4.7%) SRS and 11 (4.7%) FSRT patients were diagnosed with MD. 14% of both SRS and FSRT patients experienced the composite endpoint. There were no statistically significant differences in outcome between these two treatment groups. In our study, pre-op SRS and FSRT both appear to be safe and effective options to treat resectable brain metastases. It is important to prospectively compare pre-op SRS and FSRT in matched cohorts to assess any differences in treatment efficacy and toxicity.

Abstract Patients with large or symptomatic brain metastases and limited intracranial disease typically have surgery followed by post-operative (post-op) stereotactic radiosurgery (SRS). However, SRS can lead to elevated rates of radiation necrosis (RN), meningeal disease (MD), and local failure (LF). Fractionated treatments can deliver a higher biological effective dose and may reduce the risk of LF, and pre-operative (pre-op) treatments may reduce the risk of RN and MD through treating smaller volumes and tumor sterilization. We hypothesize that pre-op fractionated stereotactic radiation therapy (FSRT) will reduce the incidence rate of RN, MD, and LF when compared to patients who receive post-op FSRT. A retrospective analysis was performed at a single institution and included patients who had surgical resection and radiation to at least one brain metastasis. Patients with multiple metastases resected, either during the same surgery or at different times in the disease course, were eligible for inclusion. Outcomes were evaluated on a per-lesion basis. The primary outcome was a composite endpoint defined by 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. 458 patients with 534 resected brain metastases were eligible for analysis. 235 metastases received pre-op FSRT, and 299 metastases received post-op FSRT. Overall, 15% of patients had multiple brain metastases resected. Overall, 6 (2.6%) pre-op and 13 (4.3%) post-op patients experienced LF. 21 (8.9%) pre-op and 38 (12.7%) post-op patients experienced symptomatic RN. 11 (4.7%) pre-op and 29 (9.7%) post-op patients were diagnosed with MD (p=0.031). 14% and 24% of metastases that received pre-op and post-op FSRT, respectively, experienced the composite endpoint (p=0.005). In our study, pre-op FSRT compares favorably to post-op FSRT primarily due to a 50% reduction in the incidence of MD. Differences in symptomatic RN or LF were small on adjusted analyses. Prospective validation of pre-op FSRT is needed.

Abstract The treatment standard for patients with large or symptomatic brain metastases and limited intracranial disease is surgical resection followed by post-operative (post-op) stereotactic radiosurgery (SRS). The multicenter PROPS-BM cohort showed how pre-operative (pre-op) SRS may lead to a reduced incidence of radiation necrosis (RN), local failure (LF), and meningeal disease (MD) compared to historical controls. Fractionated treatments can deliver a higher biological effective dose and may reduce the incidence of LF and MD. We hypothesize that pre-op fractionated stereotactic radiation therapy (FSRT) will reduce the incidence rate of RN, MD, and LF when compared to patients who receive pre-op SRS. Patients who had surgical resection and pre-operative radiation to at least one brain metastasis at a single institution were retrospectively analyzed. Outcomes were evaluated on a per-lesion basis. The primary outcome was a composite endpoint defined by 1) LF, 2) MD, and/or 3) Grade 2 or higher (symptomatic) RN. 260 patients with 299 resected brain metastases were eligible for analysis. 64 metastases received SRS and 235 metastases received FSRT. 38 patients had multiple metastases resected pre-operatively. The median gross tumor volume was 4 ccs for SRS and 10 ccs for FSRT (p<0.001). Overall, 4 (6.3%) SRS and 6 (2.6%) FSRT patients experienced LF. 4 (6%) SRS and 21 (8.9%) FSRT patients experienced Grade 2 or higher RN. 3 (4.7%) SRS and 11 (4.7%) FSRT patients were diagnosed with MD. 14% of both SRS and FSRT patients experienced the composite endpoint. There were no statistically significant differences in outcome between these two treatment groups. In our study, pre-op SRS and FSRT both appear to be safe and effective options to treat resectable brain metastases. It is important to prospectively compare pre-op SRS and FSRT in matched cohorts to assess any differences in treatment efficacy and toxicity.

