Cavernomas: Outcomes after gamma-knife radiosurgery in Iran

Background:

Treatment of cavernomas remains a challenge in surgically inaccessible regions. The purpose of this study was to evaluate outcomes after gamma-knife surgery (GKS) for these patients.

Materials and Methods:

A retrospective review of 100 patients treated between 2003 and 2011 was conducted in order to evaluate hemorrhage rates, complications, radiation effects after GKS. Dosage at the tumor margin was stratified into two groups: those that received ≤13 Gy; and those who received >13 Gy. The demographic and clinical characteristics of patients including age, gender, and hemorrhage rates were extracted from care records.

Results:

The median age was 32.5 years (ranging from 15 to 79). 44% were female. The median follow-up time was 42.2 months (ranging from 24 to 90). The median volume of the lesions was 1050.0 mm³ (ranging from 112.0 to 4100.0) before GKS. A reduction of 27.5% in median size of cavernomas was achieved at the last follow-up. There was 12% treatment-related morbidity after GKS. The hemorrhage rate in the first 2 years after GKS was 4.1% and 1.9% thereafter. There was no mortality due to GKS, and 93 patients were alive at the last follow-up. The radiation-related complication developed with marginal dose 13 Gy.

Conclusion:

The GKS for cavernomas appears to be a safe and beneficial in carefully selected patients. Low-dose GKS may be effective for the management of cavernous malformations.

Artificial neural networks in neurosurgery

Artificial neural networks (ANNs) effectively analyze non-linear data sets. The aimed was A review of the relevant published articles that focused on the application of ANNs as a tool for assisting clinical decision-making in neurosurgery. A literature review of all full publications in English biomedical journals (1993-2013) was undertaken. The strategy included a combination of key words 'artificial neural networks', 'prognostic', 'brain', 'tumor tracking', 'head', 'tumor', 'spine', 'classification' and 'back pain' in the title and abstract of the manuscripts using the PubMed search engine. The major findings are summarized, with a focus on the application of ANNs for diagnostic and prognostic purposes. Finally, the future of ANNs in neurosurgery is explored. A total of 1093 citations were identified and screened. In all, 57 citations were found to be relevant. Of these, 50 articles were eligible for inclusion in this review. The synthesis of the data showed several applications of ANN in neurosurgery, including: (1) diagnosis and assessment of disease progression in low back pain, brain tumours and primary epilepsy; (2) enhancing clinically relevant information extraction from radiographic images, intracranial pressure processing, low back pain and real-time tumour tracking; (3) outcome prediction in epilepsy, brain metastases, lumbar spinal stenosis, lumbar disc herniation, childhood hydrocephalus, trauma mortality, and the occurrence of symptomatic cerebral vasospasm in patients with aneurysmal subarachnoid haemorrhage; (4) the use in the biomechanical assessments of spinal disease. ANNs can be effectively employed for diagnosis, prognosis and outcome prediction in neurosurgery.

A validation study of the Iranian version of STarT Back Screening Tool (SBST) in lumbar central canal stenosis patients

BACKGROUND

This study aimed to translate and validate the STarT Back Screening Tool (SBST) in Iran.

METHODS

This was a prospective clinical validation study. The translation and cross-cultural adaptation of the original questionnaire was performed, and a total of 269 patients with lumbar central canal stenosis were asked to respond to the questionnaire at their first visits. Patients also were asked to complete the Oswestry Disability Index (ODI). Reliability was assessed by internal consistency using the Cronbach's alpha coefficient. Validity was evaluated by performing convergent validity and responsiveness to change.

RESULTS

Mean patient age was 58.6 [standard deviation (SD) = 10.9] years; 56.5 % were women. According to patients' imaging, they were diagnosed as grade 1 (n = 86), grade 2 (n = 107), and grade 3 (n = 76). In general, the SBST showed good psychometric properties. Cronbach's alpha coefficient for overall scale (Q1-Q9) and psychosocial subscale (Q5-Q9) was 0.82 and 0.79, respectively. The ODI correlated strongly with overall SBST scores, lending support to its good convergent validity (r = 0.81; P < 0.001). Responsiveness to change also indicated desirable results.

