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Postoperative hemorrhage can severely affect the patients' neurological outcome after awake craniotomy. Higher postoperative blood pressure can increase the risk of postoperative hemorrhage. The aim of this study was to investigate the role of postoperative blood pressure and other common radiological and epidemiological features with the incidence of postoperative hemorrhage. In this retrospective analysis, we included patients who underwent awake surgery at our institution. We assessed the blood pressure both intra- and postoperatively as well as the heart rate for the first 12 h. We compared a cohort with postoperative hemorrhage, who required further treatment (surgical revision or intravenous antihypertensive therapy), with a cohort with no postoperative hemorrhage. We included 48 patients with a median age of 39 years. 9 patients (19%) required further treatment due to postoperative hemorrhage, which was surgery in 2 cases and intensive blood pressure measurements in 7 cases. However, with early treatment, no significant difference in Performance scores at follow-up could be found. Patients with postoperative hemorrhage showed significantly higher postoperative systolic blood pressure during the hours 3-12 (p < 0.05) as well as intraoperatively throughout the procedure (p < 0.05). In ROC and Youden Test, a strong impact of systolic blood pressure over 140mmHg during the early postoperative course could be shown. Postoperative hemorrhage is a rare but possible complication in awake surgery glioma patients. To avoid postoperative hemorrhage, treating physicians should aim strictly on systolic blood pressure of under 140mmHg for the postoperative course.
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Presión Sanguínea , Neoplasias Encefálicas , Craneotomía , Glioma , Hemorragia Posoperatoria , Vigilia , Humanos , Craneotomía/efectos adversos , Masculino , Glioma/cirugía , Glioma/complicaciones , Femenino , Adulto , Persona de Mediana Edad , Presión Sanguínea/fisiología , Neoplasias Encefálicas/cirugía , Vigilia/fisiología , Estudios Retrospectivos , Hemorragia Posoperatoria/epidemiología , Anciano , Adulto Joven , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/efectos adversosRESUMEN
Metastases are the most frequent intracranial malignant tumors in adults. While Karnofsky Performance Status (KPS) and Clinical Frailty Scale (CFS) are known to have significant impact on overall survival (OS), temporal muscle thickness (TMT) has been postulated to be a promising new parameter to estimate prognosis. Patients who received a resection of one to three brain metastases in our institution were included. Temporal muscle thickness was measured in preoperative MRI scans according to a standardized protocol. In 199 patients, the mean TMT was 7.5 mm (95CI 7.3-7.7) and the mean OS during follow-up was 31.3 months (95CI 24.2-38.3). There was no significant correlation of TMT and preoperative or follow-up CFS and KPS. While CFS and KPS did significantly correlate with OS (p < 0.001 for each), no correlation was demonstrated for TMT. CFS showed a superior prognostic value compared to KPS. TMT failed to show a significant impact on OS or patient performance, whereas the clinical scales (KPS and CFS) demonstrate a good correlation with OS. Due to its superiority over KPS, we strongly recommend the use of CFS to estimate OS in patients with brain metastases.
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Objective: Patients with idiopathic trigeminal neuralgia (TN) live in constant fear of triggering shock-like pain episodes, which may cause symptoms of depression and a reduction in quality of life. Microvascular decompressive surgery has been demonstrated to achieve satisfactory and stable results. With this study, we wanted to investigate prevalence and risk factors for depression and perceived stress in correlation with symptom relief after surgical treatment. Methods: In this prospective study, patients undergoing microvascular decompression (MVD) for TN were included. The Barrow Neurological Institute Pain Score (BNI), Beck Depression Inventory (BDI), Chronic Pain Acceptance Questionnaire (CPAQ), Perceived Stress Questionnaire (PSQ) and McGill questionnaire were used to evaluate depression, stress and anxiety disorders before and 3 months after MVD. Results: A total of 35 patients (16 male (46%)) with a mean age of 55.4 (SD 15) years were included in this study. The BDI revealed that 24 (68.8%) patients harbored mild-to-extreme depression preoperatively (2.4 ± 1.4), which improved to 1.2 (±0.6, p < 0.0001). Pain acceptance also changed from 64 (±11.3) to 67.7 (±9.3, p = 0.006). Perceived stress decreased from 46.9 (±21.9) to 19.6 (±18.6) (p < 0.0001) postoperatively, and pain decreased from 31.0 (±11.7) to 9.4 (±12.9, p < 0.0001). Microvascular decompression reduced the mean BNI pain score significantly from 4.6 to 1.8 postoperatively (p < 0.00001). Conclusions: Depression and perceived stress are prevalent in patients with idiopathic TN. Adequate treatment not only provides a high rate of satisfaction through pain relief, but also leads to immediate and significant improvements in depression and stress. Thus, in patients with TN who do not reach an adequate and timely pain reduction through medical management and develop signs of depression, early treatment with microvascular decompression should be considered.
