Predictive factors for improvement of symptomatic cerebral vasospasm following subarachnoid hemorrhage by selective intra-arterial administration of fasudil hydrochloride

BACKGROUND

Symptomatic cerebral vasospasm after subarachnoid hemorrhage (SAH) is a significant cause of delayed cerebral ischemia that leads to poor outcomes. Selective intra-arterial administration of fasudil hydrochloride (IAF) has been adopted for its vasodilatory effect on spasm arteries to prevent delayed cerebral ischemia. However, its effect on clinical outcomes and predictive factors for good recovery are not fully understood. This study aimed to investigate the outcomes of selective IAF and identify predictive factors for good outcomes in patients with cerebral vasospasm after SAH.

METHODS

A retrospective study of 36 patients with cerebral vasospasm following SAH who underwent selective IAF at our institution between January 2014 and May 2022 was conducted. We evaluated the improvements in neurological findings before and after selective IAF. Statistical analyses were performed to determine factors associated with good outcomes.

RESULTS

Selective IAF improved the neurological findings in 26 patients (72.2%). Pre-therapeutic absence of cerebral infarction in more than 1/3 of the spasm artery perfusion area was significantly associated with an improvement in neurological findings (p < 0.0001). Furthermore, there was a tendency for a good outcome when the age was younger (p = 0.093), and the spasm was limited to peripheral vessels (p = 0.065).

CONCLUSION

Our study indicates that selective IAF has a promising effect in improving symptomatic vasospasm, except when a large cerebral infarction exists in the spasm artery perfusion area. Early consideration of selective IAF could be recommended once patients experience symptomatic cerebral vasospasm after SAH.

Tumor volume and calcifications as indicators for preoperative differentiation of grade II/III diffuse gliomas

PURPOSE

To retrospectively evaluate preoperative clinical factors for their ability to preoperatively differentiate malignancy grades in patients with incipient supratentorial grade II/III diffuse gliomas.

METHODS

This retrospective study included 206 adult patients with incipient supratentorial grade II/III diffuse gliomas according to the 2016 World Health Organization classification of tumors of the central nervous system. The cohort included 136 men and 70 women, with a median age of 41 years. Preoperative factors included age, sex, presence of calcifications on computed tomography scans, and preoperative tumor volume measured using preoperative magnetic resonance imaging.

RESULTS

In patients with oligodendrogliomas (IDH-mutant and 1p/19q-codeleted), calcifications were significantly more frequent (p = 0.0034) and tumor volume was significantly larger (p < 0.001) in patients with grade III tumors than in those with grade II tumors. Moreover, in patients with IDH-mutant astrocytomas, preoperative tumor volume was significantly larger (p = 0.0042) in patients with grade III tumors than in those with grade II tumors. In contrast, none of the evaluated preoperative clinical factors were significantly different between the patients with grade II and III IDH-wildtype astrocytomas.

CONCLUSION

In adult patients with suspicison incipient supratentorial grade II/III diffuse gliomas, presence of calcifications and larger preoperative tumor volume might be used as preoperative indices to differentiate between malignancy grades II and III in oligodendrogliomas (IDH-mutant and 1p/19q-codeleted) and larger preoperative tumor volume might have similar utility in IDH-mutant astrocytomas.

Loss-of-function mutations in SGCE found in Japanese patients with myoclonus-dystonia

SGCE myoclonus-dystonia is a monogenic form of dystonia with an autosomal dominant mode of inheritance that co-occurs with a myoclonic jerk. In this study, we present 12 Japanese patients from nine families with this disease. Targeted next-generation sequencing covering major causative genes for monogenic dystonias identified nine distinct SGCE mutations from each of the families: three nonsense, two frameshift, two missense, one in-frame 15 bp deletion, and one splice donor site mutations, of which four were previously unreported. One missense mutation (c.662G>T, p.Gly221Val) was located at the 3' end of exon 5 (NM_001099400), which was predicted to cause aberrant splicing according to in silico predictions. Minigene assays performed together with the c.825+1G>C mutation demonstrated complete skipping of exon 5 and 6, respectively, in their transcripts. The other missense (c.1345A>G, p.Met449Val) and 15 bp deletion (c.168_182del, p.Phe58_Leu62del) mutations showed a significant reduction in cell membrane expression via HiBiT bioluminescence assay. Therefore, we concluded that all the detected mutations were disease-causing. Unlike the other detected mutations, p.Met449Val affects only isoform 3 (NP_001092870 encoded by NM_001099400) among the variously known isoforms of SGCE. This isoform is brain-specific and is mostly expressed in the cerebellum, which supports recent studies showing that cerebellar dysfunction is a key element in the pathophysiology of SGCE myoclonus-dystonia.

