Resilience of Patients With Brain Tumor While Awaiting Surgery.

ABSTRACT: BACKGROUND: Resilience is the ability of patients to adapt effectively when given a diagnosis of an illness. While awaiting brain tumor surgery, patients often experience uncertainty from brain tumor-related symptoms resulting in inducing depressive symptoms, having physical disability, and reducing quality of life. Resilience studies have been widely conducted in the postoperative phase with a limited knowledge on the preoperative phase. This study aimed to identify predictors of resilience while awaiting brain tumor surgery. METHODS: This cross-sectional predictive study includes 100 participants 18 years and older, with diagnosis of brain tumors, and waiting for brain tumor surgery at the outpatient department of 1 tertiary hospital in Bangkok between August 2022 and February 2023. Multiple linear regression was used to examine the predictors of resilience. RESULTS: Most of the sample (77%) were female with a mean age of 52.71 (13.17) years. The most common type of brain tumor was meningioma (38%). The median waiting time since brain tumor diagnosis until the date of preadmission for operation was 18 (3-1464) days. Symptom severity, social support, and treatment plan were able to explain 37.3% of the variance of resilience in patients awaiting brain tumor surgery ( F = 19.077, P < .01, R2 = 0.373, adjusted R2 = 0.354). CONCLUSION: Resilience is an important skill for patients with brain tumor to manage uncertainty events that occur in their lives. The preoperation phase needs to assess both physical and mental tumor-related symptoms, and include caregivers as part of the care, to promote resilience skill for patients awaiting brain tumor surgery.

Impact of Intraoperative Magnetic Resonance Imaging (i-MRI) on Surgeon Decision Making and Clinical Outcomes in Cranial Tumor Surgery.

Background Although intraoperative magnetic resonance imaging (iMRI) has an established role in guiding intraoperative extent of resection (EOR) in cranial tumor surgery, the details of how iMRI data are used by the surgeon in the real-time decision-making process is lacking. Materials and Methods The authors retrospectively reviewed 40 consecutive patients who underwent cranial tumor resection with the guidance of iMRI. The tumor volumes were measured by volumetric software. Intraoperative and postoperative EOR were calculated and compared. Surgeon preoperative EOR intention, intraoperative EOR assessment, and how iMRI data impacted surgeon decisions were analyzed. Results The pathology consisted of 29 gliomas, 8 pituitary tumors, and 3 other tumors. Preoperative surgeon intention called for gross total resection (GTR) in 28 (70%) cases. After resection and before iMRI scanning, GTR was 20 (50.0%) cases based on the surgeon's perception. After iMRI scanning, the results helped identify 19 (47.5%) cases with unexpected results consisting of 5 (12.5%) with unexpected locations of residual tumors and 14 (35%) with unexpected EOR. Additional resection was performed in 24 (60%) cases after iMRI review, including 6 (15%) cases with expected iMRI results. Among 34 cases with postoperative MRI results, iMRI helped improve EOR in 12 (35.3%) cases. Conclusion In cranial tumor surgery, the surgeon's preoperative and intraoperative assessment is frequently imprecise. iMRI data serve several purposes, including identifying the presence of residual tumors, providing residual tumor locations, giving spatial relation data of the tumor with nearby eloquent structures, and updating the neuro-navigation system for the final stage of tumor resection.

Clinical characteristics and treatment outcomes in acromegaly, a retrospective single-center case series from Thailand.

