Computed tomography texture analysis to discriminate fungal and non-fungal infected fluid collections.

Purpose: Texture analysis of computed tomography (CT) can aid in characterization of fluid collections providing biomarkers. The present study tested whether texture analysis can discriminate between fungal or non-fungal infection in patients undergoing CT-guided percutaneous drainage treatment. Approach: Overall, 214 patients [(n=76 females, 35.5%); mean age 62±14 years and range 20 to 94 years] with 255 fluid collections were included in the analysis. All patients underwent CT-guided drainage treatment and were evaluated with microbiological analysis. CT texture analysis was performed with the MaZda package. Results: Only three of the investigated CT texture features were statistically significant different between the groups, namely kurtosis (p=0.04), S(3,3)InvDfMom (p=0.02), and S(5,-5)DifEntrp (p=0.003). These texture features were further investigated by the receiver operating characteristic curve. S(3,3)InvDfMom achieved the highest accuracy with an area under the curve of 0.62, resulting in a sensitivity of 0.66 and a specificity of 0.57. Conclusion: Some CT texture features were different between fungal and non-fungal infected fluid collections. The diagnostic overlap is large, which could reduce the clinical benefit. Further studies are needed to identify the possible diagnostic benefit of texture analysis in these patients.

Venous thromboembolism and intracranial hemorrhage in patients undergoing glioblastoma surgery.

In the perioperative management of patients with glioblastoma (GBM), physicians face the question of whether and when to administer prophylactic or therapeutic anticoagulation (AC). In this study, we investigate the effects of the timing of postoperative heparinization on thromboembolic events (TE) and postoperative hemorrhage (bleeding, PH) as well as the interactions between the two in the context of an underlying intracerebral malignancy. For this retrospective data analysis, 222 patients who underwent surgery for grade IV glioblastoma, IDH-wildtype (2016 CNS WHO) between 01/01/2014 and 31/12/2019 were included. We followed up for 12 months. We assessed various biographical and clinical data for risk factors and focused on the connection between timepoint of AC and adverse events. Subgroup analyses were performed for pulmonary artery embolism (PE), deep vein thrombosis, and postoperative intracranial hemorrhage (PH) that either required surgical intervention or was controlled radiologically only. Statistical analysis was performed using Mann-Whitney U-Test, Chi-square test, Fisher's exact test and univariate binomial logistic regression. p values below 0.05 were considered statistically significant. There was no significant association between prophylactic AC within 24 h and more frequent major bleeding (p = 0.350). AC in patients who developed major bleeding was regularly postponed by the physician/surgeon upon detection of the re-bleeding; therefore, patients with PH were anticoagulated significantly later (p = 0.034). The timing of anticoagulant administration did not differ significantly between patients who experienced a thromboembolic event and those who did not (p = 0.634). There was considerable overlap between the groups. Three of the six patients (50%) with PE had to be lysed or therapeutically anticoagulated and thereafter developed major bleeding (p < 0.001). Patients who experienced TE were more likely to die during hospitalization than those with major bleeding (p = 0.022 vs. p = 1.00). Prophylactic AC within 24 h after surgery does not result in more frequent bleeding. Our data suggests that postoperative intracranial hemorrhage is not caused by prophylactic AC but rather is a surgical complication or the result of antithrombotic therapy. However, thromboembolic events worsen patient outcomes far more than postoperative bleeding. The fact that bleeding may occur as a complication of life-saving lysis therapy in the setting of a thromboembolic event should be included in this cost-benefit consideration.

A Radiomics-Based Machine Learning Perspective on the Parotid Gland as a Potential Surrogate Marker for HPV in Oropharyngeal Cancer.

