The cortical regions and white matter tracts underlying auditory comprehension in patients with primary brain tumor.

The comprehension of spoken language is one of the most essential language functions in humans. However, the neurological underpinnings of auditory comprehension remain under debate. Here we used multi-modal neuroimaging analyses on a group of patients with low-grade gliomas to localize cortical regions and white matter tracts responsible for auditory language comprehension. Region-of-interests and voxel-level whole-brain analyses showed that cortical areas in the posterior temporal lobe are crucial for language comprehension. The fiber integrity assessed with diffusion tensor imaging of the arcuate fasciculus and the inferior longitudinal fasciculus was strongly correlated with both auditory comprehension and the grey matter volume of the inferior temporal and middle temporal gyri. Together, our findings provide direct evidence for an integrated network of auditory comprehension whereby the superior temporal gyrus and sulcus, the posterior parts of the middle and inferior temporal gyri serve as auditory comprehension cortex, and the arcuate fasciculus and the inferior longitudinal fasciculus subserve as crucial structural connectivity. These findings provide critical evidence on the neural underpinnings of language comprehension.

Subgroup characteristics of insular low-grade glioma based on clinical and molecular analysis of 42 cases.

Although the classification of insular glioma has been established based on the anatomical location in order to facilitate personalized surgical resection, the diagnosis based on anatomical and functional characteristics becomes more complex when insular tumors extend into either the frontobasal brain region and/or the temporal lobe, as part of the limbic system. Moreover, prognosis of insular tumor resection is still controversial. Further analysis of subgroup characteristics of insular grade II gliomas based on clinical and molecular analysis is required to reliably determine patients' survival rates. In this retrospective study 20 purely insular grade II gliomas patients and 22 paralimbic grade II gliomas that involved frontal and/or temporal lobes were compared with regard to epidemiological and clinical characteristics. The molecular profiles including Isocitrate dehydrogenase 1 (IDH1), telomerase reverse transcriptase (TERT) promoter, and P53 mutations, 1p19q co-deletion were analyzed, and microRNA profiles were assessed by microarray and bioinformatics analysis. Purely insular grade II gliomas displayed a high frequency of IDH1 mutations with favorable outcome. IDH1 mutated paralimbic glioma shared many parameters with the purely insular glioma in respect to growth patterns, survival, and microRNA profile, but differed significantly from the IDH1 wild type paralimbic gliomas. Our findings suggest that IDH1 mutations can define subpopulations of insular gliomas with distinct disease entities regardless of tumor extension patterns. These findings could be useful to develop a customized treatment strategy for insular glioma patients.

Establishment and maintenance of a standardized glioma tissue bank: Huashan experience.

Cerebral glioma is the most common brain tumor as well as one of the top ten malignant tumors in human beings. In spite of the great progress on chemotherapy and radiotherapy as well as the surgery strategies during the past decades, the mortality and morbidity are still high. One of the major challenges is to explore the pathogenesis and invasion of glioma at various "omics" levels (such as proteomics or genomics) and the clinical implications of biomarkers for diagnosis, prognosis or treatment of glioma patients. Establishment of a standardized tissue bank with high quality biospecimens annotated with clinical information is pivotal to the solution of these questions as well as the drug development process and translational research on glioma. Therefore, based on previous experience of tissue banks, standardized protocols for sample collection and storage were developed. We also developed two systems for glioma patient and sample management, a local database for medical records and a local image database for medical images. For future set-up of a regional biobank network in Shanghai, we also founded a centralized database for medical records. Hence we established a standardized glioma tissue bank with sufficient clinical data and medical images in Huashan Hospital. By September, 2013, tissues samples from 1,326 cases were collected. Histological diagnosis revealed that 73 % were astrocytic tumors, 17 % were oligodendroglial tumors, 2 % were oligoastrocytic tumors, 4 % were ependymal tumors and 4 % were other central nervous system neoplasms.

Sensorimotor cortical changes assessed with resting-state fMRI following total brachial plexus root avulsion.

