BACKGROUND: Whether the number or cumulative volume of brain metastases affects survival in patients with metastatic non-small cell lung cancer (NSCLC) remains controversial. We conducted a volume matched multi-center study to determine whether patients with a single metastasis had better outcomes than patients with > 20 brain metastases. METHODS: Between 2014 and 2022, 317 NSCLC patients (21.14% female; single tumor: 278 patients; >20 tumors, 39 patients) underwent stereotactic radiosurgery (SRS). The prescribed margin dose, cumulative tumor volume, 12 Gy volume, and concurrent systematic disease managements were recorded. The overall survival (OS), local tumor control (LTC), adverse radiation effect (ARE) risk, and new tumor development were compared. RESULTS: No difference in OS was found between patients with > 20 brain metastases and patients with a single metastasis (p = 0.61). Compared to the single tumor cohort, where 217 of 278 (78.06%) patients had no recorded local tumor progression, patients with > 20 brain metastases had a local tumor control rate of 76.92% (p = 0.25). Patients with > 20 tumors had a significantly higher rate of distant tumor development (69.2%) after SRS compared to patients with single tumors (35.3%; **p = 0.024). No significant difference of ARE rate was found. CONCLUSION: In this volume matched multi-center study, patients with > 20 tumors showed comparable OS and LTC outcomes compared to patients with single tumors. The number of brain metastases should not be used as a criteria to exclude patients from receiving SRS.

• Keywords
• Adverse radiation effects, Non-small cell lung cancer, Stereotactic radiosurgery,
• MeSH
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Brain Neoplasms * secondary   surgery   radiotherapy   mortality   MeSH
• Lung Neoplasms * pathology   mortality   MeSH
• Follow-Up Studies MeSH
• Carcinoma, Non-Small-Cell Lung * pathology   radiotherapy   mortality   surgery   MeSH
• Radiosurgery * MeSH
• Retrospective Studies MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Treatment Outcome MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Comparative Study MeSH

Craniotomy remains one of the most intricate neurosurgical procedures in both human and veterinary medicine, demanding precise anatomical orientation to minimize risks during and after surgery. Domestic rabbits are widely used as experimental models in neuroscience due to their manageable size. However, craniotomy in rabbits is associated with a range of potential complications. Therefore, it is essential to avoid trauma to the brain parenchyma and cerebral vasculature, preserve the integrity of the dura mater, and minimize both intraoperative and postoperative bleeding. Although several studies have addressed experimental craniotomy techniques, many lack detailed anatomical descriptions for safely accessing specific brain regions while reducing the size of the bone window. The aim of this anatomical study was to describe and document craniotomy approaches in domestic rabbits in detail. Fifteen heads from adult female domestic rabbits were used. The heads were fixed in 10 % neutral buffered formalin for fourteen days. Four surgical approaches were successfully identified and described: the dorsal frontoparietal approach, the transfrontal approach, the cerebellar approach (dorsal occipito-interparietal), and the lateral frontoparietal approach (unilateral and bilateral). These approaches offer refined, reproducible access to targeted intracranial structures while minimizing surgical trauma. The findings of this study support future research in both veterinary and human medicine. Further in vivo validation is recommended to optimize these techniques and promote the development of anatomically guided, low-complication surgical protocols.

• Keywords
• Craniotomy, Experimental neurosurgery, Rabbit brain,
• MeSH
• Rabbits anatomy & histology   surgery   MeSH
• Craniotomy * veterinary   methods   MeSH
• Brain * surgery   anatomy & histology   MeSH
• Neurosurgical Procedures * veterinary   methods   MeSH
• Animals MeSH
• Check Tag
• Rabbits anatomy & histology   surgery   MeSH
• Female MeSH
• Animals MeSH
• Publication type
• Journal Article MeSH

