RESUMO
BACKGROUND AND PURPOSE: Immunodeficiency-associated CNS lymphoma may occur in different clinical scenarios beyond AIDS. This subtype of CNS lymphoma is diffuse large B-cell and Epstein-Barr virus-positive. Its accurate presurgical diagnosis is often unfeasible because it appears as ring-enhancing lesions mimicking glioblastoma or metastasis. In this article, we describe clinicoradiologic features and test the performance of DSC-PWI metrics for presurgical identification. MATERIALS AND METHODS: Patients without AIDS with histologically confirmed diffuse large B-cell Epstein-Barr virus-positive primary CNS lymphoma (December 2010 to January 2022) and diagnostic MR imaging without onco-specific treatment were retrospectively studied. Clinical, demographic, and conventional imaging data were reviewed. Previously published DSC-PWI time-intensity curve analysis methodology, to presurgically identify primary CNS lymphoma, was used in this particular lymphoma subtype and compared with a prior cohort of 33 patients with Epstein-Barr virus-negative CNS lymphoma, 35 with glioblastoma, and 36 with metastasis data. Normalized curves were analyzed and compared on a point-by-point basis, and previously published classifiers were tested. The standard percentage of signal recovery and CBV values were also evaluated. RESULTS: Seven patients with Epstein-Barr virus-positive primary CNS lymphoma were included in the study. DSC-PWI normalized time-intensity curve analysis performed the best for presurgical identification of Epstein-Barr virus-positive CNS lymphoma (area under the receiver operating characteristic curve of 0.984 for glioblastoma and 0.898 for metastasis), followed by the percentage of signal recovery (0.833 and 0.873) and CBV (0.855 and 0.687). CONCLUSIONS: When a necrotic tumor is found in a potentially immunocompromised host, neuroradiologists should consider Epstein-Barr virus-positive CNS lymphoma. DSC-PWI could be very useful for presurgical characterization, with especially strong performance of normalized time-intensity curves.
Assuntos
Infecções por Vírus Epstein-Barr , Glioblastoma , Linfoma Difuso de Grandes Células B , Humanos , Herpesvirus Humano 4 , Infecções por Vírus Epstein-Barr/complicações , Infecções por Vírus Epstein-Barr/diagnóstico por imagem , Estudos Retrospectivos , Linfoma Difuso de Grandes Células B/diagnóstico por imagem , Linfoma Difuso de Grandes Células B/patologia , PerfusãoRESUMO
BACKGROUND AND PURPOSE: DSC-PWI has demonstrated promising results in the presurgical diagnosis of brain tumors. While most studies analyze specific parameters derived from time-intensity curves, very few have directly analyzed the whole curves. The aims of this study were the following: 1) to design a new method of postprocessing time-intensity curves, which renders normalized curves, and 2) to test its feasibility and performance on the diagnosis of primary central nervous system lymphoma. MATERIALS AND METHODS: Diagnostic MR imaging of patients with histologically confirmed primary central nervous system lymphoma were retrospectively reviewed. Correlative cases of glioblastoma, anaplastic astrocytoma, metastasis, and meningioma, matched by date and number, were retrieved for comparison. Time-intensity curves of enhancing tumor and normal-appearing white matter were obtained for each case. Enhancing tumor curves were normalized relative to normal-appearing white matter. We performed pair-wise comparisons for primary central nervous system lymphoma against the other tumor type. The best discriminatory time points of the curves were obtained through a stepwise selection. Logistic binary regression was applied to obtain prediction models. The generated algorithms were applied in a test subset. RESULTS: A total of 233 patients were included in the study: 47 primary central nervous system lymphomas, 48 glioblastomas, 39 anaplastic astrocytomas, 49 metastases, and 50 meningiomas. The classifiers satisfactorily performed all bilateral comparisons in the test subset (primary central nervous system lymphoma versus glioblastoma, area under the curve = 0.96 and accuracy = 93%; versus anaplastic astrocytoma, 0.83 and 71%; versus metastases, 0.95 and 93%; versus meningioma, 0.93 and 96%). CONCLUSIONS: The proposed method for DSC-PWI time-intensity curve normalization renders comparable curves beyond technical and patient variability. Normalized time-intensity curves performed satisfactorily for the presurgical identification of primary central nervous system lymphoma.