OBJECTIVE: Peripheral nerve injury can induce immediate and long-standing remodelling of the brain cortex, which may affect outcomes of nerve repair. This study examined changes of corresponding cortical representations in patients with brachial plexus injuries. METHODS: Resting-state fMRI was acquired for 13 adult patients with total brachial plexus root avulsion, three of whom underwent second scans 7 or 8 months later. The time of examination ranged from 1 to 16 months after injuries. Nine healthy adults were enrolled as control. Seed-based functional connectivity was performed for all subjects. RESULTS: For nine patients whose first fMRI was performed from 1 to 4 months after brachial plexus injuries, images showed that their cortical maps of sensorimotor areas corresponding to the hand and arm in the hemisphere contralateral to the injured side had much weaker correlation with the supplementary motor area (SMA) than those ipsilateral to the injured side. Symmetrical maps of bilateral cortical sensorimotor areas corresponding to the hand and arm were observed in other four cases with fMRI tested from 7 to 16 months after injuries. For three of the nine patients with asymmetrical cortical representations, second scans indicated symmetric results or even stronger correlation with SMA in the cerebral cortex contralateral to the injured side. CONCLUSIONS: Total brachial plexus root avulsion causes cortical representations of the brachial plexus to undergo a change from an inactive to an active state. This implies that peripheral deafferentation after brachial plexus injuries will induce corresponding cortical representations to be occupied by adjacent non-deafferented cortical territories.

Proteomic analysis of cerebrospinal fluid: toward the identification of biomarkers for gliomas.

Gliomas are the most common primary brain tumors in adults and, despite advances in the understandings of glioma pathogenesis in the genetic era, they are still ineradicable, justifying the need to develop more reliable diagnostic and prognostic biomarkers for this malignancy. Because changes in cerebrospinal fluid (CSF) are suggested to be capable of sensitively reflecting pathological processes, e.g., neoplastic conditions, in the central nervous system, CSF has been deemed a valuable source for potential biomarkers screening in this era of proteomics. This systematic review focused on the proteomic analysis of glioma CSF that has been published to date and identified a total of 19 differentially expressed proteins. Further functional and protein-protein interaction assessments were performed by using Protein Analysis Through Evolutionary Relationships (PANTHER) website and Ingenuity Pathway Analysis (IPA) software, which revealed several important protein networks (e.g., IL-6/STAT-3) and four novel focus proteins (IL-6, galanin (GAL), HSPA5, and WNT4) that might be involved in glioma pathogenesis. The concentrations of these focus proteins were subsequently determined by enzyme-linked immunosorbent assay (ELISA) in an independent set of CSF and tumor cyst fluid (CF) samples. Specifically, glioblastoma (GBM) CF had significantly lower GAL, HSPA5, and WNT4 levels than CSF from different grades of glioma. In contrast, IL-6 level was significantly higher in GBM CF when compared with CSF and, among different CSF groups, was highest in GBM CSF. Therefore, these candidate protein biomarkers, identified from both the literatures and in silico analysis, may have potentials in clinical diagnosis, prognosis evaluation, treatment response monitoring, and novel therapeutic targets identification for patients with glioma.

Localizing hand motor area using resting-state fMRI: validated with direct cortical stimulation.

