An Experience With an Exoscope System (ORBEYE) for Surgery for Tarsal Tunnel Syndrome: A Case Report

Surgery for peripheral entrapment neuropathy aims to decompress the affected nerve and optimize the visualization of anatomical details during surgery. This paper describes our experience using the ORBEYE exoscope (Olympus) during surgery for tarsal tunnel syndrome (TTS).

The patient was a 70-year-old male with complaints of bilateral pain and numbness on the plantar surface of the bilateral soles and medial halves of both lower limbs. He was diagnosed with idiopathic TTS with the American Orthopedic Foot and Ankle Score (AOFAS) of 20/100. Surgery for the right foot was performed under local anesthesia with the patient’s body in the lateral position. All procedures were performed using the ORBEYE exoscope view. The posterior tibial artery (PTA) was transposed, and the flexor retinaculum was reconstructed between the PTA and posterior tibial nerve. Indocyanine green (ICG) video angiography confirmed the absence of PTA flow disturbance. One month after the first operation, left foot surgery was performed. Three months later, the AOFAS had improved from 20/100 to 50/100.

The ORBEYE exoscope is useful in TTS treatment and represents a feasible and comfortable technique for entrapment neuropathy surgery. In addition, ICG capability is an effective tool for confirming blood flow in PTA after transposition.

Postoperative 18F-FDG-PET/CT documents efficacy of selective peripheral denervation for treating cervical dystonia

Background:

Cervical dystonia, characterized by involuntary contraction of the cervical muscles, is the most common form of adult dystonia. We compared the preoperative versus postoperative 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) scans to confirm the efficacy of selective peripheral denervation (SPD) for treating cervical dystonia.

Case Description:

A 38-year-old male with the right-sided cervical dystonia underwent a left pallidothalamic tractotomy. However, the involuntary neck movement persisted and correlated with the ¹⁸F-FDG-PET/CT imaging that showed persistent FDG uptake in the right obliquus capitis inferior muscle. A subsequent SPD resulted in resolution of the dystonia that correlated with lack of further ¹⁸F-FDG-PET/CT uptake in the right obliquus capitis inferior muscle.

Conclusion:

The postoperative ¹⁸F-FDG-PET/CT documented the efficacy of an SPD in resolving a patient’s cervical dystonia.

The high incidence and risk factors of levetiracetam and lacosamide-related skin rashes in glioma patients

OBJECTIVE

Antiseizure drug (ASD)-induced skin rash remains the main side effect of seizure management in patients with glioma. New generations of ASDs, such as levetiracetam (LEV) and lacosamide (LCM) are associated with less frequent skin rashes than conventional ASDs. However, there are few reports regarding the incidence of skin rashes by LEV and LCM in patients with glioma. Therefore, the aim of this study was to investigate the incidence and risk factors of LEV- and LCM-associated skin rashes in patients with glioma.

METHODS

We compared the incidence of ASD-associated skin rash between 353 patients with glioma and 125 patients with meningioma, who received LEV or LCM and underwent surgery between 2017 and 2019 at our institution. Furthermore, to evaluate the association between potential risk factors and ASD-associated skin rashes, univariate and multivariate analyses were performed.

RESULTS

The incidence of ASD-associated skin rash in patients with glioma was higher (11 %) than in those with meningiomas (1.6 %). The multivariate regression analysis showed that adjuvant treatment with radiotherapy (p = 0.023) and a history of drug allergy (p = 0.023) were significant risk factors for ASD-associated skin rash. The rate of ASD-related skin rashes in patients with glioma was also higher than the previously reported rates of 1-3 % in patients with epilepsy.

CONCLUSION

Our results indicate that adjuvant treatment with radiotherapy and a history of drug allergy correlated with a high incidence of ASD-related skin rashes in patients with glioma who receive LEV and LCM. Patients with these two factors should be carefully checked for skin rashes.

