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OBJECTIVE: The overall aim of this study was to demonstrate the potential benefit of a novel mixed-reality-head-mounted display (MR-HMD) on the spatial orientation of surgeons. METHODS: In a prospective clinical investigation, the authors applied for the first time a new multicamera navigation technology in an operating room setting that allowed them to directly compare MR-HMD navigation to standard monitor navigation. In the study, which included 14 patients with nonruptured middle cerebral artery aneurysms, the authors investigated how intuitively and effectively surgical instruments could be guided in 5 different visual navigation conditions. RESULTS: The authors demonstrate that multicamera tracking can be reliably integrated in a clinical setting (usability score 1.12 ± 0.31). Moreover, the technology captures large volumes of the operating room, allowing the team to track and integrate different devices and instruments, including MR-HMDs. Directly comparing mixed-reality navigation to standard monitor navigation revealed a significantly improved intuition in mixed reality, leading to navigation times that were twice as fast (2.1×, p ≤ 0.01). Despite the enhanced speed, the same targeting accuracy (approximately 2.5 mm, freehand tool use) in comparison to monitor navigation could be observed. Intraoperative planning strategies with mixed reality clearly outperformed classic preoperative planning: surgeons scored the mixed-reality plan as the best trajectory in 63% of the cases (chance level 33%). CONCLUSIONS: The incorporation of mixed reality in neurosurgical operations marks a significant advancement in the field. The use of mixed reality in brain surgery enhances the spatial awareness of surgeons, enabling more instinctive and precise surgical interventions. This technological integration promises to refine the execution of complex procedures without compromising accuracy.
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OBJECTIVE: Contemporary oncological paradigms for adjuvant treatment of low- and intermediate-grade gliomas are often guided by a limited array of parameters, overlooking the dynamic nature of the disease. The authors' aim was to develop a comprehensive multivariate glioma growth model based on multicentric data, to facilitate more individualized therapeutic strategies. METHODS: Random slope models with subject-specific random intercepts were fitted to a retrospective cohort of grade II and III gliomas from the database at Kepler University Hospital (n = 191) to predict future mean tumor diameters. Deep learning-based radiomics was used together with a comprehensive clinical dataset and evaluated on an external prospectively collected validation cohort from University Hospital Zurich (n = 9). Prediction quality was assessed via mean squared prediction error. RESULTS: A mean squared prediction error of 0.58 cm for the external validation cohort was achieved, indicating very good prognostic value. The mean ± SD time to adjuvant therapy was 28.7 ± 43.3 months and 16.1 ± 14.6 months for the training and validation cohort, respectively, with a mean of 6.2 ± 5 and 3.6 ± 0.7, respectively, for number of observations. The observed mean tumor diameter per year was 0.38 cm (95% CI 0.25-0.51) for the training cohort, and 1.02 cm (95% CI 0.78-2.82) for the validation cohort. Glioma of the superior frontal gyrus showed a higher rate of tumor growth than insular glioma. Oligodendroglioma showed less pronounced growth, anaplastic astrocytoma-unlike anaplastic oligodendroglioma-was associated with faster tumor growth. Unlike the impact of extent of resection, isocitrate dehydrogenase (IDH) had negligible influence on tumor growth. Inclusion of radiomics variables significantly enhanced the prediction performance of the random slope model used. CONCLUSIONS: The authors developed an advanced statistical model to predict tumor volumes both pre- and postoperatively, using comprehensive data prior to the initiation of adjuvant therapy. Using radiomics enhanced the precision of the prediction models. Whereas tumor extent of resection and topology emerged as influential factors in tumor growth, the IDH status did not. This study emphasizes the imperative of advanced computational methods in refining personalized low-grade glioma treatment, advocating a move beyond traditional paradigms.