Complex regional pain syndrome after mRNA-based COVID-19 vaccination

We describe the case of a 17-year-old woman diagnosed with complex regional pain syndrome (CRPS) at a pain clinic after the second dose of the COVID-19 vaccine. She was referred to our department for surgical treatment of movement disorder seven months after the second inoculation. Baclofen (50 µg), administered intrathecally, improved the involuntary movements of her right hand. After administration of zolpidem (5 mg), involuntary movements of the right index finger almost disappeared. However, neither zolpidem nor intrathecal baclofen improved the limited range of motion of the first joint of the left-hand finger. Despite various reports on CRPS development after vaccination, only one case post COVID-19 vaccination has been reported. Therefore, healthcare providers should keep in mind that CRPS can appear after the COVID-19 vaccination.

Pituicytoma with pleomorphism: A case report with cytological findings

Pituicytoma is a rare neoplasm, arising in the posterior pituitary or in the hypophyseal stalk, and its cytological findings have not yet been well-described. We have experienced a case of pituicytoma, which was difficult to diagnose intraoperatively, because of its cellular pleomorphism. A tumor measuring 18 mm in maximum diameter was found at the sella turcica in a Japanese woman in her forties. Both intraoperative crush cytology and histology of the resected tumor showed pleomorphic spindle or round cells, including multinucleated cells. Tumor cells were positive for TTF-1, S-100 protein, and vimentin, partially positive for glial fibrillary acidic protein and epithelial membrane antigen, and negative for synaptophysin, hormones of the anterior pituitary gland, CD34, Olig2, PAX8, and napsin A. Ki-67 labeling index was 2.0%. Tumors included in the differential diagnosis in general are pituitary adenoma, craniopharyngioma, germinoma, and metastatic tumor on the radiological standpoint, and pilocytic astrocytoma and meningioma on the cytological standpoint. However, our case was difficult to differentiate especially from high-grade glioma only by morphology, and immunohistochemistry including TTF-1 was helpful.

Myotomy and Selective Peripheral Denervation Based on 18F-FDG PET/CT in Intractable Cervical Dystonia: A Case Report

Cervical dystonia, characterized by the involuntary contraction of cervical muscles, is the most common form of adult dystonia. In a patient with intractable cervical dystonia, we carried out a myotomy of the left obliquus capitis inferior and selective peripheral denervation (SPD) of the posterior branches of the C3-C6 spinal nerves based on preoperative 18F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT). The patient was a 65-year-old, right-handed man with an unremarkable medical history. His head rotated involuntarily to the left. Medication and botulinum toxin injections were ineffective, and surgical treatment was considered. ¹⁸F-FDG PET/CT imaging revealed FDG uptake in the left obliquus capitis inferior, right sternocleidomastoideus, and left splenius capitis. Myotomy of the left obliquus capitis inferior and SPD of the posterior branches of the C3-C6 spinal nerves was performed under general anesthesia. During the 6-month follow-up, the patient's Toronto Western Spasmodic Torticollis Rating Scale score improved from 35 to 9. This case shows that preoperative ¹⁸F-FDG PET/CT is effective in identifying dystonic muscles and determining the surgical strategy for cervical dystonia.

Corrigendum: Photodynamic therapy for malignant brain tumors in children and young adolescents

[This corrects the article DOI: 10.3389/fonc.2022.957267.].

Transient neurological events in childhood moyamoya disease

OBJECTIVE

Patients sometimes experience transient neurological events (TNEs) during the early postoperative period after revascularization surgery for childhood moyamoya disease. The clinical background and pathophysiology of TNEs remain unclear. This study aimed to evaluate the incidence rate of TNEs and discuss the factors associated with pediatric moyamoya disease.

METHODS

The authors retrospectively reviewed 110 cerebral hemispheres of 61 pediatric patients younger than 15 years who were treated from 2011 to 2020. All children underwent either simple double-direct or combined revascularization surgery. Of these 61 patients, 52 underwent bilateral surgery and 9 underwent unilateral surgery. The authors calculated the incidence of TNEs in accordance with a previously reported TNE definition. Cerebral blood flow (CBF) was evaluated in all eligible cases with xenon CT immediately after revascularization surgery.