BACKGROUND: Resting-state functional magnetic resonance imaging (R-fMRI) is a promising tool in clinical application, especially in presurgical mapping for neurosurgery. This study aimed to investigate the sensitivity and specificity of R-fMRI in the localization of hand motor area in patients with brain tumors validated by direct cortical stimulation (DCS). We also compared this technique to task-based blood oxygenation level-dependent (BOLD) fMRI (T-fMRI). METHODS: R-fMRI and T-fMRI were acquired from 17 patients with brain tumors. The cortex sites of the hand motor area were recorded by DCS. Site-by-site comparisons between R-fMRI/T-fMRI and DCS were performed to calculate R-fMRI and T-fMRI sensitivity and specificity using DCS as a "gold standard". R-fMRI and T-fMRI performances were compared statistically RESULTS: A total of 609 cortex sites were tested with DCS and compared with R-fMRI findings in 17 patients. For hand motor area localization, R-fMRI sensitivity and specificity were 90.91 and 89.41 %, respectively. Given that two subjects could not comply with T-fMRI, 520 DCS sites were compared with T-fMRI findings in 15 patients. The sensitivity and specificity of T-fMRI were 78.57 and 84.76 %, respectively. In the 15 patients who successfully underwent both R-fMRI and T-fMRI, there was no statistical difference in sensitivity or specificity between the two methods (p = 0.3198 and p = 0.1431, respectively) CONCLUSIONS: R-fMRI sensitivity and specificity are high for localizing hand motor area and even equivalent or slightly higher compared with T-fMRI. Given its convenience for patients, R-fMRI is a promising substitute for T-fMRI for presurgical mapping.

Diffusion tensor magnetic resonance imaging for predicting the consistency of intracranial meningiomas.

BACKGROUND: The ability of preoperative MRI-sequences to predict the consistency of intracranial meningiomas has not yet been clearly defined. We aim to demonstrate that diffusion tensor imaging (DTI) improves the prediction of intracranial meningiomas consistency. METHODS: We prospectively studied 110 meningioma patients operated on in a single center from March 1st to the 25th of May 2012. Demographic data, location and size of the tumor, peritumoral edema, T1WI, T2WI, proton density weighted (PDWI), fluid-attenuated inversion recover (FLAIR) sequences, and arterial spin labeling (ASL) perfusion were studied and compared with the gray matter signal to predict meningioma consistency. Diffusion tensor imaging (DTI) with fractional anisotropy (FA) and mean diffusivity (MD) maps were included in the preoperative MRI. Meningioma consistency was evaluated by the operating surgeon who was unaware of the neuroradiological findings. RESULTS: In univariate analysis, meningioma size (diameter > 2 cm) and supratentorial or sphenoidal wing location were more frequently associated with hard-consistency meningiomas (p < 0.05). In addition, isointense signal on MD maps (p = 0.009), hyperintense signal on FA maps, and FA value > 0.3 (p = 0.00001) were associated with hard-consistency tumors. Age and sex, T1WI, T2WI, PDWI, FLAIR, or ASL perfusion sequences and peritumoral edema were not significantly associated with meningioma consistency. In logistic regression analysis, the most accurate model (AUC: 0.9459) for predicting a hard-consistency meningioma shows that an isointense signal in MD-maps, a hyperintense signal in FA-maps, and an FA value of more than 0.3 have a significant predictive value. CONCLUSIONS: FA value and MD and FA maps are useful for prediction of meningioma consistency and, therefore, may be considered in the preoperative routine MRI examination of all patients with intracranial meningiomas.

[Prognostic evaluations of recurrent gliomas and preliminary efficacies of combined modality therapy].

OBJECTIVE: To evaluate the prognosis and efficacies of comprehensive treatment for recurrent gliomas. METHODS: A total of 62 patients diagnosed as recurrent gliomas at our hospital between May 2007 and January 2012 were reviewed and analyzed. The investigators compared the prognosis of different grades of gliomas and evaluated the efficacies of combined modality therapy of surgery, radiotherapy, chemotherapy and immunotherapy. RESULTS: Their median periods of time-to-progression (TTP) and overall survival (OS) were 6.0 and 13.0 months respectively. The median TTP of WHO grade II (n = 21), III (n = 13) and IV (n = 28) recurrent gliomas were 9.0, 9.0 and 5.0 months respectively. And the average OS of WHO grade II, III and IV recurrent gliomas were 26.6, 21.4 and 13.8 months respectively. The efficacious rate of chemotherapy was 26.7%. CONCLUSION: Combined modality therapy based on chemotherapy may moderately improve the prognosis of recurrent gliomas. And the pathological grades of primary tumors are correlated with the prognosis of recurrent gliomas.

