Two is better than one: longitudinal detection and volumetric evaluation of brain metastases after Stereotactic Radiosurgery with a deep learning pipeline.

PURPOSE: Close MRI surveillance of patients with brain metastases following Stereotactic Radiosurgery (SRS) treatment is essential for assessing treatment response and the current disease status in the brain. This follow-up necessitates the comparison of target lesion sizes in pre- (prior) and post-SRS treatment (current) T1W-Gad MRI scans. Our aim was to evaluate SimU-Net, a novel deep-learning model for the detection and volumetric analysis of brain metastases and their temporal changes in paired prior and current scans. METHODS: SimU-Net is a simultaneous multi-channel 3D U-Net model trained on pairs of registered prior and current scans of a patient. We evaluated its performance on 271 pairs of T1W-Gad MRI scans from 226 patients who underwent SRS. An expert oncological neurosurgeon manually delineated 1,889 brain metastases in all the MRI scans (1,368 with diameters > 5 mm, 834 > 10 mm). The SimU-Net model was trained/validated on 205 pairs from 169 patients (1,360 metastases) and tested on 66 pairs from 57 patients (529 metastases). The results were then compared to the ground truth delineations. RESULTS: SimU-Net yielded a mean (std) detection precision and recall of 1.00±0.00 and 0.99±0.06 for metastases > 10 mm, 0.90±0.22 and 0.97±0.12 for metastases > 5 mm of, and 0.76±0.27 and 0.94±0.16 for metastases of all sizes. It improves lesion detection precision by 8% for all metastases sizes and by 12.5% for metastases < 10 mm with respect to standalone 3D U-Net. The segmentation Dice scores were 0.90±0.10, 0.89±0.10 and 0.89±0.10 for the above metastases sizes, all above the observer variability of 0.80±0.13. CONCLUSION: Automated detection and volumetric quantification of brain metastases following SRS have the potential to enhance the assessment of treatment response and alleviate the clinician workload.

[CURRENT TRENDS IN ISRAELI NEUROSURGERY].

INTRODUCTION: In the current issue of the "Harefuah" journal, original research articles and review articles describe current trends in advanced innovative technologies implemented in neurosurgery departments in Israel in the last decade. The articles present the implications of these technologies on the quality and safety of care of neurosurgical patients. The leading current trends include the development of subspecialties within neurosurgery and the restructuring of departments to reflect this, the integration of inter- and intra-disciplinary collaborations into patient management, the development of minimally invasive techniques, the advancement of epilepsy and functional neurosurgery in Israel and the use of non-surgical therapeutics. Workflow methods and innovative technologies that improve treatment efficiency and patient safety that have been implemented are presented and discussed. The current issue reports on original research works carried out in the various departments in Israel and review articles on the relevant topics.

[GLIOBLASTOMA MULTIFORME AFTER STEREOTACTIC RADIOSURGERY TREATMENT FOR ARTERIO-VENOUS MALFORMATION].

INTRODUCTION: Stereotactic radiosurgery (SRS) is a minimally invasive option commissioned in the treatment of intracranial arteriovenous malformations (AVMs). As long-term follow-up data became available, some late adverse effects have been reported, including SRS-induced neoplasia. However, the exact incidence of this adverse effect is unknown. In this article we present and discuss the topic with an unusual case of a young patient who was treated with SRS for AVM and developed a malignant brain tumor.

VHL-Related Neuroendocrine Neoplasms And Beyond: An Israeli Specialized Center Real-Life Report.

OBJECTIVE: Von Hippel-Lindau (VHL) syndrome is a rare and complex disease. In 1996, we described a 3 generation VHL 2A kindred with 11 mutation carriers. We aim to share our experience regarding the long-term follow-up of this family and the management of all our other VHL patients focusing on frequently encountered neuroendocrine neoplasms: pheochromocytoma/paraganglioma and pancreatic neuroendocrine neoplasms (PNEN). METHODS: All VHL patients in follow-up at our tertiary center from 1980 to 2019 were identified. Clinical, laboratory, imaging, and therapeutic characteristics were retrospectively analyzed. RESULTS: We identified 32 VHL patients in 16 different families, 7/16 were classified as VHL 2 subtype. In the previously described family, the 4 initially asymptomatic carriers developed a neuroendocrine tumor; 7 new children were born, 3 of them being mutation carriers; 2 patients died, 1 due to metastatic PNEN-related liver failure. Pheochromocytoma was frequent (22/32), bilateral (13/22;59%), often diagnosed in early childhood when active screening was timely performed, associated with paraganglioma in 5/22, rarely malignant (1/22), and recurred after surgery in some cases after more than 20 years. PNEN occurred in 8/32 patients (25%), and was metastatic in 3 patients. Surgery and palliative therapy allowed relatively satisfactory outcomes. Severe disabling morbidities due to central-nervous system and ophthalmologic hemangiomas, and other rare tumors as chondrosarcoma in 2 patients and polycythemia in 1 patient were observed. CONCLUSION: A multidisciplinary approach and long-term follow-up is mandatory in VHL patients to manage the multiple debilitating morbidities and delay mortality in these complex patients.

Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF).

OBJECTIVE: The prevalence of skull fractures after mild head trauma is 2 % in children of all ages and 11 % in children younger than 2 years. The current standard management for a child diagnosed with an isolated skull fracture (ISF), in our institute, is hospitalization for a 24-h observation period. Based on data from the literature, less than 1 % of all minor head injuries require neurosurgical intervention. The main objective of this study was to evaluate the risk of neurological deterioration of ISF cases, in order to assess the need for hospitalization. METHODS: We reviewed the medical charts of 222 children who were hospitalized from 2006 to 2012 with ISF and Glascow Coma Scale-15 at the time of arrival. We collected data regarding demographic characteristics, mechanism of injury, fracture location, clinical symptoms and signs, need for hospitalization, and need for repeated imaging. Data was collected at three time points: at presentation to the emergency room, during hospitalization, and 1 month after admission, when the patients' parents were asked about the course of the month following discharge. RESULTS: None of the 222 children included in the study needed neurosurgical intervention. All were asymptomatic 1 month after the injury. Two children underwent repeated head CT due to persistence or worsening of symptoms; these CT scans did not reveal any new findings and did not lead to any intervention whatsoever. CONCLUSION: Children arriving at the emergency room with a minor head injury and isolated skull fracture on imaging studies may be considered for discharge after a short period of observation. Discharge should be considered in these cases provided the child has a reliable social environment and responsible caregivers who are able to return to the hospital if necessary. Hospital admission should be reserved for children with neurologic deficits, persistent symptoms, suspected child abuse, or when the parent is unreliable or is unable to return to the hospital if necessary. Reducing unnecessary hospitalizations can prevent emotional stress, in addition to saving costs for the child's family and the health care system.

Three scans are better than two for follow-up: An automatic method for finding missed and misidentified lesions in cross-sectional follow-up of oncology patients.

PURPOSE: Missed and misidentified neoplastic lesions in longitudinal studies of oncology patients are pervasive and may affect the evaluation of the disease status. Two newly identified patterns of lesion changes, lone lesions and non-consecutive lesion changes, may help radiologists to detect these lesions. This study evaluated a new interpretation revision workflow of lesion annotations in three or more consecutive scans based on these suspicious patterns. METHODS: The interpretation revision workflow was evaluated on manual and computed lesion annotations in longitudinal oncology patient studies. For the manual revision, a senior radiologist and a senior neurosurgeon (the readers) manually annotated the lesions in each scan and later revised their annotations to identify missed and misidentified lesions with the workflow using the automatically detected patterns. For the computerized revision, lesion annotations were first computed with a previously trained nnU-Net and were then automatically revised with an AI-based method that automates the workflow readers' decisions. The evaluation included 67 patient studies with 2295 metastatic lesions in lung (19 patients, 83 CT scans, 1178 lesions), liver (18 patients, 77 CECT scans, 800 lesions) and brain (30 patients, 102 T1W-Gad MRI scans, 317 lesions). RESULTS: Revision of the manual lesion annotations revealed 120 missed lesions and 20 misidentified lesions in 31 out of 67 (46%) studies. The automatic revision reduced the number of computed missed lesions by 55 and computed misidentified lesions by 164 in 51 out of 67 (76%) studies. CONCLUSION: Automatic analysis of three or more consecutive volumetric scans helps find missed and misidentified lesions and may improve the evaluation of temporal changes of oncological lesions.

A graph-theoretic approach for the analysis of lesion changes and lesions detection review in longitudinal oncological imaging.