Coagulation technique for remodeling anastomosis spaces in bypass surgery

Cerebrovascular bypass techniques are the current cornerstone methods to achieve cerebral revascularization for Moyamoya disease (MMD) or syndrome and select cases of vascular pathologies, such as intracranial atherosclerotic occlusive disease and complex aneurysms. Factors influencing bypass efficiency include graft patency, short temporary occlusion time, and precise anastomosis. Based mainly on our senior author's vast experience with 1300 bypasses, we recommend performing the anastomosis with the minimal amount of stitches as achievable, to avoid stenosis of the artery's internal lumen that may occur with unnecessary, additional stiches, preserving patency. After completing the anastomosis, when a leak occurs between the sutures, cottonoid tamponade, hemostatic materials or adding one or two sutures to the space is often enough to close the gap. However, additional suture placement can be difficult, which might cause stenosis of the anastomosis and reduce blood flow. In this video, we introduce a bipolar coagulation technique for remodeling the anastomosis orifices, as an alternative manner, when minor leakages occur between the knots. We demonstrate this technique in an adult MMD patient that underwent a superficial temporal artery to middle cerebral artery bypass, in this case coagulation of the donor artery wall at the anastomosis made possible to adapt the edges of the donor artery precisely to the recipient artery wall by shrinking its redundancy between the stitches. The most important is to coagulate the donor side orifice precisely with low power bipolar coagulation and never coagulate the recipient artery. This coagulation technique is a simple alternative to stop further leakage and prevents placing an additional suture, as well as it reduces temporary occlusion time.

Efficacy and Safety of Zolpidem for Focal Dystonia After Neurosurgical Treatments: A Retrospective Cohort Study

Although there are several reports of the significant efficacy of zolpidem for treating dystonia, zolpidem is still considered an anecdotal treatment. Here, we evaluated the efficacy and safety of zolpidem for treating residual dystonia in patients who previously received various neurosurgical treatments majorly including deep brain stimulation and radiofrequency ablation. We retrospectively reviewed medical records from January 2021 to September 2021 to identify patients with dystonia who had been prescribed zolpidem after undergoing neurosurgery. Twenty patients were enrolled in this study, including those with blepharospasm (two), tongue dystonia (four), mouth dystonia (one), spasmodic dysphonia (two), cervical dystonia (six), focal hand dystonia (three), hemidystonia (two), blepharospasm with cervical dystonia (one), and mouth dystonia with cervical dystonia (one). Single doses of zolpidem ranged between 2.5 and 10 mg, while daily dosages ranged from 10 to 30 mg. The zolpidem dose prescribed was 5–10 mg, with single and daily doses of 7 ± 2.9 and 14.5 ± 6.0 mg, respectively. With zolpidem administration, the participants' Burke-Fahn-Marsden Dystonia Rating Scale-Movement Scale score significantly improved from 8.1 ± 6.7 to 3.7 ± 2.5 (50.6% improvement, p < 0.0001). Improvements in arm dystonia, blepharospasm, and spasmodic dysphonia were observed using the Arm Dystonia Disability Scale, Jankovic Rating Scale, and Voice Handicap Index, respectively. No improvements were observed in cervical dystonia on the Toronto Western Spasmodic Torticollis Rating Scale. Drowsiness, including three cases each of mild and moderate drowsiness, was the most frequent adverse effect (30%), which persisted for 2–3 h. Transient amnesia and rapid eye movement sleep behavior disorder occurred in two patients and one patient, respectively. Although our findings suggest that zolpidem can be a valuable treatment option for patients with residual dystonia after neurosurgical treatments, the beneficial effects for cervical dystonia were limited.

Clinical features and difficulty in diagnosis of Langerhans cell histiocytosis in the hypothalamic-pituitary region

Langerhans cell histiocytosis (LCH) is a multi-organ disorder that rarely involves the hypothalamic-pituitary region (HPR). HPR-LCH presents with severe progressive pituitary dysfunction and its prognosis is poor. The definitive diagnosis of LCH is considerably difficult and complicated owing to the occurrence of several diseases with similar manifestations in the HPR and its location in the deepest portion of the anterior skull base, in close proximity to important normal structures, severely limiting the size of the biopsy specimen. Chemotherapy is the established treatment modality for LCH; hence, timely and accurate diagnosis of LCH is essential for early therapeutic intervention. We retrospectively reviewed clinical features and biopsy procedures in four patients with HPR-LCH (all female, 28-44 years old) from 2009 to 2020. Maximum diameter of supra-sellar lesions was 23-35 mm and 2 cases had skip lesions. All patients demonstrated central diabetes insipidus, hyper-prolactinemia, and severe anterior pituitary dysfunction. Two of the patients had progressive disease. Furthermore, four patients presented body weight gain, two visual disturbance, and two impaired consciousness. The duration from onset to diagnosis of LCH was 3 to 10 (average 7.25) years. In total, eight operations were performed until final diagnosis. The percentage of correct diagnosis by biopsy was 50% (4/8). Clinical features of HPR-LCH are very similar to those of other HPR diseases, and their symptoms are progressive and irreversible. Clinicians should consider repeated biopsy with a more aggressive approach if the lesion is refractory to steroid therapy, in order to ensure accurate diagnosis and appropriate treatment.

