Implantation of carmustine wafers (Gliadel®) for high-grade glioma treatment. A 9-year nationwide retrospective study.

BACKGROUND: Carmustine wafers (CW) are approved to treat newly or recurrent high-grade gliomas (HGG). Widespread use has been limited regarding some doubtful uncertainties about their efficacy, related increased risk of infection and expensive cost. OBJECTIVE: To describe the epidemiology of CW implantation, search for related complications, long-term survival and associated prognostic factors. METHODS: We processed the French medico-administrative national database to retrieve appropriate cases operated between 2010 and 2018. A survival analysis was conducted. RESULTS: We identified 1659 patients treated in 39 institutions. Median age at CW implantation was 61 years and there was an over-representation of male (63.5%). 491 patients (29.6%) had previous diagnosis of glioma. Time between the first surgery and CW implantation was 0.9 years, IQR[0.6, 1.6]. The frontal lobe was the most frequently involved 29%. 131 patients (7.9%) had to be re operated on for a complication of which 121 for surgical site infection. At one year, 514 patients (31%) had died. Median overall survival (OS) was 1.4 years, 95% CI [1.3, 1.5]. OS at 1 and 2 year was 66%, 95%CI [63.7, 68.5], 32.3%, 95%CI [29.9, 35]. In the adjusted Cox regression, male gender & age at CW implantation were established as independent factors of OS in all three groups. Patients with recurrent HGG have a significant worse prognosis (HR = 0.71, 95% CI [0.62, 0.80] p < 0.001). A post-operative diagnosis of infection or intracranial bleeding eventually leading to a redo surgery was not associated with a decrease OS. CONCLUSION: Over the past 9 years, there is a significant decrease utilisation of CW in France. OS after CW implantation is significantly variable as influenced by many factors such as age, gender or recurrent disease but not by post-operative complications. Compare to previous results, CW may increase the OS and this effect seems more pronounced when adjuvant RT/TMZ is given.

Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study.

BACKGROUND: Decompressive craniectomy (DC) has been shown to be an effective treatment for malignant cerebral infarction (MCI). There are limited nationwide studies evaluating outcome after craniectomy for MCI. OBJECTIVE: To describe the evolution in DC practices for MCI, long-term survival, and associated prognostic factors. METHODS: We searched the French medico-administrative national database to retrieve patients who underwent DC between 2008 and 2017. RESULTS: A total of 1841 cases of DC were performed over 10 years in 51 centers. Mean age at procedure was 50.9 years, 18% were above 60 years, and 64.4% were male. There was a significant increase in DC for MCI over the 10 years (p < 0.001), and the annual volume of procedures more than doubled (95/year vs. 243/year). Early survival at one week and one month was 86%, 95%CI (84.5, 87.6) and 79.7%, 95%CI (77.8, 81.5), respectively. Long-term survival at 1 and 5 years were 73.6%, 95%CI (71.6, 75.7) and 68.9%, 95%CI (66.5, 71.4), respectively. Patients below 60 years at the time of DC (HR = 0.5; 95%CI [0.4, 0.7], p < 0.001), DC being performed in a center with a high surgical activity (HR = 0.8; 95%CI [0.6, 0.9], p = 0.002), and the patients having unimpaired consciousness (HR = 0.6; 95%CI [0.5, 0.8], p < 0.001) were associated with increased survival in both univariate and adjusted Cox regressions. 18.7% of the survivors had a cranioplasty inserted within 3 months and 57.8% within 6 months. The probability of having a cranioplasty at one year was 75.6%, 95%CI (77.9, 73.1). CONCLUSION: Over the past 10 years in France, DC has been increasingly performed for MCI regardless of age. However, in-hospital mortality remains considerable, as about one quarter of patients died within the first weeks. For those who survive beyond 6 months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60 years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC.

Intracranial WHO grade I meningioma: a competing risk analysis of progression and disease-specific survival.

