Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome.

Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75 years) with Type II odontoid fracture managed conservatively during the last 10 years. All patients underwent CT scan on admission and at 3 months; if indicated, selected patient had CT scan at 6 and 12 months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6 weeks, 3, 6, 12, and 24 months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12 months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83 years. Patients were followed up for a minimum of 24 months: 247 (95%) showed an excellent functional outcome within 6 weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12 weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.

Multimodal techniques failed to detect cytomegalovirus in human glioblastoma samples.

The role of the human cytomegalovirus (HCMV) in gliomagenesis is largely debated. Contradictory data exist regarding the sensitivity and specificity of HCMV detection techniques, including immunohistochemistry (IHC), in situ hybridization (ISH), and RNA and DNA sequencing. The aim of this study is to detect HCMV in glioblastoma (GBM) tumor samples using IHC, ISH, and real-time PCR (qPCR), as well as to correlate the findings with serological status and HCMV DNA load in blood. Forty-seven patients with histopathological diagnosis of GBM and HCMV serological status were retrospectively reviewed. HCMV DNA quantification in whole blood was performed in 31 patients. The detection of HCMV in tumor samples was performed using IHC in 42 cases, ISH in 10 cases, and qPCR in 29 cases. All but two patients were taking high steroid doses at the time of biological testing. HCMV seroprevalence was 68%. Active infection with HCMV DNA detected in blood was diagnosed in 6 out of 21 (28%) seropositive patients. HCMV was not detected in GBM samples using IHC or ISH, while qPCR was positive in one case (also positive for blood HCMV DNA). These data do not support a crucial role of HCMV in GBM tumorigenesis. HCMV might be reactivated in GBM patients, due to steroid treatment.

Hotspots of small strokes in glioma surgery: an overlooked risk?

BACKGROUND: Small deep infarcts constitute a well-known risk of motor and speech deficit in insulo-opercular glioma surgery. However, the risk of cognitive deterioration in relation to stroke occurrence in so-called silent areas is poorly known. In this paper, we propose to build a distribution map of small deep infarcts in glioma surgery, and to analyze patients' cognitive outcome in relation to stroke occurrence. METHODS: We retrospectively studied a consecutive series of patients operated on for a diffuse glioma between June 2011and June 2017. Patients with lower-grade glioma were cognitively assessed, both before and 4 months after surgery. Areas of decreased apparent diffusion coefficient (ADC) on the immediate postoperative MRI were segmented. All images were registered in the MNI reference by ANTS algorithm, allowing to build a distribution map of the strokes. Stroke occurrence was correlated with the postoperative changes in semantic fluency score in the lower-grade glioma cohort. RESULTS: One hundred fifteen patients were included. Areas of reduced ADC were observed in 27 out of 54 (50%) patients with a lower-grade glioma, and 25 out of 61 (41%) patients with a glioblastoma. Median volume was 1.6 cc. The distribution map revealed five clusters of deep strokes, corresponding respectively to callosal, prefrontal, insulo-opercular, parietal, and temporal tumor locations. No motor nor speech long-term deficits were caused by these strokes. Cognitive evaluations at 4 months showed that the presence of small infarcts correlated with a slight decrease of semantic fluency scores. CONCLUSION: Deep small infarcts are commonly found after glioma surgery, but their actual impact in terms of patients' quality of life remains to be demonstrated. Further studies are needed to better evaluate the cognitive consequences-if any-for each of the described hotspots and to identify risk factors other than the surgery-induced damage of microvessels.

Reossification of Bone Defects After Surgical Correction of Nonsyndromic Craniosynostosis: A Review and An Original Study.

BACKGROUND AND OBJECTIVES: Surgical correction of nonsyndromic craniosynostosis (NSC) aims to restore cranial shape. Reossification of bone defects is paramount for the best aesthetic prognosis. However, the literature on the quantitative evaluation of bone defects after NSC surgery is scarce. This study aimed to quantify and analyze the surface area of bone defects after NSC surgery and establish a threshold value for predicting persistent defects. METHODS: We conducted a systematic review and a prospective study of 28 children undergoing surgical treatment for NSC. We analyzed 426 defects on the first computed tomography scan (1 year postoperative) and 132 defects on the second computed tomography scan (4.6 years postoperative). Statistical analysis was performed using Spearman's rank correlation coefficient, Mann-Whitney-Wilcoxon rank-sum test, and Youden's J statistic. RESULTS: Our systematic review identified three studies reporting on bone defects' surface area and reossification rate. In our study, we found no statistically significant differences in the number or size of defects between sex or type of NSC. The threshold value for the surface area of bone defects above which there was a higher probability of persistent defects was 0.19 cm2 (Youden point), with an 89.47 % probability of persistence. Defects with a surface area below 0.19 cm2 had a considerably lower probability, only 15.07%, of persistence over time. CONCLUSION: Our study provides valuable quantitative data for managing bone defects after NSC surgery. Defects with a surface area above 0.19 cm2 should be monitored with radiological imaging because of the risk of persistence. Our findings highlight the importance of developing robust and reproducible methods for the quantitative analysis of bone defects after NSC surgery.