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BACKGROUND: H3 K27M-mutated gliomas were first described as a new grade 4 entity in the 2016 World Health Organization classification. Current studies have focused on its typical appearance in children and young adults, increasing the need to better understand the prognostic factors and impact of surgery on adults. Here, we report a multicentric study of this entity in adults. METHODS: We included molecularly confirmed H3 K27M-mutated glioma cases in patientsâ ≥â 18 years diagnosed between 2016 and 2022. Clinical, radiological, and surgical features were analyzed. Univariate and multivariate analyses were performed to identify prognostic factors. RESULTS: Among 70 patients with a mean age of 36.1 years, the median overall survival (OS) was 13.6â ±â 14 months. Gross-total resection was achieved in 14.3% of patients, whereas 30% had a subtotal resection and 54.3% a biopsy. Tumors located in telencephalon/diencephalon/myelencephalon were associated with a poorer OS, while a location in the mesencephalon/metencephalon showed a significantly longer OS (8.7 vs. 25.0 months, Pâ =â .007). Preoperative Karnofsky-Performance Score (KPS)â ≤â 80 showed a reduced OS (4.2 vs. 18 months, Pâ =â .02). Furthermore, ATRX loss, found in 25.7%, was independently associated with an increased OS (31 vs. 8.3 months, Pâ =â .0029). Notably, patients undergoing resection showed no survival benefit over biopsy (12 vs. 11 months, Pâ =â .4006). CONCLUSIONS: The present study describes surgical features of H3 K27M-mutated glioma in adulthood in a large multicentric study. Our data reveal that ATRX status, location and KPS significantly impact OS in H3 K27M-mutated glioma. Importantly, our dataset indicates that resection does not offer a survival advantage over biopsy.
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Neoplasias Encefálicas , Glioma , Histonas , Mutación , Proteína Nuclear Ligada al Cromosoma X , Humanos , Masculino , Glioma/cirugía , Glioma/genética , Glioma/patología , Glioma/mortalidad , Femenino , Proteína Nuclear Ligada al Cromosoma X/genética , Adulto , Pronóstico , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/mortalidad , Histonas/genética , Persona de Mediana Edad , Adulto Joven , Tasa de Supervivencia , Estudios de Seguimiento , Biomarcadores de Tumor/genética , Anciano , Adolescente , Estudios RetrospectivosRESUMEN
BACKGROUND: Isocitrate dehydrogenase (IDH)1/2 wildtype (wt) astrocytomas formerly classified as WHO grade II or III have significantly shorter PFS and OS than IDH mutated WHO grade 2 and 3 gliomas leading to a classification as CNS WHO grade 4. It is the aim of this study to evaluate differences in the treatment-related clinical course of these tumors as they are largely unknown. METHODS: Patients undergoing surgery (between 2016-2019 in six neurosurgical departments) for a histologically diagnosed WHO grade 2-3 IDH1/2-wt astrocytoma were retrospectively reviewed to assess progression free survival (PFS), overall survival (OS), and prognostic factors. RESULTS: This multi-center study included 157 patients (mean age 58 years (20-87 years); with 36.9% females). The predominant histology was anaplastic astrocytoma WHO grade 3 (78.3%), followed by diffuse astrocytoma WHO grade 2 (21.7%). Gross total resection (GTR) was achieved in 37.6%, subtotal resection (STR) in 28.7%, and biopsy was performed in 33.8%. The median PFS (12.5 months) and OS (27.0 months) did not differ between WHO grades. Both, GTR and STR significantly increased PFS (P < 0.01) and OS (P < 0.001) compared to biopsy. Treatment according to Stupp protocol was not associated with longer OS or PFS compared to chemotherapy or radiotherapy alone. EGFR amplification (P = 0.014) and TERT-promotor mutation (P = 0.042) were associated with shortened OS. MGMT-promoter methylation had no influence on treatment response. CONCLUSIONS: WHO grade 2 and 3 IDH1/2 wt astrocytomas, treated according to the same treatment protocols, have a similar OS. Age, extent of resection, and strong EGFR expression were the most important treatment related prognostic factors.
