Up-regulated PLA2G10 in cancer impairs T cell infiltration to dampen immunity.

T cells are often absent from human cancer tissues during both spontaneously induced immunity and therapeutic immunotherapy, even in the presence of a functional T cell-recruiting chemokine system, suggesting the existence of T cell exclusion mechanisms that impair infiltration. Using a genome-wide in vitro screening platform, we identified a role for phospholipase A2 group 10 (PLA2G10) protein in T cell exclusion. PLA2G10 up-regulation is widespread in human cancers and is associated with poor T cell infiltration in tumor tissues. PLA2G10 overexpression in immunogenic mouse tumors excluded T cells from infiltration, resulting in resistance to anti-PD-1 immunotherapy. PLA2G10 can hydrolyze phospholipids into small lipid metabolites, thus inhibiting chemokine-mediated T cell mobility. Ablation of PLA2G10's enzymatic activity enhanced T cell infiltration and sensitized PLA2G10-overexpressing tumors to immunotherapies. Our study implicates a role for PLA2G10 in T cell exclusion from tumors and suggests a potential target for cancer immunotherapy.

Effectiveness of group cognitive behavioral therapy for depression in adults: a systematic review and meta-analysis of delivery by different healthcare professionals.

This study addresses the gap in understanding the varied effectiveness of group cognitive behavioral therapy (gCBT) delivered by different professionals. This study aims to address this gap by conducting a systematic review of randomized controlled trials (RCTs) that evaluate gCBT and compare it to inactive controls in adults with a clinical diagnosis of depression. A total of 33 RCTs were included for analysis. In the overall analysis, 'profession of gCBT deliverer' was not a significant moderator in the meta-regression model (p = 0.57). For people without comorbidity, the overall effect size estimate was -0.69 (95% CI, -1.01. to -0.37, p = 0.03). Among gCBT deliverers, psychologists and nurses/psychiatric nurses demonstrated significant effectiveness, with psychologists showing a large effect size of -0.78 (95% CI, -1.25 to -0.30, p < 0.01) and nurses/psychiatric nurses showing a medium effect size of -0.45 (95% CI, -0.85 to -0.05, p = 0.03). The certainty of evidence for both professionals was moderate. These results have significant implications for the delivery of mental healthcare, as nurses/psychiatric nurses may be more accessible and cost-effective than psychologists in some settings. However, further research is necessary to determine the effectiveness of gCBT delivered by a broader range of healthcare professionals for patients with depression and other comorbidities.

Exploring Chiropractic Healthcare in Hong Kong: Sick Leave Certification Dilemma.

Objective This study aims to investigate the characteristics of chiropractic patients in Hong Kong, their experiences with chiropractic care, and their perspectives on chiropractors' authority over sick leave certificates. Method A cross-sectional survey was conducted among individuals receiving chiropractic treatment in Hong Kong. Data were collected through an online survey from May 11 to August 8, 2023, and descriptive analysis was employed to examine patient demographics, treatment effectiveness, and views on chiropractic sick leave authorization. A total of 522 valid responses were received. Result Among respondents, back pain was the primary reason for seeking chiropractic care, with many experiencing rapid relief and high satisfaction. However, many patients initially consulted other healthcare professionals, indicating potential integration challenges. Lengthy orthopedic wait times in Hong Kong highlight the need for chiropractic care. Concerns arose over chiropractors' inability to issue sick leave certificates, impacting patient convenience, treatment effectiveness, finances, and emotional well-being. Allowing chiropractors to authorize sick leave, with proper regulation, could address these issues. Conclusion In conclusion, this study underscores chiropractic care's potential in Hong Kong's healthcare system and suggests that recognizing chiropractors' role in sick leave authorization can enhance comprehensive patient care.

Immune Inhibitory Molecule PD-1 Homolog (VISTA) Colocalizes with CD11b Myeloid Cells in Melanoma and Is Associated with Poor Outcomes.