[Long-term efficacies of sinus skeletonization plus abnormal venous reflux interruption in the treatment of parasinus dural arteriovenous fistula].

OBJECTIVE: To retrospectively explore the long-term efficacies of sinus skeletonization plus abnormal venous reflux interruption in the treatment of dural arteriovenous fistula interfering major dural sinus. METHODS: Among 15 consecutively treated patients, the lesions were located in superior sagittal sinus (n = 7), medial segment of transverse sinus (n = 3) and lateral transverse and sigmoid sinus (n = 5). And 40% of them clinically presented with intracranial hypertension and 13.3% with hemorrhage. Preoperatively, Gamma knife therapy and transarterial occlusion were used in 1 case each. All underwent sinus skeletonization plus abnormal venous reflux interruption if any. Interfered sinus was preserved in 12 cases. In another 3 cases, completely occluded segment of sinus was resected after skeletonization. RESULTS: Surgical mortality was none. At discharge, the symptoms were relieved or disappeared in 12 cases. Follow-up study was available in 11 cases over a mean period of 6 years. A Karnofsky performance status (KPS) score of 90 or more was achieved in 8 cases and a KPS score of 80, 60 or 40 was found in 1 case each. Digital subtract angiography was performed in 9 cases and computed tomographic angiography in 1 case after operation. Cure was achieved in 7 cases and 3 cases had minimal residue without recurrence. CONCLUSION: Sinus skeletonization may stably block most blood supply to fistula so as to offer cure or long-term control of dural arteriovenous fistula.

[Role of small-dose recombinant human coagulation factor VIIa for coagulopathy in patients with isolated traumatic brain injury].

OBJECTIVE: To explore the role of small-dose recombinant human coagulation factor VIIa (rFVIIa) for coagulopathy in patients with isolated traumatic brain injury. METHODS: A total of 86 isolated traumatic brain patients with coagulopathy were treated at our neurosurgery intensive care unit (NICU) from January 2010 to December 2012. Their trauma registry data included mortality, pre-and post-rFVIIa coagulation parameters. Two-tailed paired t-test was used to determine significant changes in coagulation parameters and other major clinical parameters. RESULTS: Twenty-seven patients made up the low-dose rFVIIa (20 µg/kg) group. And the control group had 59 well-matched subjects. At admission, age, blood pressure, Glasgow coma scale score, hemoglobin, platelets and international normalize ratio were similar in both groups. After treatment, the INR of patients on rFVIIa was lower than that of the conventional treatment group (1.1 ± 0.2 vs 1.2 ± 0.2, P < 0.01) and it declined more in the rFVIIa group (0.3 ± 0.2 vs 0.1 ± 0.4, P = 0.05). No significant difference existed in mortality or length of stay between two groups.There was no occurrence of subsequent thromboembolic events. CONCLUSION: The application of small-dose rFVIIa can effectively reduce the value of INR and improve the coagulation status of patients. During the course of treatment, no major adverse events occur.

Double-modified oncolytic adenovirus armed with a recombinant interferon-like gene enhanced abscopal effects against malignant glioma.

Background: The development of new therapies for malignant gliomas has been stagnant for decades. Through the promising outcomes in clinical trials of oncolytic virotherapy, there is now a glimmer of hope in addressing this situation. To further enhance the antitumor immune response of oncolytic viruses, we have equipped a modified oncolytic adenovirus (oAds) with a recombinant interferon-like gene (YSCH-01) and conducted a comprehensive evaluation of the safety and efficacy of this modification compared to existing treatments. Methods: To assess the safety of YSCH-01, we administered the oAds intracranially to Syrian hamsters, which are susceptible to adenovirus. The efficacy of YSCH-01 in targeting glioma was evaluated through in vitro and in vivo experiments utilizing various human glioma cell lines. Furthermore, we employed a patient-derived xenograft model of recurrent glioblastoma to test the effectiveness of YSCH-01 against temozolomide. Results: By modifying the E1A and adding survivin promoter, the oAds have demonstrated remarkable safety and an impressive ability to selectively target tumor cells. In animal models, YSCH-01 exhibited potent therapeutic efficacy, particularly in terms of its distant effects. Additionally, YSCH-01 remains effective in inhibiting the recurrent GBM patient-derived xenograft model. Conclusions: Our initial findings confirm that a double-modified oncolytic adenovirus armed with a recombinant interferon-like gene is both safe and effective in the treatment of malignant glioma. Furthermore, when utilized in combination with a targeted therapy gene strategy, these oAds exhibit a more profound effect in tumor therapy and an enhanced ability to inhibit tumor growth at remote sites.