Breath-holding spells after endoscopic third ventriculostomy in a post-ventriculoperitoneal shunted patient

Breath-holding spells (BHS) are commonly observed in children as a result of an autonomic nervous system disorder triggered by crying, emotional distress, or pain. There are several types of BHS and cyanotic type is one of them. We encountered a case of 3-year-old girl who presented with a delayed adaptation period and BHS 2 weeks after an endoscopic third ventriculostomy (ETV). She experienced severe headache due to increased intracranial pressure (ICP) during the delayed adaptation period, which may have contributed to the onset of BHS. Management of BHS warrants treatment of the symptoms and removal of the causative factors; in our case, intensive pain control and resolution of the increased ICP after the adaptation period were effective. While BHS are usually described as a benign condition that improves spontaneously, we highlighted the importance of recognizing and monitoring atypical symptoms such as BHS in pediatric cases.

Unilateral pallidothalamic tractotomy at Forel's field H1 for cervical dystonia

Background

Neurosurgical ablation of Forel's field H1 for cervical dystonia, which is currently abandoned, was formerly used in the 1960s–1970s. Regardless of the lack of neuroimaging modalities and objective evaluation scales, the reported efficacy was significant. Although recent studies have reappraised the ablation of the pallidothalamic tract at Forel's field H1 for Parkinson's disease, the efficacy for cervical dystonia has not been investigated well.

Methods

Data of 35 patients with cervical dystonia who underwent unilateral pallidothalamic tractotomy at Forel's field H1 were retrospectively analyzed. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores, the neck score of the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS), and adverse events were evaluated preoperatively and at the last available follow‐up period.

Results

The mean clinical follow‐up period was 13.9 ± 6.5 months. The mean TWSTRS total scores were 34.3 ± 14.0 preoperatively and 18.4 ± 16.5 at the last available follow‐up period (46.4% improvement, p < 0.0001). The BFMDRS neck score also improved significantly from 6.2 ± 2.9 preoperatively to 2.8 ± 2.8 at the last available follow‐up period (55.0% improvement on the neck score, p < 0.0001). Reduced hand dexterity in seven patients, hypophonia in five patients, dysarthria in four patients, and executive dysfunction in one patient were confirmed as adverse events at the last available follow‐up evaluation. One patient had postoperative hemorrhage.

Conclusion

The current study confirmed significant improvement in TWSTRS total scores and BFMDRS neck scores at the 13.9‐month follow‐up after unilateral pallidothalamic tractotomy. The pallidothalamic tract in Forel's field H1 is expected to be an alternative treatment target for cervical dystonia.

Triple bypass for multisystem smooth muscle dysfunction syndrome due to Arg179His ACTA2 mutation

Missense mutations in the smooth muscle-specific isoform of the alpha-actin (ACTA2) gene, which encodes smooth muscle actin, congenitally cause systemic smooth muscle dysfunction, leading to multiple systemic smooth muscle dysfunction syndrome. This disease is often diagnosed through the development of congenital mydriasis, patent ductus arteriosus, or thoracic aortic aneurysm at a young age. Some patients develop cerebrovascular lesions, also known as ACTA2 cerebral arteriopathy, which cause ischemic stroke and require surgical revascularization. However, an effective and safe treatment has not yet been established owing to the rarity of the disease. Furthermore, most reports of this disease involve children, with only a few reports on adults and few detailed reports on treatment outcomes published to date. We report a 46-year-old woman with ACTA2 cerebral arteriopathy caused by Arg179His, the most common mutation in this disease; she is the oldest patient reported with this disease to the best of our knowledge. The patient was diagnosed with multiple systemic smooth muscle dysfunction syndrome and ACTA2 cerebral arteriopathy after experiencing a stroke in the right cingulate gyrus. She underwent direct triple bypass with three anastomoses of the right superficial temporal artery to the middle and anterior cerebral arteries. She developed an ischemic stroke as a postoperative complication.The efficacy and safety of this procedure have not been clearly confirmed owing to the frailty of the donor superficial temporal artery and the poor development of collateral circulation; however, direct bypass should be considered a treatment option for patients experiencing progressive multiple strokes.

Therapeutic Options for Recurrent Glioblastoma—Efficacy of Talaporfin Sodium Mediated Photodynamic Therapy

Recurrent glioblastoma (GBM) remains one of the most challenging clinical issues, with no standard treatment and effective treatment options. 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 with PDT (PDT group) for recurrent GBM and 38 patients who underwent surgery alone (control group). 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. There was also no significant difference in TS accumulation in the tumor between these two groups. 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.

