INTRODUCTION:Brain metastases occur in approximately 20% to 40% of individuals annually diagnosed with cancer. This poor prognostic feature can severely reduce life expectancy and quality of life. Stereotactic radiosurgery (SRS) has been shown to provide excellent tumor control and clinical outcomes. ZAP-X (Zap Surgical Systems Inc., San Carlos, CA, USA) is an innovative self-shielded gyroscopic stereotactic radiosurgery (GRS) system to help further address these needs. In this study, we evaluate the clinical outcomes of patients with brain metastases who have undergone treatment with ZAP-X in a single institution. METHODS:Medical records of all patients with brain metastases treated with GRS between May 2021 and May 2023 were reviewed as a retrospective case series. Demographics, clinical symptoms, treatment trajectory, and follow-up data were collected and analyzed. RESULTS:A total of 46 patients with 140 combined brain metastases were included in this cohort. Of them, 58.7% (N=27) were female patients, and the mean age was 63 years (range 36-82). The primary pathologies were non-small cell lung cancer (NSCLC; N22, 47.8%), breast cancer (N11, 23.9%), melanoma (N5, 10.9%), and others (N8, 17.4%). The prescription dose was 18 Gy if the patient previously received whole-brain radiotherapy (WBRT); otherwise, 20 Gy. All patients received dexamethasone (3x4 mg PO). The most common symptoms included headache (45.7%), motor disturbances (30.4%), and seizures (21.7%). Mean follow-up time was 8.5 months (range 0-19). Systemic response using Response Evaluation Criteria in Solid Tumors (RECIST) criteria was 17.3% complete response, 10.9% partial response, 45.7% stable disease, and 26.1% progression of disease. Tumor control was 73.9% according to the Response Assessment in Neuro-Oncology (RANO) criteria for brain metastases. CONCLUSIONS:GRS is a novel image-guided linear accelerator-based, self-shielding gyroscopic radiosurgery platform that does not require a vault. This study shows that GRS achieves comparable results to traditional SRS platforms in the treatment of brain metastases.

OBJECTIVE Leiomyosarcoma (LMS) is a rare, aggressive soft -tissue sarcoma that seldom spreads to the bone. The spine can be either the site of LMS osseous metastases or the primary tumor site. The optimal treatment option for spinal LMS is still unclear. The authors present a cohort of patients with spinal LMS treated with either upfront surgery or upfront CyberKnife stereotactic radiosurgery (SRS). METHODS The authors retrospectively studied the clinical and radiological outcomes of 17 patients with spinal LMS treated at their institution between 2004 and 2020. Either surgery or SRS was used as the upfront treatment. The clinical and radiological outcomes were assessed. A systematic review of the literature was also conducted. RESULTS Of the 17 patients (20 spinal lesions), 12 (70.6%) were female. The median patient age was 61 years (range 41-80 years). Ten patients had upfront surgery for their spinal lesions, and 7 had upfront CyberKnife radiosurgery. The median follow-up was 11 months (range 0.3-130 months). The median overall survival (OS) for the entire cohort was 13 months (range 0.3-97 months). In subgroup analysis, the median OS was lower for the surgical group (13 months, range 0.3-50 months), while the median OS for the SRS group was 15 months (range 5-97 months) (p = 0.5). Forty percent (n = 4) of those treated with surgery presented with local recurrence at a median of 6.7 months (range 0.3-36 months), while only 14% (n = 1) of those treated with CyberKnife radiosurgery had local recurrence after 5 months. Local tumor control (LTC) rates at the 6-, 12-, and 18 -month follow-ups were 72%, 58%, and 43%, respectively, for the SRS group and 40%, 30%, and 20%, respectively, for the surgery group (p < 0.05). The literature review included 35 papers with 70 patients harboring spinal LMS; only 2 patients were treated with SRS. The literature review confirms the clinical and radiological outcomes of the surgical group, while data on SRS are anecdotal. CONCLUSIONS The authors present the largest series in the literature of spinal LMS and the first on SRS for spinal LMS. This study shows that LTC is statistically significantly better in patients receiving upfront SRS instead of surgery. The OS does not appear different between the two groups.

Sarcomas are a rare type of cancer that can develop in various parts of the body, including the brachial plexus. Leiomyosarcomas (LMs) are a subtype of sarcoma that develops in smooth muscle tissue and can metastasize to different parts of the body. In this case report, we present two patients with LM metastasized to the brachial plexus, one treated with CyberKnife (Accuray, Sunnyvale, CA) stereotactic radiosurgery (CK SRS) and the other with surgical resection. The aim of this case report is to present the treatment outcomes and adverse effects of CK SRS and surgical resection in brachial plexus LM metastasis. Patient 1 was a 39-year-old female who received CK SRS, and at three months of follow-up, the lesion was smaller, and she reported symptomatic improvement. At 15 months, the lesion was stable in size, and there was no evidence of local invasion of the adjacent vascular structures or nerves. Patient 2 was a 52-year-old male who underwent surgical resection, and at one-month follow-up, the patient was asymptomatic with no recurrence of his symptoms. The size of the residual axillary tumor was stable at three months and showed a slight interval decrease in size at five months of follow-up. He was followed for over 12 months, with no recurrence of his symptoms. Both treatments appear to have been effective in controlling LM growth and relieving symptoms. CK SRS provides a non-invasive option. However, more research is needed to fully understand the effectiveness and safety of these treatments for brachial plexus sarcoma. This case report highlights the importance of considering different treatment options for brachial plexus sarcoma and the need for further studies to understand the best approach for these rare cases.

