Temporal Muscle Thickness Compared to Functional Scales as a Prognostic Parameter in Patients with Brain Metastases.

Metastases are the most frequent intracranial malignant tumors in adults. While Karnofsky Performance Status (KPS) and Clinical Frailty Scale (CFS) are known to have significant impact on overall survival (OS), temporal muscle thickness (TMT) has been postulated to be a promising new parameter to estimate prognosis. Patients who received a resection of one to three brain metastases in our institution were included. Temporal muscle thickness was measured in preoperative MRI scans according to a standardized protocol. In 199 patients, the mean TMT was 7.5 mm (95CI 7.3-7.7) and the mean OS during follow-up was 31.3 months (95CI 24.2-38.3). There was no significant correlation of TMT and preoperative or follow-up CFS and KPS. While CFS and KPS did significantly correlate with OS (p < 0.001 for each), no correlation was demonstrated for TMT. CFS showed a superior prognostic value compared to KPS. TMT failed to show a significant impact on OS or patient performance, whereas the clinical scales (KPS and CFS) demonstrate a good correlation with OS. Due to its superiority over KPS, we strongly recommend the use of CFS to estimate OS in patients with brain metastases.

Temporal muscle thickness has no prognostic relevance in patients with high-grade glioma compared to functional scales.

Background: GBM research is constantly assessing potential valuable prognostic biomarkers to better understand the disease and prognosticate future outcomes. Measuring temporal muscle thickness (TMT) has appeared to be a promising new surrogate marker for skeletal muscle mass and sarcopenia, which further indicates frailty and predicts overall survival (OS). The aim of this study was to determine its usefulness as a prognostic marker in patients with high-grade glioma compared to functional status scales. Methods: TMT was measured in preoperative axial T1-weighted contrast-enhanced magnetic resonance images in 277 patients who received surgical treatment of newly diagnosed WHO III and IV gliomas in our institution between 2015 and 2020. Clinical Frailty Scale (CFS) and Karnofsky Performance Scale (KPS) were assessed preoperatively and during a follow-up visit. Results: Female gender has shown significant correlation with TMT, while TMT did not correlate with preoperative and follow-up functional scores, age, WHO classification, IDH mutation, MGMT promoter methylation, EGFR and ATRX expression, or 1p/19q co-deletion. No significant prognostic value of TMT could be shown in 6, 12, and 24 months OS, while changes in CFS and KPS proved to have a significant impact. Conclusion: Only female gender, but no other clinical, histological, or molecular marker showed any interrelation with TMT. Functional scores outclass measuring TMT as a reliable prognostic factor for predicting OS in patients with high-grade glioma.

The diagnostic value of contrast enhancement on MRI in diffuse and anaplastic gliomas.

PURPOSE: We evaluated differentiations in gadolinium contrast enhancement (CE) between low-grade WHO °II and high-grade WHO °III gliomas in conventional MRI, which have been repeatedly questioned. METHODS: Ninety-nine patients, who underwent first resection of WHO°II and °III gliomas, were retrospectively retrieved from a prospective database. The quantitative metric volume of Gd-CE in T1-weighted pre-operative MRI was measured using volumetric segmentation. RESULTS: The OR to detect CE in anaplastic gliomas was seven times higher than that in diffuse gliomas (CI95% 2.8-17.2, p<0.0001). No CE was seen in 50% (8/16) of focal anaplastic and in 28% (10/36) of entirely anaplastic gliomas. CE was present in 21% (10/47) of diffuse gliomas. Anaplasia correlated with a larger CE volume (r=0.49, p<0.0001) and provided additional 4 cm3 of CE volume compared to entirely diffuse tumors. The OR to have CE was 3.6 times for IDH1 wild-type tumors (CI95% 1.3-10.2, p=0.05) and 4.8 for tumors with ATRX expression (CI95% 1.3-17.2, p=0.05). In all sub-groups, at least a quarter of cases showed no CE at all and there were cases with present CE. CONCLUSION: CE is associated with higher odds of unfavorable prognostic features like anaplasia, wild-type IDH1 and retained ATRX. There was no CE in one-fourth of anaplastic gliomas and half of gliomas with focal anaplasia.

Repeated 31P-Magnetic Resonance Spectroscopy in Severe Traumatic Brain Injury: Insights into Cerebral Energy Status and Altered Metabolism.