CONCLUSION

In general, the Iranian version of the SBST performed well, and findings suggest that it is a reliable and valid measure for screening low back pain in patients with lumbar central canal stenosis in primary care settings.

Use of artificial neural networks to predict surgical satisfaction in patients with lumbar spinal canal stenosis

Object

The purpose of this study was to develop an artificial neural network (ANN) model for predicting 2-year surgical satisfaction, and to compare the new model with traditional predictive tools in patients with lumbar spinal canal stenosis.

Methods

The 2 prediction models included an ANN and a logistic regression (LR) model. The patient age, sex, duration of symptoms, walking distance, visual analog scale scores of leg pain or numbness, the Japanese Orthopaedic Association score, the Neurogenic Claudication Outcome Score, and the stenosis ratio values were determined as the input variables for the ANN and LR models that were developed. Patient surgical satisfaction was recorded using a standardized measure. The ANNs were fed patient data to predict 2-year surgical satisfaction based on several input variables. Sensitivity analysis was applied to the ANN model to identify the important variables. The receiver operating characteristic–area under curve (ROC-AUC), Hosmer-Lemeshow statistics, and accuracy rate were calculated for evaluating the 2 models.

Results

A total of 168 patients (59 male, 109 female; mean age 59.8 ± 11.6 years) were divided into training (n = 84), testing (n = 42), and validation (n = 42) data sets. Postsurgical satisfaction was 88.7% at 2-year follow-up. The stenosis ratio was the important variable selected by the ANN. The ANN model displayed a better accuracy rate in 96.9% of patients, a better Hosmer-Lemeshow statistic in 42.4% of patients, and a better ROC-AUC in 80% of patients, compared with the LR model.

Conclusions

The findings show that an ANN can predict 2-year surgical satisfaction for use in clinical application and is more accurate compared with an LR model.

Role of stereotactic biopsy in histological diagnosis of multiple brain lesions

Background and Aim:

The current advances in diagnostic and therapeutic modalities and increasing in survival of patients with systemic diseases and immunosuppressive cases have caused to increasing frequency and variety of Central Nervous System neuropathologic processes indicating the necessary need for accurate localization of space-occupying lesions by cytology and histology. This study was aimed to evaluate the usefulness and safety of stereotactic biopsy in histological diagnosis of such lesions.

Materials and Methods:

Of 2081 patients underwent stereotactic biopsy of brain lesions using Riechert-Mundinger system, 158 had multifocal brain lesions, and were enrolled.

Results:

The ages of studied cases were ranged from 2 years to 75 years (Mean age: 41.3 year), 114 were male and 44 were females. Incidence of histopathologic diagnosis of multifocal brain lesions included Astrocytoma grade II (41.3%), Astrocytoma grade I (12.9%), glioblastoma multiform (11.1%), Astrocytoma grade III (10.2%), malignant lymphoma (10.2%), metastasis (4.6%), pilocytic Astrocytoma (2.7%), abscess (2.7%), craniopharyngioma (1.8%) vascular malformations (0.9%), and tuberculosis (0.9%). Mortality due to operation is none.

Conclusions:

Histopathologic diagnosis of multiple brain lesions is necessary for decision of appropriate management and stereotactic biopsy of brain lesion is a useful and safe method for histological diagnosis.

Long-Term Results of stereotactic Brachytherapy (Temporary 125Iodine Seeds) for the Treatment of Low-Grade Astrocytoma (Grade II)

Background

Treatment of low-grade astrocytoma (WHO grade II) (LGA II) remains a challenge. There is limited information regarding the long-term effects of stereotactic brachytherapy (SBT) (temporary ¹²⁵Iodine seeds) on patients with LGA II.