BACKGROUND: Studies on meningioma are reported with inadequate allowance for competing causes of progression or death. The aim of this study was to describe the outcome of patients with intracranial WHO grade I meningioma and identify factors that may influence disease progression and cause-specific survival. METHODS: Pathology reports and clinical data of 505 WHO grade I meningiomas treated between January 2003 and December 2017 were retrospectively reviewed at a single institution. We estimated a cumulative incidence function for progression and cause-specific mortality. A competing risk analysis was conducted on clinical and histological criteria. Median follow-up was 6.2 years. RESULTS: A total of 530 surgical resections were performed on 505 cases. Forty-one patients received radiotherapy (RT). At data collection, 84 patients had died of their meningioma disease or demonstrated a recurrence eventually treated by redo surgery or RT. The risks of recurrence or meningioma-related death at 5 years were 16.2%, 95%CI[12.5, 20], whereas 5-year overall survival was 86.1%, 95%CI[82.8, 89.6]. In the multivariable Fine-Gray regression for a competing risk model, venous sinus invasion (SHR = 1.8, 95%CI[1.1, 2.9], p0.028), extent of resection (SHR = 0.2, 95%CI[0.1, 0.3], p < 0.001), and progressing meningioma (SHR = 7, 95%CI[3.3, 14.8], p < 0.001) were established as independent prognostic factors of cause-specific death or meningioma progression. In contrast, age at diagnosis < 65 years (HR = 1.1, 95%CI[1, 1.1], p < 0.001) and redo surgery for meningioma recurrence (HR = 2.6, 95%CI[1.4, 5], p = 0.00252) were predictors of the overall survival. CONCLUSIONS: In this large series, WHO grade I meningioma treatment failure correlated with venous sinus invasion, incomplete resection, and progressing tumour; shorter survival correlated with increased age and redo surgery for recurrence. We recommend the cumulative incidence competing risk approach in WHO grade I meningioma studies where unrelated mortality may be substantial, as this approach results in more accurate estimates of disease risk and associated predictors.

Titanium Three-Dimensional Printed Cranioplasty for Fronto-Nasal Bone Defect.

OBJECTIVE: To analyze the characteristics and outcome of patients who underwent the insertion of a 3-dimensional (3D) printed titanium (Materialise) cranioplasty. METHODS: Surgical and clinical data of patients who underwent 3D printed titanium cranioplasty insertion at our institution were retrospectively reviewed. RESULTS: A retrospective search identified 19 cases of titanium cranioplasty insertion between 2012 and 2018. 12 patients were male (63.2%) and mean age at cranioplasty was 47.4 ±â€Š11.3 years. 9 patients had the cranioplasty inserted during the very same procedure of the craniectomy and 10 at a separate surgical stage from the craniectomy. Median delay from the craniectomy until the prosthesis insertion was 0.6 years, interquartile range (IQR) [0.4, 0.9]. Side of cranioplasty insertion was right in 6 cases and in the midline frontal in 9. Median surface of the implant was 68.1 cm, IQR [53, 125.4]. Median follow-up since the cranioplasty insertion was 1.2 year, IQR [0.4, 2.1]. At data collection, 1 patient was lost to follow-up, 1 had its cranioplasty taken out but, none was reported dead. 6 patients (31.6%) experienced early post-operative complications following the cranioplasty insertion. One patient had its cranioplasty removed 2.5 years after the insertion for tumoral recurrence (hemagiopericytoma) and skin necrosis leading to the plate exposure. CONCLUSION: 3D printed titanium cranioplasty are useful for complex craniofacial reconstruction regardless the etiology of the skull defect. This device is not associated with a higher rate of complication.

Epidemiology of meningiomas. A nationwide study of surgically treated tumours on French medico-administrative data.

BACKGROUND: To describe the epidemiology of surgically treated meningiomas and compare the results with previously published studies. METHODS: We processed the French medico-administrative national hospital discharge summary database, Programme de Médicalisation des Systèmes d'Information (PMSI) using an algorithm combining the type of surgical procedure and codes from the International Classification of Diseases to retrieve appropriate cases of meningiomas operated between 2008 and 2016. RESULTS: This nationwide study found 25,737 cases of operated meningiomas. Global incidence of operated meningiomas equals 4.51, 95%CI[4.46-4.57] for 100 000 person-years and increased over the last 9 years. Benign neoplasms account for 91.3%, neoplasms of uncertain or unknown behaviour for 6.2% and malignant for 2.5%. There is a decrement of female over male ratios as the malignancy potential progresses. Incidence of operated meningiomas was 3 times more frequent in women than men. Mean age at surgery was 57.6 years for women and 59.5 for men. The incidence of meningioma surgery increases with age and is maximal for the 60-64 years category. Only 0.4% of operated patients were under 18 years. Meningioma surgeries of the cranial convexity and the middle skull base are the most common. CONCLUSION: The PMSI database is a reliable and effective source for studying the epidemiology of surgically treated meningiomas, including the precise location of the tumour. Our findings comfort previous studies and are comparatively correlated. This may assert the usefulness of such a database to investigate the patients' outcome after meningioma surgery.

Malignant Meningioma: An International Multicentre Retrospective Study.

