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Kishida K, Maruyama D, Kotani S, Murakami N, Hashimoto N. Clinical Significance of Stiffness during Endoscopic Surgery for Intracerebral Hemorrhage: A Retrospective Study. Neurol Med Chir (Tokyo) 2023; 63:563-570. [PMID: 37940569 PMCID: PMC10788487 DOI: 10.2176/jns-nmc.2023-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/28/2023] [Indexed: 11/10/2023] Open
Abstract
Studies regarding hematoma stiffness and removal difficulty are scarce. This study explored the association between hematoma stiffness and surgical results of endoscopic hematoma removal for intracerebral hemorrhage. It also aimed to clarify factors associated with hematoma stiffness. We classified intracerebral hematoma as either soft or firm stiffness by retrospectively evaluating operative videos by two neurosurgeons. The interobserver reliability of the classification was assessed by calculating the κ values. We investigated the relationship between hematoma stiffness and surgical results. Favorable hematoma removal (FHR) was defined as a residual hematoma volume of ≤15 mL or removal rate of ≥70%. Furthermore, we compared the background characteristics, imaging findings, and laboratory data between the two groups. Forty patients were included in this study. The mean baseline hematoma volume was 69.9 mL (range, 41.3-97.6 mL). FHR was accomplished in 35 cases (87.5%). Thirty-four patients (85%) were in the soft hematoma group (group S). Six patients (15%) were in the firm hematoma group (group F). Classification of hematoma stiffness demonstrated an excellent degree of interobserver agreement (κ score = 0.91). Patients in group S had a high FHR rate (p = 0.018) and short endoscopic procedure times (p = 0.00034). The island sign was present in group S (p = 0.030). Patients in group F had significantly high fibrinogen levels (p = 0.049) and low serum total calcium (p = 0.032), hemoglobin (p = 0.041), and hematocrit (p = 0.011) levels. Hematoma stiffness during endoscopic surgery for intracerebral hemorrhage correlates with surgical results, including the endoscopic procedure time and accomplishing rate of FHR.
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Affiliation(s)
- Kengo Kishida
- Department of Neurosurgery, Kyoto Second Red Cross Hospital
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | - Daisuke Maruyama
- Department of Neurosurgery, Kyoto Second Red Cross Hospital
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | - Saki Kotani
- Department of Neurosurgery, Kyoto Second Red Cross Hospital
| | - Nobukuni Murakami
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
| | - Naoya Hashimoto
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science
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Zheng L, Jiang P, Lin D, Chen X, Zhong T, Zhang R, Chen J, Song Y, Xue Y, Lin L. Histogram analysis of mono-exponential, bi-exponential and stretched-exponential diffusion-weighted MR imaging in predicting consistency of meningiomas. Cancer Imaging 2023; 23:117. [PMID: 38053183 DOI: 10.1186/s40644-023-00633-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/03/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The consistency of meningiomas is critical to determine surgical planning and has a significant impact on surgical outcomes. Our aim was to compare mono-exponential, bi-exponential and stretched exponential MR diffusion-weighted imaging in predicting the consistency of meningiomas before surgery. METHODS Forty-seven consecutive patients with pathologically confirmed meningiomas were prospectively enrolled in this study. Two senior neurosurgeons independently evaluated tumour consistency and classified them into soft and hard groups. A volume of interest was placed on the preoperative MR diffusion images to outline the whole tumour area. Histogram parameters (mean, median, 10th percentile, 90th percentile, kurtosis, skewness) were extracted from 6 different diffusion maps including ADC (DWI), D*, D, f (IVIM), alpha and DDC (SEM). Comparisons between two groups were made using Student's t-Test or Mann-Whitney U test. Parameters with significant differences between the two groups were included for Receiver operating characteristic analysis. The DeLong test was used to compare AUCs. RESULTS DDC, D* and ADC 10th percentile were significantly lower in hard tumours than in soft tumours (P ≤ 0.05). The alpha 90th percentile was significantly higher in hard tumours than in soft tumours (P < 0.02). For all histogram parameters, the alpha 90th percentile yielded the highest AUC of 0.88, with an accuracy of 85.10%. The D* 10th percentile had a relatively higher AUC value, followed by the DDC and ADC 10th percentile. The alpha 90th percentile had a significantly greater AUC value than the ADC 10th percentile (P ≤ 0.05). The D* 10th percentile had a significantly greater AUC value than the ADC 10th percentile and DDC 10th percentile (P ≤ 0.03). CONCLUSION Histogram parameters of Alpha and D* may serve as better imaging biomarkers to aid in predicting the consistency of meningioma.