Radiological follow-up of oncology patients requires the detection of lesions and the quantitative analysis of lesion changes in longitudinal imaging studies of patients, which is time-consuming and requires expertise. We present here a new method and workflow for the analysis and review of lesions and volumetric lesion changes in longitudinal scans of a patient. The generic graph-based method consists of lesion matching, classification of changes in individual lesions, and detection of patterns of lesion changes computed from the properties of the graph and its connected components. The workflow guides clinicians in the detection of missed lesions and wrongly identified lesions in manual and computed lesion annotations using the analysis of lesion changes. It serves as a heuristic method for the automatic revision of ground truth lesion annotations in longitudinal scans. The methods were evaluated on longitudinal studies of patients with three or more examinations of metastatic lesions in the lung (19 patients, 83 CT scans, 1178 lesions), the liver (18 patients, 77 CECT scans, 800 lesions) and the brain (30 patients, 102 T1W-Gad MRI scans, 317 lesions) with ground-truth lesion annotations. Lesion matching yielded a precision of 0.92-1.0 and recall of 0.91-0.99. The classification of changes in individual lesions yielded an accuracy of 0.87-0.97. The classification of patterns of lesion changes yielded an accuracy of 0.80-0.94. The lesion detection review workflow applied to manual and computed lesion annotations yielded 120 and 55 missed lesions and 20 and 164 wrongly identified lesions for all longitudinal studies of patients, respectively. The automatic analysis of lesion changes and review of lesion detection in longitudinal studies of oncological patients helps detect missed lesions and wrongly identified lesions. This method may help improve the accuracy of radiological interpretation and the disease status evaluation.

Stereotactic radiosurgery for brain metastases arising from gynecological malignancies: A retrospective treatment outcome analysis.

BACKGROUND: This retrospective study aims to assess the efficacy of stereotactic radiosurgery (SRS) in the treatment of brain metastases (BM) originating from gynecological cancers. It focuses on local control (LC), distant tumor control (DTC), and overall survival (OS). METHODS: The analysis comprised 18 individuals with gynecological-origin BM treated with SRS at the Hadassah Medical Center from 2004 to 2021. Statistical analyses evaluate factors impacting LC, DTC, and OS. RESULTS: A total of 36 BM of gynecological origin underwent SRS. The median age at the first SRS treatment was 60 years, with a median time of 24.5 months from the primary malignancy diagnosis to BM detection. The 12-month LC rate per patient was 84.6 %, and 5.6 % per BM. Only two instances of local recurrence were observed. The DTC at 12 months was 75 %, with a 29 % overall. Non-significant trends indicating a correlation with distant brain failure with increased cumulative volume and the occurrence of craniotomy before SRS. The median OS of the cohort was 16.5 months from SRS treatment. The 6, 12, 18, and 24-month survival rates were 77.8 %, 66.7 %, 50 %, and 22.2 % respectively. Higher number of BM was associated with lower OS (p = 0.046). On multivariate analysis, age was a significant factor for OS (p = 0.03), demonstrating that older age was associated with a more favorable prognosis. CONCLUSION: This study supports SRS effectiveness for treating BM from gynecological cancers and suggests similar outcomes to more common malignancies.

Reduced risk trajectory planning in image-guided keyhole neurosurgery.

PURPOSE: The authors present and evaluate a new preoperative planning method and computer software designed to reduce the risk of candidate trajectories for straight rigid tool insertion in image-guided keyhole neurosurgery. METHODS: Trajectories are computed based on the surgeon-defined target and a candidate entry point area on the outer head surface on preoperative CT/MRI scans. A multiparameter risk card provides an estimate of the risk of each trajectory according to its proximity to critical brain structures. Candidate entry points in the outer head surface areas are then color-coded and displayed in 3D to facilitate selection of the most adequate point. The surgeon then defines and/or revised the insertion trajectory using an interactive 3D visualization of surrounding structures. A safety zone around the selected trajectory is also computed to visualize the expected worst-case deviation from the planned insertion trajectory based on tool placement errors in previous surgeries. RESULTS: A retrospective comparative study for ten selected targets on MRI head scans for eight patients showed a significant reduction in insertion trajectory risk. Using the authors' method, trajectories longer than 30 mm were an average of 2.6 mm further from blood vessels compared to the conventional manual method. Average planning times were 8.4 and 5.9 min for the conventional technique and the authors' method, respectively. Neurosurgeons reported improved understanding of possible risks and spatial relations for the trajectory and patient anatomy. CONCLUSIONS: The suggested method may result in safer trajectories, shorter preoperative planning time, and improved understanding of risks and possible complications in keyhole neurosurgery.

Low incidence of brain tumors among Ethiopian immigrants in Israel.

