Purpose
To explore the feasibility of dynamic susceptibility contrast MRI at 7 Tesla for human spinal cord perfusion mapping and fill the gap between brain and spinal cord perfusion mapping ...techniques.
Methods
Acquisition protocols for high‐resolution single shot EPI in the spinal cord were optimized for both spin‐echo and gradient‐echo preparations, including cardiac gating, acquisition times and breathing cycle recording. Breathing‐induced MRI signal fluctuations were investigated in healthy volunteers. A specific image‐ and signal‐processing pipeline was implemented to address them. Dynamic susceptibility contrast was then evaluated in 3 healthy volunteers and 5 patients. Bolus depiction on slice‐wise signal within cord was investigated, and maps of relative perfusion indices were computed.
Results
Signal fluctuations were increased by 1.9 and 2.3 in free‐breathing compared to apnea with spin‐echo and gradient‐echo, respectively. The ratio between signal fluctuations and bolus peak in healthy volunteers was 5.0% for spin‐echo and 3.8% for gradient‐echo, allowing clear depiction of the bolus on every slice and yielding relative blood flow and volume maps exhibiting the expected higher perfusion of gray matter. However, signal fluctuations in patients were increased by 4 in average (using spin‐echo), compromising the depiction of the bolus in slice‐wise signal. Moreover, 3 of 18 slices had to be discarded because of fat‐aliasing artifacts.
Conclusion
Dynamic susceptibility contrast MRI at 7 Tesla showed great potential for spinal cord perfusion mapping with a reliability never achieved thus far for single subject and single slice measurements. Signal stability needs to be improved in acquisition conditions associated with patients; guidelines to achieve that have been identified and shared.
Aggressive meningiomas that progress after surgery/radiotherapy represent an unmet medical need. Strong and constant expression of SSTR2A receptors and activation of the Pi3K/Akt/mTOR pathway have ...been demonstrated in meningiomas. The combination of everolimus, an mTOR inhibitor, and octreotide, a somatostatin agonist, has shown additive antitumor effect
. The phase II CEVOREM trial investigated the efficacy of this combination on recurrent meningiomas.
Patients with documented recurrent tumor progression ineligible for further surgery/radiotherapy were eligible to receive octreotide (30 mg/d, day 1) and everolimus (10 mg/d, days 1-28). The primary endpoint was the 6-month progression-free survival rate (PFS6). The secondary endpoints were overall survival, response rate, tumor growth rate according to central review, and safety.
A total of 20 patients were enrolled, including 2 with World Health Organization (WHO) grade I tumors, 10 with WHO grade II tumors, and 8 with WHO grade III tumors; furthermore, 4 patients harbored
germline mutation. The overall PFS6 was 55% 95% confidence interval (CI), 31.3%-73.5%, and overall 6- and 12-month survival rates were 90% (95% CI, 65.6%-97.4%) and 75% (95% CI, 50.0%-88.7%), respectively. A major decrease (>50%) was observed in the growth rate at 3 months in 78% of tumors. The median tumor growth rate decreased from 16.6%/3 months before inclusion to 0.02%/3 months at 3 months (
< 0.0002) and 0.48%/3 months at 6 months after treatment (
< 0.0003).
The combination of everolimus and octreotide was associated with clinical and radiological activity in aggressive meningiomas and warrants further studies. Decrease in the tumor volume growth rate should be considered a complementary and sensitive endpoint to select potentially effective drugs for recurrent meningiomas.
Background
Petroclival meningiomas are one of the most challenging tumors to be operated in the realm of neurosurgery. Many approaches have been developed over the years.
Method
The authors describe ...the Half & Half (H&H) approach whose main indication is petroclival meningiomas with suprasellar extension. The part of the tumor located above CN III and in the retrochiasmatic space is addressed through a trans-sylvian, while the petroclival portion is through an extradural anterior petrosectomy approach. The wide surgical corridor given by this approach allows extensive tumor resection while avoiding the risk associated with the manipulation of intracavernous neurovascular structures.
Conclusion
The H&H approach is an effective strategy to maximize the safe resection of petroclival meningiomas.
Background
Extradural disconnection of the cavernous sinus (CS) with preservation of the internal carotid artery (ICA) is indicated for aggressive and recurrent tumors, in patients presenting loss of ...oculomotor function and non-functional circle of Willis.
