Intraoperative magnetic resonance imaging (iMRI) has witnessed significant growth in the field of neurosurgery, particularly in glioma surgery, enhancing image-guided neuronavigation and optimizing the extent of resection (EOR). Despite its extensive use in the treatment of gliomas, its utility in brain metastases (BMs) remains unexplored. This study examined the effect of iMRI on BM resection. This retrospective study was conducted at the neurosurgical center of the University Hospital of the Technical University of Munich and involved 25 patients with BM who underwent resection using 3-Tesla iMRI between 2018 and 2022. Volumetric measurements of the resected contrast-enhancing metastases were performed using preoperative, intraoperative, and postoperative MRI images. The Karnofsky Performance Score (KPS) and neurological status of the patients were assessed pre- and postoperatively. Local recurrence and in-brain progression were reported in patients who underwent follow-up MRI at 3 and 6 months postoperatively. In this cohort (n = 25, mean age 63.6 years), non-small-cell lung cancer (NSCLC) was the most common origin (28%). The mean surgical duration was 219.9 min, and that of iMRI was 61.7 min. Indications for iMRI were primarily associated with preoperative imaging, suggesting an unclear entity that is often suspicious for glioma. Gross total resection (GTR) was achieved in 21 patients (84%). Continued resection was pursued after iMRI in six cases (24%), resulting in an improved EOR of 100% in five cases and 97.6% in one case. Neurological status postoperatively remained stable in 60%, improved in 24%, and worsened in 16% of patients. No wound healing or postoperative complications were observed. Among the thirteen patients who underwent follow-up MRI 3 months postoperatively, one patient showed local recurrence at the site of resection, and seven patients showed in-brain progression. Of the eight patients who underwent a 6-month follow-up MRI, two showed local recurrence, while three exhibited in-brain progression. The observed favorable profiles of GTR, coupled with the notable absence of wound-healing problems and acute postoperative complications, affirm the safety and feasibility of incorporating iMRI into the neurosurgical workflow for resecting BM with specific indications. The real-time imaging capabilities of iMRI offer unparalleled precision, aiding meticulous tumor delineation and informed decision-making, ultimately contributing to improved patient outcomes. Although our experience suggests the potential benefits of iMRI as a safe tool for enhancing EOR, we acknowledge the need for larger prospective clinical trials. Comprehensive investigations on a broader scale are imperative to further elucidate the specific indications for iMRI in the context of BMs and to study its impact on survival. Rigorous prospective studies will refine our understanding of the clinical scenarios in which iMRI can maximize its impact, guiding neurosurgeons toward more informed and tailored decision-making.

Background and Objectives: The impact of surgery for recurrent brain metastases in elderly patients has been the object of debate due to limited information in the literature. We analyzed clinical outcome and survival of elderly patients with recurrent brain metastases in order to assess potentially beneficial role of surgery. Materials and methods: In total, 219 patients with recurrent brain metastases between 2007 and 2022 were identified, of which 95 underwent re-resection; 83 patients aged 65 and older were analyzed. A survival analysis was performed, and clinical outcomes were evaluated. Results: The median survival time after surgery for recurrent brain metastases was 6 months (95CI 4–10) in older patients and 8 (95CI 7–9) in younger patients (p = 0.619). Out of all the older patients, 33 who underwent surgical resection showed prolonged survival compared with patients who did not receive surgical resection (median: 14, 95CI 8–19 vs. 4, 95CI 4–7, p = 0.011). All patients had preoperative Karnofsky performance scores of >70, which did not deteriorate after surgery (87.02 ± 5.76 vs. 85 ± 6.85; p = 0.055). In the univariate analysis, complete cytoreduction was a favorable prognostic factor. The tumor volume, the number of metastases, extracranial disease progression, adjuvant radiation, and systemic therapy did not affect survival in this cohort. Conclusions: Patients aged 65 and older benefit from neurosurgical resections of recurrent brain metastases. Survival did not differ from that in younger patients, which can be explained by a better preoperative functional status. Moreover, independent of the extent of resection, older patients who underwent surgery showed better survival than patients who did not receive surgical treatment. Complete cytoreduction was a favorable prognostic marker.

