Is non-contrast MRI sufficient to detect meningioma residue after surgery?

BACKGROUND: Contrast-enhanced magnetic resonance imaging (MRI) is the imaging modality routinely used to follow up patients who have undergone surgical resection of brain meningiomas. There are growing concerns about the massive use of gadolinium-based contrast agents (GBCA). Our aim was to evaluate the performance of a new imaging protocol, performed without GBCA injection, in the detection of tumoral residue or local recurrence after surgery of parafalcine and convexity meningiomas. MATERIALS AND METHODS: Only adult patients with a documented resected parafalcine or convexity meningioma were included. We performed a dedicated MRI protocol that included non-contrast and post-contrast sequences. The presence or absence of residue on the unenhanced sequences was independently recorded by three observers: first blindly, then in comparison with a baseline enhanced MRI examination. RESULTS: A total of 51 patients were included. 37 of them featured a tumor residue on the reference enhanced sequence. Overall, an average of 32 of 37 (87%) residues were identified on the unenhanced sequences that were blindly reviewed; and more than 34 of 37 (93%) were identified with the help of the comparative baseline enhanced examination, with a high sensitivity. The missed cases were related to small residues. CONCLUSION: Unenhanced MRI sequences are highly sensitive and specific in identifying a tumor residue or a local recurrence in the post operative follow up of brain meningiomas. Sensitivity is even higher with the help of a comparative baseline enhanced MRI examination, whatever the strength of magnetic field.

Delayed cerebral ischemia after meningioma resection: Literature review and illustrative case.

BACKGROUND: Cerebral vasospasm results from arterial vasoconstriction, mainly following aneurysmal subarachnoid hemorrhage, and may cause delayed cerebral ischemia (DCI). DCI rarely occurs after tumor resection. We performed a systematic review of the literature together with a case report of DCI after meningioma resection. LITERATURE REVIEW: METHODS: A systematic literature review was performed following the PRISMA statement, searching the PubMed, Medline and Cochrane databases using keywords and MESH terms related to "vasospasm/DCI and meningioma resection". RESULTS: In the studies retrieved in the literature, 5 cases of DCI after meningioma surgery were identified. The average age of patients was 52 years. The average onset time of DCI was 9.7 days. Clinical presentation was highly variable: hemiparesis (60%), confusion (60%) and/or aphasia (40%). Meningioma location was most frequently sphenoidal (60%). Most patients had vasospasm in multiple cerebral vessels, involving only the anterior circulation. Various management strategies were used: endovascular treatment (33.3%), antiplatelet therapy (50%) and/or nimodipine (40%). In terms of outcome, there were no deaths, but most patients had variable neurological sequelae (80%): aphasia, visual impairment, hemiparesis. CONCLUSION: The systematic literature review and the present case of DCI following resection of an olfactory meningioma suggested that the main etiologic factors causing this rare pathology are: 1) intraoperative subarachnoid hemorrhagic contamination; 2) microvascular manipulation; 3) and possible dysregulation of hypothalamic function.

Interventional magnetic-resonance-guided cryotherapy combined with microsurgery for recurrent glioblastoma: An innovative treatment?

BACKGROUND: Glioblastoma invariably recurs after primary Stupp tumor therapy and portends a poor prognosis. Cryoablation is a well-established treatment strategy for extra-cranial tumors. The safety and efficacy of interventional MR-guided cryoablation (iMRgC) has not been explored in recurrent glioblastoma. METHODS: A retrospective analysis of data collected over a period of 24 months was performed. The inclusion criteria were: (I) recurrent glioblastoma despite Stupp protocol; (II) MRI followed by histological confirmation of recurrent glioblastoma; (III) location allowing iMRgC followed by microsurgical resection; and (IV) patient's consent. The primary objective was to assess feasibility in terms of complications. The secondary objective was to analyze progression-free survival (PFS), post-iMRgC survival and overall survival (OS). RESULTS: The study included 6 patients, with a mean age of 67±7.6 years [range, 54-70 years]. No major complications were observed. Median PFS was 7.5 months [IQR 3.75-9.75] and 6-month PFS was 50%. Median post-iMRgC survival was 9 months [IQR 7.5-15.25] and 6-month post-iMRgC survival was 80%. Median OS was 22.5 months [IQR 21.75-30]. CONCLUSION: iMRgC for recurrent glioblastoma demonstrated a good safety profile, with no major complications. Our data suggest improved PFS and OS. TRIAL REGISTRATION NUMBER: No. IRB00011687 retrospectively registred on July 7th 2021.