RESULTS

The incidence rate of TNEs in patients with childhood moyamoya disease was 26.4%. TNEs occurred after an average (range) of 6.26 (2-12) days postoperatively without triggers, and all identified TNEs spontaneously resolved within 2 weeks. The most common symptoms were dysarthria, facial palsy, and numbness around the mouth, followed by sensory disturbance of the upper extremities. The presence of focal hyperperfusion on xenon CT performed immediately after revascularization surgery was strongly correlated with the incidence of TNEs (p = 0.0001). Focal hyperperfusion was observed in 43 of 110 operative sides (39.1%). Notably, only 25.6% of patients with focal hyperperfusion showed numerical global hyperperfusion. In addition, a decrease in CBF compared with the thalamic region in the contralateral side was observed in TNE-affected cases (p = 0.0443).

CONCLUSIONS

TNEs occurred more frequently in childhood moyamoya disease patients than expected. The clinical background, including symptoms, timing, and duration, was almost identical to TNEs in adults. Focal hyperperfusion, rather than numerical global hyperperfusion, was strongly correlated with the incidence of TNEs. Furthermore, the authors advocate the notion that a clinical course where symptoms occur without triggers may be a unique characteristic of TNEs, especially in childhood moyamoya disease.

Subclavian Artery-Carotid Artery Bypass for Subclavian Artery or Common Carotid Artery Severe Stenosis or Occlusion

Various surgical treatments are available for occlusive subclavian and common carotid artery diseases. Nevertheless, to date, when cerebral endovascular treatment is utilized, revascularization via direct surgery may be required. This study reported five symptomatic cases of revascularization for CCA and SCA occlusive and stenotic lesions that were expected to be challenging to treat with endovascular treatment. We performed subclavian artery-common carotid artery or internal carotid artery bypass using artificial blood vessels or saphenous vein grafts in five patients with subclavian steal syndrome, symptomatic common carotid artery occlusion, and severe proximal common carotid artery stenosis. In this study, good bypass patency was achieved in all five cases. Although there were no intraoperative complications, one patient had a postoperative lymphatic leak. Moreover, there was no recurrence of stroke during postoperative follow-up for an average of 2 years. Conclusively, subclavian artery-common carotid artery bypass can be an effective surgical treatment for common carotid artery occlusion, proximal common carotid artery stenosis, and subclavian artery occlusion.

Bilateral Radiofrequency Ventral Intermediate Thalamotomy for Essential Tremor

INTRODUCTION

With the advent of MR-guided focused ultrasound, the importance of the efficacy and safety of bilateral ventral intermediate (Vim) thalamotomy for essential tremor (ET) has increased. However, reports on bilateral Vim thalamotomy for ET remain scarce.

METHODS

To review the results and complications of bilateral Vim thalamotomy for the treatment of ET in the upper extremities, we retrospectively analyzed the patients with ET who underwent bilateral Vim thalamotomy with radiofrequency (RF) thermal coagulation. As bilateral simultaneous thalamotomy can cause surgical complications, thalamotomy was performed in stages. The interval between the first and second thalamotomies was 21.3 ± 14.7 months. We evaluated the efficacy using the Clinical Rating Scale for Tremor (CRST) before and after the first and second treatments, respectively. We also evaluated the complications before and after the first and second treatments, respectively. Moreover, we assessed the adverse events.

RESULTS

Seventeen patients were included in the study. The mean follow-up period following the second thalamotomy was 29.3 ± 15.0 months. The CRST part A + B scores were 34.9 ± 9.7, 20.8 ± 7.0, and 7.4 ± 6.8 before, following the first (40.4% improvement, p < 0.0001) and second thalamotomies (78.6% improvement, p < 0.0001), respectively. Nine patients presented with prolonged adverse events, including dysarthria, dysgeusia, dysphagia, tongue numbness, unsteady gait, and postural instability at the last available evaluation. All adverse events were mild and did not interfere with the patient's daily activities.

DISCUSSION/CONCLUSIONS

Bilateral Vim thalamotomy with RF thermal coagulation was an effective treatment for ET in both upper extremities. Despite most possible complications being mild, additional studies with a larger sample size are required to ensure patient safety.

