BACKGROUND/IMPORTANCE:Both percutaneous and paddle leads are utilized when implanting spinal cord stimulation (SCS). Both leads appear to be safe and effective, yet, there is a scarcity of guidelines for deciding which type of lead a physician should use. OBJECTIVE:The main goal is to provide an overview of clinical indications for percutaneous and paddle leads for SCS in patients with chronic spinal pain. EVIDENCE REVIEW:Databases consulted for this systematic review were PubMed, Web of Science, Scopus and Embase. Only studies evaluating SCS in chronic spinal pain patients, with or without previous spine surgery, were eligible. The study protocol was prospectively registered (PROSPERO, CRD42022347329). FINDINGS:Of the 102 included studies, 66.67% studies (n=68) implanted percutaneous leads, 30.4% (n=31) paddle leads and 2.9% (n=3) paddle leads with a percutaneous approach. Percutaneous leads are implanted when patients have no anatomic abnormalities, including no previous spinal interventions at the target location or thoracolumbar junction, and no previous experience with SCS or intrathecal drug delivery. Percutaneous leads may be considered for patients without a history of spinal surgery. Paddle leads are preferred when percutaneous lead placement is technically too difficult, including patients with a history of previous spine surgeries, or as a rescue therapy for failed percutaneous trials. CONCLUSIONS:Lead-specific indications were revealed for patients with chronic spinal pain, yet, the experience of the physician or affiliated department is suggested to have an important role. A clinical flowchart is proposed to help physicians in the decision-making process in daily clinical practice. PROSPERO REGISTRATION NUMBER:CRD42022347329.

The determination of prognoses for patients with recurrent glioblastoma remains challenging. This study aimed to evaluate the prognostic value of static O-(2-18F-fluoroethyl)-l-tyrosine (18F-FET) PET parameters in patients with recurrent glioblastoma. Methods: We retrospectively evaluated patients treated in 3 institutional clinical trials examining vascular endothelial growth factor inhibition, immune checkpoint inhibition, or their combination in recurrent glioblastoma. Patients with a baseline 18F-FET PET were included in the analysis and stratified by treatment group. Prognostic value was evaluated using univariate Kaplan-Meier and multivariate Cox regression analyses, with receiver-operating-characteristic analysis to identify optimal thresholds. Results: Both univariate and multivariate analysis revealed that patients with a larger baseline metabolic tumor volume (MTV) and higher mean tumor-to-background ratio (TBRmean) had an increased risk of death independent of treatment (MTV per 10 mL: hazard ratio, 1.06; 95% CI, 1.01-1.12; P = 0.023; TBRmean: hazard ratio, 1.91; 95% CI, 1.14-3.21; P = 0.014). Receiver-operating-characteristic analysis showed that an MTV and TBRmean of more than 27.94 cm3 and 2.15, respectively, identified patients with worse overall survival in our patient population. Conclusion: Pretreatment MTV and TBRmean had a significant prognostic value in patients with recurrent glioblastoma, independent of treatment, and could be useful to stratify and select patients for future clinical trials.

Introduction: The management of neurovascular pathologies has changed globally over the last few decades. Endovascular treatments are increasing, and fewer surgical procedures are performed. Research question: Evaluate the evolution of vascular neurosurgery in Belgium over the last 30 years and compare with other countries. Material and methods: Belgian nationwide data was obtained from 1991 to 2021 via the National Institute for Health and Disability Insurance (INAMI-RIZIV). Cost of surgical and endovascular implants used in 2022 was obtained. Results: Over a 30-year period a total of 37,504 procedures were performed in Belgium, consisting of 13,767 (36.7%) surgeries and 23,737 (63.3%) endovascular treatments (EVT).Adjusted to population per 100000, surgical management peaked at 6.02 in 1996 and gradually dropped below 3.0 in 2019. EVT increased from 1.06 in 1991 to 10.5 in 2021.Important regional differences are seen in terms of total number of procedures as well as ratio of surgery to endovascular surgery.The total cost of surgical implants in 2022 was the equivalent of 1% of the total cost of endovascular implants. Discussion and conclusions: This data confirms a similar trend to other regions in the world: a reduction in surgical management and increase in endovascular management for CNS vascular pathologies.Important regional differences are noted in terms of volume and ratio of endovascular to surgery.A nationwide registry based on patient data and outcomes can help decide whether there should be centralization to manage vascular pathologies.