Assuntos
Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias do Sistema Nervoso Central/diagnóstico por imagem , Interpretação de Imagem Assistida por Computador/métodos , Neuroimagem/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Neoplasias Encefálicas/patologia , Neoplasias do Sistema Nervoso Central/patologia , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND AND PURPOSE: The main aim of this study was to identify which patients with glioblastoma multiforme (GBM) have a higher risk of presenting seizures during follow-up. METHODS: Patients with newly diagnosed GBM were reviewed (n = 306) and classified as patients with (Group 1) and without (Group 2) seizures at onset. Group 2 was split into patients with seizures during follow-up (Group 2A) and patients who never had seizures (Group 2B). The anatomical location of GBM was identified and compared by voxel-based lesion symptom mapping (discovery set). Seizure-susceptible brain regions obtained were assessed visually and automatically in external GBM validation series (n = 85). RESULTS: In patients with GBM who had no seizures at onset, an increased risk of presenting seizures during follow-up was identified in the superior frontal and inferior occipital lobe, as well as in inferoposterior regions of the temporal lobe. Conversely, those patients with GBM located in medial and inferoanterior temporal areas had a significantly lower risk of suffering from seizures during follow-up. Additionally, the seizure-susceptible brain region maps obtained classified patients in the validation set with high positive and negative predictive values. CONCLUSIONS: Tumor location is a useful marker to identify patients with GBM who are at risk of suffering from seizures during follow-up. These results may help to support the use of antiepileptic prophylaxis in a selected GBM population and to improve stratification in antiepileptic clinical trials.
Assuntos
Neoplasias Encefálicas/complicações , Neoplasias Encefálicas/patologia , Córtex Cerebral/patologia , Glioblastoma/complicações , Glioblastoma/patologia , Convulsões/etiologia , Adulto , Idoso , Anticonvulsivantes/uso terapêutico , Neoplasias Encefálicas/diagnóstico por imagem , Córtex Cerebral/diagnóstico por imagem , Feminino , Seguimentos , Glioblastoma/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Convulsões/prevenção & controleRESUMO
PURPOSE: We assessed agreement among neurosurgeons on surgical approaches to individual glioblastoma patients and between their approach and those recommended by the topographical staging system described by Shinoda. METHODS: Five neurosurgeons were provided with pre-surgical MRIs of 76 patients. They selected the surgical approach [biopsy, partial resection, or gross total resection (GTR)] that they would recommend for each patient. They were blinded to each other's response and they were told that patients were younger than 50 years old and without symptoms. Three neuroradiologists classified each case according to the Shinoda staging system. RESULTS: Biopsy was recommended in 35.5-82.9%, partial resection in 6.6-32.9%, and GTR in 3.9-31.6% of cases. Agreement among their responses was fair (global kappa = 0.28). Nineteen patients were classified as stage I, 14 as stage II, and 43 as stage III. Agreement between the neurosurgeons and the recommendations of the staging system was poor for stage I (kappa = 0.14) and stage II (kappa = 0.02) and fair for stage III patients (kappa = 0.29). An individual analysis revealed that in contrast to the Shinoda system, neurosurgeons took into account T2/FLAIR sequences and gave greater weight to the involvement of eloquent areas. CONCLUSIONS: The surgical approach to glioblastoma is highly variable. A staging system could be used to examine the impact of extent of resection, monitor post-operative complications, and stratify patients in clinical trials. Our findings suggest that the Shinoda staging system could be improved by including T2/FLAIR sequences and a more adequate weighting of eloquent areas.
Assuntos
Neoplasias Encefálicas/cirurgia , Glioblastoma/cirurgia , Estadiamento de Neoplasias/métodos , Procedimentos Neurocirúrgicos/normas , Adulto , Neoplasias Encefálicas/patologia , Ensaios Clínicos Fase II como Assunto , Glioblastoma/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Neurocirurgiões/normas , Procedimentos Neurocirúrgicos/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Palliative techniques such as partial corpus callosotomy (CC) and vagus nerve stimulation (VNS) may be effective for adequate control of seizures in pharmacoresistant patients who are not candidates for resective surgery. OBJECTIVE: The objective of this study was to analyze the efficacy of the combination of these two techniques in patients where the first surgery had not achieved adequate control. MATERIALS AND METHODS: This is a retrospective review of 6 patients with refractory epilepsy in which both types of surgery were performed, CC and VNS. We analyzed variables such as age, sex, age at onset of epilepsy, seizure types, electroencephalogram and magnetic resonance imaging results, and number of pre- and postoperative seizures. RESULTS: Three patients first underwent VNS and then CC, and 3 patients were treated in reverse order. All patients had some improvement after the first surgery, but they continued to experience persistent falls, so a second palliative technique was used. The mean improvement after both surgeries was 89% (90% in patients first receiving CC and 87% in patients who first underwent VNS). CONCLUSIONS: In adequately studied patients who are not optimal candidates for resective surgery, palliative surgery is a choice. The combination of VNS and CC shows good results in our series, although the right order to perform both procedures has not been defined. These results should be confirmed in a larger group of patients.
