Suicidal ideation, depression, and health-related quality of life in patients with benign and malignant brain tumors: a prospective observational study in 83 patients.

OBJECTIVE: Health-related quality of life (HRQoL) and psychosocial burden are of relevance in patients with intracranial tumors. We investigated the prevalence of suicidal ideation (SI), depression, and their association with HRQoL in patients with intra- (IA) and extraaxial (EA) tumors during the first 9 months after diagnosis. METHODS: Patients were recruited immediately following surgery, and re-evaluated after 3, 6, and 9 months (EORTC QLQ-C30/BN20, Beck Depression Inventory (BDI) and Appendix). Patients with a personal history of psychological comorbidity were excluded. Sociodemographic and clinical data were evaluated. RESULTS: IA patients had lower functioning scores and experienced more symptoms. Global Health Status was significantly lower at baseline (p = 0.038), but improved over time (p < 0.001). Seventeen patients (21.5 %) admitted to having had SI at least once during the study period (IA: n = 10/EA: n = 7). The highest rates were observed after 6 (IA: 18.8 %) and 9 months (EA: 10.0 %). Patients reporting SI had significantly higher BDI scores [p = 0.22 (baseline), p = 0.031 (3 months), p < 0.001 (6 months)]. After 6 months, HRQoL differed greatest between patients with and without SI. Most patients experienced good familial support (76 %). CONCLUSIONS: Patients with intracranial tumors suffer from decreased HRQoL and SI regardless of histopathology. SI is associated with higher BDI scores, but not evident depression (BDI ≥ 18). Thus, patients should be screened specifically and regularly. Lower HRQoL and greatest prevalence of SI at 6 months may help clinicians to find the right time for careful monitoring of patients at risk.

Feasibility of fluorescence-guided resection of recurrent gliomas using five-aminolevulinic acid: retrospective analysis of surgical and neurological outcome in 58 patients.

Five-aminolevulinic-acid (5-ALA) is known for its benefits in surgery of primary gliomas, but has only been cautiously used in recurrent gliomas dreading over-resection, insufficient or false-positive fluorescence in adjuvantly treated tumors. We evaluated intraoperative fluorescence based on tumor pathology, pretreatment as well as surgical and neurological outcome in patients with recurrent gliomas. Patients who underwent fluorescence-guided surgery for recurrent gliomas between 6/2010 and 2/2014 at our institution were retrospectively selected. Degree of surgical resection, neurological status, pathology results, intraoperative fluorescence and follow up status were analyzed. Patients who underwent repeat surgery without 5-ALA were selected as controls. 58 patients with high grade gliomas (°III and °IV) were included. 10 of 63 tumors (15.9 %) failed to fluoresce intraoperatively of which nine (90 %) had been adjuvantly treated prior to recurrence, as were 46 of the 53 fluorescing tumors (86.8 %). Non-fluorescing tumors were IDH mutated significantly more often (p = 0.005). 30 tumors (47.6 %) were located eloquently. 51 (80.9 %) patients showed no new neurologic deficits postoperatively. 13 patients (20.6 %) showed no signs of recurrence at their latest follow up. Eight patients were lost to follow up. Overall survival was significantly longer in the 5-ALA group (p = 0.025). Fluorescence-guided surgery in recurrent gliomas is safe and allows for a good surgical and neurological outcome in a difficult surgical environment, especially when used in combination with neuronavigation and intraoperative ultrasound to prevent over-resection. Adjuvant therapy did not significantly influence fluorescing properties.

Endoscopic surgery for tumors of the pineal region via a paramedian infratentorial supracerebellar keyhole approach (PISKA).

The tumors of the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options were commonly used to approach this area causing considerable surgical morbidity and mortality. We report for the first time on a series of endoscopic procedures for lesions of the pineal region performed via an infratentorial supracerebellar keyhole approach (PISKA) in the prone position using endoscope-assisted and endoscope-controlled technique. A single-institution series of 11 consecutive patients (five male and six female patients [11 total cases]; mean age 21 years, range 1-75 years) treated via the endoscope-assisted and endoscope-controlled PISKA for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 24 months. The endoscopic PISKA was successfully used to approach a variety of pineal lesions, including pineocytoma (three patients), pineal cysts (four patients), germinoma, lipoma, medulloblastoma, and glioblastoma (one patient each). Gross total resection was achieved in ten cases and subtotal resection in one case. The mean preoperative tumor volumes were approximately 2 × 2 cm. Five patients developed postoperatively transient Parinaud's syndrome. One patient underwent surgical revision for cerebrospinal fluid leak. There was no mortality. Ten patients had an uneventful postoperative course with restitutio ad integrum after a mean follow-up duration of 13.5 months. The endoscopically PISKA is a safe and effective minimally invasive approach that enables endoscopic treatment of different lesions of the pineal region with comparable results to standard microsurgical technique but less morbidity.

Navigated versus non-navigated intraoperative ultrasound: is there any impact on the extent of resection of high-grade gliomas? A retrospective clinical analysis.