Tumors evade immunity through the overexpression of immune inhibitory molecules in the tumor microenvironment such as PD-L1/B7-H1. An immune inhibitory molecule named PD-1 homolog (also known as V-domain Ig-containing suppressor of T cell activation [VISTA]) functions to control both T cells and myeloid cells. Current clinical trials using anti-VISTA-blocking agents for treatment of cancer are ongoing. We sought to determine the extent of VISTA expression in primary cutaneous melanomas (n = 190), identify the critical cell types expressing VISTA, and correlate its expression with PD-L1 expression using multiplexed quantitative immunofluorescence. Within the tumor subcompartments, VISTA is most highly expressed on CD11b myeloid cells, and PD-L1 is most highly expressed on CD68 myeloid cells in our melanoma cohort. There is little correlation between VISTA and PD-L1 expression intensity, suggesting that individual tumors have distinct immunosuppressive tumor microenvironments. High levels of VISTA expression on CD11b myeloid cells but not PD-L1 expression were associated with greater melanoma recurrence and greater all-cause mortality. Our findings suggest that cell-specific VISTA expression may be a negative prognostic biomarker for melanoma and a future potential therapeutic target.

Personalized, parcel-guided rTMS for the treatment of major depressive disorder: Safety and proof of concept.

BACKGROUND: Not all patients with major depressive disorder (MDD) benefit from the US Food and Drug Administration-approved use of repetitive transcranial magnetic stimulation (rTMS) at the dorsolateral prefrontal cortex. We may be undertreating depression with this one-size-fits-all rTMS strategy. METHODS: We present a retrospective review of targeted and connectome-guided rTMS in 26 patients from Cingulum Health from 2020 to 2023 with MDD or MDD with associated symptoms. rTMS was conducted by identifying multiple cortical targets based on anomalies in individual functional connectivity networks as determined by machine learning connectomic software. Quality of life assessed by the EuroQol (EQ-5D) score and depression symptoms assessed by the Beck Depression Inventory (BDI) were administered prior to treatment, directly after, and at a follow-up consultation. RESULTS: Of the 26 patients treated with rTMS, 16 (62%) attained remission after treatment. Of the 19 patients who completed follow-up assessments after an average interval of 2.6 months, 11 (58%) responded to treatment and 13 (68%) showed significant remission. Between patients classified with or without treatment-resistant depression, there was no difference in BDI improvement. Additionally, there was significant improvement in quality of life after treatment and during follow-up compared to baseline. LIMITATIONS: This review is retrospective in nature, so there is no control group to assess the placebo effect on patient outcomes. CONCLUSION: The personalized, connectome-guided approach of rTMS is safe and may be effective for depression. This personalized rTMS treatment allows for co-treatment of multiple disorders, such as the comorbidity of depression and anxiety.

ChatGPT in glioma adjuvant therapy decision making: ready to assume the role of a doctor in the tumour board?

OBJECTIVE: To evaluate ChatGPT's performance in brain glioma adjuvant therapy decision-making. METHODS: We randomly selected 10 patients with brain gliomas discussed at our institution's central nervous system tumour board (CNS TB). Patients' clinical status, surgical outcome, textual imaging information and immuno-pathology results were provided to ChatGPT V.3.5 and seven CNS tumour experts. The chatbot was asked to give the adjuvant treatment choice, and the regimen while considering the patient's functional status. The experts rated the artificial intelligence-based recommendations from 0 (complete disagreement) to 10 (complete agreement). An intraclass correlation coefficient agreement (ICC) was used to measure the inter-rater agreement. RESULTS: Eight patients (80%) met the criteria for glioblastoma and two (20%) were low-grade gliomas. The experts rated the quality of ChatGPT recommendations as poor for diagnosis (median 3, IQR 1-7.8, ICC 0.9, 95% CI 0.7 to 1.0), good for treatment recommendation (7, IQR 6-8, ICC 0.8, 95% CI 0.4 to 0.9), good for therapy regimen (7, IQR 4-8, ICC 0.8, 95% CI 0.5 to 0.9), moderate for functional status consideration (6, IQR 1-7, ICC 0.7, 95% CI 0.3 to 0.9) and moderate for overall agreement with the recommendations (5, IQR 3-7, ICC 0.7, 95% CI 0.3 to 0.9). No differences were observed between the glioblastomas and low-grade glioma ratings. CONCLUSIONS: ChatGPT performed poorly in classifying glioma types but was good for adjuvant treatment recommendations as evaluated by CNS TB experts. Even though the ChatGPT lacks the precision to replace expert opinion, it may serve as a promising supplemental tool within a human-in-the-loop approach.