Phosphorous magnetic resonance spectroscopy (31P-MRS) is suited to noninvasively investigate energy metabolism and to detect molecules containing phosphorus in the human brain. The aim of this longitudinal study was to perform 31P-MRS at two different time points (within 72 h and between day 10-14) after severe traumatic brain injury (sTBI) to reveal alterations in cerebral energy metabolism. Twenty-six ventilated patients with sTBI, aged between 20 and 75 years, with a median initial Glasgow Coma Scale score of 5 were analyzed prospectively. The 31P-MRS data of the structurally more affected side were compared with data from contralateral normal appearing areas and with data of age- and gender-matched healthy controls. There were no significant intraindividual differences between the lesioned and the less affected side at either of the time points. In the acute phase, phosphocreatine/adenosine triphosphate (PCr/ATP) and phosphocreatine/inorganic phosphate (PCr/Pi) were significantly elevated whereas phosphomonoesters/phosphodiesters (PME/PDE) and Pi/ATP were significantly decreased in contrast to healthy controls. In the subacute phase, these differences gradually dissipated, remaining lower Pi/ATP ratio, and only partly altered levels of PCr/Pi and PME/PDE. Our data affirm that cerebral metabolism is globally altered after sTBI, demonstrating the diffuse impairment of brain bioenergetics at multiple levels, with resultant developments in terms of time.

Cervical Lymph Node Metastases in Oral Squamous Cell Carcinoma-How Much Imaging Do We Need?

Cervical lymph node metastases in oral squamous cell carcinoma (OSCC) are key predictors of disease specific survival. It was therefore the aim of this study to evaluate how much imaging is minimally needed for reliable and efficient identification of cervical lymph node metastases. In this retrospective cross-sectional study, results (metastasis yes/no) of ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) were compared to the final histopathological results of the corresponding neck dissection (ND) specimens (metastasis yes/no). A score was calculated to account for cervical lymph node size, shape, clustering, peripheral enhancement, hilus sign, architecture, blood flow, and central necrosis. Sensitivity and specificity were analyzed for each imaging technique separately. In 164 patients diagnosed with OSCC, 96 underwent uni- or bilateral ND (122 ND in total). One hundred percent sensitivity was achieved by CT+MRI, MRI+PET, US+CT+MRI, US+MRI+PET, CT+MRI+PET, and US+CT+MRI+PET. The highest specificity was realized by US with 79% (95% CI [0.698-0.890]). Specificity for CT+MRI and PET+MRI was 51% (95% CI [0.359-0.665]) and 70% (95% CI [0.416-0.984]), respectively. Regarding 100% sensitivity with acceptable specificity, the combination of CT+MRI or PET+MRI appeared to be suitable for staging cervical lymph nodes in primary OSCC.

Routine Postoperative Computed Tomography Is Not Helpful After Elective Craniotomy.

BACKGROUND: Next-day postoperative computed tomography (CT) has been routinely used to obtain radiographic "clearance" for transferring patients after elective craniotomy out of the intensive care unit. The value of this traditional policy, however, has repeatedly been questioned. However, the limited patient numbers might have underestimated the very rare, but catastrophic, events. Therefore, we analyzed the value of routine postoperative CT in a larger cohort of elective tumor, epilepsy, and vascular cases. METHODS: All the patients who had undergone elective craniotomy were included in our study. The routine postoperative CT scans were analyzed by a neuroradiologist who was unaware of the clinical data. The medical records were retrospectively reviewed for events of arterial hypertension and clinical deterioration. RESULTS: The data from 660 patients with tumors (n = 393; 59.5%), aneurysms (n = 107; 16.2%), and skull base lesions were evaluated. In nearly one half of the patients (n = 264; 45.8%), CT depicted the presence of blood that was not associated with symptoms. Of the 660 patients, 21 (3.6%) showed a mass effect radiographically, 11 of whom underwent revision surgery. Arterial hypertension was documented in only 8 patients (1.3%) and was related to the revision surgery (P = 0.018). The overall revision rate was 2.7% (n = 18). All patients who had undergone revision for postoperative hematoma had presented with a new neurological deficit immediately before CT. CONCLUSION: Routine postoperative CT did not reveal 1 patient with a serious hematoma that would not have been identified by clinical examination. Patients could be transferred safely from the intensive care unit, if the weaning process and clinical observation findings were uneventful, without deterioration of neurological symptoms or consciousness.

The Volume of Ischemic Brain Predicts Poor Outcome in Patients with Surgically Treated Malignant Stroke.