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Astrocitoma , Neoplasias Encefálicas , Glioma , Femenino , Humanos , Persona de Mediana Edad , Masculino , Estudios Retrospectivos , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/terapia , Neoplasias Encefálicas/patología , Glioma/diagnóstico , Glioma/genética , Glioma/terapia , Astrocitoma/genética , Astrocitoma/terapia , Astrocitoma/patología , Resultado del Tratamiento , Pronóstico , Mutación , Isocitrato Deshidrogenasa/genética , Organización Mundial de la Salud , Receptores ErbB/genéticaRESUMEN
The conventional microscope has the disadvantage of a potentially unergonomic posture for the surgeon, which can affect performance. Monitor-based exoscopes could provide a more ergonomic posture, as already shown in pre-clinical studies. The aim of this study was to test the usability and comfort of a novel head-mounted display (HMD)-based exoscope on spinal surgical approaches in a simulated OR setting. A total of 21 neurosurgeons naïve to the device were participated in this prospective trial. After a standardized training session with the device, participants were asked to perform a single-level thoracolumbar decompression surgery on human cadavers using the exoscope. Subsequently, all participants completed a comfort and safety questionnaire. For the objective evaluation of the performance, all interventions were videotaped and analyzed. Twelve men and nine women with a mean age of 34 (range: 24-57) were participating in the study. Average time for decompression was 15 min (IqR 9.6; 24.2); three participants (14%) terminated the procedure prematurely. In these dropouts, a significantly higher incidence of back/neck pain (p = 0.002 for back, p = 0.046 for neck pain) as well as an increased frequency of HMD readjustments (p = 0.045) and decreased depth perception (p = 0.03) were documented. Overall, the surgeons' satisfaction with the exoscope was 84% (IqR 75; 100). Using a standardized, pre-interventional training, it is possible for exoscope-naïve surgeons to perform sufficient spinal decompression using the HMD-based exoscope with a high satisfaction. However, inaccurate HMD setup prior to the start of the procedure may lead to discomfort and unsatisfactory results.
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Dolor de Cuello , Procedimientos Quirúrgicos Robotizados , Adulto , Femenino , Humanos , Masculino , Cadáver , Ergonomía , Estudios Prospectivos , Procedimientos Quirúrgicos Robotizados/métodosRESUMEN
BACKGROUND: Radiation necrosis (RN) is a possible late complication of stereotactic radiosurgery (SRS), but only a few risk factors are known. The aim of this study was to assess tumor location in correlation to the development of radiation necrosis for skull base (SB) and non-skull base tumors. METHODS: All patients treated with radiosurgery for benign neoplasms (2004-2020) were retrospectively evaluated. The clinical, imaging and medication data were obtained and the largest axial tumor diameter was determined using MRI scans in T1-weighted imaging with gadolinium. The diagnosis of RN was established using imaging parameters. Patients with tumors located at the skull base were compared to patients with tumors in non-skull base locations. RESULTS: 205 patients could be included. Overall, 157 tumors (76.6%) were located at the SB and compared to 48 (23.4%) non-SB tumors. Among SB tumors, the most common were vestibular schwannomas (125 cases) and meningiomas (21 cases). In total, 32 (15.6%) patients developed RN after a median of 10 (IqR 5-12) months. Moreover, 62 patients (30.2%) had already undergone at least one surgical resection. In multivariate Cox regression, SB tumors showed a significantly lower risk of radiation necrosis with a Hazard Ratio (HR) of 0.252, p < 0.001, independently of the applied radiation dose. Furthermore, higher radiation doses had a significant impact on the occurrence of RN (HR 1.372, p = 0.002). CONCLUSIONS: The risk for the development of RN for SB tumors appears to be low but should not be underestimated. No difference was found between recurrent tumors and newly diagnosed tumors, which may support the value of radiosurgical treatment for patients with recurrent SB tumors.
