Correlation of glioma proliferation assessed by flow cytometry with Tc-Tetrofosmin SPECT uptake

Objectives

Brain single-photon emission computed tomography (SPECT) has been proposed as a potentially useful modality for the metabolic assessment of various brain tumors.

Material and methods

In a 10-patient prospective pilot study we evaluated whether ^99mTc-Tetrofosmin (^99mTc-TF) uptake correlates with glioma proliferative activity assessed by flow cytometric analysis. ^99mTc-TF brain SPECT was performed shortly before surgical tumor excision.

Results

Eight patients were diagnosed with glioblastoma multiform and 2 with anaplastic astrocytoma. All tumors were aneuploid. We found a significant positive linear correlation between ^99mTc-TF uptake and percentage of tumor cells on the S-phase of the cell cycle (r = 0.92, P = 0.001).

Conclusion

Initial evidence suggests that ^99mTc-TF could provide a non-invasive indicator of glioma proliferative activity.     

Preoperative spinal tumor embolization: An institutional experience with Onyx

Background

Preoperative embolization has the potential to decrease intraoperative blood loss and facilitate spinal cord decompression and tumor resection.

Objective

We report our institutional experience with the embolization of hypervascular extradural spinal tumors with Onyx as well as earlier embolic agents in a series of 28 patients.

Methods

A retrospective case review was conducted on patients undergoing preoperative transarterial embolization of a spinal tumor between 1995 and 2012 at our institution.

Results

Twenty-eight patients met the inclusion criteria, with a mean age of 60.6 years. Twenty-eight patients had metastatic tumors. In 14 (50%) patients the metastases were from renal cell carcinomas. Fifty-four vessels were embolized using PVA, NBCA, Onyx, coils, or embospheres. Sixteen patients were treated with Onyx, 6 patients with PVA, 3 patients with embospheres, 2 patients with NBCA, and 3 patients with a combination of embolic agents. The average decrease in tumor blush was 97.8% with Onyx versus 92.7% with the rest of the embolic agents (p = 0.08). The estimated blood loss was 1616 ml (range 350–5000 ml). Blood loss was 750 cm³ on average with Onyx versus 1844 with the rest of the embolic agents (p = 0.14). The mean length of stay was 16 days. The mortality rate was zero. Pre- and post-operative modified Rankin Score (mRS) did not differ significantly in the series (3.12 versus 3.10, respectively, p = 0.9).

Conclusion

In our experience, the use of transarterial tumor embolization as an adjunct for spinal surgery is a safe and feasible option.     

The influence of surgery on recurrence pattern of glioblastoma

Objectives

Glioblastoma recurs within 2 cm from the primary tumor's margins in 90–95% of cases. Natural history of recurrence is not well defined. The aim of this study was to verify if pattern of recurrence can be influenced by the extent of surgery.

Patients and methods

131 patients with glioblastoma underwent tumor removal, followed by standard adjuvant radio-chemotherapy. Depending on the amount of apparently normal white matter measured around the tumor in the surgical specimen, the extent of surgery was classified into: “border resection” (BR, resection margins at the level of tumor border) or “extended resection” (ER, resection margins 1–2 cm far from tumor border). 88 patients had no residual tumor at post-operative MRI. Among these, 60 patients had a local recurrence (LR) – within 2 cm from the primary tumor's margins, 15 patients had a distant recurrence (DR), 13 patients had no recurrence. Survival curves were obtained through the Kaplan–Meier method. Dichotomous data were compared with the chi-square test.

Results

Patients who underwent ER presented a LR in 67% of cases. Patients who underwent BR presented a LR in 87.5% of cases (p = 0.03). Survival for 60 patients with LR was 16 months vs 35 months for 15 patients with DR (p = 0.06). PFS for patients with LR was 9 months vs 21 months for patients with DR (p = 0.05).

Conclusions

If tumor grows far from eloquent areas, ER may increase the probability to obtain a gross total resection, a greater number of patients with DR and, therefore, a longer survival.     

Differentiation of pure vasogenic edema and tumor-infiltrated edema in patients with peritumoral edema by analyzing the relationship of axial and radial diffusivities on 3.0T MRI

Object

The purpose of this study was to analyze the relationship of axial diffusivity (AD) and radial diffusivity (RD) in peritumoral edema of high grade glioma, metastasis, and meningioma, and to differentiate tumor-infiltrated edema from pure vasogenic edema.