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Neoplasias Encefálicas , Glioma , Oligodendroglioma , Humanos , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/cirurgia , Neoplasias Encefálicas/patologia , Imageamento por Ressonância Magnética/métodos , Estudos Retrospectivos , Radiômica , Glioma/cirurgia , Isocitrato Desidrogenase/genética , MutaçãoRESUMO
BACKGROUND AND OBJECTIVE: Patients with presumed nonlesional focal epilepsy-based on either MRI or histopathologic findings-have a lower success rate of epilepsy surgery compared with lesional patients. In this study, we aimed to characterize a large group of patients with focal epilepsy who underwent epilepsy surgery despite a normal MRI and had no lesion on histopathology. Determinants of their postoperative seizure outcomes were further studied. METHODS: We designed an observational multicenter cohort study of MRI-negative and histopathology-negative patients who were derived from the European Epilepsy Brain Bank and underwent epilepsy surgery between 2000 and 2012 in 34 epilepsy surgery centers within Europe. We collected data on clinical characteristics, presurgical assessment, including genetic testing, surgery characteristics, postoperative outcome, and treatment regimen. RESULTS: Of the 217 included patients, 40% were seizure-free (Engel I) 2 years after surgery and one-third of patients remained seizure-free after 5 years. Temporal lobe surgery (adjusted odds ratio [AOR]: 2.62; 95% CI 1.19-5.76), shorter epilepsy duration (AOR for duration: 0.94; 95% CI 0.89-0.99), and completely normal histopathologic findings-versus nonspecific reactive gliosis-(AOR: 4.69; 95% CI 1.79-11.27) were significantly associated with favorable seizure outcome at 2 years after surgery. Of patients who underwent invasive monitoring, only 35% reached seizure freedom at 2 years. Patients with parietal lobe resections had lowest seizure freedom rates (12.5%). Among temporal lobe surgery patients, there was a trend toward favorable outcome if hippocampectomy was part of the resection strategy (OR: 2.94; 95% CI 0.98-8.80). Genetic testing was only sporadically performed. DISCUSSION: This study shows that seizure freedom can be reached in 40% of nonlesional patients with both normal MRI and histopathology findings. In particular, nonlesional temporal lobe epilepsy should be regarded as a relatively favorable group, with almost half of patients achieving seizure freedom at 2 years after surgery-even more if the hippocampus is resected-compared with only 1 in 5 nonlesional patients who underwent extratemporal surgery. Patients with an electroclinically identified focus, who are nonlesional, will be a promising group for advanced molecular-genetic analysis of brain tissue specimens to identify new brain somatic epilepsy genes or epilepsy-associated molecular pathways.
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Epilepsias Parciais , Epilepsia do Lobo Temporal , Epilepsia , Humanos , Estudos de Coortes , Eletroencefalografia , Epilepsias Parciais/diagnóstico por imagem , Epilepsias Parciais/cirurgia , Epilepsia/diagnóstico por imagem , Epilepsia/cirurgia , Epilepsia do Lobo Temporal/cirurgia , Imageamento por Ressonância Magnética , Estudos Retrospectivos , Convulsões , Resultado do TratamentoRESUMO
BACKGROUND: Anterior lumbar interbody fusion (ALIF) is a well-established surgical treatment option for various diseases of the lumbar spine, including spondylolisthesis. This study aimed to evaluate the postoperative correction of spondylolisthesis and restoration of lumbar and segmental lordosis after ALIF. METHODS: Patients with spondylolisthesis who underwent ALIF between 2013 and 2019 were retrospectively assessed. We assessed the following parameters pre-and postoperatively (6-months follow-up): Visual Analogue Scale (VAS) for pain, Oswestry Disability Index (ODI), lumbar lordosis (LL), segmental lordosis (SL), L4/S1 lordosis, and degree of spondylolisthesis. RESULTS: 96 patients were included. In 84 cases (87.50%), additional dorsal instrumentation was performed. The most frequent diagnosis was isthmic spondylolisthesis (73.96%). VAS was reduced postoperatively, from 70 to 40, as was ODI (50% to 32%). LL increased from 59.15° to 64.45°, as did SL (18.95° to 28.55°) and L4/S1 lordosis (37.90° to 44.00°). Preoperative spondylolisthesis was 8.90 mm and was reduced to 6.05 mm postoperatively. Relative spondylolisthesis was 21.63% preoperatively and 13.71% postoperatively. All clinical and radiological improvements were significant (all p < 0.001). No significant difference considering the lordosis values nor spondylolisthesis was found between patients who underwent ALIF surgery without dorsal instrumentation and patients who received additional dorsal instrumentation. Venous laceration was the most frequent complication (10.42%). CONCLUSIONS: With ALIF, good clinical results and safe and effective reduction of spondylolisthesis and restoration of lordosis can be achieved. Additional dorsal instrumentation does not significantly affect postoperative lordosis or spondylolisthesis. Individual vascular anatomy must be reviewed preoperatively before considering ALIF.
