The Role of Ketone Bodies in Treatment Individualization of Glioblastoma Patients.

Glioblastoma is the most common and aggressive primary brain tumor in adults. According to the 2021 WHO CNS, glioblastoma is assigned to the IDH wild-type classification, fulfilling the specific characteristic histopathology. We have conducted a prospective observational study to identify the glucose levels, ketone bodies, and the glucose-ketone index in three groups of subjects: two tumoral groups of patients with histopathological confirmation of glioblastoma (9 male patients, 7 female patients, mean age 55.6 years old) or grade 4 astrocytoma (4 male patients, 2 female patients, mean age 48.1 years old) and a control group (13 male patients, 9 female patients, mean age 53.9 years old) consisting of subjects with no personal pathological history. There were statistically significant differences between the mean values of glycemia (p value = 0.0003), ketones (p value = 0.0061), and glucose-ketone index (p value = 0.008) between the groups of patients. Mortality at 3 months in glioblastoma patients was 0% if the ketone levels were below 0.2 mM and 100% if ketones were over 0.5 mM. Patients with grade 4 astrocytoma and the control subjects all presented with ketone values of less than 0.2 mM and 0.0% mortality. In conclusion, highlighting new biomarkers which are more feasible to determine such as ketones or glucose-ketone index represents an essential step toward personalized medicine and survival prolongation in patients suffering from glioblastoma and grade 4 astrocytoma.

Preoperative Immune-Inflammatory Status of the Patients With Newly-Diagnosed Glioblastoma - Could It Genuinely Predict Their Survival?

BACKGROUND: Glioblastoma multiforme (GBM) is the most aggressive brain tumor affecting adult patients, with an extremely reduced overall survival despite rapid diagnosis and treatment. Therefore, it is crucial to establish accurate and affordable markers that allow an individualized approach to GBM patients. Serum biomarkers could be the most accessible, as complete blood counts should be performed on all GBM patients before undergoing any surgical and/or pharmacological treatment. However, their prognostic role is still unclear. Our study aims to assess the influence of various hematological markers of inflammation in predicting the outcome of GBM patients. MATERIAL AND METHODS: We retrospectively analyzed all adult patients diagnosed with primary glioblastoma in the Neurosurgery Department of the Emergency Clinical County Hospital of Târgu Mureș, Romania, from January 2017 until December 2019. We aimed to discover whether the immune/inflammatory status of the patients before receiving any kind of pharmacological or surgical treatment influenced their overall survival. RESULTS: Our study showed that pre-therapeutic elevated white blood count could predict reduced overall survival in not otherwise specified subtype (NOS) of GBMs (HR 0.4153, 95% CI 0.1825-0.9449, p 0.0362). Furthermore, patients with increased systemic immune response index (SIRI) had much larger tumors at the time of diagnosis (p 0.0359). In wild type, isocitrate dehydrogenase subpopulation (IDHwt), the higher values of neutrophil-to-lymphocyte ratio (NLR, p 0.0412), platelet-to-lymphocyte ratio (PLR, p 0.0376) and monocyte-to-lymphocyte ratio (MLR, p 0.0412) were related to more advanced age at the moment of diagnosis. Moreover, our results revealed a weakly positive association between tumor size and NLR values in the NOS group (Spearman r 0.3212, p 0.0493). CONCLUSIONS: Our study does not provide enough evidence for the immune/inflammatory status of GBM patients to be used as an efficient prognostic marker to guide the therapeutic approach.

Suboccipital Retrocondylar Approach for an Anterolateral Foramen Magnum Meningioma.

Objectives This study was to demonstrate surgical technique for an anterolateral foramen magnum meningioma. Design Present study is presented through an operative video. Setting This study is conducted at the Department of Neurosurgery, Tîrgu Mureș, Romania. Participants A 62-year-old female is the participant who was diagnosed with a foramen magnum meningioma. Main Outcome Measures Complete surgical resection of the tumor with no postoperative deficits or complications. Results A 62 years-old female was admitted for left hemilingual atrophia, dysphonia, right hemiparesis grade 2 of 5, right hemihypesthesia, and cervical pain. The magnetic resonance imaging (MRI) showed a right foramen magnum meningioma, sized approximately 2 cm in all planes ( Fig. 1 ). This was classified with the Bernard system as an intradural foramen magnum meningioma with anterolateral insertion to the dura mater and below the vertebral artery. A suboccipital, retrocondylar, and c1 right hemilaminectomy approach was performed. Using microsurgical tumoral decompression techniques, ultrasonic aspiration, and following the natural cleavage planes, complete tumor removal was achieved ( Fig. 2 ). The patient presented an uneventful postoperative course with no postoperative new neurological deficits and was discharged at home 7 days following surgery. Control MRI at 6 months ( Fig. 1 ) and 2 years showed no tumor residue or recurrence. Neurologic status at 6 months was excellent, showing complete remission of symptoms. Conclusion Retrocondylar suboccipital approach is a safe and feasible option for anterolateral foramen magnum meningiomas provided that natural corridors and dynamic retraction are used. The link to the video can be found at: https://youtu.be/jpxMcjCpN6E .

