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1. Frisoli FA, Srinivasan VM, Catapano JS, et al. Vertebrobasilar dissecting aneurysms: microsurgical management in 42 patients. J Neurosurg 2022;137(August):393–401

Dissecting intracranial aneurysms are formed by a longitudinally oriented tear in the arterial wall that creates a false lumen with intramural thrombus and luminal stenosis. Multiple consequences of these aneurysms include vessel thrombosis, thromboembolism, and subarachnoid hemorrhage (SAH). Unlike saccular aneurysms, dissecting aneurysms are not amenable to conventional clipping or coil obliteration. Experiences with endovascular management using VA sacrifice, stent coiling, and flow diversion have shown good results, but fewer modern microsurgical series have been published. Three surgical options exist to treat VBD aneurysms: clip wrapping, bypass trapping, and parent artery occlusion.

The medical records of patients with dissecting aneurysms affecting the intracranial VA (V4), basilar artery, and PICA that were treated microsurgically over a 19-year period were reviewed. Patient demographics, aneurysm characteristics, surgical procedures, and clinical outcomes were analyzed.

Forty-two patients with 42 VBD aneurysms were identified. Twenty-six aneurysms (62%) involved the PICA, 14 (33%) were distinct from the PICA origin on the V4 segment of the VA, and 2 (5%) were located at the vertebrobasilar junction. Thirty-four patients (81%) presented with SAH with a mean Hunt and Hess grade of 3.2 at presentation. Six (14%) of the 42 patients had been previously treated using endovascular techniques. Nineteen aneurysms (45%) underwent clip wrapping, 17 (40%) were treated with bypass trapping, and 6 (14%) underwent parent artery sacrifice. The complete aneurysm obliteration rate was 95% (n = 40), and the surgical complication rate was 7% (n = 3). Good outcomes (mRS score ≤ 2) were observed in 20 patients (48%). Eight patients (19%) died.

These data demonstrate that patients with VBD aneurysms often present after a rupture in poor neurological condition, but favorable results can be achieved with open microsurgical repair in almost half of such cases. Microsurgery remains a viable treatment option.

4 tables, 3 figures with intraop photos, CTA and catheter angiograms

2. Benjamin CG, Gurewitz J, Kavi A, et al. Survival and outcomes in patients with ≥ 25 cumulative brain metastases treated with stereotactic radiosurgery. J Neurosurg 2022;137(August):571–81

In the era in which more patients with greater numbers of brain metastases (BMs) are being treated with stereotactic radiosurgery (SRS) alone, it is critical to understand how patient, tumor, and treatment factors affect functional status and overall survival (OS). The authors examined the survival outcomes and dosimetry to critical structures in patients treated with Gamma Knife radiosurgery (GKRS) for ≥ 25 metastases in a single session or cumulatively over the course of their disease.

The institution’s prospective Gamma Knife (GK) SRS registry was queried to identify patients treated with GKRS for ≥ 25 cumulative BMs between June 2013 and April 2020. Ninety-five patients were identified, and their data were used for analysis.

Ninety-five patients were treated for ≥ 25 cumulative metastases, resulting in a total of 3596 tumors treated during 373 separate treatment sessions. The median number of SRS sessions per patient was 3 (range 1–12 SRS sessions), with nearly all patients (n = 93, 98%) having > 1 session. On univariate analysis, factors affecting OS in a statistically significant manner included histology, tumor volume, tumor number, diagnosis-specific graded prognostic assessment (DS-GPA), brain metastasis velocity (BMV) (the cumulative number of new brain metastases that developed over time since first SRS in years) and need for subsequent whole-brain radiation therapy (WBRT).

Seventy-nine patients (83%) had all treated tumors controlled at last follow-up, reflecting the high and durable control rate. Corticosteroids for tumor or treatment-related effects were prescribed in just over one-quarter of the patients. Of the patients with radiographically proven adverse radiation effects (AREs; 15%), 4 were symptomatic. Four patients required subsequent craniotomy for hemorrhage, progression, or AREs.