BACKGROUND: In contrast to benign meningiomas, malignant meningiomas (MM) are rare and associated with an unfavourable prognosis. Reports on MM concern fairly small cohorts, often comprising less than 30 cases. OBJECTIVE: To describe the outcome MM and identify factors that may influence survival. METHODS: Pathology reports and clinical data of 178 patients treated between 1989 and 2017 for a MM at 6 different international institutions were retrospectively reviewed. Seventy-six patients (42.7%) had a previous history of grade I or grade II meningioma. The patients underwent a total of 380 surgical resections and 72.5% received radiotherapy. Median follow-up was 4.5 yr. RESULTS: At data collection, 111 patients were deceased (63.4%) and only 23 patients (13.7%) were alive without any residual tumor on the most recent scan. Median overall survival was 2.9 yr, 95% confidence interval [CI; 2.4, 4.5]. Overall survival rates at 1, 5, and 10 yr, respectively, were: 77.7%, 95% CI [71.6, 84.3], 40%, 95% CI [32.7, 49], and 27.9%, 95% CI [20.9, 37.3]. In the multivariable analysis, age at MM surgery <65 yr (hazard ratio [HR] = 0.44, 95% CI [0.29, 0.67], P < .001), previous benign or atypical meningioma surgery (HR = 1.9, 95% CI [1.23, 2.92], P = .004), completeness of resection (HR = 0.51, 95% CI [0.34, 0.78], P = .002), and adjuvant radiotherapy (HR = 0.64, 95% CI [0.42, 0.98], P = .039) were established as independent prognostic factors for survival. CONCLUSION: This large series confirms the poor prognosis associated with MM, the treatment of which remains challenging. Patients under 65-yr-old with primary MM may live longer after complete resection and postoperative radiotherapy. Even with aggressive treatments, local control remains difficult to achieve.

Obstructive Hydrocephalus Caused by an Unruptured Arteriovenous Malformation Successfully Treated by Endoscopic Third Ventriculostomy After Shunt Dysfunction.

The authors report on a patient harbouring an unruptured cortical arteriovenous malformation (AVM), who had presented with obstructive hydrocephalus due to compression of the cerebral aqueduct by a large venous varix. A ventriculoperitoneal (VP) shunt was inserted in emergency. Due to its large volume, the AVM was not referred for treatment and a follow-up policy was chosen. After the second VP shunt dysfunction, endoscopic third ventriculostomy was performed under neuronavigation. The procedure went uneventfully and the patient recovered well. In the rare eventuality of obstructive hydrocephalous caused by an unruptured AVM, endoscopic third ventriculostomy is feasible, efficient and can avoid shunt-related complications.

Meningeal haemangiopericytoma and solitary fibrous tumour: a retrospective bi centre study for outcome and prognostic factor assessment.

To describe the outcome of patients diagnosed with central nervous system haemangiopericytoma (HPC) or solitary fibrous tumour (SFT) and identify factors that may influence recurrence and survival. Between January 2000 and September 2016, a retrospective search identified 55 HPCs/SFTs. The patients underwent a total of 101 surgical resections and 56.9% received radiation therapy. Median follow-up was 7.8 years. 28 patients (50.9%) were re-operated for tumour recurrence. At the end of the study, 21 patients (42%) had no residual tumour on the last scan. Surgical recurrence-free survival at 5 years was 75.2%, 95% CI [63.3-89.3] and, the median surgical recurrence-free survival was 7.4 years. In the adjusted analysis, venous sinus invasion (present vs. absent) (HR 3.39, 95% CI [1.16, 9.93], p = 0.026), completeness of resection (HR 0.38, 95% CI [0.15-0.97], p = 0.042) and tumour subtype (SFT vs. HPC) (HR 3.02, 95% CI[1.02, 8.91], p = 0.045) were established as independent prognostic factors. At the end of the study, 25 patients were deceased (45.5%). and only 15 patients (27.3%) had no residual tumour on the last scan and were alive. Overall survival at 5 years was 80.2, 95% CI [69.3-92.8] and the median overall survival was 13.1 years. None of the investigated variables was associated with overall survival. Patients who received radiation therapy demonstrated neither a reduced risk of surgical recurrence (p = 0.370) nor a longer overall survival (p = 1.000). SFTs/HPCs are associated with a significant risk of recurrence that may reduce the survival of the patients. Total tumour resection upon initial surgery is associated with a lower risk of relapse but not with a prolonged survival. We did not observe a significant improvement in any of the clinical outcomes after radiation therapy.