INTRODUCTION: acromegaly, an overproduction of growth hormone (GH), is associated with high rate of morbidity and mortality particularly in case of delayed in diagnosis and treatment. A wide variation of clinical presentations, treatment outcomes and morbidities have been reported. METHODS: a retrospective study was conducted to review clinical characteristics and treatment outcomes of patients with acromegaly treated in King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between 2006 and 2018. RESULTS: eighty-four patients (31 males and 53 females) were reviewed, mean age at diagnosis was 45.7 ± 12.6 years (±SD), mean time of disease onset was 7.6 ± 6.4 years and mean follow-up period was 7.8 ± 5.3 years. The most common presenting symptoms were maxillofacial change (96.8%) and acral enlargement (94.7%). Hypertension (39.3%), diabetes mellitus (28.6%) and dyslipidemia (23.8%) were prevalent co-existing conditions. Four patients were identified having cancer at presentation; however, no additional malignancy was reported during the follow up. Most patients harbored macroadenomas, only 10 were found to have microadenomas. The outcomes of treatment were controlled disease in 70% of microadenoma and 64.9% of macroadenoma. Permanent loss of pituitary function was found in about 21.3% and there was one case reported of mortality. The logistic regression analysis for controlled disease outcome showed the IGF-I index after surgery was associated with controlled disease outcome with statistically significant result (P-value=0.006). CONCLUSION: our study offers descriptive clinical data of case series of acromegalic patients, which had favorable outcomes comparable with previous reports. In addition, IGF-I index after surgery is a predictive parameter for outcome of treatment.

Duration of symptoms in brain tumors: influencing factors and its value in predicting malignant tumors.

BACKGROUND: Although brain tumor is a common neurosurgical condition, diagnosis is generally made after long duration of symptoms. This may have negative impact on treatment outcome. OBJECTIVE: Study the duration of symptoms of brain tumor, how it is influenced by various factors, and find their value in predicting malignant tumors. MATERIAL AND METHOD: The authors retrospectively reviewed 185 patients with pathologically proven brain tumors. Pertinent data including age, types of tumors, locations of tumors, symptoms, and duration of symptoms were analyzed by univariate and multivariate analysis. RESULTS: There were 70 males and 115 females. The mean age at diagnosis was 47.3 years. The average duration of symptoms was 471 days with median of 120 days. On univariate analysis, hormone symptoms (p = 0.001), age more than 45 years old (p = 0.005), malignant tumor (p < 0.001), auditory symptoms (p = 0.004), and motor symptoms (p < 0.001) had significant influence on duration of symptom. In multivariate analyses, malignant types of tumor, age, and hormonal symptoms were significant. In addition, there was higher risk of malignant brain tumor in patients with duration of symptoms 1 month or less (p < 0.001). CONCLUSION: Certain factors were associated with longer duration of symptoms in brain tumors. This information may lead to early diagnosis of brain tumors. Furthermore, duration ofsymptoms of 1 month or less was suggestive of malignant brain tumors.

The outcome of surgical treatment for tumors of the craniocervical junction.

OBJECTIVE: The authors report the clinical, radiological, and surgicalfindings ofpatients with craniocervical junction tumors surgically treated in the institution over the last 8 years. MATERIAL AND METHOD: A retrospective study was performed. Clinical, radiological, and operative data were evaluated, and follow-up information was obtained from outpatient examinations, and telephone interviews. RESULTS: There were 25 patients consisting of nine chordomas, eight meningiomas, three cysts, two schwannomas, one each of aneurysmal bone cyst, plasmacytoma, and metastasis. Twenty-nine operative procedures were performed, classified as 12 anterior nine posterior-lateral, and eight posterior approaches. Gross total removal was achieved in 17 cases, subtotal removal in six cases, and partial removal in two cases. Re-operation was performed in six cases. Median follow-up time was 31 months. The authors found significant improvement in Karnofsky Performance Scale scores. CONCLUSION: Appropriate surgical approaches provide successful tumor removal with less surgical morbidities, nevertheless recurrent tumors occasionally occur and so, long-term follow-up is mandatory.

Three-Dimensional Cortical Surface Reconstruction Versus Operative Findings: Their Similarity and Applications.