Introduction: Understanding the factors that contribute to efficient surgical behaviour and the prevention of technical errors poses a significant challenge in neurosurgery. Current training curricula lack proficiency-centred training and objective tools to assess surgical performance, leading to considerable variability in surgical competencies and practices among neurosurgeons. This study aims to evaluate the determinants of proficient surgical behaviour exhibited by expert surgeons, with the goal of establishing a set of surgical performance metrics serving as a foundation for objective assessment and benchmarking of surgical performance. Material and methods: Eight aneurysm clipping cases by three senior neurosurgeons were recorded via a surgical microscope. Surgeons' actions, workflow parameters, and adverse events during Sylvian fissure dissection were catalogued into Surgical Process Models (SPMs). Performance metrics were extracted, compared, and analysed using clustering analysis to assess proficiency differences. Results: 23 parameters were identified as potential metrics of surgical proficiency. Proficient surgeons exhibited predominant bimanual activity, optimal non-dominant hand use, a limited tool repertoire, minimal instrument changes, and efficient microscope use with minimal adjustments. Despite varying instrument and microscope usage, practitioners achieved consistent outcomes across metrics, indicating similar surgical proficiency. Discussion and conclusion: Findings illustrate that performance metrics derived from surgical video analysis can reliably contribute to the assessment of surgical skills. SPMs offer a structured understanding of the factors that contribute to surgical proficiency. This approach provides an optimal framework for objective assessment of performance metrics, demonstrating potential for automated and objective analysis of surgical performance.

Brain arteriovenous malformations (bAVMs) can be treated curatively by endovascular embolization. However, limited data exist on late recanalization rates. We investigated the rate of late bAVM recanalization following complete endovascular obliteration, confirmed by primary control angiography.We performed a single-center retrospective cohort study on late recurrences in adult patients with bAVMs after complete endovascular obliteration at a Radboud - Isala - MUMC+ (RIM) collaborative AVM center in the Netherlands between 2014 and 2022.Additionally, we conducted a systematic review to evaluate the rate of late recanalization following complete endovascular obliteration, confirmed on primary control angiography, in adults with bAVMs. The protocol for this review was registered in PROSPERO (CRD42024546875).Our retrospective study revealed 42 adult patients treated by endovascular means only; 90.5% (38 patients with mean age of 48.1 years) had confirmed complete obliteration. Both primary (6 months post-treatment) and secondary (more than 1 year post-treatment) angiographic control confirmed complete obliteration in 21 of 23 patients with complete follow-up. Mean follow-up was 47.8 months. Two late recurrences (9.5%) were detected at 5- and 6-years' follow-up imaging.Our systematic review included two studies encompassing a total of 19 patients with mean angiographical follow-up of 20.8 months. There were no late recurrences.Late bAVM recurrence after endovascular treatment with proven complete obliteration may be underestimated owing to limited long-term follow-up. Our findings suggest that after a 6-month angiographic confirmed obliteration, a 5-year angiographic imaging control is justified.

Introduction: Exogenous and endogenous sex hormones, especially Progesterone agonists, may be causally linked to meningioma progression. Cessation of treatment leads to stabilization or regression of Progestin-induced meningioma. In many cases, avoiding sex hormone therapy may be possible in the context of meningioma treatment. However, hormonal treatment is not always easily replaceable and concise real-world recommendations regarding sex hormones and meningioma are lacking. Material and methods: A combined effort was initiated between Neurosurgical, Gynaecological and Endocrinological societies of Belgium to gather relevant information regarding sex hormone therapies and meningioma. After complete literature review, consensual recommendations were established. Results: Collegial recommendations regarding sex hormones therapies and meningioma in the context of oral contraceptives, menopause hormonal treatment, fertility treatment, pregnancy and gender-affirming therapies are emitted and nuanced. Discussion and conclusion: Withdrawal and monitoring of sex hormone therapies are discussed in detail.A decision tree regarding Meningioma and Combined contraception, Progestin Contraception, Menopause Hormonal treatment, Progestin and Gender-affirming therapy is suggested.