Assuntos
Corpo Caloso/cirurgia , Epilepsia/cirurgia , Epilepsia/terapia , Convulsões/cirurgia , Convulsões/terapia , Estimulação do Nervo Vago , Adulto , Fatores Etários , Idade de Início , Encéfalo/patologia , Encéfalo/fisiopatologia , Eletroencefalografia , Epilepsia/patologia , Epilepsia/fisiopatologia , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Estudos Retrospectivos , Convulsões/patologia , Convulsões/fisiopatologia , Fatores Sexuais , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND AND PURPOSE: Vagus nerve stimulation (VNS) has been reported to be a safe and effective treatment for drug-resistant epilepsy. The aim of this study is to describe the effect of VNS in patients with a history of repeated episodes of status epilepticus (SE) before implantation. METHODS: From a total of 83 adult patients with drug-resistant epilepsy who had VNS implanted in four tertiary centers in Spain between 2000 and 2010, eight had a previous history of repeated episodes of SE. We performed a retrospective observational study analyzing the outcome of seizures and episodes of SE after implantation. Stimulation was started at the usual settings, and intensity increased according to clinical response and tolerability. RESULTS: Regarding the eight patients with a history of SE, the mean age at time of VNS implantation was 25.1 [14-40] years. Duration of epilepsy until the implantation was 21.7 [7-39.5] years, and they had been treated with a mean of 12 antiepileptic drugs [10-16]. Mean follow-up since implantation was 4.15 [2-7.5] years. Average seizure frequency decreased from 46 to 8.2 per month. Interestingly, four of the eight patients remained free of new episodes of SE after implantation, and in two additional patients, the frequency decreased by >75%. Adverse effects were mild or moderate in intensity and included mainly coughing and dysphonia. CONCLUSION: In those patients with refractory epilepsy and history of SE who are not surgical candidates, VNS is a safe and effective method to reduce seizure frequency and episodes of SE.
Assuntos
Epilepsia/terapia , Estado Epiléptico/terapia , Estimulação do Nervo Vago/métodos , Adolescente , Adulto , Epilepsia/complicações , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estado Epiléptico/etiologia , Resultado do TratamentoRESUMO
INTRODUCTION: The authors present the results of a series of 121 cases of posterior vertebral fixation carried out from Sept 2008 to Sept 2010 using Flouro 2D-TC assisted Vector Vision o Kolibri navigator. ( Brain LAB, Feldkirchen, Germany). MATERIAL: The sample included 68 males and 53 females. Age range was 24-75 with an average of 50.35., all with indication for instrumentation by different pathologies. METHOD: Patients presenting vertebral lesions of varying ethiology and lesion level with vertebral posterior fixation indication were included in the study. All underwent a CT before surgery, according to navigation protocol, and the images obtained were merged in the navigator with those obtained in the operating room with a Flouro 2D, which allowed a high quality 3D reconstruction to be performed and thus the capacity to navigate in a real-virtual manner. To evaluate the results of the implant a post-op CT was performed and the position of the implant was defined according to the Heary scale. The calabration time of the material was also evaluated, number of shots with the Flouro-2D, and for clinical evaluation VAS scales were employed, Oswestry and JOA (L), as well as the degree of satisfaction and acceptance of the procedure. RESULTS: A total of 580 screws were implanted, distributed in 62 cervicals of which 24 were in C1-C2, 38 dorsals, 370 lumbar and 110 sacral. Open surgery was performed in 42 cases, MIS in 28 and percutaneous in 51. The presision of the implant was 98.45% with a global deviation of 1.55%, that according to the Heary scale was distributed in grade ll: 2 (1 cervical, 1 lumbar) grade lll: 4 (1 cervical, 2 dorsal, 1 lumbar), grade IV: 3 (1 cervical, 2 lumbar). General average time of calibration per procedure was 2 min. 49 seconds and the mean flouroscopic exposure was one shot at cervical and dorsal and two shots at lumbar level. The clinical evaluation at one month of 121 patients was 8.6/3.0 in the VAS, 68.0% / 23.0% in Oswestry and 6.4/13.1 in JOA (L), with those parameters remaining stable at 3 months in 100 and at 6 months in 87 patients respectively, and the degree of satisfaction between being completely and very satisfied with the procedure was 94.9%, and those who would submit to another treatment was more than 94%. CONCLUSION: Navigation with Flouro-2D-CT is a high precision technique that reduces complications of varying severity according to the level operated well as number of reinterventions, radiation exposure and surgical time.