A systematic review and individual participant data meta-analysis of gonadal steroid hormone receptors in meningioma.

OBJECTIVE: The relationship between patient and meningioma characteristics and hormone receptors (HRs) of progesterone, estrogen, and androgen remains poorly defined despite literature suggesting that meningiomas are sensitive to gonadal steroid hormones. Therefore, the authors sought to collect and compare data on this topic by performing a systematic review and meta-analysis of reported studies of HR status in meningiomas. METHODS: A MEDLINE PubMed literature review conducted for articles published between January 1, 1951, and December 31, 2020, resulted in 634 unduplicated articles concerning meningiomas and HRs. There were 114 articles that met the criteria of detailed detection protocols for progesterone receptor (PR), estrogen receptor (ER), and/or androgen receptor (AR) using immunohistochemistry (IHC) or ligand-binding (LB) assays and simultaneous reporting of HR status with at least one variable among age, sex, histology, location, grade, or recurrence. Between-study heterogeneity and risk of bias were evaluated using graphical and statistical methods. The authors performed a multilevel meta-analysis using random-effects modeling on aggregated data (n = 4447) and individual participant data (n = 1363) with subgroup results summarized as pooled effects. A mixed-effects meta-regression using individual participant data was performed to analyze independently associated variables. RESULTS: The 114 selected articles included data for 5810 patients with 6092 tumors analyzed to determine the expression of three HRs in human meningiomas: PRs, ARs, and ERs. The proportions of HR+ meningiomas were estimated to be 0.76 (95% CI 0.72-0.80) for PR+ and 0.50 (95% CI 0.33-0.66) for AR+ meningiomas. ER+ meningioma detection varied depending on the measurement method used and was 0.06 (95% CI 0.03-0.10) with IHC and 0.11 (95% CI 0.06-0.20) with LB assays. There were associations between age and PR and ER expression that varied between male and female patients. PR+ and AR+ were more common in female patients (OR 1.84, 95% CI 1.47-2.29 for PR and OR 4.16, 95% CI 1.62-10.68 for AR). Additionally, PR+ meningiomas were enriched in skull base locations (OR 1.89, 95% CI 1.03-3.48) and meningothelial histology (OR 1.86, 95% CI 1.23-2.81). A meta-regression showed that PR+ was independently associated with age (OR 1.11 95% CI 1.09-1.13; p < 0.0001) and WHO grade I tumors (OR 8.09, 95% CI 3.55-18.44; p < 0.0001). ER+ was negatively associated with meningothelial histology (OR 0.94, 95% CI 0.86-0.98; p = 0.044) and positively associated with convexity location (OR 1.12, 95% CI 1.05-1.18; p = 0.0003). CONCLUSIONS: The association between HRs and meningioma features has been investigated but unexplained for decades. In this study the authors demonstrated that HR status has a strong association with known meningioma features, including WHO grade, age, female sex, histology, and anatomical location. Identifying these independent associations allows for a better understanding of meningioma heterogeneity and provides a foundation for revisiting targeted hormonal therapy in meningioma on the basis of proper patient stratification according to HR status.

Prevention-Focused Care: The Potential Role of Chiropractors in Hong Kong's Primary Healthcare Transformation.