Surgical management of persistent post-traumatic trans-tentorial brain hernia.

INTRODUCTION: Temporal engagement may persist after etiologic surgical treatment of acute subdural hematoma (ASH) without clinical improvement despite normalized intracranial pressure (ICP). The aim of this study was to assess the feasibility of secondary direct temporal lobe disengagement (DTLD) after surgery for supratentorial ASH and to evaluate clinical outcome. MATERIALS AND METHODS: This was a retrospective analysis of 4 patients undergoing secondary DTLD. Patient data were recorded at admission, pre- and postoperatively and at 6months' follow-up (FU): age, gender, Rotterdam score, Glasgow Coma Scale (GCS), neurological deficits, oculomotor nerve palsy (ONP), ICP, midline shift, complications and Extended Glasgow Outcome Scale (GOS-E). RESULTS: At postoperative evaluation 48h after DTLD, we observed a significant improvement in GCS score (initial 6±3, preoperative 7±3, postoperative 14±1; P=0.02), midline shift (initial 16±3mm, preoperative 13±5mm, postoperative 9±2mm; P=0.049) and ONP (P=0.01). In all cases, early postoperative imaging documented visualization of a patent ipsilateral peri-mesencephalic cistern. At 6-month FU, GOS-E showed 75% good recovery and 25% disability. Complete ONP recovery was observed in 75% of patients (P=0.01). Neurological deficits were present at FU in 25% of patients. No surgery-related complications or mortality were recorded. CONCLUSIONS: In traumatic brain injury, secondary DTLD may allow simple, effective and safe management of trans-tentorial uncal herniation, avoiding more challenging procedures. Clinical results are promising, as this technique seems to favorably influence neurological outcome in this selected subgroup of patients with persistent clinical and radiological signs of temporal engagement after etiological treatment with normal ICP values.

Is physical activity a trigger factor for subarachnoid hemorrhage?

INTRODUCTION: Subarachnoid hemorrhage (SAH) is a serious pathology, associated with 43% mortality and significant disability. In the absence of relevant guidelines, some teams advocate that patients harboring an unruptured intracranial aneurysm (ICA) abstain from all sports activity, as a prophylactic precaution. The aim of the present study was to evaluate the impact of physical activity as a risk factor for SAH, through a review of the literature. METHOD: A systematic literature review was performed for the period 2000 to 2020 in accordance with the PRISMA guidelines. Prospective and retrospective articles reporting more than 50 patients whose physical activity was associated with onset of SAH were included. The main end-point was prevalence of SAH occurring after physical activity. For comparison purposes, the prevalences of other circumstances were calculated to establish a range of frequency. RESULTS: Physical activity appeared to be quite rarely associated with onset of SAH, with a prevalence of 3%, compared to 30% at rest, 7.3% in association with defecation and 4.5% in association with sexual activity. Age under 60 years, male gender (M/F ratio 1.38) and smoking (67.1%) were associated with onset of SAH during physical activity. CONCLUSION: Physical activity appears to be a rare trigger factor for SAH. These results are in contrast to the idea that physical activity should, as a precaution, be avoided in patients with unruptured ICA. There is at present no scientific evidence of an association with aneurysmal SAH.

Management of intracranial aneurysms in France: Place of microsurgery and demography of vascular neurosurgeons.