Method
Extradural resection of the anterior clinoid process disconnects the CS anteriorly. The ICA is dissected in the
foramen lacerum
via extradural subtemporal approach. The intracavernous tumor is split and removed following the ICA. Bleeding control of the inferior and superior petrosal and intercavernous sinuses completes posterior CS disconnection.
Conclusion
This technique can be proposed for recurrent CS tumors and need of ICA preservation.
The preservation of acceptable facial nerve (FN) function after surgery is the key concern for most patients with vestibular schwannomas (VS). To assess predictive factors of early postoperative and ...long-term FN function in patients harboring large VS operated with a FN-sparing technique.
Single-center retrospective cohort study with 169 consecutive large VS operated on between January 2003 and May 2015. Clinical, radiologic, and intraoperative factors were assessed according to FN function.
At last follow-up examination, among the 145 patients without preoperative FN palsy, FN function was good (House-Brackmann HB grades I or II) in 84% and moderate (HB grade III) in 15% of patients. Only 1 patient presented with poor HB grade IV function. Multivariate logistic regression model showed the mean preoperative VS extrameatal diameter as being an independent predictor of an unfavorable initial FN outcome (odds ratio OR, 1.062; P = 0.038). Surgical anatomic preservation of the cochlear nerve was associated with better FN outcomes (OR, 0.237; P = 0.012). A history of previous surgery seemed to be related to long-term impaired FN function (OR, 71.405; P = 0.042), as well as early postoperative FN function (OR, 19.068; P = 0.000). No correlation was found between a history of previous Gamma Knife surgery treatment (P = 0.225) or the extent of resection (P = 0.438) and impaired FN outcomes. History of previous surgery was identified as an unfavorable predictive recovery factor of impaired postoperative FN function (P = 0.034).
As long as the extent of resection or additional Gamma Knife surgery have not been identified as predictive risk factors of postoperative FN palsy, we suggest that optimal resection is the main option for patients harboring large VS.
Stereotactic radiosurgery (SRS) is one of the main treatment options in the management of small to medium size vestibular schwannomas (VSs), because of high tumor control rate and low cranial nerves ...morbidity. Series reporting long-term hearing outcome (>3 years) are scarce.
To perform a systematic review of the literature and meta-analysis, with the aim of focusing on long-term hearing preservation after SRS.
Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we reviewed articles published between January 1990 and October 2020 and referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical study or case series of VSs treated with SRS (single dose), reporting hearing outcome after SRS with a median or mean audiometric follow-up of at least 5 years. Hearing preservation, cranial nerves outcomes, and tumor control were evaluated.
Twenty-three studies were included. Hearing preservation was found in 59.4% of cases (median follow-up 6.7 years, 1409 patients). Main favorable prognostic factors were young age, good hearing status, early treatment after diagnosis, small tumor volume, low marginal irradiation dose, and maximal dose to the cochlea. Tumor control was achieved in 96.1%. Facial nerve deficit and trigeminal neuropathy were found in 1.3% and 3.2% of patients, respectively, both significantly higher in Linear Accelerator series than Gamma Knife series ( P < .05).
Long-term hearing preservation remains one of the main issues after SRS, with a major impact on health-related quality of life. Our meta-analysis suggests that hearing preservation can be achieved in almost 60% of patients after a median follow-up of 6.7 years, irrespective of the technique.
Background and objective
The optimal management of large vestibular schwannomas continues to be debated. We constituted a task force comprising the members of the EANS skull base committee along with ...international experts to derive recommendations for the management of this problem from a European perspective.
Material and methods
A systematic review of MEDLINE database, in compliance with the PRISMA guidelines, was performed. A subgroup analysis screening all surgical series published within the last 20 years (January 2000 to March 2020) was performed. Weighted summary rates for tumor resection, oncological control, and facial nerve preservation were determined using meta-analysis models. This data along with contemporary practice patterns were discussed within the task force to generate consensual recommendations regarding preoperative evaluations, optimal surgical strategy, and follow-up management.
