Differentiation of astrocytoma between grades II and III using a combination of methionine positron emission tomography and magnetic resonance spectroscopy.

Objective: This study aimed to establish a method for differentiating between grades II and III astrocytomas using preoperative imaging. Methods: We retrospectively analyzed astrocytic tumors, including 18 grade II astrocytomas (isocitrate dehydrogenase (IDH)-mutant: IDH-wildtype = 8:10) and 56 grade III anaplastic astrocytomas (37:19). We recorded the maximum methionine (MET) uptake ratios (tumor-to-normal: T/N) on positron emission tomography (PET) and three MRS peak ratios: choline (Cho)/creatine (Cr), N-acetyl aspartate (NAA)/Cr, and Cho/NAA, between June 2015 and June 2020. We then evaluated the cut-off values to differentiate between grades II and III. We compared the grading results between contrast enhancement effects on MR and combinational diagnostic methods (CDM) on a scatter chart using the cutoff values of the T/N ratio and MRS parameters. Results: The IDH-mutant group showed significant differences in the Cho/NAA ratio between grades II and III using univariate analysis; however, multiple regression analysis results negated this. The IDH-wildtype group showed no significant differences between the groups. Contrast enhancement effects also showed no significant differences in IDH status. Accordingly, regardless of the IDH status, no statistically independent factors differentiated between grades II and III. However, CDMs showed higher sensitivity and negative predictive value in distinguishing them than MRI contrast examinations for both IDH statuses. We demonstrated a significantly higher diagnostic rate of grade III than of grade II with CDM, which was more striking in the IDH-mutant group than in the wild-type group. Conclusions: CDM could be valuable in differentiating between grade II and III astrocytic tumors.

A case of reinfection with a different variant of SARS-CoV-2: case report.

Background: Coronavirus disease 2019 (COVID-19) was previously thought to have a low reinfection rate, but there are concerns that the reinfection rate will increase with the emergence and spread of mutant variants. This report describes the case of a 36-year-old, non-immunosuppressed man who was infected twice by two different variants of COVID-19 within a relatively short period. Case presentation: A 36-year-old Japanese man with no comorbidities was infected with the E484K variant (R.1 lineage) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Symptoms were mild and improved with symptomatic treatment alone. About four months later he presented to another outpatient department with high fever and headache. We diagnosed him as infected with the Alpha variant (B.1.1.7) of SARS-CoV-2 based on SARS-CoV-2 real-time reverse transcription polymerase chain reaction testing (RT-PCR). The patient was hospitalized with high fever. The patient received treatment in the form of anti-inflammatory therapy with corticosteroid and antibacterial chemotherapy. The patient improved without developing severe disease. Conclusion: Concerns have been raised that the reinfection rate of COVID-19 will increase with the emergence of mutant variants. Particularly in mild cases, adequate amounts of neutralizing antibodies may not be produced, and reinfection may thus occur. Continued attention to sufficient infection control is thus essential.

Cerebral Glucose Metabolism in Patients with Chronic Disorders of Consciousness.

OBJECTIVE: To measure regional cerebral metabolic rate of glucose (CMRGlu) in patients with chronic disorders of consciousness (DOCs) using 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). METHODS: This retrospective cohort study examined 50 patients (mean age: 40.9 ± 20.1 years) with traumatic brain injury (TBI)-induced chronic DOCs [minimally conscious state (MCS)+, n = 20; MCS-, n = 15 and vegetative state (VS), n = 15]. We measured FDG-PET-based CMRGlu values in 12 regions of both brain hemispheres and compared those among MCS+, MCS - and VS patients. RESULTS: In both hemispheres, the regional CMRGlu reduced with consciousness deterioration in 11 of 12 regions (91.7%). In seven right hemisphere regions, CMRGlu values were markedly higher in MCS+ patients than in MCS- patients. Furthermore, CMRGlu was suggestively higher in the left occipital region in MCS- patients than in VS patients. CONCLUSION: Functional preservation in the left occipital region in patients with chronic DOCs might reflect an awareness of external environments, whereas extensive functional preservation in the right cerebral hemisphere might reflect communication motivation.

Prediction of nuclide accumulation spread based on the volume of enhancing MRI lesion in glioblastoma patients.