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Background: GBM research is constantly assessing potential valuable prognostic biomarkers to better understand the disease and prognosticate future outcomes. Measuring temporal muscle thickness (TMT) has appeared to be a promising new surrogate marker for skeletal muscle mass and sarcopenia, which further indicates frailty and predicts overall survival (OS). The aim of this study was to determine its usefulness as a prognostic marker in patients with high-grade glioma compared to functional status scales. Methods: TMT was measured in preoperative axial T1-weighted contrast-enhanced magnetic resonance images in 277 patients who received surgical treatment of newly diagnosed WHO III and IV gliomas in our institution between 2015 and 2020. Clinical Frailty Scale (CFS) and Karnofsky Performance Scale (KPS) were assessed preoperatively and during a follow-up visit. Results: Female gender has shown significant correlation with TMT, while TMT did not correlate with preoperative and follow-up functional scores, age, WHO classification, IDH mutation, MGMT promoter methylation, EGFR and ATRX expression, or 1p/19q co-deletion. No significant prognostic value of TMT could be shown in 6, 12, and 24 months OS, while changes in CFS and KPS proved to have a significant impact. Conclusion: Only female gender, but no other clinical, histological, or molecular marker showed any interrelation with TMT. Functional scores outclass measuring TMT as a reliable prognostic factor for predicting OS in patients with high-grade glioma.
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PURPOSE: Data on differences in overall survival and molecular characteristics between incidental (iLGG) and symptomatic lower grade Glioma (sLGG) are limited. The aim of this study was to investigate differences between patients with iLGG and sLGG. METHODS: All adult patients with a histologically proven diffuse (WHO°II) or anaplastic (WHO°III) glioma who underwent their first surgery at the authors' institution between 2010 and 2019 were retrospectively included. Tumor volume on pre- and postoperative MRI scans was determined. Clinical and routine neuropathological data were gained from patients' charts. If IDH1, ATRX and EGFR were not routinely assessed, they were re-determined. RESULTS: Out of 161 patients included, 23 (14%) were diagnosed as incidental findings. Main reasons for obtaining MRI were: headache(n = 12), trauma(n = 2), MRI indicated by other departments(n = 7), staging examination for cancer(n = 1), volunteering for MRI sequence testing(n = 1). The asymptomatic patients were significantly younger with a median age of 38 years (IqR28-48) vs. 50 years (IqR38-61), p = 0.011. Incidental LGG showed significantly lower preoperative tumor volumes in T1 CE (p = 0.008), FLAIR (p = 0.038) and DWI (p = 0.028). Incidental LGG demonstrated significantly lower incidence of anaplasia (p = 0.004) and lower expression of MIB-1 (p = 0.008) compared to sLGG. IDH1-mutation was significantly more common in iLGG (p = 0.024). Incidental LGG showed a significantly longer OS (mean 212 vs. 70 months, p = 0.005) and PFS (mean 201 vs. 61 months, p = 0.001) compared to sLGG. CONCLUSION: Our study is the first to depict a significant difference in molecular characteristics between iLGG and sLGG. The findings of this study confirmed and extended the results of previous studies showing a better outcome and more favorable radiological, volumetric and neuropathological features of iLGG.