Hong Kong's healthcare system is moving toward preventive and primary care to address the complicated demands of the aging population. Chiropractic professionals are in an advantageous position to support a prevention-focused strategy by identifying musculoskeletal problems early, reducing risks, and promoting healthy lifestyles. This article examines how the involvement of chiropractors in public health programs could improve population health in Hong Kong and boost primary care. The inclusion of chiropractors in district health centers and other initiatives would offer safer and more cost-effective choices for treating functional problems and chronic pain. Chiropractors should be involved in policymakers' attempts to create a sustainable healthcare system that meets Hong Kong's long-term healthcare requirements.

Recognizing Hong Kong Chiropractors' Sick Leave Authority: Valuing a Conservative Approach to Workers' Compensation.

Although registered under Hong Kong's legislative framework, chiropractors are not able to certify sick leave, restricting the effectiveness of their services for patients with musculoskeletal issues requiring time away from work. This paper explores the evolution of chiropractic regulation in Hong Kong, the growth of the profession, and the tardy recognition of chiropractors' power to issue sick leave certificates. The chiropractic profession and its patients have long lobbied for this authority, but the government has been slow to respond. This document presents a comprehensive analysis of the benefits and restrictions of allowing chiropractors prescriptive authority for sick leave and requests that this change in policy be considered. Developing responsible criteria for chiropractors to prescribe sick leave within their scope of practice could legitimize chiropractic's position in the population's health and interdisciplinary pain care while lowering the burden on injured workers.

Meeting Future Demand for Chiropractic Services in Hong Kong: A Strategic Manpower Planning Approach.

Chiropractic treatment in Hong Kong has demonstrated high effectiveness in cases where traditional therapies have failed, with minimal associated adverse events. The growing aging population, prevalence of disabilities, and musculoskeletal conditions have increased the demand for rehabilitation services. Over the past few years, the chiropractic profession has raised awareness of treatment benefits. Providing high-quality training and education, licensing/regulation, interprofessional collaboration, increased accessibility, and research are factors influencing the chiropractic workforce and meeting the population's health needs. To achieve the number of chiropractors required by Hong Kong for adequate service according to international standards, future efforts could include increased licensing/registration efficiency, expanded coverage of public/private insurance, system integration/interprofessional collaboration, public education, and local research to build evidence and to support workforce growth and acceptance.

Topology of the lateral visual system: The fundus of the superior temporal sulcus and parietal area H connect nonvisual cerebrum to the lateral occipital lobe.

BACKGROUND AND PURPOSE: Mapping the topology of the visual system is critical for understanding how complex cognitive processes like reading can occur. We aim to describe the connectivity of the visual system to understand how the cerebrum accesses visual information in the lateral occipital lobe. METHODS: Using meta-analytic software focused on task-based functional MRI studies, an activation likelihood estimation (ALE) of the visual network was created. Regions of interest corresponding to the cortical parcellation scheme previously published under the Human Connectome Project were co-registered onto the ALE to identify the hub-like regions of the visual network. Diffusion Spectrum Imaging-based fiber tractography was performed to determine the structural connectivity of these regions with extraoccipital cortices. RESULTS: The fundus of the superior temporal sulcus (FST) and parietal area H (PH) were identified as hub-like regions for the visual network. FST and PH demonstrated several areas of coactivation beyond the occipital lobe and visual network. Furthermore, these parcellations were highly interconnected with other cortical regions throughout extraoccipital cortices related to their nonvisual functional roles. A cortical model demonstrating connections to these hub-like areas was created. CONCLUSIONS: FST and PH are two hub-like areas that demonstrate extensive functional coactivation and structural connections to nonvisual cerebrum. Their structural interconnectedness with language cortices along with the abnormal activation of areas commonly located in the temporo-occipital region in dyslexic individuals suggests possible important roles of FST and PH in the integration of information related to language and reading. Future studies should refine our model by examining the functional roles of these hub areas and their clinical significance.

Improving quality of life post-tumor craniotomy using personalized, parcel-guided TMS: safety and proof of concept.