[Microsurgical removal of olfactory groove meningiomas].

OBJECTIVE: To explore an effective method for further improving the surgical results of treatment of olfactory groove meningiomas. METHODS: Sixty seven cases of olfactory groove meningiomas were treated by microneurosurgery, among which fifty seven were de novo cases, eight were recurrent tumors and the other two re-recurrent cases. Modified Derome approach was used in 12 cases, bilateral subfrontal approach in 28 cases, modified pterional approach in 21 cases and unilateral subfrontal approach in six cases. Tumors were resected microsurgically with radical removal of invaded dura, bone, and paranasal sinus mucosa. Reconstruction was performed in patients with skull base defect. RESULTS: Simpson grade I removal was accomplished in 59 cases, grade II in seven cases and grade IV in one case. Among 57 patients with de novo tumor, Simpson I resection was accomplished in 54 cases. Postoperative rhinorrhea and intracranial infection occurred in one case and was cured after temporal lumbar CSF drainage and antibiotic therapy. Two patients (2.9%) died within one month after operation, i.e.one aged patient of heart failure and the other of severe hypothalamus complication. Forty seven patients (72.3%) were followed up from one to ten years with an average of five years and four months. With the exception of two cases died, among the alive 45 patients, there were only three patients with tumor recurrence, which had undergone Simpson II or IV tumor resection. No recurrence was found in cases with Simpson I tumor removal. Previous blurred vision was not improved in three patients, hemiparalysis in two patients, and the other patients recovered well, resuming previous jobs or being able to take care themselves. CONCLUSIONS: Total tumor removal (Simpson I) should be the surgical goal for treatment of olfactory groove meningiomas, especially for de novo cases. An appropriate approach is fundamental in the effort to remove an OGM totally. Appropriate anterior skull base reconstruction with vascularized material is important and mandatory.

[Resection of brainstem cavernous malformations via lateral approaches].

OBJECTIVE: To explore the surgical indications and efficacy of lateral approaches in the removal of brainstem cavernous malformations retrospectively. METHODS: From July 1999 to June 2008, 10 cases of brainstem cavernous malformations were removed via lateral approaches. Four of them had reached the lateral pial surface and 6 were covered by parenchyma or glial tissue. Three lesions were located dorsal to the cranial nerve roots and 4 lesions rostral to the facial nerve root. All 7 lesions were removed via the retrosigmoidal approach. Far lateral approach was used for 2 cases with the lesions ventral or caudal to the posterior cranial nerves. Subtemporal approach was adopted in 1 patient with the lesion ventral and rostral to the trigeminal nerve. The preoperative visual reality technique, in combination with intraoperative neuronavigation, was employed in the recent 3 cases to select a safe entry point on the surface of brainstem and a surgical corridor so as to maintain minimal damage to the surrounding fiber tracts and cranial nerve nuclei. RESULTS: Total lesion removal was achieved in all patients. Four cases of associated venous malformation were all preserved. The mean NIHSS score was 1.1 after a mean post-operative follow-up of 41 months. Eight patients improved, 1 worsened and 1 remained unchanged versus the preoperative state. CONCLUSION: Lateral approaches are recommended for lesions reaching the lateral glial surface or accessible via the lateral safe entry zone approaches.