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Vértebras Lombares , Procedimentos de Cirurgia Plástica , Fusão Vertebral , Espondilolistese , Humanos , Vértebras Lombares/cirurgia , Estudos Retrospectivos , Fusão Vertebral/métodos , Espondilolistese/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVES: In high-grade glioma (HGG) surgery, intraoperative MRI (iMRI) has traditionally been the gold standard for maximizing tumor resection and improving patient outcomes. However, recent Level 1 evidence juxtaposes the efficacy of iMRI and 5-aminolevulinic acid (5-ALA), questioning the continued justification of iMRI because of its associated costs and extended surgical duration. Nonetheless, drawing from our clinical observations, we postulated that a subset of intricate HGGs may continue to benefit from the adjunctive application of iMRI. METHODS: In a prospective study of 73 patients with HGG, 5-ALA was the primary technique for tumor delineation, complemented by iMRI to detect residual contrast-enhanced regions. Suboptimal 5-ALA efficacy was defined when (1) iMRI detected contrast-enhanced remnants despite 5-ALA's indication of a gross total resection or (2) surgeons observed residual fluorescence, contrary to iMRI findings. Radiomic features from preoperative MRIs were extracted using a U2-Net deep learning algorithm. Binary logistic regression was then used to predict compromised 5-ALA performance. RESULTS: Resections guided solely by 5-ALA achieved an average removal of 93.14% of contrast-enhancing tumors. This efficacy increased to 97% with iMRI integration, albeit not statistically significant. Notably, for tumors with suboptimal 5-ALA performance, iMRI's inclusion significantly improved resection outcomes (P-value: .00013). The developed deep learning-based model accurately pinpointed these scenarios, and when enriched with radiomic parameters, showcased high predictive accuracy, as indicated by a Nagelkerke R2 of 0.565 and a receiver operating characteristic of 0.901. CONCLUSION: Our machine learning-driven radiomics approach predicts scenarios where 5-ALA alone may be suboptimal in HGG surgery compared with its combined use with iMRI. Although 5-ALA typically yields favorable results, our analyses reveal that HGGs characterized by significant volume, complex morphology, and left-sided location compromise the effectiveness of resections relying exclusively on 5-ALA. For these intricate cases, we advocate for the continued relevance of iMRI.
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PURPOSE: The treatment of oligodendroglioma consists of tumor resection and radiochemotherapy. The timing of radiochemotherapy remains unclear, and predictive biomarkers are limited. EXPERIMENTAL DESIGN: Adult patients diagnosed with isocitrate dehydrogenase (IDH)-mutated, 1p/19q-codeleted CNS WHO grade 2 and 3 oligodendroglioma at the Medical University of Vienna and the Kepler University Hospital Linz (Austria) in 1992 to 2019 were included. Progression-free (PFS) and overall survival (OS) between early postoperative treatment and initial observation were compared using propensity score-weighted Cox regression models. DNA methylation analysis of tumor tissue was performed using Illumina MethylationEPIC 850k microarrays. RESULTS: One hundred thirty-one out of 201 (65.2%) patients with CNS WHO grade 2 and 70 of 201 (34.8%) with grade 3 oligodendroglioma were identified. Eighty-three of 201 (41.3%) patients underwent early postoperative treatment, of whom 56 of 83 (67.5%) received radiochemotherapy, 15 of 84 (18.1%) radiotherapy (RT) only and 12 of 83 (14.5%) chemotherapy only. Temozolomide-based treatment was administered to 64 of 68 (94.1%) patients, whereas RT + procarbazine, lomustine (CCNU), and vincristine (PCV) were applied in 2 of 69 (3.5%) patients. Early treatment was not associated with PFS [adjusted hazard ratio (HR) 0.74; 95% CI, 0.33-1.65, P = 0.459] or OS (adjusted HR: 2.07; 95% CI, 0.52-8.21, P = 0.302) improvement. Unsupervised clustering analysis of DNA methylation profiles from patients receiving early treatment revealed two methylation clusters correlating with PFS, whereas no association of clustering with O6-methylguanine methyltransferase (MGMT) promoter methylation, CNS WHO grade, extent of resection, and treating center could be observed. CONCLUSIONS: In this retrospective study, early postoperative treatment was not associated with improved PFS/OS in oligodendroglioma. The potentially predictive value of whole-genome methylation profiling should be validated in prospective trials.
