Prognostic Factors and Nomogram for Choroid Plexus Tumors: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis.

Background: Choroid plexus tumors (CPTs) are rare neoplasms found in the central nervous system, comprising 1% of all brain tumors. These tumors include choroid plexus papilloma (CPP), atypical choroid plexus papilloma (aCPP), and choroid plexus carcinoma (CPC). Although gross total resection for choroid plexus papillomas (CPPs) is associated with long-term survival, there is a scarcity of prospective data concerning the role and sequence of neoadjuvant therapy in treating aCPP and CPC. Methods: From the years 2000 to 2019, 679 patients with CPT were identified from the Surveillance, Epidemiology, and End Result (SEER) database. Among these patients, 456 patients had CPP, 75 patients had aCPP, and 142 patients had CPC. Univariate and multivariable Cox proportional hazard models were run to identify variables that had a significant impact on the primary endpoint of overall survival (OS). A predictive nomogram was built for patients with CPC to predict 5-year and 10-year survival probability. Results: Histology was a significant predictor of OS, with 5-year OS rates of 90, 79, and 61% for CPP, aCPP, and CPC, respectively. Older age and African American race were prognostic for worse OS for patients with CPP. Older age was also associated with reduced OS for patients with aCPP. American Indian/Alaskan Native race was linked to poorer OS for patients with CPC. Overall, treatment with gross total resection or subtotal resection had no difference in OS in patients with CPP or aCPP. Meanwhile, in patients with CPC, gross total resection (GTR) was associated with significantly better OS than subtotal resection (STR) only. However, there is no difference in OS between patients that receive GTR and patients that receive STR with adjuvant therapy. The nomogram for CPC considers types of treatments received. It demonstrates acceptable accuracy in estimating survival probability at 5-year and 10-year intervals, with a C-index of 0.608 (95% CI of 0.446 to 0.77). Conclusions: This is the largest study on CPT to date and highlights the optimal treatment strategies for these rare tumors. Overall, there is no difference in OS with GTR vs. STR in CPP or aCPP. Furthermore, OS is equivalent for CPC with GTR and STR plus adjuvant therapy.

Prognostic Indicators for Intracranial Metastases from Pancreatic Cancer: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis.

OBJECTIVE: The natural history, treatment options, and clinical outcomes of pancreatic metastases to the brain remain largely unknown. Here, we seek to investigate characteristics that influence OS in pancreatic metastases to the brain. METHODS: This is a population-based retrospective study of OS in 508 patients with pancreatic metastases to the brain using the SEER database. Univariate and multivariate Cox regression analyses were utilized, and a predictive nomogram was developed. RESULTS: There were 508 patients identified for this study, with a median OS of 2 months. In the univariate analysis, patients older than 65 years had significantly reduced OS (P < 0.001). Patients with liver metastases (P < 0.001) and liver and lung metastases (P < 0.001) exhibited significantly reduced OS. Treatment of the primary tumor with chemotherapy only (P < 0.001), radiation only (P = 0.01), radiation and chemotherapy (P < 0.001), and surgery only (P = 0.01) were associated with increased OS. Resection of a distant metastasis site (P = 0.009) and of a brain metastasis (P = 0.03) were associated with increased OS. In the multivariable analysis, factors that remained significant included patient age (P = 0.01), liver metastases (P < 0.001), liver and lung metastases (P < 0.001), treatment with chemotherapy (P < 0.001), treatment with radiation and chemotherapy (P < 0.001), and treatment with surgery and chemotherapy (P < 0.001). The nomogram had a C-index of 0.766, suggesting congruence between the findings on the nomogram and the results in the internal verification. CONCLUSIONS: Median OS is influenced by age, multiorgan metastases, and treatment of the primary tumor. These data highlight the marginal benefit of treatment, yet improved quality of life (QOL) remains to be elucidated.

Survival Benefit from Multimodal Treatment for Patients with Atypical Teratoid Rhabdoid Tumor in a Surveillance, Epidemiology, and End Results Database Analysis.