Assuntos
Parafusos Ósseos , Neuronavegação , Radiografia Intervencionista , Doenças da Coluna Vertebral/cirurgia , Coluna Vertebral/cirurgia , Cirurgia Assistida por Computador , Adulto , Idoso , Feminino , Fluoroscopia , Fixação Interna de Fraturas/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite/cirurgia , Satisfação do Paciente , Cuidados Pré-Operatórios , Estudos Retrospectivos , Fraturas da Coluna Vertebral/cirurgia , Neoplasias da Coluna Vertebral/cirurgia , Espondilite/cirurgia , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
OBJECTIVES: The main objective of the present work was to identify, by means of intraoperative electrical stimulation, the supplementary motor area (SMA) region which is implicated in complex motor function. The functional prognostic relevance of the surgical preservation of this area was also analyzed. METHOD: Fifteen patients with tumors infiltrating the premotor cortex were selected. All patients were operated under awake conditions. Primary motor cortex was identified with intraoperative electrical stimulation (IES). To identify the SMA, patients were asked to do a finger opposition motor task with their hand contralateral to the lesion, that was blocked by electrically stimulating the premotor cerebral cortex. RESULTS: SMA was identified in all patients with IES. Complete surgical resection was achieved in 13 patients (86.6%) and subtotal in 2 patients (13.3%). SMA function was preserved in 14 patients (93.3%). In only one patient the SMA was partially resected because of tumor infiltration (6.6%). In the immediate postoperative period, 8 patients (53.3%) did not show changes in comparison to their preoperative clinical status, and 2 patients improved. At 6 months follow up, 5 patients (33.3%) were asymptomatic and 10 patients showed permanent deficits. In this last group, five patients (33.3%) showed mild deficits that did not interfere with a normal life. In the other 5 patients (33.3%), permanent deficits interfered with daily life activities: two patients presented severe hemiparesis 3/5 (same similar to their preoperative status with no improvement), one patient had motor aphasia, and two other patients (13.3%) showed permanent left SMA syndrome. In two patients with severe postoperative hemiparesis, tumor infiltration of primary motor cortex and piramidal pathway was observed; severe preoperative motor deficit (KPS <70) was associated with poor functional outcome. CONCLUSIONS: Intraoperative electrical cortical stimulation is useful to identify the SMA. Once identified, SMA preservation decreases the risk of postoperative symptoms and permanent SMA syndrome. When SMA is infiltrated by the tumor, radical resection may cause permanent neurological deficits, specially in the dominant hemisphere. Severe preoperative motor deficit was associated with poor outcome.
Assuntos
Neoplasias Encefálicas/cirurgia , Córtex Motor/anatomia & histologia , Córtex Motor/cirurgia , Procedimentos Neurocirúrgicos/métodos , Adulto , Idoso , Mapeamento Encefálico/métodos , Estimulação Elétrica , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Atividade Motora , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias , Resultado do TratamentoRESUMO
Intraventricular haemorrhage (IVH) is associated with a poor outcome. Simple external ventricular drainage has not modified the high morbidity and mortality of these patients. Our objective was to review our experience using intraventricular urokinase (UK) in treating patients with moderate to severe IVH. Prospective analysis of medical records of 14 patients diagnosed with spontaneous IVH who received ventriculostomy and intraventricular infusion of UK from January 2002 to December 2005. Patients with the following characteristics were included: 18-70 years of age, GCS between 5 and 14, and moderate to severe IVH (Graeb > or = 6) without simultaneous intraparenchymal haematoma > 30 ml. The final results were compared to historic control group (14 patients) treated between January 1999 to December 2001 with ventriculostomy alone. All 28 patients accomplished the inclusion criteria. Patient age, initial GCS and Graeb classification of IVH were similar in the two groups of treatment. There was higher ventriculostomy obstruction rate in the non-UK group (33.3 vs. 0%; p > 0.05), a higher rate of intracranial hypertension in the non-UK group (66.6 vs. 16.6%; p = 0.036) and a lower mortality rate in the UK group (25 vs. 58.3%, p > 0.05). There was no rebleeding associated with UK treatment. Intraventricular UK appears to be a safe treatment. It is effective in the prevention of catheter blockage, speeding the clearance of IVH, and it is associated with lower rate of intracranial hypertension and death.