Background:Extent of resection (EOR) is a well-known prognostic factor in patients with newly diagnosed IDH-wildtype glioblastoma. However, reported survival times across resection categories vary between reports, and outcomes of submaximal or supramaximal resection remain less well defined. Methods:We conducted a systematic review and meta-analysis on the association between EOR and overall survival (OS) in patients with newly diagnosed IDH-wildtype glioblastoma treated with chemoradiotherapy. Studies were included if OS was reported by EOR category. Risk ratios (RRs) for 1- and 2-year survival were pooled using a random-effects model. Study quality was assessed using the Newcastle-Ottawa Scale. Results:Thirty-one studies involving 26,167 patients were included. Supramaximal resection (SupraMR) was associated with significantly improved 2-year survival compared to maximal CE resection (MR) (RR 0.70, 95 % CI 0.55-0.88). Compared to submaximal resection (subMR), MR was associated with higher 1-year survival (RR 0.59, 95 % CI 0.53-0.67) and 2-year survival (RR 0.82, 95 % CI 0.77-0.87). Biopsy alone was associated with the poorest outcome. Findings remained robust in sensitivity analyses excluding SEER and RTOG cohorts. Conclusions:Increasing EOR seems to be associated with improved survival in newly diagnosed IDH-wildtype glioblastoma. SupraMR offers the greatest benefit, while submaximal resection appears to be more favorable than biopsy. These findings support the prognostic relevance of EOR and underscore the need for prospective studies with standardized resection classifications. The balanced summary of survival data for each resection class provided in this review can serve as a basis for effect estimation and sample size calculations in future trials.

BACKGROUND AND OBJECTIVES:External ventricular drain (EVD) placement is often performed freehand, a technique subpar to accurate yet impractical image-guided methods, yielding optimal placement in only 70%. The aim of this study was to address shortcomings in EVD placement and image guidance technologies by implementing high-accuracy augmented reality (AR) guidance. METHODS:We conducted a prospective clinical pilot study to assess feasibility, safety, and clinical performance of EVD placement using a standalone AR headset equipped with high-accuracy inside-out infrared tracking and software addressing EVD placement. Placement quality was reported using a newly defined extended modified Kakarla scale, and dichotomized into clinically relevant outcome parameters. Results were compared with a nonconcurrent freehand control group using one-sided Fisher exact tests. RESULTS:Eleven AR-guided EVD placements were performed, achieving functional placement in all cases on the first attempt, vs 7 (64%) in the control group ( P = .045); successful placement in 9 (82%) vs 5 (45%); optimal in 8 (73%) vs 3 (27%) ( P = .043); suboptimal in 2 (18%) vs 5 (45%); and failed in 0 vs 1 (9%). No AR-guided placements required revision, whereas the freehand group had a 36% reintervention rate ( P = .045). Procedure-related complications occurred in 2 AR-guided cases (18%), vs 5 (45%) freehand (all post-reintervention). CONCLUSION:This study presents the first clinical use case of EVD placement using high-accuracy AR guidance contained in a standalone head-worn navigation system. Safe and reliable outcomes using a validated pipeline were demonstrated, eliminating stick-and-poke attempts and resulting in improved quality, increased single attempt success rates, and reduced revision and complication rates. Based on these results, a multicenter randomized controlled trial will be initiated.

This study aimed to examine the effects of a single dose of a betalain-rich concentrate (BRC) on determinants of running performance and recovery lactate clearance. In this a randomized, triple-blind, placebo-controlled, crossover trial, 17 male recreational runners (Age: 19.0 ± 1.0 years; Height: 176.8 ± 6.2 cm; Weight: 70.62 ± 8.1 kg; Body fat: 12.8 ± 0.03

