Neurosurgical focus最新文献

Objective: Hyperspectral imaging (HSI) is an emerging new intraoperative, noninvasive, contrast agent-free, easy, and quick-to-use imaging modality. The present study aimed to correlate intraoperative HSI in glioma surgery with fluid attenuated inversion recovery (FLAIR) signal intensity.

Methods: The present prospective study performed intraoperative in vivo HSI with the TIVITA Tissue system to measure spectral signatures ranging from 500 to 1000 nm. The following tissue parameters were measured: oxygen saturation, perfusion, and hemoglobin, water, and fat content. The signal intensity of noncontrast-enhancing FLAIR regions was measured using ImageJ. The datasets were analyzed for correlations between HSI parameters and FLAIR signal intensity.

Results: Measurements were included from 15 patients. Histopathological analysis identified 10 cases of glioblastoma and 5 cases of astrocytoma, which were classified as WHO grade 2 (1 patient), WHO grade 3 (3 patients), and WHO grade 4 (1 patient). The area under the curve of the tissue water index (TWI) based on HSI for predicting increased FLAIR signal intensity was 0.70 (95% CI 0.40-0.99). TWI ≥ 0.416 had sensitivity and specificity of 75.0% and 85.7%, respectively. Six of 7 patients (85.7%) with TWI ≥ 0.416 had high FLAIR signal intensity, whereas 6 of 8 patients (75.0%) with TWI < 0.416 had low FLAIR signal intensity (p = 0.04).

Conclusions: The present investigation shows that the use of HSI to measure tissue water content correlates with the FLAIR signal intensity of nonenhancing glioma areas. Future studies evaluating the sensitivity and specificity of HSI to detect histopathologically confirmed nonenhancing glioma areas are needed.

Objective: Despite advances in the management of high-grade glioma (HGG), overall survival (OS) and progressionfree survival (PFS) remain suboptimal given the aggressive nature of these tumors. Difficult-to-access tumor locations, high complication rates, and high tumor progression rates further complicate the treatment of HGG. Herein, the authors aimed to comprehensively evaluate the safety and efficacy of laser interstitial thermal therapy (LITT) for HGG.

Methods: A systematic review of the literature was conducted through four electronic databases (Web of Science, PubMed, Embase, and the Cochrane Library) to identify studies on LITT for HGG treatment. Binary and continuous outcomes were assessed using odds ratios, mean differences, and 95% confidence intervals. Meta-regression was conducted to determine the source of heterogeneity and to assess predictors of key outcomes with high heterogeneity.

Results: Twenty-one studies with 602 patients harboring HGG were included in this review. Mean OS following LITT was 11.74 months (95% CI 10.9-12.6 months), with 6-, 12-, and 24-month OS rates of 77.0% (95% CI 65.8%-86.6%), 48.9% (95% CI 40.5%-57.3%), and 16.1% (95% CI 10.7%-22.3%), respectively. Mean PFS was 5.3 months (95% CI 4.97-5.7 months), with 6-, 12-, and 24-month PFS rates of 37.1% (95% CI 24.3%-44.6%), 12.8% (95% CI 8.7%-17.5%), and 4.3% (95% CI 2.2%-6.9%), respectively. Postoperative permanent deficits occurred in 5.7% of patients (95% CI 0.85%-13.1%). Subgroup analysis showed that LITT for deep and unresectable HGG had a 12-month OS rate of 53.0% (95% CI 20.0%-84.7%) and 12-month PFS rate of 12.9% (95% CI 0.02%-38.3%). Additionally, newly diagnosed HGG had a significantly higher rate of permanent deficits (4.15%, 95% CI 0.4%-10.2%) than recurrent HGG (0.02%, 95% CI 0.0%-2.2%; p = 0.023). Sensitivity analysis showed significantly higher 6-month OS in newly diagnosed cases (p = 0.0069), with no differences in OS, PFS, post-LITT tumor progression, Karnofsky Performance Status change from baseline, or temporary deficits.

Conclusions: LITT is an effective treatment for HGGs, with an acceptable safety profile. However, further randomized prospective studies are necessary to validate these findings and establish the procedure's long-term efficacy.