Intracranial Mycotic Aneurysm after Left Ventricular Assist Device Implantation Treated with Trans-arterial Embolization via the Brachial Artery: A Case Report

Implantation of left ventricular assist device (LVAD) is widely performed in patients with end-stage chronic heart failure. Infection and stroke are major complications after LVAD implantation. However, the incidence of intracranial mycotic aneurysm after LVAD implantation is rare, and with no standard of care. In this study, we describe a case of an intracranial mycotic aneurysm after LVAD implantation that was successfully treated with trans-arterial embolization (TAE) with N-butyl 2-cyanoacrylate (NBCA) via the brachial artery. A 49-year-old man with a history of implantation of LVAD for ischemic cardiomyopathy was admitted to our institution. He had infectious endocarditis and was administered systemic antibiotics. At 3 weeks after admission, intracranial mycotic aneurysm of the left posterior parietal artery was detected during a diagnostic examination for asymptomatic intracranial hemorrhage. Anticoagulant therapy was administered to prevent thromboembolic complications of LVAD implantation. Under local anesthesia, TAE with NBCA was performed via the brachial artery because of the tortuous anatomy of the origin of the innominate artery and implant of the aortic arch. The aneurysm was completely obliterated. The patient was discharged without neurological deficits. TAE using NBCA could be an effective modality for the treatment of intracranial mycotic aneurysm after LVAD implantation.

Combining Pre-operative Diffusion Tensor Images and Intraoperative Magnetic Resonance Images in the Navigation Is Useful for Detecting White Matter Tracts During Glioma Surgery

Purpose

We developed a navigation system that superimposes the fractional anisotropy (FA) color map of pre-operative diffusion tensor imaging (DTI) and intraoperative magnetic resonance imaging (MRI). The current study aimed to investigate the usefulness of this system for neurophysiological monitoring and examination under awake craniotomy during tumor removal.

Method

A total of 10 glioma patients (4 patients with right-side tumors; 5 men and 5 women; average age, 34 years) were evaluated. Among them, the tumor was localized to the frontal lobe, insular cortex, and parietal lobe in 8, 1, and 1 patient, respectively. There were 3 patients who underwent surgery on general anesthesia, while 7 patients underwent awake craniotomy. The index of DTI anisotropy taken pre-operatively (magnetic field: 3 tesla, 6 motion probing gradient directions) was analyzed as a color map (FA color map) and concurrently co-registered in the intraoperative MRI within the navigation. In addition to localization of the bipolar coagulator and the cortical stimulator for brain mapping on intraoperative MRI, the pre-operative FA color map was also concurrently integrated and displayed on the navigation monitor. This white matter nerve functional information was confirmed directly by using neurological examination and referring to the electrophysiological monitoring.

Results

Intraoperative MRI, integrated pre-operative FA color map, and microscopic surgical view were displayed on one screen in all 10 patients, and white matter fibers including the pyramidal tract were displayed as a reference in blue. Regarding motor function, motor-evoked potential was monitored as appropriate in all cases, and removal was possible while directly confirming motor symptoms under awake craniotomy. Furthermore, the white matter fibers including the superior longitudinal fasciculus were displayed in green. Importantly, it was useful not only to localize the resection site, but to identify language-related, eye movement-related, and motor fibers at the electrical stimulation site. All motor and/or language white matter tracts were identified and visualized with the co-registration and then with an acceptable post-operative neurological outcome.

Conclusion

Co-registering an intraoperative MR images and a pre-operative FA color map is a practical and useful method to predict the localization of critical white matter nerve functions intraoperatively in glioma surgery.

Prediction of cross-clamp-induced cerebral ischemia during carotid endarterectomy using arterial blood flow assessment

BACKGROUND

Cross-clamping during carotid endarterectomy (CEA) is associated with the risk of cerebral ischemia. Various studies have evaluated different criteria for detecting cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid artery is cross-clamped and incised. Here, we explored a parameter that can predict cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter.

METHODS

The carotid arterial blood flow was measured directly (direct ABF) in the common carotid artery prior to cross-clamping. The anatomical information in preoperative magnetic resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and carotid peak systolic flow velocity by carotid echo from the skin surface were also evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP) during cross-clamping to insert a shunt was assessed, and a decrease in amplitude of ≥50% was considered an indicator for cerebral ischemia. Surgery was performed under general anesthesia, and a shunt was inserted in all cases.