BACKGROUND: 11C-methionine-PET (MET) and Thallium-201 chloride-SPECT (TL) are useful for predictive proliferation ability and tumor invasion range identification in glioma patients, however they are not always possible in any hospital or country. Our study aimed to assess whether the range of MET and Tl accumulation could be predicted from the contrast-enhanced lesions in Gadolinium (Gd)-T1 weighted MR image (Gd-MRI) in glioblastoma multiforme (GBM) patients. METHODS: In 25 cases, the MET-Area, TL-Area, O-Area where MET and TL overlap, and all accumulation area (AA-Area) were measured in the same axial cross section as the Gd enhanced maximum area (Gd-Area). This tracing operation was repeated with all axial fusion slices, and each volume was also measured (Gd-V, MET-V, TL-V, O-V, AA-V). RESULTS: The maximum accumulation distance of MET and TL beyond the Gd-Area was limited to within 30 mm, 35 mm, respectively. Significant positive correlations were showed in all combinations with Gd-Area: MET-Area (r=0.851, p<0.0001), TL-Area (r=0.955, p<0.0001), O-Area (r=0.935, p<0.0001) and AA-Area (r=0.893, p<0.0001), respectively. All combinations with Gd-V showed significant positive correlation: MET-V (r=0.867, p<0.0001), TL-V (r=0.952, p<0.0001), O-V (r=0.935, p<0.0001) and AA-V (r=0.897, p<0.0001), respectively. CONCLUSIONS: Approximate tumor volume Gd-V can be calculated using the formula A * B * C / 2, where A, B, and C represent the dimensions of Gd-enhanced lesion in 3 axes perpendicular to each other. The nuclide accumulation predictive table created using the obtained linear approximation functions can be used to predict the average tumor invasion range from the Gd-V without preoperative nuclear examinations.

Acupuncture for Chronic Constipation in Patients with Chronic Disorders of Consciousness After Severe Traumatic Brain Injury.

Objective: Patients with chronic disorders of consciousness (DOC) frequently develop chronic constipation. This study evaluated the effects of acupuncture on bowel movements (BMs) in patients with DOC and chronic constipation resulting from severe traumatic brain injury (TBI). Materials and Methods: This retrospective observational study took place in the Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, of Kizawa Memorial Hospital, in Minokamo, Gifu, Japan. The study included 25 patients with chronic DOC resulting from TBI, who received acupuncture treatment. The patients received 2 sessions of acupuncture treatment per week. Information on frequency of defecation, number of days during which patients had BMs, and use of laxatives prior to the acupuncture treatment and after 10 weeks of treatment was extracted from medical records and compared. Results: The median (first quartile and third quartile) frequency of defecation increased significantly after 10 weeks of acupuncture from 3.0 (2.5, 3.5) to 3.5 (2.5, 4.5) times/week (P = 0.038). The number of days on which defecation occurred also increased significantly, from 2.0 (2.0, 2.5) to 2.5 (2.0, 3.5) days/week (P < 0.001). The use of bisacodyl suppositories decreased significantly from 1.5 (1.5, 2.0) to 1.5 (0.5, 2.0) times/week (P = 0.041). The mean ± standard error use of sodium picosulfate for 10 patients decreased significantly, from 20.4 ± 3.5 to 14.3 ± 3.3 drops/week (P = 0.004). Conclusions: Acupuncture treatment could be beneficial for chronic constipation in patients with DOC caused by TBI. A large prospective cohort study with a control group is warranted.

Usefulness of positron emission tomography for differentiating gliomas according to the 2016 World Health Organization classification of tumors of the central nervous system.

OBJECTIVE: Positron emission tomography (PET) is important in the noninvasive diagnostic imaging of gliomas. There are many PET studies on glioma diagnosis based on the 2007 WHO classification; however, there are no studies on glioma diagnosis using the new classification (the 2016 WHO classification). Here, the authors investigated the relationship between uptake of 11C-methionine (MET), 11C-choline (CHO), and 18F-fluorodeoxyglucose (FDG) on PET imaging and isocitrate dehydrogenase (IDH) status (wild-type [IDH-wt] or mutant [IDH-mut]) in astrocytic and oligodendroglial tumors according to the 2016 WHO classification. METHODS: In total, 105 patients with newly diagnosed cerebral gliomas (6 diffuse astrocytomas [DAs] with IDH-wt, 6 DAs with IDH-mut, 7 anaplastic astrocytomas [AAs] with IDH-wt, 24 AAs with IDH-mut, 26 glioblastomas [GBMs] with IDH-wt, 5 GBMs with IDH-mut, 19 oligodendrogliomas [ODs], and 12 anaplastic oligodendrogliomas [AOs]) were included. All OD and AO patients had both IDH-mut and 1p/19q codeletion. The maximum standardized uptake value (SUV) of the tumor/mean SUV of normal cortex (T/N) ratios for MET, CHO, and FDG were calculated, and the mean T/N ratios of DA, AA, and GBM with IDH-wt and IDH-mut were compared. The diagnostic accuracy for distinguishing gliomas with IDH-wt from those with IDH-mut was assessed using receiver operating characteristic (ROC) curve analysis of the mean T/N ratios for the 3 PET tracers. RESULTS: There were significant differences in the mean T/N ratios for all 3 PET tracers between the IDH-wt and IDH-mut groups of all histological classifications (p < 0.001). Among the 27 gliomas with mean T/N ratios higher than the cutoff values for all 3 PET tracers, 23 (85.2%) were classified into the IDH-wt group using ROC analysis. In DA, there were no significant differences in the T/N ratios for MET, CHO, and FDG between the IDH-wt and IDH-mut groups. In AA, the mean T/N ratios of all 3 PET tracers in the IDH-wt group were significantly higher than those in the IDH-mut group (p < 0.01). In GBM, the mean T/N ratio in the IDH-wt group was significantly higher than that in the IDH-mut group for both MET (p = 0.034) and CHO (p = 0.01). However, there was no significant difference in the ratio for FDG. CONCLUSIONS: PET imaging using MET, CHO, and FDG was suggested to be informative for preoperatively differentiating gliomas according to the 2016 WHO classification, particularly for differentiating IDH-wt and IDH-mut tumors.

