Low rCBV values in glioblastoma tumor progression under chemoradiotherapy

PURPOSE

After standard treatment for glioblastoma, perfusion MRI remains challenging for differentiating tumor progression from post-treatment changes. Our objectives were (1) to correlate rCBV values at diagnosis and at first tumor progression and (2) to analyze the relationship of rCBV values at tumor recurrence with enhancing volume, localization of tumor progression, and time elapsed since the end of radiotherapy in tumor recurrence.

METHODS

Inclusion criteria were (1) age > 18 years, (2) histologically confirmed glioblastoma treated with STUPP regimen, and (3) tumor progression according to RANO criteria > 12 weeks after radiotherapy. Co-registration of segmented enhancing tumor VOIs with dynamic susceptibility contrast perfusion MRI was performed using Olea Sphere software. For tumor recurrence, we correlated rCBV values with enhancing tumor volume, with recurrence localization, and with time elapsed from the end of radiotherapy to progression. Analyses were performed with SPSS software.

RESULTS

Sixty-four patients with glioblastoma were included in the study. Changes in rCBV values between diagnosis and first tumor progression were significant (p < 0.001), with a mean and median decreases of 32% and 46%, respectively. Mean rCBV values were also different (p < 0.01) when tumors progressed distally (radiation field rCBV values of 1.679 versus 3.409 distally). However, changes and, therefore, low rCBV values after radiotherapy in tumor recurrence were independent of time.

CONCLUSION

Chemoradiation alters tumor perfusion and rCBV values may be decreased in the setting of tumor progression. Changes in rCBV values with respect to diagnosis, with low rCBV in tumor progression, are independent of time but related to the site of recurrence.

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study

OBJECTIVES

The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery.

DESIGN

This was an observational retrospective study.

SETTINGS

A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020.

PARTICIPANTS

A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection.

RESULTS

More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic.

CONCLUSIONS

Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: a nationwide study in Spain

OBJECTIVE

To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain.

SETTINGS

The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied.

PARTICIPANTS

This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020.

INTERVENTIONS

An exploratory factorial analysis was performed to select the most relevant variables of the sample.

PRIMARY AND SECONDARY OUTCOME MEASURES

Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection.

RESULTS

Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/10⁵ people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade ≥3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/10⁵ people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated.

CONCLUSIONS

Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/10⁵ people/week) was a statistically independent predictor of mortality.

TRIAL REGISTRATION NUMBER

CEIM 20/217.

Reduction in the infection rate of cranioplasty with a tailored antibiotic prophylaxis: a nonrandomized study

BACKGROUND

Cranioplasty carries a high risk of surgical site infections (SSIs) for a scheduled procedure, particularly with antibiotic-resistant bacteria.

METHODS

The goal of this retrospective study was to measure the effect of tailored antibiotic prophylaxis on SSIs resulting from cranioplasties. The authors collected a prospective database of cranioplasties from 2009 to 2018. Risk factors for SSI were registered, as well as infection occurring during the first year postoperatively. A new protocol was initiated in 2016 consisting of antibiotic prophylaxis tailored to the colonizing flora of the skin of the scalp and decolonization of patients who were nasal carriers of methicillin-resistant S. aureus (MRSA); infection rates were compared.

RESULTS

One hundred nine cranioplasties were identified, 64 in the old protocol and 45 in the new protocol. Of the 109 cranioplasties, 16 (14.7%) suffered an infection, 14 (21.9%) in the old protocol group and 2 (4.4%) in the new protocol group (OR for the new protocol 0.166, 95% CI 0.036-0.772). Multiple surgeries (OR 3.44), Barthel ≤ 70 (OR 3.53), and previous infection (OR 3.9) were risk factors for SSI. Of the bacteria identified in the skin of the scalp, 22.2% were resistant to routine prophylaxis (cefazoline). Only one patient was identified as a nasal carrier of MRSA and was decolonized.