RESULTS

Of 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during cross-clamping. The baseline characteristics and intra- and postoperative findings were not significantly different between patients with and without a decrease in SSEP. Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) differed significantly between the two groups (p=0.011). The direct-ABF ratio ≤0.58 was predictive of cerebral ischemia during CEA.

CONCLUSIONS

Direct-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting cerebral ischemia prior to carotid artery cross-clamping during CEA.

Case Report: Long-Term Suppression of Paroxysmal Kinesigenic Dyskinesia After Bilateral Thalamotomy

Background: Paroxysmal kinesigenic dyskinesia (PKD) is a movement disorder characterized by transient dyskinetic movements, including dystonia, chorea, or both, triggered by sudden voluntary movements. Carbamazepine and other antiepileptic drugs (AEDs) are widely used in the treatment of PKD, and they provide complete remission in 80–90% of medically treated patients. However, the adverse effects of AEDs include drowsiness and dizziness, which interfere with patients' daily lives. For those with poor compatibility with AEDs, other treatment approaches are warranted.

Case Report: A 19-year-old man presented to our institute with right hand and foot dyskinesia. He had a significant family history of PKD; his uncle, grandfather, and grandfather's brother had PKD. The patient first experienced paroxysmal involuntary left hand and toe flexion with left forearm pronation triggered by sudden voluntary movements at the age of 14. Carbamazepine (100 mg/day) was prescribed, which led to a significant reduction in the frequency of attacks. However, carbamazepine induced drowsiness, which significantly interfered with his daily life, especially school life. He underwent right-sided ventro-oral (Vo) thalamotomy at the age of 15, which resulted in complete resolution of PKD attacks immediately after the surgery. Four months after the thalamotomy, he developed right elbow, hand, and toe flexion. He underwent left-sided Vo thalamotomy at the age of 19. Immediately after the surgery, the PKD attacks resolved completely. However, mild dysarthria developed, which spontaneously resolved within three months. Left-sided PKD attacks never developed six years after the right Vo thalamotomy, and right-sided PKD attacks never developed two years after the left Vo thalamotomy without medication.

Conclusion: The present case showed long-term suppression of bilateral PKDs after bilateral thalamotomy, which led to drug-free conditions.

Five-day bed rest reduces postoperative intracerebral hemorrhage after direct bypass for Moyamoya disease

OBJECTIVES

Postoperative intracerebral hemorrhage (ICH) after direct bypass surgery for Moyamoya disease (MMD) could contribute to neurological deterioration. The aim of this study was to evaluate the effectiveness of five-day bed rest in reducing the occurrence of postoperative ICH.

METHODS

This study included 122 consecutive hemispheres in 87 Japanese adult MMD patients, comprised of 80 control hemispheres from historical data and 42 hemispheres after five-day bed rest. They all underwent direct bypass surgery. The incidence of postoperative ICH and neurological deterioration assessed via the modified Rankin Scale (mRS) were investigated and statistically analyzed.

RESULTS

Postoperative ICH was observed in 9 out of the 80 (11.3%) control patients, but not in the 42 patients with five-day bed rest. The incidence of postoperative ICH and neurological deterioration via the mRS were significantly different between the two groups (p= 0.0268 and 0.0078, respectively). Univariate logistic analysis revealed that five-day bed rest significantly reduced the incidence of postoperative ICH (p= 0.0048).

CONCLUSIONS

Five-day bed rest after direct bypass surgery dramatically can reduce the incidence of postoperative ICH and neurological deterioration after direct bypass surgery.

Deep Brain Stimulation of the Forel's Field for Dystonia: Preliminary Results

The field of Forel (FF) is a subthalamic area through which the pallidothalamic tracts originating from the globus pallidus internus (GPi) traverse. The FF was used as a stereotactic surgical target (ablation and stimulation) to treat cervical dystonia in the 1960s and 1970s. Although recent studies have reappraised the ablation and stimulation of the pallidothalamic tract at FF for Parkinson’s disease, the efficacy of deep brain stimulation of FF (FF-DBS) for dystonia has not been well investigated. To confirm the efficacy and stimulation-induced adverse effects of FF-DBS, three consecutive patients with medically refractory dystonia who underwent FF-DBS were analyzed (tongue protrusion dystonia, cranio-cervico-axial dystonia, and hemidystonia). Compared to the Burke-Fahn-Marsden Dystonia Rating Scale-Movement Scale scores before surgery (23.3 ± 12.7), improvements were observed at 1 week (8.3 ± 5.9), 3 months (5.3 ± 5.9), and 6 months (4.7 ± 4.7, p = 0.0282) after surgery. Two patients had stimulation-induced complications, including bradykinesia and postural instability, all well controlled by stimulation adjustments.