IntroductionTechnical advances and the increasing role of interdisciplinary decision-making may warrant formal definitions of expertise in surgical neuro-oncology.Research questionThe EANS Neuro-oncology Section felt that a survey detailing the European neurosurgical perspective on the concept of expertise in surgical neuro-oncology might be helpful.Material and MethodsThe EANS Neuro-oncology Section panel developed an online survey asking questions regarding criteria for expertise in neuro-oncological surgery and sent it to all individual EANS members.ResultsOur questionnaire was completed by 251 respondents (consultants: 80.1%) from 42 countries. 67.7% would accept a lifetime caseload of >200 cases and 86.7% an annual caseload of >50 as evidence of neuro-oncological surgical expertise. A majority felt that surgeons who do not treat children (56.2%), do not have experience with spinal fusion (78.1%) or peripheral nerve tumors (71.7%) may still be considered experts. Majorities believed that expertise requires the use of skull-base approaches (85.8%), intraoperative monitoring (83.4%), awake craniotomies (77.3%), and neuro-endoscopy (75.5%) as well as continuing education of at least 1/year (100.0%), a research background (80.0%) and teaching activities (78.7%), and formal interdisciplinary collaborations (e.g., tumor board: 93.0%). Academic vs. non-academic affiliation, career position, years of neurosurgical experience, country of practice, and primary clinical interest had a minor influence on the respondents’ opinions.Discussion and ConclusionOpinions among neurosurgeons regarding the characteristics and features of expertise in neuro-oncology vary surprisingly little. Large majorities favoring certain thresholds and qualitative criteria suggest a consensus definition might be possible.

BACKGROUND:Danger-associated molecular patterns (DAMPs) may be implicated in the pathophysiological pathways associated with an unfavorable outcome after acute brain injury (ABI).METHODS:We collected samples of ventricular cerebrospinal fluid (vCSF) for 5 days in 50 consecutive patients at risk of intracranial hypertension after traumatic and nontraumatic ABI. Differences in vCSF protein expression over time were evaluated using linear models and selected for functional network analysis using the PANTHER and STRING databases. The primary exposure of interest was the type of brain injury (traumatic vs. nontraumatic), and the primary outcome was the vCSF expression of DAMPs. Secondary exposures of interest included the occurrence of intracranial pressure ≥20 or ≥ 30 mm Hg during the 5 days post-ABI, intensive care unit (ICU) mortality, and neurological outcome (assessed using the Glasgow Outcome Score) at 3 months post-ICU discharge. Secondary outcomes included associations of these exposures with the vCSF expression of DAMPs.RESULTS:A network of 6 DAMPs ( DAMP_trauma ; protein-protein interaction [PPI] P =0.04) was differentially expressed in patients with ABI of traumatic origin compared with those with nontraumatic ABI. ABI patients with intracranial pressure ≥30 mm Hg differentially expressed a set of 38 DAMPS ( DAMP_ICP30 ; PPI P < 0.001). Proteins in DAMP_ICP30 are involved in cellular proteolysis, complement pathway activation, and post-translational modifications. There were no relationships between DAMP expression and ICU mortality or unfavorable versus favorable outcomes.CONCLUSIONS:Specific patterns of vCSF DAMP expression differentiated between traumatic and nontraumatic types of ABI and were associated with increased episodes of severe intracranial hypertension.

Introduction: Pleiomorphic xanthoastrocytoma (PXA) is considered a low-grade glioma with a favorable prognosis following surgical resection. We present a case report of a BRAFV600E mutant malignantly transformed and disseminated PXA that was successfully treated with BRAF-/MEK-targeted therapy (dabrafenib/trametinib). Case Presentation: At the age of 16 years, our patient underwent an initial subtotal resection of a right occipital PXA. Six months later, a reintervention for an asymptomatic tumor recurrence was performed and complete resection was achieved. The patient has been followed up by MRI for 14 years without arguments for recurrence but was lost to follow-up thereafter. At 38 years of age, he presented with a symptomatic local recurrence with extra-cerebral soft tissue extension, for which a third surgical resection was performed. Anatomopathological examination reported a grade 3 anaplastic PXA (aPXA); molecular analysis detected a BRAFV600E mutation. Three months later, before the initiation of radiotherapy, a local tumor recurrence was diagnosed, for which he underwent a fourth surgical resection. Radiotherapy was performed following the surgical debulking. One month after completion of radiotherapy, disease progression was documented including multiple sites of extracranial metastases (skeletal, lung, cervical lymph node, and subcutaneous metastases). Systemic treatment with a combination of BRAF-/MEK-inhibitors (dabrafenib/trametinib) was initiated and resulted in a rapid and deep tumor response (partial response according to RECISTv1.1) and absence of BRAFV600E mutant ctDNA in plasma at 6 weeks after treatment initiation. A near-complete metabolic remission was documented on [18F]FDG-PET/CT 3 months after starting systemic therapy. Conclusion: We present a rare case of malignant transformation and systemic dissemination of a BRAFV600E mutant PXA, occurring 20 years after the initial diagnosis. This case highlights the importance of long-term follow-up of patients diagnosed with these rare central nervous system tumors that initially are considered benign and also illustrates that BRAF/MEK inhibition can be an effective therapy for BRAFV600E mutated PXA, underscoring the importance of performing molecular genetic profiling of these tumors.