BACKGROUND AND PURPOSE: Preservation of neurocognitive function is gaining importance for patients with brain metastases (BM). Several methods of neuroprotection in radiotherapy of BM have been developed and tested in prospective clinical trials, including stereotactic radiotherapy (SRT), hippocampal-sparing whole-brain radiotherapy (HS-WBRT) and concomitant memantine. The present analysis aimed to assess the current treatment patterns in European countries. MATERIALS AND METHODS: We distributed an online survey among radiation oncologists (ROs) registered within the European Society for Radiotherapy and Oncology (ESTRO). Questions included characteristics of treatment centers and institutional standard operating procedures, focusing on the use of neuroprotective measures. RESULTS: The survey was completed by 234 ROs from 31 countries. WBRT is the preferred treatment modality over SRT for 4-5 BM for 18 % and for 6-10 BM for 53 % of ROs. While HS-WBRT is generally offered by most ROs (85 %), only a minority apply the technique regularly (25 %), and prescription parameters vary considerably. Concomitant memantine is prescribed by 30 % of ROs. Besides concerns about available evidence, limited staff capacity and reimbursement issues constitute frequent obstacles. Boost treatments as part of WBRT are rarely performed on a regular basis (22 %). Prognostic scores are used by a majority of ROs, while cognitive tests are not. There were significant differences between higher- and lower-income countries, and between university hospitals and other centers. CONCLUSION: There is considerable heterogeneity regarding neuroprotective radiotherapy approaches in European countries and regular application is limited. Besides clinical trial results, improved technical availability and reimbursement might be required to improve their utilization for BM treatment.

• Keywords
• Brain metastases, Clinical practice patterns, Hippocampus, Memantine, Neuroprotection, Radiotherapy, Stereotactic radiotherapy, Survey,
• MeSH
• Cranial Irradiation * methods   MeSH
• Practice Patterns, Physicians' * statistics & numerical data   MeSH
• Humans MeSH
• Memantine therapeutic use   MeSH
• Brain Neoplasms * radiotherapy   secondary   MeSH
• Neuroprotection * MeSH
• Surveys and Questionnaires MeSH
• Radiosurgery methods   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Geographicals
• Europe MeSH
• Names of Substances
• Memantine MeSH

OBJECTIVE: The objective of this study was to develop a deep learning model for automated pituitary adenoma segmentation in MRI scans for stereotactic radiosurgery planning and to assess its accuracy and efficiency in clinical settings. METHODS: An nnU-Net-based model was trained on MRI scans with expert segmentations of 582 patients treated with Leksell Gamma Knife over the course of 12 years. The accuracy of the model was evaluated by a human expert on a separate dataset of 146 previously unseen patients. The primary outcome was the comparison of expert ratings between the predicted segmentations and a control group consisting of original manual segmentations. Secondary outcomes were the influence of tumor volume, previous surgery, previous stereotactic radiosurgery (SRS), and endocrinological status on expert ratings, performance in a subgroup of nonfunctioning macroadenomas (measuring 1000-4000 mm3) without previous surgery and/or radiosurgery, and influence of using additional MRI modalities as model input and time cost reduction. RESULTS: The model achieved Dice similarity coefficients of 82.3%, 63.9%, and 79.6% for tumor, normal gland, and optic nerve, respectively. A human expert rated 20.6% of the segmentations as applicable in treatment planning without any modifications, 52.7% as applicable with minor manual modifications, and 26.7% as inapplicable. The ratings for predicted segmentations were lower than for the control group of original segmentations (p < 0.001). Larger tumor volume, history of a previous radiosurgery, and nonfunctioning pituitary adenoma were associated with better expert ratings (p = 0.005, p = 0.007, and p < 0.001, respectively). In the subgroup without previous surgery, although expert ratings were more favorable, the association did not reach statistical significance (p = 0.074). In the subgroup of noncomplex cases (n = 9), 55.6% of the segmentations were rated as applicable without any manual modifications and no segmentations were rated as inapplicable. Manually improving inaccurate segmentations instead of creating them from scratch led to 53.6% reduction of the time cost (p < 0.001). CONCLUSIONS: The results were applicable for treatment planning with either no or minor manual modifications, demonstrating a significant increase in the efficiency of the planning process. The predicted segmentations can be loaded into the planning software used in clinical practice for treatment planning. The authors discuss some considerations of the clinical utility of the automated segmentation models, as well as their integration within established clinical workflows, and outline directions for future research.