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Neoplasias Encefálicas , Glioma , Adulto , Humanos , Persona de Mediana Edad , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/patología , Estudios Retrospectivos , Glioma/diagnóstico por imagen , Glioma/genética , Glioma/patología , Imagen por Resonancia Magnética , CefaleaRESUMEN
OBJECTIVE: Increased intracranial pressure (ICP) is most likely not being transmitted uniformly within the cranium. The ICP profiles in the supra- and infratentorial compartments remain largely unclear. Increased ICP in the cerebellum, however, is insufficiently captured by supratentorial ICP (ICPsup) monitoring due to compartmentalization through the tentorium. The authors hypothesized that additional infratentorial ICP (ICPinf) monitoring can be clinically valuable in selected patients. The aims of this study were to demonstrate the safety and feasibility of ICPinf monitoring and to investigate the influence of the ICPinf on clinical outcome in a real-world setting. METHODS: Fifteen consecutive patients with posterior fossa (PF) lesions requiring surgery and anticipated prolonged neurointensive care between June 2019 and December 2021 were included. Simultaneous ICPsup and ICPinf were recorded. ICP burden was defined as a 15-minute interval with a mean ICP > 22 mm Hg. The Glasgow Outcome Scale score was assessed after 3 months. RESULTS: The mean ICPinf was substantially higher compared with ICPsup throughout the entire period of ICP recording (16.08 ± 4.44 vs 10.74 ± 3.6 mm Hg, p < 0.01). ICPinf was significantly higher in patients with unfavorable outcome when compared with those with favorable outcome (mean 17.2 ± 4.1 vs 11.4 ± 3.5 mm Hg, p < 0.05). Patients with unfavorable outcome showed significantly higher ICPinf burden compared with those with favorable outcome (mean 40.6 ± 43.8 vs 0.3 ± 0.4 hours, p < 0.05). Neither absolute ICPsup nor ICPsup burden was significantly associated with unfavorable outcome (p = 0.13). No monitoring-associated complications occurred. CONCLUSIONS: Supplementary ICPinf monitoring is safe and reliable. There is a significant transtentorial pressure gradient within the cranium showing elevated ICPs in the PF. Elevated ICP levels in the PF were strongly associated with unfavorable neurological outcome irrespective of ICPsup values.
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Lesiones Encefálicas , Hipertensión Intracraneal , Humanos , Presión Intracraneal , Encéfalo , Cerebelo , Escala de Consecuencias de Glasgow , Hipertensión Intracraneal/etiología , Hipertensión Intracraneal/terapia , Monitoreo FisiológicoRESUMEN
BACKGROUND: Advanced intercellular communication is a known oncogenic factor. In the central nervous system, Connexin-43 (Cx43) forms this junctional networking. Moreover, it correlates with the proliferation rate, and thus behavior, of gliomas. We assessed the expression of Cx43 and its relationship to Ki67 in other common central nervous system tumors. METHODS: The expression of Cx43 and Ki67 were assessed in formalin-fixed paraffin embedded samples of human brain metastases, meningiomas, and neurinomas using immunohistochemistry. Neurinomas and meningiomas were jointly evaluated due to similar non-malignant behavior. RESULTS: A total of 14 metastases of different extracerebral carcinomas, 6 meningiomas, and 10 neurinomas were evaluated. Five (36%) metastases and 5 (31%) meningiomas/neurinomas showed minor expression, whereas 6 (43%) metastases and 2 (13%) meningiomas/neurinomas showed no Cx43 expression at all. In 3 (21%) metastases and 9 (56%) meningiomas/neurinomas, moderate or strong expression of Cx43 was identified. The higher expression of Cx43 in meningiomas and neurinomas directly correlated with Ki67, r = 0.53 (P = 0.034). For metastases no significant correlation was found. Mitotic index in meningiomas/neurinomas correlated with Ki67 expression, r = 0.74 (P < 0.001), but did not show statistically significant correlation with Cx43 expression in these tumors. CONCLUSIONS: The expression of Cx43 as a marker of cell-to-cell networking exposed a significant correlation with the Ki67-defined proliferation index in case of primary central nervous system neuroectodermal neoplasms. However, it does not seem to play a comparable role in metastases with extracerebral origin.