ABSTRACT Alzheimer’s disease and dementia are public health issues anticipated to triple in numbers by 2050. No known cures exist, and developed pharmacologics have been ineffective and produced side effects, warranting the need for more lifestyle approaches. We review the pathophysiology, risk factors, diagnoses, and contemporary treatments for Alzheimer’s and other dementias for clinical exercise physiologists.

Purpose After glioblastoma (GB) recurrence, prognosis is very cumbersome. Therefore, health-related quality of life (HRQoL) and neurocognitive functioning (NCF) have become important endpoints in clinical trials when evaluating novel treatments. We aimed to evaluate the HRQoL and NCF in patients with recurrent glioblastoma (rGB) treated with a combination of surgical intervention (reoperation or biopsy) and intracerebral immune checkpoint inhibition. Methods Patients who participated in the trial ( N = 23), at a single-center university hospital were included. Data were collected using 3 patient-reported outcome measures (EORTC-QLQ-C30, EORTC-QLQ-BN20, and HADS) and computerized NCF testing. In the responder group, baseline values were compared to results at a 6-month follow-up. Additionally, exploratory analyses compared baseline HRQoL and NCF between responders and non-responders. Results There were five responders and 18 non-responders. When comparing the mean and individual baseline with follow-up results for the responders, we observed overall a stable to slight clinically relevant improvement of HRQoL in multiple subsets of the questionnaires while maintaining a stable NCF. One patient deteriorated on anxiety and depression symptoms from baseline to follow-up. Conclusions In patients that responded to intracerebral immunotherapy in our institutional trial, HRQoL and NCF remained stable over time, suggesting that no detrimental effect on cognitive function or quality of life may be expected with this treatment approach. Furthermore, there seems to be an overall tendency for responders to score better on HRQoL and NCF than non-responders at baseline.

Interacting with nature may promote mental and physical health. There are multiple ways to interact with nature: indirectly, incidentally, and intentionally. How these types of interactions with nature may be associated with mental and physical health status and health behaviors is unclear. The purpose of this narrative review is to (1) describe the relationship between interactions with nature (indirect, incidental, and intentional) and mental and physical health outcomes and behaviors, (2) identify gaps in the literature, and (3) provide recommendations for future research. Considerable evidence suggests that interacting with nature, indirectly and intentionally, is associated with improvements in mental health and physical exhibitions of mental status. Furthermore, intentionally interacting with nature is associated with engagement in physical activity and gardening is associated with fruit and vegetable consumption. Research suggests that incidentally interacting with nature may be associated with positive mental health status. More research is needed to understand the relationships between incidental interactions with nature and physical health status and behaviors; as well as among all types of interactions with nature and physical health disorders, sleep, and dietary behaviors.

Introduction: Intraoperative fluorescence guidance is a well-established surgical adjunct in high-grade glioma surgery. In contrast, the clinical use of such dyes and technology has been scarcely reported in skull base surgery. Research question: We aimed to systematically review the clinical applications of different fluorophores in both open and endonasal skull base surgery. Material and methods: We performed a systematic review and discussed the current literature on fluorescence guidance in skull base surgery. Results: After a comprehensive literature search, 77 articles on skull base fluorescence guidance were evaluated. A qualitative analysis of the articles is presented, discussing clinical indications and current controversies. The use of intrathecal fluorescein was the most frequently reported in the literature. Beyond that, 5-ALA and ICG were two other fluorescent dyes most extensively discussed, with some experimental fluorophore applications in skull base surgery. Discussion and conclusion: Intraoperative fluorescence imaging can serve as an adjunct technology in skull base surgery. The scope of initial indications of these fluorophores has expanded beyond malignant glioma resection alone. We discuss current use and controversies and present an extensive overview of additional indications for fluorescence imaging in skull base pathologies. Further quantitative studies will be needed in the future, focusing on tissue selectivity and time-dependency of the different fluorophores currently commercially available, as well as the development of new compounds to expand applications and facilitate skull base surgeries.