BACKGROUND: In treatment of oropharyngeal squamous cell carcinoma (OPSCC), human papillomavirus status (HPV) plays a crucial role. The HPV-positive subtype tends to affect younger patients and is associated with a more favorable prognosis. HPV-associated lesions have been described in the parotid gland, which is included in routine imaging for OPSCC. This work aims to explore the ability of an ML system to classify HPV status based on imaging of the parotid gland, which is routinely depicted on staging imaging. METHODS: Using a radiomics approach, we investigate the ability of five contemporary machine learning (ML) models to distinguish between HPV-positive and HPV-negative OPSCC based on non-contrast computed tomography (CT) data of tumor volume (TM), locoregional lymph node metastasis (LNM), and the parotid gland (Parotid). After exclusion of cases affected by streak artefacts, 53 patients (training set: 39; evaluation set: 14) were retrospectively evaluated. Classification performances were tested for significance against random optimistic results. RESULTS: The best results are AUC 0.71 by XGBoost (XGB) for TM, AUC 0.82 by multi-layer perceptron (MLP) for LNM, AUC 0.76 by random forest (RF) for Parotid, and AUC 0.86 by XGB for a combination of all three regions of interest (ROIs). CONCLUSIONS: The results suggest involvement of the parotid gland in HPV infections of the oropharyngeal region. While the role of HPV in parotid lesions is under active discussion, the migration of the virus from the oral cavity to the parotid gland seems plausible. The imaging of the parotid gland offers the benefit of fewer streak artifacts due to teeth and dental implants and the potential to screen for HPV in cases of an absent or unlocatable tumor. Future investigation can be directed to validation of the results in independent datasets and to the potential of improvement of current classification models by addition of information based on the parotid gland.

Preserved White Matter Integrity and Recovery After Brain Tumor Surgery: A Prospective Pilot Study on the Frontal Aslant Tract.

Introduction: Damage to white matter tracts can cause severe neurological deficits, which are often hardly predictable before brain tumor surgery. To explore the possibility of assessing white matter integrity and its preservation, we chose the frontal aslant tract (FAT) due to its involvement in multiple neurological functions such as speech and movement initiation. Methods: Right-handed patients with left hemispheric intracerebral tumors underwent FAT tractography within 7 days before and 3 days after surgery. Neurological performance score and aphasia score were assessed within 7 days before and after surgery, as well as at follow-up 3 months postoperatively. Results: Fifteen patients were prospectively analyzed. After multivariate analysis and receiver operating characteristic analysis, we found that preoperative fractional anisotropy (FA) of the left FAT indicated the preoperative aphasia score (cutoff 0.40, p = 0.015). Aphasia scores 3 months postoperatively were predicted by both postoperative FA of the left FAT (cutoff 0.35, p = 0.005) and postoperatively preserved FA of the left FAT (cutoff 95.8%, p = 0.017). Postoperatively preserved right FAT FA inversely predicted postoperative aphasia score (cutoff 95.1%, p = 0.016). Discussion: Assessment of white matter integrity preservation is possible and correlates with outcome after brain tumor surgery. It may be useful for patient counseling and assessment of rehabilitation potential, as well as to investigate relevant brain networks in the future. Clinical Trial Registration: The trial was prospectively registered at ClinicalTrials.gov (NCT04302857).

Tissue Outcome Prediction in Patients with Proximal Vessel Occlusion and Mechanical Thrombectomy Using Logistic Models.

Perfusion CT is established to aid selection of patients with proximal intracranial vessel occlusion for thrombectomy in the extended time window. Selection is mostly based on simple thresholding of perfusion parameter maps, which, however, does not exploit the full information hidden in the high-dimensional perfusion data. We implemented a multiparametric mass-univariate logistic model to predict tissue outcome based on data from 405 stroke patients with acute proximal vessel occlusion in the anterior circulation who underwent mechanical thrombectomy. Input parameters were acute multimodal CT imaging (perfusion, angiography, and non-contrast) as well as basic demographic and clinical parameters. The model was trained with the knowledge of recanalization status and final infarct localization. We found that perfusion parameter maps (CBF, CBV, and Tmax) were sufficient for tissue outcome prediction. Compared with single-parameter thresholding-based models, our logistic model had comparable volumetric accuracy, but was superior with respect to topographical accuracy (AUC of receiver operating characteristic). We also found higher spatial accuracy (Dice index) in an independent internal but not external cross-validation. Our results highlight the value of perfusion data compared with non-contrast CT, CT angiography and clinical information for tissue outcome-prediction. Multiparametric logistic prediction has high potential to outperform the single-parameter thresholding-based approach. In the future, the combination of tissue and functional outcome prediction might provide an individual biomarker for the benefit from mechanical thrombectomy in acute stroke care.