Materials and methods

Twenty patients with high-grade glioma and 16 with meningioma or metastatic tumor were enrolled in our study. All cases were confirmed by histopathological study. Diffusion tensor imaging (DTI) was performed in all patients. Peritumoral edema of high-grade glioma was considered tumor-infiltrated edema, and edema of meningioma or metastasis was considered pure vasogenic edema. Fractional anisotropy (FA), mean diffusivity (MD), AD, RD, regression coefficient of RD to AD (RC_RD–AD), and tumor infiltration index (TII) in tumor-infiltrated edema and pure vasogenic edema were analyzed and compared. Receiver operating characteristic (ROC) curve analysis was conducted to demonstrate their differential effectiveness.

Results

RC_RD–AD in tumor-infiltrated edema (0.724 ± 0.125) was significantly higher than that in pure vasogenic edema (0.571 ± 0.111) (P = 0.001). FA of tumor-infiltrated edema (0.175 ± 0.025) was significantly lower than that of pure vasogenic edema (0.203 ± 0.035) (P = 0.007). Other parameters showed no significant difference between the 2 types of edema. ROC curve analysis showed RC_RD–AD was the most effective parameter in distinguishing tumor-infiltrated edema from pure vasogenic edema. Using a threshold of 0.6, a sensitivity of 0.85 and specificity of 0.69 can be achieved with RC_RD–AD.

Conclusion

Analysis of the AD and RD relationship may reflect differences in diffusion characteristics of edema surrounding high-grade glioma and meningioma or metastasis, and may be helpful in detecting peritumoral infiltration in high-grade glioma.     

Non-functioning pituitary macro-incidentalomas benefit from early surgery before becoming symptomatic

Objective

Pituitary incidentalomas (PIs) constitute an increasingly clinical problem. While the therapeutic management is well defined for symptomatic non-functioning PIs (NFPIs), a controversy still exists for asymptomatic macro-NFPIs between surgery and a “wait and see” approach. The aim of this study is to compare surgical results between symptomatic and asymptomatic macro-NFPIs.

Methods

We conducted a retrospective study on 76 patients with newly diagnosed symptomatic and asymptomatic macro-NFPIs operated on between 2001 and 2010. We compared age, tumor size and surgical results between these two patient groups.

Results

After the initial evaluation, 48 patients were found to be symptomatic. Gross total removal (GTR) rate was significantly higher in asymptomatic (82%) than in symptomatic patients (58%; p = 0.03). Gross total removal was strongly associated with Knosp's classification (p = 0.01). Postoperative endocrinological impairment was significantly associated with the existence of preoperative symptoms (p = 0.03). It was 10 times less frequent in the asymptomatic group. In symptomatic patients, postoperative visual and endocrinological impairment were present in 49% and 78% versus 0% and 14% in asymptomatic patients respectively.

Conclusions

The endocrinological and visual outcome was better in those patients who underwent surgery for asymptomatic tumors. The extent of tumor resection was also significantly greater in smaller tumors. It would therefore be appropriate to offer surgery to patients with asymptomatic macro-NFPIs.     

Clinical outcome of surgically treated low-grade gliomas: A retrospective analysis of a single institute

Objective

Low grade gliomas (LGGs) are slow-growing primary brain tumors with heterogeneous clinical behaviors. The aim of our study is to review the treatment outcome of 63 patients with LGGs focusing on surgical outcome and the current therapeutic strategy.

Methods

We retrospectively enrolled 63 patients surgically treated for LGGs. The gross total resection (GTR) was performed in 35 patients (60.3%), subtotal resection (STR) was performed in 19 patients (31.7%) and partial resection (PR) or biopsy was performed in 9 patients (14.3%). We analyzed their progression-free survival (PFS), overall survival (OS), and malignant transformation with regard to age, gender, Karnofsky performance score (KPS), clinical presentation, tumor location, radiologic pattern, contrast enhancement, extent of removal, pathologic subtype, chemotherapy (CT) and radiotherapy (RT) treatment.