BACKGROUND: Malignant middle cerebral artery stroke is a life-threatening condition. The outcomes of surgical treatments have presented strong evidence in favor of decompressive hemicraniectomy (DHC). A significant subpopulation of patients still experience very poor outcomes. In particular, indication for DHC is based on few objective parameters to facilitate decision making. We hypothesized that larger ischemic brain volume would have a large impact on the outcome. METHODS: A cohort study of 34 patients undergoing DHC was performed using a volumetric analysis of infarction volume (measured preoperatively and again on postoperative day [POD] 1 and POD 3). Outcomes were assessed using the modified Rankin Scale (mRS), and a favorable outcome was defined as modified Rankin Scale score ≤3. RESULTS: Median age of patients was 53.5 years (range, 25-72 years), the median time from onset of first symptoms to surgical intervention was 38 hours (range, 10-150 hours), and male-to-female ratio was 2:1. The median ischemic volume was 250 cm3 preoperatively, 315 cm3 on POD1, and 349 cm3 on POD3. Modified Rankin Scale score ≤3 after 6 months was attained in 7 (20%) patients. Within the first 24 hours after DHC, ischemic volume increased significantly (P = 0.0003) and was associated with a worse outcome (P < 0.0001) after exceeding a cutoff volume of 300 cm3. CONCLUSIONS: Volumetric analysis of infarction can predict the outcome of patients. DHC should be reserved for patients with prognosticated good outcome, which was observed only in patients with a volume <301 cm3.

The DNA methylation landscape of glioblastoma disease progression shows extensive heterogeneity in time and space.

Glioblastoma is characterized by widespread genetic and transcriptional heterogeneity, yet little is known about the role of the epigenome in glioblastoma disease progression. Here, we present genome-scale maps of DNA methylation in matched primary and recurring glioblastoma tumors, using data from a highly annotated clinical cohort that was selected through a national patient registry. We demonstrate the feasibility of DNA methylation mapping in a large set of routinely collected FFPE samples, and we validate bisulfite sequencing as a multipurpose assay that allowed us to infer a range of different genetic, epigenetic, and transcriptional characteristics of the profiled tumor samples. On the basis of these data, we identified subtle differences between primary and recurring tumors, links between DNA methylation and the tumor microenvironment, and an association of epigenetic tumor heterogeneity with patient survival. In summary, this study establishes an open resource for dissecting DNA methylation heterogeneity in a genetically diverse and heterogeneous cancer, and it demonstrates the feasibility of integrating epigenomics, radiology, and digital pathology for a national cohort, thereby leveraging existing samples and data collected as part of routine clinical practice.

Measures to Prevent Air Embolism in Transthoracic Biopsy of the Lung.

OBJECTIVE: Systemic air embolism (AE) is a rare but feared complication of transthoracic biopsy with potentially fatal consequences. The aim of the study was to assess the effect of patient positioning during transthoracic biopsy on preventing systemic AE. MATERIALS AND METHODS: We compared a historical control group of 610 patients (group 1) who underwent transthoracic biopsy before the implementation of measures to prevent systemic AE during transthoracic biopsy and a group of 1268 patients (group 2) who underwent biopsy after the measures were implemented. The patients in group 2 were placed in the ipsilateral-dependent position so that the lesion being biopsied was located below the level of the left atrium. RESULTS: The rate of systemic AE was reduced from 3.77% to 0.16% (odds ratio [OR], 0.040; 95% CI, 0.010-0.177; p < 0.001). Logistic regression analyses identified needle penetration depth, prone position of the patient during biopsy, location above the level of the left atrium, needle path through ventilated lung, and intubation anesthesia as independent risk factors for systemic AE (p < 0.05). Propensity score-matched analyses identified the number of biopsy samples obtained as an additional risk factor (p = 0.003). The rate of pneumothorax was reduced from 15.41% in group 1 to 5.99% in group 2 (OR, 0.374; 95% CI, 0.307-0.546; p < 0.001). CONCLUSION: Performing transthoracic biopsy with the patient in an ipsilateral-dependent position so that the lesion is located below the level of the left atrium is an effective measure for preventing systemic AE. Needle path through ventilated lung and intubation anesthesia should be avoided whenever possible.

Correlation of Tumor and Peritumoral Edema Volumes with Survival in Patients with Cerebral Metastases.