Preoperative language tract integrity is a limiting factor in recovery from aphasia after glioma surgery.

Aphasia can occur in a broad range of pathological conditions that affect cortical or subcortical structures. Here we test the hypothesis that white matter integrity of language pathways assessed by preoperative diffusion tensor imaging (DTI) is associated with language performance and its recovery after glioma resection. 27 patients with preoperative DTI were included. Segmentation of the arcuate fascicle (AF), the inferior fronto-occipital fascicle (IFOF), the inferior longitudinal fascicle (ILF), the superior longitudinal fascicle (SLF), and the uncinate fascicle (UF) was performed with a fully-connected neural network (FCNN, TractSeg). Median fractional anisotropy (FA) was extracted from the resulting volumes as surrogate marker for white matter integrity and tested for correlation with clinical parameters. After correction for demographic data and multiple testing, preoperative white matter integrity of the IFOF, the ILF, and the UF in the left hemisphere were independently and significantly associated with aphasia three months after surgery. Comparison between patients with and without aphasia three months after surgery revealed significant differences in preoperative white matter integrity of the left AF (p = 0.021), left IFOF (p = 0.015), left ILF (p = 0.003), left SLF (p = 0.001, p = 0.021, p = 0.043 for respective sub-bundles 1-3), left UF (p = 0.041) and the right AF (p = 0.027). Preoperative assessment of white matter integrity of the language network by time-efficient MRI protocols and FCNN-driven segmentation may assist in the evaluation of postoperative rehabilitation potential in glioma patients.

White Matter Integrity of the Corticospinal Tract for Estimation of Individual Patient Risk for Postoperative Neurological Deterioration after Glioma Surgery.

BACKGROUND: Tractography has become a standard tool for planning neurosurgical operations and has been proven to be useful for risk stratification. In various conditions, tractography-derived white matter integrity has been shown to be associated with neurological outcome. Postoperative performance has been shown to be a prognostic marker in glioma. We aimed to assess the relation of preoperative corticospinal tract (CST) integrity with postoperative neurological deterioration in patients with malignant glioma. METHODS: We retrospectively analyzed a cohort of 24 right-handed patients (41.7% female) for perioperative neurological performance score (NPS) and applied our anatomical tractography workflow to extract the median fractional anisotropy (FA) of the CST in preoperative magnetic resonance imaging (MRI). RESULTS: Median FA of the CST ipsilateral to the tumor correlated significantly with preoperative NPS (p = 0.025). After rank order correlation and multivariate linear regression, we found that the preoperative median FA of the right CST correlates with preoperative NPS, independently from epidemiological data (p = 0.019). In patients with lesions of the right hemisphere, median FA of the right CST was associated with a declining NPS in multivariate linear regression (p = 0.024). Receiver operating characteristic (ROC) analysis revealed an optimal FA cutoff at 0.3946 in this subgroup (area under the curve 0.83). Patients below that cutoff suffered from a decline in neurological performance significantly more often (p = 0.020). CONCLUSIONS: Assessment of preoperative white matter integrity may be a promising biomarker for risk estimation of patients undergoing craniotomy for resection of malignant glioma.

Usefulness and Limits of Tractography for Surgery in the Precentral Gyrus-A Case Report.

The resection of tumors within the primary motor cortex is a constant challenge. Although tractography may help in preoperative planning, it has limited application. While it can give valuable information on subcortical fibers, it is less accurate in the cortical layer of the brain. A 38-year-old patient presented with paresis of the right hand and focal epileptic seizures due to a tumor in the left precentral gyrus. Transcranial magnetic stimulation was not applicable due to seizures, so microsurgical resection was performed with preoperative tractography and intraoperative direct electrical stimulation. A histopathological assessment revealed a diagnosis of glioblastoma. Postoperative magnetic resonance imaging (MRI) showed complete resection. The paresis dissolved completely during follow-up. Surgery within the precentral gyrus is of high risk and requires multimodal functional planning. If interpreted with vigilance and consciousness of the underlying physical premises, tractography can provide helpful information within its limitations, which is especially subcortically. However, it may also help in the identification of functional cortex columns of the brain in the presence of a tumor.