INTRODUCTION: Atypical teratoid rhabdoid tumor (ATRT) is among the most aggressive central nervous system malignancies. Although rare, this tumor typically afflicts young children and results in mortality within months. Here, we aim to determine key clinical features and treatment options that impact the survival of patients with ATRT. METHODS: From the year 2000 to 2019, 363 patients with ATRT were identified from the Surveillance, Epidemiology, and End Results database. Univariate analysis was used to identify variables that had a significant impact on the primary endpoint of overall survival (OS). Multivariable analysis was then used to identify independent predictors of survival. RESULTS: The median OS of the entire cohort was 13 months. Univariate analysis identified ages between 1 and 3 years, ages between 4 and 17 years, years of diagnosis between 2010 and 2019, and the receipt of treatment to have a significant impact on survival. In multivariable analysis, ages between 1 and 3 years and receipt of treatment were the only significant independent predictors of survival. The median OS was significantly greater in patients who received surgical treatment, chemotherapy, or radiation when compared to those who did not receive any treatment. In general, the receipt of any combination of therapies improved the median OS significantly. The receipt of triple therapy had the greatest impact on survival. DISCUSSION: This study highlights the survival benefit of a multimodal approach in the treatment of ATRT. The use of triple therapy, including surgery, radiation, and chemotherapy, was found to have the greatest survival benefit for patients. Overall, these findings may guide future care for patients with ATRT.

Prognostic factors of survival for grade III solitary fibrous tumor/hemangiopericytoma: a population-based retrospective Surveillance, Epidemiology, and End Results database analysis.

BACKGROUND: Grade 3 solitary fibrous tumor, previously known as anaplastic hemangiopericytoma, is a rare and highly malignant intracranial tumor with a limited understanding of its natural history and treatment outcomes. METHODS: We conducted a retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database spanning 2000-2019 to evaluate the clinical characteristics and treatment modalities that influence overall survival in this tumor entity. A cohort of 249 patients with intracranial grade 3 solitary fibrous tumors was identified. Univariate and multivariable Cox proportional hazard models were employed to determine significant prognostic factors for overall survival. Kaplan-Meier models were used to visualize survival curves, and a nomogram was constructed to predict survival probabilities at 6- and 12-months following diagnosis. RESULTS: Our findings indicated that patient age (<65 years), localized or regional disease burden, surgical resection, and radiation therapy were significant predictors of better overall survival. Combination therapies showed improved survival, with surgery and radiation therapy having the most significant impact. However, chemotherapy alone or in combination did not demonstrate a significant survival benefit, likely due to limited sample size. The nomogram provided personalized prognosis predictions based on significant clinical factors. CONCLUSIONS: These data emphasize the importance of surgical resection and radiation therapy in the management of grade 3 solitary fibrous tumors, supporting the use of combination therapies to improve overall survival in this rare and aggressive intracranial neoplasm.

Prognostic Indicators for H3K27M-Mutant Diffuse Midline Glioma: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis.

BACKGROUND: Diffuse midline glioma with histone H3K27M mutation (H3K27M DMG) is a recently recognized World Health Organization grade IV glioma with a dismal prognosis. Despite maximal treatment, this high-grade glioma exhibits an estimated median survival of 9-12 months. However, little is known with regards to prognostic risk factors for overall survival (OS) for patients with this malignant tumor. The aim of the present study is to characterize risk factors influencing survival in H3K27M DMG. METHODS: This is a population-based retrospective study of survival in patients with H3K27M DMG. The Surveillance, Epidemiology, and End Results database was examined from the years 2018 to 2019 and data from 137 patients were collected. Basic demographics, tumor site, and treatments regimens were retrieved. Univariate and multivariable analyses were conducted to assess for factors associated with OS. Nomograms were built based on the results of the multivariable analyses. RESULTS: Median OS of the entire cohort was 13 months. Patients with infratentorial H3K27M DMG exhibited worse OS compared to their supratentorial counterparts. Any form of radiation treatment resulted in a significantly improved OS. Most combination treatments significantly improved OS with the exception of the surgery plus chemotherapy group. The combination of surgery and radiation had the greatest impact on OS. CONCLUSIONS: Overall, the infratentorial location of H3K27M DMG portends a worse prognosis compared to their supratentorial counterparts. The combination of surgery and radiation had the greatest impact on OS. These data highlight the survival benefit in utilizing a multimodal treatment approach for H3K27M DMG.

Co-occurrence of dural arteriovenous fistula and meningioma: A rare case and systematic review.