CONCLUSIONS

A high percentage of bacteria resistant to routine prophylaxis (cefazoline) was identified in the skin of these patients' scalps. The use of tailored antibiotic prophylaxis reduced significantly the infection rate in this particular set of patients.

Perfusion MRI grading diffuse gliomas: Impact of permeability parameters on molecular biomarkers and survival

BACKGROUND AND PURPOSE

Our objectives were: (1) compare dynamic susceptibility-weighted (DSC) and dynamic contrast-enhanced (DCE) permeability parameters, (2) evaluate diagnostic accuracy of DSC and DCE discriminating high- and low-grade tumors, (3) analyze relationship of permeability parameters with overall (OS) and progression-free survival (PFS) and (4) assess differences in high-grade tumors classified according to molecular biomarkers.

MATERIALS AND METHODS

49 patients with histologically proved diffuse gliomas underwent DSC and DCE imaging. Parametric maps of cerebral blood volume (CBV), CBV-leakage corrected, volume transfer coefficient (Ktrans), fractional volume of the extravascular extracellular space (EES) (Ve), fractional blood plasma volume (Vp) and rate constant between EES and blood plasma (Kep) were calculated. High-grade gliomas were also classified according to isocitrate dehydrogenase (IDH), alpha-thalassemia/mental retardation syndrome X-linked (ATRX) and O6-methylguanine-dna-methyltransferase promoter methylation (MGMT) status.

RESULTS

There is correlation between parameters leakage, Ktrans and Vp. ROC curve analysis showed significance in both Ktrans and Ve for glioma grading. Threshold value of 0.075 for Ve generated the best combination of sensitivity (80%) and specificity (75%) in tumor gradation. Leakage was the only permeability parameter related to OS (P=0.006) and PFS (0.012); with prolonged survival for leakage values lower than 1.2. IDH-mutated high-grade tumors showed lower leakage and Ktrans values. High-grade tumors with loss of ATRX presented lower leakage and Vp values.

CONCLUSIONS

Both DSC and DCE permeability parameters serve as non-invasive method for glioma grading. Leakage was the unique permeability parameter related to survival and the best discriminating high-grade gliomas classified according to IDH and ATRX status.

Leakage decrease detected by dynamic susceptibility-weighted contrast-enhanced perfusion MRI predicts survival in recurrent glioblastoma treated with bevacizumab

BACKGROUND AND PURPOSE

In glioblastoma, tumor progression appears to be triggered by expression of VEGF, a regulator of blood vessel permeability. Bevacizumab is a monoclonal antibody that inhibits angiogenesis by clearing circulating VEGF, resulting in a decline in the contrast-enhancing tumor, which does not always correlate with treatment response. Our objectives were: (1) to evaluate whether changes in DSC perfusion MRI-derived leakage could predict survival in recurrent glioblastoma, and (2) to estimate whether leakage at baseline was related to treatment outcome.

MATERIALS AND METHODS

We retrospectively analyzed DSC perfusion MRI in 24 recurrent glioblastomas treated with bevacizumab as second line chemotherapy. Leakage at baseline and changes in maximum leakage between baseline and the first follow-up after treatment were selected for quantitative analysis. Survival univariate analysis was made constructing survival curves using Kaplan-Meier method and comparing subgroups by log rank probability test.

RESULTS

Leakage reduction at 8 weeks after initiation of bevacizumab treatment had a significant influence on overall survival (OS) and progression-free survival (PFS). Median OS and PFS were 2.4 and 2.8 months longer for patients with leakage reduction at the first follow-up. Higher leakage at baseline was associated with leakage reduction after treatment. Odds ratio of treatment response was 9 for patients with maximum leakage at baseline >5.

CONCLUSIONS

Leakage decrease may predict OS and PFS in recurrent glioblastomas treated with bevacizumab. Leakage reduction postulates as a potential biomarker for treatment response evaluation. Leakage at baseline seems to predict response to treatment, but was not independently associated with survival.

