Search Results (87)

Background: Glioblastoma (GBM), IDH-wildtype, is one of the most aggressive primary brain malignancies, and maximal safe resection is consistently recognized as a significant prognostic factor. Intraoperative adjuncts including functional mapping, neuronavigation, and fluorescence-guidance are not always present in many centers around the world. The aim is not to suggest equivalence to adjunct-assisted resections, but rather to illustrate the feasibility of anatomy-guided surgery in carefully selected cases and to contribute to the broader discussion on safe operative strategies in resource-limited environments. Methods: We present the case of a 54-year-old right-handed male who presented with progressive non-fluent aphasia, seizures, and signs of intracranial hypertension. Pre-operative MRI showed a heterogeneously hyperintense, frontobasal intra-axial mass involving the dominant inferior frontal gyrus, extending toward the corpus callosum and orbitofrontal cortex, and early subfalcine shift. Surgery was performed via a left frontobasal craniotomy, using subpial dissection and cortical–sulcal anatomical landmarks while aiming to preserve eloquent subcortical tracts (frontal aslant tract, superior longitudinal fasciculus). Nueronavigation, functional mapping or fluorescence was not used. We defined our outcomes by the extent of resection, functional preservation, and early radiological stability. Results: The procedure achieved a subtotal-near-total resection (>95% estimated volume) while maintaining functional motor function from prior to surgery and the patient’s baseline expressive aphasia, with no new neurological deficits. Early post-operative CT showed decompression of the resection cavity without hemorrhage or shift. At three months post-operative, CT showed stability of the cavity and resolution of the most perilesional edema with no evidence of recurrence. Clinically, the patient showed gradual improvement in verbal fluency, he remained seizure free, and maintained independence, which allowed for timeliness of the initiation of adjuvant chemoradiotherapy. Conclusions: We intend for the case to illustrate that, in selected dominant frontal GBM, following microsurgical anatomical principles closely may provide a high extent of resection with the preservation of function, even without advanced intraoperative adjuncts. We hope that our experience may support our colleagues who practice in resource-limited settings and contribute to our shared goal of both oncological outcomes and the quality of life of our patients. Full article

Mesial temporal lobe epilepsy (mTLE) surgery, particularly selective amygdalohippocampectomy (sAHE), is a recognized treatment for pharmacoresistant temporal lobe epilepsy (TLE). Accurate intraoperative orientation is crucial for complete resection while maintaining functional integrity. This study evaluated the usability and effectiveness of multimodal neuronavigation and microscope-based augmented reality (AR) with intraoperative computed tomography (iCT) and navigated intraoperative ultrasound (iUS) in 28 patients undergoing resective surgery. Automatic iCT-based registration provided high initial navigation accuracy. Navigated iUS was utilized to verify navigational accuracy and assess the extent of resection during the procedure. AR support was successfully implemented in all cases, enhancing surgical orientation, surgeon comfort, and patient safety, while also aiding training and education. At one-year follow-up, 60.7% of patients achieved complete seizure freedom (ILAE Class 1), rising to 67.9% at the latest follow-up (median 4.6 years). Surgical complications were present in three cases (10.7%), but none resulted in permanent deficits. The integration of microscope-based AR with iCT and navigated iUS provides a precise and safe approach to resection in TLE surgery, additionally serving as valuable tool for neurosurgical training and education. Full article

Cholesterol granuloma is an uncommon inflammatory lesion whose etiology is still unclear. It is thought to originate from blood accumulation in a pneumatized space, probably after bleeding. The most frequent site is the petrous apex of the temporal bone, whilst it is very uncommon in the paranasal sinuses. We present a clinical case of an 80-year-old female patient with intense frontal headache and diplopia who underwent a neuro-navigated endoscopic sinus surgery. The histological diagnosis was a cholesterol granuloma of the frontal sinus, contaminated by Aspergillus Fumigatus hyphae. Cholesterol granuloma of the frontal sinus is a rare finding in clinical practice, but it should be taken into account in the diagnostic path in presence of rapidly increasing sight alterations and headache, even without rhinological symptoms. Full article