Background: The coexistence of meningioma and dural arteriovenous fistula (dAVF) is a rare, but highly complex condition. Various pathophysiological mechanisms underlie intracranial meningiomas with continuous or distant dAVFs. We describe a case of coexisting meningioma and dAVF with a systematic review of the literature. Result: Including the present case, there are 21 reported cases of coexisting intracranial dAVF and meningioma. The patients' ages ranged from 23 to 76 years, with a mean age of 61 years. The most common presenting symptom was headache. The dAVFs were commonly located at the transverse-sigmoid sinus (43%) and superior sagittal sinus (24%). The most common meningioma locations were the tentorium and parietal convexity. In 76% of the cases, the meningioma occluded the sinus. The most common dAVF treatment was transcatheter arterial embolization, followed by tumor resection (52%). Among the 20 cases with available outcome data, 90% reported favorable outcomes. Conclusion: This report highlights some of the features of coexisting dAVF and meningioma and presents a systematic review of other reports on this phenomenon. Through an in-depth analysis of the literature, we highlight some of the leading theories regarding the causes of concomitant dAVF and meningiomas. Our report supports one of the leading theories that impaired venous return, whether through the occlusion of sinuses or sinus manipulation during surgery, plays a role in the development of dAVF. Further understanding may help guide future clinical decision-making and surgical planning.

Differences in Hearing, Balance, and Quality-of-Life Outcomes in Petroclival Versus Nonpetroclival Posterior Fossa Meningiomas.

OBJECTIVE: To compare hearing, tinnitus, balance, and quality-of-life treatment outcomes of petroclival meningioma and nonpetroclival cerebellopontine angle meningioma cohorts. STUDY DESIGN: A retrospective cohort study of 60 patients with posterior fossa meningiomas, 25 petroclival and 35 nonpetroclival, who were treated at a single tertiary care center between 2000 and 2020. INTERVENTION: A survey battery that included the Hearing Effort of the Tumor Ear, Speech and Spatial Qualities of Hearing, Tinnitus Functional Index, Dizziness Handicap Inventory (DHI), and Short Form Health Survey. Petroclival and nonpetroclival cohorts were matched for tumor size and demographic features. MAIN OUTCOME MEASURES: Differences between groups in hearing, balance outcomes, and quality of life and patient factors that influence posttreatment quality of life. RESULTS: Petroclival meningioma patients reported poorer audiovestibular outcomes with a higher rate of deafness in the tumor ear (36.0% versus 8.6%, p = 0.032) and lower functional hearing by the Hearing Effort of the Tumor Ear, Speech and Spatial Qualities of Hearing (76.6 [6.1] versus 82.0 [4.4], p < 0.001). Current dizziness rate was higher (48.0% versus 23.5%, p = 0.05), with more severe dizziness by DHI (18.4 [4.8] versus 5.7 [2.2], p < 0.001). Both cohorts had similar high quality of life and low tinnitus severity indices. Quality-of-life Short Form Health Survey predictors were tumor size ( p = 0.012) and DHI ( p = 0.005) in multivariable analysis. CONCLUSIONS: Hearing and dizziness treatment outcomes of petroclival meningioma are poorer relative to other posterior fossa meningiomas. Despite audiovestibular outcome distinctions, the overall posttreatment quality of life was high for both petroclival and nonpetroclival meningioma.

Treated large posterior fossa vestibular schwannoma and meningioma: Hearing outcome and willingness-to-accept brain implant for unilateral deafness.

Background/Objective: To compare functional hearing and tinnitus outcomes in treated large (~ 3 cm) vestibular schwannoma (VS) and posterior fossa meningioma cohorts, and construct willingness-to-accept profiles for an experimental brain implant to treat unilateral hearing loss. Methods: A two-way MANOVA model with two independent variables (tumor type; time from treatment) and three dependent variables (hearing effort of tumor ear; abbreviated Speech, Spatial, and Qualities of Hearing scale (SSQ12); Tinnitus Functional Index (TFI)) was used to analyze data from VS (N = 32) and meningioma (N = 50) patients who were treated at a tertiary care center between 2010 and 2020. A query to probe acceptance of experimental treatment for hearing loss relative to expected benefit was used to construct willingness-to-accept profiles. Results: Tumor type was statistically significant on the combined dependent variables analysis (F[3, 76] = 19.172, p < .0005, Wilks' Λ = 0.569). Meningioma showed better outcome for hearing effort (F[1, 76] = 14.632, p < .0005) and SSQ12 (F[1, 76] = 16.164, p < .0005), but not for TFI (F[1, 76] = 1.247, p = .268) on univariate two-way ANOVA analyses. Superior hearing effort and SSQ12 indices in the short-term (< 2 years) persisted in the long-term (> 2 years) (p ≤ .017). At the 60% speech understanding level, 77% of respondents would accept an experimental brain implant. Conclusion: Hearing outcome is better for posterior fossa meningioma compared to VS. Most patients with hearing loss in the tumor ear would consider a brain implant if the benefit level would be comparable to a cochlear implant. Level of Evidence: 2.