Carole A. Miller, M.D., was born (May 7, 1939) and raised in Kalamazoo, Michigan. She obtained her undergraduate and medical degrees at the Ohio State University. She went on to complete her neurosurgical training at the Ohio State University Medical Center. After her first faculty role at the University of Michigan (1971), she returned to the Ohio State University Medical Center (1975) where she spent nearly 4 decades. She thrived in the specialty, achieving in every facet of academic practice including scientific contributions, graduate medical education, clinical care, and leadership roles within her academic department, locally, and at the national level of organized neurosurgery. Dr. Miller passed away peacefully, on October 28, 2015, after a courageous battle with cancer. Based on her essential programmatic and specialty-related contributions, she is remembered as the 'founding mother' of neurosurgery at the Ohio State University.

There are surgical options available for those patients with idiopathic intracranial hypertension (IIH) who have significant visual threat or visual deterioration despite best medical management or whose visual deterioration is rapid enough to warrant urgent intervention. Optic nerve sheath fenestrations, venous sinus stenting, and cerebrospinal fluid diversion via ventriculoperitoneal and lumboperitoneal shunting are useful adjuncts in the management of this condition. Significant resources are used in the care of patients with IIH. Further understanding of the pathophysiology of IIH will likely direct future treatment options to more targeted therapeutics including surgery for IIH in the future.

In an effort, to curtail rising health care costs, government and private payers have begun to focus on measuring quality of care. Along with quality improvement initiatives, clinical practice guidelines may also be utilized to provide better care. Clinical practice guidelines are recommendations for clinicians about the care of patients with specific conditions. This review provides an overview of clinical practice guidelines and quality improvement initiatives to highlight strategies to optimize patient outcomes.

Patients with idiopathic intracranial hypertension (IIH) frequently utilize healthcare services and undergo radiological studies to assess refractory headache symptoms despite cerebrospinal fluid diversion. To delineate the clinical utility of different imaging modalities and to estimate cumulative patient radiation exposure in shunted patients with IIH, we retrospectively reviewed 100 randomly selected patients with IIH and a prior cerebrospinal fluid diversion procedure treated at our institution between July 2010 and August 2018. Patients had an average of 16.3 office (SD ± 13.8), 12.4 emergency department (± 21.0), and 4.6 inpatient (± 5.1) encounters over an average 4.8 years of follow-up. Patients underwent an average of 9.0 head CTs (± 8.1), 10.3 shunt series x-rays (± 11.2), and 4.3 MRIs (± 3.7). Approximated radiation exposure per patient was 21.4 mSv (± 18.7). Radiological studies performed for acute symptoms usually demonstrated no actionable findings (82.5% CTs, 97.5% shunt series x-rays, and 79.6% MRIs). Shunted IIH patients undergo numerous radiological studies and are subject to considerable levels of radiation, yet imaging shows actionable findings in less than 10% percent of radiographic studies. IIH patients may benefit from radiation-reducing protocols and the use of alternative imaging to assess symptoms.

Background: Gamma knife (GK) and linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) both offer excellent local control in the management of multiple brain metastases. The efficacy and toxicity of LINAC and GK SRS have not been directly compared in the modern era. We studied outcomes in patients treated with LINAC SRS and GK at two separate institutions. Methods: We identified patients treated with either LINAC or GK who were treated to >2 lesions and had available follow up. LINAC patients were treated using single-isocenter multitarget technique. We used Cox regression, Fine and Gray competing risks regression, and nearest neighbor propensity score matching to account for confounders and imbalance between cohorts. Kaplan-Meier curves were used to estimate overall survival and rates of radionecrosis. Results: We identified 391 patients who were treated in 537 courses to a total 2699 lesions (LINAC: 1014, GK: 1685). After propensity score matching, GK was associated with similar overall survival (HR = 0.86; 95% CI 0.59-1.24; p = 0.41) and higher rate of radionecrosis (HR = 3.83; 95% CI 1.66-8.84; p = 0.002) compared to LINAC. In a secondary propensity score matched analysis comparing radionecrosis in singlefraction LINAC and GK, GK remained associated with higher incidence of radionecrosis (HR = 4.42; 95% CI 1.28-15.29; p = 0.019). Conclusions: In this multi-institutional study, we found similar overall survival with lower incidence of radionecrosis in patients treated with LINAC compared to GK SRS. These findings are hypothesis generating and should be validated in an independent cohort. (c) 2020 Elsevier B.V. All rights reserved. Radiotherapy and Oncology 147 (2020) 136-143

Kyphotic deformity is a well-recognized complication of thoracic vertebral osteomyelitis, often requiring multi-level vertebral column resection for mobilization of the spine and reduction of the deformity. We present a case of severe post-infectious kyphosis treated with multi-level vertebral column resection via a unilateral approach. We obtained excellent decompression and deformity correction without neurologic decline. We review relevant literature regarding spinal cord blood supply and known potential complication of nerve root ligations.