Objectives

The purpose of this study was to evaluate disease control and survival after stereotactic brachytherapy in patients with circumscribed and relatively small size tumors.

Materials and Methods

A retrospective review of 29 patients, treated between 1991 and 2011, was conducted to evaluate survival, complications, and local disease control after stereotactic brachytherapy. They belonged to a larger group of 48 cases with low-grade gliomas, treated with stereotactic brachytherapy. The demographic and clinical characteristics in patients including age, sex, and survival time were extracted from records.

Results

Thirteen patients were male and 16 were female, with the median age of 29 years (range, 2.5 – 64 years). The median follow-up was 95 (range, 6 – 240) months. Based on Pignatti classification, 10 patients were at low- and 19 patients at high-risk. The median overall as well as progression-free survivals for patients were 135 months (95% confidence interval: 76 – 194) and 96 months (95% confidence interval: 1 – 199), respectively. Five- and 10-year progression-free survivals were 41.4 % and 34.5 %, respectively, and the 5- and 10-year overall survivals were 65.5 % and 44.8%, respectively. Progression-free survival was not significantly higher in smaller size tumors (P = 0.224), nor for spherical versus non-spherical tumors (P = 0.307). There was no treatment-related morbidity after stereotactic brachytherapy, and no radiogenic complications occurred during the follow-up period. Mortality due to tumor progression occurred in 4 patients (14%), and 11 patients were alive at the last follow-up.

Conclusions

The stereotactic brachytherapy for patients with circumscribed and relatively small size tumors appears to be a safe, feasible, and minimally-invasive treatment.

Severity of symptoms, physical functioning and satisfaction in patients with lumbar spinal stenosis: a validation study of the Iranian version of the Swiss Spinal Stenosis Score (SSS)

Background:

A common cause of low back pain is lumbar spinal stenosis (LSS). The Swiss Spinal Stenosis Score (SSS) is a well-known questionnaire measuring the severity of symptoms, physical functioning and patient’s satisfaction in these patients. This study aimed to translate and validate the SSS in Iran.

Methods:

This was a prospective clinical validation study. Forward-backward procedure was applied to translate the original questionnaires into Persian. A sample of patients with lumbar spinal stenosis completed the questionnaire twice: pre- and post-operative (6-month follow-up) assessments. To test reliability the internal consistency was assessed; Validity was evaluated using known groups comparison. In addition Oswestry Disability Index was used to perform convergent validity.

Results:

In all 121 patients were entered into the study. The mean age of patients was 62.3 (SD equal to 10.2) years. Cronbach’s alpha coefficient for the SSS was found to be 0.88. Validity assessment was performed using common group’s analysis and showed satisfactory results. The instrument discriminated efficiently between sub-groups of patients who differed in age, severity of lumbar spinal stenosis, and Self-Paced Walking Test (SPWT). The change in Oswestry Disability Index strongly correlated with the change in patients’ scores on the SSS, lending support to its good convergent validity (r equal to 0.82; P Less than 0.001).

Conclusions:

The Iranian version of the Swiss Spinal Stenosis Score performed well and the findings suggest that it is a valid measure of the severity of symptoms, physical function and satisfaction among lumbar spinal stenosis patients.

Keywords:

Lumbar, Spinal stenosis, Swiss Spinal Stenosis Score

The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) for low back disorders: a validation study from Iran

Background:

Lumbar Disc Herniation (LDH) and Lumbar Spinal Stenosis (LSS) are the most common diagnoses of low back and leg pain symptoms. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) is a measure of health related quality of life in these patients. This study aimed to cross-culturally translate and validate the JOABPEQ in Iran.

Methods:

This was a prospective clinical validation trial. The translation and cross-cultural adaptation of the original questionnaire were performed in accordance with the published guidelines. A total of 103 patients with LDH or LSS were asked to respond to the questionnaire at two time points: pre- and post-operation (pre- and post-operative assessments) and were followed up for 6 months. To evaluate the reliability the internal consistency was assessed using the Cronbach's alpha coefficient and validity was assessed using the convergent validity. Responsiveness to the clinical change also was assessed comparing patients’ pre- and postoperative scores.