PURPOSE: Deficits in neuro-cognitive function are not uncommon for patients who have undergone surgical removal of brain tumors. Our goal is to evaluate the safety and efficacy of repetitive Transcranial Magnetic Stimulation (rTMS) as a non-invasive tool for the treatment of neuro-cognitive dysfunctions following craniotomy. METHODS: We present a retrospective review of individualized rTMS in twelve patients from Cingulum Health from December 2019 to July 2021 who presented with neuro-cognitive deficits following craniotomy. Multiple cortical targets were selected based on the patient's neurological disorder, associated networks, and anomalies in the functional connectivity of the brain as determined by machine-learning. TMS treatment was performed for five consecutive days. EuroQol quality of life (EQ-5D), functional extremity scales, and neuropsychiatric questionnaires related to the patient's deficit were assessed prior to, after, and during two-month follow-up of rTMS treatment. RESULTS: Nine patients had unilateral functional deficits in either upper, lower, or both limbs. One patient reported post-operative depression, another experienced short term memory difficulties, and a third reported hypobulia. All twelve patients reported significantly improved EQ5D after rTMS treatment and during follow-up. More than half of the patients with lower and upper functional deficits had a 9-point improvement during follow-up. In the patient who developed depression, an 88% reduction in depressive symptoms based on the Beck's Depression Inventory (BDI) was observed during follow-up. No adverse events, such as seizures, occurred. CONCLUSION: The personalized functional connectivity approach to rTMS treatment may be effective and safe for patients with post-craniotomy neuro-cognitive dysfunction.

A connectivity model of the anatomic substrates underlying Gerstmann syndrome.

The Gerstmann syndrome is a constellation of neurological deficits that include agraphia, acalculia, left-right discrimination and finger agnosia. Despite a growing interest in this clinical phenomenon, there remains controversy regarding the specific neuroanatomic substrates involved. Advancements in data-driven, computational modelling provides an opportunity to create a unified cortical model with greater anatomic precision based on underlying structural and functional connectivity across complex cognitive domains. A literature search was conducted for healthy task-based functional MRI and PET studies for the four cognitive domains underlying Gerstmann's tetrad using the electronic databases PubMed, Medline, and BrainMap Sleuth (2.4). Coordinate-based, meta-analytic software was utilized to gather relevant regions of interest from included studies to create an activation likelihood estimation (ALE) map for each cognitive domain. Machine-learning was used to match activated regions of the ALE to the corresponding parcel from the cortical parcellation scheme previously published under the Human Connectome Project (HCP). Diffusion spectrum imaging-based tractography was performed to determine the structural connectivity between relevant parcels in each domain on 51 healthy subjects from the HCP database. Ultimately 102 functional MRI studies met our inclusion criteria. A frontoparietal network was found to be involved in the four cognitive domains: calculation, writing, finger gnosis, and left-right orientation. There were three parcels in the left hemisphere, where the ALE of at least three cognitive domains were found to be overlapping, specifically the anterior intraparietal area, area 7 postcentral (7PC) and the medial intraparietal sulcus. These parcels surround the anteromedial portion of the intraparietal sulcus. Area 7PC was found to be involved in all four domains. These regions were extensively connected in the intraparietal sulcus, as well as with a number of surrounding large-scale brain networks involved in higher-order functions. We present a tractographic model of the four neural networks involved in the functions which are impaired in Gerstmann syndrome. We identified a 'Gerstmann Core' of extensively connected functional regions where at least three of the four networks overlap. These results provide clinically actionable and precise anatomic information which may help guide clinical translation in this region, such as during resective brain surgery in or near the intraparietal sulcus, and provides an empiric basis for future study.

Surgical treatment of symptomatic pineal cysts without hydrocephalus-meta-analysis of the published literature.

BACKGROUND: To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. METHODS: Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query 'Pineal Cyst' AND 'Surgery' as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. RESULTS: All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4-63) with 77% females. Mean cyst size was 15 mm (5-35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0-228). PRESENTATION: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), 'psychiatric' (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0-9). OUTCOMES: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74-19.02) and resection over fenestration (OR = 12.64; 3.07-52.01). Age predicted worse outcomes (OR = 0.95; 0.91-0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). CONCLUSIONS: Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Delayed, Progressive Multivessel Occlusion After Resection of a Recurrent Glioma.