Brain metastases (BMs) are the most common intracranial tumors in adults. Their heterogeneity, potential multifocality, and complex biomolecular behavior pose significant diagnostic and therapeutic challenges. Artificial intelligence (AI) has the potential to revolutionize BM diagnosis by facilitating early lesion detection, precise imaging segmentation, and non-invasive molecular characterization. Machine learning (ML) and deep learning (DL) models have shown promising results in differentiating BMs from other intracranial tumors with similar imaging characteristics—such as gliomas and primary central nervous system lymphomas (PCNSLs)—and predicting tumor features (e.g., genetic mutations) that can guide individualized and targeted therapies. Intraoperatively, AI-driven systems can enable optimal tumor resection by integrating functional brain maps into preoperative imaging, thus facilitating the identification and safeguarding of eloquent brain regions through augmented reality (AR)-assisted neuronavigation. Even postoperatively, AI can be instrumental for radiotherapy planning personalization through the optimization of dose distribution, maximizing disease control while minimizing adjacent healthy tissue damage. Applications in systemic chemo- and immunotherapy include predictive insights into treatment responses; AI can analyze genomic and radiomic features to facilitate the selection of the most suitable, patient-specific treatment regimen, especially for those whose disease demonstrates specific genetic profiles such as epidermal growth factor receptor mutations (e.g., EGFR, HER2). Moreover, AI-based prognostic models can significantly ameliorate survival and recurrence risk prediction, further contributing to follow-up strategy personalization. Despite these advancements and the promising landscape, multiple challenges—including data availability and variability, decision-making interpretability, and ethical, legal, and regulatory concerns—limit the broader implementation of AI into the everyday clinical management of BMs. Future endeavors should thus prioritize the development of generalized AI models, the combination of large and diverse datasets, and the integration of clinical and molecular data into imaging, in an effort to maximally enhance the clinical application of AI in BM care and optimize patient outcomes. Full article

Background: Intraoperative ultrasound (IOUS) provides real-time imaging during brain tumor surgery but remains underused in brain metastasis resection. This study evaluates the effectiveness of 2D IOUS in improving the extent of resection compared to standard neuronavigation. Methods: We retrospectively analyzed 55 adult patients with brain metastases treated surgically at a single center. Patients were divided into two groups: IOUS-guided surgery (n = 20) and standard neuronavigation (n = 35). Gross total resection (GTR) was defined as the extent of resection > 96%, assessed volumetrically. Statistical analyses included chi-square tests, logistic regression, and ROC curve analysis. Results: GTR > 96% was achieved in 80% of IOUS-guided cases compared to 42.86% in the control group (p = 0.008). IOUS significantly increased the odds of achieving GTR (OR = 5.33, p = 0.011). Larger tumor volume reduced the likelihood of GTR (OR = 0.469, p = 0.025), but this effect was mitigated by IOUS use (interaction OR = 1.986, p = 0.044). The regression model showed excellent discrimination (AUC = 0.930, p < 0.001). Functional outcomes improved postoperatively in both groups. Conclusions: 2D IOUS significantly enhances the extent of resection in brain metastasis surgery, including that for larger tumors. Its accessibility, real-time feedback, and low cost support its wider adoption in neurosurgical practice, especially in settings with limited resources. Full article

Background/Objectives: The insula is a deep, functionally heterogeneous region involved in various pathological conditions. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising therapeutic avenue for neuromodulation, yet very few studies have directly investigated its effects on insular activity. Moreover, empirical evidence of target engagement of this region remains scarce. This study aimed to stimulate the insula with rTMS and assess blood oxygen level-dependent (BOLD) signal modulation using concurrent functional magnetic resonance imaging (fMRI). Methods: Ten participants were recruited, six of whom underwent a single session of 5 Hz high-frequency rTMS over the right insular cortex inside the MRI scanner. Stimulation was delivered using a compatible MRI-B91 TMS coil. Stimulation consisted of 10 trains of 10 s each, with a 50 s interval between trains. Frameless stereotactic neuronavigation ensured precise targeting. Paired t-tests were used to compare the mean BOLD signal obtained between stimulation trains with resting-state fMRI acquired before the rTMS stimulation session. A significant cluster threshold of q < 0.01 (False Discovery Rate; FDR) with a minimum cluster size of 10 voxels was applied. Results: Concurrent rTMS-fMRI revealed the significant modulation of BOLD activity within insular subregions. Increased activity was observed in the anterior, middle, and middle-inferior insula, while decreased activity was identified in the ventral anterior and posterior insula. Additionally, two participants reported transient dysgeusia following stimulation, which provides further evidence of insular modulation. Conclusions: These findings provide preliminary evidence that rTMS can modulate distinct subregions of the insular cortex. The combination of region-specific BOLD responses and stimulation-induced dysgeusia supports the feasibility of using rTMS to modulate insular activity. Full article