• Keywords
• Leksell Gamma Knife, automated segmentation, machine learning, pituitary adenoma, pituitary surgery, stereotactic radiosurgery,
• MeSH
• Adenoma * diagnostic imaging   radiotherapy   surgery   MeSH
• Deep Learning * MeSH
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Magnetic Resonance Imaging methods   MeSH
• Pituitary Neoplasms * diagnostic imaging   radiotherapy   surgery   MeSH
• Radiosurgery * methods   MeSH
• Aged MeSH
• Artificial Intelligence * MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH

PURPOSE: Bladder cancer rarely metastasizes to the brain. This study was performed to evaluate stereotactic radiosurgery (SRS) for the management of bladder cancer brain metastases. METHODS: Cases of bladder cancer brain metastases treated with SRS were collected by members of the International Radiosurgery Research Foundation (IRRF) and outcome data was analyzed for patients with at least one clinical or imaging follow-up. RESULTS: 103 patients received SRS for 301 brain metastases. Median age at SRS was 68 and 73.8% of patients were male. Median KPS was 80%. Median time from primary to brain metastases diagnosis was 18 months. At the time of SRS, 50% of patients had other systemic metastases. The median number of metastases treated was 1, and median cumulative SRS volume was 1.16 cc. Most patients had single fraction SRS using a median margin dose of 18 Gy. At the time of analysis, 9.7% of patients were alive. Median survival after SRS was 7 months. Local control was achieved for 89.3% of metastases, 42% of patients developed new remote brain metastases, and 4.9% had leptomeningeal dissemination. Subsequent management included repeat SRS in 21.7%, surgical resection in 8.8% and WBRT in 7.6% of patients. At last follow-up, 32.1% of patients had improvement of their symptoms, whereas 38.5% remained stable. Adverse radiation effects occurred in 4.3% of treated metastases. On multivariate analyses, KPS ≥ 80% and non-urothelial histology predicted improved survival, while absence of corticosteroid intake predicted longer tumor control. CONCLUSION: Bladder cancer brain metastases can be safely managed with SRS.

• Keywords
• Bladder cancer, Brain metastases, Gamma knife, Stereotactic radiosurgery,
• MeSH
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Urinary Bladder Neoplasms * pathology   MeSH
• Brain Neoplasms * secondary   surgery   mortality   MeSH
• Follow-Up Studies MeSH
• Radiosurgery * methods   MeSH
• Retrospective Studies MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Treatment Outcome MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH

Extra-intracranial bypass represents a controversial yet significant component of neurosurgical treatment for cerebrovascular diseases. The indications are moyamoya dis-ease, steno-occlusive atherosclerotic disease of the internal carotid artery, acute ischemic stroke, and, more rarely, complex intracranial aneurysms and skull base tumors. Although historical studies have yielded mixed results and limited its use, modern diagnostic and surgical techniques are reopening the path for selective application of bypass in high-risk patients. A clear indication is the rare moyamoya disease, where bypass is a proven method for preventing ischemic or hemorrhagic strokes. In patients with symptomatic chronic internal carotid artery occlusion and exhausted cerebrovascular reserve, bypass may serve as a potential treatment modality, provided it is carefully indicated -through comprehensive specialized evaluation. Emergent bypass should be considered for a narrow group of patients with acute ischemic stroke when standard treatment fails or is not feasible. Despite ongoing debate, extra-intracranial bypass remains an essential part of cerebrovascular surgery. The key to success lies in the proper selection of patients and precise microsurgical execution. Modern approaches and technologies help reduce the risk of complications and enhance the effectiveness of this intervention, offering hope to patients with otherwise limited treatment options.

