World Neurosurg
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The current standard of care for patients with high-grade gliomas includes surgical resection, chemotherapy, and radiation; but even still most patients experience disease progression and succumb to their illness within a few years of diagnosis. Immunotherapy, which stimulates an anti-tumor immune response, has been revolutionary in the treatment of some hematologic and solid malignancies, generating substantial excitement for its potential for patients with glioblastoma. However, to date, the preclinical success of these approaches against high-grade glioma models has not been replicated in human clinical trials. Moreover, the complex response to these biologically active treatments can complicate management decisions, and the neurosurgical oncology community needs to be actively involved in and up to date on the use of these agents in patients with high-grade glioma. In this review, we discuss the challenges immunotherapy faces for high-grade gliomas, the completed and ongoing clinical trials for the major immunotherapies, and the nuances in management for patients being actively treated with one of these agents. ⋯ Although immunotherapy has yet to fully fulfill its promise for patients with glioblastoma and improve patient outcomes, there is still excitement that these approaches will eventually lead to durable anti-tumor responses. As neurosurgeons, an understanding of the complex interactions between the standard of care therapies and the other medications used in the treatment arsenal for patients with high-grade brain tumors is crucial to the management of these patients.
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Review
Case Report and Review of the Literature of Schwannomas that Originate from the Falx Cerebri.
Schwannomas not related to cranial nerves are rare. Here, we present a case of a schwannoma that originated from the falx cerebri and review reported cases in the literature. ⋯ Although distinguishing a schwannoma of the falx cerebri from a falx meningioma and metastasis is difficult preoperatively, inclusion of schwannoma of the falx cerebri in the differential diagnosis is important, especially when the patient is relatively young and/or the tumor lacks a dural tail sign.
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Primary spinal glioblastoma multiforme (GBM) of the conus medullaris is a rare and devastating pathologic entity. The presenting symptoms commonly include progressive neurologic deficits in the lower extremities, bowel and bladder dysfunction, and low back pain. ⋯ However, recent advancements in the field of molecular oncology have been beginning to elucidate a unique molecular blueprint for these spinal gliomas. Given the lack of standardized treatment strategies, we have presented our institutional experience in treating a small series of patients with conus medullaris GBM and have reviewed the reported data on the relevant molecular markers, management strategies, and complication avoidance for this malignant pathologic entity.
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Cerebral venous thrombosis (CVT), a rare cerebrovascular condition, is induced by blocked cerebral venous reflux, often presenting nonspecific symptoms. Magnetic resonance imaging (MRI) of the brain may improve the often elusive diagnosis of CVT. However, the sensitivity, specificity, and full spectrum of such MRI findings are poorly understood. ⋯ We conclude that such cases may occur where CVT appears tumor-like on MRI, including mass effect and abnormal contrast enhancement. Therefore, for young and middle-aged adults with episodic and progressive headaches presenting such MRI findings, the possibility of CVT should always be considered. MRI combined with MR venography should be used as the preferred strategy for early diagnosis of CVT.
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To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case. ⋯ Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.