Objective: The aim of this study is to present the initiation of robotic-guided (RG) spine surgery into routine clinical care at a single center with the use of intraoperative CT (iCT) automatic registration-based navigation. The workflow included iCT with automatic registration, fusion with preoperative imaging, verification of preplanned screw trajectories, RG introduction of K-wires, and the insertion of pedicle screws (PSs), followed by a control iCT scan. Methods: All patients who underwent RG implantation of pedicle screws using the Cirq^® robotic arm (BrainLab, Munich, Germany) in the thoracolumbar spine at our department were included in the study. The accuracy of the pedicles screws was assessed using the Gertzbein–Robbins scale (GRS). Results: In total, 108 patients (60 female, mean age 68.7 ± 11.4 years) in 109 surgeries underwent RG PS placement. Indications included degenerative spinal disorders (n = 30 patients), spondylodiscitis (n = 24), tumor (n = 33), and fracture (n = 22), with a mean follow-up period of 7.7 ± 9 months. Thirty-seven cases (33.9%) were performed percutaneously, and all others were performed openly. Thirty-three operations were performed on the thoracic spine, forty-four on the lumbar and lumbosacral spine, thirty on the thoracolumbar, one on the cervicothoracic spine, and one on the thoracolumbosacral spine. The screws were inserted using a fluoroscopic (first 12 operations) or navigated technique (latter operations). The mean operation time was 228.8 ± 106 min, and the mean robotic time was 31.5 ± 18.4 min. The mean time per K-wire was 5.35 ± 3.98 min. The operation time was lower in the percutaneous group, while the robot time did not differ between the two groups. Robot time and the time per K-wire improved over time. Out of 688 screws, 592 were GRS A screws (86.1%), 54 B (7.8%), 22 C (3.2%), 12 D (1.7%), and 8 E (1.2%). Seven screws were revised intraoperatively, and after revision, all were GRS A. E screws were either revised or removed. In the case of D screws, screws located at the end of the construct were revised, while so-called in-out-in screws in the middle of the construct were not revised. Conclusions: Brainlab’s Cirq^® Robotic Alignment Module feature enables placement of pedicle screws in the thoracolumbar spine with high accuracy. A learning curve is shown through improvements in robotic time and time per K-wire. Full article

Background/Objectives: Advancements in neuronavigation and intraoperative imaging have made gross-total resection of deep-seated lesions more feasible. However, in eloquently located regions, brain shift can lead to unintentional damage of functionally critical tissue during the approach. This study analyzes the feasibility and outcomes of a stereotactically guided microsurgical approach supported by intraoperative CT (iCT) for such lesions. Methods: Patients with deep-seated, eloquently located lesions treated between 03/2017 and 04/2023 at the Department of Neurosurgery, Ludwig-Maximilians-University (LMU) Munich, Germany, were included. Frame-based, image-guided stereotaxy was used for trajectory planning and catheter placement, verified by iCT. Microsurgical resection was conducted along the catheter trajectory using 2 mm conical blade retractors and continuous neurophysiological monitoring. Postoperative MRI assessed the extent of resection. Neurological outcomes were evaluated postoperatively, at 6 weeks, and at long-term follow-up in 12/2023. Results: A total of 12 patients were treated using the stereotactically guided microsurgical approach described in this study. In all cases, the implanted catheter precisely matched the preoperative trajectory, as confirmed by fused iCT data. Median durations were 23 min for stereotaxy and 3 h 7 min for microsurgery. Complete resection was achieved in all cases. One patient experienced transient hemiparesis and aphasia, both of which were fully resolved. All other patients showed neurological improvement or remained seizure-free at long-term follow-up. Conclusions: In selected cases, a stereotactically guided microsurgical approach with iCT enabled intraoperative localization of the target with high spatial accuracy and without immediate procedure-related complications in this limited cohort. Our findings support the feasibility of the technique; however, conclusions regarding clinical efficacy or broader applicability are limited by the small sample size and non-comparative study design. Full article

Background/Objectives: Transcranial magnetic stimulation (TMS) is a non-invasive and well-tolerated treatment, offering an effective alternative for elderly patients with depression, especially when side effects or comorbidities limit medication. Methods: This scoping review analyzes 16 studies published over the past seven years, to evaluate the efficacy, safety, and clinical applications of TMS in older adults with depression. Results: The review examines various TMS modalities, including repetitive TMS (rTMS), deep TMS, and theta burst stimulation (TBS), with most protocols targeting the dorsolateral prefrontal cortex (DLPFC). Adverse effects were rare, mild, and transient, supporting the treatment’s safety profile. Pharmacological co-treatment was common but not essential for clinical improvement, highlighting TMS’s potential as a standalone therapy. A subset of studies used neuroplasticity (SICI, ICF, CSP) or neuroimaging measures (MRI and MRI-based neuronavigation), revealing that age-related cortical inhibition may limit plasticity rather than depression itself. Conclusions: Overall, TMS demonstrates promising effectiveness and tolerability in managing late-life depression. Across studies, remission rates varied from 20% to 63%, with higher efficacy generally observed in bilateral stimulation or high-frequency protocols. Standardization of protocols and further research into individualized targeting and long-term outcomes are warranted to support broader clinical adoption. Full article

