A case of anaplastic pleomorphic xanthoastrocytoma (PXA) in a 9-year-old girl is reported. Histological features of PXAs are cellular pleomorphism of GFAP-positive cells, with intracytoplasmic lipidic vacuoles and a reticulin network, bizarre giant cells, low mitotic activity, and lack of necrosis and of endothelial vascular proliferations. These tumors are generally reported to have a favorable postoperative course. In our case, a poor clinical prognosis and spread of the illness through the CSF was observed. Immunohistochemical features of the tumor, which were histologically anaplastic in nature, were analyzed. There were small foci of necrosis in the sections of the material obtained at the first operation and extensive necrosis in that from the second operation, although the patient had not received radiotherapy between the operations. The presence of necrosis in PXA is an uncommon and significant feature. It predicts the poor prognosis seen in this case, and therefore this report strongly supports the notion that necrosis should automatically exclude a tumor from the PXA category. The histological grade was evaluated as grade 3 (according to the WHO classification).

Background The COVID-19 pandemic confronts healthcare workers, including neurosurgeons, with difficult choices regarding which patients to treat. Methods In order to assist ethical triage, this article gives an overview of the main considerations and ethical principles relevant when allocating resources in times of scarcity. Results We discuss a framework employing four principles: prioritizing the worst off, maximizing benefits, treating patients equally, and promoting instrumental value. We furthermore discuss the role of age and comorbidity in triage and highlight some principles that may seem intuitive but should not form a basis for triage. Conclusions This overview is presented on behalf of the European Association of Neurosurgical Societies and can be used as a toolkit for neurosurgeons faced with ethical dilemmas when triaging patients in times of scarcity.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. Methods We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. Results We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. Conclusion Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

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