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Affiliation(s)
- Lingmin Zheng
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Peirong Jiang
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Danjie Lin
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Xiaodan Chen
- Department of Radiology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Tianjin Zhong
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Rufei Zhang
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Jing Chen
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Yang Song
- MR Scientific Marketing, Healthineers Ltd, Siemens, Shanghai, China
| | - Yunjing Xue
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
| | - Lin Lin
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, 350001, China.
- School of Medical Technology and Engineering, Fujian Medical University, Fuzhou, 350004, China.
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Indriani RV, Munir G, Dewayani BM. A rare case of multiple supratentorial brain lesions due to meningiomatosis. Radiol Case Rep 2023; 18:3997-4001. [PMID: 37691764 PMCID: PMC10491766 DOI: 10.1016/j.radcr.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/04/2023] [Indexed: 09/12/2023] Open
Abstract
Meningeal tumors represent the most common primary central nervous system tumors. The term "multiple meningiomas" or "meningiomatosis" refers to the occurrence of 2 or more spatially separated meningiomas without the features of neurofibromatosis. Meningiomatosis accounts for only less than 10% of all cases and is more prevalent in women. We report a rare case of a 53-year-old female patient complaining of a headache characterized by a throbbing pain in the right side of the head. Neurological examination was largely normal, with the exception of a slight weakening of the right extremity. Multiple brain masses, due to meningiomatosis, were revealed upon CT scan and MRI. Subsequent tissue biopsy confirmed the diagnosis of meningothelial meningiomas.
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Affiliation(s)
- R. Vera Indriani
- Department of Radiology, Faculty of Medicine, Hasan Sadikin General Hospital, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Bandung, West Java, 40161 Indonesia
| | - Gustiara Munir
- Department of Radiology, Faculty of Medicine, Hasan Sadikin General Hospital, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Bandung, West Java, 40161 Indonesia
| | - Birgitta M. Dewayani
- Department of Pathology Anatomy, Faculty of Medicine, Hasan Sadikin General Hospital, Padjadjaran University, Jl. Pasteur No.38, Pasteur, Bandung, West Java, 40161 Indonesia
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Nagao T, Nemoto M, Sugo N, Harada N, Masuda H, Nagao T, Shibuya K, Kondo K. Relationship Between Quantitative Tumor Consistency and Pathological Factors in Intracranial Meningioma. Acta Neurochir (Wien) 2023; 165:2895-2902. [PMID: 37432556 DOI: 10.1007/s00701-023-05712-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND The consistency of intracranial meningiomas is an important clinical factor because it affects the success of surgical resection. This study aimed at identifying and quantitatively measuring pathological factors that contribute to the consistency of meningiomas. Furthermore, we investigated the relationship between these factors and preoperative neuroradiological imaging. METHODS We analyzed 42 intracranial meningioma specimens, which had been removed at our institution between October 2012 and March 2018. Consistency was measured quantitatively after resection using an industrial stiffness meter. For pathological evaluation, we quantitatively measured the collagen-fiber content through binarization of images of Azan-Mallory-stained section. We assessed calcification and necrosis semi-quantitatively using images acquired of Hematoxylin and Eosin stained samples. The relationship between collagen-fiber content rate and imaging findings was examined. RESULTS The content of collagen fibers significantly positively correlated with meningioma consistency (p < 0.0001). Collagen-fiber content was significantly higher in low- and iso-intensity regions compared with high-intensity regions on the magnetic resonance T2-weighted images (p = 0.0148 and p = 0.0394, respectively). Calcification and necrosis showed no correlation with tumor consistency. CONCLUSIONS The quantitative hardness of intracranial meningiomas positively correlated with collagen-fiber content; thus, the amount of collagen fibers may be a factor that determines the hardness of intracranial meningiomas. Our results demonstrate that T2-weighted images reflect the collagen-fiber content and are useful for estimating tumor consistency preoperatively and non-invasively.
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Affiliation(s)
- Takaaki Nagao
- Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University, Sakura-shi, Chiba, Japan.
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Ota-ku, Tokyo, Japan.