Objective: Resection of gliomas within the superior frontal gyrus can result in prolonged and, in some cases, persistent supplementary motor area (SMA) syndrome. This highlights the need to accurately identify the cortical SMA and its underlying fiber tracts. In this study, the authors utilized navigated transcranial magnetic stimulation (nTMS) mapping and function-based fiber tractography to delineate the SMA in patients with frontal brain tumors.

Methods: Continuous theta burst stimulation was performed over six stimulation targets in the pre-SMA and SMA proper within the superior frontal gyrus. Patients performed the nine-hole peg test during stimulation using the hand contralateral to the stimulation.

Results: The study included 22 patients with a mean age of 47.7 ± 17.3 (range 25.3-79.4) years without motor deficits (11 low-grade gliomas, 11 high-grade gliomas), 12 (54.5%) of whom had left-sided lesions. Navigated TMS-positive sites were observed equally on both hemispheres (right: median 3 [range 2-4] vs left: median 3 [range 1-4], p = 0.694). Six patients (27.3%) developed a prolonged SMA syndrome postoperatively, persisting at the 3-month follow-up examination. Additionally, 1 patient (4.5%) exhibited permanent motor deficits related to the primary motor area. In patients with prolonged SMA syndrome, the number of resected nTMS-positive SMA sites was significantly higher, with a median of 2 (range 2-3) compared with 0 (range 0-2) in patients without SMA syndrome (p = 0.004). Resection of nTMS-positive SMA points showed a sensitivity of 100% and a specificity of 73.3% for the occurrence of a prolonged SMA syndrome. On the subcortical level, resection of the frontal aslant tract (FAT) showed the highest specificity (0.867) and negative predictive value (0.929). Combining findings of the FAT and frontostriatal tract resulted in a specificity of 0.667, with a sensitivity and negative predictive value of 1.00.

Conclusions: Navigated TMS-based mapping of the SMA is feasible, accurate, and reliable. Resection of nTMS-positive cortical sites and underlying subcortical fiber tracts provides excellent sensitivity and negative predictive value for the occurrence of prolonged SMA syndrome. However, these data are currently insufficient to fully elucidate the occurrence of SMA syndrome. Navigated TMS-based mapping of the SMA should be performed in addition to nTMS motor mapping in motor eloquent brain lesions to identify at-risk patients and optimize surgical outcomes.

Objective: Despite optimal therapy, high-grade glioma (HGG) still has a very unfavorable prognosis. Gross-total resection is not often possible, and even when it is, many patients still succumb to the disease due to resistance to temozolomide (TMZ) and radiotherapy. As the mechanism behind such resistance is multifactorial, microribonucleic acids (miRNAs) with their wide-ranging epigenetic effects on cancer have emerged as potential research targets. Among others, miRNA-10b and miRNA-21 are the most widely studied miRNAs in HGG. In this review, the authors aimed to investigate the role and predictive value of miRNA-10b and miRNA-21 in TMZ and radiotherapy resistance in HGG patients.

Methods: The PubMed, Europe PMC, and Web of Science databases were searched to find in vitro, in vivo, or clinical studies assessing the relationship between miRNA-10b and miRNA-21 expression with TMZ resistance, radiotherapy resistance, and survival. Review articles, editorials, correspondence, case reports, case series, non-English-language articles, and studies that only analyzed datasets were excluded. Results were then synthesized according to those three outcomes. This review has been registered in PROSPERO (International Prospective Register of Systematic Reviews) under registration no. CRD1004470.

Results: There were 34 studies included in this review, with 25 studies evaluating miRNA-21, 6 studies evaluating miRNA-10b, and 3 studies evaluating both miRNA-10b and miRNA-21. The results of the in vitro and in vivo studies were unequivocal in demonstrating that miRNA-10b and miRNA-21 expression correlated with resistance. The two miRNAs increased tumor stemness, viability, invasiveness, and resistance to apoptosis. However, not all the clinical studies demonstrated a significant relationship between both miRNAs and survival. This was possibly caused by differences in resection status and sampling method.

Conclusions: MiRNA-10b and miRNA-21 expression correlated with TMZ and radiotherapy resistance in vivo and in vitro. With properly designed human studies, these results could translate to tremendous benefits in the clinical field. Future clinical studies should be designed to better account for resection status and sampling method.