In selected patients with a large number of cumulative BMs, multiple courses of SRS are feasible and safe. Together with new systemic therapies, the study results demonstrate that the achieved survival rates compare favorably to those of larger contemporary cohorts, while avoiding WBRT in the majority of patients.

3 figures, 5 tables with no imaging

3. Yoo J, Yoon S-J, Kim KH, et al. Patterns of recurrence according to the extent of resection in patients with IDH–wild-type glioblastoma: a retrospective study. J Neurosurg 2022;137(August):533–43

This single-center study included 358 eligible patients with histologically confirmed isocitrate dehydrogenase (IDH)–wild-type GBM from November 1, 2005, to December 31, 2018. Patients were assigned to one of three separate groups according to EOR: supratotal resection (SupTR), gross-total resection (GTR), and subtotal resection (STR) groups. The patterns of recurrence were classified as local, marginal, and distant based on the range of radiation. The relationship between EOR and recurrence pattern was statistically analyzed.

To determine the patterns of recurrence, they merged simulation CT images containing isodose volumes from RT planning with the MR images used to diagnose the recurrence. Recurrence was categorized along with T1 CE images as follows: local (i.e., infield gross target volume [GTV] within the 60-Gy isodose line and infield clinical target volume [CTV] within the 46-Gy isodose line); marginal, within 2 cm of the 46-Gy isodose line; and distant, all outside the 46-Gy isodose line. Illustrations and clinical examples with isodose lines are shown in Fig. 3 in the manuscript.

Observed tumor recurrence rates for each group were as follows: SupTR group, 63.4%; GTR group, 75.3%; and STR group, 80.5% (p = 0.072). Statistically significant differences in patterns of recurrences among groups were observed with respect to local recurrence (SupTR, 57.7%; GTR, 76.0%; STR, 82.8%; p = 0.036) and distant recurrence (SupTR, 50.0%; GTR, 30.1%; STR, 23.2%; p = 0.028). Marginal recurrence showed no statistical difference between groups. Both overall survival and progression-free survival were significantly increased in the SupTR group compared with the STR and GTR groups.

Whereas novel treatments, including immunotherapy, have recently been attempted, surgical treatment remains one of the most important approaches in the treatment of GBM. In this study on the effects of EOR on GBM recurrence, the authors demonstrated a significant decrease in local recurrence and an increase in distant recurrence as the EOR increased. These findings may aid in making decisions regarding the EOR and adjuvant therapy, help identify patients at risk for recurrence, and inform planned postoperative surveillance imaging.

3 tables and 5 figures, with MRI

4. Charidimou A, Boulouis G, Frosch MP, et al. The Boston criteria version 2.0 for cerebral amyloid angiopathy: a multicentre, retrospective, MRI-neuropathology diagnostic accuracy study. Lancet Neurol 2022;21:71 4–25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/35841910

The clinical and imaging Boston criteria, first introduced in the 1990s and later updated to the modified Boston criteria in 2010, are widely used for the diagnosis of cerebral amyloid angiopathy (CAA). Two independent reviewers did a systematic review of diagnostic accuracy studies that used different versions of the Boston criteria against the reference standard of neuropathologically proven CAA. Studies were restricted to those listed in PubMed published between Sept 15, 1994, and Feb 23, 2022, in the English language.

According to the 2010 version of the criteria a diagnosis of probable CAA entails demonstration of multiple (ie, two or more) hemorrhagic lesions restricted to lobar brain regions, including intracerebral hemorrhage, cerebral microbleeds, and the presence of cortical superficial siderosis. The 2010 criteria have not been validated across the spectrum of CAA clinical presentations and have not systematically incorporated more recently identified MRI features.

The authors derived the Boston criteria version 2.0 (v2.0) by selecting MRI features to optimize diagnostic specificity and sensitivity in a prespecified derivat