Functional Outcome after Spinal Meningioma Surgery.

STUDY DESIGN: A multicenter cross-sectional analytical retrospective study. PURPOSE: To assess functional outcome (FO) after a spinal meningioma (SM) surgery. OVERVIEW OF LITERATURE: All studies report functional improvement after SM removal. METHODS: We performed an analytical retrospective cohort study at five different institutions. All patients with a diagnosis of SM were included in this study, including those with recurrent tumors. Meningiomas of the foramen magnum were excluded. Useful histopathological characteristics were separately extracted. Surgical resection was evaluated according to the Simpson grading scale. Patient outcomes and clinical states were assessed with the help of their medical records using four different scales: the modified Ranawat score, the Nurick scale, the Prolo score, the Frankel grade, and the Eastern Cooperative Oncology Group-World Health Organization- Zubrod score. RESULTS: Between 1991 and 2018, 417 patients were identified, of which 85.8% were female. The median age at surgery was 67.2 years (interquartile range [IQR], 56.7-76.5). The lesion was located in the thoracic region in 77.9% of the patients, cervical region in 16.8%, and lumbar region in 4.1%. Surgical resection was complete in 95.5% of the cases. Only 0.96% of the patients died within the first postoperative month. Neurological status, which improved in 76.9% of the patients, was unchanged in 17.5% and even worsened in 4.4%. Functional status was assessed using the Ranawat score and Nurick scale, with scores of 1 (IQR, 0-2) (i.e., hyperreflexia and asymptomatic; mean, 1.3±1.3) and 1 (IQR, 0-2) (i.e., signs of spinal cord disease, but no difficulty in walking; mean, 1.2±1.4), respectively. Approximately 10.1% of the patients were not ambulant at the last neurosurgical follow-up visit. Older age at surgery was not significantly associated with a chair-bound status (p =0.427). CONCLUSIONS: This large series confirms the favorable FO after spinal meningioma surgery even in the case of seriously impaired preoperative status. A validated scale is needed to assess the factors predicting a worsening of the functional status and guide the management of patients.

Role of hippocampal location and radiation dose in glioblastoma patients with hippocampal atrophy.

BACKGROUND: The hippocampus is a critical organ for irradiation. Thus, we explored changes in hippocampal volume according to the dose delivered and the location relative to the glioblastoma. METHODS: All patients were treated for glioblastoma with surgery, concomitant radiotherapy and temozolomide, and adjuvant temozolomide. Hippocampi were retrospectively delineated on three MRIs, performed at baseline, at the time of relapse, and on the last MRI available at the end of follow-up. A total of 98, 96, and 82 hippocampi were measured in the 49 patients included in the study, respectively. The patients were stratified into three subgroups according to the dose delivered to 40% of the hippocampus. In the group 1 (n = 6), the hippocampal D40% was < 7.4 Gy, in the group 2 (n = 13), only the Hcontra D40% was < 7.4 Gy, and in the group 3 (n = 30), the D40% for both hippocampi was > 7.4 Gy. RESULTS: Regardless of the time of measurement, homolateral hippocampal volumes were significantly lower than those contralateral to the tumor. Regardless of the side, the volumes at the last MRI were significantly lower than those measured at baseline. There was a significant correlation among the decrease in hippocampal volume regardless of its side, and Dmax (p = 0.001), D98% (p = 0.028) and D40% (p = 0.0002). After adjustment for the time of MRI, these correlations remained significant. According to the D40% and volume at MRIlast, the hippocampi decreased by 4 mm3/Gy overall. CONCLUSIONS: There was a significant relationship between the radiotherapy dose and decrease in hippocampal volume. However, at the lowest doses, the hippocampi seem to exhibit an adaptive increase in their volume, which could indicate a plasticity effect. Consequently, shielding at least one hippocampus by delivering the lowest possible dose is recommended so that cognitive function can be preserved. Trial registration Retrospectively registered.

Aneurysmal bone cyst of the frontal bone - A radiologic-pathologic correlation.

We present a case of 27-year-old female who presented for a progressive frontal swelling with ipsilateral headache. Subsequent CT scan revealed an extradural and expansile multiloculated mass with thin and strongly enhanced septations and MRI evaluation showed internal hyperintensity on T2 with no restriction of diffusion and confirmed the multiple cystic spaces with enhancing septations and rare hemorrhagic fluid-fluid levels. Surgery was performed and diagnosis of aneurysmal bone cyst was made on frozen section. Identification of USP6 fusion gene by in situ hybridization technique permitted to confirm the diagnosis of primary ABC. Although aneurysmal bone cyst (ABC) of the skull is a very rare entity and accounts for 2-6% of all ABCs, we should think about it in front of osteolytic and cystic skull changes even with very few fluid-fluid levels. Following description of our case and differential diagnoses, we conduct a literature review of skull ABCs imaging characteristics and discuss the interest of USP6 rearrangement identification.