Enterprise Treatment for Recurrent Basilar Tip Aneurysm after PulseRider-assisted Coil Embolization: A Case Report

PulseRider (Cerenovus, Irvine, CA, USA) is a relatively novel device used for the treatment of wide-neck aneurysms with a coil-assisted effect. However, treatment options for recurrent aneurysms after PulseRider-assisted coil embolization remain controversial. Here we report a case of recurrent basilar tip aneurysm (BTA) treated with Enterprise 2 after PulseRider-assisted coil embolization. A woman in her 70s underwent coil embolization for a subarachnoid hemorrhage with ruptured BTA 16 years ago. Recurrence was detected at 6-year follow-up, and an additional coil embolization was performed. Nevertheless, gradual recurrence still occurred, and PulseRider-assisted coil embolization was performed without any complications 9 years after the second treatment. However, recurrence was detected once more at 6-month follow-up. Thus, stent-assisted coil embolization using Enterprise 2 (Cerenovus) through PulseRider was selected for angular remodeling. Enterprise 2 was deployed between the right P2 segment of the posterior cerebral artery (PCA) and basilar artery (BA) after an effective coil embolization, which achieved effective angular remodeling between the right PCA and BA. The patient's postoperative course was uneventful, and no recanalization was detected after half a year. Although PulseRider is effective for wide-neck aneurysm treatment, recurrence remains a possibility. Additional treatment using Enterprise 2 is safe and effective with the expectation of angular remodeling.

Seven-year resolution of cervical dystonia after unilateral pallidotomy: A case report

Background

Reports on the long-term effects of pallidotomy for cervical dystonia remain scarce.

Case Description

We report a case of cervical dystonia successfully treated by unilateral pallidotomy. The patient was a 29-year-old man without past medical and family history of cervical dystonia. At the age of 28 years, neck rotation to the right with right shoulder elevation developed and gradually became worse. After symptoms failed to respond to repetitive botulinum toxin injections and oral medications, he underwent left pallidotomy, which resulted in significant improvement of cervical dystonia and shoulder elevation without surgical complications. At the 3-month evaluation, the symptoms completely improved. The Toronto Western Spasmodic Torticollis Rating Scale score dramatically improved from 39 points before surgery to 0 points at 7-year postoperative evaluation.

Conclusion

This case suggests that unilateral pallidotomy can be an alternative treatment option for cervical dystonia.

Networked lymphatic endothelial cells in a transplanted cell sheet contribute to form functional lymphatic vessels

This study evaluated whether cell sheets containing a network of lymphatic endothelial cells (LECs) promoted lymphangiogenesis after transplantation in vivo. Cell sheets with a LEC network were constructed by co-culturing LECs and adipose-derived stem cells (ASCs) on temperature-responsive culture dishes. A cell ratio of 3:2 (vs. 1:4) generated networks with more branches and longer branch lengths. LEC-derived lymphatic vessels were observed 2 weeks after transplantation of a three-layered cell sheet construct onto rat gluteal muscle. Lymphatic vessel number, diameter and depth were greatest for a construct comprising two ASC sheets stacked on a LEC/ASC (3:2 ratio) sheet. Transplantation of this construct in a rat model of femoral lymphangiectomy led to the formation of functional lymphatic vessels containing both transplanted and host LECs. Further development of this technique may lead to a new method of promoting lymphangiogenesis.

ACT-24 LONG TERM CLINICAL RESULTS OF NEWLY DIAGNOSED GLIOBLASTOMA BY AGE AND TREATMENT STRATEGY

Introduction

Glioblastoma has the poorest prognosis among brain tumors, and most cases recur. On the other hand, evidence of prognosis improvement by maximal surgical removal of the tumor is being established, and in recent years, new treatments such as temozolomide (2006), photodynamic therapy (2014), and TTF therapy (2018) were approved by insurance. and patient outcome has improved. In addition, molecular targeted therapy (bevacizumab approved in 2011) and immunotherapy are also used in clinical practice. In this study, we retrospectively analyzed the long-term treatment results of newly diagnosed glioblastoma cases treated at our facility, the correlation with the resection rate, and the treatment results by age and treatment method.

Methods

We retrospectively analyzed the clinical characteristics, resection rate, and treatment outcomes of adult patients with primary supratentorial glioblastoma who underwent surgery and treatment at our institution during the 20-year period from 2001 to 2021.