| | - Masaaki Nemoto
- Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University, Sakura-shi, Chiba, Japan
| | - Nobuo Sugo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Ota-ku, Tokyo, Japan
| | - Naoyuki Harada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Ota-ku, Tokyo, Japan
| | - Hiroyuki Masuda
- Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University, Sakura-shi, Chiba, Japan
| | - Takeki Nagao
- Department of Neurosurgery (Sakura), School of Medicine, Faculty of Medicine, Toho University, Sakura-shi, Chiba, Japan
| | - Kazutoshi Shibuya
- Department of Surgical Pathology, Toho University Omori Medical Center, Ota-ku, Tokyo, Japan
| | - Kosuke Kondo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Ota-ku, Tokyo, Japan
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Li M, Liu L, Qi J, Qiao Y, Zeng H, Jiang W, Zhu R, Chen F, Huang H, Wu S. MRI-based machine learning models predict the malignant biological behavior of meningioma. BMC Med Imaging 2023; 23:141. [PMID: 37759192 PMCID: PMC10537075 DOI: 10.1186/s12880-023-01101-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The WHO grade and Ki-67 index are independent indices used to evaluate the malignant biological behavior of meningioma. This study aims to develop MRI-based machine learning models to predict the malignant biological behavior of meningioma from the perspective of the WHO grade, Ki-67 index, and their combination. METHODS This multicenter, retrospective study included 313 meningioma patients, of which 70 were classified as high-grade (WHO II/III) and 243 as low-grade (WHO I). The Ki-67 expression was classified into low-expression (n = 216) and high-expression (n = 97) groups with a threshold of 5%. Among them, there were 128 patients with malignant biological behavior whose WHO grade or Ki-67 index increased either or both. Data from Center A and B are were utilized for model development, while data from Center C and D were used for external validation. Radiomic features were extracted from the maximum cross-sectional area (2D) region of Interest (ROI) and the whole tumor volume (3D) ROI using different paraments from the T1, T2-weighted, and T1 contrast-enhanced sequences (T1CE), followed by five independent feature selections and eight classifiers. 240 prediction models were constructed to predict the WHO grade, Ki-67 index and their combination respectively. Models were evaluated by cross-validation in training set (n = 224). Suitable models were chosen by comparing the cross-validation (CV) area under the curves (AUC) and their relative standard deviations (RSD). Clinical and radiological features were collected and analyzed; meaningful features were combined with radiomic features to establish the clinical-radiological-radiomic (CRR) models. The receiver operating characteristic (ROC) analysis was used to evaluate those models in validation set. Radiomic models and CRR models were compared by Delong test. RESULTS 1218 and 1781 radiomic features were extracted from 2D ROI and 3D ROI of each sequence. The selected grade, Ki-67 index and their combination radiomic models were T1CE-2D-LASSO-LR, T1CE-3D-LASSO-NB, and T1CE-2D-LASSO-LR, with cross-validated AUCs on the training set were 0.857, 0.798, and 0.888, the RSDs were 0.06, 0.09, and 0.05, the validation set AUCs were 0.829, 0.752, and 0.904, respectively. Heterogeneous enhancement was found to be associated with high grade and Ki-67 status, while surrounding invasion was associated with the high grade status, peritumoral edema and cerebrospinal fluid space surrounding tumor were correlated with the high Ki-67 status. The Delong test showed that these significant radiological features did not significantly improve the predictive performance. The AUCs for CRR models predicting grade, Ki-67 index, and their combination in the validation set were 0.821, 0.753, and 0.906, respectively. CONCLUSIONS This study demonstrated that MRI-based machine learning models could effectively predict the grade, Ki-67 index of meningioma. Models considering these two indices might be valuable for improving the predictive sensitivity and comprehensiveness of prediction of malignant biological behavior of meningioma.
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Affiliation(s)
- Maoyuan Li
- Department of Radiology, Chengdu Qingbaijiang District People's Hospital, Chengdu, 610300, Sichuan, China
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan, China
| | - Luzhou Liu
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan, China
| | - Jie Qi
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan, China
| | - Ying Qiao
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan, China
| | - Hanrui Zeng
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan, China
| | - Wen Jiang
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan, China
| | - Rui Zhu
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, Sichuan, China
| | - Fujian Chen
- Department of Radiology, Mianyang Central Hospital, Mianyang, 621000, Sichuan, China
| | - Huan Huang
- Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Shaoping Wu
- Department of Radiology, Chengdu Medical College, Chengdu, 610500, Sichuan, China.
- Department of Radiology, Sichuan Taikang Hospital, Chengdu, 610041, Sichuan, China.