Studies comparing brain tumor incidence have consistently shown lower incidence in Africans compared to European populations. We compared the incidence of brain tumors in Ethiopian immigrants and their Israel-born descendants with other Israeli subpopulations. We included all cases of benign or malignant brain tumors from 1992 to 2003, as reported to the Israel Cancer Registry, except individuals known to have been irradiated for tinea capitis. Age standardized incidence rates (ASR) and standardized incidence ratios (SIR) were calculated. Among Ethiopian-born immigrants, 38 brain tumors were diagnosed (an ASR of 6.68 per 10(5) for all brain tumors among Ethiopian immigrants). The incidence of all brain tumors and malignant brain tumors among Ethiopian immigrants was significantly lower than that in Israeli-born Jews [SIR = 0.73, 95% confidence interval (CI) 0.50-0.96, and SIR = 0.65, 95% CI 0.32-0.98, respectively] and in all other Jewish subpopulations. Brain tumor incidence was not significantly different in Israeli-born children of Ethiopian immigrants aged 0-14 compared to Ethiopian immigrants of the same age group (SIR = 0.68, 95% CI 0.14-1.23), and was comparable to incidence among Israeli children of non-Ethiopian parents. We concluded that ethnicity influences brain tumor incidence, and that Ethiopian immigrants to Israel appear to be protected. If an environmental influence on the protective effect of the Ethiopian population in Israel exists, it was not demonstrated in the study in a statistically significant manner. Further investigation is needed to understand the factors involved in the incidence variation among different populations.

Flow-diverter stents in the early management of acutely ruptured brain aneurysms: effective rebleeding protection with low thromboembolic complications.

OBJECTIVE: Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome. METHODS: The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed. RESULTS: Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0-2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage. CONCLUSIONS: Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors' experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.

[18F]-FDHT PET/CT as a tool for imaging androgen receptor expression in high-grade glioma.

BACKGROUND: G lioblastoma (GBM) is associated with poor overall survival. Recently, we showed that androgen receptor (AR) protein is overexpressed in 56% of GBM specimens and AR antagonists induced dose-dependent death in several GBM cell lines and significantly reduced tumor growth and prolonged the lifespan of mice implanted with human GBM. 16ß-18F-fluoro-5α-dihydrotestosterone ([18F]-FDHT) is a positron emission tomography (PET) tracer used to detect AR expression in prostate and breast cancers. This study was aimed at exploring the ability of [18F]-FDHT-PET to detect AR expression in high-grade gliomas. METHODS: Twelve patients with suspected high-grade glioma underwent a regular workup and additional dynamic and static [18F]-FDHT-PET/CT. Visual and quantitative analyses of [18 F]-FDHT kinetics in the tumor and normal brain were performed. Mean and maximum (max) standardized uptake values (SUVs) were determined in selected volumes of interest. The patients had surgery or biopsy after PET/CT. AR protein was analyzed in the tumor samples by western blot. Fold change in AR expression was calculated by densitometry analysis. Correlation between imaging and AR protein samples was determined. RESULTS: In six of the 12 patients, [18 F]-FDHT uptake was significantly higher in the tumor than in the normal brain. These patients also had increased AR protein expression within the tumor. Pearson correlation coefficient analysis for the tumor-to-control normal brain uptake ratio in terms of SUVmean versus AR protein expression was positive and significant (R = 0.84; P = .002). CONCLUSION: [18 F]-FDHT-PET/CT could identify increased AR expression in high-grade glioma.

Rapid growth of primary cerebral fibrosarcoma with conversion to glioblastoma at second recurrence.

We present a case of de novo fibrosarcoma in a 43-year-old male, with MRI documented evolution from a 5 mm hyperintense area to 5 cm tumor mass in a 12-month period. The diagnosis of low-grade fibrosarcoma was established by three experienced neuropathologists. The patient underwent gross total resection with adjuvant fractionated conformal radiotherapy. Following first recurrence 3 months later, the patient was reoperated and stereotactic radiosurgery of a residual tumor was performed thereafter. The pathological diagnosis was similar, but with additional extensive radiation effects. Six months later the patient underwent aggressive surgical resection for second recurrence. The pathological diagnosis was WHO grade IV glioblastoma. The etiology of this highly unusual progression from primary mesenchymal neoplasm to high-grade glioma is discussed.

Radiation-induced vascular malformations in the brain, mimicking tumor in MRI-based treatment response assessment maps (TRAMs).

•Of 310 brain tumors patients recruited, histology of 99 lesions was available.•Of those, 5 were histologically confirmed as radiation-induced malformations.•TRAMs cannot differentiate active tumor from vascular malformation.