The impact of neurological performance and volumetrics on overall survival in brain metastasis in colorectal cancer: a retrospective single-center case series.

BACKGROUND: Brain metastasis (BM) of colorectal cancer is a disease with a poor prognosis of only a few months survival. However, it is difficult to estimate the individual prognosis of each patient due to the lack of definitive prognosis parameters. The number of metastases and the Karnofsky performance score are known predictors for survival. We investigated whether or not the neurological performance score and the tumor volumetrics are equally suitable predictors for survival. DESIGN: All patients with histologically diagnosed BM linked to colorectal cancer between 2012 and March 2020 were reviewed. The Medical Research Council Neurological Performance Score was used to quantify neurological performance. Univariate analysis with Kaplan-Meier estimate and log-rank test was performed. Survival prediction and multivariate analysis were performed employing Cox proportional hazard regression. RESULTS: Twenty-five patients were included in our analysis with an overall survival of 4.9 months after surgery of the BM. Survival decreased in the univariate analysis with increasing postoperative neurological performance score, low Karnofsky performance score, absence of radiation therapy and radiation therapy modality. The neurological performance score is a reliable scoring parameter for estimating the prognostic course analogous to the Karnofsky performance score. Neither preoperative nor post resection residual tumor volume had any impact on overall survival in our small cohort. CONCLUSION: Our data suggest that the postoperative neurological performance is a valuable prognostic factor for colorectal cancer patients with BM. Tumor volumetrics show no correlation to survival. Further investigations with a larger number of cases are mandatory.

Comparison of the unruptured intracranial aneurysm treatment score recommendations with clinical treatment results - A series of 322 aneurysms.

Intracranial aneurysms occur with a prevalence of 3-5 %. Subarachnoid hemorrhage (SAH) due to aneurysm rupture is a rare but possibly fatal complication, so that occlusion of unruptured intracranial aneurysms (UIA) must be considered. The Unruptured Intracranial Aneurysm Treatment Score (UIATS) offers support for clinical decision making and has been shown to correlate with real life decisions in clinical practice. However, there is no data concerning the correlation of patient outcome and UIATS. Patients presenting to our outpatient clinic between January 1st, 2014 and December 31st, 2017 were retrospectively analyzed. We recorded the Extended Glasgow Outcome Scale (GOS-E) for longest possible follow-up, the choice of treatment, complications and UIATS recommendation. We included 221 patients with 322 UIA. 124 (38.5 %) UIA were observed and 198 (61.5 %) were occluded, of which 62 (31.3 %) underwent open surgery and 136 (68.7 %) were treated endovascularly. Spearman's rank correlation between our treatment choice and conclusive UIATS recommendation was 0.362 (p < 0.001). If UIATS was inconclusive, there were significantly more treatment-associated deteriorations (10/66 versus 7/132, p = 0.020). Otherwise, UIATS was not significantly associated with outcome. Therefore, treatment choice for UIA remains an individual decision. However, inconclusive UIATS must trigger vigilance and may be a negative prognostic marker for complications.

Associations between tumor and edema volumes with tumor infiltrating lymphocytes in brain metastasis - A preliminary study.

OBJECTIVE: Perifocal edema of brain tumors is associated with survival and neurological symptoms. The present study sought to elucidate the association between edema volume and tumor infiltrating lymphocytes (TIL) in brain metastasis. METHODS: 25 patients with brain metastasis were included into the retrospective study. TILs expressing CD45 was analyzed with leucocyte common antigen staining. MRI was used to semiautomatically estimate tumor and edema volumes. RESULTS: No correlation between tumor volume and edema volume was identified. A positive correlation was identified between tumor volume and TILs expressing CD45 of the stromal compartment (r = 0.46, p = 0.02). No correlations were identified between TILs expressing CD45 and edema volume. CONCLUSIONS: The present study identified correlations between TILs expressing CD45 and volume of BM. The tumor growth of BM might lead to a recruitment of TIL, which could be assessed by MRI.

The Prognostic Value of NANO Scale Assessment in IDH-Wild-Type Glioblastoma Patients.

