Impact of extent of resection and adjuvant radiation therapy in the progression free survival in patients with spheno-orbital meningioma.

BACKGROUND: Spheno-orbital meningiomas (SOM) are known to invaded critical skull base areas. The authors report a series of WHO I SOM, propose a subclassification of this tumor according to its extension to critical positions and analyze the impact of extent of resection and the role of stereotactic radiotherapy in tumor recurrence. METHODS: A prospective maintained university medical center registry was utilized to undertake a retrospective review of patients operated with WHO I SOM. Details related to critical skull base region's extension (superior orbital fissure, cavernous sinus, orbital apex), extent of resection and adjuvant radiosurgery were collected. Statistical calculations were preformed using IBM SPSS Statistics version 25. A p value < 0.05 was considered significant. Survival analysis was performed using Kaplan-Meier survival analysis and the log rank test. RESULTS: A total of 77 patients operated from 2002 to 2021 were included. There were 65 women (84.4 %) and 12 men (15.6 %). Mean age at surgery was 54.8 years (median 53 years, range 23 - 88). Tumors were defined as local in 28 (35.4 %) and with extension into the skull base critical structures in 51 (64.6 %). GTR was achieved in 35 (44.3 %), STR in 40 (50.6 %), and PR in four (5.1 %). Surgical morbidity was 10 %. There was no surgical mortality. 28 patients with STR or PR were treated with adjuvant radiotherapy. The total length of follow up was a mean of 172.3 months. There were 14 recurrences/progressive growth (17.7 %), 63 patients (79.7 %) had no recurrence/progressive growth, and two patients (2.5 %) were lost to follow-up. PFS was significant statistically different in patients with invasive tumors in whom the extent of resection was subtotal, with a longer PFS in patients that were treated with adjuvant radiotherapy. (P value < 0.001). CONCLUSIONS: SOM could be divided in two groups according to its skull base extension facilitating decision management and outcome prediction. Patients with local WHO I SOM had higher rate of GTR and better PFS than tumors extending to involve critical regions. When STR or PR is achieved postoperative adjuvant radiotherapy is advised if there is evidence of previous tumor growth.

Recovery of cranial nerve neuropathies after LINAC-based stereotactic radiosurgery for benign cavernous sinus meningioma.

PURPOSE: Cranial Nerve Neuropathies (CNNs) often accompany Cavernous Sinus Meningioma (CSM), for which Stereotactic Radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSR) are established treatments. This study assesses CNNs recovery in CSM patients treated with LINAC, offering insight into treatment effectiveness. METHODS: This study was conducted on 128 patients with CSM treated with LINAC-based SRS/FSR between 2005 and 2020 at a single institution. 46 patients presented with CNNs. The study analyzed patients' demographics, clinical parameters, SRS/FSR treatment characteristics, post-treatment CNNs recovery duration, status, and radiological control on their last follow-up. RESULTS: The median follow-up duration was 53.4 months. Patients were treated with SRS (n = 25) or FSR (n = 21). The mean pretreatment tumor volume was 9.5 cc decreasing to a mean end-of-follow-up tumor volume was 5.1 cc. Radiological tumor control was achieved in all cases. CNN recovery was observed in 80.4% of patients, with specific nerve recoveries documented as follows: extra-ocular nerves (43.2%), trigeminal nerve (32.4%), and optic nerve (10.8%). A higher CNNs recovery rate was associated with a smaller pre-treatment tumor volume (p < 0.001), and the median time-to-improvement was 3.7 months. Patients with tumor volumes exceeding 6.8 cc and those treated with FSR exhibited prolonged time-to-improvement (P < 0.03 and P < 0.04 respectively). CONCLUSIONS: This study suggests that SRS/FSR for CSM provides good and sustainable CNNs recovery outcomes with excellent long-term radiological control. A higher CNNs recovery rate was associated with a smaller pre-treatment tumor volume. while shorter time-to-improvement was identified in patients treated with SRS compared to FSR, particularly in those with small pre-treatment tumor volume.

A graph-theoretic approach for the analysis of lesion changes and lesions detection review in longitudinal oncological imaging.