Results

493 cases, median age 58 years (18-85 years), 293 males and 200 females. The median and mean contrast-enhanced lesion resection rates in resection cases were 98% and 96.6%, respectively. Median PFS and OS for all patients (including biopsies) were 9.4 months and 22.7 months, respectively. The median OS for each age was 12.9 months, 22.9 months, 23 months, and 31.1 months when analyzed separately for 2001-2006, 2007-2010, 2011-2015, and 2016-2021 before TMZ. (p&lt;0.0001), and treatment results improved with age. In particular, the median OS of 23 patients who combined PDT and autologous tumor vaccine (AFTV) was 63.1 months.

Conclusion

Treatment results for glioblastoma improve with age, and the time has come when we can aim for a 5-year survival rate of 50% by combining a high resection rate with multidisciplinary therapy including intraoperative MRI, PDT, AFTV and TTF.

RT-7 DIFFERENTIATION AND TREATMENT OF RECURRENCE AND RADIATION NECROSIS IN THE TREATMENT OF MALIGNANT GLIOMAS

Background

In the course of treatment of malignant gliomas, the appearance of contrast-enhanced lesions and surrounding T2/FLAIR high-signal after treatment is often experienced. There is no modality that can reliably diagnose whether the lesion is a recurrence or a response to treatment, including radiation necrosis. Furthermore, the choice of treatment modality is often difficult, such as reexcision, stereotactic irradiation, Avastin. Very few reports have examined the relationship between the irradiation field and histology.

Methods

Thirty-seven lesions in 30 patients who underwent repeat resection of malignant gliomas at our institution from October 2019 to December 2021 were analyzed retrospectively. Based on postoperative pathology, the patients were classified into two groups: recurrence group and radiation necrosis group.In each group, age, gender, histology at initial surgery, IDH status, radiation and chemotherapy, TNR of Methionine-PET, and the number of days after the end of treatment until the appearance of contrast lesions were considered.

Results

The recurrence group consisted of 20 patients with 26 lesions, mean age 48 years, male/female = 13/7, pathology was GBM 13, DA 1, AA 3, AO 2, AE 1, TNR 3.33 (1.41-6.32), and time to contrast appearance 547 (14-2427) days. PDT in combination with initial surgery was seen in 9 patients.The necrosis group consisted of 10 patients with 11 lesions, mean age 47 years, male/female = 4/6, pathology GBM 5, AA 2, AO 1, PXA 2. TNR 2.51 (1.20-3.75), 318 (24-678) days to contrast appearance, 2 patients had PDT.

Conclusions

Radiation necrosis tended to have lower TNR and shorter time to lesion appearance than recurrence, but no significant difference was observed. Improvement of diagnostic accuracy with modalities is desirable, and unnecessary irradiation is highly likely to contribute to ADL deterioration such as leukoencephalopathy and higher functional impairment.

STMO-17 USEFULNESS OF INTEGRATION OF PREOPERATIVE FUNCTIONAL IMAGING AND INTRAOPERATIVE MRI NAVIGATION SYSTEM IN GLIOMA SURGERY

Purpose

Intraoperative magnetic resonance imaging (MRI) update navigation is performed in all cases to preserve neurological function and remove the tumor as much as possible, and to prevent recurrence and improve prognosis. And under awake craniotomy, we supported operators by integrating preoperative functional images with intraoperative MRI. We report our usefulness of image superimposition between medium magnetic field intraoperative MRI and preoperative position emission tomography (PET) and preoperative diffusion tensor imaging (DTI) color-map.

Method

Of more than 2,200 cases using intraoperative MRI since 2000, 58 preoperative PET (57 methionine and 1 FDG nuclides) superimposed cases (32 left-sided, 35 males, 15 under awake craniotomy, mean 44.8 y.o.) were evaluated. The tumor was located to 34 frontal-, 12 temporal-, 10 parietal lobes, 1 insular gyrus, 1 thalamus. Color-map image superimposition of preoperative DTI (3T, 6-axis application) anisotropic indices in 12 cases (localized in 8 frontal-, 2 insular-, 2 parietal lobes, 7 left-sided, 7 females, mean 35 y.o.). Neurophysiological monitoring was combined (5 under general, 7 awake anesthesia).