Vagus Nerve Stimulation Removal or Replacement Involving the Lead and the Electrode: Surgical Technique, Institutional Experience and Outcome.

OBJECTIVE: To analyze the outcome of epileptic patients who had redo surgery involving the vagus nerve stimulation's lead. METHODS: We reviewed the clinical and surgical records of all patients who had a complete vagus nerve stimulation (VNS) removal or replacement or any redo surgical procedure involving the system lead at Sainte-Anne Hospital in Paris, France. RESULTS: Between the years 1999 and 2016, 41 redo surgical procedures involving the lead or electrode were achieved, of which 23 were complete VNS explantations, 12 were complete system replacements, 5 were lead changes only, and 1 was isolated lead removal. 41% of the surgical procedures were achieved in female patients. This population has a median age at VNS implantation of 33.6 years (interquartile range [IQR], [21.4-38.6]. Median time between the VNS implantation and the redo surgery involving the lead was 4.9 years (IQR, 2.9-8). The reason for VNS removal was mainly a lack of clinical effectiveness. No preoperative or postoperative complications occurred after complete VNS system removal or lead replacement. The effectiveness of the VNS therapy remained unchanged after lead replacement. No vagus nerve injury was reported, nor did symptoms suggest that it was disabled. CONCLUSIONS: Complete removal or replacement of the VNS system including the lead and the electrode is feasible and safe. These procedures should be offered to patients who would no longer benefit from the VNS or when only a lead change is needed.

Usefulness of Motor-Evoked Potentials Monitoring for Neurosurgical Treatment of an Unusual Distal Anterior Choroidal Artery Aneurysm.

A 35 years old woman presented with an acute meningeal syndrome following an intra ventricular haemorrhage without subarachnoid haemorrhage. The angiography demonstrated a 6 mm partially thrombosed saccular aneurysm at the plexal point of the right anterior choroidal artery (AChoA). It was surgically approached inside the ventricle through a trans-temporal corticotomy. The aneurysm was excised after distal exclusion of the feeding artery under motor-evoked potentials monitoring. Of the 19 cases of distal AChoA aneurysm neurosurgical treatment, this is the only one performed under electrophysiology monitoring, a simple and safe method to detect and prevent motor tract ischemia. We discuss this rare case, along with a comprehensible review of the literature of the previous surgical cases of distal AChoA aneurysms.

WHO grade II meningioma: a retrospective study for outcome and prognostic factor assessment.

To analyse the outcome of patients with WHO grade II meningioma and identify factors that may influence recurrence and survival. Between January 2007 and September 2015, a retrospective search identified 194 WHO grade II meningiomas at the National Hospital for Neurology and Neurosurgery, London. Survival methods were implemented. 31 patients (16 %) had a previous history of grade I meningioma. The patients underwent a total of 344 surgical resections and 43.3 % received radiotherapy. 55 patients (28.4 %) had been re-operated on for a WHO grade II meningioma relapse. Median follow-up was 4.4 years. At the end of the study, 75 patients (40.1 %) had no residual tumour on the last scan. Surgical recurrence free survival at 5 years was 71.6, 95 % CI [63.5, 80.8]. Secondary grade II meningioma (HR = 2.29, p = 0.010), and, Simpson resection grade 1, 2 and 3 vs. 4 and 5 (HR = 0.57, p = 0.050) were associated with the surgical recurrence-free survival. 32 died from meningioma (16.5 %). Overall survival probability at 5 years was 83.2, 95 % CI [76.6, 90.4]. Age at diagnosis (HR = 0.22, p < 0.001), WHO grade I meningioma progressing into grade II (HR = 3.2, p = 0.001), tumour location (HR = 0.19, p < 0.001), and mitosis count (HR = 0.36, p = 0.010) were independently associated with the overall survival. Patients who received radiotherapy demonstrated neither a reduced risk of recurrence nor a longer overall survival (p = 0.310). In our series shorter survival correlated with older age, increased mitoses, progression from grade I to II and location. We were not able to demonstrate a significant improvement in any of the clinical outcomes after radiotherapy.

World Health Organization grade II meningiomas.