Aspergillus sphenoiditis growth on long cut ends of a non-absorbable sellar floor dura closure suture

Background:

Cerebrospinal fluid (CSF) rhinorrhea is a common complication after transsphenoidal surgery (TSS). Suturing of sellar dura is effective in the prevention of postoperative CSF rhinorrhea, but it may cause rare postoperative infections. Herein, we report a case of Aspergillus sphenoiditis with the growth noted on cut ends of a polyvinylidene fluoride (PVDF) suture used for dural closure.

Case Description:

A previously healthy 51-year-old woman complained of abnormal odor 5 years after TSS for null cell adenoma. A white mass in the sphenoidal sinus was detected on rhinoscopy. Fungal balls were found clustered around the ends of a PVDF suture used for dural closure at the initial surgery. She underwent removal of both the fungal ball and dural suture. The pathological diagnosis was Aspergillus hyphae. It is thought that a dural suture protruding out of the sphenoid sinus mucosa can cause Aspergillus infection even in immunocompetent patients. A rapid and accurate diagnosis followed by surgical removal of the fungal ball and follow-up with oral antimycotic drugs result in good clinical outcomes.

Conclusion:

It is crucial to cut short the suture end and cover it with sphenoid sinus mucosa to avoid such complications.

NI-16 Verification of APT image and relationship with T2/FLAIR mismatch sign in WHO2016 brain tumor pathology classification

Introduction: Amide Proton Transfer Imaging(APT)is an MRI imaging method that images the increased concentration of amide groups in tumors and is expected to be clinically applied to the diagnostic imaging of gliomas.On the other hand,T2/FLAIR mismatch sign(T2/FLms)has been proposed as an MRI finding specific to astrocytoma with IDH gene mutation.This time,in the WHO2016 Brain Tumor Pathological Classification,we report the verification of the pathological gene classification of APT and the retrospective verification based on the pathological diagnosis results of whether there is a relationship between APT and T2/FLms. Method: We examined 88 cases of preoperative glioma (Grade:G2/3/4)in which APT/T2/FLAIR was imaged.resultIt showed a high value in high malignancy and a significant difference was observed.In the verification of genetic classification, the measured APT values were 1.91 ±0.71 for oligodendroglioma(16 cases),2.58±0.17 for astrocytoma(2 cases),2.40±0.90 for anaplastic oligodendroglioma(12 cases),Anaplastic astrocytoma(20 cases)2.63±0.42,The oligodendroglioma system showed lower values than the astrocytoma system.For anaplastic astrocytoma IDH mutant and glioblastoma IDH mutant,APT measurement values were measured after evaluating the presence or absence of T2/FL ms. APT measured values are anaplastic astrocytoma IDH mutant T2/FL ms present(7 cases) 2.63±0.38,T2/FL ms not (5 cases) 2.76±0.37, glioblastoma IDH mutant T2/FL ms present(5 cases)2.67±0.50, no T2/FL ms(3 cases)3.48±0.27,suggesting low APT measured values with T2/FL ms,respectively.ConclusionIn the verification of genetic classification, the oligodendroglioma system shows a lower value than the astrocytoma system,and it is considered that it can be one of the options such as treatment policy.Regarding the relationship between T2/FL ms and APT,it was suggested that the APT measured value with T2/FL ms tended to be low,but since it wasreported that the sensitivity of T2/FL ms was 30%,it was verified by accumulating cases.is required.

COT-31 Risk Factors for the Development of Skin Rash with Levetiracetam and Lacosamide in Patients with Glioma