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Yu H, Zhu L, Wang Y, Yue X, Wang W, Sun Z, Jiang S, Chen Y, Wen Z. Amide Proton Transfer Weighted MR Imaging for Predicting Meningioma Stiffness: A Feasibility Study. J Magn Reson Imaging 2023; 57:1071-1078. [PMID: 35932167 DOI: 10.1002/jmri.28379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stiffness of meningioma is an important factor affecting the surgical resection and the prognosis of patients. PURPOSE To examine the feasibility of APTw-magnetic resonance imaging (MRI) in evaluating meningioma stiffness. STUDY TYPE Retrospective. POPULATION Seventy-one patient with meningiomas, 39 were male and 32 were female; the mean age was 51 ± 10 years. FIELD STRENGTH/SEQUENCE 3.0T; Turbo-spin-echo T1 -weighted and Gd-T1 -weighted sequence; Turbo-spin-echo T2 -weighted sequence; 2D fat-suppressed, turbo-spin-echo APTw pulse sequence. ASSESSMENT The T1 WI signal intensity score, T2 WI signal intensity score, APTwmin , APTwmax , and APTwmean values were compared between soft, medium stiff and stiff meningiomas or non-stiff meningiomas and stiff meningiomas group. STATISTICAL TESTS Chi-square test, one-way ANOVA analysis, independent-samples t-test, intra-class correlation coefficient, rank-sum test, receiver operating characteristic curve analysis. P < 0.05 was considered statistically significant in all tests. RESULTS APTwmin and APTwmean in the stiff group were significantly lower than that in the non-stiff group (2.79% ± 0.42% vs. 1.90% ± 0.60% and 3.20% ± 0.31% vs. 2.55% ± 0.61%). APTwmin and APTwmean in the stiff group were significantly lower than that in the medium stiff and soft groups (1.90% ± 0.60% vs. 2.69% ± 0.40% and 3.12% ± 0.32%, 2.55% ± 0.61% vs. 3.17% ± 0.33% and 3.39% ± 0.18%), APTwmin in the medium stiff group was significantly lower than in the soft group, there was no significant difference in APTwmean between the medium stiff and soft groups (P = 0.190). APTwmin showed the best diagnostic performance for evaluating meningioma stiffness with an area under the curve of 0.913, when the APTwmin was lower than 2.4%, the meningioma was defined as a stiff tumor, the sensitivity, specificity, and accuracy were 87.1%, 87.5%, and 85.9%, respectively. DATA CONCLUSION APTw-MRI could be used to evaluate meningioma stiffness, with APTwmin having the best evaluative efficiency. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Hao Yu
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, China
| | - Laimin Zhu
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, China
| | - Yanting Wang
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, China.,Clinical Medical College of Jining Medical University, Jining, Shandong, China
| | | | - Weiwei Wang
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, China
| | - Zhanguo Sun
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, China
| | - Shanshan Jiang
- Division of MR Research, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yueqin Chen
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong, China
| | - Zhibo Wen
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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Rabiee S, Kankam SB, Shafizadeh M, Ahmadi M, Khoshnevisan A, Hashemi A. Supratentorial Meningioma Consistency Prediction Utilizing Tumor to Cerebellar Peduncle Intensity on T1 and T2-Weighted and Fluid Attenuated Inversion Recovery Magnetic Resonance Imaging Sequences. World Neurosurg 2023; 170:e180-e187. [PMID: 36328167 DOI: 10.1016/j.wneu.2022.10.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Predicting meningioma consistency with preoperative imaging is critical for surgery planning. Preoperative T1 and T2-weighted and fluid attenuated inversion recovery magnetic resonance imaging (MRI) findings of supratentorial meningioma tumors were studied and compared with intraoperative supratentorial meningioma tumor consistency based on the Cavitron ultrasound surgical aspirator (CUSA) and ZADA grading scales in this cohort to predict the tumor consistency before surgery. METHODS MRI from 78 consecutive patients who underwent supratentorial meningioma tumor resection between 2018 and 2021 were evaluated preoperatively. An intraoperative tumor consistency grade was applied to these lesions prospectively by the operating surgeon based on CUSA and ZADA grading scales. Tumor/cerebellar peduncle T2-weighted intensity, tumor/cerebellar peduncle T1-weighted intensity (TCT1I), and tumor/cerebellar peduncle fluid attenuated inversion recovery intensity (TCFI) ratios were calculated. Tumor consistency grades and MRI intensity ratios were correlated using one-way ANOVA. RESULTS Of the 78 patients, 52 (66.7%) were female and 26 (33.3%) were male. Tumor volume correlated with tumor consistency grades on both CUSA (P = 0.005) and ZADA (P = 0.024) grading scales. Also patients age correlated with tumor consistency according to ZADA grading scale (P = 0.024). TCT1I (P = 0.009) and TCFI (P < 0.005) ratios correlated significantly with tumor consistency grade according to CUSA. Similarly, TCT1I (P = 0.0032) and TCFI (P = 0.001) ratios was significantly associated with tumor consistency according to ZADA grading scales. CONCLUSIONS Our findings suggest that higher tumor/cerebellar peduncle T2-weighted intensity and TCFI ratios correlate with softer tumors, while higher TCT1I ratios reveal firmer tumors. These data can assist the surgeon predict the supratentorial meningioma consistency before surgery.