Radiological follow-up of oncology patients requires the detection of lesions and the quantitative analysis of lesion changes in longitudinal imaging studies of patients, which is time-consuming and requires expertise. We present here a new method and workflow for the analysis and review of lesions and volumetric lesion changes in longitudinal scans of a patient. The generic graph-based method consists of lesion matching, classification of changes in individual lesions, and detection of patterns of lesion changes computed from the properties of the graph and its connected components. The workflow guides clinicians in the detection of missed lesions and wrongly identified lesions in manual and computed lesion annotations using the analysis of lesion changes. It serves as a heuristic method for the automatic revision of ground truth lesion annotations in longitudinal scans. The methods were evaluated on longitudinal studies of patients with three or more examinations of metastatic lesions in the lung (19 patients, 83 CT scans, 1178 lesions), the liver (18 patients, 77 CECT scans, 800 lesions) and the brain (30 patients, 102 T1W-Gad MRI scans, 317 lesions) with ground-truth lesion annotations. Lesion matching yielded a precision of 0.92-1.0 and recall of 0.91-0.99. The classification of changes in individual lesions yielded an accuracy of 0.87-0.97. The classification of patterns of lesion changes yielded an accuracy of 0.80-0.94. The lesion detection review workflow applied to manual and computed lesion annotations yielded 120 and 55 missed lesions and 20 and 164 wrongly identified lesions for all longitudinal studies of patients, respectively. The automatic analysis of lesion changes and review of lesion detection in longitudinal studies of oncological patients helps detect missed lesions and wrongly identified lesions. This method may help improve the accuracy of radiological interpretation and the disease status evaluation.

Three scans are better than two for follow-up: An automatic method for finding missed and misidentified lesions in cross-sectional follow-up of oncology patients.

PURPOSE: Missed and misidentified neoplastic lesions in longitudinal studies of oncology patients are pervasive and may affect the evaluation of the disease status. Two newly identified patterns of lesion changes, lone lesions and non-consecutive lesion changes, may help radiologists to detect these lesions. This study evaluated a new interpretation revision workflow of lesion annotations in three or more consecutive scans based on these suspicious patterns. METHODS: The interpretation revision workflow was evaluated on manual and computed lesion annotations in longitudinal oncology patient studies. For the manual revision, a senior radiologist and a senior neurosurgeon (the readers) manually annotated the lesions in each scan and later revised their annotations to identify missed and misidentified lesions with the workflow using the automatically detected patterns. For the computerized revision, lesion annotations were first computed with a previously trained nnU-Net and were then automatically revised with an AI-based method that automates the workflow readers' decisions. The evaluation included 67 patient studies with 2295 metastatic lesions in lung (19 patients, 83 CT scans, 1178 lesions), liver (18 patients, 77 CECT scans, 800 lesions) and brain (30 patients, 102 T1W-Gad MRI scans, 317 lesions). RESULTS: Revision of the manual lesion annotations revealed 120 missed lesions and 20 misidentified lesions in 31 out of 67 (46%) studies. The automatic revision reduced the number of computed missed lesions by 55 and computed misidentified lesions by 164 in 51 out of 67 (76%) studies. CONCLUSION: Automatic analysis of three or more consecutive volumetric scans helps find missed and misidentified lesions and may improve the evaluation of temporal changes of oncological lesions.

Stereotactic radiosurgery for brain metastases arising from gynecological malignancies: A retrospective treatment outcome analysis.

BACKGROUND: This retrospective study aims to assess the efficacy of stereotactic radiosurgery (SRS) in the treatment of brain metastases (BM) originating from gynecological cancers. It focuses on local control (LC), distant tumor control (DTC), and overall survival (OS). METHODS: The analysis comprised 18 individuals with gynecological-origin BM treated with SRS at the Hadassah Medical Center from 2004 to 2021. Statistical analyses evaluate factors impacting LC, DTC, and OS. RESULTS: A total of 36 BM of gynecological origin underwent SRS. The median age at the first SRS treatment was 60 years, with a median time of 24.5 months from the primary malignancy diagnosis to BM detection. The 12-month LC rate per patient was 84.6 %, and 5.6 % per BM. Only two instances of local recurrence were observed. The DTC at 12 months was 75 %, with a 29 % overall. Non-significant trends indicating a correlation with distant brain failure with increased cumulative volume and the occurrence of craniotomy before SRS. The median OS of the cohort was 16.5 months from SRS treatment. The 6, 12, 18, and 24-month survival rates were 77.8 %, 66.7 %, 50 %, and 22.2 % respectively. Higher number of BM was associated with lower OS (p = 0.046). On multivariate analysis, age was a significant factor for OS (p = 0.03), demonstrating that older age was associated with a more favorable prognosis. CONCLUSION: This study supports SRS effectiveness for treating BM from gynecological cancers and suggests similar outcomes to more common malignancies.