Serum S100B levels after meningioma surgery: A comparison of two laboratory assays.

BACKGROUND: S100B protein is a potential biomarker of central nervous system insult. This study quantitatively compared two methods for assessing serum concentration of S100B. METHODS: A prospective, observational study performed in a single tertiary medical center. Included were fifty two consecutive adult patients undergoing surgery for meningioma that provided blood samples for determination of S100B concentrations. Eighty samples (40 pre-operative and 40 postoperative) were randomly selected for batch testing. Each sample was divided into two aliquots. These were analyzed by ELISA (Sangtec) and a commercial kit (Roche Elecsys(R)) for S100B concentrations. Statistical analysis included regression modelling and Bland-Altman analysis. RESULTS: A parsimonious linear model best described the prediction of commercial kit values by those determined by ELISA (y = 0.045 + 0.277*x, x = ELISA value, R2 = 0.732). ELISA measurements tended to be higher than commercial kit measurements. This discrepancy increased linearly with increasing S100B concentrations. At concentrations above 0.7 microg/L the paired measurements were consistently outside the limits of agreement in the Bland-Altman display. Similar to other studies that used alternative measurement methods, sex and age related differences in serum S100B levels were not detected using the Elecsys(R) (p = 0.643 and 0.728 respectively). CONCLUSION: Although a generally linear relationship exists between serum S100B concentrations measured by ELISA and a commercially available kit, ELISA values tended to be higher than commercial kit measurements particularly at concentrations over 0.7 microg/L, which are suggestive of brain injury. International standardization of commercial kits is required before the predictive validity of S100B for brain damage can be effectively assessed in clinical practice.

Radiation-induced meningioma.

The long-term or delayed side effects of irradiation on neural tissue are now known to include the induction of new central nervous system neoplasms. However, during the first half of the 20th century, human neural tissue was generally considered relatively resistant to the carcinogenic and other ill effects of ionizing radiation. As a result, exposure to relatively high doses of x-rays from diagnostic examinations and therapeutic treatment was common. In the present article the authors review the literature relating to radiation-induced meningiomas (RIMs). Emphasis is placed on meningiomas resulting from childhood treatment for primary brain tumor or tinea capitis, exposure to dental x-rays, and exposure to atomic explosions in Hiroshima and Nagasaki. The incidence and natural history of RIMs following exposure to high- and low-dose radiation is presented, including latency, multiplicity, histopathological features, and recurrence rates. The authors review the typical presentation of patients with RIMs and discuss unique aspects of the surgical management of these tumors compared with sporadic meningioma, based on their clinical experience in treating these lesions.

Ruptured middle cerebral artery aneurysm in an infant presenting as acute subdural hematoma: a case report.

We present an unusual case of ruptured infantile cerebral aneurysm. An eight-month-old infant was delivered to the hospital in poor condition, after convulsions, with no history of trauma. His emergent CT study revealed acute subdural hematoma. The clinical and radiological picture evoked suspicion that the hematoma was of aneurysmal origin. The infant was operated with special preparations and precautions appropriate for aneurysmal surgery, and has shown a good recovery. It is important to consider the possibility of vascular accident in infants with subdural hematoma of nontraumatic origin. A good outcome may be achieved when appropriate preparations are made prior to surgery.

Related to testes-specific, vespid, and pathogenesis protein-1 (RTVP-1) is overexpressed in gliomas and regulates the growth, survival, and invasion of glioma cells.

In this study, we examined the expression and functions of related to testes-specific, vespid, and pathogenesis protein 1 (RTVP-1) in glioma cells. RTVP-1 was expressed in high levels in glioblastomas, whereas its expression in low-grade astrocytomas and normal brains was very low. Transfection of glioma cells with small interfering RNAs targeting RTVP-1 decreased cell proliferation in all the cell lines examined and induced cell apoptosis in some of them. Overexpression of RTVP-1 increased astrocyte and glioma cell proliferation and the anchorage-independent growth of the cells. In addition, overexpression of RTVP-1 rendered glioma cells more resistant to the apoptotic effect of tumor necrosis factor-related apoptosis-inducing ligand and serum deprivation. To delineate the molecular mechanisms involved in the survival effects of RTVP-1, we examined the expression and phosphorylation of various apoptosis-related proteins. We found that overexpression of RTVP-1 decreased the phosphorylation of c-Jun-NH2-kinase and increased the expression of Bcl2 and that the protective effect of RTVP-1 was partially mediated by Bcl2. Finally, we found that RTVP-1 regulated the invasion of glioma cells as was evident by their enhanced migration through Matrigel and by their increased invasion in a spheroid confrontation assay. The increased invasive potential of the RTVP-1 overexpressors was also shown by the increased activity of matrix metalloproteinase 2 in these cells. Our results suggest that the expression of RTVP-1 is correlated with the degree of malignancy of astrocytic tumors and that RTVP-1 is involved in the regulation of the growth, survival, and invasion of glioma cells. Collectively, these findings suggest that RTVP-1 is a potential therapeutic target in gliomas.