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Affiliation(s)
- Shervin Rabiee
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Samuel Berchi Kankam
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; International Neurosurgery Group (ING), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Milad Shafizadeh
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; International Neurosurgery Group (ING), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maryam Ahmadi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshnevisan
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; International Neurosurgery Group (ING), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Amirpajman Hashemi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Efficient Prediction of Ki-67 Proliferation Index in Meningiomas on MRI: From Traditional Radiological Findings to a Machine Learning Approach. Cancers (Basel) 2022; 14:cancers14153637. [PMID: 35892896 PMCID: PMC9330288 DOI: 10.3390/cancers14153637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 02/05/2023] Open
Abstract
Background/aim This study aimed to explore the value of radiological and radiomic features retrieved from magnetic resonance imaging in the prediction of a Ki-67 proliferative index in meningioma patients using a machine learning model. Methods This multicenter, retrospective study included 371 patients collected from two centers. The Ki-67 expression was classified into low-expressed and high-expressed groups with a threshold of 5%. Clinical features and radiological features were collected and analyzed by using univariate and multivariate statistical analyses. Radiomic features were extracted from contrast-enhanced images, followed by three independent feature selections. Six predictive models were constructed with different combinations of features by using linear discriminant analysis (LDA) classifier. Results The multivariate analysis suggested that the presence of intratumoral necrosis (p = 0.032) and maximum diameter (p < 0.001) were independently correlated with a high Ki-67 status. The predictive models showed good performance with AUC of 0.837, accuracy of 0.810, sensitivity of 0.857, and specificity of 0.771 in the internal test and with AUC of 0.700, accuracy of 0.557, sensitivity of 0.314, and specificity of 0.885 in the external test. Conclusion The results of this study suggest that the predictive model can efficiently predict the Ki-67 index of meningioma patients to facilitate the therapeutic management.
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Shi Y, Huo Y, Pan C, Qi Y, Yin Z, Ehman RL, Li Z, Yin X, Du B, Qi Z, Yang A, Hong Y. Use of magnetic resonance elastography to gauge meningioma intratumoral consistency and histotype. Neuroimage Clin 2022; 36:103173. [PMID: 36081257 PMCID: PMC9463601 DOI: 10.1016/j.nicl.2022.103173] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether tumor shear stiffness, as measured by magnetic resonance elastography, corresponds with intratumoral consistency and histotype. MATERIALS AND METHODS A total of 88 patients with 89 meningiomas (grade 1, 74 typical [13 fibroblastic, 61 non-fibroblastic]; grade 2, 12 atypical; grade 3, 3 anaplastic) were prospectively studied, each undergoing preoperative MRE in conjunction with T1-, T2- and diffusion-weighted imaging. Contrast-enhanced T1-weighted sequences were also obtained. Tumor consistency was evaluated as heterogeneous or homogenous, and graded on a 5-point scale intraoperatively. MRE-determined shear stiffness was associated with tumor consistency by surgeon's evaluation and whole-slide histologic analyses. RESULTS Mean tumor stiffness overall was 3.81+/-1.74 kPa (range, 1.57-12.60 kPa), correlating well with intraoperative scoring (r = 0.748; p = 0.001). MRE performed well as a gauge of tumor consistency (AUC = 0.879, 95 % CI: 0.792-0.938) and heterogeneity (AUC = 0.773, 95 % CI: 0.618-0.813), significantly surpassing conventional MR techniques (DeLong test, all p < 0.001 after Bonferroni adjustment). Shear stiffness was independently correlated with both fibrous content (partial correlation coefficient = 0.752; p < 0.001) and tumor cellularity (partial correlation coefficient = 0.547; p < 0.001). MRE outperformed other imaging techniques in distinguishing fibroblastic meningiomas from other histotypes (AUC = 0.835 vs 0.513 ∼ 0.634; all p < 0.05), but showed limited ability to differentiate atypical or anaplastic meningiomas from typical meningiomas (AUC = 0.723 vs 0.616 ∼ 0.775; all p > 0.05). Small (<2.5 cm, n = 6) and intraventricular (n = 2) tumors displayed inconsistencies between MRE and surgeon's evaluation. CONCLUSIONS The results of this prospective study provide substantial evidence that preoperative evaluation of meningiomas with MRE can reliably characterize tumor stiffness and spatial heterogeneity to aid neurosurgical planning.
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Affiliation(s)
- Yu Shi
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Yunlong Huo
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Chen Pan
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Yafei Qi
- Department of Pathology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Ziying Yin
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Richard L Ehman
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Zhenyu Li
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Xiaoli Yin
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Bai Du
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Ziyang Qi
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, PR China
| | - Aoran Yang
- Department of Neurosurgery, Shengjing Hospital, China Medical University, Shenyang, PR China.
| | - Yang Hong
- Department of Neurosurgery, Shengjing Hospital, China Medical University, Shenyang, PR China.
