Purpose
There is limited knowledge about the associations between sodium and proton MRI measurements in brain tumors. The purpose of this study was to quantify intra- and intertumoral correlations ...between sodium, diffusion, and perfusion MRI in human gliomas.
Methods
Twenty glioma patients were prospectively studied on a 3T MRI system with multinuclear capabilities. Three mutually exclusive tumor volumes of interest (VOIs) were segmented: contrast-enhancing tumor (CET), T2/FLAIR hyperintense non-enhancing tumor (NET), and necrosis. Median and voxel-wise associations between apparent diffusion coefficient (ADC), normalized relative cerebral blood volume (nrCBV), and normalized sodium measurements were quantified for each VOI.
Results
Both relative sodium concentration and ADC were significantly higher in areas of necrosis compared to NET (
P
= 0.003 and
P
= 0.008, respectively) and CET (
P
= 0.02 and
P
= 0.02). Sodium concentration was higher in CET compared to NET (
P
= 0.04). Sodium and ADC were higher in treated compared to treatment-naïve gliomas within NET (
P
= 0.006 and
P
= 0.01, respectively), and ADC was elevated in CET (
P
= 0.03). Median ADC and sodium concentration were positively correlated across patients in NET (r = 0.77,
P
< 0.0001) and CET (r = 0.84,
P
< 0.0001), but not in areas of necrosis (r = 0.45,
P
= 0.12). Median nrCBV and sodium concentration were negatively correlated across patients in areas of NET (r=-0.63,
P
= 0.003). Similar associations were observed when examining voxel-wise correlations within VOIs.
Conclusion
Sodium MRI is positively correlated with proton diffusion MRI measurements in gliomas, likely reflecting extracellular water. Unique areas of multinuclear MRI contrast may be useful in future studies to understand the chemistry of the tumor microenvironment.
Mass effect has demonstrated prognostic significance for glioblastoma, but is poorly quantified. Here we define and characterize a novel neuroimaging parameter, lateral ventricle displacement (LVd), ...which quantifies mass effect in glioblastoma patients. LVd is defined as the magnitude of displacement from the center of mass of the lateral ventricle volume in glioblastoma patients relative to that a normal reference brain. Pre-operative MR images from 214 glioblastoma patients from The Cancer Imaging Archive (TCIA) were segmented using iterative probabilistic voxel labeling (IPVL). LVd, contrast enhancing volumes (CEV) and FLAIR hyper-intensity volumes (FHV) were determined. Associations with patient survival and tumor genomics were investigated using data from The Cancer Genome Atlas (TCGA). Glioblastoma patients had significantly higher LVd relative to patients without brain tumors. The variance of LVd was not explained by tumor volume, as defined by CEV or FLAIR. LVd was robustly associated with glioblastoma survival in Cox models which accounted for both age and Karnofsky's Performance Scale (KPS) (p = 0.006). Glioblastomas with higher LVd demonstrated increased expression of genes associated with tumor proliferation and decreased expression of genes associated with tumor invasion. Our results suggest LVd is a quantitative measure of glioblastoma mass effect and a prognostic imaging biomarker.
BACKGROUND:Pediatric anatomy is more restricted, and the propagation of endonasal endoscopic approaches in the pediatric population has been limited.
OBJECTIVE:To demonstrate the feasibility of the ...endonasal endoscopic approach in a variety of age groups and to perform measurements of the corridors and spaces available for surgery as a guide for case selection.
METHODS:Only patients <18 years were included. The choice of operative corridor/approach is described in relation to pathological entity and location. Preoperative/postoperative visual fields and endocrine panels, extent of resection, as well as postoperative long-term complications are described. Prospective magnetic resonance image-based anatomic measurements of key distances were performed to determine age-dependent surgical indications and limitations.
RESULTS:Forty purely endoscopic procedures were performed in 33 pediatric patients (5-18 years of age) harboring a variety of skull base lesions, from benign tumors to congenital malformations. For the 20 patients in whom gross total resection was the intended goal of surgery, gross total resection was attained in 15 (75%). There were 2 infections (5%) and no cerebrospinal fluid leaks. Significant improvement was shown in 58.3% of patients with visual deficits. Hormone overproduction resolved in 75% of patients, while preoperative hormone insufficiency only improved in 29.2%. Wider intercarotid distance at the superior clivus (P = .01) and shorter nare-dens working distance (P = .001) predicted improved outcomes and fewer postoperative complications.
CONCLUSION:Endonasal endoscopic skull base approaches are viable in the pediatric population, they are not impeded by sphenoid sinus aeration, and they have minimal risk of cerebrospinal fluid leak and meningitis. Outcomes and complications can be predicted based on specific radio anatomical skull base measurements rather than age.