Results

The preoperative TN ratio was 3.8 (in 57 methionine-PET cases), and pathological results (Grade 3-4 in 15-31 cases respectively, out of 54 cases) were used for reliable and preferential removal of sites with higher malignancy and recurrence-prone sites. Recurrent cases (41/58) had altered brain structures that were too difficult to identify without the navigation. In the DTI cases, intraoperative MRI, DTI color-map, and microscopic surgical images were displayed on one screen, and white matter tracts information as a reference is quickly conveyed to operators, and helped to reduce perioperative neurological complications.

Conclusion

Co-registering an effective superimposition of medium magnetic field intraoperative MRI with high positional accuracy, and preoperative PET- and DTI- images according to the patient's characteristics is currently the most practical navigation application method for intraoperative prediction of important functional information.

MPC-10 RECURRENT ASTROCYTOMA WITH SOMATIC IDH MOSAICISM: A CASE REPORT AND WARRANT FOR MOLECULAR DIAGNOSTICS

Introduction

Acquisition of somatic mutations is essential for the development of malignant tumors such as diffuse gliomas. Recent single-cell analyses have pointed out the importance of somatic mosaicism in the pathogenesis of cancer. Here we report a case of IDH (isocitrate dehydrogenase)-mutant astrocytoma that has relapsed after intensive chemoradiation with somatic mosaicism for the IDH1 R132H mutation.

Clinical and Pathological Findings

A 36-year-old male presented with epileptic symptoms and a mass lesion in the right frontal lobe. A needle biopsy demonstrated IDH-mutant astrocytoma (grade 2). At the age of 41, relapsed tumor was completely resected, and the tumor cells were diffusely positive for IDH1 R132H with grade 4 morphology. Chemoradiotherapy (PAV + IMRT 60Gy/30fr) was added, but contrast-enhanced lesions reappeared 5 months after the initial surgery. The re-excised specimen was grade 4 astrocytoma, and the number of IDH1 R132H-positive tumor cells was very small compared to the total number of tumor cells, suggesting somatic mosaicism for IDH mutations.

Conclusion

It is imperative to clarify the induction mechanism and significance of somatic cell mosaicism in cancer, and molecular genetic assessment with sequencing and digital PCR would be necessary in addition to immunostaining for accurate molecular diagnoses of the brain tumors.

IgG4-related brain pseudotumor mimicking CNS lymphoma. A case report

Here, we report a case of IgG4-related brain pseudotumor (IgG4-BP) in a 39-year-old woman, mimicking central nervous system (CNS) lymphoma. She presented with headache, fever, and fatigue. Her medical history was notable for appearance of a tumefactive brain lesion seven years before. Brain biopsy performed at the age of 32 revealed nonspecific inflammatory changes, and her condition improved with oral low-dose steroid therapy. Magnetic resonance imaging performed at the age of 39 identified a hyperintensity lesion with edema located at the medial temporal lobe region adjacent to the inferior horn of the left lateral ventricle on fluid-attenuated inversion recovery images, which showed gadolinium-contrast enhancement on T1-weighted images and a slightly hyperintensity signal on diffusion-weighted images. Methionine-positron emission tomography (PET) depicted a high methionine uptake in the lesion. Additionally, soluble levels of interleukin (IL)-2 receptor (sIL-2R) and IL-10 were increased in cerebrospinal fluid (CSF). Based on these findings, we suspected CNS lymphoma and performed partial resection of the brain lesion. Pathological examination revealed prominent lymphocytic infiltration associated with plasma cell infiltration. Most of the plasma cells were immunoreactive for IgG4. Storiform fibrosis and partially obliterative phlebitis were concomitantly observed. Thus, the patient was diagnosed as having IgG4-BP. To the best of our knowledge, this is the first case report of IgG4-BP with detailed findings obtained by CSF testing, methionine-PET, and pathological examination. Because IgG4-related diseases can present as a pseudotumor that mimics CNS lymphoma, it is essential to carefully differentiate IgG4-BP from CNS lymphoma.