[Preliminary application of 3.0 T intraoperative magnetic resonance imaging neuronavigation system in China].

OBJECTIVE: To report the preliminary experience in clinical application of 3.0 T intraoperative magnetic resonance imaging (iMRI) neuronavigation system in China. METHODS: From September 2010 to March 2011, a consecutive series of 122 patients with intracranial lesions underwent operations in guidance with 3.0 T iMRI. A retrospective analysis was conducted regarding clinical efficiency. RESULTS: Among 122 procedures, the numbers of intraoperative scanning were 2 - 4 times with an average of 2.6. The qualities of images were excellent. Due to the discovery and further possibility of resection of residual tumors, the ratio of gross total resection was increased from 71.7% to 90.0% in cerebral gliomas (n = 60), while from 75.9% to 93.1% in macroadenomas (n = 29). There were 6.7% of all patients occurred postoperative paralysis, but only 3.3% of patients had persistent paralysis at 1 - 2 months follow-up. There was no iMRI-related adverse event occurred. During the same period, more than 2500 patients underwent diagnostic MRI scanning. CONCLUSIONS: 3.0 T iMRI neuronavigation system provides high-quality intraoperative structural, functional and metabolic images for real time tumor resection control and accurate functional preservation, resulting in an improvement in maximal safe brain surgery. The system is cost-effective.

[Awake craniotomy and intraoperative language cortical mapping for eloquent cerebral glioma resection: preliminary clinical practice in 3.0 T intraoperative magnetic resonance imaging integrated surgical suite].

OBJECTIVES: To evaluate preliminary clinical experience for combining awake craniotomy and intraoperative language brain mapping within the integrated 3.0 T intraoperative magnetic resonance imaging (iMRI) suite. METHODS: From December 2010 to April 2011, 11 right hand-dominant patients with left glioma were involved in, or adjacent to, eloquent cortex was carried out awake craniotomies with cortical stimulation within an integrated 3.0 T iMRI suite. Aphasia battery of Chinese was used to test the language function before the operation. During the procedure, after the occipital, temporal, and supraorbital nerves were blocked by the anesthesiologists, the head was fixed with a custom high-field MRI-compatible head holder. The skull and dura was opened as usual and language brain mapping was then performed. Language testing followed a set protocol: counting numbers from 1 to 50, naming objects, reading single words. Resection of the tumor was guided by neuronavigation system and continued until eloquent areas were encountered or the margin of assessment was reached. An interdissection MRI was acquired to evaluate the glioma removal in a movable MRI scanner after minimal draping. Meanwhile, adverse effects caused by electrical stimulation and iMRI were recorded. The follow-up speech tests were assessed on 7th day and 1 month at least after the operation. RESULTS: The combined use of 3.0 T iMRI and awake craniotomy was performed safely in all patients. No adverse effects were reported. The duration of surgery was prolonged by 2 to 4 h. The patients' perception of iMRI during surgery was favorable. First-look MRI studies led to further resection attempts in 6/11 cases as well as a 3/11 increase in the number of gross-total resections. One week after surgery, baseline language function worsened in 4 cases. However, no patients had a persistent language deficit one month after surgery. CONCLUSIONS: Awake craniotomy and direct cortical electrical stimulation can be performed safely and effectively within a 3.0 T iMRI suite. The combination of high-field iMRI and awake craniotomy may facilitate safe removal of eloquent glioma.

Factors affecting prognosis of patients with intracranial anaplastic oligodendrogliomas: a single institutional review of 70 patients.