STUDY DESIGN: Observational retrospective survey-based study. INTRODUCTION: Intracranial aneurysms (IA) can be treated with microsurgery or by endovascular treatments (EVT). EVT have taken an increasingly important part in IA management; the ability of neurosurgical teams to perform such surgery as well as the quality of their training is being questioned. We therefore wanted to assess the proportion of IA treated by microsurgery in France, the demography and caseload of surgeons trained in vascular neurosurgery. METHODOLOGY: A 60-question survey was sent to the 34 French neurosurgical centers treating IA. Twenty-seven questions dealt with the demography of neurovascular surgeons and caseload. Descriptive data are reported here. RESULTS: Twenty-seven centers answered, giving us a response rate of 79.4%. A total of 209 neurosurgeons worked in these centers. Forty-six neurosurgeons were designated as referents in vascular neurosurgery, 47% of them were under 45 years old. Among the centers, 96.3% had at least one surgeon that was a referent in neurovascular surgery. A total of 88 surgeons performed IA surgery, but only 11 operated more than 20 IA per year. Two thousand four hundred and thirty seven unruptured IA were treated every year in these centers, 25% of which by microsurgery. A total of 2727 ruptured IA were treated in these centers, of which 15% were treated by microsurgery. The most common indications for microsurgical treatment of IA were: middle cerebral artery aneurysms, wide-neck intracranial aneurysms, and giant intracranial aneurysms, as well as aneurysms associated with a hematoma for the ruptured ones. CONCLUSION: Demography of vascular neurosurgeons remains favorable, with a referent neurosurgeon in most centers, who, in half of the cases, is a young practitioner. The percentage of microsurgery in the treatment of IA is low, especially for ruptured ones. The most frequently operated types of intracranial aneurysm correspond to good practice recommendations.

Cerebellar swelling after surgery for medulloblastoma with leptomeningeal dissemination in children. A case based-update.

OBJECT: Despite the improvement in the overall management of medulloblastomas in recent years, certain phenomena and in particular postoperative cerebellar swelling remain an enigma. This rare complication, little described in the literature, is nonetheless life threatening for the patients. CASE REPORTS: We report our experience about two children who developed severe cerebellar swelling with hydrocephalus and upward herniation soon after a gross total resection of a fourth ventricle medulloblastoma by a telo-velar approach. Despite rapid management of ventricular dilation and optimal medical intensive treatment of intracranial hypertension, both children died quickly after the surgery. Pathological examination analyses were in favour of anaplastic/large cell medulloblastoma. DISCUSSION: Diffuse cerebellar swelling with upward herniation may occur postoperatively in young children with anaplastic/large cell medulloblastoma with leptomeningeal spread. In the literature, only 4 cases have been so far described with delayed onset of symptoms. Two children survived with an aggressive management (decompressive surgery and early radio-chemotherapy). CONCLUSION: Cerebellar swelling is an unrecognised and sudden complication of posterior fossa surgery for metastatic anaplastic medulloblastoma with leptomeningeal dissemination in young children. An initial less invasive surgical approach could be considered in such cases, in order to prevent this complication with potentially tragic issue, and which cannot be managed with a CSF shunt alone.

The Cryo-immunologic effect: A therapeutic advance in the treatment of glioblastomas?

The immunotherapy of cerebral glioblastoma has become a hot topic. Immune checkpoint blockade antibodies have progressively acquired a role in the management of malignant tumors. A multimodal approach using surgery, radiotherapy, chemotherapy in combination with immunotherapy represent a potent weapon against glioblastomas. In parallel, clinical applications of cryotherapy-freezing tumors based on repetition of rapid freeze-slow thaw cycle-for various cancers such as skin, lung, breast, esophagus, hepatic, kidney, prostate and bone tumors were developed. The future immunomodulatory approaches might be combined with brain tumors cryoablation to increase the cryoimmune response. The objective of this study was to analyze from the literature the relationship between cerebral cryosurgery and immunomodulation using PRISMA method. The animals' studies demonstrate the dendritic cells maturation and activation with the enhancement of antigen-presenting function after cryotherapy suggesting the potential usefulness of the association of cryotherapy and immunomodulator in the management of gliomas.