Photodynamic therapy for malignant brain tumors in children and young adolescents

Photodynamic therapy (PDT) targets tumor cell remnants after resection. Here, we evaluated the feasibility of PDT for malignant brain tumors in children and young adolescents. This was a single-center, non-randomized, phase I/II clinical study. The primary endpoints were the safety of treatment with talaporfin sodium (TS) (phase I) and overall survival (OS) after PDT (phase II). The secondary endpoint was progression-free survival (PFS) after PDT. The TS dose was determined by dose escalation from 10 to 20 to 40 mg/m² for every three cases starting from the initial enrolled case. Eight patients with a mean age of 170.2 months (129-214 months) at the time of PDT received nine procedures with a mean follow-up duration of 16.8 months (1-42 months) after PDT. Histopathological diagnoses included supratentorial anaplastic ependymoma (n = 2), anaplastic astrocytoma (n = 1), diffuse midline glioma with H3K27M mutation (n = 1), glioblastoma (n = 3), and pediatric high-grade glioma (n = 1). The outcome was survival in five patients and death in three patients. Recurrence occurred in six of the eight patients; the remaining two were recurrence-free after PDT. Therefore, OS and PFS were calculated as 21 and 6 months, respectively. Seizures and fevers, which were likely surgery-related symptoms, were commonly observed. Photosensitive skin rashes or liver dysfunction, which are common adverse effects in adults, were not observed. Our results showed that TS can be used safely in children at doses comparable to those used in adults, as there was no major complication associated with TS administration. However, we cannot make a definitive conclusion about the efficacy of PDT because of the small number of participants. Accumulating cases was difficult because of the rarity of pediatric brain tumors and the difficulty in making a preoperative differential diagnosis, considering the wide range of histopathological findings. Moreover, the psychological stress associated with light-shielding management in pediatric patients was more severe than initially expected. In conclusion, TS at doses comparable to those used in adults may be safe for use in children and young adolescents between the ages of 6 and 20 years. However, further studies are needed to clarify its efficacy.

CTNI-41. TRANSITION OF LONG-TERM TREATMENT RESULTS OF 493 CASES OF NEWLY DIAGNOSED GLIOBLASTOMA AND SURVIVAL BENEFIT BY COMBINATION WITH PDT AND AFTV - AIMING TO ESTABLISH NEW STANDARD TREATMENT

INTRODUCTION

Glioblastoma has the worst prognosis of brain tumors. Evidence for improving prognosis by maximal tumor removal is being established, and in recent years, new treatments such as photodynamic therapy (PDT, 2014 in Japan), and TTF therapy (2018) have been approved, the treatment results are improving. In principle, our facility performs maximum tumor removal using intraoperative MRI (iMRI) follow by the standard chemoradiation. Intraoperative PDT and autologous tumor vaccine (AFTV) will be given to desired patients. We retrospectively analyzed the long-term clinical results of the patients with newly diagnosed glioblastoma who underwent surgical treatment at our facility, and the treatment results by era and treatment method.

METHODS

The clinical features, extent of removal (EOR), OS and PFS of the adult patients with newly diagnosed glioblastoma treated from 2001 to 2021 were analyzed retrospectively. Clinical results of those patients who received PDT and AFTV treatment was also investigated.

RESULTS

The number of cases was 493, median age 58 years (18-85 years), 293 males, 200 females. The median and average EOR of contrast-enhanced lesions were 98% and 96.6%, respectively. The median PFS and OS of all cases (including biopsy) were 9.4 months and 22.7 months, respectively. When the cases were analyzed separately for 2001-2006 (before TMZ), 2007-2010, 2011-2015, and 2016-2021, the median OS for each age group was 12.9 months, 22.9 months, 23 months, and 31.1 months. The treatment results improved with age ( p &lt; 0.0001). In particular, the median OS of 23 cases treated with PDT and AFTV was 63.1 months. The efficacy of AFTV for newly diagnosed glioblastoma is currently being verified in a multicenter Investigator-led clinical trial.

CONCLUSION

The treatment results for glioblastoma have improved over the years. The combination of maximal tumor removal using iMRI, PDT and AFTV may aim for a 5-year survival rate of 50%.

SURG-27. THERAPEUTIC OPTIONS FOR RECURRENT GLIOBLASTOMA-EFFICACY AND SAFETY OF TALAPORFIN SODIUM MEDIATED PHOTODYNAMIC THERAPY WITH MAXIMAL RESECTION

INTRODUCTION

Recurrent glioblastoma (GBM) remains one of the most challenging clinical issues, with no standard treatment and effective treatment options.

METHODS

To evaluate the efficacy of talaporfin sodium (TS) mediated photodynamic therapy (PDT) as a new treatment for this condition, we retrospectively analyzed 70 patients who underwent surgery of maximal resection with PDT (PDT group) for recurrent GBM and 38 patients who underwent surgery of maximal resection alone (control group).