Results

Among all LGGs, the 3-year OS rate was 80% and the 5-year OS was 76%. The 3-year PFS rate was 83.6% and the 5-year PFS was 25%. The non-eloquent area location showed a longer PFS than the eloquent area location (p = 0.05). Oligodendroglial pathology showed a longer PFS compared to oligoastrocytomas and astrocytomas (p = 0.02). Patients older than 60 years had poorer OS than younger patients (p < 0.05). Female gender had a shorter OS than male gender (p < 0.05), and a KPS of 90 or 100 had a longer OS than a KPS of 80 (p < 0.05). Oligodendroglial pathology statistically correlated with a longer OS (p < 0.05).

Conclusion

The findings from our study, which were confirmed by uni- and multivariate analyses, demonstrated that radical tumor resection was associated with better long-term outcomes and tumor progression for patients with LGG.     

Management and outcome of primary spinal ependymomas: A single center experience from Taiwan

Background

Surgical treatment of spinal ependymomas requires careful consideration of the relative risks of neurological worsening from surgery. Our aim was to determine the risk factors of neurological deterioration after surgery for spinal ependymomas.

Material and methods

This 20-year study included 17 patients (seven men and 10 women; 44.65 ± 13.62 years) with histologically confirmed spinal ependymomas. The basic features were reviewed and the functional status was assessed by using the modified McCormick classification. We subdivided the patient population into two groups according to whether neurological deterioration occurred after primary tumor resection (N = 5) or not (N = 12), and compared their clinical characteristics.

Results

The average duration of presenting symptoms in the 17 patients was 23.53 ± 21.45 months. Three (17.6%) patients underwent subtotal or partial resection and 14 (82.4%) patients underwent gross total resection. The incidence of neurological deterioration after primary resection of spinal ependymomas was 29.4%. There were five (100%) and two (16.7%) male patients in the neurological-deterioration and no-deterioration groups, respectively (p = 0.003). The duration of presenting symptoms was 24 months or over in all the patients with neurological deterioration and five of the 12 patients with improved or stabilized function (p = 0.044).

Conclusion

The risk associated with surgical resection of spinal ependymomas should not be overlooked because of the significant incidence of neurological deterioration. The male gender and long-standing symptom (≥24 months) are risk factors of postoperative neurological worsening. Early diagnosis and surgery are therefore critical for successful treatment of spinal ependymomas.     

Radiation induced early necrosis in patients with malignant gliomas receiving temozolomide

Background

Temozolomide is the major drug in the treatment of malignant gliomas. Radiation induced necrosis can behave radiologically and clinically like a recurrent tumor. The major problem is the differentiation between recurrence and radiation injury especially in early phases of treatment. The aim of this study was to evaluate the patients receiving temozolomide showing early clinical or radiological progression and impact of early necrosis on follow-up.

Patients and methods

We retrospectively evaluated medical records of 67 patients with malignant glioma receiving temozolomide. All patients received concomitant radiotherapy and temozolomide followed by adjuvant temozolomide. In case of any radiological or clinical progression, MRI spectroscopy evaluation was used to confirm tumoral progression.

Results

Radiological or clinical progression was observed in 17 (25.4%) patients. Early radiation induced necrosis was diagnosed in 4 of 17 patients (23.5%) by surgery (n = 3) and MRI spectroscopy (n = 1). The observed incidence of pseudoprogression was 4 in 67 (6%) patients. Patients with diagnosis of early radiation injury had median progression-free survival of 7 months compared to 5 months in patients without radiation damage (p = 0.004). However, there was no statistically significant difference in terms of overall survival between groups.

Conclusion

Temozolomide can cause early radiation induced injury which can mimic progressive tumor. Although the discrimination between two entities results in the accurate evaluation of response to therapy and benefits those patients, it did not affect overall survival. MRI spectroscopy is a valuable tool to define early radiation necrosis and should be further evaluated in larger prospective studies.     

Spectroscopy-supported frame-based image-guided stereotactic biopsy of parenchymal brain lesions: Comparative evaluation of diagnostic yield and diagnostic accuracy

Objective

Comparative evaluation of diagnostic efficacy of stereotactic brain biopsy performed with and without additional use of spectroscopic imaging (¹H-MRS) for target selection was done.

Methods

From 2002 to 2006, 30 patients with parenchymal brain lesions underwent ¹H-MRS-supported frame-based stereotactic biopsy, whereas in 39 others MRI-guided technique was used. Comparison of diagnostic yield of the procedure in these two groups was performed. Additionally, the diagnostic accuracy was evaluated in 37 lesions, which were surgically resected within 1 month thereafter.