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Neoplasias Encefálicas , Neoplasias Meníngeas , Meningioma , Neurilemoma , Humanos , Meningioma/genética , Meningioma/metabolismo , Meningioma/patología , Antígeno Ki-67/genética , Neurilemoma/patología , Neoplasias Encefálicas/genética , Neoplasias Meníngeas/metabolismo , Neoplasias Meníngeas/patologíaRESUMEN
Distant intercellular communication in gliomas is based on the expansion of tumor microtubuli, where actin forms cytoskeleton and GAP-43 mediates the axonal conus growth. We aimed to investigate the impact of GAP-43 and actin expression on overall survival (OS) as well as crucial prognostic factors. FFPE tissue of adult patients with diffuse and anaplastic gliomas, who underwent first surgery in our center between 2010 and 2019, were selected. GAP-43, Cx43 and actin expression was analyzed using immunohistochemistry and semi-quantitatively ranked. 118 patients with a median age of 46 years (IqR: 35-57) were evaluated. 48 (41%) presented with a diffuse glioma and 70 (59%) revealed anaplasia. Tumors with higher expression of GAP-43 (p = 0.024, HR = 1.71/rank) and actin (p < 0.001, HR = 2.28/rank) showed significantly reduced OS. IDH1 wildtype glioma demonstrated significantly more expression of all proteins: GAP-43 (p = 0.009), Cx43 (p = 0.003) and actin (p < 0.001). The same was confirmed for anaplasia (GAP-43 p = 0.028, actin p = 0.029), higher proliferation rate (GAP-43 p = 0.016, actin p = 0.038), contrast-enhancement in MRI (GAP-43 p = 0.023, actin p = 0.037) and age (GAP-43 p = 0.004, actin p < 0.001; Cx43 n.s. in all groups). The intercellular distant communication network in diffuse and anaplastic gliomas formed by actin and GAP-43 is associated with a negative impact on overall survival and with unfavorable prognostic features. Cx43 did not show relevant impact on OS.
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Neoplasias Encefálicas , Glioma , Adulto , Humanos , Persona de Mediana Edad , Actinas/genética , Anaplasia , Neoplasias Encefálicas/patología , Conexina 43/genética , Conexina 43/metabolismo , Proteína GAP-43 , Glioma/patología , PronósticoRESUMEN
INTRODUCTION AND PURPOSE: Brain metastases appear to be well resectable due to dissectable tumor margins, but postoperative MRI quite often depicts residual tumor with potential influence on tumor control and overall survival. Therefore, we introduced sodium fluoresceine into the routine workflow for brain metastasis resection. The aim of this study was to evaluate whether the use of fluorescence-guided surgery has an impact on postoperative tumor volume and local recurrence. MATERIAL AND METHODS: We retrospectively included patients who underwent surgical resection for intracranial metastases of systemic cancer between 11/2017 and 05/2021 at our institution. Tumor volumes were assessed pre- and postoperatively on T1-CE MRI. Clinical and epidemiological data as well as follow-up were gathered from our prospective database. RESULTS: Seventy-nine patients (33 male, 46 female) were included in this study. Median preoperative tumor volume amounted to 11.7cm3 and fluoresceine was used in 53 patients (67%). Surgeons reported an estimated gross total resection (GTR) in 95% of the cases, while early postoperative MRI could confirm GTR in 72%. Patients resected using fluoresceine demonstrated significantly lower postoperative residual tumor volumes with a difference of 0.7cm3 (p = 0.044) and lower risk of local tumor recurrence (p = 0.033). The use of fluorescence did not influence the overall survival (OS). Postoperative radiotherapy resulted in a significantly longer OS (p = 0.001). DISCUSSION: While GTR rates may be overrated, the use of intraoperative fluorescence may help neurosurgeons to achieve a more radical resection. Fluoresceine seems to facilitate surgical resection and increase the extent of resection thus reducing the risk for local recurrence.
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Neoplasias Encefálicas , Humanos , Masculino , Femenino , Estudios Retrospectivos , Neoplasia Residual/cirugía , Neoplasias Encefálicas/patología , Encéfalo/patología , FluoresceínaRESUMEN
BACKGROUND: The most frequent peripheral entrapment neuropathy is compression of the median nerve in the carpal tunnel, known as carpal tunnel syndrome. The most effective treatment is surgery, where the flexor retinaculum (FR) is divided. Nevertheless, after this operation, a significant number of patients suffer from persistent symptoms due to incomplete FR distal release. It may be difficult to identify the distal boundary of the FR due to the minimal skin incision. We aimed to identify an anatomical landmark to avoid incomplete distal FR release. The radiocarpal (RC) joint can be palpated, and lies in close proximity to the boundaries of the FR. Thus, the distance between the RC joint space and the distal FR margin - the RC-FR distance - could be a reliable and individual morphologic measurement from easily acquired regional anthropological measurements. METHODS: During this study, 39 radiocarpal regions of 23 embalmed cadavers were dissected, and measurements were taken. Linear regression corresponding to the ulnar length and the RC-FR distance was established. RESULTS: The mean RC-FR distance from the RC joint space to the distal FR margin was 3.8 cm (95 % CI 3.5-4.0), and the range was 2.3-5.1 cm. This distance was 1.1 cm (95 % CI 0.8-1.4) longer in males than in females (p < 0.00001), and there were no side-specific differences. The individual projection of the distal FR margin in centimeters can be calculated by measurement of the ipsilateral ulnar length divided by 4 and reduced by 2.9, p < 0.005. CONCLUSIONS: The side-equal and sex-specific position of the distal flexor retinaculum margin could be calculated from the palpable radiocarpal joint space based on the ipsilateral ulnar length.
