Background: Due to demographic changes and an increased incidence of cancer with age, the number of patients with brain metastases (BMs) constantly increases, especially among the elderly. Novel systemic therapies, such as immunotherapy, have led to improved survival in recent years, but intracranial tumor progression may occur independently of a systemically effective therapy. Despite the growing number of geriatric patients, they are often overlooked in clinical trials, and there is no consensus on the impact of BM resection on survival.Objectives: The aim of this study was to analyze the impact of resection and residual tumor volume on clinical outcome and overall survival (OS) in elderly patients suffering from BM.Methods: Patients ≥ 75 years who had surgery for BM between April 2007 and January 2020 were retrospectively included. Residual tumor burden (RTB) was determined by segmentation of early postoperative brain MRI (72 h). Contrast-enhancing tumor subvolumes were segmented manually. “Postoperative tumor volume” refers to the targeted BMs. Impact of preoperative Karnofsky performance status scale (KPSS), age, sex and RTB on OS was analyzed. Survival analyses were performed using Kaplan-Meier estimates for the univariate analysis and the Cox regression proportional hazards model for the multivariate analysis.Results: One hundred and one patients were included. Median age at surgery was 78 years (IQR 76-81). Sixty-two patients (61%) had a single BM; 16 patients (16%) had two BMs; 13 patients (13%) had three BMs; and 10 patients (10%) had more than three BMs. Median preoperative tumor burden was 10.3 cm³ (IQR 5–25 cm³), and postoperative tumor burden was 0 cm³ (IQR 0–1.1 cm³). Complete cytoreduction (RTB = 0) was achieved in 52 patients (52%). Complete resection of the targeted metastases was achieved in 78 patients (78%). Median OS was 7 months (IQR 2–11). In univariate analysis, high preoperative KPSS (HR 0.986, 95% CI 0.973–0.998, p = 0.026) and small postoperative tumor burden (HR 1.025, 95% CI 1.002–1.047, p = 0.029) were significantly associated with prolonged OS. Patients with RTB = 0 survived significantly longer than those with residual tumor did (12 [IQR 5–19] vs. 5 [IQR 3–7] months, p = 0.007). Furthermore, prolongation of survival was significantly associated with surgery in patients with favorable KPSS, with an adjusted HR of 0.986 (p = 0.026). However, there were no significances regarding age.Conclusions: RTB is a strong predictor for prolonged OS, regardless of age or cancer type. Postoperative MRI should confirm the extent of resection, as intraoperative estimates do not warrant a complete resection. It is crucial to aim for maximal cytoreduction to achieve the best long-term outcomes for these patients, despite the fact the patients are advanced in age.

Many patients with high-grade gliomas (HGG) are of older age. We hypothesize that pre- and intraoperative mapping and monitoring preserve functional status in elderly patients while gross total resection (GTR) is the aim, resulting in overall survival (OS) rates comparable to the general population with HGG. We subdivided a prospective cohort of 168 patients above 65 years with eloquent high-grade gliomas into four groups ([years/cases] 1: 65–69/58; 2: 70–74/47; 3: 75–79/43; 4: >79/20). All patients underwent preoperative noninvasive mapping, which was also used for decision-making, intraoperative neuromonitoring in 138 cases, direct cortical and/or subcortical motor mapping in 66 and 50 cases, and awake language mapping in 11 cases. GTR and subtotal resection (STR) could be achieved in 65% and 28%, respectively. Stereotactic biopsy was performed in 8% of cases. Postoperatively, we found transient and permanent functional deficits in 13% and 11% of cases. Postoperative Karnofsky Performance Scale (KPS) did not differ between subgroups. Patients with long-term follow-up (51%) had a progression-free survival of 5.5 (1–47) months and an overall survival of 10.5 (0–86) months. The interdisciplinary glioma treatment in the elderly is less age-dependent but must be adjusted to the functional status. Function-guided surgical resections could be performed as usual, with maximal tumor resection being the primary goal. However, less network capacity in the elderly to compensate for deficits might cause higher rates of permanent deficits in this group of patients with more fast-growing malignant gliomas.

Introduction: Intraoperative neuromonitoring (IOM) of motor/somatosensory evoked potentials is a wellestablished approach for reducing ischemic complications after aneurysm clipping. Research question: To determine the predictive validity of IOM for postoperative functional outcome and its perceived added value for intraoperative real-time feedback of functional impairment in the surgical treatment of unruptured intracranial aneurysms (UIAs). Material and methods: Prospective study of patients scheduled for elective clipping of UIAs between 02/2019-02/ 2021. Transcranial motor evoked potentials (tcMEP) were used in all cases, a significant decline was defined as loss of & GE;50% in amplitude or 50% latency increase. Clinical data were correlated to postoperative deficits. A surgeon's questionnaire was conceived. Results: 47 patients were included, median age 57 years (range 26-76). IOM was successful in all cases. In 87.2%, IOM was stable throughout surgery, although 1 patient (2.4%) demonstrated a permanent postoperative neurological deficit. All patients with an intraoperatively reversible tcMEP-decline (12.7%) showed no surgery-related deficit, regardless of the decline duration (range 0.5-40.0 min; mean: 13.8). Temporary clipping (TC) was performed in 12 cases (25.5%), with a decline in amplitude in 4 patients. After clip-removal, all amplitudes returned to baseline. IOM provided the surgeon with a higher sense of security in 63.8%. Discussion and conclusion: IOM remains invaluable during elective microsurgical clipping, particularly during TC of MCA and AcomA-aneurysms. It alerts the surgeon of impending ischemic injury and offers a way of maximizing the time frame for TC. IOM has highly increased surgeons' subjective feeling of security during the procedure.