[Rehabilitation outcomes of terror victims with multiple trauma: the experience in Hadassah University Hospital 2000-2004].

From late September 2000 until 2005, the State of Israel was attacked by continuing acts of terrorism known as the Al Aqsa Intifada. During this period the number of terror victims treated in rehabilitation facilities has escalated significantly. The city of Jerusalem has a unique place in the heart of the Israel-Palestinian conflict and, therefore, almost 20% of national atrocities have been carried out in Jerusalem. Between September.2000 and September 2004, 72 terror victims were treated in the department of rehabilitation in Hadassah University Hospital. Among them, 47 (65%) suffered from multiple trauma without CNS involvment, 19 (26%) suffered from traumatic brain injury and 6 (8%) suffered from spinal cord injury. The rehabilitation outcomes of terror victims was compared to the rehabilitation outcomes of non-terror multiple trauma patients treated in the same rehabilitation facility over the same period. The rehabilitation outcomes were evaluted using the following parameters: length of hospitalization (LOH) in acute care departments, inpatient and outpatient rehabilitation departments, functional outcome (Functional Independence Measurement, FIM), occupational outcome (returning to previous occupation) and psychological outcome (Salomon PTSD questionnaire). The mean LOH of terror victims was 218 +/- 131 days as opposed to 152 +/- 114 days for the non-terror group (p < 0.01). The difference between FIM value at entry and discharge (delta FIM) was significantlly higher in terror victims as compared to controls (41.1 +/- 21.6 vs. 30.8 +/- 21.8, p = 0.002). The rate of PTSD was higher among terror victims than non-terror control (40.9% vs. 24.2%, p = 0.04). The rate of returning to previous occupation was similar between terror and non-terror victims (53% vs. 46.9% respectively). Long term study showed that terror victims still suffer from lower quality of life and life satisfaction 2 years after the insult. In summary, terror victims spent longer periods in rehabilitation and regained most of the Activities of Daily Living (ADL) functions similar to the non-terror group. In spite of the higher rate of PTSD, terror victims succeeded in returning to their previous occupation similar to the non-terror group.

Computer-based radiological longitudinal evaluation of meningiomas following stereotactic radiosurgery.

PURPOSE: Stereotactic radiosurgery (SRS) is a common treatment for intracranial meningiomas. SRS is planned on a pre-therapy gadolinium-enhanced T1-weighted MRI scan (Gd-T1w MRI) in which the meningioma contours have been delineated. Post-SRS therapy serial Gd-T1w MRI scans are then acquired for longitudinal treatment evaluation. Accurate tumor volume change quantification is required for treatment efficacy evaluation and for treatment continuation. METHOD: We present a new algorithm for the automatic segmentation and volumetric assessment of meningioma in post-therapy Gd-T1w MRI scans. The inputs are the pre- and post-therapy Gd-T1w MRI scans and the meningioma delineation in the pre-therapy scan. The output is the meningioma delineations and volumes in the post-therapy scan. The algorithm uses the pre-therapy scan and its meningioma delineation to initialize an extended Chan-Vese active contour method and as a strong patient-specific intensity and shape prior for the post-therapy scan meningioma segmentation. The algorithm is automatic, obviates the need for independent tumor localization and segmentation initialization, and incorporates the same tumor delineation criteria in both the pre- and post-therapy scans. RESULTS: Our experimental results on retrospective pre- and post-therapy scans with a total of 32 meningiomas with volume ranges 0.4-26.5 cm[Formula: see text] yield a Dice coefficient of [Formula: see text]% with respect to ground-truth delineations in post-therapy scans created by two clinicians. These results indicate a high correspondence to the ground-truth delineations. CONCLUSION: Our algorithm yields more reliable and accurate tumor volume change measurements than other stand-alone segmentation methods. It may be a useful tool for quantitative meningioma prognosis evaluation after SRS.