Anaplastic oligodendroglioma (AO) is an uncommon intracranial tumor and prognosis is poor. In this study, we assessed the factors affecting the prognosis of AO patients. Seventy AO patients were recruited from 2001 to 2006 in Shanghai Huashan Hospital of Fudan University; all were treated surgically. Kaplan-Meier survival analysis and Cox regression analysis were used to analyze the prognostic effects of 14 different factors, which were selected from clinical, radiological, pathological, and treatment variables. The results showed that chemotherapy, age, primary or secondary tumors, preoperative Karnofsky Performance Scale (KPS) scores, the presence of epilepsy at initial presentation, radiological contrast infusion, and neurological parameters all correlated with the prognosis of the patients. Furthermore, Cox multivariate analysis also showed that the age (P < 0.048), primary or secondary tumors (P < 0.010), and chemotherapy (P < 0.010) were significantly correlated with the prognosis of the patients. Age and chemotherapy correlated with the prognosis of AO. The patients younger than 50 years old and who received regular chemotherapy were likely to achieve a good outcome. Moreover, individualized treatment after molecular biological typing of AO may improve the prognosis of AO.

Virtual reality presurgical planning for cerebral gliomas adjacent to motor pathways in an integrated 3-D stereoscopic visualization of structural MRI and DTI tractography.

OBJECTIVE: Resection of gliomas invading primary motor cortex and subcortical motor pathway is difficult in both surgical decision-making and functional outcome prediction. In this study, magnetic resonance (MR) diffusion tensor imaging (DTI) data were used to perform tractography to visualize pyramidal tract (PT) along its whole length in a stereoscopic virtual reality (VR) environment. The potential value of its clinical application was evaluated. METHODS: Both three-dimensional (3-D) magnetic resonance imaging (MRI) and DTI datasets were obtained from 45 eligible patients with suspected cerebral gliomas and then transferred to the VR system (Dextroscope; Volume Interactions Pte. Ltd., Singapore). The cortex and tumor were segmented and reconstructed via MRI, respectively, while the tractographic PTs were reconstructed via DTI. All those were presented in a stereoscopic 3-D display synchronously, for the purpose of patient-specific presurgical planning and surgical simulation in each case. The relationship between increasing amplitude of the number of effective fibers of PT (EPT) at affected sides and the patients' Karnofsky Performance Scale (KPS) at 6 months was addressed out. RESULTS: In VR presurgical planning for gliomas, surgery was aided by stereoscopic 3-D visualizing the relative position of the PTs and a tumor. There was no significant difference between pre- and postsurgical EPT in this population. A positive relationship was proved between EPT increasing amplitude and 6-month KPS. CONCLUSIONS: 3-D stereoscopic visualization of tractography in this VR environment enhances the operators to well understand the anatomic information of intra-axial tumor contours and adjacent PT, results in surgical trajectory optimization initially, and maximal safe tumor resection finally. In accordance to the EPT increasing amplitude, surgeon can predict the long-term motor functional outcome.

[Radiosurgery for cavernous sinus hemangiomas: medium- and long-term results].

OBJECTIVE: To describe the personal experiences of treating cavernous sinus hemangiomas (CSH) with gamma knife or cyberknife and evaluate the medium and long-term outcomes. METHODS: From June 1999 to December 2008, 20 CSH patients were treated by radiosurgery (gamma knife or cyberknife). Among them, 11 had residual tumor after surgery and 9 were diagnosed by neuroradiology. All cases on magnetic resonance imaging (MRI) showed well-defined and homogeneous hyperintensity on T2-weighted images. The mean maximum diameter of tumors was 38.7 ± 9.3 mm (range: 23.0 - 60.6). The volume of tumors ranged between 4.1 - 52.6 cm(3) with a mean of (18.7 ± 12.5) cm(3). The tumor margin dose irradiated by gamma knife ranged from 9 to 16 Gy (mean 12.3 ± 2.3 Gy). The tumor margin dose irradiated by cyberknife was 20 - 21 Gy in 3 fractions. The mean follow-up period was (60 ± 32) months (range: 12 - 120). RESULTS: Follow-up imaging showed tumor volume decreased over 90% (n = 5), tumor regressed over 50% in volume (n = 9) and no change in tumor volume (n = 1). One patient with large tumor (irradiated 10 Gy) was operated by open surgery at 5 months after gamma knife. Four giant tumors decreased over 50% in volume after cyberknife. Neurologically, none of these patients showed any deterioration. And 16 patients demonstrated an obvious improvement after radiosurgery. At the last follow-up, there were no complications related to radiosurgery. CONCLUSION: Radiosurgery (Gamma knife or cyberknife) is a safe and effective modality for small- and medium-sized CSH. Fractionated Cyberknife proves to be an effective treatment for large or giant CSH. Thus radiosurgery will be an alternative option to surgery.