Background: Graded Prognostic Assessment (GPA) has been proposed for various brain metastases (BMs) tailored to the primary histology and molecular profiles. However, it does not consider whether patients have been operated on or not and does not include surgical outcomes as prognostic factors. The residual tumor burden (RTB) is a strong predictor of overall survival. We validated the GPA score and introduced “volumetric GPA” in the largest cohort of operated patients and further explored the role of RTB as an additional prognostic factor. Methods: A total of 630 patients with BMs between 2007 and 2020 were included. The four GPA components were analyzed. The validity of the original score was assessed using Cox regression, and a modified index incorporating RTB was developed by comparing the accuracy, sensitivity, specificity, F1-score, and AUC parameters. Results: GPA categories showed an association with survival: age (p < 0.001, hazard ratio (HR) 2.9, 95% confidence interval (CI) 2.5–3.3), Karnofsky performance status (KPS) (p < 0.001, HR 1.3, 95% CI 1.2–1.5), number of BMs (p = 0.019, HR 1.4, 95% CI 1.1–1.8), and the presence of extracranial manifestation (p < 0.001, HR 3, 95% CI 1.6–2.5). The median survival for GPA 0–1 was 4 months; for GPA 1.5–2, it was 12 months; for GPA 2.5–3, it was 21 months; and for GPA 3.5–4, it was 38 months (p < 0.001). RTB was identified as an independent prognostic factor. A cut-off of 2 cm³ was used for further analysis, which showed a median survival of 6 months (95% CI 4–8) vs. 13 months (95% CI 11–14, p < 0.001) for patients with RTB > 2 cm³ and <2 cm³, respectively. RTB was added as an additional component for a modified volumetric GPA score. The survival rates with the modified GPA score were: GPA 0–1: 4 months, GPA 1.5–2: 7 months, GPA 2.5–3: 18 months, and GPA 3.5–4: 34 months. Both scores showed good stratification, with the new score showed a trend towards better discrimination in patients with more favorable prognoses. Conclusion: The prognostic value of the original GPA was confirmed in our cohort of patients who underwent surgery for BM. The RTB was identified as a parameter of high prognostic significance and was incorporated into an updated “volumetric GPA”. This score provides a novel tool for prognosis and clinical decision making in patients undergoing surgery. This method may be useful for stratification and patient selection for further treatment and in future clinical trials.

Background and Purpose: Decompressive surgery is a potentially life-saving treatment in patients with malignant space-occupying cerebellar infarction. However, there is only limited literature on functional outcomes and complications after surgery. Our aim was to establish markers which predict poor outcome. Methods: We retrospectively analyzed data of all patients who underwent surgery due to malignant swelling of a space-occupying cerebellar infarction in our hospital between 2005 and 2023. Statistical analyses were conducted on multiple parameters to identify predictors of poor functional outcome (mRS 4–6) 90 days after surgery. Complications during hospitalization were reviewed for each patient. Results: In total, 58 patients received decompressive surgery. The 90-day mortality rate was 27.6% (n = 16). A good functional outcome (mRS 0–3) 90 days after surgery was achieved in 24 patients (41.4%). Multivariable analysis revealed multiple factors associated with a poor outcome on day 90 (mRS 4–6): a higher premorbid mRS score (OR 2.715 [95% CI, 1.166–6.323]; p = 0.021), higher NIHSS score on admission (OR 1.088 [95% CI, 1.014, 1.168]; p = 0.019) and the presence of an additional brainstem infarction (OR 7.035, [95% CI, 1.255, 39.424], p = 0.027). Hyperactive delirium was associated with good clinical outcome (OR 0.020 [95%CI, 0.001–0.623]; p = 0.026). Aspiration pneumonia (n = 22, 37.9%), urinary tract infection (n = 15, 25.9%), and hyperactive delirium (n = 8, 13.8%) were the most common complications during hospitalization. Conclusions: Decompressive surgery is a safe, life-saving treatment for malignant space-occupying cerebellar infarction. Higher premorbid mRS, higher NIHSS score on admission and the presence of brainstem infarction are associated with a poor functional outcome.