BACKGROUND: Surgical resection in combination with radiotherapy in selected cases remains the best option for patients with cerebral metastases. Postoperative relapse of brain metastases occurs frequently and can be reduced by postoperative whole-brain radiotherapy (WBRT). Continuous spread of tumor cells from the primary lesions is debated as a cause of recurrence. It is well known that in gliomas, infiltration takes place within the surrounding edema. Obviously, most brain metastases are usually associated with peritumoral edema, which may act as an indicator of infiltration and more aggressive tumor biology. Therefore, we aimed to investigate the correlation of tumor and edema volumes with overall survival in patients with cerebral metastases. PATIENTS AND METHODS: A total of 143 patients diagnosed with brain metastasis (male:female=1.1:1) who underwent surgical resection were included retrospectively in this analysis. Clinical data were retrieved from electronic patient files. The volumes of tumor and edema calculated by manual delineation. The ratio of edema to tumor volume was calculated, leading to dichotomization of the patients. RESULTS: The median tumor volume was 20.1 cc (range=0.8-90.8 cc) and the median volume of edema 49.5 cc (range=0-179.9 cc). The volume of metastases did not significantly correlate with overall survival. The ratio of edema to tumor volume was also not a prognostic factor in terms of overall survival. Only surgical resection, preoperative recursive partitioning analysis class, and postoperative addition of WBRT, as well as female sex, demonstrated beneficial effects. CONCLUSION: The extent of edema surrounding cerebral metastases does not appear to influence overall survival in patients suffering from brain metastases, although it seems to be responsible for most of the patients' symptoms. The hypothesis that the extent of edema was disadvantageous concerning survival was supported by our data.

Optical Neuronavigation without Rigid Head Fixation During Awake Surgery.

OBJECTIVE: Optical neuronavigation without rigid pin fixation of the head may lead to inaccurate results because of the patient's movements during awake surgery. In this study, we report our results using a skull-mounted reference array for optical tracking in patients undergoing awake craniotomy for eloquent gliomas. METHODS: Between March 2013 and December 2014, 18 consecutive patients (10 men, 8 women) with frontotemporal (n = 16) or frontoparietal (perirolandic; n = 2) lesions underwent awake craniotomy without rigid pin fixation. All patients had a skull-mounted reference array for optical tracking placed on the forehead. Accuracy of navigation was determined with pointer tip deviation measurements on superficial and bony anatomic structures. Good accuracy was defined as a tip deviation <2 mm. RESULTS: Gross total resection (>98%) was achieved in 7 patients (38%); >90% of tumor was resected in 8 patients (44%). In 3 patients, only subtotal resection or biopsy was performed secondary to stimulation results. In all patients, good accuracy of the optical neuronavigation system could be demonstrated without intraoperative peculiarities or complications. The reference array had to be repositioned because of loosening in 1 patient. Neuronavigation could be reliably applied to support stimulation-based resection. CONCLUSIONS: A skull-mounted reference array is a simple and safe method for optical neuronavigation tracking without rigid pin fixation of the patient's head.

Systemic air embolism causing acute stroke and myocardial infarction after percutaneous transthoracic lung biopsy - a case report.

The air embolism in this case was likely to have been caused by positioning the patient in a prone position, which was associated with the lesion to be biopsied being at a maximum height over the left atrium. Due to the resulting negative pressure, air entered through a fistula that formed between the airspace and the pulmonary vein. The air could have been trapped in the left atrium by positioning the patient in left lateral position. The event itself could have been prevented by positioning the patient in an ipsilateral dependent position during the biopsy. In addition to hyperbaric oxygen therapy, the preferred treatment options are positioning maneuvers, administration of pure oxygen, and heparinization.

Retrospective morphometric study of the suitability of renal arteries for renal denervation according to the Symplicity HTN2 trial criteria.