Diagnosis and treatment of intracranial immature teratoma.

OBJECTIVE: The purpose of this paper is toexplore the clinical features, treatment and prognosis of intracranial immature teratomas. METHODS: The clinical data, serum levels of tumor markers, treatment regimens and prognosis of 15 patients with intracranial immature teratomas were reviewed retrospectively. RESULTS: In patients whose plasma alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-HCG) were determined, AFP and beta-HCG were elevated in 57.1 and 16.7% of the cases, respectively. All patients received surgical treatment. The tumor was totally removed in 12 cases, subtotally in 2, and partially in 1 case. After surgery, of the 15 patients, 9 received radiotherapy, 4 gamma knife surgery and 7 chemotherapy. Thirteen patients were followed up. Compared to the common 5-year survival rate of 40%, in patients who received gamma knife surgery, the 5-year survival rate after surgery was 100%, which is better than the 5-year survival rate of patients who did not receive gamma knife surgery (p = 0.0049). Postoperative radiotherapy and chemical therapy had no significant impact on the 5-year survival rate (p > 0.05). CONCLUSIONS: The prognosis of intracranial immature teratomas is poor. The detection of their clinical manifestation, the analysis of imaging features and the serum levels of tumor markers are helpful in diagnosing intracranial teratomas. The total removal of the tumor is important to cure the disease. We did not see a difference in outcome between patients who received postoperative chemotherapy or radiotherapy and those who did not. Regular follow-up MRI examinations are necessary so that the conditions of the patients can be closely monitored. If a patient has residual or recurrent tumor after surgery, gamma knife surgery can be effective.

[Grading system for diagnosis and treatment of intracranial nongerminomatous malignant germ cell tumors].

OBJECTIVE: To discuss the clinical feature, treatment and prognosis of intracranial nongerminomatous malignant germ cell tumors (NGMGCT). METHODS: The records of 39 patients receiving treatment at our hospital between 1995 and 2007 were reviewed retrospectively. According to the classification of Matsutani, they were grouped into intermediate prognosis and poor prognosis groups based on tumor histology. Clinical manifestations, diagnosis, treatment and outcome were analyzed in each group. RESULTS: In these 39 cases, there were 15 mix germ cell tumors, 15 immature teratomas, 7 embryonal carcinomas and 2 yolk sac tumors. All patients were treated surgically. The tumor was totally removed in 29 cases, sub-totally in 5 and partially in 3. Biopsy was performed in the other 2 cases. Thirty-four patients (87.2%) were followed up. The overall 5-year survival rate was 36.8%. The 5-year actuarial survival rate for patients in the intermediate prognosis and poor prognosis groups were 42.6% and 0 respectively. Chemoradiotherapy had a significant correlation with the prognosis of intermediate prognosis group (P = 0.039). The 5-year survival rate of immature teratoma patients receiving post-operative gamma knife surgery was 100%. It had significant difference (P = 0.0049) as compared to the 5-year survival rate of patients receiving no gamma knife surgery. CONCLUSION: NGMGCT can be divided into the intermediate and poor groups based on the prognosis (P = 0.0003). Embryonal carcinoma can be classified to the intermediate prognosis group because of its similar prognosis with immature teratoma and mixed tumors composed mainly of germinoma or teratoma. Surgery remains the first choice for NGMGCT since treatment should be based on tumor histology. For patients in the intermediate prognosis group, a combined regimen of surgical resection, radiotherapy, chemotherapy and gamma knife surgery is mostly effective.