Two is better than one: longitudinal detection and volumetric evaluation of brain metastases after Stereotactic Radiosurgery with a deep learning pipeline.

PURPOSE: Close MRI surveillance of patients with brain metastases following Stereotactic Radiosurgery (SRS) treatment is essential for assessing treatment response and the current disease status in the brain. This follow-up necessitates the comparison of target lesion sizes in pre- (prior) and post-SRS treatment (current) T1W-Gad MRI scans. Our aim was to evaluate SimU-Net, a novel deep-learning model for the detection and volumetric analysis of brain metastases and their temporal changes in paired prior and current scans. METHODS: SimU-Net is a simultaneous multi-channel 3D U-Net model trained on pairs of registered prior and current scans of a patient. We evaluated its performance on 271 pairs of T1W-Gad MRI scans from 226 patients who underwent SRS. An expert oncological neurosurgeon manually delineated 1,889 brain metastases in all the MRI scans (1,368 with diameters > 5 mm, 834 > 10 mm). The SimU-Net model was trained/validated on 205 pairs from 169 patients (1,360 metastases) and tested on 66 pairs from 57 patients (529 metastases). The results were then compared to the ground truth delineations. RESULTS: SimU-Net yielded a mean (std) detection precision and recall of 1.00±0.00 and 0.99±0.06 for metastases > 10 mm, 0.90±0.22 and 0.97±0.12 for metastases > 5 mm of, and 0.76±0.27 and 0.94±0.16 for metastases of all sizes. It improves lesion detection precision by 8% for all metastases sizes and by 12.5% for metastases < 10 mm with respect to standalone 3D U-Net. The segmentation Dice scores were 0.90±0.10, 0.89±0.10 and 0.89±0.10 for the above metastases sizes, all above the observer variability of 0.80±0.13. CONCLUSION: Automated detection and volumetric quantification of brain metastases following SRS have the potential to enhance the assessment of treatment response and alleviate the clinician workload.

[GLIOBLASTOMA MULTIFORME AFTER STEREOTACTIC RADIOSURGERY TREATMENT FOR ARTERIO-VENOUS MALFORMATION].

INTRODUCTION: Stereotactic radiosurgery (SRS) is a minimally invasive option commissioned in the treatment of intracranial arteriovenous malformations (AVMs). As long-term follow-up data became available, some late adverse effects have been reported, including SRS-induced neoplasia. However, the exact incidence of this adverse effect is unknown. In this article we present and discuss the topic with an unusual case of a young patient who was treated with SRS for AVM and developed a malignant brain tumor.

[18F]-FDHT PET/CT as a tool for imaging androgen receptor expression in high-grade glioma.

BACKGROUND: G lioblastoma (GBM) is associated with poor overall survival. Recently, we showed that androgen receptor (AR) protein is overexpressed in 56% of GBM specimens and AR antagonists induced dose-dependent death in several GBM cell lines and significantly reduced tumor growth and prolonged the lifespan of mice implanted with human GBM. 16ß-18F-fluoro-5α-dihydrotestosterone ([18F]-FDHT) is a positron emission tomography (PET) tracer used to detect AR expression in prostate and breast cancers. This study was aimed at exploring the ability of [18F]-FDHT-PET to detect AR expression in high-grade gliomas. METHODS: Twelve patients with suspected high-grade glioma underwent a regular workup and additional dynamic and static [18F]-FDHT-PET/CT. Visual and quantitative analyses of [18 F]-FDHT kinetics in the tumor and normal brain were performed. Mean and maximum (max) standardized uptake values (SUVs) were determined in selected volumes of interest. The patients had surgery or biopsy after PET/CT. AR protein was analyzed in the tumor samples by western blot. Fold change in AR expression was calculated by densitometry analysis. Correlation between imaging and AR protein samples was determined. RESULTS: In six of the 12 patients, [18 F]-FDHT uptake was significantly higher in the tumor than in the normal brain. These patients also had increased AR protein expression within the tumor. Pearson correlation coefficient analysis for the tumor-to-control normal brain uptake ratio in terms of SUVmean versus AR protein expression was positive and significant (R = 0.84; P = .002). CONCLUSION: [18 F]-FDHT-PET/CT could identify increased AR expression in high-grade glioma.