INTRODUCTION: The extent of tumor resection is a significant predictor of survival in high-grade gliomas. In recent years, several authors showed the benefit of intraoperative ultrasound partially matched with magnetic resonance imaging (MRI). The aim of this study was to find out if intraoperative neuronavigation in combination with intraoperative ultrasound has any impact on the complete resection of gliomas. A comparison between the ultrasound-controlled resection of brain tumors and operations controlled by navigated ultrasound was performed. MATERIALS AND METHODS: A total of 92 patients (54 men and 39 women) with a mean age of 53.2 years underwent 93 operations over a period of 4 years (2007-2010). They harbored a tumor with suspicion of glioma; 32 of them had undergone previous surgery, and additional chemotherapy, and 29 of them had undergone irradiation. Overall, 49 operations were performed with navigated ultrasound (group A) and 44 with non-navigated ultrasound (group B). A standardized early postoperative MRI was performed . Complete or gross total resection (GTR) was defined by a resection of ≥ 95% of the tumor. Skin incision and craniotomy were planned after registration of the neuronavigation system. The ultrasound system was used systematically before and after opening the dura, and during and at the end of resection. RESULTS: GTR could be achieved in 28 of 49 cases in group A and in 23 of 44 cases in group B. In group A, sensitivity and specificity of tumor remnants detected by ultrasound were higher than in group B. Concerning recurrent gliomas, the sensitivity of ultrasound visualizing tumor remnants was lower than in primary tumors. In case of preoperatively planned GTR, in both groups (navigated and non-navigated ultrasound) similar tumor remnant sizes were postoperatively detected by MRI. In nine cases the removal was incomplete because of eloquently located tumors. There was no significant difference between navigated and not-navigated ultrasound concerning GTR (p > 0.05). CONCLUSION: Navigated ultrasound is an important technical tool that helps in intraoperative orientation. Further prospective investigation is needed to assess the impact on GTR.

First preoperative functional mapping via navigated transcranial magnetic stimulation in a 3-year-old boy.

Preoperative functional mapping in children younger than 5 years old remains a challenge. Awake functional MRI (fMRI) is usually not an option for these patients. Except for a description of passive fMRI in sedated patients and magnetoencephalography, no other noninvasive mapping method has been reported as a preoperative diagnostic tool in children. Therefore, invasive intraoperative direct cortical stimulation remains the method of choice. To the authors' knowledge, this is the first case of a young child undergoing preoperative functional motor cortex mapping with the aid of navigated transcranial magnetic stimulation (nTMS). In this 3-year-old boy with a rolandic ganglioglioma, awake preoperative mapping was performed using nTMS. A precise location of Broca area 4 could be established. The surgical approach was planned according to the preoperative findings. Intraoperative direct cortical stimulation verified the location of the nTMS hotspots, and complete resection of the precentral tumor was achieved. Navigated TMS is a precise tool for preoperative motor cortex mapping and is feasible even in very young pediatric patients. In children for whom performing the fMRI motor paradigm is challenging, nTMS is the only available option for functional mapping.

The keyhole concept in aneurysm surgery: results of the past 20 years.

BACKGROUND: Improvements in preoperative imaging and intraoperative visualization have led to a refinement in surgical techniques. OBJECTIVE: Report of a 20-year experience with application of the keyhole technique as a contribution to the ongoing debate on the impact of limited craniotomies in aneurysm surgery. METHODS: Over a 20-year period, 1000 consecutive patients with 1297 aneurysms were surgically treated in 1062 operations: 651 in the acute stage after SAH and 411 with unruptured aneurysms. The outcome was assessed with the modified Rankin scale and approach-related complications. RESULTS: The majority of the cases were treated by 4 different keyhole approaches: The supraorbital approach was used in 793 patients for 989 aneurysms, the subtemporal in 48 patients for 50 aneurysms, the interhemispheric in 46 patients for 51 aneurysms, and the retromastoidal in 55 patients for 55 aneurysms. In 120 patients, the classic pterional approach was applied to treat 152 aneurysms. The results of unruptured aneurysms were good (modified Rankin scale ≤ 2) in 96.52%. The complication rates of the keyhole approaches were less than in the pterional group, although the difference did not reach statistical significance. CONCLUSION: The overall outcome, rate of retreatment, and approach-related complications with keyhole approaches for the management of ruptured and unruptured aneurysms are comparable to recently published conventional surgical aneurysm series. In addition to the common benefits of limited-exposure approaches, this series demonstrates appropriate safety and applicability of the keyhole technique in aneurysm surgery.

Minimally invasive neurosurgery for vascular lesions.

Intracranial vascular lesions are known to affect 2% to 4% of the population, predisposing those affected to a lifetime risk of hemorrhagic stroke, ischemia, focal neurologic deficits, or epileptic seizures. These lesions constitute a heterogeneous group, with different lesion types characterized by distinct biologic mechanisms of pathogenesis and progression. In this article, the minimally invasive management of intracranial aneurysms, arteriovenous malformations including arteriovenous fistulas, and cavernous malformations are discussed.

Omovertebral bone associated with Sprengel deformity and Klippel-Feil syndrome leading to cervical myelopathy.

The unusual association of an omovertebral bone with Sprengel deformity and Klippel-Feil syndrome is a complex bone anomaly of unknown incidence and etiology. However, several cases of this rare disease pattern have been reported in the literature. In this paper, the authors present the case of a 34-year-old woman with a 5-month history of progressive gait ataxia and intermittent urinary incontinence, which was found to be caused by aberrant bone growth into the spinal canal from an omovertebral bone that extended from the left scapula pressing into the C-6 vertebral arch and subsequently causing cervical myelopathy. The patient underwent isolated resection of the omovertebral bone and decompression of the spinal canal, and her functional and neurological outcome was favorable.