Objective: Visuospatial neglect corresponds to a burdening cognitive deficit with reduced space attention and disturbed stimuli detection of the contralateral side. Unilateral strokes, tumor lesions, or intracerebral hemorrhage may cause it. Identifying specific areas responsible for the onset of visuospatial neglect has proven difficult. The authors hereby aimed to detect neglect-positive areas in patients with parietal gliomas undergoing tumor resection through navigated repetitive transcranial magnetic stimulation (nrTMS).

Methods: The authors performed a monocentric prospective study that included patients with suspected parietal lobe gliomas. After obtaining patient consent, time-locked nrTMS was performed for neglect testing using the Landmark Task and grayscale test on 52 predefined cortical spots before and after surgery. Errors were categorized as leftward/rightward errors or deviations and no response errors. Additionally, patients performed two paper-and-pencil tests to evaluate clinical neglect.

Results: Nineteen patients were enrolled in the study. Ten patients had a glioma, 8 had brain metastases, and 1 patient had a meningioma. Error rates and leftward deviations were significantly higher in the right hemisphere. The supramarginal and angular gyrus and the superior parietal and occipital areas seemed especially important. After surgery, errors increased substantially in the right hemisphere. The Landmark Task and grayscale test showed high sensitivity (100%) and a negative predictive value (100%).

Conclusions: Visuospatial neglect can be evoked reliably by nrTMS in patients with parietal tumors. The study showed promising results for the intraoperative use of nrTMS visuospatial neglect mapping.

Seizures following resection for glioma can significantly impact patient quality of life. Resection and antiseizure medications have been first-line treatments for glioma-associated epilepsy since the survival benefit of maximizing the extent of resection was established. Given recent advances in tumor molecular profiling and neuron-glioma circuit interactions, should the management of tumor-associated epilepsy change? Here the authors present a literature review of the current state of the surgical and medical management of postoperative seizures in patients with glioma, summarize key findings from investigations of the molecular processes governing tumor-associated seizures, and provide a retrospective review correlating tumor mutational profiles obtained from next generation sequencing with seizure history in patients from a single institution. This paradigm of comparing clinical seizure outcomes and tumor genetics may broaden the understanding of glioma-associated epilepsy and prognostic factors, potentially leading to new therapeutic strategies.

Objective: This study aimed to analyze the comparative tumor resection rates and complication profiles of the transsylvian (TS) and transcortical (TC) approaches to the insular glioma (IG) and emphasize the concept of onco-microneurosurgery as a key to surgical success in these difficult areas.

Methods: A retrospective analysis of a single surgeon's prospectively maintained data of surgically resected, newly diagnosed IGs in adult patients (≥ 18 years old) was conducted. Propensity score matching was performed with a tolerance limit of 0.05 for comparison of the TS and TC cohorts. The extent of resection (EOR) was categorized with 90% resection as a cutoff. Neurological complications persisting beyond 3 months were considered permanent complications. These two variables were combined to derive a Composite Postoperative Outcome Index (CPOI) and graded as 0, 1a, 1b, or 2.

Results: Fifty-two patients (male-to-female ratio of 2.25:1) were studied, with 26 patients in each group. Radical tumor resection (≥ 90%) was obtained in 77% patients (n = 40), with transient and permanent neurological complication rates of 46.2% (n = 24) and 15.4% (n = 8), respectively. A significantly higher rate of maximal safe resection (CPOI grade 0) was obtained using a TS approach for the entire TS cohort (p = 0.008), as well as subgroups of non-giant segmental IGs (p = 0.011) and those with specific Berger-Sanai zone II involvement (p = 0.01). The TC approach was found to be significantly safer in giant IGs when a subtotal resection was performed (p = 0.03). Permanent neurological complications with ≥ 90% EOR (CPOI grade 1b) were significantly higher in the TC group (p = 0.009), including non-giant segmental IGs (p = 0.001) and those specifically involving Berger-Sanai zone II (p = 0.01) of the insula. Long-term functional status and disease progression were similar in both groups.