Dissociation Between 11C-Methionine-Positron Emission Tomography and Gadolinium-Enhanced Magnetic Resonance Imaging in Longitudinal Features of Glioblastoma After Postoperative Radiotherapy.

The aims of the present study were to compare the longitudinal changes of glioblastoma multiforme after radiotherapy (RT) between 11C-methionine positron emission tomography (MET-PET) and gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) and to clarify whether these changes were predictive of survival. We included 30 patients, who had undergone MET-PET and Gd-MRI before and every 3 months after RT. The lesion/normal brain uptake (L/N) ratio and contrast-enhancing lesion volume were examined. The L/N ratio was decreased until 9 months after RT with significance until 3 months. The contrast-enhancing lesion volume was decreased until 3 months and thereafter increased until 9 months with significance. The variation rates of the L/N ratio between pre-RT and 3 months differentiated survival of >23 months from ≤23 months. A dissociation could exist in the longitudinal changes of GBM after RT between MET-PET and Gd-MRI. The variation rate of the L/N ratio could be related to survival.

Surgical Treatment of Complex Cerebral Aneurysms Using Interposition Short Vein Graft.

BACKGROUND AND AIMS: Cerebral revascularization strategies may become necessary in select patients who present with challenging cerebral aneurysms. In this study, we present the techniques of a moderate-flow extra-intracranial bypass using a short interposition vein graft and concurrent aneurysm management. METHODS: The short interposition vein graft was used for the reconstruction of complex cerebral aneurysms in nine patients. In eight of them, the superficial temporal artery (STA) main trunk was used as a donor site for the anastomosis of a short interposition vein graft, and an extracranial vertebral artery (VA) was used in one case. The vein grafts were implanted into the M2 of the middle cerebral artery (MCA) for the adjunctive treatment of internal carotid artery (ICA) aneurysms in three patients, into the A3 of the anterior cerebral artery (ACA) in one patient, into the P2 of the posterior cerebral artery (PCA) for the adjunctive treatment of complex PCA aneurysms in three patients, into the P3 of the PCA for the adjunctive treatment of a basilar artery (BA) trunk giant aneurysm in 1 patient, and into the postero-inferior cerebellar artery (PICA) for the adjunctive treatment of the VA dissecting aneurysm in one patient. RESULTS: All of the bypasses were patent. Intraoperative flow measurements confirmed a moderate flow-carrying capacity of the short interposition short vein graft (30-70 ml; mean: 43 ml/min). CONCLUSION: The STA main trunk to proximal MCA/PCA bypass and the extracranial VA to PICA bypass using short interposition vein grafts can provide sufficient blood flow and may be a reasonable alternative to the conventional EC-IC bypass/high-flow bypass.

Surgical Approach to Ponto-mesencephalic Cavernoma.

BACKGROUND AND AIMS: The surgical treatment of intrinsic brainstem lesions remains a major challenge. In this article we present the results of using an infratentorial-supracerebellar (ITSC) approach for the resection of intrinsic ponto-mesencephalic lesions. MATERIALS AND METHODS: The authors reviewed the cases of 16 patients. In seven of them, a paramedian ITSC transcollicular approach was used to resect intrinsic mid-brain lesions, and in the other nine patients, an intermediate or lateral ITSC infra-trochlear approach was used for ponto-mesencephalic lesions. RESULTS: All 16 lesions were completely removed. There was no recurrence of bleeding during the follow-up period, and no mortality. In seven patients with mid-brain lesions, the preoperative ocular symptoms improved in three of them, and the neurological deficits - other than ocular symptoms improved - in five of them. The preoperative modified Rankin Scale score of 1.8 improved to 1.3 postoperatively. In nine patients with a ponto-mesencephalic lesion, the preoperative ocular symptoms improved in four of nine patients, and the neurological deficits other than ocular symptoms improved in five of them, while one patient exhibited venous infarction in a cerebellar hemisphere that caused neurological deterioration. The preoperative modified Rankin Scale score of 3.75 improved to 2.5 postoperatively in these patients. CONCLUSION: The ITSC transcollicular or infra-trochlear approach provide a wide operative entry zone and minimize the functional damage to the surrounding structures for access to ponto-mesencephalic lesions.