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Miyoshi K, Wada T, Uwano I, Sasaki M, Saura H, Fujiwara S, Takahashi F, Tsushima E, Ogasawara K. Predicting the consistency of intracranial meningiomas using apparent diffusion coefficient maps derived from preoperative diffusion-weighted imaging. J Neurosurg 2021; 135:969-976. [PMID: 33186907 DOI: 10.3171/2020.6.jns20740] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The consistency of meningiomas is a critical factor affecting the difficulty of resection, operative complications, and operative time. The apparent diffusion coefficient (ADC) is derived from diffusion-weighted imaging (DWI) and is calculated using two optimized b values. While the results of comparisons between the standard ADC and the consistency of meningiomas vary, the shifted ADC has been reported to be strongly correlated with liver stiffness. The purpose of the present prospective cohort study was to determine whether preoperative standard and shifted ADC maps predict the consistency of intracranial meningiomas. METHODS Standard (b values 0 and 1000 sec/mm2) and shifted (b values 200 and 1500 sec/mm2) ADC maps were calculated using preoperative DWI in patients undergoing resection of intracranial meningiomas. Regions of interest (ROIs) were placed within the tumor on standard and shifted ADC maps and registered on the navigation system. Tumor tissue located at the registered ROI was resected through craniotomy, and its stiffness was measured using a durometer. The cutoff point lying closest to the upper left corner of a receiver operating characteristic (ROC) curve was determined for the detection of tumor stiffness such that an ultrasonic aspirator or scissors was always required for resection. Each tumor tissue sample with stiffness greater than or equal to or less than this cutoff point was defined as hard or soft tumor, respectively. RESULTS For 76 ROIs obtained from 25 patients studied, significant negative correlations were observed between stiffness and the standard ADC (ρ = -0.465, p < 0.01) and the shifted ADC (ρ = -0.490, p < 0.01). The area under the ROC curve for detecting hard tumor (stiffness ≥ 20.8 kPa) did not differ between the standard ADC (0.820) and the shifted ADC (0.847) (p = 0.39). The positive predictive value (PPV) for the combination of a low standard ADC and a low shifted ADC for detecting hard tumor was 89%. The PPV for the combination of a high standard ADC and a high shifted ADC for detecting soft tumor (stiffness < 20.8 kPa) was 81%. CONCLUSIONS A combination of standard and shifted ADC maps derived from preoperative DWI can be used to predict the consistency of intracranial meningiomas.
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Affiliation(s)
| | | | - Ikuko Uwano
- 2Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, and
| | - Makoto Sasaki
- 2Division of Ultrahigh Field MRI, Institute for Biomedical Sciences, and
| | | | | | - Fumiaki Takahashi
- 3Division of Medical Engineering, Department of Information Science, Iwate Medical University School of Medicine, Morioka; and
| | - Eiki Tsushima
- 4Department of Physical Therapy, Hirosaki University School of Health Science, Hirosaki, Japan
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11
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Erickson NJ, Mooney JH, Walters BC, Agee B, Fisher WS. The Validity of the Koos Classification System With Respect to Facial Nerve Function. Neurosurgery 2021; 88:E523-E528. [PMID: 33862623 DOI: 10.1093/neuros/nyab086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Koos classification of vestibular schwannomas is designed to stratify tumors based on extrameatal extension and compression of the brainstem. Our prior study demonstrated excellent reliability. No study has yet assessed its validity. OBJECTIVE To present a retrospective study designed to assess the validity of the Koos grading system with respect to facial nerve function following treatment of 81 acoustic schwannomas. METHODS We collected data retrospectively from 81 patients with acoustic schwannomas of various Koos grades who were treated with microsurgical resection or stereotactic radiosurgery. House-Brackmann (HB) scores were used to assess facial nerve function and obtained at various time points following treatment. We generated Spearman's rho and Kendall's tau correlation coefficients along with a logistic regression curve. RESULTS We found no significant difference in the presence or absence of facial dysfunction by Koos classification when looking at all patients. There was a positive but fairly weak correlation between HB score and Koos classification, which was only significant at the first postoperative clinic appointment. There was a statistically significant difference in the presence or absence of facial dysfunction between patients treated with surgery vs radiation, which we expected. We found no statistically significant difference when comparing surgical approaches. Logistic regression modeling demonstrated a poor ability of the Koos grading system to predict facial nerve dysfunction following treatment. CONCLUSION The Koos grading system did not predict the presence of absence of facial nerve dysfunction in our study population. There were trends within subgroups that require further exploration.