In 2013, hoarding disorder was officially recognized as a separate Diagnostic and Statistical Manual psychiatric diagnosis after years of debate. Prior to 2013, hoarding disorder was generally considered a subset of obsessive-compulsive disorder. Though modern medicine has only recently deepened the analysis of hoarding disorder, hoarding was regularly featured as a character trait in numerous European literary works dating back over 700 years. Several prominent European writers incorporated hoarding behavior in the fictional characters they created. Each author's individual social and economic experiences may have been motivators for perpetuating hoarding-like behavior. It can be postulated that specific historical events and economic circumstances in the country at the time of each author's life likely impacted their interpretation of hoarding behaviors, and the authors carried these influences into their portrayal of their fictional characters. This analysis discusses the various portrayals of hoarding in key pieces of literature and seeks to explain the rationale for these authors' inclusion of hoarding traits in their characters.

Cerebral arteriovenous malformations are dysplastic vascular tangles with aberrant vascular dynamics and can result significant morbidity and mortality. A myriad of challenges are encountered when treating these lesions and are largely based on nidal size, location, and prior hemorrhage. Currently, stereotactic radiosurgery is an accepted form of treatment for small to medium sized lesions and is especially useful in the treatment of lesions in non-surgically assessable eloquent areas of the brain. Despite overall high rates of nidal obliteration, there is relatively limited understand on the mechanisms that drive the inflammatory and obliterative pathways observed after treatment with stereotactic radiosurgery. This review provides an overview of arteriovenous malformations with respect to stereotactic radiosurgery and the current understanding of the mechanisms that lead to nidal obliteration.

BACKGROUND:Radiosurgical treatment of brain metastases is usually performed without brain tissue confirmation. While it is extremely rare for glioblastoma to develop concurrently in patients with brain metastases, they can look radiographically similar, and recognition is important because it alters management and prognosis. The synchronous presence of brain metastases and glioblastoma has not been published to date in the literature, making this a rare illustrative case.OBSERVATIONS:A 70-year-old female had lung biopsy-proven metastatic lung adenocarcinoma and multiple brain metastases. Her treatment course included initial carboplatin, pemetrexed, and bevacizumab followed by maintenance nivolumab, and she underwent stereotactic radiosurgery to the multiple brain metastases. During interval radiological surveillance, one lesion in the right temporal lobe was noted to slowly progress associated with development of significant perilesional edema causing midline shift despite repeated stereotactic radiosurgical treatments. Biopsy of this lesion revealed glioblastoma, IDH wildtype.LESSONS:Glioblastomas and brain metastases have similar radiological features, so the possibility of incorrect diagnosis needs to be considered for all lesions with interval growth poststereotactic radiosurgery. Biopsy and/or resection/laser ablation should be considered prior to reirradiation.

The contributions of both Dominique Anel and John Hunter in the development of the eponymous Hunterian ligation of aneurysms are presented. John Hunter, the ?father of scientific surgery? lent his name to the eponymous practice of applying ligatures to aneurysmal dilatation of arteries. However, evidence suggests that the operation might antedate him by decades. Dominique Anel was a surgeon in the time of Louis XIV who, after his initial apprenticeships in Toulouse and Montpellier, subsequently served in the French navy. He famously described the lacrimal syringe that bears his name but was also interested in diseases of the bones and arteries. Anel described his technique of ligating an aneurysm of the brachial artery in the winter of 1709e1710 in Turin. His description of ligating just the upper end of the aneurysm without touching the sac was described in his collected works in 1714. This technique was exactly the same as that used by Hunter. However, Hunter had based his decision not to excise the sac on his own research. Hunterian ligation was used routinely before endoaneurysmorrhaphy, after which its popularity declined. Hunterian ligation has been superseded by development of surgical clips and endovascular techniques for intracranial aneurysms. However, the technique is still described occasionally in vascular and neurosurgical literature in the context of treating large aneurysms not amenable to traditional treatment modalities.

Abstract Introduction Many institutions lack an organized system of informal network for medical students wishing to explore neurosurgery. We sought to evaluate the role of extracurricular neurosurgical events in influencing student perceptions of neurosurgery. Method Participants for this study were recruited from a neurosurgical careers seminar and practical workshop. Responses were collected prospectively using a multi-method strategy consisting of closed and open-ended questions. Additionally, semi-structured interviews were conducted to gain a deeper insight of students’ evaluation of these events and their perceptions of neurosurgery. Results A total of 124 students attended our extracurricular neurosurgery events. These events showed benefits in clinical knowledge and career planning. Students perceived the practical workshops to be useful in improving their basic surgical skills. Semi-structured interviews revealed that students felt their opportunities in exploring clinical neurosciences to be limited, which was seen as contributing towards the wider culture of neurophobia. Conclusions Undergraduate neuroscience societies provide useful educational platforms for students interested in neurosurgery, even in regions lacking institutional neuroscience networks. To help mitigate the wider culture of neurophobia, undergraduate neuroscience societies should focus on non-academic aspects of neurosurgery that are more personal and engaging, in an effort to spark interest in those who have had little exposure to the specialty.

We present the case of a 33 year old lady presenting with progressive cranial nerve palsies caused by an Extrarenal Rhabdoid tumour manifesting as a sellar/suprasellar mass. We share our experience of managing the tumour and review the existing literature.