VHL-Related Neuroendocrine Neoplasms And Beyond: An Israeli Specialized Center Real-Life Report.

OBJECTIVE: Von Hippel-Lindau (VHL) syndrome is a rare and complex disease. In 1996, we described a 3 generation VHL 2A kindred with 11 mutation carriers. We aim to share our experience regarding the long-term follow-up of this family and the management of all our other VHL patients focusing on frequently encountered neuroendocrine neoplasms: pheochromocytoma/paraganglioma and pancreatic neuroendocrine neoplasms (PNEN). METHODS: All VHL patients in follow-up at our tertiary center from 1980 to 2019 were identified. Clinical, laboratory, imaging, and therapeutic characteristics were retrospectively analyzed. RESULTS: We identified 32 VHL patients in 16 different families, 7/16 were classified as VHL 2 subtype. In the previously described family, the 4 initially asymptomatic carriers developed a neuroendocrine tumor; 7 new children were born, 3 of them being mutation carriers; 2 patients died, 1 due to metastatic PNEN-related liver failure. Pheochromocytoma was frequent (22/32), bilateral (13/22;59%), often diagnosed in early childhood when active screening was timely performed, associated with paraganglioma in 5/22, rarely malignant (1/22), and recurred after surgery in some cases after more than 20 years. PNEN occurred in 8/32 patients (25%), and was metastatic in 3 patients. Surgery and palliative therapy allowed relatively satisfactory outcomes. Severe disabling morbidities due to central-nervous system and ophthalmologic hemangiomas, and other rare tumors as chondrosarcoma in 2 patients and polycythemia in 1 patient were observed. CONCLUSION: A multidisciplinary approach and long-term follow-up is mandatory in VHL patients to manage the multiple debilitating morbidities and delay mortality in these complex patients.

Radiation-induced vascular malformations in the brain, mimicking tumor in MRI-based treatment response assessment maps (TRAMs).

•Of 310 brain tumors patients recruited, histology of 99 lesions was available.•Of those, 5 were histologically confirmed as radiation-induced malformations.•TRAMs cannot differentiate active tumor from vascular malformation.

Prevalence, Characteristics, and Long-Term Prognosis of Epilepsy Associated with Pediatric Brain Tumors.

OBJECTIVE: We investigated the prevalence, onset, characteristics, and long-term course of epilepsy disease in children who underwent surgical intervention for diagnosed brain tumors. METHODS: We reviewed the medical records of children with diagnosed brain tumors who underwent surgery during 2004-2014 at the Hadassah Medical Center. All patients with epilepsy were invited to a clinical visit that included a neurologic examination. The primary outcome measures were neurologic status according to the Glasgow outcome score (GOS) and postoperative seizure outcome according to the Engel system. We compared clinical characteristics according to the timing of epilepsy onset. RESULTS: The mean follow-up was 49 months. Of 128 patients included in the study, 44 (34%) had seizures; 23 (18%) developed epilepsy after surgery. Of the 30 patients with epilepsy who survived, 21 (70%) are in Engel class I and 13% Engel are in class II. Forty-five percent of the children are classified as GOS 5. Children who developed epilepsy after surgery were more likely to be in GOS 1-2 than were those who had seizures before surgery (P = 0.0173). Children with seizures were more likely to have cortical tumors and less likely to have tumors of the posterior fossa (P < 0.001). Children who underwent gross total resection were less likely to have epilepsy (P < 0.001). CONCLUSIONS: We show a high incidence of epilepsy in the late course of pediatric brain tumor disease. In the long term, seizure outcome was excellent. However, postsurgical onset of epilepsy was associated with a less favorable neurologic outcome.

Computer-based radiological longitudinal evaluation of meningiomas following stereotactic radiosurgery.