ABBREVIATIONS:ASB, anterior sphenoid boneASW, anterior sellar wallDI, diabetes insipidusEEA, endonasal endoscopic approachFSE, fast spin echoGH, growth hormoneGTR, gross total resectionICD-CS, intercarotid distance at the level of the cavernous sinusICD-SC, intercarotid distance at the superior clivusMaxWiT, maximum width between middle turbinatesNDD, nare-dens distanceNSD, nare-sellar distanceNVD, nare-vomer distanceSKB, skull baseSTR, subtotal resectionTA, transsphenoidal angleVCD, vomer-clival distance
Purpose
Although intracranial meningiomas are the most common primary brain tumor in adults, treatment options are few and have traditionally been limited to surgical resection and radiotherapy. ...Additional targeted therapies and biomarkers are needed, especially as complete surgical resection is frequently not feasible in many patients.
Methods
Non-pathologic brain tissue from 3 patients undergoing routine autopsies and tumor specimens from 16 patients requiring surgical resection for meningioma were collected. EMP2 protein expression was evaluated by immunohistochemistry and western blot analysis. EMP2 mRNA expression was also investigated using surgical specimens and validated by analysis of several independent NCBI GEO databases.
Results
EMP2 mRNA expression levels were found to be higher in meningioma relative to non-pathologic meninges (
P
=
0.0013
) and brain (
P
=
0.0011
). Concordantly, strong EMP2 protein expression was demonstrated in 100% of meningioma specimens from all 16 patients, with no observable protein expression in normal brain tissue samples from 3 subjects (
P
<
0.001
). EMP2 expression was confirmed by western blot analysis in five samples, with EMP2 protein intensity positively correlating with histologic staining score (
R
2
=
0.780; P
=
0.047
). No association was found between EMP2 mRNA or protein levels and WHO grade or markers of proliferation. However, EMP2 expression was positively associated with an angiomatous pattern on histologic evaluation (
P
=
0.0597
), VEGF-A mRNA expression (
P
<
0.001
), and clinical markers of tumor vascularity such as operative blood loss (
P
=
0.037
).
Conclusions
EMP2 is not found in normal brain tissue, yet has shown consistently high mRNA and protein expression in meningiomas, and may serve as a useful molecular marker for these tumors.
BACKGROUND:The authors reviewed published articles pertaining to the preoperative imaging evaluation of nonfunctioning pituitary adenomas (NFPAs) and formulated recommendations.
OBJECTIVE:To provide ...an exhaustive review of published articles pertaining to the preoperative imaging evaluation of nonfunctioning pituitary adenomas.
METHODS:The MEDLINE database was queried for studies investigating imaging for the preoperative evaluation of pituitary adenomas.
RESULTS:From an initial search of 5598 articles, 122 articles were evaluated in detail and included in this article. Based on analysis of these articles, the recommendations are as follows(1) High-resolution magnetic resonance imaging (level II) is recommended as the standard for preoperative assessment of nonfunctioning pituitary adenomas, but may be supplemented with CT (level III) and fluoroscopy (level III). (2) Although there are promising results suggesting the utility of magnetic resonance spectroscopy, magnetic resonance perfusion, positron emission tomography, and single-photon emission computed tomography, there is insufficient evidence to make formal recommendations pertaining to their clinical applications.
CONCLUSION:The authors identified 122 articles that form the basis of recommendations for preoperative imaging evaluation of nonfunctioning pituitary adenomas. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_2.
ABBREVIATIONS:CT, computed tomographyDWI, diffusion-weighted imagingMRI, magnetic resonance imagingNFPA, nonfunctioning pituitary adenoma
Gliosarcoma is a rare and highly malignant cancer of the central nervous system with the ability to metastasize. Secondary gliosarcoma, or the evolution of a spindle cell-predominant tumor after the ...diagnosis of a World Health Organization grade IV glioblastoma, has also been shown to metastasize. There is little information on metastatic secondary gliosarcoma.
The authors present a series of 7 patients with previously diagnosed glioblastoma presenting with recurrent tumor and associated metastases with repeat tissue diagnosis consistent with gliosarcoma. The authors describe the clinical, imaging, and pathological characteristics in addition to carrying out a systematic review on metastases in secondary gliosarcoma.
The present institutional series and the systematic review of the literature show that metastatic secondary gliosarcoma is a highly aggressive disease with a poor prognosis.
Best practice guidelines for treating lumbar stenosis include a multidisciplinary approach, ranging from conservative management with physical therapy, medication, and epidural steroid injections to ...surgical decompression with or without instrumentation. Marketed as an outpatient alternative to a traditional lumbar decompression, interspinous process devices (IPDs) have gained popularity as a minimally invasive stabilization procedure. IPDs have been embraced by non-surgical providers, including physiatrists and anesthesia interventional pain specialists. In the interest of patient safety, it is imperative to formally profile its safety and identify its role in the treatment paradigm for lumbar stenosis.