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Neoplasias Encefálicas , Oligodendroglioma , Adulto , Neoplasias Encefálicas/tratamento farmacológico , Neoplasias Encefálicas/terapia , Metilação de DNA , Humanos , Isocitrato Desidrogenase/genética , Lomustina , Metiltransferases/genética , Oligodendroglioma/genética , Oligodendroglioma/cirurgia , Procarbazina/uso terapêutico , Estudos Prospectivos , Estudos Retrospectivos , Temozolomida/uso terapêutico , Vincristina , Organização Mundial da SaúdeRESUMO
INTRODUCTION: Adult brainstem gliomas (BSGs) are rare central nervous system tumours characterized by a highly heterogeneous clinical course. Median survival times range from 11 to 84 months. Beyond surgery, no treatment standard has been established. We investigated clinical and radiological data to assess prognostic features providing support for treatment decisions. METHODS: 34 BSG patients treated between 2000 and 2019 and aged ≥ 18 years at the time of diagnosis were retrospectively identified from the databases of the two largest Austrian Neuro-Oncology centres. Clinical data including baseline characteristics, clinical disease course, applied therapies, the outcome as well as neuroradiological and neuropathological findings were gathered and analysed. The tumour apparent diffusion coefficient (ADC), volumetry of contrast-enhancing and non-contrast-enhancing lesions were determined on magnetic resonance imaging scans performed at diagnosis. RESULTS: The median age at diagnosis was 38.5 years (range 18-71 years). Tumour progression occurred in 26/34 (76.5%) patients after a median follow up time of 19 months (range 0.9-236.2). Median overall survival (OS) and progression-free survival (PFS) was 24.1 months (range 0.9-236.2; 95% CI 18.1-30.1) and 14.5 months (range 0.7-178.5; 95% CI 5.1-23.9), respectively. Low-performance status, high body mass index (BMI) at diagnosis and WHO grading were associated with shorter PFS and OS at univariate analysis (p < 0.05, log rank test, respectively). ADC values below the median were significantly associated with shorter OS (14.9 vs 44.2 months, p = 0.018). CONCLUSION: ECOG, BMI, WHO grade and ADC values were associated with the survival prognosis of BSG patients and should be included in the prognostic assessment.
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Neoplasias Encefálicas , Glioma , Adolescente , Adulto , Idoso , Neoplasias Encefálicas/patologia , Tronco Encefálico/patologia , Glioma/diagnóstico por imagem , Glioma/terapia , Humanos , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Centros de Atenção Terciária , Adulto JovemRESUMO
Background: One of the most frequent complications of spinal surgery is accidental dural tears (ADTs). Minimal access surgical techniques (MAST) have been described as a promising approach to minimizing such complications. ADTs have been studied extensively in connection with open spinal surgery, but there is less literature on minimally invasive spinal surgery (MISS). Materials and Methods: We reviewed 187 patients who had undergone degenerative lumbar spinal surgery using minimally invasive spinal fusions techniques. We analyzed the influence of age, Body Mass Index (BMI), smoking, diabetes, and previous surgery on the rate of ADTs in MISS. Results: Twenty-two patients (11.764%) suffered from an ADT. We recommended bed rest for two and a half to 5 days, depending on the type of repair required and the amount of cerebrospinal fluid (CSF) leakage. We could not find any statistically significant correlation between ADTs and age (p = 0.34,), BMI (p = 0.92), smoking (p = 0.46), and diabetes (p = 0.71). ADTs were significantly more frequent in cases of previous surgery (p < 0.001). None of the patients developed a transcutaneous CSF leak or post-operative infection. Conclusions: The frequency of ADTs in MISS appears comparable to that encountered when using open surgical techniques. Additionally, MAST produces less dead space along the corridor to the spine. Such reduced dead space may not be enough for pseudomeningocele to occur, cerebrospinal fluid to accumulate, and fistula to form. MAST, therefore, provides a certain amount of protection.
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BACKGROUND: The literature on white matter anatomy underlying the human orbitofrontal cortex (OFC) is scarce in spite of its relevance for glioma surgery. OBJECTIVE: To describe the anatomy of the OFC and of the underlying white matter fiber anatomy, with a particular focus on the surgical structures relevant for a safe and efficient orbitofrontal glioma resection. Based on anatomical and radiological data, the secondary objective was to describe the growth pattern of OFC gliomas. METHODS: The study was performed on 10 brain specimens prepared according to Klingler's protocol and dissected using the fiber microdissection technique modified according to U.T., under the microscope at high magnification. RESULTS: A detailed stratigraphy of the OFC was performed, from the cortex up to the frontal horn of the lateral ventricle. The interposed neural structures are described together with relevant neighboring topographic areas and nuclei. Combining anatomical and radiological data, it appears that the anatomical boundaries delimiting and guiding the macroscopical growth of OFC gliomas are as follows: the corpus callosum superiorly, the external capsule laterally, the basal forebrain and lentiform nucleus posteriorly, and the gyrus rectus medially. Thus, OFC gliomas seem to grow ventriculopetally, avoiding the laterally located neocortex. CONCLUSION: The findings in our study supplement available anatomical knowledge of the OFC, providing reliable landmarks for a precise topographical diagnosis of OFC lesions and for perioperative orientation. The relationships between deep anatomic structures and glioma formations described in this study are relevant for surgery in this highly interconnected area.