Preclinical Test of Dacomitinib, an Irreversible EGFR Inhibitor, Confirms Its Effectiveness for Glioblastoma

Glioblastomas (GBM) are devastating tumors in which there has been little clinical improvement in the last decades. New molecularly directed therapies are under development. EGFR is one of the most promising targets, as this receptor is mutated and/or overexpressed in nearly half of the GBMs. However, the results obtained with first-generation tyrosine-kinase inhibitors have been disappointing with no clear predictive markers of tumor response. Here, we have tested the antitumoral efficacy of a second-generation inhibitor, dacomitinib (PF299804, Pfizer), that binds in an irreversible way to the receptor. Our results confirm that dacomitinib has an effect on cell viability, self-renewal, and proliferation in EGFR-amplified ± EGFRvIII GBM cells. Moreover, systemic administration of dacomitinib strongly impaired the in vivo tumor growth rate of these EGFR-amplified cell lines, with a decrease in the expression of stem cell-related markers. However, continuous administration of the compound was required to maintain the antitumor effect. The data presented here confirm that dacomitinib clearly affects receptor signaling in vivo and that its strong antitumoral effect is independent of the presence of mutant receptor isoforms although it could be affected by the PTEN status (as it is less effective in a PTEN-deleted GBM line). Dacomitinib is being tested in second line for EGFR-amplified GBMs. We hope that our results could help to select retrospectively molecular determinants of this response and to implement future trials with dacomitinib (alone or in combination with other inhibitors) in newly diagnosed GBMs.

A prognostic model based on preoperative MRI predicts overall survival in patients with diffuse gliomas

BACKGROUND AND PURPOSE

Diffuse gliomas are classified as grades II-IV on the basis of histologic features, with prognosis determined mainly by clinical factors and histologic grade supported by molecular markers. Our aim was to evaluate, in patients with diffuse gliomas, the relationship of relative CBV and ADC values to overall survival. In addition, we also propose a prognostic model based on preoperative MR imaging findings that predicts survival independent of histopathology.

MATERIALS AND METHODS

We conducted a retrospective analysis of the preoperative diffusion and perfusion MR imaging in 126 histologically confirmed diffuse gliomas. Median relative CBV and ADC values were selected for quantitative analysis. Survival univariate analysis was made by constructing survival curves by using the Kaplan-Meier method and comparing subgroups by log-rank probability tests. A Cox regression model was made for multivariate analysis.

RESULTS

The study included 126 diffuse gliomas (median follow-up of 14.5 months). ADC and relative CBV values had a significant influence on overall survival. Median overall survival for patients with ADC < 0.799 × 10(-3) mm(2)/s was <1 year. Multivariate analysis revealed that patient age, relative CBV, and ADC values were associated with survival independent of pathology. The preoperative model provides greater ability to predict survival than that obtained by histologic grade alone.

CONCLUSIONS

ADC values had a better correlation with overall survival than relative CBV values. A preoperative prognostic model based on patient age, relative CBV, and ADC values predicted overall survival of patients with diffuse gliomas independent of pathology. This preoperative model provides a more accurate predictor of survival than histologic grade alone.

Brainstem gliomas

Historically, brainstem gliomas have been considered as a single entity. Since the introduction of magnetic resonance (MR) imaging in the late 1980s, these tumors are now regarded as a heterogeneous group of neoplasms with different age of onset, clinical and radiologic presentation, and varying behavior and natural history. This article describes the different subtypes of brainstem gliomas in children and adults. We focus on recent advances in MR such as MR spectroscopy, MR perfusion, and diffusion tensor imaging that often strongly suggest the histopathologic diagnosis of the lesion.

The added value of apparent diffusion coefficient to cerebral blood volume in the preoperative grading of diffuse gliomas

BACKGROUND AND PURPOSE

In cerebral gliomas, rCBV correlates with tumor grade and histologic findings of vascular proliferation. Moreover, ADC assesses water diffusivity and is inversely correlated with tumor grade. In the present work, we have studied whether combined rCBV and ADC values improve the diagnostic accuracy of MR imaging in the preoperative grading of gliomas.