Results

Stereotactic biopsy permitted establishment of a definitive histopathological diagnosis in 57 cases and diagnosis of low-grade glioma without specific tumor typing in 8 cases. In 4 cases tissue sampling was non-diagnostic. In 5 out of 8 cases with incomplete diagnosis and in all non-diagnostic cases target selection was performed without the use of ¹H-MRS (P = 0.2073). The diagnostic yields of ¹H-MRS-supported and MRI-guided procedures were 100% and 90%, respectively (P = 0.1268). Comparison of the histopathological diagnoses after stereotactic biopsy and surgical resection revealed complete diagnostic agreement in 13 cases, minor disagreement in 14 cases, and major disagreement in 10 cases. Among these last 10 cases, initial undergrading of non-enhancing WHO grade III gliomas was the most common (7 cases). The diagnostic accuracy of ¹H-MRS-supported and MRI-guided procedures was 67% and 79%, respectively (P = 0.4756).

Conclusion

While in the present study the diagnostic yield of ¹H-MRS-supported frame-based stereotactic brain biopsy was 100%, its statistically significant diagnostic advantages over MRI-guided technique were not proved. Optimal selection of the spectroscopic target for tissue sampling remains unclear.     

Interhemispheric approach to tumors of the posterior gyrus cinguli

Objective

Posterior gyrus cinguli tumors are a well-defined group of tumors that pose considerable challenges in creating surgical access and manipulating adjacent eloquent areas (visual and motor). Here we report our 5-year experience in the surgical treatment of these tumors and describe tumor characteristics, surgical steps, critical aspects, and prognostic factors.

Methods

This series comprises 37 patients operated on for glioma (high-grade in 28, low-grade in 9), often presenting with motor impairment (n = 20), intracranial hypertension (n = 15), seizures (n = 11), and/or hemianopia (n = 9). Preoperative assessment was performed with magnetic resonance imaging. Half of the tumors were more than 4 cm in size, and the majority presented secondary extension into the fronto-parieto-occipital area, the temporo-mesial area, and/or the corpus callosum. Positioning and assisted surgery were optimized in each patient based on preoperative planning.

Results

The ipsilateral interhemispheric approach was elected in all cases. Tumor size and extension were significantly associated with the degree of tumor removal. Total removal was achieved in 25 patients (65%); 4 (10%) had persistent morbidity (visual or motor deficits). The occurrence of local and systemic complications was negligible.

Conclusions

Surgical treatment of posterior gyrus cinguli tumors can be safely approached via the interhemispheric route as it permits several beneficial operative maneuvers in selected cases.     

The impact of repeated surgery and adjuvant therapy on survival for patients with recurrent glioblastoma

Objective

Treatment of glioblastoma recurrence can have a palliative aim, after considering risks and potential benefits. The aim of this study is to verify the impact of surgery and of palliative adjuvant treatments on survival after recurrence.

Methods

From January 2002 to June 2008, we treated 76 consecutive patients with recurrent glioblastoma. Treatment was: 1-surgery alone – 17 patients; 2-adjuvant-therapy alone – 24 patients; 3-surgery and adjuvant therapy – 16 patients; no treatment – 19 patients. The impact on median overall-survival (OS-time between recurrence and death/last follow-up) of age, Karnofsky performance scale (KPS), resection extent and adjuvant treatment scheme (Temozolomide alone vs low-dose fractionated radiotherapy vs others) was determined. Survival curves were obtained through the Kaplan–Meier method. Cox proportional-hazards was used for multivariate analyses. Significance was set at p < 0.05.

Results

Median OS was 7 months. At univariate analysis, patients with a KPS ≥ 70 had a longer OS (9 months vs 5 months – p < 0.0001). OS was 6 months for patients treated with surgery alone, 5 months for patients that received no treatment, 8 months for patients treated with chemotherapy alone, 14 months for patients treated with surgery and adjuvant therapy-p = 0.01. Patients with a KPS < 70 were significantly at risk for death – HR 2.8 – p = 0.001.Subgroup analysis showed no significant differences between patients receiving gross total or partial tumor resection and among patients receiving different adjuvant therapy schemes. Major surgical morbidity at tumor recurrence occurred in 16 out of 33 patients (48%).