Although a rare condition generally, we have seen a growing population of idiopathic intracranial hypertension (IIH) patients over the years. We have evolved better management strategies and improved on our options for diagnosis and treatment. These patients all have elevated intracranial pressures (ICP). Symptomatic presentation varies. The possibilities of visual deterioration and blindness drive our therapeutic interventions. When patients have reached the point where their condition is no longer effectively managed by medical means and lifestyle adjustments, we have developed procedural strategies and surgical interventions to assist in the management. We hope to share these in this presentation.

Radiosurgery and linear accelerator-based stereotactic radiosurgery (SRS) are both effective and offer excellent local control in the management of multiple brain metastases. When compared to conventional SRS, single-isocenter multitarget (SIMT) linear accelerator-based SRS offers superior treatment time and patient convenience, at the theoretical expense of dose conformity. To date, the clinical efficacy of SIMT and GK SRS has not been compared. We studied overall survival (OS) and radionecrosis (RN) in a multi-institutional cohort of patients treated with SIMT technique at our institution and GK at a collaborating institution. We identified patients treated with either SIMT or GK who were treated to ≥ 2 lesions and had available follow up. To account for confounders, cox proportional hazards and 1:1 nearest neighbor propensity score matching (caliper=0.1) were performed on the basis of sex, year of treatment, primary tumor site, number of lesions, tumor volume, prior whole brain radiation therapy, and use of concurrent immunotherapy. We used Kaplan-Meier curves to estimate freedom from RN using the matched data. We identified 361 patients who were treated in 523 courses to a total 2605 lesions (SIMT: 1014, GK: 1591). Median follow up was 13.1 months. There was no difference in OS between SIMT and GK (hazard ratio [HR] = 1.01; 95% confidence interval [CI] 0.77 - 1.33; p = 0.92). There was no significant difference in freedom from any grade RN (HR = 1.45; 95% CI 0.78 - 2.70; p = 0.24) or grade 2 or higher (grade 2+) RN (HR = 1.59; 95% CI 0.78 - 3.23; p = 0.20). Actuarial 6-, 12-, and 18-month freedom from any grade RN were 93.8%, 91.7%, and 89.5% for SIMT and 93.8%, 90.0%, and 84.9% for GK, respectively. Six-, 12-, and 18-month freedom from grade 2+ RN were 94.8%, 92.7%, and 90.4% for SIMT and 94.8%, 90.8%, 85.0% for GK, respectively. Crude rates of lesional any grade RN were 1.8% and 2.8% for SIMT and GK, respectively. On multivariate analysis, treatment with GK was associated with worse freedom from any grade RN (HR = 2.75; 95% CI 1.33 - 5.71; p = 0.006) and grade 2+ RN (HR = 3.18; 95% CI 1.33 - 7.61; p = 0.009). After propensity score matching, there were 140 treatment courses in each group. Standardized mean differences were <0.2 for all variables. SIMT was associated with better freedom any grade (log rank p = 0.04) and grade 2+ RN (log rank p = 0.03). In this multi-institutional study, we found no difference in OS or rates of RN between patients treated with GK or SIMT SRS. After adjusting for confounders, we found SIMT was associated with better freedom from RN. While these results should be interpreted with caution due to the potential for institutional selection bias, it appears that SIMT SRS has at least comparable rates of RN when compared to GK. These findings should be validated in an independent cohort.

Purpose: Multiple studies have reported favorable outcomes for stereotactic radiosurgery (SRS) in the treatment of limited brain metastases. An obstacle of SRS in the management of numerous metastases is the longer treatment time using traditional radiosurgery. Single-isocenter multitarget (SIMT) SRS is a novel technique that permits rapid therapy delivery to multiple metastases. There is a lack of clinical evidence regarding its efficacy and safety. We report the outcomes of patients treated with this technique. Methods and Materials: We reviewed the records of patients with intact or resected brain metastases treated with SRS in 1 to 5 fractions using SIMT technique at our institution, with at least 1 available follow-up brain magnetic resonance imaging. Survival, disease control, and toxicity were evaluated using Cox regression, logistic regression, and Kaplan-Meier analysis. Results: We identified 173 patients with 1014 brain metastases. Median follow up was 12.7 months. Median beam-on time was 4.1 minutes. The median dose to the brain was 219.4 cGy. Median overall survival and freedom from intracranial progression were 13.2 and 6.3 months, respectively. Overall survival did not differ between patients treated with greater than or less than 4 lesions (hazard ratio, 1.03; 95% confidence interval 0.66-1.61; P = .91). Actuarial 1- and 2-year local control were 99.0% and 95.1%, respectively. Rates of grade 2 and grade 3 or higher radionecrosis were 1.4% and 0.9%, respectively. Conclusions: SIMT radiosurgery delivered in 1 to 5 fractions offers excellent local control and acceptable toxicity in the treatment of multiple intact and postoperative brain metastases. This technique should be evaluated prospectively. (C) 2019 The Author(s). Published by Elsevier Inc. on behalf of American Society for Radiation Oncology.