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Prosencéfalo Basal , Glioma , Substância Branca , Corpo Caloso , Glioma/diagnóstico por imagem , Glioma/cirurgia , Humanos , Córtex Pré-Frontal , Substância Branca/diagnóstico por imagemRESUMO
BACKGROUND: In the literature, surveys of malignant intracerebral nerve sheath tumors are very rare (Table 1). Therapeutic guidelines do not exist. CASE REPORT: A 28-year-old female patient presented with a tumor in the postcentral region of the left parietal lobe (Figures 1 and 2). The specimen could not be categorized into a common tumor entity and was classified as sarcoma NOS. Shortly after surgery, a recurrence occurred (Figures 3 to 5) followed by a further excision. Due to the rapid tumor growth irradiation with CT-aided treatment planning (Figure 6) has been started immediately afterwards. A dose of 5,400 cGy in 22 fractions was administered. RESULT: 2 weeks after treatment, the patient presented with a noticeable tumor regression (magnetic resonance imaging; Figures 7 to 9). She developed pulmonary metastases. A partial remission could be achieved by systemic chemotherapy. Unfortunately, the patient died because of an exacerbation of a hepatic encephalopathy. CONCLUSION: In cases of intracerebrally localized sarcomas NOS, the earliest possible start of radiotherapy after surgery seems useful because of the noticed radiosensitivity of these tumors. In regard of the local control, this tumor entity shows a documented excellent response to radiotherapy. Expectedly, distant metastases cannot be influenced. Interdisciplinary cooperation is mandatory to enhance the diagnostic process, the treatment decisions, and the results.
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Neoplasias Encefálicas/radioterapia , Irradiação Craniana , Neoplasias Primárias Múltiplas/radioterapia , Neurofibrossarcoma/radioterapia , Lobo Parietal , Equipe de Assistência ao Paciente , Adulto , Neoplasias Encefálicas/patologia , Neoplasias Encefálicas/cirurgia , Terapia Combinada , Comportamento Cooperativo , Evolução Fatal , Feminino , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/secundário , Imageamento por Ressonância Magnética , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/radioterapia , Recidiva Local de Neoplasia/cirurgia , Neoplasias Primárias Múltiplas/patologia , Neoplasias Primárias Múltiplas/cirurgia , Neurofibrossarcoma/patologia , Neurofibrossarcoma/secundário , Neurofibrossarcoma/cirurgia , Planejamento da Radioterapia Assistida por Computador , Radioterapia Adjuvante , RetratamentoRESUMO
OBJECTIVE: Surgical resection of cranial base meningiomas is often limited owing to involvement of crucial neural structures. Within the last 2 decades Gamma Knife radiosurgery (GKRS) has gained increasing importance as an adjunct treatment after incomplete resection and as an alternative treatment to open surgery. However, reports of long-term results are still sparse. We therefore performed this study to analyze the long-term results of GKRS treatment of cranial base meningiomas, following our previously published early follow-up experience. METHODS: A retrospective analysis of the medical files for Gamma Knife and surgical treatments, clinicoradiological findings, and outcome was carried out focusing on tumor control, clinical course, and morbidity. RESULTS: Between 1992 and 1995, we treated 36 patients with cranial base meningiomas using GKRS (male:female ratio, 1:5; mean age, 59 yr; range, 44-89 yr). Twenty-five patients were treated with GKRS after open surgery, and 11 patients received GKRS alone. Tumor control, neurological outcomes, and adverse effects were analyzed after a long-term follow-up period (mean, 103 mo; range, 70-133 mo) and compared with our previous results after an early follow-up period (mean, 48 mo; range, 36-76 mo). Control of tumor growth was achieved in 94% of patients. Compared with the early follow-up period, the late neuroradiological effects of GKRS on cranial base meningiomas were continuing tumor shrinkage in 11 patients (33%), stable tumor size in 20 patients (64%) and tumor progression in two meningiomas (6%). The neurological status improved in 16 patients (44%), remained stable in 19 patients (52%), and deteriorated in one patient (4%). Adverse side effects of GKRS were found only during the early follow-up period. CONCLUSION: Our data confirm that GKRS is not only a safe and effective treatment modality for cranial base meningiomas in short-term observation, but also in a mean long-term follow-up period of more than 8 years. Tumor shrinkage and clinical improvement also continued during the longer follow-up period.