Results
Tumor classification grades should be systematically used in the perioperative management of patients, with large vestibular schwannomas (VS) defined as > 30 mm in the largest extrameatal diameter. Grading scales for pre- and postoperative hearing (AAO-HNS or GR) and facial nerve function (HB) are to be used for reporting functional outcome. There is a lack of consensus to support the superiority of any surgical strategy with respect to extent of resection and use of adjuvant radiosurgery. Intraoperative neuromonitoring needs to be routinely used to preserve neural function. Recommendations for postoperative clinico-radiological evaluations have been elucidated based on the surgical strategy employed.
Conclusion
The main goal of management of large vestibular schwannomas should focus on maintaining/improving quality of life (QoL), making every attempt at facial/cochlear nerve functional preservation while ensuring optimal oncological control, thereby allowing to meet patient expectations. Despite the fact that this analysis yielded only a few Class B evidences and mostly expert opinions, it will guide practitioners to manage these patients and form the basis for future clinical trials.
Objective
This study aimed to identify factors affecting proptosis recovery in spheno-orbital meningioma (SOM) surgery and assess functional and oncological outcomes.
Methods
Data from 32 consecutive ...SOM surgery cases (2002–2021) were analyzed. Clinical, radiological, operative, and oncological parameters were examined. Proptosis was assessed using the exophthalmos index (EI) on MRI or CT scans. Statistical analyses were performed to identify predictive factors for proptosis recovery.
Results
Proptosis improved in 75% of patients post-surgery (EI decreased from 1.28 ± 0.16 to 1.20 ± 0.13,
p
= 0.048). Patients with stable or worsened EI had higher body mass index (28.5 ± 7.9 vs. 24.1 ± 4.7,
p
= 0.18), Simpson grade (IV 75% vs. 65%,
p
= 0.24), and middle sphenoid wing epicenter involvement (63% vs. 38%,
p
= 0.12), but no significant factors were associated with unfavorable exophthalmos outcomes. The improvement group had higher
en plaque
morphology, infratemporal fossa invasion, and radiation treatment for cavernous sinus residual tumor (88% vs. 75%,
p
= 0.25; 51% vs. 25%,
p
= 0.42; 41% vs. 25%,
p
= 0.42, respectively), but without statistical significance. Visual acuity remained stable in 78%, improved in 13%, and worsened in 9% during follow-up. Surgery had a positive impact on preoperative oculomotor nerve dysfunction in 3 of 4 patients (75%). Postoperative oculomotor nerve dysfunction was observed in 25%, of which 75% fully recovered. This occurrence was significantly associated with irradiation of an orbital tumor residue (
p
= 0.04). New postoperative trigeminal hypoesthesia was observed in 47%, of which 73% recovered. All SOMs were classified as WHO grade 1, and complementary treatments achieved oncological control, requiring gamma-knife radiosurgery in 53% and standard radiotherapy in 6%.
Conclusions
Surgery effectively improves proptosis in SOM, though complete resolution is rare. The absence of predictive factors suggests multifactorial causes, including body mass index and tumor resection grade. Postoperative oculomotor nerve dysfunction and trigeminal hypoesthesia are common but often recover. Gamma-knife radiosurgery maintains long-term oncological control for evolving tumor residue.
The neurosurgical community is particularly exposed to burnout. The objectives of this study were to report the prevalence and associated factors of burnout within the French neurosurgical community ...using validated academic and psychologic scales.
A national survey was sent to 141 French residents and 432 neurosurgeons between April and July 2019. Burnout was surveyed using the Maslach burnout inventory. The survey included demographic data and several academic psychologic scales. A stepwise multiple regression was used to determine factors that are associated with burnout scores.
The response rate was 100% and 23.6% for residents and neurosurgeons, respectively. Prevalence of burnout within the French neurosurgical community was 49%. There were no significant differences between residents and neurosurgeons. Two categories of factors were associated with the main dimensions of burnout during the stepwise multiple regression: personality and factors related with neurosurgical practice. Personality types such as neuroticism were negatively associated with burnout while agreeableness was protective. Work addictive profile with excessive work and absorption at work were negatively associated. Factors associated with neurosurgical practice such as conflict of work into family life, unbalanced effort to reward ratio, work duration were negatively associated. Pleasure at work was protective.
Prevalence of burnout is high among French neurosurgeons. Predictive models can be used to identify and prevent burnout among profiles at risk.
Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who ...were operated on.
This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed.
At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1–3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5.
The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.
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