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Síndrome del Túnel Carpiano , Masculino , Femenino , Animales , Humanos , Síndrome del Túnel Carpiano/cirugía , Articulación de la Muñeca/cirugía , Articulación de la Muñeca/anatomía & histología , Nervio Mediano/cirugía , Nervio Mediano/anatomía & histología , Ligamentos , Cadáver , PecesRESUMEN
Biological but not chronological age plus performance have more impact on decision making in glioblastoma patients. We investigated how progression-free survival (PFS) and overall survival (OS) in older patients with IDH wild-type glioblastoma were influenced by concomitant radio-chemotherapy and MGMT promotor methylation status in real-life settings. In total, 142 out of 273 (52%) evaluated patients were older than 65 years, and 77 (55%) of them received concomitant radio-chemotherapy. In senior patients, the initiation of concomitant radio-chemotherapy was associated with significantly better PFS: 15.3 months (CI95: 11.7−18.9) vs. 7.0 months (CI95: 4.3−9.6; p = 0.002). The favorable influence on PFS was not related to MGMT promotor methylation status as it was in the younger cohort. In seniors, concomitant radio-chemotherapy was related to significantly better OS: 20.0 months (CI95: 14.3−26.7) vs. 4.9 months (CI95: 3.5−6.2), p < 0.001. MGMT promotor methylation was related to a more favorable OS only, if concomitant radio-chemotherapy was initiated. In conclusion, more than half of the glioblastoma cohort was older than 65 years of age. Even if PFS and OS were shorter than in the younger cohort, concomitant radio-chemotherapy provided a survival advantage. In real life, MGMT promotor methylation had a positive impact on OS only if the adjuvant therapy was applied.
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Introduction: Conventional microscopes have certain limitations in terms of posture and ergonomics. Monitor-based exoscopes could solve this problem and thereby lead to less work-related sick leave for surgeons. Research question: The aim of this study was to assess the ergonomics, usability, and neurosurgeon's comfort of a novel three-dimensional head-mounted display-based exoscope in a standardized setting. Material & Methods: 34 neurosurgeons participated in a workshop on the exoscope, which features a head-mounted display and a head gesture-triggered control panel. After completion of a custom-made 10-step microsurgical exercise, image quality and comfort were assessed using a questionnaire. The participants' posture during the exercise was analyzed using a video motion analysis software. Results: 34 participants (median neurosurgical experience: 6 years) were included. The median time to complete the exercise was 12 âmin [IqR 9.4, 15.0]. Younger participants (p â= â0.005) and those with video game experience (p â= â0.03) had a significantly steeper learning curve. The median overall satisfaction was at 80% in general and 82% for image quality. The median upper body as well as the median head coronal displacement from the neutral axis were 0°. Participants with less microsurgical experience showed less head/body displacement during the exercise (p â= â0.01). Discussion and conclusion: Using the microsurgical training tool, we were able to depict a steep learning curve with a sufficient learnability of the most relevant commands. The exoscope excelled in usability, image quality as well as in ergonomic and favorable posture and could thus become an alternative to conventional microscopes due to the potentially elevated surgeons' comfort.