BACKGROUND: IDH-wild-type glioblastoma (GBM) is the most frequent brain-derived malignancy. Despite intense research efforts, it is still associated with a very poor prognosis. Several parameters were identified as prognostic, including general physical performance. In neuro-oncology (NO), special emphasis is put on focal deficits and cognitive (dys-)function. The Neurologic Assessment in Neuro-Oncology (NANO) scale was proposed in order to standardize the assessment of neurological performance in NO. This study evaluated whether NANO scale assessment provides prognostic information in a standardized collective of GBM patients. METHODS: The records of all GBM patients treated between 2014 and 2019 at our facility were retrospectively screened. Inclusion criteria were age over 18 years, at least 3 months postoperative follow-up, and preoperative and postoperative cranial magnetic resonance imaging. The NANO scale was assessed pre- and postoperatively as well as at 3 months follow-up. Univariate and multivariate survival analyses were carried to investigate the prognostic value. RESULTS: One hundred and thirty-one patients were included. In univariate analysis, poor postoperative neurological performance (HR 1.13, p = 0.004), poor neurological performance at 3 months postsurgery (HR 1.37, p < 0.001), and neurological deterioration during follow-up (HR 1.38, p < 0.001), all assessed via the NANO scale, were associated with shorter survival. In multivariate analysis including other prognostic factors such as the extent of resection, adjuvant treatment regimen, or age, NANO scale assessment at 3 months postoperative follow-up was independently associated with survival prediction (HR 1.36, p < 0.001). The optimal NANO scale cutoff for patient stratification was 3.5 points. CONCLUSION: Neurological performance assessment employing the NANO scale might provide prognostic information in patients suffering from GBM.

Newly Diagnosed IDH-Wildtype Glioblastoma and Temporal Muscle Thickness: A Multicenter Analysis.

BACKGROUND: Reduced temporal muscle thickness (TMT) has been discussed as a prognostic marker in IDH-wildtype glioblastoma. This retrospective multicenter study was designed to investigate whether TMT is an independent prognostic marker in newly diagnosed glioblastoma. METHODS: TMT was retrospectively measured in 335 patients with newly diagnosed glioblastoma between 1 January 2014 and 31 December 2019 at the University Hospitals of Leipzig and Rostock. The cohort was dichotomized by TMT and tested for association with overall survival (OS) after 12 months by multivariate proportional hazard calculation. RESULTS: TMT of 7.0 mm or more was associated with increased OS (46.3 ± 3.9% versus 36.6 ± 3.9%, p > 0.001). However, the sub-groups showed significant epidemiological differences. In multivariate proportional hazard calculation, patient age (HR 1.01; p = 0.004), MGMT promoter status (HR 0.76; p = 0.002), EOR (HR 0.61), adjuvant irradiation (HR 0.24) and adjuvant chemotherapy (HR 0.40; all p < 0.001) were independent prognostic markers for OS. However, KPS (HR 1.00, p = 0.31), BMI (HR 0.98, p = 0.11) and TMT (HR 1.06; p = 0.07) were not significantly associated with OS. CONCLUSION: TMT has not appeared as a statistically independent prognostic marker in this cohort of patients with newly diagnosed IDH-wildtype glioblastoma.

Associations Between ADC Texture Analysis and Tumor Infiltrating Lymphocytes in Brain Metastasis - A Preliminary Study.

BACKGROUND/AIM: Tumor infiltrating lymphocytes (TILs) are an important prognostic factor in brain metastasis (BM). This study elucidated associations between apparent diffusion coefficient (ADC) texture analysis and TIL in BM. PATIENTS AND METHODS: Eleven patients with BM were retrospectively included into the study. TIL levels were analyzed with Leucocyte-common antigen staining. Clinical routine magnetic resonance imaging was used to calculate the texture features. RESULTS: ADC GrayLevelNonUniformity correlated with TILs of the stromal compartment (r=0.67, p=0.02). ADC HighGrayLevelRunEmphasis and ADC Coarseness showed associations with TILs of the tumoral compartment (r=-0.60, p=0.04 and r=0.68, p=0.02, respectively). CONCLUSION: ADC texture features correlated with TIL levels in BM. ADC texture features could aid in reflecting the complex tumor-micromilieu in a non-invasive manner.