Clinical Vignette of Bacterial Meningitis Complicated by a Cerebrovascular Event.

Community-acquired bacterial meningitis is a life-threatening illness that is commonly caused by Streptococcus pneumoniae. Often, it can be associated with high mortality and morbidity rates especially due to the frequency of added neurological complications like hydrocephalus, seizures, stroke, and cerebrovascular events. Here we present an unusual case of cerebrovascular infarction complicating the outcome of a patient who suffered from community-acquired bacterial meningitis.

Clinical Manifestations of Severe Untreated Hypothyroidism.

Thyroid hormones play a crucial role in maintaining homeostasis throughout the human body. Hypothyroidism is a result of insufficient circulating levels of thyroid hormone. In a hypothyroid state, not only do all metabolic processes tend to slow down but so do neurological processes. Here, we present an interesting case of a woman with a history of severe hypothyroidism that was untreated for the past 10 years.

Delayed Presentation of Posterior Reversible Encephalopathy Syndrome in the Setting of Serotonin-Norepinephrine Reuptake Inhibitors.

Posterior reversible encephalopathy syndrome (PRES) is a complex process that has been implicated in the setting of many chronic diseases (i.e., hypertension, chronic kidney disease, autoimmune diseases, infections, transplant treatments, etc.). The exact pathogenesis of PRES is still unclear; however, it has been suggested to involve endothelial injury leading to immune system activation and cytokine release. This case report examines an atypical presentation of PRES caused by serotonin-norepinephrine reuptake inhibitors (SNRIs).

Clinical Validation of the Champagne Algorithm for Evoked Response Source Localization in Magnetoencephalography.

Magnetoencephalography (MEG) is a robust method for non-invasive functional brain mapping of sensory cortices due to its exceptional spatial and temporal resolution. The clinical standard for MEG source localization of functional landmarks from sensory evoked responses is the equivalent current dipole (ECD) localization algorithm, known to be sensitive to initialization, noise, and manual choice of the number of dipoles. Recently many automated and robust algorithms have been developed, including the Champagne algorithm, an empirical Bayesian algorithm, with powerful abilities for MEG source reconstruction and time course estimation (Wipf et al. 2010; Owen et al. 2012). Here, we evaluate automated Champagne performance in a clinical population of tumor patients where there was minimal failure in localizing sensory evoked responses using the clinical standard, ECD localization algorithm. MEG data of auditory evoked potentials and somatosensory evoked potentials from 21 brain tumor patients were analyzed using Champagne, and these results were compared with equivalent current dipole (ECD) fit. Across both somatosensory and auditory evoked field localization, we found there was a strong agreement between Champagne and ECD localizations in all cases. Given resolution of 8mm voxel size, peak source localizations from Champagne were below 10mm of ECD peak source localization. The Champagne algorithm provides a robust and automated alternative to manual ECD fits for clinical localization of sensory evoked potentials and can contribute to improved clinical MEG data processing workflows.

Magnetoencephalography Imaging Reveals Abnormal Information Flow in Temporal Lobe Epilepsy.

Background/Introduction: Widespread network disruption has been hypothesized to be an important predictor of outcomes in patients with refractory temporal lobe epilepsy (TLE). Most studies examining functional network disruption in epilepsy have largely focused on the symmetric bidirectional metrics of the strength of network connections. However, a more complete description of network dysfunction impacts in epilepsy requires an investigation of the potentially more sensitive directional metrics of information flow. Methods: This study describes a whole-brain magnetoencephalography-imaging approach to examine resting-state directional information flow networks, quantified by phase-transfer entropy (PTE), in patients with TLE compared with healthy controls (HCs). Associations between PTE and clinical characteristics of epilepsy syndrome are also investigated. Results: Deficits of information flow were specific to alpha-band frequencies. In alpha band, while HCs exhibit a clear posterior-to-anterior directionality of information flow, in patients with TLE, this pattern of regional information outflow and inflow was significantly altered in the frontal and occipital regions. The changes in information flow within the alpha band in selected brain regions were correlated with interictal spike frequency and duration of epilepsy. Conclusions: Impaired information flow is an important dimension of network dysfunction associated with the pathophysiological mechanisms of TLE.

Interhemispheric Auditory Cortical Synchronization in Asymmetric Hearing Loss.