We carried out a retrospective review at our institution of neurosurgical consultations for patients with hardware complications following the interspinous device placement procedure. Eight cases within a 3-year period were identified, and patient characteristics and management are illustrated. The series describes the migration of hardware, spinous process fracture, and worsening post-procedural back pain.
IPD placement carries procedural risk and requires a careful pre-operative evaluation of patient imaging and surgical candidacy. We recommend neurosurgical consultation and supervision for higher-risk IPD cases.
BACKGROUND:Nonfunctioning pituitary adenomas (NFPAs) are the most frequent pituitary tumors. Due to the lack of hormonal hypersecretion, posttreatment follow-up evaluation of NFPAs is challenging.
...OBJECTIVE:To create evidence-based guidelines in an attempt to formulate guidance for posttreatment follow-up in a consistent, rigorous, and cost-effective way.
METHODS:An extensive literature search was performed. Only clinical articles describing postoperative follow-up of adult patients with NFPAs were included. To ascertain the class of evidence for the posttreatment follow-ups, the authors used the Clinical Assessment evidence-based classification.
RESULTS:Twenty-three studies met the inclusion criteria with respect to answering the questions on the posttreatment radiologic, endocrinologic, and ophthalmologic follow-up. Through this search, the authors formulated evidence-based guidelines for radiologic, endocrinologic, and ophthalmologic follow-up after surgical and/or radiation treatment.
CONCLUSION:Long-term radiologic, endocrinologic, and ophthalmologic surveillance monitoring after surgical and/or radiation therapy treatment of NFPAs to evaluate for tumor recurrence or regrowth, as well as pituitary and visual status, is recommended. There is insufficient evidence to make a recommendation on the duration of time of surveillance and its frequency. It is recommended that the first radiologic study to evaluate the extent of resection of the NFPA be performed ≥3 months after surgical intervention. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_8.
ABBREVIATION:NFPA, nonfunctioning pituitary adenoma
Objective To evaluate the efficacy of combining an endonasal endoscopic skull-base approach and repair with a transcranial orbitozygomatic approach for spheno-orbital meningiomas (SOMs). Methods ...Three patients with recurrent SOMs underwent combined orbitozygomatic and endonasal endoscopic surgery. In 2 patients both procedures were done in 1 operation and in 1 patient the endonasal surgery was done 2.5 months after the craniotomy. Extent of resection, complications, morbidity, and mortality were evaluated. Results Gross total resection was achieved in 1 patient and near total resection in the other 2 patients with tumor left in the cavernous sinus and parapharyngeal space. Two patients suffered cranial neuropathy from the transcranial surgery and the other developed a pseudomeningocele. There were no complications from the endonasal surgery. Patients having combined single setting cranionasal surgery were discharged on day 6 and 8, whereas the patient having only the endonasal component on a later date was discharged on day 2. Conclusions A combined cranionasal approach involving transcranial orbitozygomatic and endonasal endoscopic approaches is an effective 2-stage surgery for resecting SOMs invading into the sinuses and paranasal compartments. The ability to perform a multilayer closure involving a vascularized nasoseptal flap additionally decreases the risk of postoperative cerebrospinal fluid leak.
Abstract
BACKGROUND:
Nonfunctioning pituitary adenomas (NFPAs) are the most frequent pituitary tumors. Due to the lack of hormonal hypersecretion, posttreatment follow-up evaluation of NFPAs is ...challenging.
OBJECTIVE:
To create evidence-based guidelines in an attempt to formulate guidance for posttreatment follow-up in a consistent, rigorous, and cost-effective way.
METHODS:
An extensive literature search was performed. Only clinical articles describing postoperative follow-up of adult patients with NFPAs were included. To ascertain the class of evidence for the posttreatment follow-ups, the authors used the Clinical Assessment evidence-based classification.
RESULTS:
Twenty-three studies met the inclusion criteria with respect to answering the questions on the posttreatment radiologic, endocrinologic, and ophthalmologic follow-up. Through this search, the authors formulated evidence-based guidelines for radiologic, endocrinologic, and ophthalmologic follow-up after surgical and/or radiation treatment.
CONCLUSION:
Long-term radiologic, endocrinologic, and ophthalmologic surveillance monitoring after surgical and/or radiation therapy treatment of NFPAs to evaluate for tumor recurrence or regrowth, as well as pituitary and visual status, is recommended. There is insufficient evidence to make a recommendation on the duration of time of surveillance and its frequency. It is recommended that the first radiologic study to evaluate the extent of resection of the NFPA be performed ≤3 months after surgical intervention. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_8.
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