Cervical myelopathy caused by ventrally located atlanto-axial synovial cysts: An open quest for the safest and most effective surgical management. Case series and systematic review of the literature.

OF BACKGROUND DATA: Despite a good understanding of the natural history of spinal synovial cysts (SCs), a widespread agreement regarding their optimal management is still lacking. This is particularly true for SCs occurring at the C1-C2 level, which are rare, but oftentimes lead to a rapidly evolving cervical myelopathy. METHODS: We report a series of 4 patients (M:F ratio=1:1; mean age 63.5 years) presenting with progressive cervical myelopathy secondary to ventrally located C1-C2 SCs. All patients underwent a postero-lateral facet-sparing intradural approach with total excision of the SCs. Functional status was assessed pre- and postoperatively with Nurick scale and the modified Japanese Orthopaedic association grading. Furthermore we conducted a systematic review, following PRISMA guidelines of pertinent literature to contextualize the options for surgical management of such lesions. RESULTS: Complete excision of the SCs was confirmed radiologically and on histological analysis. All measures of functional status improved post-operatively, and no cyst recurrence or need for instrumented fusion were noted during follow up (range from 22 to 88 months). CONCLUSION: Our experience suggests that the facet-sparing intradural approach provides excellent clinical outcomes without causing any C1-C2 instability. This is in keeping with the take home message emerging from our literature review, which confirms that treatment should aim at radical resection of SCs while minimizing the risk of postoperative instability.

[What is the place of surgery in the management of brain metastases in 2020?] / Quelle est la place de la chirurgie dans la prise en charge des métastases cérébrales en 2020 ?

Brain metastases are the most common intracranial tumors and are associated with a dismal prognosis. The management of patients with brain metastases has become more important because of the increased incidence of these tumours, the better treatment of the systemic disease and the improvement of surgical techniques. The treatment requires multidisciplinary approaches and become complex because of new emerging systemic therapy and advancements in neurosurgery and radiation oncology. The surgical treatment has an indispensable role to obtain a tissue diagnosis, in relieving intracranial effect mass and improving neurological status by improving induced encephalopathy. An understanding of the role and indications of the surgery in patients with metastatic brain lesions is essential for the effective management of this growing population.

Vagus nerve stimulation in epilepsy: Efficiency and safety of outpatient practice.

INTRODUCTION: Over the past 20 years, Vagus Nerve Stimulation (VNS) has become one of the tools for surgical treatment of patients with refractory cryptogenic epilepsy. The objective of this study was to determine the feasibility of implanting a Vagus Nerve Stimulation in ambulatory patients with chronic epilepsy. PATIENTS AND METHODS: VNS procedure was consecutively performed in outpatient surgery between November 2016 and November 2018 in patients with refractory epilepsy. The main endpoints were complications, prolonged hospitalization and readmission during the first postoperative month. This information was collected by retrospective analysis of clinical files. RESULTS: Of the 22 patients included, the majority were autonomous (77%) with only 5 institutionalized patients. Retrospective analysis revealed a single complication of temporary dysphonia (4.5%) and an unplanned hospitalisation for immediate post-operative vomiting (4.5%). No readmissions were observed during the postoperative month but an emergency room visit for generalized seizure disorder was reported for one patient. CONCLUSION: The outpatient implantation of VNS in patients with epilepsy is a valid strategy for 95% of patients.

Impact of discontinuation of antithrombotic therapy after surgery for chronic subdural hematoma.