Conclusion

It is fundamental, before deciding to operate patients for recurrence, to carefully consider the impact of surgical morbidity on outcome.     

Preservation of olfaction in surgery of olfactory groove meningiomas

Introduction

Olfaction is commonly considered as secondary among the sensory functions, perhaps reflecting a lack of interest in sparing olfaction after surgery for the olfactory groove meningiomas (OGM). However, considering the repercussions of olfaction for the quality of life, the assessment of post-operative olfaction should be necessary. We retrospectively reviewed the olfactory outcome in patients with OGM and investigated the factors associated with sparing the post-operative olfaction.

Methods

Between 1993 and 2012, 40 patients with OGM underwent surgical resection and estimated the olfactory function using the Korean version of “Sniffin'Sticks” test (KVSS). Variable factors, such as tumor size, degree of preoperative edema, tumor consistency, preoperative olfactory function, surgical approaches, patient's age, and gender were analyzed with attention to the post-operative olfactory function.

Results

Anatomical and functional preservation of olfactory structures were achieved in 26 patients (65%) and 22 patients (55%), respectively. Among the variable factors, size of tumor was significant related to the preservation of post-operative olfaction. (78.6% in size <4 cm and 42.3% in size >4 cm, p = 0.035). Sparing the olfaction was significantly better in patients without preoperative olfactory dysfunction (84.6%) compared with ones with preoperative olfactory dysfunction (40.7%, p = 0.016). The frontolateral approach achieved much more excellent post-operative olfactory function (71.4%) than the bifrontal approach (36.8%, p = 0.032).

Conclusions

If the tumor was smaller than 4 cm and the patients did not present olfactory dysfunction preoperatively, the possibility of sparing the post-operative olfaction was high. Among the variable surgical approaches, frontolateral route may be preferable sparing the post-operative olfaction.     

Calculating the tumor volume of acoustic neuromas: Comparison of ABC/2 formula with planimetry method

Objective

The ABC/2 equation is commonly applied to measure the volume of intracranial hematoma. However, the precision of ABC/2 equation in estimating the tumor volume of acoustic neuromas is less addressed. The study is to evaluate the accuracy of the ABC/2 formula by comparing with planimetry method for estimating the tumor volumes.

Methods

Thirty-two patients diagnosed with acoustic neuroma received contrast-enhanced magnetic resonance imaging of brain were recruited. The volume was calculated by the ABC/2 equation and planimetry method (defined as exact volume) at the same time. The 32 patients were divided into three groups by tumor volume to avoid volume-dependent overestimation (<3 ml, 3–6 ml and >6 ml).

Results

The tumor volume by ABC/2 method was highly correlated to that calculated by planimetry method using linear regression analysis (R² = 0.985). Pearson correlation coefficient (r = 0.993, p < 0.001) demonstrates nearly perfect association between two methods.

Conclusions

The ABC/2 formula is an easy method in estimating the tumor volume of acoustic neuromas that is not inferior to planimetry method.     

Seizure outcomes of lesionectomy in pediatric lesional epilepsy with brain tumor – Single institute experience

Purpose

To determine the clinical characteristics, surgical strategy, and outcome in pediatric lesional epilepsy patients younger than 5 years of age undergoing surgery in a single institute.

Method

Retrospective data were collected and analyzed on patients younger than 5 years of age who underwent lesionectomy for lesional epilepsy at single institute from January 2001 to August 2010. Fourteen pediatric lesional epilepsy patients were enrolled in this study. Engel classification was used to classify seizure outcome.

Results

Median preoperative seizure period was 1 month (range, 1–21). Median post-operative follow up period was 35 months (range 13–84). Ten patients who underwent gross total resection of tumor showed Engel class Ia seizure outcome without any antiepileptic drug (AED). Subtotal resection was performed in four patients to avoid eloquent area injury. Two of these four patients with subtotal removal became seizure-free (Engel class Ia) without AED, while two were in Engel class Ib with AED medication. There was no significant surgical morbidity or mortality.

Conclusion

Lesionectomy in children younger than 5 years of age is relatively safe and effective in controlling seizures. Short preoperative seizure periods and total removal of tumor might be associated with good outcome. Therefore, early and complete lesionectomy alone may help allow for seizure freedom and optimal brain development in pediatric patients.     