Results:

The Cronbach’s alpha coefficients for the JOABPEQ at preoperative and postoperative assessments ranged from 0.71 to 0.81 indicating a good internal consistency for the questionnaire. Furthermore, the correlation of each item with its hypothesized subscale of the JOABPEQ showed satisfactory results suggesting that the items had a substantial association with the subscale representing the concept. Further analysis also indicated that the questionnaire was responsive to change (P less than 0.0001).

Conclusions:

In conclusion, the Iranian version of JOABPEQ performed well and the findings suggest that it is a reliable and valid measure of back pain evaluation among LDH and LCS patients.

Keywords:

Japanese Orthopedic Association Back Pain Evaluation Questionnaire, Low back pain, Postoperative

Functional evaluation using the modified Japanese Orthopedic Association score (mJOA) for cervical spondylotic myelopathy disease by age, gender, and type of disease

Background:

Cervical spondylotic myelopathy (CSM) is a common cause of significant clinical morbidity. The modified Japanese Orthopedic Association score (mJOA) is a very short instrument for functional evaluation in these patients. This study aimed to evaluate functionality in patients diagnosed with CSM diseases using the mJOA and to compare the scores based on age, sex, and type of disease.

Methods:

A sample of patients with CSM who were candidate for decompressive surgery entered into this cross sectional study. The mJOA scores were obtained for the functional assessment of patients. Score on the mJOA range from 0 to 18 with higher scores indicating a better condition. In addition to descriptive statistics, the data were compared among study subgroups as categorized by age, gender and type of disease.

Results:

A total of 63 patients were studied. The mean age of the patients was 54 ± 8.3 (SD)(range 21-79 years) All patients diagnosed as having cervical herniated disc (n = 36) or cervical spinal stenosis (n = 27). Overall, the mean mJOA score for all patients was 9.82 (SD = 1.0). The mJOA score for men were significantly higher than women (P less than 0.0001). The mJOA score in younger patients was significantly higher than older patients (P less than 0.0001). No significant difference was observed for type of disease (P = 0.47).

Conclusions:

The findings of the study suggest that functionality score as measured by the mJOA can be a useful parameter for clinicians help them to manage patients with cervical spondylotic myelopathy prior to surgery.

Keywords:

Score, Cervical, Spondylotic, Myelopathy

A graded prognostic assessment scale to predict overall survival in patients diagnosed with brain metastases undergoing Gamma-knife radiosurgery

Background:

The present study aims to evaluate the Graded Prognostic Assessment (GPA) score for predicting overall survival in patients diagnosed with brain metastases undergoing Gamma-knife radiosurgery.

Methods:

This was a cross sectional study conducted on the patients diagnosed with brain metastases undergoing Gamma-knife radiosurgery during 2003 to 2011. Clinical and radiological parameters were evaluated, and the GPA score were determined. Kaplan–Meier and log-rank tests were used to assess prognostic factors of the GPA.

Results:

Two hundred and twenty patients were eligible to enter the study during the eight years course of study. The mean age of the patients was 54 ± 12.7 years (ranged 19 to 82 years) and were followed up for an average of 7 (range=1-25) months post Gamma-knife surgery. Median survival times according to the GPA were: GPA 0–1, 4 ± 0.4 months; GPA 1.5–2.5, 6 ± 0.7 months; GPA 3, 9 ± 0.9 months; and GPA 3.5–4.0, 12 ± 1.8 months and overall survival were 7 ± 0.6 months. The level of statistical significance among GPA groups was p less than 0.0001.

Conclusions:

It seems that the preoperative GPA is able to predict Gamma-knife radiosurgery results in patients with brain metastases. However, the results should be confirmed with further clinical trial assessments.

