Tumour growth rate predicts overall survival in patients with recurrent WHO grade 4 glioma.

PURPOSE: Accurate prognostication may aid in the selection of patients who will benefit from surgery at recurrent WHO grade 4 glioma. This study aimed to evaluate the role of serial tumour volumetric measurements for prognostication at first tumour recurrence. METHODS: We retrospectively analyzed patients with histologically-diagnosed WHO grade 4 glioma at initial and at first tumour recurrence at a tertiary hospital between May 2000 and September 2018. We performed auto-segmentation using ITK-SNAP software, followed by manual adjustment to measure serial contrast-enhanced T1W (CE-T1W) and T2W lesional volume changes on all MRI images performed between initial resection and repeat surgery. RESULTS: Thirty patients met inclusion criteria; the median overall survival using Kaplan-Meier analysis from second surgery was 10.5 months. Seventeen (56.7%) patients received treatment post second surgery. Univariate cox regression analysis showed that greater rate of increase in lesional volume on CE-T1W (HR = 2.57; 95% CI [1.18, 5.57]; p = 0.02) in the last 2 MRI scans leading up to the second surgery was associated with a higher mortality likelihood. Patients with higher Karnofsky Performance Score (KPS) (HR = 0.97; 95% CI [0.95, 0.99]; p = 0.01) and who received further treatment following second surgery (HR = 0.43; 95% CI [0.19, 0.98]; p = 0.04) were shown to have a better survival. CONCLUSION: Higher rate of CE-T1W lesional growth on the last 2 MRI images prior to surgery at recurrence was associated with increase mortality risk. A larger prospective study is required to determine and validate the threshold to distinguish rapidly progressive tumour with poor prognosis.

An unusual presentation of primary malignant B-cell-type dural lymphoma.

Primary malignant B-cell-type dural lymphoma is a rare subtype of primary central nervous system lymphoma (PCNSL). We herein report an unusual case of diffuse B-cell lymphoma that presents as a chronic subdural haematoma without extracranial involvement. The notable aspects of this case include the patient's immunocompetence, a short clinical history of symptom onset, rapid neurological deterioration and a fi nal diagnosis of high-grade PCNSL. This case highlights the challenges neurosurgeons face, especially in the emergency setting, when the disease manifests in varied presentations.

Post-traumatic hydrocephalus after ventricular shunt placement in a Singaporean neurosurgical unit.

Ventricular enlargement is a common finding after severe head injury and has a poor prognosis if associated with post-traumatic hydrocephalus (PTH). We retrospectively reviewed our head injury database and identified patients who suffered from severe head injury and subsequently had shunt insertion after a diagnosis of PTH. A total of 871 patients with severe head injury were admitted from April 1999 to December 2006. Twenty-three patients (2.6%) were diagnosed with post-traumatic hydrocephalus and had a shunt inserted. Multiple logistic regression analysis showed that age, and unilateral and bilateral decompressive craniectomy, were significant predictors of PTH. The timing of shunt placement was between 2 weeks and 5 months post-head injury with a mean interval of 70 days. Three patients developed complications after shunt insertion. Seventeen patients (74%) achieved improvement after shunt insertion while the remainder had no significant change in neurological status. Eleven patients (48%) had improvements in their Glasgow Coma Scale (GCS) score of ≥2 points, while six patients (26%) had a single-point improvement in their GCS score. At 1 year after shunting, 35% of patients had Glasgow Outcome Scale scores of 3 to 4. PTH is a condition that has an insidious onset with varying clinical and radiological presentations. The incidence is low but there is a significant benefit from ventricular shunt insertion. The use of cerebrospinal fluid dynamic studies, in addition to clinical and radiological findings, has the potential for better diagnosis and management of these patients.

Brain metastases as a cause of malignant cerebrospinal fluid ascites: case report and review of the literature.

The development of cerebrospinal fluid ascites after a ventriculo-peritoneal shunt operation is an extremely rare complication. There have been only sporadic case reports and small series reviews published in regards to this condition. They are usually found in the context of primary brain tumors, usually affecting the pediatric population. We present an unusual case of a patient with known metastatic breast carcinoma to the brain who develops malignant cerebrospinal fluid ascites after a ventriculo-peritoneal shunt insertion. This is the first known adult case of a metastatic breast primary to the brain causing tumor dissemination via a ventriculo-peritoneal shunt.