Supraorbital trans-eyebrow craniotomy and fluorescence-guided resection of fronto-basal high grade gliomas

Object

To determine the effectiveness of fluorescence-guided resection of fronto-basal high grade gliomas by using the supraorbital trans-eyebrow craniotomy.

Methods

We present a single-institution experience of 6 consecutive patients presenting high grade brain glioma located on the fronto-basal area that were operated through a supraorbital trans-eyebrow craniotomy. Previous to surgery all patients were administered 20 mg/kg of 5 aminolevulic acid so microscopic fluorescence-guided resection could be accomplished. Tumors were located on gyrus rectus (3 patients), medial orbital gyrus (2 patients), and anterior orbital gyrus (1 patient).

Results

Despite the narrow surgical corridor, fluorescence was useful in all cases. Fluorescence-guided resection allowed inclusion into the margins of resection of areas previously considered as normal under white light. Complete resection was obtained in 5 patients. No neurological postoperative new deficit was observed in this series. All six cases corresponded to glioblastoma. Only one case of superficial infection with delayed wound healing was reported as complication. All patients expressed a high level of satisfaction related to cosmetic result.

Conclusions

Fluorescence-guided resection of fronto-basal high grade gliomas can be successfully achieved through supraorbital trans-eyebrow craniotomy. Benefits of supraorbital craniotomy in the management of fronto-basal high grade gliomas as well as usefulness of fluorescence-guided resection through a very narrow corridor are exposed.     

Surgical resection of osteolytic calvarial lesions: Clinicopathological features

Objective

Osteolytic calvarial lesions are infrequent findings. Some cases are found incidentally during cancer staging or subsequent to unspecific symptoms. There are no standardized algorithms for the treatment of such lesions. Thus, the aim of this study was to describe the clinicopathological features and surgical outcome in various osteolytic calvarial lesions.

Material and methods

The clinical presentation, radiological imaging findings, surgical treatment and histopathological findings of 36 patients who underwent surgery for an osteolytic calvarial lesion at our institution between 1998 and 2008 were reviewed.

Results

Thirty-six osteolytic calvarial lesions were identified in 20 men and 16 women. Mean age at diagnosis was 37 years. Ten patients were children younger than 15 years. Five lesions were detected during cancer staging. Complete removal of the calvarial lesions was achieved in all patients without complications. The most common histopathological diagnosis was metastasis (n = 9), Langerhans-cell histiocytosis (n = 9), and intraosseous hemangioma (n = 5). In two asymptomatic patients, histopathological findings revealed metastases of a previously unknown tumor. In two other patients known to suffer from cancer, histopathological findings indicated intraosseous hemangioma and intraosseous meningioma, respectively. Reconstruction of the calvarial defect was performed in 24 cases with poly-methyl-methacrylate and with titanium mesh in 1 case.

Conclusions

Osteolytic calvarial lesions can be found in any age group. The histopathological examination reveals various entities, and in some instances it was not concurrent with a primary malignancy. Because surgical morbidity is low, we recommend complete resection of osteolytic calvarial lesions with reconstruction when feasible.     

Neurosurgical tools to extend tumor resection in pediatric hemispheric low-grade gliomas: iMRI

Introduction

The treatment of low-grade gliomas (LGGs) in pediatric age is still controversial. However, most authors report longer life expectancy in case of completely removed cerebral gliomas. Intraoperative magnetic resonance imaging (iMRI) is increasingly utilized in the surgical management of intra-axial tumor in adults following the demonstration of its effectiveness. In this article, we analyze the management of LGG using iMRI focusing on its impact on resection rate and its limits in the pediatric population.

Methods

We performed review of the literature regarding the treatment of LGG using iMRI focusing on its impact on resection rate and its limits in the pediatric population. Some exemplary cases are also described.

Results

Intraoperative MRI allowed extension of tumor resection after the depiction of residual tumor at the intraoperative imaging control from 21 to 52 % of the cases in the published series. Moreover, the early reoperation rate was significantly lower when compared with the population treated without this tool (0 % vs 7–14 %). Some technical difficulties have been described in literature regarding the use of iMRI in the pediatric population especially for positioning due to the structure of the headrest coil designed for adult patients.