INTRODUCTION: The management of antithrombotic therapy (AT) after surgery for chronic subdural hematoma (cSDH) requires taking account of the balance of risk between hemorrhage recurrence (HR) and the prophylactic thromboembolic effect (TE). The goal of the present study was to evaluate the prevalence of vascular events (VE: TE and/or HR) in the first 3 postoperative months after cSDH evacuation in patients previously treated by AT. The impact of AT resumption was also evaluated. PATIENTS AND METHODS: This observational prospective multicenter collaborative study (14 French neurosurgery centers) included patients with cSDH treated by AT and operated on between May 2017 and March 2018. Data collection used an e-CRF, and was principally based on an admission questionnaire and outcome/progression at 3 months. RESULTS: In this cohort of 211 patients, VE occurred in 58 patients (27.5%): HR in 47 (22.3%), TE in 17 (8%), with mixed event in 6 cases (2%). Median overall time to onset of complications 26 days±31.5, and specifically 43.5 days±29.25 for HR. Non-resumption of AT significantly increased the relative risk of VE [OR: 4.14; 95% CI: 2.08 - 8.56; P <0.001] and especially of TE [OR: 7.5; 95% CI: 1.2 - 42; P<0.001]. The relative risk of HR was significantly increased when AT was resumed at less than 30 days (P=0.015). CONCLUSION: The occurrence of VE in patients operated on for cSDH and previously treated by AT was statistically significant (27.5%). HR was the most common event (22.3%), whereas TE accounted for only the 8%, although with shorter time to onset. In order to prevent TE risk, AT should be restarted after 30 days, as HR risk is greatly decreased beyond this time.

A combined single-stage procedure to treat brain AVM.

Complete resection of brain arteriovenous malformation (AVM) is a surgical challenge, mainly due to risk of intraoperative rupture. The objective of this feasibility study was to analyze complete resection rate at 3 months and clinical outcome at 6 months after treatment of brain AVM by combined single-stage embolization and surgical resection. A retrospective observational study from July 2015 to February 2019 was conducted at the Department of Neurosurgery of Strasbourg University Hospital, France. Decision to treat was taken on the basis of history of AVM rupture, symptomatic AVM, or morphologic risk factors for rupture. Complete resection rate was assessed on postoperative cerebral subtraction angiography at 3 months and clinical outcome at 6 months was evaluated on the modified Rankin Scale (mRS). In the 16 patients treated for symptomatic brain AVM, the rate of complete resection was 75%, resection with residual shunt 18.7%, and incomplete resection with residual nidus 6.3%. Good clinical outcome (mRS=0 or 1) was achieved in 81.3% of patients at 6 months. The transfusion rate was 7.1%. There were procedural complications in 12.5% of patients but no intraoperative ruptures. This combined single-stage procedure allows extensive preoperative embolization of the AVM, facilitating surgical microdissection by identifying the dissection plane and perforating arteries and allowing the operator to work in close contact with the nidus without fear of intraoperative rupture.

Diagnostic value of fusion of metabolic and structural images for stereotactic biopsy of brain tumors without enhancement after contrast medium injection.

BACKGROUND: The heterogeneous nature of glioma makes it difficult to select a target for stereotactic biopsy that will be representative of grade severity on non-contrast-enhanced lesion imaging. The objective of this study was to evaluate the benefit of fusion of metabolic images (PET 18F-DOPA) with magnetic resonance imaging (MRI) morphological images for cerebral biopsy under stereotactic conditions of glioma without contrast enhancement. PATIENTS AND METHODS: This single-center prospective observational study conducted between January 2016 and April 2018 included 20 consecutive patients (mean age: 45±19.5 years; range, 9-80 years) who underwent cerebral biopsy for a tumor without MRI enhancement but with hypermetabolism on 18F-FDOPA PET (positron emission tomography). Standard 18F-FDOPA uptake value (SUVmax) was determined for diagnosis of high-grade glioma, with comparison to histomolecular results. RESULTS: Histological diagnosis was made in all patients (100%). Samples from hypermetabolism areas revealed high-grade glial tumor in 16 patients (80%). For a SUVmax threshold of 1.75, sensitivity was 81.2%, specificity 50%, PPV 86.7% and VPN 40% for diagnosis of high-grade glioma. No significant association between SUVmax and histomolecular mutation was found. CONCLUSION: 18F-FDOPA metabolic imaging is an aid in choosing the target to be biopsied under stereotactic conditions in tumors without MR enhancement. Nevertheless, despite good sensitivity, 18F-FDOPA PET is insufficient for definitive diagnosis of high-grade tumor.