Glioblastoma multiforme (GBM) is one of the most common primary brain tumors with an aggressive natural history consistent with a median survival of less than two years. Most clinical research has primarily focused on improving overall survival through aggressive cytoreductive surgery and adjuvant radiochemotherapy. However, far less clinical guidance has been given for unexpected instances of neurologic decline following safe glioma resection in the setting of vascular etiology. Here, we report a 50-year-old man who presented to our clinic with a seizure. His preoperative magnetic resonance imaging (MRI) demonstrated a left hippocampal glioblastoma. Ten months following total resection, the patient presented again with rapid loss of vision and hemorrhagic papilledema. An MRI demonstrated a recurrence of his glioma, which was partially resected with no complications. Eight days after surgery, the patient suddenly became unresponsive and imaging revealed moderate blood in the resection cavity, which was evacuated in the operating room. Follow-up scans showed a posterior cerebral artery infarction, and two days later, a middle cerebral artery infarction, upon which care was withdrawn. We do not propose a mechanism by which this delayed ischemia occurred, especially as the middle cerebral artery was not damaged during surgery, however, we note that delayed ischemia may be one mechanism of damage following glioma resection, which should be studied further to improve patient outcomes.

Changes in the Brain Connectome Following Repetitive Transcranial Magnetic Stimulation for Stroke Rehabilitation.

Repetitive transcranial magnetic stimulation (rTMS) is a promising approach for post-stroke rehabilitation but there lacks a rationale strategy to plan, execute, and monitor treatment. We present a case of targeted rTMS using the Omniscient Infinitome software to devise targets for treatment in a post-stroke patient and describe the functional connectomic changes after treatment. A 19-year-old female with no medical history presented 19 months after suffering a left middle cerebral artery (MCA) superior division ischemic stroke, resulting in language impairment and diminished right upper extremity motor function. She underwent a resting-state MRI (rsMRI) with tractography and images were processed using the Omniscient Infinitome software. Analysis using the anomaly detection within the software enabled us to identify three targets for rTMS (left area 1, left area 45, and right area SFL). These areas were treated with 25 sessions of intermittent Theta Burst Stimulation (iTBS) over five days at 80% of motor threshold concomitantly with targeted physical therapy and speech therapy. At five months follow-up, her language and right upper extremity functions significantly improved. Her connectomic analysis revealed substantial neural changes, including normalization of the sensorimotor network, substantially thicker callosal fiber bundle connecting the two hemispheres, and increased cortical recruitment in her language network. We present the first description of robust connectomic alterations in a post-stroke patient following targeted rTMS treatment. Further studies on the use of rTMS with an emphasis on functional connectomics are warranted.

Reducing the Cognitive Footprint of Brain Tumor Surgery.

The surgical management of brain tumors is based on the principle that the extent of resection improves patient outcomes. Traditionally, neurosurgeons have considered that lesions in "non-eloquent" cerebrum can be more aggressively surgically managed compared to lesions in "eloquent" regions with more known functional relevance. Furthermore, advancements in multimodal imaging technologies have improved our ability to extend the rate of resection while minimizing the risk of inducing new neurologic deficits, together referred to as the "onco-functional balance." However, despite the common utilization of invasive techniques such as cortical mapping to identify eloquent tissue responsible for language and motor functions, glioma patients continue to present post-operatively with poor cognitive morbidity in higher-order functions. Such observations are likely related to the difficulty in interpreting the highly-dimensional information these technologies present to us regarding cognition in addition to our classically poor understanding of the functional and structural neuroanatomy underlying complex higher-order cognitive functions. Furthermore, reduction of the brain into isolated cortical regions without consideration of the complex, interacting brain networks which these regions function within to subserve higher-order cognition inherently prevents our successful navigation of true eloquent and non-eloquent cerebrum. Fortunately, recent large-scale movements in the neuroscience community, such as the Human Connectome Project (HCP), have provided updated neural data detailing the many intricate macroscopic connections between cortical regions which integrate and process the information underlying complex human behavior within a brain "connectome." Connectomic data can provide us better maps on how to understand convoluted cortical and subcortical relationships between tumor and human cerebrum such that neurosurgeons can begin to make more informed decisions during surgery to maximize the onco-functional balance. However, connectome-based neurosurgery and related applications for neurorehabilitation are relatively nascent and require further work moving forward to optimize our ability to add highly valuable connectomic data to our surgical armamentarium. In this manuscript, we review four concepts with detailed examples which will help us better understand post-operative cognitive outcomes and provide a guide for how to utilize connectomics to reduce cognitive morbidity following cerebral surgery.