• Keywords
• carotid occlusion, extra-intracranial bypass, moyamoya, revascularization, stroke,
• MeSH
• Cerebrovascular Disorders * surgery   MeSH
• Humans MeSH
• Neurosurgical Procedures * methods   MeSH
• Cerebral Revascularization * methods   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH

OBJECTIVE: The management of unruptured intracranial aneurysms (UIA) is complex, balancing the risks of surgical intervention against aneurysm rupture. The PHASES, ELAPSS, and UIATS scoring systems have been developed to assist in clinical decision-making, but their efficacy in predicting surgical outcome remains unclear. METHODS: In this monocentric, retrospective, observational study, we included 380 patients with UIA from January 2010 to January 2021. We assessed the predictive value of the PHASES, ELAPSS, and UIATS scores in determining clinical outcome post-surgery, including different variables. Statistical analyses, including Principal Component Analysis and Multiple logistic and linear regression, were employed to analyze the data. RESULTS: Our cohort of 380 predominantly female patients (71.3%) had a mean age of 54.7 years. The PHASES and UIATS pro-conservative scores were significant predictors of poor clinical outcome (p = 0.03 and p = 0.04, respectively), while the ELAPSS score was predictive of new neurological deficits post-surgery (p = 0.01). Aneurysm size was significantly associated with new neurological deficits but not with long-term clinical performance/outcome. CONCLUSIONS: The study underscores the utility of PHASES, ELAPSS, and UIATS scores in preoperative risk stratifications. Conservative PHASES and UIATS scores were associated with poor outcome, therefore supporting their predictive value of non-operative management. Our findings suggest the routine implementation of these scores into clinical practice could improve the management of UIAs.

• Keywords
• ELAPSS score, PHASES score, Predictive analysis, Surgical outcome, UIATS score, Unruptured intracranial aneurysms,
• MeSH
• Adult MeSH
• Intracranial Aneurysm * surgery   MeSH
• Clinical Decision-Making * methods   MeSH
• Middle Aged MeSH
• Humans MeSH
• Microsurgery * methods   MeSH
• Neurosurgical Procedures * methods   MeSH
• Retrospective Studies MeSH
• Aged MeSH
• Treatment Outcome MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Observational Study MeSH

AIMS: Stereotactic arrhythmia radioablation (STAR) has emerged as bail-out treatment for ventricular tachycardia (VT). Accurate, reproducible, and easy-to-use data transfer from electroanatomical mapping (EAM) systems to radiotherapy planning CT is desirable. We aim to evaluate interobserver variability, ease of use, and learning curve for EAM based target volume (CardTV-EPinv) creation and transfer using available software packages. METHODS AND RESULTS: In patients considered for STAR, CardTV-EPinv were created using ADAS and Slicer3D for workflow comparison. Four CardTV-EPinv (clinically targeted volume and three mock targets) were created by an experienced operator and a 2nd-year medical student, based on endocardial EAM tags indicating VT substrate location. CardTV-EPinv sizes, Hausdorff distances (HDs), and workflow duration were measured to assess interobserver variability and learning curve. Agreement between CardTV-EPinv was high using ADAS and Slicer3D workflows (HD 3.64 mm [2.7-4.5]). ADAS workflow was faster and more robust (ADAS 26 min [24-29] vs. Slicer3D 65 min [61-70], P < 0.001; system crashes: ADAS 0 vs. Slicer3D 7). In 20 patients (80% non-ischaemic cardiomyopathy, LVEF 35 ± 14%), 80 CardTV-EPinv were created using ADAS. CardTV-EPinv size was similar for both observers (11.8 mL [10.1-13.7] vs. 10.7 mL [9.6-11.8], P = 0.17), with high interobserver agreement (HD 1.68 mm [1.45-1.96]; 95th percentile HD < 4.8 mm [3.5-5.7]). Linear regression showed a steep learning curve for the student (P = 0.01). CONCLUSION: CardTV-EPinv creation showed excellent interobserver agreement and was faster and more robust using ADAS than 3D slicer. The steep learning curve appears clinically relevant given the limited use of STAR even in high-volume VT ablation centres.