MATERIALS AND METHODS

One hundred sixty-two patients with histopathologically confirmed diffuse gliomas underwent DWI and DSC. Mean rCBV and ADC values were compared among the tumor groups with the Student t test or ANOVA. ROC analysis was used to determine rCBV and ADC threshold values for glioma grading.

RESULTS

rCBV had significantly different values between grade II and IV gliomas and between grade III and IV tumors, but there were no significant differences between grade II and III gliomas (P > .05). Grade II and III tumors also did not differ when astrocytomas, oligodendrogliomas, and oligoastrocytomas were considered separately. ADC values were significantly different for all 3 grades. The ADC threshold value of 1.185 × 10(-3) mm(2)/s and the rCBV cutoff value of 1.74 could be used with high sensitivity in the characterization of high-grade gliomas. The area under the ROC curve for the maximum rCBV and minimum ADC was 0.72 and 0.75, respectively. The combination of rCBV and ADC values increased the area under the ROC curve to 0.83.

CONCLUSIONS

ADC measurements are better than rCBV values for distinguishing the grades of gliomas. The combination of minimum ADC and maximum rCBV improves the diagnostic accuracy of glioma grading.

Intradural extramedullary spinal hydatidosis: case report

The parasitic tapeworm Echinococcus granulosis causes hydatid disease, which is rarely encountered in nonendemic regions. It is a progressive disease with serious morbidity risks. Rarely, these cysts are found in the spine. They are mainly found epidurally, originating from direct extension from pulmonary, abdominal or pelvic infestation. Nevertheless, the main mechanism for intradural involvement is not yet clear. Antihelminthic treatment should be administered for a long period following early decompressive surgery. We report a case of recurrent hydatid disease that presented unusual intradural dissemination. Prognosis for spinal hydatid disease remains very poor and comparable to that of a malignant neoplasm.

Dural arteriovenous fistula presenting as brainstem ischaemia

Dural arteriovenous fistulas presenting with ascending myelopathy are characterised by the presence of an abnormal retrograde drainage through spinal veins. The authors present a case of cranial dural arteriovenous fistula causing brainstem dysfunction secondary to venous hypertension, treated by surgical interruption of the pial venous drainage which resulted in complete clinical and radiological resolution of the brainstem lesion.

Early transcranial Doppler after subarachnoid hemorrhage: clinical and radiological correlations

BACKGROUND

The initial decrease in the level of consciousness after subarachnoid hemorrhage (SAH) is commonly considered secondary to cerebral hypoperfusion and metabolic depression. Age, intracranial pressure, and the amount of cisternal blood are closely related to the clinical grade on admission after SAH. Transcranial Doppler (TCD) may partially and indirectly estimate cerebral blood flow through analysis of flow velocity in the middle cerebral artery (MCA). Besides, pulsatility index (PI) can also be considered an indirect estimator of cerebrovascular resistance. The objective of this study was to determine the TCD parameters in the early stage after SAH and to analyze their correlation with the main clinical and radiological variables on admission.

METHODS

A series of 52 consecutive patients diagnosed with SAH, with an abnormal computed tomography (CT) scan on admission and a TCD performed in the first 24 hours from the onset of the hemorrhage, were retrospectively reviewed. Age, sex, clinical grade, presence of cisternal blood or hydrocephalus on initial CT scan, and parameters of TCD examination were recorded for every patient. The relationship between sonographic and clinical and radiological variables was evaluated by partial correlation test, Kruskal-Wallis, and Student t test for paired samples.

RESULTS

There were no significant differences in blood flow velocities or PIs between the left and right sides. Lower velocities and higher PIs correlated with a worse clinical condition at admission. Lower velocities also correlated with larger amounts of cisternal blood on the initial CT scan. No significant correlation was observed between PI and the amount of blood in the initial CT scan.