The blood–brain barrier (BBB) is a complex anatomic and physiologic structure made up of associated structures known as the neurovascular unit (NVU). The NVU protects the sensitive central nervous system (CNS) from molecules with potential toxic or unwanted neurologic effects. These protective mechanisms have prevented introduction of therapeutic drugs for treatment of diseases of the CNS; however, extensive study of the BBB has identified a wide variety of opportunities to exploit it in future drug development. Efforts to accurately measure the ability of medications to cross the NVU into positions of therapeutic benefit are varied and are, in many ways, complementary. Certain drug modifications opened the door to enhanced therapeutics, but also to unexpected CNS toxicities and unanticipated concentrations and toxicities in systemic organ systems. Osmotic BBB disruption with intra-arterial mannitol has been well characterized and clinically applied for years as a successful method for delivery of CNS therapeutics across the NVU. Preclinical analysis, clinical applications of drug delivery and safety, and therapeutic benefit with minimal toxicities have evolved over the years thanks to preclinical and translational studies of the effects of BBB disruption. Future developments will shed light on opportunities for targeted drug delivery using known pathways through the NVU, with continued emphasis on specificity, safety, and therapeutic benefit.

Background: Idiopathic intracranial hypertension (IIH) is a condition of abnormally high intracranial pressure with an unknown etiology. The objective of this study is to characterize craniospinal compliance and measure the cerebrospinal fluid (CSF) pressure waveform as CSF is passively drained during a diagnostic and therapeutic lumbar puncture (LP) in IIH. Methods: Eighteen subjects who met the Modified Dandy Criteria, including papilledema and visual field loss, received an ultrasound guided LP where CSF pressure (CSFP) was recorded at each increment of CSF removal. Joinpoint regression models were used to calculate compliance from CSF pressure and the corresponding volume removed at each increment for each subject. Twelve subjects had their CSFP waveform recorded with an electronic transducer. Body mass index, mean CSFP, and cerebral perfusion pressure (CPP) were also calculated. T-tests were used to compare measurements, and correlations were performed between parameters. Results: Cerebrospinal fluid pressure, CSFP pulse amplitude (CPA), and CPP were found to be significantly different (p < 0.05) before and after the LP. CSFP and CPA decreased after the LP, while CPP increased. The craniospinal compliance significantly increased (p < 0.05) post-LP. CPA and CSFP were significantly positively correlated. Conclusions: Both low craniospinal compliance (at high CSFP) and high craniospinal compliance (at low CSFP) regions were determined. The CSFP waveform morphology in IIH was characterized and CPA was found to be positively correlated to the magnitude of CSFP. Future studies will investigate how craniospinal compliance may correlate to symptoms and/or response to therapy in IIH subjects.

The clear, accurate, and effective exchange of clinical information has always played a central role in the delivery of health care. It remains one of the most critical events that allows for health care providers to be effective at managing patients and their conditions. In this chapter, the scope and background of the importance of the handoff for effective patient care delivery will be reviewed. A background of the current literature will be discussed. Studies demonstrating the importance of handoffs and those describing some of the limitations found in the current literature will be reviewed. The current thinking on the complexities of the handover process and the implications for further study and improvement will be described in an effort to encourage quality projects in this area. The limitations of available research specifically in Neurosurgery will be addressed. Further research into the development of data driven, safety promoting guidelines and best practices are desired that are acceptable for the neurosurgical setting with its particular complexities and its need for flexibilities in multiple environments, that will still provide for quality and safety in patient care. Guidelines shown to have improved clinical outcomes based on study data are needed. With more attention to quality projects that feature the development of the characteristics of the proper handoff in Neurosurgery, the implications are for improved quality and safety in the care and treatment of our Neurosurgery patients.