Keywords:

Brain metastases, GPA Score, Gamma-knife radiosurgery, Predict

Updated measuring motor, sensory and sphincter dysfunctions in patients with cervical myelopathy using the modified Japanese Orthopedic Association (mJOA) score: a validation study

Background:

Cervical myelopathy population (CMP) is a common cause of significant clinical morbidity. This study aimed to translate and validate the modified Japanese Orthopedic Association score (mJOA) English version in Iran.

Methods:

This was a prospective clinical validation study. Psychometric properties of the questionnaire were assessed using internal consistency; inter-observer reliability, discriminant validity, and responsive ness of the questionnaire to change.

Results:

A total of 63 patients were studied. The mean mJOA score was 9.82 (SD = 1.0). Internal consistency of the mJOA as measured by Cronbach’s alpha coefficient was satisfactory (alpha = 0.77). Inter-observer agreement as measured by Kappa statistics also was found to be acceptable (0.75). Known-groups comparison was performed to test discriminant validity and the findings indicated that the mJOA was able to differentiate between males and females and different age groups as expected (P less than 0.0001). Finally the questionnaire was found to be responsive to change as patients’ pre- and post-operative scores on the mJOA (P less than 0.0001).

Conclusions:

The Iranian version of mJOA performed well and the findings suggest that it is a reliable and valid measure of motor, sensory and sphincter dysfunctions among CMP patients.

Keywords:

Cervical myelopathy patients, Grading scale, Modified japanese orthopedic Association score

The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) for low back disorders: a validation study from Iran

BACKGROUND

Lumbar disc hernia (LDH) and lumbar spinal stenosis (LSS) are the most common diagnoses of low back and leg pain symptoms. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) is a measure of health-related quality of life in these patients. This study aimed to cross-culturally translate and validate the JOABPEQ in Iran.

METHODS

This was a prospective clinical validation study. The translation and cross-cultural adaptation of the original questionnaire was performed in accordance with published guidelines. A total of 103 patients with LDH or LSS were asked to respond to the questionnaire at two points in time: pre- and postoperative assessments (6 months follow-up). To test reliability, the internal consistency was assessed by Cronbach's alpha coefficient, and validity was assessed using convergent validity. Responsiveness to change was also assessed comparing patients' pre- and postoperative scores.

RESULTS

The Cronbach's alpha coefficients for the JOABPEQ at pre- and postoperative assessments ranged from 0.71 to 0.81, indicating a good internal consistency for the questionnaire. In addition, the correlation of each item with its hypothesized subscale of the JOABPEQ showed satisfactory results, suggesting that the items had a substantial association with the subscale representing the concept. Further analysis also indicated that the questionnaire was responsive to change (P < 0.0001).

CONCLUSIONS

In general, the Iranian version of JOABPEQ performed well, and the findings suggest that it is a reliable and valid measure of back pain evaluation among LDH and LCS patients.

Computed tomography-guided stereotactic biopsy of intracranial lesions in pediatric patients

PURPOSE

The primary objective of this study was to report the results of author's 18-year experience of diagnostic stereotactic biopsy procedures in children with intracranial lesions.

METHODS AND MATERIALS

A retrospective analysis was conducted on stereotactic procedures performed on children with brain tumor between 1989 and 2007.

RESULTS

Stereotactic biopsy of intracranial tumors was performed in 172 children (69 girls, and 103 boys) with the mean age of 9.17 ± 3.66 years at the time of diagnosis. The most frequent anatomical location of lesions was brainstem (45.9%). Glioma was the most common diagnosis, represented in 90.7% of patients (156 patients). Other diagnosed tumors (4.7%) were classified as metastatic (1.7%), lymphomas (1.2%), oligodendroglioma (0.6%), craniopharyngioma (0.6%), and pineocytoma (0.6%). Nonneoplastic lesions were revealed in 4.7% of patients.

CONCLUSION

The most frequent brain pathology of children is glioma, but the incidence of brain lesions other than gliomas and the frequency of brain lesions in the inoperable areas are compelling reasons to establish tissue diagnosis.