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Affiliation(s)
- Nicholas J Erickson
- Department of Neurological Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James H Mooney
- Department of Neurological Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Beverly C Walters
- Department of Neurological Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Bonita Agee
- Department of Neurological Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Winfield S Fisher
- Department of Neurological Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Takamura T, Motosugi U, Ogiwara M, Sasaki Y, Glaser KJ, Ehman RL, Kinouchi H, Onishi H. Relationship between Shear Stiffness Measured by MR Elastography and Perfusion Metrics Measured by Perfusion CT of Meningiomas. AJNR Am J Neuroradiol 2021; 42:1216-1222. [PMID: 33985944 DOI: 10.3174/ajnr.a7117] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 01/10/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE When managing meningiomas, intraoperative tumor consistency and histologic subtype are indispensable factors influencing operative strategy. The purposes of this study were the following: 1) to investigate the correlation between stiffness assessed with MR elastography and perfusion metrics from perfusion CT, 2) to evaluate whether MR elastography and perfusion CT could predict intraoperative tumor consistency, and 3) to explore the predictive value of stiffness and perfusion metrics in distinguishing among histologic subtypes of meningioma. MATERIALS AND METHODS Mean tumor stiffness and relative perfusion metrics (blood flow, blood volume, and MTT) were calculated (relative to normal brain tissue) for 14 patients with meningiomas who underwent MR elastography and perfusion CT before surgery (cohort 1). Intraoperative tumor consistency was graded by a neurosurgeon in 18 patients (cohort 2, comprising the 14 patients from cohort 1 plus 4 additional patients). The correlation between tumor stiffness and perfusion metrics was evaluated in cohort 1, as was the ability of perfusion metrics to predict intraoperative tumor consistency and discriminate histologic subtypes. Cohort 2 was analyzed for the ability of stiffness to determine intraoperative tumor consistency and histologic subtypes. RESULTS The relative MTT was inversely correlated with stiffness (P = .006). Tumor stiffness was positively correlated with intraoperative tumor consistency (P = .01), while perfusion metrics were not. Relative MTT significantly discriminated transitional meningioma from meningothelial meningioma (P = .04), while stiffness did not significantly differentiate any histologic subtypes. CONCLUSIONS In meningioma, tumor stiffness may be useful to predict intraoperative tumor consistency, while relative MTT may potentially correlate with tumor stiffness and differentiate transitional meningioma from meningothelial meningioma.
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Affiliation(s)
- T Takamura
- From the Department of Radiology (T.T.), Shizuoka General Hospital, Shizuoka, Japan .,Department of Radiology (T.T.), Juntendo University, Tokyo, Japan
| | - U Motosugi
- Department of Radiology (U.M.), Kofu-Kyoritsu Hospital, Yamanashi, Japan
| | - M Ogiwara
- Departments of Neurosurgery (M.O., H.K.)
| | - Y Sasaki
- Radiology (Y.S., H.O.), University of Yamanashi, Yamanashi, Japan
| | - K J Glaser
- Department of Radiology (K.J.G., R.L.E.), Mayo Clinic College of Medicine, Rochester, Minnesota
| | - R L Ehman
- Department of Radiology (K.J.G., R.L.E.), Mayo Clinic College of Medicine, Rochester, Minnesota
| | - H Kinouchi
- Departments of Neurosurgery (M.O., H.K.)
| | - H Onishi
- Radiology (Y.S., H.O.), University of Yamanashi, Yamanashi, Japan
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Meningioma Consistency Can Be Defined by Combining the Radiomic Features of Magnetic Resonance Imaging and Ultrasound Elastography. A Pilot Study Using Machine Learning Classifiers. World Neurosurg 2020; 146:e1147-e1159. [PMID: 33259973 DOI: 10.1016/j.wneu.2020.11.113] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The consistency of meningioma is a factor that may influence surgical planning and the extent of resection. The aim of our study is to develop a predictive model of tumor consistency using the radiomic features of preoperative magnetic resonance imaging and the tumor elasticity measured by intraoperative ultrasound elastography (IOUS-E) as a reference parameter. METHODS A retrospective analysis was performed on supratentorial meningiomas that were operated on between March 2018 and July 2020. Cases with IOUS-E studies were included. A semiquantitative analysis of elastograms was used to define the meningioma consistency. MRIs were preprocessed before extracting radiomic features. Predictive models were built using a combination of feature selection filters and machine learning algorithms: logistic regression, Naive Bayes, k-nearest neighbors, Random Forest, Support Vector Machine, and Neural Network. A stratified 5-fold cross-validation was performed. Then, models were evaluated using the area under the curve and classification accuracy. RESULTS Eighteen patients were available for analysis. Meningiomas were classified as hard or soft according to a mean tissue elasticity threshold of 120. The best-ranked radiomic features were obtained from T1-weighted post-contrast, apparent diffusion coefficient map, and T2-weighted images. The combination of Information Gain and ReliefF filters with the Naive Bayes algorithm resulted in an area under the curve of 0.961 and classification accuracy of 94%. CONCLUSIONS We have developed a high-precision classification model that is capable of predicting consistency of meningiomas based on the radiomic features in preoperative magnetic resonance imaging (T2-weighted, T1-weighted post-contrast, and apparent diffusion coefficient map).