Over the last decade, the quality of neurosurgical procedures dramatically improved, also thanks to the development and increased accessibility of several technological recourses (e.g., imaging, neuronavigation, neurophysiology, microscopy), allowing to plan increasingly complex approaches, while reducing the risk of postoperative complications. Among these resources, three-dimensional rendering and simulation systems, such as virtual and augmented reality, provide a high-quality visual reconstruction of brain structures and interaction with advanced anatomical models. Although the usefulness of these systems is now widely recognized, the additional availability of proprioceptive (haptic) feedback might help to further enhance the realism of surgical simulation. A systematic literature review on the application of haptic technology in simulation of cranial neurosurgical procedures was made. Inclusion criteria were the usage of simulators with haptic feedback for specific neurosurgical procedures whereas the studies that did not include an evaluation of the surgical simulation system by a surgeon were excluded. According to inclusion and exclusion criteria, 10 studies were selected. Simulation in neurosurgery still lacks a system capable of rehearsing the entire procedure—from skin incision to skin closure—while providing both visual and proprioceptive feedback. Consequently, further advancements in this area are necessary. Full article

Purpose: To evaluate the role of tumor invasiveness profile in a homogeneous cohort of patients with newly diagnosed GBM (2021 WHO) that underwent SUPR by the RANO criteria, and to analyze its impact on survival outcomes. Methods: Patients with newly diagnosed, histologically confirmed glial tumors featuring contrast-enhancing lesions, who underwent surgery at our institution between January 2007 and January 2024, were retrospectively reviewed. Preoperative total tumor volume (T-TV), contrast-enhancing (CE), and infiltrative FLAIR tumor volume (FLAIR-TV) were calculated in cubic centimeters (cc) via manual segmentation. A neuronavigation system was utilized for surgery and lesions were molecularly evaluated following the 2021 WHO CNS tumor classification. Therefore, all patients were classified into extent of resection categories by the 2022 RANO-Resect classification. The tumor invasiveness profile was assessed using the proliferation/diffusion (ρ/D) ratio, calculated following Swanson’s method. A statistical analysis was finally performed. Results: Between 2007 and 2024, 410 adult patients with newly diagnosed gliomas were treated at our institution. Methylation of the MGMT promoter was statistically significant (HR = 0.43, 95% CI: 0.20–0.94, p = 0.035), indicating that methylation has a protective effect on survival. In multivariate analysis, only MGMT status was confirmed to be an independent predictor of overall survival (OS). MGMT methylation was significantly associated with improved progression-free survival (PFS) in moderately diffuse tumors (HR = 0.18, 95% CI: 0.03–0.95, p = 0.044). Conclusions: Using the proliferation–diffusion model to classify tumors, we identified moderately diffuse tumors with methylated MGMT status as a subgroup with significant survival benefits from SUPR. Full article

Background: Spinal metastases affect approximately 40% of patients with systemic cancers; metastatic epidural spinal cord compression (MESCC) occurs in up to 20% of cases and leads to potential significant morbidity. Recent advancements in high-dose conformal radiation techniques, such as Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS), enable histology-independent ablative treatments, yet optimal dose fractionation remains undetermined. Methods and Results: This case of vertebral metastases with high-grade ESCC exemplifies the model of a comprehensive treatment workflow that emphasizes interdisciplinary collaboration, within the framework of a personalized medicine. The “Hybrid Therapy” combines Separation Surgery, aimed at achieving circumferential spinal cord decompression, with SBRT/SRS. The oncologic resection has been performed in a navigation-assisted technique that is tailored to the SBRT target, pre-operatively defined on the neuronavigation station. Conclusions: This seamless integration during initial planning of surgery with the ideal radio-oncological target is aimed at avoiding delays in referral and limitations in subsequent treatment options. This integrative holistic strategy not only prioritizes functional preservation, minimizing surgical invasiveness, but also promotes tumor control, thus offering potential promising new avenues for patient-centered oncologic care. Future high-quality studies are warranted to validate the widespread potential utility and safety of this approach. Full article