OBJECTIVE: The aim of this study was to describe the renal arteries of humans in vivo, as precisely as possible, and to formulate an expected value for the exclusion of renal denervation due to the anatomical situation based on the criteria of the Symplicity HTN trials. DESIGN AND SETTING: In a retrospective cohort study, the renal arteries of 126 patients (57 women, 69 men, mean age 60 ± 17.2 years (CI 57.7 to 63.6)) were segmented semiautomatically from high-contrast CT angiographies. RESULTS: Among the 300 renal arteries, there were three arteries with fibromuscular dysplasia and one with ostial renal artery stenosis. The first left renal artery was shorter than the right (34 ± 11.4 mm (CI 32 to 36) vs 45.9 ± 15 mm (CI 43.2 to 48.6); p<0.0001), but had a slightly larger diameter (5.2 ± 1.4 mm (CI 4.9 to 5.4) vs 4.9 ± 1.2 mm (CI 4.6 to 5.1); p>0.05). The first left renal arteries were 1.1 ± 0.4 mm (CI 0.9 to 1.3), and the first right renal arteries were 0.3 ± 0.6 mm (CI 0.1 to 0.5) thinner in women than in men (p<0.05). Ostial funnels were up to 14 mm long. The cross-sections were elliptical, more pronounced on the right side (p<0.05). In 23 cases (18.3%), the main artery was shorter than 2 cm; in 43 cases (34.1%), the diameter was not >4 mm. Some 46% of the patients, or 58.7% when variants and diseases were taken into consideration, were theoretically not suitable for denervation. CONCLUSIONS: Based on these precise measurements, the anatomical situation as a reason for ruling out denervation appears to be significantly more common than previously suspected. Since this can be the cause of the failure of treatment in some cases, further development of catheters or direct percutaneous approaches may improve success rates.

Multimodal imaging in cerebral gliomas and its neuropathological correlation.

INTRODUCTION: Concerning the preoperative clinical diagnostic work-up of glioma patients, tumor heterogeneity challenges the oncological therapy. The current study assesses the performance of a multimodal imaging approach to differentiate between areas in malignant gliomas and to investigate the extent to which such a combinatorial imaging approach might predict the underlying histology. METHODS: Prior to surgical resection, patients harboring intracranial gliomas underwent MRIs (MR-S, PWI) and (18)F-FET-PETs. Intratumoral and peritumoral biopsy targets were defined, by MRI only, by FET-PET only, and by MRI and FET-PET combined, and biopsied prior to surgical resection and which then received separate histopathological examinations. RESULTS: In total, 38 tissue samples were acquired (seven glioblastomas, one anaplastic astrocytoma, one anaplastic oligoastrocytoma, one diffuse astrocytoma, and one oligoastrocytoma) and underwent histopathological analysis. The highest mean values of Mib1 and CD31 were found in the target point "T' defined by MRI and FET-PET combined. A significant correlation between NAA/Cr and PET tracer uptake (-0.845, p<0.05) as well as Cho/Cr ratio and cell density (0.742, p<0.05) and NAA/Cr ratio and MIB-1 (-0761, p<0.05) was disclosed for this target point, though not for target points defined by MRI and FET-PET alone. CONCLUSION: Multimodal-imaging-guided stereotactic biopsy correlated more with histological malignancy indices, such as cell density and MIB-1 labeling, than targets that were based solely on the highest amino acid uptake or contrast enhancement on MRI. The results of our study indicate that a combined PET-MR multimodal imaging approach bears potential benefits in detecting glioma heterogeneity.

Endoscopic transnasal resection of the odontoid: case series and clinical course.

The transoral route is the gold standard for odontoid resection. Results are satisfying though surgery can be challenging for patients and surgeons due to its invasiveness. A less invasive transnasal approach could provide a sufficient extent of resection with less collateral damage. The technique of transnasal endoscopic odontoid resection is demonstrated by a case series of three patients. A fully endoscopic transnasal odontoid resection was conducted by use of CT-based neuronavigation. A complete odontoid resection succeeded in all patients. Symptoms such as dysarthria, swallowing disturbance, salivary retention, myelopathic gait disturbances, neck pain, and tetraparesis improved in all patients markedly. Transnasal endoscopic odontoid resection is a feasible alternative to the transoral technique. It leaves the oropharynx intact, which could result in lower approach related complications especially in patients with bulbar symptoms.

Black brain: transformation of a melanocytoma with diffuse melanocytosis into a primary cerebral melanoma.

We describe here a rare case of the transformation of a supratentorial melanocytoma and diffuse melanocytosis into a primary malignant, CNS melanoma. A 71-year-old woman was admitted after suffering from bulbar speech and dysfunction of fine motor skills for three years. Cerebral imaging revealed an inhomogeneous tumor mass in the right frontal lobe. After craniotomy and opening of the dura, a partially black brain surface was exposed. The solid tumor mass was completely resected. Histopathological workup of the surgical specimen (solid tumor) revealed a melanocytoma with transformation into a malignant melanoma. Three months after surgery, an MR scan was carried out, revealing local tumor recurrence and intracranial spreading. At this time the patient agreed to undergo whole brain radiation therapy, which was carried out. At this date patient has survived 18 months since primary diagnosis with progressive neurological symptoms.