Conclusion

The analysis of the literature and our own experience with iMRI in children indicates significant advantages in the resection of LGG offered by the technique. All these advantages are obtained without elongation of the surgical times or increased risk for complications, namely infection. The main limit for a wider diffusion of iMRI for the pediatric neurosurgical center is the cost required, for acquisition of the system, especially for high-field magnet, and the environmental and organizational changes necessary for its use.

     

Lateralisation of sound in temporal-lobe epilepsy: Comparison between pre- and postoperative performances and ERPs

Objective

Our aim was to investigate if spatial hearing is impaired in mesial temporal lobe epilepsy and temporal lobectomy has an effect on this function.

Methods

Thirteen patients with mesial temporal lobe epilepsy (TLE) due to sclerosis in their left (n = 6) or right (n = 7) hippocampus were studied. Their sound lateralisation performance indexed by d′ was tested against that of a group of normal subjects (n = 13). Patients’ ERPs to lateralisation shifts induced by interaural disparities of intensity (IID) and time (ITD) were also recorded. Eight of the patients were re-tested after they underwent anterior temporal lobectomy, which involved the resection/removal of medial structures including amygdala, hippocampus and parahippocampal gyrus.

Results

The sound-lateralisation performance of the TLE patients was significantly lower than normal subjects, and this disadvantage of the patients was specific to IID-based lateralisation. Amplitudes of their N1 and P2 responses to laterally shifting sounds were much lower than those reported previously for normal subjects. Lobectomy did not have a statistically significant effect on patients’ sound-lateralisation performance nor on the amplitude of their auditory directional ERPs.

Conclusions

The results show that especially the IID-based sound-lateralisation performance is impaired in TLE patients and that lobectomy should not cause any further deterioration.

Significance

This study suggests that a test for assessing the ability of sound lateralisation based on each of the IID and ITD cues should be included in the evaluation of TLE patients.     

Survival of brain metastatic patients treated with gamma knife radiosurgery alone

Purpose

To evaluate the impact of gamma knife radiosurgery (GKRS) alone on the survival of brain metastasis patients.

Methods

Fifty patients, 17 men and 33 women, with 169 metastatic tumors were retrospectively reviewed. Before therapy, their mean Karnofsky Performance Score was 78. The majority of their primary cancers stemmed from the lung (56%). Thirty-five patients harbored multiple tumors. The mean tumor volume was 3.7 ml. The mean margin dose was 16 Gy. The mean/median clinical follow-up period was 37/25 weeks.

Results

The overall image-proven tumor control rate was 76%, and the median tumor progression-free period was 26 weeks after radiosurgery. The survival rate of the patients was 58% and 30% at 6 and 12 months, respectively, and the overall median post-radiosurgery survival time was 38 weeks. Both uni- and multi-variate Cox analyses demonstrated that patients with KPS ≧ 80 or who were in Recursive Partitioning Analysis Class I survived significantly longer (p < 0.05).

Conclusions

Patients treated with GKRS alone can prolong their median lifespan by a range of 6–10 months if they are in a good pre-GKRS functional state.     

Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer

Backgrounds

Enoxaparin, low-molecular-weight heparin, has become a routine thromboprophylaxis in general surgery.

Study design

A retrospective cohort study was performed in 281 patients who underwent hepatic resections for liver cancers from 2011 to 2013. These patients were divided into two groups; an enoxaparin (-) group (n = 228) and an enoxaparin (+) group (n = 53). Short-term surgical results including venous thromboembolism (VTE) and portal vein thrombosis (PVT) were compared.

Results

In the enoxaparin (+) group, the patients’ age (65 vs. 69 years; p = 0.01) and BMI (22.9 vs. 24.4; p < 0.01) were significantly higher. According to the symptomatic VTE, symptomatic pulmonary embolism occurred in one patient (0.4%) in the enoxaparin (-) group, but the complication rate was not significantly different (p = 0.63). The complication rate of PVT was significantly lower in the enoxaparin (+) group (10 vs. 2%; p = 0.04). The independent risk factors for PVT were an operation time ≥ 300 minutes (Odds ratio 6.66) and non-treatment with enoxaparin (Odds ratio 2.49).

Conclusions

Postoperative anticoagulant therapy with enoxaparin could prevent PVT in patients who underwent hepatic resection for liver cancers.