BACKGROUND: Three-dimensional cortical surface reconstruction (3DCSR) is an important tool for operations involving cerebral cortex, but data on its similarity to actual cortical architecture are lacking. In this study, the authors systematically tested the similarity between operative findings and 3DCSR built by a neuronavigation system and illustrated its applications. METHODS: The authors retrospectively retrieved operative photographs and 3DCSR of patients who underwent craniotomy with the aid of 3DCSR and asked 4 evaluators to perform a series of matching tests. Test 1 was to match 3DCSR and operative photographs. Test 2 was a repetition of test 1 to determine the consistency of matching ability. Test 3 was to match detailed anatomy of the 3DCSR with operative photographs. Scores on all tests were analyzed to measure the degree of similarity between 3DCSR and operative findings. The scores between patients with and without cortical distortion were compared to determine the impact of distortion on matching ability. RESULTS: Tests of similarity were performed on 22 patients. Mean scores of tests 1, 2, and 3 were 84.09%, 93.18%, and 89.77%, respectively. The Kappa statistic for agreement between test 1 and 2 ranged from 0.76 to 0.88. There was no statistically significant difference between average score of patients with and without cortical distortion in all tests. CONCLUSIONS: Authors have systematically demonstrated that 3DCSR built by neuronavigation system in this study provides detailed anatomy of cortical surface with a high degree of similarity to operative findings even in the presence of cortical distortion, leading to various applications beyond navigation alone.

Quantitative analysis of the working area and angle of attack for the retrosigmoid, combined petrosal, and transcochlear approaches to the petroclival region.

OBJECT: The authors quantitatively assessed the working areas and angles of attack associated with retrosigmoid (RS), combined petrosal (CP), and transcochlear (TC) craniotomies. METHODS: Four silicone-injected cadaveric heads were bilaterally dissected using three approaches progressing from the least to the most extensive. Working areas were determined using the Optotrak 3020 system on the upper and middle thirds of the petroclivus and brainstem. Angles of attack were studied using the Elekta SurgiScope at the Dorello canal and the origin of the anterior inferior cerebellar artery (AICA). The TC approach provided significantly greater (p < 0.001) working areas at the petroclivus (755.6 +/- 130.1 mm2) and brainstem (399.3 +/- 68.2 mm2) than the CP (354.1 +/- 60.3 and 289.7 +/- 69.9 mm2) and RS approaches (292.4 +/- 59.9, 177.2 +/- 54.2 mm2, respectively). The brainstem working area associated with the CP approach was significantly larger (p < 0.001) than that associated with the RS route. There was no difference in the petroclival working area comparing the CP and RS approaches (p = 0.149). The horizontal and vertical angles of attack achieved using the TC approach were wider than those of the CP and RS at the Dorello canal and the origin of the AICA (p < 0.001). CONCLUSIONS: The CP approach offers a more extensive working area than the RS for lesions involving the anterolateral surface of the brainstem, but not for petroclival lesions. The TC approach provides the widest corridor, improving the working area and angle of attack to both areas, but hearing must be sacrificed and the facial nerve is at risk.

Localizing value of pain distribution patterns in cervical spondylosis.

STUDY DESIGN: Prospective observational study. PURPOSE: To investigate the value of pain distribution in localizing appropriate surgical levels in patients with cervical spondylosis. OVERVIEW OF LITERATURE: Previous studies have investigated the value of pain drawings in its correlation with various features in degenerative spine diseases including surgical outcome, magnetic resonance imaging findings, discographic study, and psychogenic issues. However, there is no previous study on the value of pain drawings in identifying symptomatic levels for the surgery in cervical spondylosis. METHODS: The study collected data from patients with cervical spondylosis who underwent surgical treatment between August 2009 and July 2012. Pain diagrams drawn separately by each patient and physician were collected. Pain distribution patterns among various levels of surgery were analyzed by the chi-square test. Agreement between different pairs of data, including pain diagrams drawn by each patient and physician, intra-examiner agreement on interpretation of pain diagrams, inter-examiner agreement on interpretation of pain diagrams, interpretation of pain diagram by examiners and actual surgery, was analyzed by Kappa statistics. RESULTS: The study group consisted of 19 men and 28 women with an average age of 55.2 years. Average duration of symptoms was 16.8 months. There was no difference in the pain distribution pattern at any level of surgery. The agreement between pain diagram drawn by each patient and physician was moderate. Intra-examiner agreement was moderate. There was slight agreement of inter-examiners, examiners versus actual surgery. CONCLUSIONS: Pain distribution pattern by itself has limited value in identifying surgical levels in patients with cervical spondylosis.

Colorectal cancer manifesting with metastasis to prolactinoma: report of a case involving symptoms mimicking pituitary apoplexy.