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Thammaroj J, Wongwichit N, Boonrod A. Evaluation of Perienhancing Area in Differentiation between Glioblastoma and Solitary Brain Metastasis. Asian Pac J Cancer Prev 2020; 21:2525-2530. [PMID: 32986348 PMCID: PMC7779443 DOI: 10.31557/apjcp.2020.21.9.2525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose: Accurate differential diagnosis between glioblastoma and brain metastasis is important. We aimed to differentiate these tumors by evaluation of the perienhancing area. Materials and Methods: Thirty patients with glioblastoma and solitary brain metastasis were included. The diameters of perienhancing and enhancing areas were measured, and the percentage of enhancing area was calculated. We measured Apparent diffusion coefficient (ADC) of perienhancing and enhancing areas. Intratumoral necrotic areas were measured. Results: The enhancing area of glioblastoma was 56.61% and metastasis was 42.55% (p = 0.08). The ADC values of the perienhancing part of GBM was 0.7 and metastasis was 0.79 (p = 0.052). The ADC value of the enhancing part of the GBM was 0.82 and metastasis was 0.8 (p-value = 0.72). The intratumoral necrotic area of glioblastoma (152.25 mm3) was higher than in metastasis (0 mm3) (p-value = 0.003) with a cutoff area of 11.8 mm2. Conclusion: The ADC values of the perienhancing area were lower in glioblastoma with a near-significant p-value. Other perienhancing parameters demonstrated no significant difference between both tumors. The intratumoral necrotic area of glioblastoma is larger than metastasis.
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Affiliation(s)
- Jureerat Thammaroj
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Nattha Wongwichit
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Arunnit Boonrod
- Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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Kunigelis KE, Hosokawa P, Arnone G, Raban D, Starr A, Gurau A, Sunshine A, Bunn J, Thaker AA, Youssef AS. The predictive value of preoperative apparent diffusion coefficient (ADC) for facial nerve outcomes after vestibular schwannoma resection: clinical study. Acta Neurochir (Wien) 2020; 162:1995-2005. [PMID: 32440924 DOI: 10.1007/s00701-020-04338-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/07/2020] [Indexed: 02/07/2023]
Abstract
OBJECT Diffusion MRI has been used to predict intraoperative consistency of tumors. Apparent diffusion coefficient (ADC) has shown predictive value as an imaging biomarker in many CNS tumors but has not been studied in a large cohort of patients with vestibular schwannoma. In this study, we examine the utility of ADC as a predictive biomarker for intraoperative tumor characteristics and postoperative facial nerve outcome. METHODS A retrospective review of patients who underwent vestibular schwannoma resection at our institution from 2008 to 2018 yielded 87 patients, of which 72 met inclusion criteria. Operative reports and clinical records were reviewed for clinical data; MRI data were interpreted in a blinded fashion for qualitative and quantitative biomarkers, including tumor ADC. RESULTS Mean tumor ADC values did not predict intraoperative consistency or adherence (p = 0.63). Adherent tumors were associated with worse facial nerve outcomes (p = 0.003). Regression tree analysis identified 3 ADC categories with statistically different facial nerve outcomes. The categories identified were ADC < 1006.04 × 10-6 mm2/s; ADC 1006.04-1563.93 × 10-6 mm2/s and ADC ≥ 1563.94 × 10-6 mm2/s. Postoperative and final House-Brackmann (HB) scores were significantly higher in the intermediate ADC group (2.3, p = 0.0038). HB outcomes were similar between the group with ADC < 1006.04 × 10-6 mm2/s and ≥ 1563.94 × 10-6 mm2/s (1.3 vs 1.3). CONCLUSIONS Middle-range preoperative ADC in vestibular schwannoma suggests a less favorable postoperative HB score. Preoperative measurement of ADC in vestibular schwannoma may provide additional information regarding prognostication of facial nerve outcomes.
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Affiliation(s)
- Katherine E Kunigelis
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Patrick Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO, USA
| | - Gregory Arnone
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - David Raban
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Adam Starr
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Andrei Gurau
- University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Alexis Sunshine
- University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Jason Bunn
- University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Ashesh A Thaker
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - A Samy Youssef
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
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Salah F, Tabbarah A, ALArab y N, Asmar K, Tamim H, Makki M, Sibahi A, Hourani R. Can CT and MRI features differentiate benign from malignant meningiomas? Clin Radiol 2019; 74:898.e15-898.e23. [DOI: 10.1016/j.crad.2019.07.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/25/2019] [Indexed: 12/01/2022]
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17
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Korfiatis P, Erickson B. Deep learning can see the unseeable: predicting molecular markers from MRI of brain gliomas. Clin Radiol 2019; 74:367-373. [DOI: 10.1016/j.crad.2019.01.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/31/2019] [Indexed: 11/26/2022]
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