A randomized trial of endovascular versus surgical management of ruptured intracranial aneurysms: Interim results from ISAT2.

BACKGROUND AND PURPOSE: Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. METHODS: The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS>2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. RESULTS: An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS>2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%-53%), and 10/34 patients allocated to coiling (29%; 17%-46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%-94%), and 18/27 patients allocated to coiling (67%; 47%-81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%-60%]) than EVT (9/48 [19%; 10%-31%]). CONCLUSION: Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

[Skull base meningioma: Clinical and radiological efficacy based on a quantitative volumetric analysis]. / Méningiomes de la base du crâne : efficacité clinique et radiologique basée sur une analyse volumétrique quantitative.

PURPOSE: To date, no correlation has been found between clinical and radiological efficacy after irradiation of skull base meningiomas. However, the evaluation of the radiological response was most often made by questionable methods that may have underestimated the radiological effectiveness of radiotherapy. The objective of this work is to verify this hypothesis by quantitative volumetric analysis. MATERIAL AND METHODS: Data from 35 patients treated with either helical tomotherapy (45.7%) or fractionated stereotactic radiotherapy (54.3%) were retrospectively analysed. These were mainly women (94%) aged 59 (43-81) with lesions mainly of the cavernous sinus (60%). There was a median of 2 (1-4) symptoms and the main symptoms were visual impairment (39%), cranial nerve deficits (23.4%) and headaches (17.2%). RESULTS: Median tumour volume decreased significantly (P<0.05) from 9.6mL (0.3-36.6) to 6.8mL (0.1-26.5) after median follow-up of 44 months (24-77). Sixty-three percent of patients had an improvement of at least one symptom. In univariate analysis, clinical efficacy (P<0.05), radiotherapy technique (P<0.05), tumor topography (P<0.05) and initial tumor volume (P<0.05) were predictive factors for radiological response. In multivariate analysis, only the inverse correlation between radiological response and initial tumor volume remained significant (ρ: -0.47 95% CI -3.2 to 5.7; P<0.05). CONCLUSION: The quantitative volumetric monitoring demonstrates a major radiological efficiency of radiotherapy. However, no clear correlation between clinical and radiological efficacy was found.

Biopsying a spinal cord lesion: A diagnostic dilemma. Case report and review of literature.

Spinal cord biopsy is a difficult procedure fraught with the risk of false-negative results or even misdiagnosis in up to 30% of cases. Differential diagnoses of spinal cord lesions include a wide range of inflammatory, infectious and neoplastic diseases. Given the importance of correctly managing these pathologies, it is crucial to avoid delays in making the correct diagnosis in order to improve the patient's outcome. We present here the case of a 21-year-old male with rapidly progressing sphincter and lower limb motor dysfunctions up to complete paraplegia with evidence of thoracic spinal cord lesion on magnetic resonance imaging. None of the blood and cerebrospinal fluid tests pointed to a diagnosis, while a first spinal cord biopsy revealed an inflammatory necrotic process. After several weeks of empirical treatments and clinical stability, the patient started having focal structural seizures that became generalized with local progression of the lesion and diffuse leptomeningeal spread on magnetic resonance imaging. A second spinal cord biopsy found a grade IV glioblastoma with H3 K27M histone mutation. Unfortunately the patient passed away before any treatment could be initiated. In this report, the authors analyze the difficulty of making the rapid, correct diagnosis of a highly malignant intrinsic spinal cord lesion, discussing also possible strategies to avoid diagnostic delays and to improve the outcome of these difficult patients.