Assuntos
Fibrinolíticos/uso terapêutico , Hemorragias Intracranianas/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tipo Uroquinase/uso terapêutico , Adolescente , Adulto , Idoso , Ventrículos Cerebrais/irrigação sanguínea , Drenagem/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Myxopapillary ependymomas (ME) are considered benign tumours (WHO grade I) of the central nervous system with long term survival rates and a tendency to local recurrence. However an aggressive course has occasionally been described, leading to CSF dissemination and even systemic metastases. We describe the case of a 23-year-old man diagnosed with intracranial subarachnoid dissemination of a filum terminale ME three years after the initial diagnosis. We have performed a careful review of the literature on CSF dissemination in ME and finally propose treatment of these cases.
Assuntos
Neoplasias Encefálicas/secundário , Cauda Equina/patologia , Ependimoma/secundário , Neoplasias Meníngeas/secundário , Metástase Neoplásica/fisiopatologia , Neoplasias da Medula Espinal/patologia , Espaço Subaracnóideo/fisiopatologia , Adulto , Neoplasias Encefálicas/radioterapia , Cauda Equina/fisiopatologia , Cauda Equina/cirurgia , Descompressão Cirúrgica , Progressão da Doença , Ependimoma/radioterapia , Cefaleia/diagnóstico , Cefaleia/etiologia , Cefaleia/fisiopatologia , Humanos , Neoplasias Hipotalâmicas/radioterapia , Neoplasias Hipotalâmicas/secundário , Hipotálamo/patologia , Hipotálamo/fisiopatologia , Hipotálamo/cirurgia , Laminectomia , Dor Lombar/etiologia , Dor Lombar/fisiopatologia , Dor Lombar/cirurgia , Vértebras Lombares/cirurgia , Imageamento por Ressonância Magnética , Masculino , Neoplasias Meníngeas/radioterapia , Metástase Neoplásica/diagnóstico , Neuro-Hipófise/patologia , Neuro-Hipófise/fisiopatologia , Neuro-Hipófise/cirurgia , Radioterapia/métodos , Espaço Subaracnóideo/patologia , Espaço Subaracnóideo/cirurgia , Terceiro Ventrículo/patologia , Terceiro Ventrículo/fisiopatologia , Terceiro Ventrículo/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: Spontaneous and non-spontaneous spinal epidural hematoma (SEH) is a rare condition in neurosurgical practice. It presents as an acute spinal cord compression and usually requires emergent surgical decompression. Recently non-surgical treatment (corticoid therapy) has been proposed in selected cases of SEH with good neurological recovery. OBJECTIVES: To identify the prognostic factors of this condition. A treatment management based upon our results is proposed. MATERIAL AND METHODS: Between 1985 and 2001, 22 patients suffering SEH were treated at our Department. Age, sex, initial neurological condition (evaluated using the Frankel grading scale), surgical timing, radiological data such as location, extension and degree of radiological cord compression, anticoagulation or antiplatelet therapy, epidural anesthesia and previous spinal surgery were analyzed in order to find prognostic factors. Finally, conservative or surgical treatment as well as final neurological condition were also considered for the analysis. RESULTS: The average age was 69 years with a male preponderance (72.7%). Surgical decompression was done in 17 cases, most of them (11 cases) presenting with high neurological deficit (Frankel A-B). Conservative treatment was used on 5 patients. Operated patients showed a larger degree of neurological recovery. The incidence of post-operative complications was of 13%. CONCLUSIONS: This study shows the efficiency of SEH surgical evacuation performed within the first 24 hours, particularly when the patient presents a severe neurological deficit (Frankel A-B). Patients presenting minimal neurological involvement (Frankel D-E) can be managed successfully with conservative treatment.