PURPOSE: Stereotactic radiosurgery (SRS) is a common treatment for intracranial meningiomas. SRS is planned on a pre-therapy gadolinium-enhanced T1-weighted MRI scan (Gd-T1w MRI) in which the meningioma contours have been delineated. Post-SRS therapy serial Gd-T1w MRI scans are then acquired for longitudinal treatment evaluation. Accurate tumor volume change quantification is required for treatment efficacy evaluation and for treatment continuation. METHOD: We present a new algorithm for the automatic segmentation and volumetric assessment of meningioma in post-therapy Gd-T1w MRI scans. The inputs are the pre- and post-therapy Gd-T1w MRI scans and the meningioma delineation in the pre-therapy scan. The output is the meningioma delineations and volumes in the post-therapy scan. The algorithm uses the pre-therapy scan and its meningioma delineation to initialize an extended Chan-Vese active contour method and as a strong patient-specific intensity and shape prior for the post-therapy scan meningioma segmentation. The algorithm is automatic, obviates the need for independent tumor localization and segmentation initialization, and incorporates the same tumor delineation criteria in both the pre- and post-therapy scans. RESULTS: Our experimental results on retrospective pre- and post-therapy scans with a total of 32 meningiomas with volume ranges 0.4-26.5 cm[Formula: see text] yield a Dice coefficient of [Formula: see text]% with respect to ground-truth delineations in post-therapy scans created by two clinicians. These results indicate a high correspondence to the ground-truth delineations. CONCLUSION: Our algorithm yields more reliable and accurate tumor volume change measurements than other stand-alone segmentation methods. It may be a useful tool for quantitative meningioma prognosis evaluation after SRS.

Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture.

OBJECTIVE: To assess the incidence of cerebrospinal fluid (CSF) leak and meningitis, and the need for prophylactic antibiotics, antipneumococcal vaccination, and surgical interventions, in children with a skull base fracture. METHODS: We reviewed the records of children with a skull base fracture who were admitted to our tertiary care center between 2009 and 2014. RESULTS: A total of 196 children (153 males), age 1 month to 18 years (mean age, 6 ± 4 years), were hospitalized with skull base fracture. Causes of injury were falls (n = 143), motor vehicle accidents (n = 34), and other (n = 19). Fracture locations were the middle skull base in 112 patients, frontal base in 62, and occipital base in 13. Fifty-four children (28%) had a CSF leak. In 34 of these children (63%), spontaneous resolution occurred within 3 days. Three children underwent surgery on admission owing to a CSF leak from an open wound, 3 underwent CSF diversion by spinal drainage, and 4 (2%) required surgery to repair a dural tear after failure of continuous spinal drainage and acetazolamide treatment. Twenty-eight children (14%) received prophylactic antibiotic therapy, usually due to other injuries, and 11 received pneumococcal vaccination. Two children developed meningitis, and 3 children died. Long-term follow up in 124 children revealed 12 children with delayed hearing loss and 3 with delayed facial paralysis. CONCLUSIONS: This is the largest pediatric series of skull base fractures reporting rates of morbidity and long-term outcomes published to date. The rate of meningitis following skull base fracture in children is low, supporting a policy of not administering prophylactic antibiotics or pneumococcal vaccine. Long-term follow up is important to identify delayed complications.

Review of controversies in management of non-benign meningioma.

Meningiomas are one of the most common brain tumors. World Health Organisation (WHO) Grade II and Grade III meningiomas are grouped together as non-benign meningioma (NBM). There are several controversies surrounding NBM management, including the significance of extent of resection and the efficacy of post-operative radiation and drug treatment. We reviewed the literature to develop recommendations for management of NBM. The questions we sought to answer were: Does gross total resection (GTR) improve patient outcome? Is radiation therapy (RT) warranted after complete or after incomplete resection of NBM? What drug therapies have been proven to improve outcome in patients with NBM? We found that GTR improves outcome in WHO Grade II meningioma, and should be attempted whenever considered safe. GTR correlates less closely to outcome in Grade III meningioma compared to subtotal resection (STR). Extreme measures to completely resect Grade III meningioma are not warranted. RT following GTR of Grade II meningioma does not improve patient outcome, and may be reserved for recurrence. RT improves outcome following STR of Grade II meningioma. RT improves outcome after resection of Grade III meningioma. No drug therapy has been shown to improve outcome in NBM. This review elucidates recommendations for some of the controversies involving NBM.