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Introduction: Tumor-treating fields (TTFs) are a specific local oncological treatment modality in glioblastoma multiforme WHO° IV (GBM). Their mechanism of action is based on the effect of electrical fields interfering with the mitotic activity of malignant cells. Prospective studies have demonstrated efficacy, but TTF benefits are still controversially discussed. This treatment was implemented in our center as the standard of care in January 2016. We thus discuss the current state of the art and our long-term experience in the routine application of TTF. Methods: The data of 48 patients suffering from GBM and treated with TTF were assessed and compared with previously published studies. Up-to-date information from open sources was evaluated. Results: A total of 31 males and 17 females harboring a GBM were treated with TTF, between January 2016 and August 2021, in our center. In 98% of cases, TTFs were started within 6 weeks after concomitant radiochemotherapy (Stupp protocol). Mean overall survival was 22.6 months (95% CI: 17.3-27.9). Current indications, benefits, and restrictions were evaluated. Future TTF opportunities and ongoing studies were reviewed. Conclusion: TTFs are a feasible and routinely applicable specific oncological treatment option for glioblastoma multiforme WHO° IV. Further research is ongoing to extend the indications and the efficacy of TTF.
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Background: The median age for diagnosis of glioblastoma is 64 years and the incidence rises with increasing age to a peak at 75-84 years. As the total number of high-grade glioma patients is expected to increase with an aging population, neuro-oncological surgery faces new treatment challenges, especially regarding aggressiveness of the surgical approach and extent of resection. In the elderly, aspects like frailty and functional recovery time have to be taken into account before performing surgery. Material & Methods: Patients undergoing surgery for malignant glioma (WHO grade III and IV) at our institution between 2015 and 2020 were compiled in a centralized tumor database and analyzed retrospectively. Karnofsky Performance Scale (KPS) and Clinical Frailty Scale (CFS) were used to determine functional performance pre- and postoperatively. Overall survival (OS) was compared between age groups of 65-69 years, 70-74 years, 75-79 years, 80-84 years and >85 years in view of extent of resection (EOR). Furthermore, we performed a literature evaluation focusing on surgical treatment of newly diagnosed malignant glioma in the elderly. Results: We analyzed 121 patients aged 65 years and above (range 65 to 88, mean 74 years). Mean overall survival (OS) was 10.35 months (SD = 11.38). Of all patients, only a minority (22.3%) received tumor biopsy instead of gross total resection (GTR, 61.2%) or subtotal resection (STR, 16.5%). Postoperatively, 52.9% of patients were treated according to the Stupp protocol. OS differed significantly between extent of resection (EOR) groups (4.0 months after biopsy vs. 8.3 after STR vs. 13.8 after GTR, p < 0.05 and p < 0.001 correspondingly). No significant difference was observed regarding EOR across different age groups. Conclusion: GTR should be the treatment of choice also in elderly patients with malignant glioma as functional outcome and survival after surgery are remarkably better compared to less aggressive treatment. Elderly patients who received GTR of high-grade gliomas survived significantly longer compared to patients who underwent biopsy and STR. Age seems to have little influence on overall survival in selected surgically extensive treated patients, but high preoperative functional performance is mandatory.
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BACKGROUND: The Clinical Frailty Scale (CFS) describes the general level of fitness or frailty and is widely used in geriatric medicine, intensive care and orthopaedic surgery. This study was conducted to analyze, whether CFS could be used for patients with high-grade glioma. METHODS: Patients harboring high-grade gliomas, undergoing first resection at our center between 2015 and 2020 were retrospectively evaluated. Patients' performance was assessed using the Rockwood Clinical Frailty Scale and the Karnofsky Performance Scale (KPS) preoperatively and 3-6 months postoperatively. RESULTS: 289 patients were included. Pre- as well as postoperative median frailty was 3 CFS points (IqR 2-4) corresponding to "managing well". CFS strongly correlated with KPS preoperatively (r = - 0.85; p < 0.001) and at the 3-6 months follow-up (r = - 0.90; p < 0.001). The reduction of overall survival (OS) was 54% per point of CFS preoperatively (HR 1.54, CI 95% 1.38-1.70; p < 0.001) and 58% at the follow-up (HR 1.58, CI 95% 1.41-1.78; p < 0.001), comparable to KPS. Patients with IDH mutation showed significantly better preoperative and follow-up CFS and KPS (p < 0.05). Age and performance scores correlated only mildly with each other (r = 0.21 0.35; p < 0.01), but independently predicted OS (p < 0.001 each). CONCLUSION: CFS seems to be a reliable tool for functional assessment of patients suffering from high-grade glioma. CFS includes non-cancer related aspects and therefore is a contemporary approach for patient evaluation. Its projection of survival can be equally estimated before and after surgery. IDH-mutation caused longer survival and higher functionality.