OBJECTIVES: Auditory cortical activation of the two hemispheres to monaurally presented tonal stimuli has been shown to be asynchronous in normal hearing (NH) but synchronous in the extreme case of adult-onset asymmetric hearing loss (AHL) with single-sided deafness. We addressed the wide knowledge gap between these two anchoring states of interhemispheric temporal organization. The objectives of this study were as follows: (1) to map the trajectory of interhemispheric temporal reorganization from asynchrony to synchrony using magnitude of interaural threshold difference as the independent variable in a cross-sectional study and (2) to evaluate reversibility of interhemispheric synchrony in association with hearing in noise performance by amplifying the aidable poorer ear in a repeated measures, longitudinal study. DESIGN: The cross-sectional and longitudinal cohorts were comprised of 49 subjects (AHL; N = 21; 11 male, 10 female; mean age = 48 years) and NH (N = 28; 16 male, 12 female; mean age = 45 years). The maximum interaural threshold difference of the two cohorts spanned from 0 to 65 dB. Magnetoencephalography analyses focused on latency of the M100 peak response from auditory cortex in both hemispheres between 50 msec and 150 msec following monaural tonal stimulation at the frequency (0.5, 1, 2, 3, or 4 kHz) corresponding to the maximum and minimum interaural threshold difference for better and poorer ears separately. The longitudinal AHL cohort was drawn from three subjects in the cross-sectional AHL cohort (all male; ages 49 to 60 years; varied AHL etiologies; no amplification for at least 2 years). All longitudinal study subjects were treated by monaural amplification of the poorer ear and underwent repeated measures examination of the M100 response latency and quick speech in noise hearing in noise performance at baseline, and postamplification months 3, 6, and 12. RESULTS: The M100 response peak latency values in the ipsilateral hemisphere lagged those in the contralateral hemisphere for all stimulation conditions. The mean (SD) interhemispheric latency difference values (ipsilateral less contralateral) to better ear stimulation for three categories of maximum interaural threshold difference were as follows: NH (≤ 10 dB)-8.6 (3.0) msec; AHL (15 to 40 dB)-3.0 (1.2) msec; AHL (≥ 45 dB)-1.4 (1.3) msec. In turn, the magnitude of difference values were used to define interhemispheric temporal organization states of asynchrony, mixed asynchrony and synchrony, and synchrony, respectively. Amplification of the poorer ear in longitudinal subjects drove interhemispheric organization change from baseline synchrony to postamplification asynchrony and hearing in noise performance improvement in those with baseline impairment over a 12-month period. CONCLUSIONS: Interhemispheric temporal organization in AHL was anchored between states of asynchrony in NH and synchrony in single-sided deafness. For asymmetry magnitudes between 15 and 40 dB, the intermediate mixed state of asynchrony and synchrony was continuous and reversible. Amplification of the poorer ear in AHL improved hearing in noise performance and restored normal temporal organization of auditory cortices in the two hemispheres. The return to normal interhemispheric asynchrony from baseline synchrony and improvement in hearing following monoaural amplification of the poorer ear evolved progressively over a 12-month period.

Semi-Automated and Direct Localization and Labeling of EEG Electrodes Using MR Structural Images for Simultaneous fMRI-EEG.

Electroencephalography (EEG) source reconstruction estimates spatial information from the brain's electrical activity acquired using EEG. This method requires accurate identification of the EEG electrodes in a three-dimensional (3D) space and involves spatial localization and labeling of EEG electrodes. Here, we propose a new approach to tackle this two-step problem based on the simultaneous acquisition of EEG and magnetic resonance imaging (MRI). For the step of spatial localization of electrodes, we extract the electrode coordinates from the curvature of the protrusions formed in the high-resolution T1-weighted brain scans. In the next step, we assign labels to each electrode based on the distinguishing feature of the electrode's distance profile in relation to other electrodes. We then compare the subject's electrode data with template-based models of prelabeled distance profiles of correctly labeled subjects. Based on this approach, we could localize EEG electrodes in 26 head models with over 90% accuracy in the 3D localization of electrodes. Next, we performed electrode labeling of the subjects' data with progressive improvements in accuracy: with ∼58% accuracy based on a single EEG-template, with ∼71% accuracy based on 3 EEG-templates, and with ∼76% accuracy using 5 EEG-templates. The proposed semi-automated method provides a simple alternative for the rapid localization and labeling of electrodes without the requirement of any additional equipment than what is already used in an EEG-fMRI setup.