Using Quicktome for Intracerebral Surgery: Early Retrospective Study and Proof of Concept.

BACKGROUND: Neurosurgeons have limited tools in their armamentarium to visualize critical brain networks during surgical planning. Quicktome was designed using machine-learning to generate robust visualization of important brain networks that can be used with standard neuronavigation to minimize those deficits. We sought to see whether Quicktome could help localize important cerebral networks and tracts during intracerebral surgery. METHODS: We report on all patients who underwent keyhole intracranial surgery with available Quicktome-enabled neuronavigation. We retrospectively analyzed the locations of the lesions and determined functional networks at risks, including chief executive network, default mode network, salience, corticospinal/sensorimotor, language, neglect, and visual networks. We report on the postoperative neurologic outcomes of the patients and retrospectively determined whether the outcomes could be explained by Quicktome's functional localizations. RESULTS: Fifteen high-risk patients underwent craniotomies for intra-axial tumors, with the exception of one meningioma and one case of leukoencephalopathy. Eight patients were male. The median age was 49.6 years. Quicktome was readily integrated in our existing navigation system in every case. New postoperative neurologic deficits occurred in 8 patients. All new deficits, except for one resulting from a postoperative stroke, were expected and could be explained by preoperative findings by Quicktome. In addition, in those who did not have new neurologic deficits, Quicktome offered explanations for their outcomes. CONCLUSIONS: Quicktome helps to visualize complex functional connectomic networks and tracts by seamlessly integrating into existing neuronavigation platforms. The added information may assist in reducing neurological deficits and offer explanations for postsurgical outcomes.

Optimal timing of post-operative enoxaparin after neurosurgery: A single institution experience.

PURPOSE: Venous thromboembolism (VTE) is a well-known problem in patients with intracranial tumors, especially high-grade gliomas. Optimal management of VTE complications is critical given that the development of deep vein thrombosis (DVT) and/or pulmonary embolism can exacerbate medical comorbidities and increase mortality. However, little is known about the optimum time to initiate post-operative anticoagulant prophylaxis. Therefore, there is a keen interest amongst neurosurgeons to develop evidence-based protocols to prevent VTE in post-operative brain tumor patients. METHODS: We retrospectively identified adult patients who underwent elective craniotomy for intracranial tumor resection between 2012 and 2017. Patients were categorized according to the time at which they began receiving prophylactic enoxaparin in the immediate post-operative period, within one day (POD 1), two days (POD 2), three days (POD 3), five days (POD 5), or seven days (POD 7). RESULTS: A total of 1087 patients had a craniotomy for intracranial tumor resection between 2012 and 2017. Multivariate binomial logistic regression analysis demonstrated that initiation of prophylactic enoxaparin within 72 h of surgery was protective against the likelihood of developing a lower extremity DVT (OR: 0.32; CI: 0.10-0.95; p = 0.049) while controlling for possible risk factors for DVTs identified on univariate analysis. Furthermore, complication rates between the anticoagulation and non-anticoagulation groups were not statistically significant. CONCLUSION: Initiating anticoagulant prophylaxis with subcutaneous enoxaparin sodium 40 mg once per day within 72 h of surgery can be done safely while reducing the risk of developing lower extremity DVT.