Background/Objectives: Primary brain tumors are difficult to identify intraoperatively due to their infiltrative character in the marginal zone. Several optical methods have been suggested. Of these, 5-ALA-induced fluorescence visualized through a microscope is the most common. The aim is to present an investigational probe-based optical system and its translation for clinical use, summarize previous studies, and give examples of clinical implementations during resection and burr hole biopsies. Methods: The FluoRa system combines 5-ALA fluorescence spectroscopy with laser Doppler flowmetry (LDF). Probe designs are available for brain tumor resection (hand-held probe) or burr hole needle biopsies (frame-based or navigated). The outer cannulas of biopsy needles are modified with an opening at the tip for simultaneous use with optical probes during insertion along the trajectory. An updated version of FluoRa is introduced and experimentally investigated. Results: Probe-based fluorescence spectroscopy has been successfully translated for clinical use and applied during brain tumor resection (n = 75) and burr hole needle biopsies (n = 47). Forward-looking optical measurements through the biopsy needle reduce the number of trajectories (28/27) compared to prior to insertion (28/20), at the same time that the target for tissue sampling can be identified in situ. Additionally, increased microcirculation is identified along the trajectory with LDF. This is accomplished with FluoRa. Conclusions: Intraoperative probe-based spectroscopic measurements quantify 5-ALA fluorescence and thus identify glioblastoma and lymphoma tissue in situ during resection and burr hole needle biopsies. Full article

Background: Different lateral and postero-lateral cranial approaches to the petroclival region and to the mid-upper brain stem have been described so far, some of which require extensive osseous demolition and possible damage of neurovascular structures. Neuronavigational systems are now extensively available for preoperative planning and intraoperative navigation to assist the surgeons in choosing the optimally invasive approach for each pathology. Herein, we describe a detailed navigation-augmented morphometric analysis to bring insight into the usefulness of an anterior petrosectomy (AP) to handle lesions in the petroclival region. Methods: Eight cadaveric, silicone injected heads were used. A total of 14 approaches (AP, n = 8; retrosigmoid, RS, n = 6) using a standard microsurgical dissection technique were performed. All specimens had preoperative CT and MRI scans, as well as a post-dissection CT. The neuronavigational system was used for distance measurements, craniotomy sizes and surgical corridor volumes, for each approach. Results: The distance from the skull surface to the petrous apex was significantly shorter in the AP approach when compared with the RS (46.0 ± 1.9 mm versus 71.3 ± 1.8 mm, respectively, p < 0.001). Although the craniotomy size was not different, the volume of the surgical corridor was significantly larger with the AP approach (21.31 ± 1.91 cm³ vs. 13.39 ± 1.8 cm³). The AP approach increased the length of the basilar artery exposure from 6.9 ± 1.5 mm (obtained with a standard subtemporal approach) to 22.1 ± 1.7 mm (p < 0.0001). Conclusions: The surgical corridor to the petroclival region achieved by virtue of an AP was significantly larger and featured shorter working distances, resulting in a higher degree of surgical freedom. Although significant individual anatomical variations of fundamental neurovascular and bony structures were found, these difficulties were overcome by careful pre- and intraoperative use of neuronavigation. Full article

Background: Stereotactic biopsy of posterior fossa lesions, which are often inoperable, enables a safe trajectory and provides tissue samples for accurate diagnosis, which is crucial for correct treatment since the latest World Health Organization Classification of Tumors of the Central Nervous System from 2021 places immense emphasis on molecular diagnostics. Stereotactic biopsy using the Leksell Vantage headframe is, due to its rigid design, extremely accurate, but stiffer, making the procedure more challenging and the learning curve steeper. Methods: This retrospective analysis demonstrates the introduction of the new Leksell Vantage headframe in day-to-day practice at the University Medical Center in Maribor, Slovenia, in demanding procedures of posterior fossa biopsies, and also provides a review of the literature available on the topic with emphasis on the technical aspect of posterior fossa biopsy using the Leksell Vantage headframe in adults. Results: In the observed series of three patients with posterior fossa lesions, all biopsies were representative, despite tissue samples being small, providing conclusive histopathologic reports (glioblastoma, rosette-forming glioneuronal tumor and metastasis of melanoma) with additional molecular diagnostics. After the initial biopsy case, the preoperative planning times and procedure times were shortened as we learnt about the importance of a tailored approach from the first case. In all cases, the biopsy was performed under local anesthesia with patients being awake throughout surgery. Conclusions: The rigid Leksell Vantage headframe makes access to the posterior fossa tougher when compared to its predecessors. However, the procedure is very accurate but requires precise preoperative planning and a customized approach when placing the headframe. Full article