Pituitary metastasis is an uncommon first presentation of systemic malignancy. The most common presenting symptom of pituitary metastasis is diabetes insipidus reflecting involvement of the stalk and/or posterior pituitary. We herein present a unique case of the coexistence of both a functioning pituitary adenoma (prolactinoma) and pituitary metastasis of advanced colorectal cancer with pituitary apoplexy as the first manifestation of underlying malignancy. The present case emphasizes the need to consider pituitary metastasis as a differential diagnosis in patients presenting with pituitary lesions and be aware that tumor-to-tumor metastasis can occur unexpectedly in those with pituitary metastases.

Microsurgical anatomy of the transcallosal anterior interforniceal approach to the third ventricle.

OBJECTIVE: We explored relevant regional microanatomy as it relates to the challenging anterior interforniceal (AIF) approach for removing hypothalamic hamartomas. METHODS: Five silicone-injected cadaveric heads were dissected by use of frameless stereotactic navigation to reveal microanatomy and extent of exposure through the transcallosal AIF approach. Distances between trajectories to the coronal suture and the genu of the corpus callosum (CC) and between the posterior border of the anterior commissure to the lower end of the rostrum of the CC and posterior border of the foramen of Monro were measured. RESULTS: The AIF approach provided adequate access to the anterior third ventricle and related structures (i.e., hypothalamus, infundibular recess, and mamillary bodies) through the corridor bounded by the anterior commissure anteriorly and the choroid plexus at the foramen of Monro posteriorly. The mean distances from the posterior trajectory to the coronal suture and the genu of the CC were 44.8 mm (range, 43.8-46.2 mm) and 14.88 mm (14.1-15.7 mm), respectively. The mean distance from the anterior trajectory posterior to the coronal suture was 4.66 mm (0-8.9 mm), and 32.6 mm (30.5-33.9 mm) to the genu of the CC. The mean length of callosotomy was 17.52 mm (16.2-19.1 mm). The mean distance between the posterior border of the anterior commissure and the lower end of the rostrum of the CC was 5.22 mm (4.6-5.6 mm), and 10.52 mm (9.7-11.5 mm) to the posterior border of the foramen of Monro. CONCLUSION: The technically safe AIF approach permitted limited interforniceal splitting, no major deep vein manipulation, and adequate visualization of the hypothalamus, infundibular recess, and mamillary bodies.

Microsurgical anatomy and quantitative analysis of the transtemporal-transchoroidal fissure approach to the ambient cistern.

OBJECTIVE: Surgical approaches to ambient cistern lesions are complex. We investigated the microanatomy of the transtemporal-transchoroidal fissure approach to the ambient cistern with emphasis on exposure of the posterior cerebral artery. METHODS: Dissections were performed bilaterally in five silicone-injected cadaveric heads. Critical anatomic distances, specifically with reference to the P2 segment of posterior cerebral artery in relation to the inferior choroidal point and P2-P3 junction, were measured with digital calipers. Other landmarks (temporal lobe tip, points from the temporal base to the choroidal fissure) were included for quantitative analysis. RESULTS: The transtemporal-transchoroidal fissure approach provided adequate exposure of the ambient cistern, minimized temporal lobe retraction, and allowed assessment of regional microanatomy. The mean distance from the temporal base to the choroidal fissure measured 18.09 mm (range, 16.9-21.9 mm). The distances from the choroidal fissure to P2 varied at the coronal plane of the inferior choroidal point (mean, 6.96 mm; range, 3.6-12.0 mm) and the P2-P3 junction (mean, 6.02 mm; range, 4.3-6.9 mm), respectively. CONCLUSION: The transtemporal-transchoroidal fissure approach provides a corridor to the ambient cistern and P2-P3 junction while minimizing temporal lobe retraction and avoiding interruption of temporal lobe venous drainage. Because of widely variable vascular anatomy, access to posterior cerebral artery lesions using this approach requires preoperative imaging to identify the specific location of the P2-P3 junction.

Microsurgical anatomy of the transcallosal anterior interforniceal approach to the third ventricle.

