Traditional deep brain stimulation requires intraoperative neurophysiological confirmation of electrode placement. Recently, purely image guided methods are being evaluated as to their clinical efficacy in comparison to surgery using microelectrode recordings. We used the ClearPoint(®) system to place electrodes in both the subthalamic nucleus and globus pallidus internus in patients with advanced Parkinson's disease. Off medication UPDRS scores were assessed before and 1 year after surgery as well as pre- and 1 year post-operative neuropsychological outcomes. Targeting precision was also assessed. Patients implanted in the subthalamic nucleus improved by 46.2 % in their UPDRS scores post-operatively (p = 0.03) whereas the globus pallidus group improved by 41 % (p = 0.06). There were no significant adverse neuropsychological outcomes in either group of patients. Mean radial error for the STN group was 1.2 ± 0.7 mm and for the GPi group 0.8 mm ± 0.3 mm. Image guided DBS using the ClearPoint(®)system has high targeting precision with robust clinical outcomes. Our data are in accord with recent studies using the same or similar technologies and provide a rationale for a large comparative study of image-guided versus microelectrode guided DBS.

OBJECTIVE Recent studies have demonstrated that periventricular tumor location is associated with poorer survival and that tumor location near the ventricle limits the extent of resection. This finding may relate to the perception that ventricular entry leads to further complications and thus surgeons may choose to perform less aggressive resection in these areas. However, there is little support for this view in the literature. This study seeks to determine whether ventricular entry is associated with more complications during craniotomy for brain tumor resection. METHODS A retrospective analysis of patients who underwent craniotomy for tumor resection at Henry Ford Hospital between January 2010 and November 2012 was conducted. A total of 183 cases were reviewed with attention to operative entry into the ventricular system, postoperative use of an external ventricular drain (EVD), subdural hematoma, hydrocephalus, and symptomatic intraventricular hemorrhage (IVH). RESULTS Patients in whom the ventricles were entered had significantly higher rates of any complication (46% vs 21%). Complications included development of subdural hygroma, subdural hematoma, intraventricular hemorrhage, subgaleal collection, wound infection, urinary tract infection/deep venous thrombosis, hydrocephalus, and ventriculoperitoneal (VP) shunt placement. Specifically, these patients had significantly higher rates of EVD placement (23% vs 1%, p < 0.001), hydrocephalus (6% vs 0%, p = 0.03), IVH (14% vs 0%, p < 0.001), infection (15% vs 5%, p = 0.04), and subgaleal collection (20% vs 4%, p < 0.001). It was also observed that VP shunt placement was only seen in cases of ventricular entry (11% vs 0%, p = 0.001) with 3 of 4 of these patients having a large ventricular entry (defined here as entry greater than a pinhole [< 3 mm] entry). Furthermore, in a subset of glioblastoma patients with and without ventricular entry, Kaplan-Meier estimates for survival demonstrated a median survival time of 329 days for ventricular entry compared with 522 days for patients with no ventricular entry (HR 1.13, 95% CI 0.65-1.96; p = 0.67). CONCLUSIONS There are more complications associated with ventricular entry during brain tumor resection than in nonviolated ventricular systems. Better strategies for management of periventricular tumor resection should be actively sought to improve resection and survival for these patients.

OBJECTIVE Severe traumatic brain injury (TBI) is a dynamic neuropathologic process in which a substantial proportion of patients die within the first 48-hours. The assessment of injury severity and prognosis are of primary concern in the initial management of severe TBI. Supplemental testing that aids in the stratification of patients at high risk for deterioration may significantly improve posttraumatic management in the acute setting. METHODS This retrospective study assessed the utility of both single-marker and multimarker models as predictive indicators of acute clinical status after severe TBI. Forty-four patients who sustained severe TBI (admission Glasgow Coma Scale [GCS] score ≤8) were divided into two cohorts according to a dichotomized clinical outcome at 72 hours after admission: Poor status (death or GCS score ≤8) and improved status (GCS score improved to >8). Threshold values for clinical status prediction were calculated for serum S-100B, matrix metalloproteinase-9, and plasma D-dimer, upon admission and at 24 hours after TBI by the use of receiver operating characteristic analysis. Performance characteristics of these single-marker predictors were compared with those derived from a multimarker logistic regression analysis. RESULTS Biomarkers with the greatest predictive value for poor status at 72 hours included serum S-100B on admission, as well as plasma D-dimer and serum S-100B at 24 hours, for which, associations were strongly significant. Multimarker analysis indicated no substantial improvement in prediction accuracy over the best single predictors during this time frame. CONCLUSION In conjunction with other clinical, physical, and radiologic evidence, blood-derived biochemical markers may serve to enhance prediction of early clinical trends after severe TBI.

11 The majority of Grade I meningiomas behave in an indolent manner and can be completely removed by resective surgery, or their growth can be controlled by radiation therapy. A small percentage of meningiomas are Grades II and III, which have variable growth patterns and are likely to recur after initial treatment. Grade III meningiomas are considered to be anaplastic (malignant) and warrant aggressive management. Unfortunately, there are limited treatment options beyond surgery and radiation for patients with Grades II and III meningiomas. In many patients the Grade II meningioma will gradually convert to Grade III. Initial treatment(s) will fail in most patients with Grade III meningiomas, and they will ultimately succumb to recurrent and progressive tumor. In this report, we present an encouraging case of a patient who-after 5 intracranial surgeries and 3 stereotactic radiation treatments for malignant meningioma-has had stable disease for 3.5 years following the initiation of octreotide therapy. We also review the current treatment options for recurrent malignant meningioma. case report History and ExaminationIn 1994, a 35-year-old woman presented with worsening seizures and was found to have a right frontal mass, which was embolized and subsequently resected. Histological examination demonstrated a proliferation of relatively uniform, bland meningothelial cells that were frequently arranged as the characteristic whorls ( Fig. 1). At most, we identified 2 mitoses per 10 hpf (magnification ×400). A thin rim of brain tissue was present and did not show invasion by the meningioma. Per the 2007 WHO Classification of Tumours of the Central Nervous System guidelines, 11 this tumor was consistent with the diagnosis of a Grade I meningioma. In 1998, the patient experienced a small recurrence that was treated by Gamma Knife radiosurgery with 16 Gy to the 90% isodose line. Subsequent progression at the treated site led to additional radiosurgery in 2002 (16 Gy to the 15% isodense line) and 2004 (15 Gy to the 40% isodense line).In 2008, the tumor continued to progress and was noted primarily on the right side of the falx and extending slightly across the midline, occluding the sagittal sinus ( Fig. 2A). The next intervention was embolization followed by resection leading to minimal residual tumor at the posterior aspect of the involved sagittal sinus (Fig. 2B). Histological examination revealed an atypical meningioma (WHO Grade II; Fig. 2C) with marked cytological atypia, up to 6 mitoses per 10 hpf, and a Ki 67 labeling index of approximately 30% in the most active areas. Repeat MRI 2 months postoperatively demonstrated an increased size of the residual tumor. Stereotactic radiation was recomabbreviatioNs PBS = phosphate-buffered saline; SST = somatostatin receptor. submitted October 1, 2014. accepted January 28, 2015. iNclude wheN citiNg Published online August 14, 2015; DOI: 10.3171/2015.1.JNS142260. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the ...