Conclusions: These results suggest the continued role of the TS approach in IG resection in the contemporary era. Irrespective of the approach, the key variable appears to be a meticulous microsurgical technique, supplemented by the available adjuncts, in the preservation of perforator arteries and subcortical circuitry. Thus, an optimally designed, individual institution-tailored hybrid onco-microneurosurgical approach is the most pragmatic approach to IGs.

Objective: The intratumoral heterogeneous vascular permeability and cell density of gliomas are associated with IDH mutation status. Therefore, the authors aimed to construct vascular-cellular habitats based on MRI to investigate their correlation with IDH status.

Methods: In this retrospective analysis, 165 patients with pathologically confirmed glioma who underwent preoperative contrast-enhanced T1-weighted imaging and diffusion-weighted imaging (DWI) at three hospitals were included. Four spatial habitats (subregions) based on contrast-enhanced T1-weighted and DWI-derived apparent diffusion coefficient (ADC) images were defined using K-means voxel-wise clustering. The sensitive habitat of IDH mutation was identified and radiomic features were extracted and screened from the whole tumor and the four habitats. Logistic regression classifiers were used to construct predictive models for IDH mutation.

Results: Of the included patients, 109 (mean age 50.78 years) were assigned to the training set and 56 (mean age 48.21 years) to the external test set. The high contrast enhancement (CE)-high ADC subregion was determined as the sensitive habitat. The four habitats model achieved an area under the receiver operating characteristic curve (AUC) of 0.716 (95% CI 0.553-0.879) in the external test set, indicating better performance than that of the traditional whole tumor model (AUC 0.619, 95% CI 0.446-0.792). Model performance was further improved when focusing on the sensitive habitat, for which the external test set AUC was 0.817 (95% CI 0.676-0.958).

Conclusions: MRI habitat analysis based on contrast-enhanced T1-weighted and DWI sequences had high prediction capabilities for glioma IDH mutation status, which could be used to refine individualized treatment regimens for patients with glioma.

Objective: Reoperation for recurrent glioblastoma (GBM) remains controversial but is commonly offered to maximize patient quality of life (QOL) and functional status. While there is mixed evidence that waiting for surgery in primary GBM does not affect survival, this has not been studied in the context of recurrent disease, which is more aggressive. The aim of this study was to assess how recurrent tumor kinetics (i.e., tumor growth relative to the time to resection) affect survival and QOL, as measured by time toxicity, after repeat resection in patients with recurrent GBM.

Methods: A prospectively collected database was queried for patients with first-time recurrent IDH-wildtype GBM, with progression confirmed by the modified Response Assessment in Neuro-Oncology criteria, from 2012 to 2022. Only patients who were recommended surgery as the first-line treatment for disease progression were included. Recursive partitioning analysis was used to automatically detect growth rate and time to repeat resection (TTRR) thresholds that affected repeat resection survival (RRS). Time toxicity was the percentage of days of medical contact for the TTRR and RRS.

Results: Seventy-three patients were included in the analysis. The median TTRR of the overall cohort was 27.2 days (range 1-90 days), with a mean TTRR time toxicity of 25.2% (SD 29.2%). The median RRS was 270 days (range 23-1495 days), with a mean RRS time toxicity of 19.3% (SD 17.7%). Patients with tumor growth of 0.08 cm3 per day or faster (faster-growth group) had significantly worse RRS (p = 0.004) and time toxicity (p = 0.016). Patients who underwent repeat resection ≥ 43 days (longer TTRR group) after confirmed progression had significantly worse survival (p = 0.015) and the time toxicity increased after surgery (11.6% to 25.1%, p = 0.014). While there was no significant survival difference between the faster tumor growth and longer TTRR group compared with the faster growth and shorter TTRR group (p = 0.20), the group with faster tumor growth but shorter TTRR had better survival (median 179 days vs 81 days).

Conclusions: Faster-growing GBM recurrence was associated with worse survival and time toxicity. Patients with a shorter time to surgery had improved survival compared with those with longer wait times, and this effect partially attenuated the poor risk of fast tumor growth. Therefore, tumor kinetics in recurrent GBM appear to be an important consideration for patient prognosis and QOL after surgery.