Introduction: Seizure control of in glioma patients is essential for quality of life. The new generation anti-seizure drug (ASD) is represented by lacosamide (LCM) and levetiracetam (LEV), and is said to have few side effects of eruption. We retrospectively analyzed the incidence of rash and related factors of the ASD, evaluated the safety of patients with glioma, and conducted a comparison with the evaluation of patients with meningioma. Method: We calculated the incidence of rash in patients who underwent glioma resection at our Hospital from January 2017 to December 2019 and were prescribed LEV or LCM, and compared it with the same incidence in meningioma patients. Multivariate logistic regression analysis was used to analyze the risk factors for the ASD-related eruption. Result: The subjects were 353 gliomas and 125 meningiomas who received LEV or LCM.The median ages are 44 ± 14.8 and 58 ± 13.2, respectively, and the male-female ratio is 203/150 and 53/72. There was no difference in the incidence of eruptions between the two groups, LEV and LCM, and the incidence of ASD-related eruptions was 11% (39/353) for gliomas, significantly higher than 1.6% (2/125) for meningiomas (p = 0.006). The incidence of ASD-related eruptions in glioma patients was not significantly different between the LEV group (10% (21/216)) and the LCM group (13% (20/154)) (p = 0.53). In a multivariate analysis of risk factors for eruption, chemoradiotherapy (p = 0.01), history of drug allergy (p = 0.039) was significantly higher. Conclusion: The incidence of LEV and LCM eruptions in glioma patients was higher than that in meningioma patients, and it was speculated that the treatment course specificity was more important than the disease-specific factors. Patients with glioma, especially those who have undergone chemoradiotherapy or have a history of drug allergies, require careful confirmation of the eruption.

STMO-21 The Outcome of tumor resection followed by photodynamic therapy for recurrent glioblastoma

Recurrent glioblastoma remains a clinical problem with no standard treatment and quite a few effective treatment options. We evaluated the efficacy of photodynamic therapy (PDT) using talaporfin sodium (TS) as a treatment for recurrent glioblastoma in a retrospective analysis of 70 patients who underwent PDT with surgery (PDT group) between 2014 and 2018, and 38 patients who underwent surgery alone (control group) during the same period. The median overall survival (OS) of the PDT and control groups were 16.03 and 12.75 months, respectively (P=0.0311). The median progression-free survival (PFS) of these two groups were 5.67 and 2.2 months, respectively (P=0.00428). Univariate and multivariate analyses showed PDT with surgery and preoperative Karnofsky Performance Scale as significant independent prognostic factors for both PFS and OS.On the other hand, IDH mutation and previous pathology before recurrence were not significant prognostic factors in this study. In the PDT group, there was no significant difference in PFS and OS between patients with GBM from the previous pathology before recurrence and those with malignant transformation to GBM from lower-grade glioma. Furthermore, there was also no significant difference in TS accumulation in the tumor between these two groups. These results suggest that additional PDT treatment for recurrent glioblastoma can have potential survival benefits and that its efficacy is independent of the pathology before recurrence or IDH status.

SURG-11. TUMOR RECURRENCE PATTERNS AFTER SURGICAL RESECTION OF INTRACRANIAL LOW-GRADE GLIOMAS

INTRODUCTION

Tumor recurrence patterns after resection of intracranial low-grade gliomas (LGG) generally remain obscured. The objective of the present retrospective study was their multifaceted analysis, evaluation of associated factors, and assessment of impact on prognosis.

METHODS

Study group comprised 81 consecutive adult patients (46 men and 35 women; median age, 37 years) with recurrent diffuse astrocytomas (DA; 51 cases) and oligodendrogliomas (OD; 30 cases). The median length of follow-up after primary surgery was 6.7 years.

RESULTS

Early (within 2 years after primary surgery) and non-early ( &gt; 2 years after primary surgery) recurrence was noted in 23 (28%) and 58 (72%) cases, respectively. Fast (≤ 6 months) and slow ( &gt; 6 months) radiological progression of relapse was noted in 31 (38%) and 48 (59%) cases, respectively. Tumor recurrence was local and non-local in 71 (88%) and 10 (12%) cases, respectively. Recurrence patterns have differed in OD, IDH1-mutant DA, and IDH wild-type DA. Early onset, fast radiological progression, and non-local site of relapse had statistically significant negative impact on overall survival of patients and were often associated with malignant transformation of the tumor (38 cases). However, in subgroup with extent of resection ≥ 90% (56 cases) no differences in recurrence characteristics were found between 3 molecularly defined groups of LGG. Follow-up MRI also showed same results.

CONCLUSIONS

Recurrence patterns after resection of LGG show significant variability, differ in distinct molecularly defined types of tumors, and demonstrate definitive impact on prognosis. Aggressive resection at the time of primary surgery may result in more favorable characteristics of recurrence at the time of its development.

PATH-19. TERT PROMOTER MUTATION, NOT H3K27M MUTATION IS A PROGNOSTIC FACTOR FOR ADULT THALAMIC GLIOMAS

Purpose

Thalamic diffuse glioma is classified as WHO grade 4 as Diffuse midline glioma, H3K27M mutation if H3K27M mutation was found regardless of its histological findings, but the significance of H3K27M mutation is not clear compared with pediatric cases. We aimed to find genetic prognostic factors in adult thalamic diffuse gliomas.