CONCLUSIONS

A global decrease in blood velocity in the MCA along with a rise in PI is present in the first 24 hours after SAH. These changes correlate with the clinical deterioration and partially with the amount of blood in the initial CT scan. These findings support the hypothesis that low cerebral perfusion caused by high intracranial pressure leads to diffuse ischemic changes in the early phase of SAH.

[Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan]

OBJECTIVE

To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT scan with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intra-cranial mass effect and improving the final outcome.

MATERIAL AND METHODS

56 patients (ages 15-80 years) consecutively admitted during a 2 years period were included. All had the initial CT scan < 24 hours after injury (mean interval = 150 min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20 mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the occurrence of deterioration and the final outcome as assessed with the GOS.

RESULTS

The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusion and 21.4% small extraaxial hematomas. 57.1% of the patients showed CT changes through the acute post-traumatic period consisting of new contusion (26.8% of the cases), growing of previous contusion (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome. Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10.7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the occurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusion at the initial CT scan (p= 0.01) and the occurrence of CT change (only generalized brain swelling, p= 0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR = 9.8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outcome than those without new pathologies, but the difference did not reach statistical significance,

DISCUSSION AND CONCLUSIONS

Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2-4, 12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases. Though it is clear that the presence of severe intra-cranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the occurrence of new mass effect and/or raised ICP contributed to the development of moderate and severe disability in the survivors which were mainly due to the occurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outcome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones.

Meningiomas of the basal posterior fossa. Surgical experience in 80 cases

INTRODUCTION

Despite recent improvements in microsurgical and radiotherapy techniques, treatment of basal posterior fossa meningiomas still carries an elevated risk of morbidity. We present our results in a series of patients with this type of tumor and review the recent literature looking for the results obtained with different approaches and the new tendencies and algorithms proposed for managing these challenging lesions.

MATERIAL AND METHODS

We analyzed retrospectively the clinical presentation and outcome of 80 patients consecutively operated between 1979 and 2003 for basal posterior fossa meningioma (foramen magnum tumors excluded). All patients had preoperative CT scans and the majority MRI studies. A total of 114 operations were performed including two-stage operations, reoperation for recurrence, CSF diversion, and XII-VII anastomosis. The most commonly used approaches were lateral suboccipital retrosigmoid, subtemporal-transtentorial, frontotemporal pterional and supra-infratentorial presigmoid. Thirteen patients received postoperative radiotherapy.

RESULTS

There were 59 (73.7%) women and 21 men (mean age = 51.5 years; range = 18-78 yrs). Most common presenting symptoms were cranial nerve dysfunction, gait disturbances and intracranial hypertension. The mean duration of symptoms was 2.9 years. 70% of the tumors were over 3 cm in size. Fifty patients (62.5%) had a complete resection, 22 (27.5%) subtotal resection (> 90% tumor volume removed), and 8 (10%) only partial resection. Postoperative complications included hematoma, CSF leak, and infection. Fifty four (67.5%) patients developed new or increased cranial nerve deficits and 12.5% somatomotor, somatosensory or cerebellar deficits immediately after surgery with subsequent improvement in most cases. Following initial surgery 67 patients made a good recovery, 10 developed variable degrees of disability and 3 died. Eleven patients died later in the course for tumor recurrence with or without reoperation, malignant meningioma or unrelated causes. There were 9 recurrences in the subgroup of patients having complete resection initially (mean follow-up = 8.6 years). The majority of patients having initial subtotal or partial resections have been managed without reoperation during a mean follow-up period of 6.5 years (radiosurgery and/or observation).

DISCUSSION AND CONCLUSION

Current microsurgical and radiotherapy techniques allow either a cure or an acceptable control of basal posterior fossa meningiomas. In patients with tumor invasion of the cavernous sinus, extracranial extension, violation of the arachnoidal membranes in front of the brainstem, or encasement and infiltration of major arteries, a subtotal excision seems preferable followed by observation and/ or radiosurgical treatment. Apart from the patients age and the clinical presentation (symptomatic or not), the size and secondary extensions of the tumor must be taken into account for planning treatment in the individual patient.