RESULTS

The median progression-free survival (PFS) in the PDT and control groups after second surgery was 5.7 and 2.2 months, respectively (p = 0.0043). The median overall survival (OS) after the second surgery was 16.0 and 12.8 months, respectively (p = 0.031). Both univariate and multivariate analyses indicated that surgery with PDT and a preoperative Karnofsky Performance Scale were significant independent prognostic factors for PFS and OS. In the PDT group, there was no significant difference regarding PFS and OS between patients whose previous pathology before recurrence was already GBM and those who had malignant transformation to GBM from lower grade glioma. PDT was well tolerated by all patients and in no case did treatment-related severe adverse effects. There was also no significant difference in TS accumulation in the tumor between these two groups.

CONCLUSION

According to these results, additional PDT treatment for recurrent GBM could have potential survival benefits and its efficacy is independent of the pre-recurrence pathology.

NCMP-24. RISK FACTORS OF SURGICAL SITE INFECTION IN GLIOMA SURGERY

BACKGROUND

Surgical site infection(SSI) in neurosurgery can increase mortality and worsen functional outcome. There are few reports on risk factors for SSI in glioma surgery. In this study, we investigated the risk factors for SSI in glioma surgery at our institution.

METHODS

We included 1013 patients with gliomas who underwent craniotomy between November 2013 and March 2022 at our institution. SSI was defined as requiring surgical treatment. Various factors including age, gender, number of operations, prior radiology, prior chemotherapy, use of intraoperative MRI, operation time, tumor WHO grade were investigated.

RESULTS

Among 1013 craniotomies, 31 (3.06%) cases of SSI required surgical procedure. In univariate analysis, the most significant factors were multiple prior craniotomy (p = 0.0067) and prior radiation therapy ( p = 0.0286). Among these factors, multivariate analysis revealed the number of surgeries ( p = 0.0151) as a significant independent factor for infection.Discussion and

CONCLUSION

Patients with gliomas often requires multiple craniotomy due to tumor recurrence. Although there have been reported the reoperation is an independent risk factor for postoperative infection, the is the first time that a specific number of prior surgeries ( 2 or more) has been reported. Radiotherapy is said to cause skin damage at a threshold of 10 Gy or less. Since radiation therapy for gliomas is given a dose of 50 Gy or more and irradiated scalp causes radiation dermatitis, and patients who have undergone prior radiotherapy must be carefully monitored.

[Development of Medical Materials and Infection]

Surgery has the possibility to cause infections. Surgical site infection(SSI)is a common complication of various surgical procedures. On the other hand, allogeneic tissue-derived material-induced infections, such as transfusion-related hepatitis and Creutzfeldt-Jakob disease, are rare but occur. The risk of surgery-related infections needs to be reduced because such infections not only affect morbidity and mortality but also lead to increased medical costs and longer hospitalization. Recently, various allogeneic and synthetic medical materials have been developed, and many types of materials have been used in daily neurosurgical procedures. Some synthetic materials have been advertised to have an SSI-preventive effect. Technology has also been developed to minimize the infectivity of allogeneic materials. In this paper, we introduce some information focused on the infectivity of fibrin glue and DuraGen^® and the SSI-preventive effect of Surgicel^® and antimicrobial sutures.

Successful treatment of focal hand dystonia after cervical whiplash injury by thalamotomy

Background:

Posttraumatic focal hand dystonia after cervical whiplash injury is rare. Moreover, the treatment of peripheral posttraumatic dystonia is usually ineffective. Herein, we report a case of successful thalamotomy for a patient with focal hand dystonia after cervical whiplash injury.

Case Description:

A 39-year-old woman was hit from behind by a car; subsequently, she felt strange in the right hand and was diagnosed with whiplash injury. A month later, she developed a persistent abnormal posture of the right hand. Brain imaging showed no lesions, and cervical magnetic resonance imaging showed stenosis but no spinal cord signal changes. Posttraumatic dystonia was diagnosed, for which the patient underwent left ventro-oral (Vo) thalamotomy. One year after the first surgery, the patient underwent left Vo and ventral intermediate nucleus (Vim) thalamotomy due to recurrence of dystonia. Nine years after the second surgery, the patient continues to be able to maintain her normal physical routine.

Conclusion:

Vo-Vim thalamotomy may be a feasible and effective treatment for focal hand dystonia after cervical whiplash injury.