METHODS

Pathological diagnosis, genetic abnormalities, and clinical course of adult newly diagnosed thalamic gliomas diagnosed and treated at our institution from July 2007 to March 2020 were retrospectively analyzed.

RESULTS

The number of cases was 41 (24 males, 17 females), median age was 47 years (20-75 years). Tumor localization was 20 cases on the left, 14 cases on the right, and 7 cases on both sides. The pathological diagnosis was GBM 15 cases, DMG 15 cases, AA-IDH WT 7 cases, DA-IDH WT 4 cases, all of which were IDH wild type, and none of them had IDH mutation and 1p/19q co-deletion. H3K27M mutations were found in 15 cases and TERT promoter mutations were found in 12 cases, both of which were completely mutually exclusive. Tumor resection and biopsy was performed in 33 and 8 cases, respectively, and the median removal rate was 95% for those who underwent tumor resection. The median PFS and OS of all cases were 14.3 months and 38 months, respectively, and the median OS by pathological diagnosis was GBM 12.4 months, DMG 47.4 months, AA-IDH WT 37.3 months, DA-IDH WT not reached. The median OS in the H3K27M mutant group (47.4 months) was significantly better (p=0.02) than that in the TERT promoter mutation group (13.5 months).

CONCLUSION

There was no IDH mutation in adult thalamic gliomas, the H3K27M mutation and the TERT promoter mutation were mutually exclusive. The H3K27M mutation was not a prognostic factor, but the TERT promoter mutation was the strongest prognostic factor.

IOTG-03. Rapid intraoperative flow cytometry of brain tumor useful for surgical decision-making

Flow cytometry is a measuring device frequently used in basic research, we have developed a fully automatic flow cytometer device that performs cell isolation, staining of cell nuclei, and measurement for intraoperative diagnosis. Placing a small specimen in a reagent containing PI calculates, the total number of cells, the DNA histogram, and the Malignancy Index (MI), which means in the proliferation phase, the ratio of the number of cells (S, G2, M) / total number of cells. The major feature of this device is that calculating takes only 10 minutes by thoroughly reviewing the process. We here introduce our study of this device, rapid diagnosis, WHO grading, prognosis in glioma, and differentiation from malignant lymphoma (PCNSL), then how to use it in decision making in the operation. In the analysis of 323 gliomas, the threshold between the peripheral brain and the tumor was 7%, and the MI value was correlated with WHO grade (II 13%, III 35%, IV 47%) (J Neurosurg 2013). A correlation was also found between the MI value and the number of residual tumors (Brain Tumor Path 2018). Furthermore, it was also useful for differentiating from PCNSL with many S-phase cells (World Neurosurg 2018). In addition, the relationship between the presence of DNA aneuploidy and poor prognosis in 102 grade II patients (Clin Neuro Neurosurg 2018), and the high MI in 102 grade IV patients showed a good prognosis and an inverse correlation with expectations (Neurosurg 2018). Intraoperative flow cytometry has enabled various intraoperative decision-making support by converting intraoperative histology, which was an analog-like transmission, into digitized histological information. In the future, the development of this research makes expectations for more accurate diagnosis and prediction by artificial intelligence and the development of other departments.

C6 nerve root palsy after double-door cervical laminoplasty

Background:

This study correlated the relationship between postoperative C6 nerve root palsies and various patient-related clinical, radiographic, and surgical parameters.

Methods:

The medical records of 318 patients undergoing double-door cervical laminoplasty for myelopathy were reviewed. Twelve (3.8%) had postoperative C6 nerve root palsies. Their clinical, radiographic, and surgical procedures were analyzed looking for a correlation/explanation for these new C6 root deficits.

Results:

The following factors correlated with patients’ developing new postoperative C6 nerve root deficit following double-door cervical laminoplasty; a high correlation with additional C5 palsies, narrower C6 intervertebral foraminal widths, greater anterior protrusions of the C6 articular process, and larger posterior shifts of the spinal cord on magnetic resonance (MR) between the C4/C5-C6/C7 levels.

Conclusion:

Factors correlating with the new onset of C6 nerve root palsies following double-door cervical laminoplasty included; a high correlation with new C5 palsies, more severe foraminal stenosis, greater anterior protrusions of the C6 articular process, and more extensive dorsal spinal cord migration.