BACKGROUND: We analyzed WHO grade II meningioma cases to identify factors influencing survival. MATERIALS AND METHODS: Between January 2000 and August 2015, 206 cases of World Health Organization (WHO) grade II meningioma were operated at our institution. This population underwent a total of 298 surgical resections and 55 patients received a radiotherapy. A Cox multivariate regression was conducted on clinical and histological criteria. RESULTS: Sixty-four patients were deceased (31.1 %), of which 38 died following the disease progression (18.4 %). Overall survival probability at 1, 5, and 10 years were 95.4 %, 95 % CI [92.5, 98.4]; 84 %, 95 % CI [78.3, 90.2], and 72.9 %, 95 % CI [64.5, 82.4], respectively (Fig. 1a). At the end of the study, only 87 patients (42.2 %) were alive with no tumor residual or recurrence on the last scan. Age at diagnosis (hazard ratio (HR) = 0.31, 95 % CI [0.15, 0.63], p < 0.001), extent of resection (HR = 0.25, 95 % CI [0.12, 0.49], p < 0.001), and tumoral brain invasion (HR = 0.49, 95 % CI [0.25, 0.98], p = 0.040) were independent factors associated with the overall survival. The patients who received radiotherapy did not demonstrate a longer overall survival (p = 0.540). CONCLUSIONS: WHO grade II meningioma significantly impaired the survival of the patients. In the adjusted Cox regression, a macroscopic gross total resection (Simpson grades 1, 2, and 3), an age below 62 years at diagnosis and the absence of brain invasion were independent factors associated with a longer survival. Radiotherapy may not increase the overall survival after complete or incomplete resection.

World Health Organization Grade II Meningioma: A 10-Year Retrospective Study for Recurrence and Prognostic Factor Assessment.

BACKGROUND: We analyzed the characteristics of patients with World Health Organization (WHO) Grade II meningioma to identify factors that may influence recurrence. MATERIALS AND METHODS: Between January 2000 and August 2015, 178 cases of WHO Grade II meningioma were operated at our institution. This population underwent a total of 224 surgical resections, and 36 patients received radiotherapy. Median follow-up was 3.6 years, and interquartile range was 1.5-6.2. RESULTS: A total of 28 patients (16.1%) were re operated for a relapse of their Grade II meningioma. The median time between the first and the second surgery was 4.2 years [interquartile range 1.4-5.3]. Surgical recurrence-free survival at 1, 2, 5, and 10 years were: 96.9% (95% confidence interval [95% CI] 94.2-99.6; 91.7%, 95% CI 87.3-96.3; 85%, 95% CI 78.6-92; and 70.8%, 95% CI 60.1-83.5), respectively. At the end of the study, 93 patients (57.8%) had no residual tumor on the last scan. Age at diagnosis (hazard ratio [HR] 0.17, 95% CI 0.05-0.56, P < 0.001), extent of resection (HR 0.22, 95% CI 0.08-0.64, P = 0.01), and Ki-67 index (HR 0.18, 95% CI 0.06-0.56, P < 0.001) were independent factors associated with the surgical recurrence-free survival. CONCLUSIONS: Younger patients with a lower proliferation rate and gross total resection are less likely to undergo a reintervention for WHO Grade II meningioma recurrence. Observation rather than systematic adjuvant radiotherapy may be preferred. If possible, a redo surgery may be considered in case of relapse or tumor residual progression, because radiotherapy may not decrease the surgical recurrence-free survival after complete or incomplete resection.

World Health Organization grade III meningiomas. A retrospective study for outcome and prognostic factors assessment.

BACKGROUND: Anaplastic meningiomas are uncommon primary intracranial tumours associated with high level of recurrence and low life expectancy. Through three institutions experience, we analysed the clinical characteristics of patients with malignant meningiomas to determine their outcome and identify prognostic factors that may influence recurrence and survival. MATERIAL AND METHODS: A retrospective search identified 62 cases of WHO grade III meningiomas, of whom 9 (14.5%) were not considered in the survival analysis as no follow-up data were available. Thirty patients (48.4%) had a previous history of non-malignant meningioma surgery. The patients underwent a total of 139 surgical resections and 42 courses of radiotherapy of which 27 were given after the WHO grade III meningioma diagnosis. RESULTS: Eighteen patients (29.5%) were re-operated for a relapse of their anaplastic meningioma. Median time between the first and the second surgery was 1.3 years. Median overall survival time was 3.5 years. Overall survival probabilities at 1, 2 and 5 years were 74.6%, 95% confidence interval (CI) [63.8, 87.1], 58.7%, 95% CI [46.4, 74.3] and 37.7%, 95% CI [25, 56.8], respectively. Extent of resection was associated with the survival. DISCUSSION: This retrospective series highlights the poor prognosis associated with the diagnosis of malignant meningioma. Complete or subtotal resection may prolong the patients' survival. We could not confirm the usefulness of postoperative radiotherapy.