Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.

Together, these results demonstrate that human gliomas contain multiple populations of cells with the capacity to form tumors and specifically identify a population of tumorigenic A2B5+ cells that are phenotypically distinct from CD133+ cells.

Primary spinal primitive neuroectodermal tumors (PNETs) are uncommon malignancies that are increasingly reported in the literature. Spinal PNETs, like their cranial counterparts, are aggressive tumors and patients with these tumors typically have short survival times despite maximal surgery, chemotherapy, and radiation. Because no standard management guidelines exist for treating these tumors, a multitude of therapeutic strategies have been employed with varying success. In this study the authors perform a comprehensive review of the literature on primary spinal PNETs and provide 2 new cases that highlight the salient features of their clinical management.

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BACKGROUND Cerebral bypass operation is a technically challenging operation that requires excellent surgical visibility and efficient ergonomics to minimize complications and maximize successful revascularization. Despite the operative microscope's utilization for the past two generations, there remains a need for continued improvement in operative visualization and surgical ergonomics. OBJECTIVE To report the positives and negatives of our initial experience using a novel 4 K high-definition (4K-HD) 3-dimensional (3D) exoscope (EX) for cranial bypass surgery. METHODS A retrospective review over 6 mo was performed of all patients who have undergone cerebral bypass surgery at a single institution using the 4K-HD 3D EX. Advantages and disadvantages of the EX and clinical outcome of the patients were assessed. RESULTS A total of 5 patients underwent cerebral EC-IC bypass surgery with no EX-related complications and successful revascularization. The lightweight design of the EX allowed for easy instrument maneuverability as well as uncomplicated surgical set up in the operating room. The assistance of the cosurgeon was significantly more efficient compared to that of the operating microscope. The large monitor allowed for an immersive, collaborative, and valuable educational surgical experience. CONCLUSION Using the EX for cerebral bypass surgery, with 3D ultra-high-definition optics, enhancements of ergonomics, and improved training, we believe that the 3D 4K-HD EX may represent the next generation of operative scopes in microneurosurgery.

Pilocytic astrocytoma is a slow-growing, circumscribed glioma that most frequently occurs within the pediatric population. In general, surgical resection for pilocytic astrocytoma is thought to be curative with tumor recurrence or malignant transformation being relatively rare. However, there have been very few studies specifically looking at the prognosis for adult patients diagnosed with pilocytic astrocytoma. To evaluate the frequency of recurrence and malignant transformation of pilocytic astrocytoma in adults, we performed a retrospective analysis of all adult patients who underwent surgical resection for this tumor at our institution over a period of 10 years. In our cohort of 20 patients, there were 6 (30%) recurrences with four patients requiring repeat surgery due to symptomatic progression. Relatively rapid recurrences were noted with the median time to recurrence being 16.5 months. All recurrences occurred within 4 years of initial surgery while patients requiring repeat surgery presented within 17 months of initial surgery. Based on this study estimated rates of freedom from recurrence (FFR) at 12 and 24 months after initial surgery are 94 +/- 5% and 76 +/- 10%, respectively. A high rate of malignant transformation was observed in the patients that underwent repeat surgery with 75% (3/4) progressing to anaplastic astrocytoma on pathological examination. This study provides further evidence that the clinical course of a subset of adult patients with pilocytic astrocytoma will not be benign. The potential for rapid tumor recurrence and malignant transformation necessitates careful post-operative follow-up for adult patients with this tumor.

OBJECT While extent of resection has been shown to correlate with outcomes after myxopapillary ependymoma (MPE) resection, the effect of capsular violation has not been well studied. The role of adjuvant radiation also remains controversial. In this paper the authors' goals were to evaluate outcomes following resection of MPE based on intraoperative capsular violation and to explore the role of adjuvant radiotherapy in cases of capsular violation. METHODS A retrospective review of patients undergoing resection of MPE at 2 academic institutions between 1990 and 2013 was performed. Cases with dissemination at presentation, less than 12 months of follow-up, or incomplete records were excluded. Extent of resection was defined as en bloc if all visible tumor was removed without capsular violation, gross-total resection (GTR) if all visible tumor was removed, but with capsular violation, and subtotal resection (STR) if a known residual was left at the time of surgery. Postoperative MR images were reviewed to confirm the extent of resection. Primary outcomes were progression-free survival (PFS) and overall recurrence rates. The effects of extent of resection, capsular violation, and adjuvant radiotherapy on recurrence rates and PFS were analyzed using Kaplan-Meier statistics. Associations between recurrence and preoperative variables were evaluated using Fisher exact methods and t-tests where appropriate. RESULTS Of the 107 patients reviewed, 58 patients (53% were male) met inclusion criteria. The mean age at surgery was 40.8 years (range 7–68 years). The median follow-up was 51.5 months (range 12–243 months). Extent of resection was defined as en bloc in 46.5% (n = 27), GTR in 34.5% (n = 20), and STR in 18.9% (n = 11). No recurrences were noted in the en bloc group, compared with 15% (n = 3) and 45% (n = 5) in the GTR and STR groups. En bloc resection was achieved most frequently in tumors involving the conus. Twelve patients (20%) underwent adjuvant radiotherapy following either STR or GTR. The overall recurrence rate was 13.8% (n = 8), and the 5-year PFS was 81%. Capsular violation was associated with a higher recurrence rate (p = 0.005). Adjuvant radiotherapy showed a nonsignificant trend of lower recurrence rates (16.7% vs 31.6%, p = 0.43) and longer PFS at 5 years (83.3% vs 49.9%, p = 0.16) in cases of capsular violation. CONCLUSIONS A strong correlation between capsular violation and recurrence was found following removal of MPE and should be assessed when defining extent of resection in future studies. Although the use of adjuvant radiotherapy in cases of capsular violation showed a trend toward improved PFS, further investigation is needed to establish its role as salvage therapy also appears to be effective at halting disease progression.

Background Pituicytomas are rare tumors of the sellar region that are derived from specialized glial cells called pituicytes. They characteristically exhibit spindle cell features and fascicular or storiform patterns of growth. No other histological variants of this tumor have been described. Case Description Here we report a diagnostically challenging case of pituicytoma in a 42 year-old man with a sellar mass arising from the pituitary stalk. On histological examination, the tumor displayed an epithelioid histoarchitecture with no characteristic spindle cell or fascicular growth features. Strong immunopositivity for the pituicyte marker thyroid transcription factor-1 (TTF-1) within tumor cells proved essential for diagnosing this unusual pituicytoma variant. Conclusion Pituicytomas may display epithelioid rather than fascicular or storiform histoarchitecture. Epithelioid pituicytoma variants may be diagnosed in cases such as ours where both the clinical findings and immunohistochemical analysis suggest a tumor derived from pituicytes.