Ventriculoperitoneal shunt malfunction caused by proximal catheter fat obstruction.

Ventriculoperitoneal (VP) shunt placement is the mainstay of treatment for hydrocephalus, yet shunts remain vulnerable to a variety of complications. Although fat droplet migration into the subarachnoid space and cerebrospinal fluid pathways following craniotomy has been observed, a VP shunt obstruction with fat droplets has never been reported to our knowledge. We present the first reported case of VP shunt catheter obstruction by migratory fat droplets in a 55-year-old woman who underwent suboccipital craniotomy for removal of a metastatic tumor of the left medullocerebellar region, without fat harvesting. A VP shunt was inserted 1month later due to communicating hydrocephalus. The patient presented with gait disturbance, intermittent confusion, and pseudomeningocele 21days after shunt insertion. MRI revealed retrograde fat deposition in the ventricular system and VP shunt catheter, apparently following migration of fat droplets from the fatty soft tissue of the craniotomy site. Spinal tap revealed signs of aseptic meningitis. Steroid treatment for aseptic "lipoid" meningitis provided symptom relief. MRI 2months later revealed partial fat resorption and resolution of the pseudomeningocele. VP shunt malfunction caused by fat obstruction of the ventricular catheter should be acknowledged as a possible complication in VP shunts after craniotomy, even in the absence of fat harvesting.

Supraciliary keyhole craniotomy for anterior frontal lesions in children.

Treatment for anterior frontal space occupying lesions such as epidural hematoma, vascular malformations or brain tumors, have typically involved invasive craniotomies. This method often requires large incisions with wide exposure and may be associated with high morbidity rates. The basis for the "keyhole" method is that a minimally invasive craniotomy is often sufficient for exposing large areas deep in tissue, and may limit exposure and decrease surgically related morbidity while enabling adequate removal and decompression. The supraciliary method includes a cut above the eyebrow and a small craniotomy to uncover the base of the frontal lobe and the orbital roof. We demonstrate our experience with this method. We identified children who were operated via the supraciliary approach between January 2009 and December 2013, and gathered their pre- and post-operative clinical and radiological statistics. Fourteen patients were identified. Pathologies included tumors, abscesses and epidural hematomas. Nine were operated due to epidural hematoma, two due to tumors, two due to brain abscesses, and one for anterior encephalocele. No significant peri-operative or post-operative complications were observed. Long-term follow-up shows that the surgical scars were nearly invisible. The supraciliary approach is a safe, effective and elegant technique for treating lesions in the anterior skull base. The method should be weighed alongside traditional methods on a case-by-case basis.

Intracranial pressure monitoring following decompressive hemicraniectomy for malignant cerebral infarction.

Randomized controlled trials have demonstrated the efficacy of decompressive craniectomy in substantially decreasing mortality and improving functional outcome in middle cerebral artery infarction. The role of intracranial pressure (ICP) monitoring following decompressive craniectomy for stroke has not been well studied. We present a retrospective review of our experience with postoperative ICP monitoring in 12 stroke patients who underwent decompressive craniectomy. All elevations of ICP above a 20 mm Hg threshold were noted. ICP was recorded for 1417 hours during which 68 ICP elevations were seen. Nine out of 12 patients had events of raised ICP, including eight with more than three elevations. A total of 81 interventions were employed to treat elevated ICP; 71 were effective in reducing ICP below the 20 mm Hg threshold. The most frequent intervention was cerebrospinal fluid drainage via an external ventricular drain, which was effective in 85.4% of cases. Eleven out of 12 patients survived (92%) and attained a median modified Rankin Scale score of 4 (interquartile range 4-5) at a mean 15 month follow-up. In our experience, elevated ICP may commonly occur following decompressive craniectomy for stroke. Monitoring ICP influenced postoperative management and standard measures for reducing ICP were usually effective in the current series.

Delayed contrast extravasation MRI: a new paradigm in neuro-oncology.