Surgical Strategies and Clinical Outcome of Large to Giant Sphenoid Wing Meningiomas: A Case Series Study.

Large to giant sphenoid wing meningiomas (SWMs) remain surgically challenging due to frequent vascular encasement and a tendency for tumoral invasion of the cavernous sinus and optic canal. We aimed to study the quality of resection, postoperative clinical evolution, and recurrence rate of large SWMs. This retrospective study enrolled 21 patients who underwent surgery between January 2014 and December 2019 for SWMs > 5 cm in diameter (average 6.3 cm). Tumor association with cerebral edema, extension into the cavernous sinus or optic canal, degree of encasement of the major intracranial arteries, and tumor resection grade were recorded. Cognitive decline was the most common symptom (65% of patients), followed by visual decline (52%). Infiltration of the cavernous sinus and optical canal were identified in five and six patients, respectively. Varying degrees of arterial encasement were seen. Gross total resection was achieved in 67% of patients. Long-term follow-up revealed improvement in 17 patients (81%), deterioration in two patients (9.5%), and one death (4.7%) directly related to the surgical procedure. Seven patients displayed postoperative tumor progression and two required reintervention 3 years post initial surgery. Tumor size, vascular encasement, and skull base invasion mean that, despite technological advancements, surgical results are dependent on surgical strategy and skill. Appropriate microsurgical techniques can adequately solve arterial encasement but tumor progression remains an issue.

First-Onset Hypokalemic Periodic Paralysis Following Surgery for Myxopapillary Ependymoma.

BACKGROUND: Hypokalemic periodic paralysis is a rare skeletal muscle channelopathy characterized by intermittent episodes of acute flaccid paralysis with associated hypokalemia. We present here the case of a first-onset hypokalemic periodic paralysis triggered by lumbar spinal surgery for tumor resection. CASE DESCRIPTION: A 37-year-old male without any known prior medical conditions presented with a first-onset attack of hypokalemic paralysis 1.5 days after lumbar spinal surgery for myxopapillary ependymoma. Initially, the patient presented paraparesis mimicking a spinal cord compression, and while en route for imaging there was an abrupt onset of flaccid paralysis with significant respiratory distress. The emergency blood tests revealed extreme hypokalemia with a serum potassium of 1.42 mm/L. The patient was transferred to the intensive care unit, intubated, sedated, and administered intravenous reperfusion with an infusion dose of 20 mEq/hour potassium in a solution of 5% mannitol. Following reperfusion, the patient recovered completely in 12 hours. Renal potassium hyperexcretion and hyperthyroidism were excluded by laboratory tests. The diagnosis was confirmed by genetic tests showing mutation of the CACNA1S gene. CONCLUSIONS: To the best of our knowledge, this is the first described case with the first onset triggered by a neurosurgical intervention and the second case following any kind of surgery. Neurosurgeons should consider hypokalemic periodic paralysis when encountering a rapidly evolving tetraparesis, even in an apparently healthy patient.

Gross-total versus near-total resection of large vestibular schwannomas. An institutional experience.

OBJECTIVE: We will report our experience of the surgical treatment of large vestibular schwannomas (VSs). PATIENTS, MATERIALS AND METHODS: We conducted a retrospective study of patients operated on for Koos grade IV VS between 2007 and 2015 at the Department of Neurosurgery, Emergency County Hospital, Târgu Mures, Romania. We studied the general preoperatory clinical data, the preoperative and postoperative facial nerve status, preoperative hearing on the affected side, and any postoperative complications, including death. RESULTS: Sixty-six cases were included in our study. The mean age was 52.95 years and 66.7% (n=44) of the sample were female. All patients had suffered from tinnitus and this had been followed by loss of serviceable hearing on the affected side in 89.4% (n=59) of cases. Preoperative facial palsy was found in 53% (n=35) of patients. The mean tumor size was 40.35 mm. Gross-total resection (GTR) was achieved in 24 (36.36%) cases, while near-total resection (NTR) was obtained in 42 (63.64%) cases. New-onset facial palsy or degradation of the preoperative facial deficit occurred in 12 (18.18%) cases, most of whom were patients with a GTR (n=9, 37.5%). This was statistically significant. There were no significant postoperative differences between the GTR and NTR groups. There was one death in the GTR group. CONCLUSIONS: We conclude that near-total tumor removal provides good surgical results and better postsurgical quality of life for patients when compared to gross-total tumor resection. Therefore, this should be the end goal of the resection of large VSs.