OBJECTIVE: We explored relevant regional microanatomy as it relates to the challenging anterior interforniceal (AIF) approach for removing hypothalamic hamartomas. METHODS: Five silicone-injected cadaveric heads were dissected by use of frameless stereotactic navigation to reveal microanatomy and extent of exposure through the transcallosal AIF approach. Distances between trajectories to the coronal suture and the genu of the corpus callosum (CC) and between the posterior border of the anterior commissure to the lower end of the rostrum of the CC and posterior border of the foramen of Monro were measured. RESULTS: The AIF approach provided adequate access to the anterior third ventricle and related structures (i.e., hypothalamus, infundibular recess, and mamillary bodies) through the corridor bounded by the anterior commissure anteriorly and the choroid plexus at the foramen of Monro posteriorly. The mean distances from the posterior trajectory to the coronal suture and the genu of the CC were 44.8 mm (range, 43.8-46.2 mm) and 14.88 mm (14.1-15.7 mm), respectively. The mean distance from the anterior trajectory posterior to the coronal suture was 4.66 mm (0-8.9 mm), and 32.6 mm (30.5-33.9 mm) to the genu of the CC. The mean length of callosotomy was 17.52 mm (16.2-19.1 mm). The mean distance between the posterior border of the anterior commissure and the lower end of the rostrum of the CC was 5.22 mm (4.6-5.6 mm), and 10.52 mm (9.7-11.5 mm) to the posterior border of the foramen of Monro. CONCLUSION: The technically safe AIF approach permitted limited interforniceal splitting, no major deep vein manipulation, and adequate visualization of the hypothalamus, infundibular recess, and mamillary bodies.

Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex.

OBJECTIVE: To compare the angles of approach and area of exposure to the anterior communicating artery (AComA) complex associated with pterional (PT), orbitopterional (OPT), and orbitozygomatic (OZ) craniotomies before and after gyrus rectus resection. METHODS: PT, OPT, and OZ craniotomies were performed on both sides of four heads, and the angles of approach and area of exposure to the AComA complex were measured before and after resection of the gyrus rectus. RESULTS: The vertical angle of approach increased significantly among the PT and OPT (P = 0.001), PT and OZ (P = 0.001), and OPT and OZ approaches (P = 0.005). The horizontal angle of approach was significantly larger between the PT to OPT (P = 0.001) and PT to OZ (P = 0.001) approaches but not between the OPT and OZ approaches (P = 0.757). After gyrus rectus resection, the vertical and horizontal angles of approach increased significantly for the PT approach but not for the OPT and OZ approaches. The area of exposure to the AComA complex increased progressively from the PT to OPT to OZ approach but did not reach statistical significance (P = 0.124). Resection of the gyrus rectus resulted in significant relative gains in the area of exposure for the PT (P = 0.01) and OPT (P = 0.04) approaches but not for the OZ approach (P = 0.88). CONCLUSION: The vertical and horizontal angles of approach to the AComA complex are significantly larger for the OPT and OZ approaches compared with the PT approach. Use of the OZ approach may decrease the need for frontal lobe retraction and resection of the gyrus rectus.

The outcome of surgical treatment for tumors of the craniocervical junction.

OBJECTIVE: The authors report the clinical, radiological, and surgicalfindings ofpatients with craniocervical junction tumors surgically treated in the institution over the last 8 years. MATERIAL AND METHOD: A retrospective study was performed. Clinical, radiological, and operative data were evaluated, and follow-up information was obtained from outpatient examinations, and telephone interviews. RESULTS: There were 25 patients consisting of nine chordomas, eight meningiomas, three cysts, two schwannomas, one each of aneurysmal bone cyst, plasmacytoma, and metastasis. Twenty-nine operative procedures were performed, classified as 12 anterior nine posterior-lateral, and eight posterior approaches. Gross total removal was achieved in 17 cases, subtotal removal in six cases, and partial removal in two cases. Re-operation was performed in six cases. Median follow-up time was 31 months. The authors found significant improvement in Karnofsky Performance Scale scores. CONCLUSION: Appropriate surgical approaches provide successful tumor removal with less surgical morbidities, nevertheless recurrent tumors occasionally occur and so, long-term follow-up is mandatory.