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.

Despite advancements in bionic technology, disrupted afferent and efferent pathways in individuals with limb loss may hinder prosthetic embodiment. Transcranial Magnetic Stimulation (TMS) has emerged as a promising tool for investigating and modulating sensorimotor processes, though its application in neurorehabilitation for individuals with limb differences remains limited. This pilot study explores whether TMS over parietal regions associated with the grasping-function and motor planning can enhance the sense of embodiment and influence motor behaviour. In this feasibility protocol, six healthy participants and two prosthesis users underwent a virtual reality TMS-training protocol. Its effects were assessed through pre- and post-training evaluations using standard self-reported embodiment surveys, functional performance metrics, and a Locus of Attention Index. Participants completed two assessments without TMS, before and after a training session with TMS. Additionally, one final assessment with TMS was conducted, designed to evaluate its direct impact on performance metrics. Results in healthy participants indicate that while TMS did not significantly alter the perceived embodiment, it affected the visual attention allocation. Additionally, trajectory velocity differed between no-TMS and TMS assessments. Finally, the online system evaluation on two prosthesis users highlights the feasibility of applying parietal TMS in training for prosthetic embodiment research, warranting further investigation with larger and more comprehensive samples to better establish the role of TMS in sensorimotor rehabilitation with amputees.

Sex-related differences in the epidemiology of malignant gliomas are acknowledged; however, information regarding their clinical characteristics and outcomes after surgery is limited. To identify sex-specific differences of all patients with high-grade glioma at our institution and assessed clinical outcomes and prognostic factors. This single-center study included those who underwent surgery for malignant gliomas between 2010 and 2020. Categorical, normally distributed, and skewed continuous variables were compared between men and women using the chi-square test, independent samples t-test, and Mann–Whitney U test, respectively. Survival was calculated using the log-rank and Kaplan–Meier methods. In total, 621 patients with WHO grade IV gliomas were identified (370 (59.58%) male). Men were significantly younger, underwent surgery faster after imaging diagnosis, and had a slightly higher surgical complications incidence than women. Women reported a worse preoperative performance status. Multivariate analysis showed that sex did not affect survival, surgical complications, nicotine or alcohol abuse, or preoperative tumor volume. Age, Karnofsky performance status, neurosurgical resection, and adjuvant radiotherapy with temozolomide showed a survival advantage. Men are diagnosed with malignant glioma at a younger age than women; however, no advantage in clinical outcomes was observed. No sex-related differences were observed.

Unilateral biportal endoscopic (UBE) lumbar decompression has emerged as a minimally invasive technique for the treatment of degenerative lumbar pathologies, including disc herniation and spinal canal stenosis. The reproducibility of this technique depends on standardized positioning, imaging, portal placement and stepwise decompression under continuous endoscopic visualization. We present a navigation-assisted workflow that integrates intraoperative three-dimensional imaging (Loop-X, Brainlab AG, Munich, Germany). Patients are positioned prone on a radiolucent table. A pelvic reference array is secured prior to skin incision, followed by intraoperative 3D fluoroscopy. Based on navigational planning, two paramedian skin incisions are created to establish a dedicated viewing portal and a separate working portal. Navigation-guided trajectory planning enables controlled access to the interlaminar window and targeted osseous decompression while preserving surrounding anatomical structures. Stepwise decompression of neural elements is performed under continuous irrigation and endoscopic visualization, with intraoperative confirmation of adequate decompression. Navigation-assisted UBE for lumbar decompression with intraoperative 3D imaging allows precise trajectory planning and controlled portal placement, potentially enhancing reproducibility while maintaining the benefits of minimally invasive surgery.