BACKGROUND: Conventional magnetic resonance imaging (MRI) is unable to differentiate tumor/nontumor enhancing tissues. We have applied delayed-contrast MRI for calculating high resolution treatment response assessment maps (TRAMs) clearly differentiating tumor/nontumor tissues in brain tumor patients. METHODS: One hundred and fifty patients with primary/metastatic tumors were recruited and scanned by delayed-contrast MRI and perfusion MRI. Of those, 47 patients underwent resection during their participation in the study. Region of interest/threshold analysis was performed on the TRAMs and on relative cerebral blood volume maps, and correlation with histology was studied. Relative cerebral blood volume was also assessed by the study neuroradiologist. RESULTS: Histological validation confirmed that regions of contrast agent clearance in the TRAMs >1 h post contrast injection represent active tumor, while regions of contrast accumulation represent nontumor tissues with 100% sensitivity and 92% positive predictive value to active tumor. Significant correlation was found between tumor burden in the TRAMs and histology in a subgroup of lesions resected en bloc (r(2) = 0.90, P < .0001). Relative cerebral blood volume yielded sensitivity/positive predictive values of 51%/96% and there was no correlation with tumor burden. The feasibility of applying the TRAMs for differentiating progression from treatment effects, depicting tumor within hemorrhages, and detecting residual tumor postsurgery is demonstrated. CONCLUSIONS: The TRAMs present a novel model-independent approach providing efficient separation between tumor/nontumor tissues by adding a short MRI scan >1 h post contrast injection. The methodology uses robust acquisition sequences, providing high resolution and easy to interpret maps with minimal sensitivity to susceptibility artifacts. The presented results provide histological validation of the TRAMs and demonstrate their potential contribution to the management of brain tumor patients.

Spontaneous spinal epidural hematoma: the importance of preoperative neurological status and rapid intervention.

We describe the presentation, management, and outcome of spontaneous spinal epidural hematoma (SSEH) in two tertiary academic centers. We retrospectively reviewed clinical and imaging files in patients diagnosed with SSEH from 2002-2011. Neurologic status was assessed using the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A total of 17 patients (10 females; mean age 54 years, range 10-89) were included. Among patients presenting with AIS A, 5/8 showed no improvement and 3/8 reached AIS C. Among those presenting with AIS C, 5/6 reached AIS E and 1/6 reached AIS D. Of those presenting with AIS D, 3/3 reached AIS E. Mean time-to-surgery (TTS) was 28 hours (range 3-96). TTS surgery in two patients remaining at AIS A was ⩽ 12 hours; in 4/8 patients recovering to AIS E it was > 12 hours, including three patients operated on after > 24 hours. In patients remaining at AIS A, a mean of 4.4 levels were treated compared with means of 3.7 and 3.5 in those with AIS C and E, respectively, at late follow-up. In this series, preoperative neurological status had greater impact on late outcome than time from symptom onset to surgery in patients with SSEH.

Efficacy and safety of vertebral stenting for painful vertebral compression fractures in patients with metastatic disease.

BACKGROUND AND PURPOSE: Painful vertebral compression fractures in cancer patients reduce quality of life and may limit survival. We assessed pain relief, vertebral height restoration, and kyphosis correction following vertebral augmentation using a novel expandable titanium stent implant in cancer patients with painful vertebral compression fractures. MATERIALS AND METHODS: Patients >18 years of age with metastatic disease who presented symptomatic compression fractures of vertebral bodies T5-L5, with or without a history of osteoporosis, were included in the study. Back pain at presentation, immediately after vertebral stenting, and at 1-, 3-, 6-, and 12-month follow-up was estimated using the visual analog scale (VAS). Vertebral height and local kyphotic angle (alpha angle) were measured on lateral standing X-ray before and 1-3 months after stenting. RESULTS: Forty-one cancer patients with painful vertebral compression fractures underwent vertebral stenting procedures at 55 levels. There was no perioperative mortality and no significant complication. Median preoperative VAS was 8.0 (range 8-10), falling to 2.0 immediately postop (range 1-6, P  =  0.000) and 0 at all subsequent follow-up (P ≤ 0.012). Mean preoperative vertical height loss was 25.8% (range 0-84.0%) versus a postoperative mean of 18.0% (range 0-66.0%, P  =  0.000). Median pre- and postoperative kyphotic angle improved from 8.3° (range 0.2°-54.0°) to 7.1° (range 0.2°-25.0°, P  =  0.000). Wilcoxon signed rank test or student's t-test was used for comparisons. CONCLUSIONS: Vertebral augmentation using a novel vertebral stenting system provided immediate and enduring pain relief and improved vertebral height loss and kyphotic angle.