• Keywords
• Ablation, Interobserver variability in imaging and EAM merging, STAR, Stereotactic arrhythmia radioablation, Ventricular tachycardia,
• MeSH
• Electrophysiologic Techniques, Cardiac MeSH
• Tachycardia, Ventricular * physiopathology   surgery   diagnostic imaging   radiotherapy   diagnosis   MeSH
• Learning Curve * MeSH
• Humans MeSH
• Observer Variation MeSH
• Radiotherapy Planning, Computer-Assisted * methods   MeSH
• Tomography, X-Ray Computed MeSH
• Predictive Value of Tests MeSH
• Workflow MeSH
• Radiosurgery * methods   MeSH
• Reproducibility of Results MeSH
• Software * MeSH
• Treatment Outcome MeSH
• Check Tag
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

• Keywords
• ERAS for craniotomy, ERAS global perspective, enhanced recovery in craniotomy, hospital cost reduction, hospital length of stay,
• MeSH
• Length of Stay MeSH
• Craniotomy * methods   MeSH
• Humans MeSH
• Enhanced Recovery After Surgery * MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH

BACKGROUND: There is a paucity of data on treatment outcomes following stereotactic radiosurgery (SRS) for brain metastases from sarcoma primaries. METHODS: The International Radiosurgery Research Foundation member-sites were queried for patients with brain metastases from sarcoma primaries treated with SRS. Overall survival (OS) and local control (LC) were calculated via Kaplan-Meier analysis. Univariate analyses examined prognostic factors associated with LC and OS via log-rank t-tests and multivariate analyses (MVA) via Cox proportional hazards model. RESULTS: A total of 146 patients with 309 brain metastases were identified. Two-hundred and thirty lesions were treated with single-fraction SRS with a median dose of 20 Gy (15-24 Gy). Ninety-five patients had extracranial metastases, including 75 oligometastatic patients. One- and 2-year OS and LC rates were 47.7% and 37.3%, and 78.3% and 62.2%, respectively. On univariate analyses, superior 1-year OS was noted among leiomyosarcomas (69.7% vs. 42.6%; p = .02) with poorer outcomes among pleomorphic histologies (10.5% vs. 50.7%; p = .002). Pleomorphic histologies were associated with poorer OS on MVA (hazard ratio [HR], 3.13; p = .006). On MVA, LC was inferior among patients of age ≥45 years (HR, 3.78; p < .001) and superior among leiomyosarcomas (HR, 0.31; p = .03). OS was prognosticated based on adverse factors (ie, nonleiomyosarcoma histology and progressive extracranial metastases). Two-year OS for patients with and without adverse features were 78.6% and 31.5%, respectively. CONCLUSIONS: LC outcomes were driven by histology and age with superior LC among leiomyosarcomas and patients of age <45 years. OS was driven by nonleiomyosarcoma histology and the presence of progressive extracranial disease.

• Keywords
• brain metastases, local control, overall survival, sarcoma primary, stereotactic radiosurgery,
• MeSH
• Adult MeSH
• Kaplan-Meier Estimate MeSH
• Middle Aged MeSH
• Humans MeSH
• Young Adult MeSH
• Brain Neoplasms * secondary   radiotherapy   mortality   surgery   MeSH
• Prognosis MeSH
• Radiosurgery * methods   MeSH
• Retrospective Studies MeSH
• Sarcoma * pathology   mortality   radiotherapy   secondary   MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Treatment Outcome MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Young Adult MeSH
• Male MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH