Hypnosis-Aided Awake Surgery for the Management of Intrinsic Brain Tumors versus Standard Awake-Asleep-Awake Protocol: A Preliminary, Promising Experience

Resection of supratentorial high-grade gliomas availing of neuronavigation matched intraoperative ultrasound and Fluorescein: How far is it safe to push the resection?

Background

High-Grade Gliomas are the most common primary brain malignancies and despite the multimodal treatment, and the increasing amount of adjuvant treatment options the overall prognosis remains dismal. The present investigation aims to analyze the safety profile of the use of intraoperative ultrasounds (Io-US) in a homogeneous and matched cohort of patients suffering from High-grade gliomas (HGG) operated on with or without the aid of Io-US and Fluorescein in specific relation to the incidence of neurological and functional status sequelae.

Methods and materials

A retrospective analysis was performed on 74 patients affected by HGG. 22 patients were treated with Io-US matched with neuronavigational system (Group A); 15 patients were treated both with the use of Io-US and Fluorescein matched with neuronavigational system (Group B); 37 patients were treated with the use of the neuronavigational system only (Group C). Primary endpoints were the extent of resection and functional outcome (measured with Karnofski Performance Status).

Results

Significative differences were observed in terms of a higher extent of resection in Group B. In a multivariate analysis, this data appears to be independent of the location (eloquent/non-eloquent) of the lesion and from its histology. Regarding functional outcomes, no differences were detected between the two groups.

Conclusions

The present study is the first that analyzes the simultaneous use of Io-US and Fluorescein, and the results demonstrate that these two instruments together could improve the extent of resection in HGG while ensuring good outcomes in terms of functional status.

Touching the unconscious in the unconscious - hypnotic communication with unconscious patients

If hypnosis means contact to the unconscious to modulate psychological and physiological functions by means of suggestions, and if this is facilitated by attenuation of the critical mind, then the question arises as to whether suggestions also have an effect when waking consciousness is otherwise eliminated, namely by coma or anesthesia. A prerequisite would be perception, which actually is evidenced by reports of patients after traumatic brain injury, artificial coma, resuscitation or general anesthesia. Moreover, posttraumatic stress disorder (PTSD) frequently observed after these medical situations is hardly explainable without some sort of awareness under such conditions. Even advanced neurophysiological diagnostic cannot yet rule out consciousness or sensory processing. Especially reference to perception during unconsciousness is given by the results of a recent multicenter study on the effects of hypnotic communication with patients under controlled adequate deep general anesthesia. The observed reductions in incidence and severity of postoperative pain, opioid use, nausea and vomiting cannot be explained by the reaction of a few but only by a considerable proportion of patients. This leads to a strong plea for a more careful treatment of unconscious patients in the emergency room, operating theater or intensive care unit, for the abandonment of the restriction of therapeutic communication to awake patients, and for new aspects of communication and hypnosis research. Obviously, loss of consciousness does not protect against psychological injury, and continuation of communication is needed. But how and what to talk to unconscious patients? Generally addressing the unconscious mind with suggestions that generally exert their effects unconsciously, hypnotic communication appears to be the adequate language. Especially addressing meaningful topics, as derived from the basic psychological needs and known stressors, appears essential. With respect to negative effects by negative or missing communication or to the proposed protective and supporting effects of therapeutic communication with patients clinically rated as unconscious, the role of consciousness is secondary. For the effects of perceived signals and suggestions it does not matter whether consciousness is absent, or partial, or unrecognized present.

An update on tests used for intraoperative monitoring of cognition during awake craniotomy

PURPOSE

Mapping higher-order cognitive functions during awake brain surgery is important for cognitive preservation which is related to postoperative quality of life. A systematic review from 2018 about neuropsychological tests used during awake craniotomy made clear that until 2017 language was most often monitored and that the other cognitive domains were underexposed (Ruis, J Clin Exp Neuropsychol 40(10):1081-1104, 218). The field of awake craniotomy and cognitive monitoring is however developing rapidly. The aim of the current review is therefore, to investigate whether there is a change in the field towards incorporation of new tests and more complete mapping of (higher-order) cognitive functions.

METHODS

We replicated the systematic search of the study from 2018 in PubMed and Embase from February 2017 to November 2023, yielding 5130 potentially relevant articles. We used the artificial machine learning tool ASReview for screening and included 272 papers that gave a detailed description of the neuropsychological tests used during awake craniotomy.

RESULTS

Comparable to the previous study of 2018, the majority of studies (90.4%) reported tests for assessing language functions (Ruis, J Clin Exp Neuropsychol 40(10):1081-1104, 218). Nevertheless, an increasing number of studies now also describe tests for monitoring visuospatial functions, social cognition, and executive functions.

CONCLUSIONS

Language remains the most extensively tested cognitive domain. However, a broader range of tests are now implemented during awake craniotomy and there are (new developed) tests which received more attention. The rapid development in the field is reflected in the included studies in this review. Nevertheless, for some cognitive domains (e.g., executive functions and memory), there is still a need for developing tests that can be used during awake surgery.

Hypnosis-Assisted Awake Craniotomy for Eloquent Brain Tumors: Advantages and Pitfalls

BACKGROUND

Awake craniotomy (AC) is recommended for the resection of tumors in eloquent areas. It is traditionally performed under monitored anesthesia care (MAC), which relies on hypnotics and opioids. Hypnosis-assisted AC (HAAC) is an emerging technique that aims to provide psychological support while reducing the need for pharmacological sedation and analgesia. We aimed to compare the characteristics and outcomes of patients who underwent AC under HAAC or MAC.

METHODS

We retrospectively analyzed the clinical, anesthetic, surgical, and neuropsychological data of patients who underwent awake surgical resection of eloquent brain tumors under HAAC or MAC. We used Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated-measures analyses of variance to identify statistically significant differences at the 0.05 level.

RESULTS

A total of 22 patients were analyzed, 14 in the HAAC group and 8 in the MAC group. Demographic, radiological, and surgical characteristics as well as postoperative outcomes were similar. Patients in the HAAC group received less remifentanil (p = 0.047) and propofol (p = 0.002), but more dexmedetomidine (p = 0.025). None of them received ketamine as a rescue analgesic. Although patients in the HAAC group experienced higher levels of perioperative pain (p < 0.05), they reported decreasing stress levels (p = 0.04) and greater levels of satisfaction (p = 0.02).

CONCLUSION

HAAC is a safe alternative to MAC as it reduces perioperative stress and increases overall satisfaction. Further research is necessary to assess whether hypnosis is clinically beneficial.

Hypnosis in psychotherapy, psychosomatics and medicine. A brief overview

Aspects of hypnosis and its application in psychotherapy, psychosomatics and medicine are examined and contextualized in the 250-year history of hypnosis. Imagination as an essential element of hypnotic treatments appeared as early as 1784 as an argument rejecting the theory of animal magnetism of Franz Anton Mesmer. In somnambulism of German romanticism, another proto-form of hypnosis after 1800, concepts of the mind-body problem were dealt with, which still characterize the understanding of unconscious mental processes today. Hypnosis was at the beginning of psychoanalysis, but was not pursued further by Sigmund Freud from 1900 onwards. Nevertheless, there were some hypnoanalytical approaches in the 20th century, as well as attempts to integrate hypnosis into behavior therapy. Techniques of imagination and relaxation combine both; in particular findings from cognitive psychology explain processes of both hypnosis and cognitive behavioral therapy. The influence of social psychology brought a new perspective to the debate about the nature of hypnosis, which continues to this day: is hypnosis to be understood as a special state of consciousness or is it a completely normal, mundane interaction? The experiments that were carried out to support one side or the other were also dependent on the hypnotizability of the subjects involved, as the more difficult hypnotic phenomena such as paralysis, hallucinations or identity delusions can only be demonstrated by highly hypnotizable subjects. The fact that these are not mere compliance reactions has now been proven by many studies using imaging techniques. But even those who are moderately hypnotizable benefit from hypnosis rituals. Variables postulated by socio-cognitive hypnosis researchers, such as motivation and expectation, are relevant, as is a good "hypnotic rapport." Practical application of hypnotherapy today is characterized by the innovative techniques and strategies developed by Milton H. Erickson. Research into the effectiveness of hypnosis in the field of psychotherapy and psychosomatics still leaves much to be done. The situation is different in the field of medical hypnosis, where there are considerably more studies with a satisfactory design and verifiable effects. However, the impact in practical application in everyday medical practice is still low. Newer developments such as virtual reality and artificial intelligence are being looked at with critical interest.

EGFR-Driven Mutation in Non-Small-Cell Lung Cancer (NSCLC) Influences the Features and Outcome of Brain Metastases

Background: Brain metastases (BMs) is one of the most frequent metastatic sites for non-small-cell lung cancer (NSCLC). It is a matter of debate whether EGFR mutation in the primary tumor may be a marker for the disease course, prognosis, and diagnostic imaging of BMs, comparable to that described for primary brain tumors, such as glioblastoma (GB). This issue was investigated in the present research manuscript. Methods: We performed a retrospective study to identify the relevance of EGFR mutations and prognostic factors for diagnostic imaging, survival, and disease course within a cohort of patients affected by NSCLC-BMs. Imaging was carried out using MRI at various time intervals. The disease course was assessed using a neurological exam carried out at three-month intervals. The survival was expressed from surgical intervention. Results: The patient cohort consisted of 81 patients. The overall survival of the cohort was 15 ± 1.7 months. EGFR mutation and ALK expression did not differ significantly for age, gender, and gross morphology of the BM. Contrariwise, the EGFR mutation was significantly associated with MRI concerning the occurrence of greater tumor (22.38 ± 21.35 cm³ versus 7.68 ± 6.44 cm³, p = 0.046) and edema volume (72.44 ± 60.71 cm³ versus 31.92 cm³, p = 0.028). In turn, the occurrence of MRI abnormalities was related to neurological symptoms assessed using the Karnofsky performance status and mostly depended on tumor-related edema (p = 0.048). However, the highest significant correlation was observed between EGFR mutation and the occurrence of seizures as the clinical onset of the neoplasm (p = 0.004). Conclusions: The presence of EGFR mutations significantly correlates with greater edema and mostly a higher seizure incidence of BMs from NSCLC. In contrast, EGFR mutations do not affect the patient's survival, the disease course, and focal neurological symptoms but seizures. This contrasts with the significance of EGFR in the course and prognosis of the primary tumor (NSCLC).

Stress, Anxiety, and Depression Associated With Awake Craniotomy: A Systematic Review

BACKGROUND

Awake craniotomy (AC) enables real-time monitoring of cortical and subcortical functions when lesions are in eloquent brain areas. AC patients are exposed to various preoperative, intraoperative, and postoperative stressors, which might affect their mental health.

OBJECTIVE

To conduct a systematic review to better understand stress, anxiety, and depression in AC patients.

METHODS

PubMed, Scopus, and Web of Science databases were searched from January 1, 2000, to April 20, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline.

RESULTS

Four hundred forty-seven records were identified that fit our inclusion and exclusion criteria for screening. Overall, 24 articles consisting of 1450 patients from 13 countries were included. Sixteen studies (66.7%) were prospective, whereas 8 articles (33.3%) were retrospective. Studies evaluated stress, anxiety, and depression during different phases of AC. Twenty-two studies (91.7%) were conducted on adults, and 2 studies were on pediatrics (8.3 %). Glioma was the most common AC treatment with 615 patients (42.4%). Awake-awake-awake and asleep-awake-asleep were the most common protocols, each used in 4 studies, respectively (16.7%). Anxiety was the most common psychological outcome evaluated in 19 studies (79.2%). The visual analog scale and self-developed questionnaire by the authors (each n = 5, 20.8%) were the most frequently tools used. Twenty-three studies (95.8%) concluded that AC does not increase stress, anxiety, and/or depression in AC patients. One study (4.2%) identified younger age associated with panic attack.

CONCLUSION

In experienced hands, AC does not cause an increase in stress, anxiety, and depression; however, the psychiatric impact of AC should not be underestimated.

Patient-reported intraoperative experiences during awake craniotomy for brain tumors: a scoping review

Awake craniotomy (AC) is a neurosurgical procedure that may be used to excise tumors located in eloquent areas of the brain. The techniques and outcomes of AC have been extensively described, but data on patient-reported experiences are not as well known. To determine these, we performed a scoping review of patient-reported intraoperative experiences during awake craniotomy for brain tumor resection. A total of 21 articles describing 534 patients were included in the review. Majority of the studies were performed on adult patients and utilized questionnaires and interviews. Some used additional qualitative methodology such as grounded theory and phenomenology. Most of the evaluation was performed within the first 2 weeks post-operatively. Recollection of the procedure ranged from 0 to 100%, and most memories dealt with the cranial fixation device application, cranial drilling, and intraoperative mapping. All patients reported some degree of pain and discomfort, mainly due to the cranial fixation device and uncomfortable operative position. Most patients were satisfied with their AC experience. They felt that participating in AC gave them a sense of control over their disease and thought that trust in the treatment team and adequate pre-operative preparation were very important. Patients who underwent AC for brain tumor resection had both positive and negative experiences intraoperatively, but overall, majority had a positive perception of and high levels of satisfaction with AC. Successful AC depends not only on a well-conducted intraoperative course, but also on adequate pre-operative information and patient preparation.

IDH Wild-type Glioblastoma Presenting with Seizure: Clinical Specificity, and Oncologic and Surgical Outcomes

BACKGROUND

 Glioblastoma (GBM) is the most common and aggressive primary brain neoplasia in adults. Seizure is a common manifestation in GBM. Up to 25 to 60% of patients with GBM have seizures. We aim to summarize all the relevant clinical, surgical, radiologic, and molecular features of a cohort of patients suffering from GBM-related epilepsy and measure the outcome, to understand the possible existence of a clinical/phenotypical specificity of this subgroup of patients.

METHODS

 We retrospectively analyzed a cohort of 177 patients affected by isocitrate dehydrogenase wild-type (IDH-WT) GBM; 49 patients presented seizure at onset (SaO) and 128 were seizure free (SF). We investigated the relationship between seizures and other prognostic factors of GBMs.

RESULTS

 A statistically significant association between the location of the lesions in the parietal lobe and seizures was observed. The left side was more commonly affected. Interestingly, there was a statistical relationship between tumors involving the subventricular zone (SVZ) and SaO patients. The tumors were also smaller on average at diagnosis, and generalized SaOs were associated with longer overall survival.

CONCLUSIONS

 The typical patient with IDH-WT GBM with SaO is a young (<55 year) male without a history of headache. The lesion is typically small to medium in size and located in the temporoparietal dominant lobe, with a high tendency to involve the SVZ.

Anesthetic Management of Asleep and Awake Craniotomy for Supratentorial Tumor Resection

Understanding how anesthetics impact cerebral physiology, cerebral blood flow, brain metabolism, brain relaxation, and neurologic recovery is crucial for optimizing anesthesia during supratentorial craniotomies. Intraoperative goals for supratentorial tumor resection include maintaining cerebral perfusion pressure and cerebral autoregulation, optimizing surgical access and neuromonitoring, and facilitating rapid, cooperative emergence. Evidence-based studies increasingly expand the impact of anesthetic care beyond immediate perioperative care into both preoperative optimization and minimizing postoperative consequences. New evidence is needed for neuroanesthesia's role in neurooncology, in preventing conversion from acute to chronic pain, and in decreasing risk of intraoperative ischemia and postoperative delirium.

Use of hypnosis preoperatively for surgery of the spine: Pilot study

INTRODUCTION

Hypnosis is a technique requiring no drugs that acts during the three phases of surgery, reducing stress at the pre-surgical phase and the adminstration of anesthetic drugs during the intraoperative phase, as well as leading to improved management of postoperative pain and quality of life management.

MATERIAL ET METHOD

We carried out a retrospective study of 46 patients operated on for herniated disc or one or two-level laminectomy without arthrodesis. All patients benefited from a preoperative hypnosis session and completed a questionnaire about their possible concerns. The day after surgery, patients completed a second questionnaire on their postoperative experience following hypnosis.

RESULTATS

Our results indicate that this technique had a positive impact on the management of preoperative stress (80% of patients) and on postoperative quality of life (48% of patients). Pain measured by decreased from 4.8/10 preoperatively to 0.9/10 postoperatively.

CONCLUSION

Our results are consistent with previous findings in the literature as to the positive contribution of this technique in the management of preoperative stress and patient quality of life. Further studies are however required involving considerably larger cohorts and more extensive surgeries to confirm the effect of this technique on management of anesthesia and pain in spine surgery.

No prognostic differences between GBM-patients presenting with postoperative SMA-syndrome and GBM-patients involving cortico-spinal tract and primary motor cortex

BACKGROUND

The supplementary motor area (SMA) is involved in several aspects of motor control and its can be associated to a contralateral motor deficit and speech disorders. After the resection of low-grade gliomas, this syndrome is diffusely reported but it is rarely investigated in high-grade gliomas. SMA deficits may resolve completely or with minor sequelae within weeks. Whether this condition of transient deficit affects survival, was not previously investigated, and is not currently understood.

OBJECTIVE

The study aimed to perform an accurate investigation concerning the real clinical and prognostic impact of the postoperative SMA syndrome in order to shed light over its relationship to survival parameters and postoperative functional status of the patients.

METHODS

We performed a retrospective review of a series of 176 surgically treated patients suffering from Glioblastomas. Tumors classified as Group A: Involving the SMA and Group B: Lesion located outside and distal to the SMA but in anatomical relationship to primary motor cortices (PM1) or corticospinal tract (CST), in order to investigate differences concerning immunohistochemical and molecular profiles in regard to the survival parameters.

RESULTS

Although lesions involving SMA demonstrated a significantly higher volume in respect to their general counterparts they did not significantly differ in concerns to the molecular patterns, pre and postoperative KPS scores and in PFS and OS findings.

CONCLUSIONS

In our cohort SMA-syndrome is reversible and therefore guarantees a satisfactory functional status at follow-up, apparently not compromising survival when compared to other lesions affecting the primary or cortical motor area -spinal tract.

Awake craniotomy for resection of supratentorial glioblastoma: a systematic review and meta-analysis

Background

The goal of glioblastoma (GBM) surgery is to maximize the extent of resection (EOR) while minimizing postoperative neurological complications. Awake craniotomy (AC) has been demonstrated to achieve this goal for low-grade gliomas in or near eloquent areas. However, the efficacy of AC for GBM resection has not been established. Therefore, we aimed to investigate the outcomes of AC for surgical resection of GBM using a systematic review and meta-analysis of published studies.

Methods

Systematic searches of Ovid MEDLINE, Embase, Cochrane Controlled Register of Controlled Trials, and PubMed were performed from database inception to September 14, 2019 for published studies reporting outcomes of AC for GBM resection. Outcome measures analyzed included EOR and the event rate of postoperative neurological deficits.

Results

A total of 1928 unique studies were identified. Fourteen studies reporting 278 patients were included in our meta-analysis. Mean age of patients was 46.9 years (95% confidence interval [CI]: 43.9–49.9). Early and late postoperative neurological deficits occurred in 34.5% (95% CI: 21.9–48.2) and 1.9% (95% CI: 0.0–9.2) of patients, respectively. Pooled percentage of gross total resection (GTR) was 74.7% (95% CI: 66.7–82.1), while the pooled percentage reduction in tumor volume was 95.3% (95% CI: 92.2–98.4).

Conclusions

Limited current evidence suggests that the use of AC for resection of supratentorial GBM is associated with a low rate of persistent neurological deficits while achieving an acceptable rate of GTR. Our findings demonstrate the potential viability of AC in GBM resection and highlight the need for further research on this topic.

Is Ki-67 index overexpression in IDH wild type glioblastoma a predictor of shorter Progression Free survival? A clinical and Molecular analytic investigation

BACKGROUND

Ki-67 proliferation index is widely used for differentiating between high and low-grade gliomas, but differentiating between the same grade IV appears to be more problematic, and the point about its prognostic value for GBM patients remains unclear. To reduce the possibility to find a marked histological heterogeneity, and may contain areas that could be diagnosed as lower grade, in this study we considered a large group of patients with IDH wild-type Glioblastoma (IDH-WT GBM) and we have analyzed previously reported prognostic factors, in regards to their relationship with the Ki-67 expression index.

METHODS

We explore the prognostic impact of ki-67 index status in 127 patients affected by IDH-WT GBM. We therefore analyzed clinical characteristics, tumor genetics, dimension and clinical outcomes. We selected a total of 127 patients affected by newly diagnosed IDH-WT GBM who underwent surgery, radiation, and chemotherapy in our Institution in the period ranging between January 2014 and December 2016 RESULTS: The volume of the lesion had a strong association with the Ki67 overexpression. In particular lesions whose volume was greater than 45  cm³, presented a higher percentage of Ki67 expression demonstrating that greater tumors are more likely associated to higher values of Ki67 percentages. On a multivariate analysis, it was possible to outline that Ki67 was significant a predictor of shorter PFS independently from the age of the patients, the volume of the lesion and preoperative KPS.

CONCLUSIONS

There is a correlation between percentage staining of Ki-67 and OS in our cohort of patients with IDH-WT GBM. This is only the third observational study documenting a positive correlation between Ki-67 and overall survival in GBM and the first one demonstrates that percentage Ki-67 staining >20 % predicts poorer progression free survival in IDH-WT GBM.

Anesthesia management for low-grade glioma awake surgery: a European Low-Grade Glioma Network survey

BACKGROUND

Awake surgery has become a key treatment of diffuse low-grade gliomas (DLGG) and is divided in three main phases: opening, tumor resection - during which the patient needs to be fully awake - and closure. The anesthetic management of awake neurosurgery is a challenge, and there are currently no guidelines.

OBJECTIVE

The objective of the survey was to explore differences and commonalities regarding the anesthetic management of awake DLGG surgery within the European Low-Grade Glioma Network (ELGGN) centers.

METHODS

A form that contained 14 questions about the anesthetic management was sent to 28 centers in May 2015.

RESULTS

Twenty centers responded. During the opening and closing non-awake periods, 56% of teams chose general anesthesia with mechanical ventilation for at least one period (asleep-awake-asleep, SAS protocol), and 44% monitored anesthesia care including sedation without mechanical ventilation (MAC protocol). In case of SAS, all the teams chose intravenous anesthesia, 82% used laryngeal mask instead of endotracheal intubation during the opening sequence, and 71% during closure. Local and regional anesthesia was practiced by all the teams. The most frequently reported cause of pain was dural and cerebral vessels manipulation (77%). Pain management was mostly based on paracetamol (70%) and remifentanil (55%).

CONCLUSION

Our survey showed that there was an equivalent proportion of centers using SAS or MAC protocols in the anesthetic management of awake surgery in ELGGN centers. The advantages and disadvantages of each anesthesia protocol were reviewed.

Histological, molecular, clinical and outcomes characteristics of Multiple Lesion Glioblastoma. A retrospective monocentric study and review of literature

BACKGROUND

Multiple lesion glioblastoma (M-GBM) represent a group of GBM patients in which there exist multiple foci of tumor enhancement. The prognosis is poorer than that of single-lesion GBM patients, but this actually is a controversial data. Is unknown whether multifocality has a genetic and molecular basis. Our specific aim is to identify the molecular characteristics of M-GBM by performing a comprehensive multidimensional analysis.

METHODS

The surgical, radiological and clinical outcomes of patients that underwent surgery for GBM at our institution for 2 years have been retrospectively reviewed. We compared the overall survival (OS), progression free survival and extent of resection (EOR) between M-GBM tumors (type I) and S-GBM (single contrast-enhancing lesion, type II).

RESULTS

A total of 177 patients were included in the final cohort, 12 patients had M-GBM and 165 patients had S-GBM. Although patients with M-GBM had higher tumor volumes and midline location, the EOR was not different between both type of lesions. Higher percentage of tumors with EGFR overexpression was detected in M-GBM. PFS and OS was significantly shorter in M-GBM.

CONCLUSIONS

Considering no differences in EOR, patients with M-GBM showed shorter PFS and OS in comparison with S-GBM. Evidences about the M-GBM origin as a multifocal lesion because its molecular profile are suggested.

Role of endoscopic surgical biopsy in diagnoses of intraventricular/periventricular tumors: review of literature including a monocentric case series

The intra- and periventricular location tumor (IPVT) of a brain remains a hard challenge for the neurosurgeon because of the deep location and eloquent anatomic associations. Due to this high risk of iatrogenic injury, many surgeons elect to perform biopsies of such lesions to establish a diagnosis. On the one hand, stereotaxic needle biopsy (SNB) is a minimally invasive procedure but with a significant risk of complications and a high risk of lack of tissue for molecular analyses for this region [Fukushima in Neurosurgery 2:110-113 (1978)]; on the other hand, the use of endoscopic intraventricular biopsy (EIB) allows for diagnosis with minimal surgical intervention [Iwamoto et al. in Ann Neurol 64(suppl. 6):628-634 (2008)]. IPVTs and related CSF pathway obstructions can be safely and effectively treated with endoscopic techniques. It is not possible to compare EIB with diagnoses made by any other method or with the established treatment. We aim to analyze the accuracy of EIB results by comparing them with results of biopsies performed later, in other methods and thereby evaluating the treatment evolution considering our personal experience. The difficulties and complications encountered are presented and compared with those reported in the literature to obtain the best review possible for this topic. A systematic review of literature was done using MEDLINE, the NIH Library, PubMed, and Google Scholar yielded 1.951 cases for EIB and 1912 for SNB, according to standard systemic review techniques. Review was conducted on 50 studies describing surgical procedures for lesions intra- and para-ventricular. The primary outcome measure was a diagnostic success. We also consider 20 patients with IPVT treated in our department. Clinical characteristics and surgical outcome were evaluated and a systematic review of the literature was performed. Overall, all our biopsies were diagnostic, with a positive histologic sample in 100% of our patients. 8 patients underwent a concurrent endoscopic third ventriculostomy. 4 patients underwent a concurrent ventriculostomy combined with septostomy. For 1 patient was necessary the only septostomy combined with biopsy. Every case has obtained a histological diagnosis. The percentage of complications was very low with only 1 case of post-operative infection and 1 case of hemorrhage. It was impossible to create a specific comparison from literature data of IPVTs between a stereotactic and endoscopic procedure, it presents only the collection of pineal gland tumor [Kelly in Neurosurgery 25(02):185-194 (1989); Quick-Weller in World Neurosurgery 96:124-128 (2016)] or unknown location of the lesion in major review [Marenco-Hillembrand et al. in Front Oncol 8:558 (2018)]. The present study aims to report our experience with the surgical management of IPVTs. The EIB sample yields an accurate histologic diagnosis tumor, with a positive histologic sample in 87, 95% of patients. The choice of the appropriate procedure should consider not only the preference and the experience of the neurosurgeon but also the several other variables as the location. While some periventricular lesions are better approached by endoscopic techniques, others are more suited for stereotactic-guided approaches. The ability to perform an EIB and relieve tumor-associated hydrocephalus by neuroendoscopy is considered to be a benefit of this procedure since this is less invasive than other treatments.

Standard awake surgery versus hypnosis aided awake surgery for the management of high grade gliomas: A non-randomized cohort comparison controlled trial

Hypnosis could extend the time of Intraoperative Neuropsychological Testing and Brain Mapping in Awake Surgery. A clinical validation for the Hypnosis aided AS (HAs) is still ongoing and further evidences are required. The objective of the present study is to compare two homogeneous cohorts of patients undergoing AS, the first with the aid of the hypnosis and the second according to a standard AS (SAs) protocols. The clinical, radiological and surgical data of two comparable procedures cohorts were retrospectively examined for the present study. All surgeries in Group A were performed with a HAs protocol. Procedures belonging to Group B were performed with a SAs protocol. Endpoints: to compare 1. Incidence of complications in the immediate postoperative period, 2. Clinical and neurological status in the immediate postoperative period and 30 days after surgery, 3. Duration of surgical interventions, 4. Extent of Resection (EOR). The final cohort is composed of 15 procedures; 6 belonging to Group A and 9 to Group B. The different methods outline statistically comparable results from the clinical (Neurological outcomes) both in the postoperative period and one month after surgery and from the surgical point of view (comparable EOR). The incidence of complications is comparable either. The duration of the procedures was significantly longer in HAs group. Hypnosis is a promising approach to increasing the duration of intraoperative "testability" of patients at the price of a longer operative time. A specific professional is needed to induce hypnosis in the difficult intraoperative setting.

EGFR amplification is a real independent prognostic impact factor between young adults and adults over 45yo with wild-type glioblastoma?

BACKGROUND

In 2019 a group of University of Pennsylvania (Hoffman et al., J Neurooncol 145: 321-328, 2019) aimed to explore the prognostic impact of expression of epidermal growth factor receptor (EGFR), one of the most common genetic alterations in WT-GBM, in young adults with IDH-WT GBM, suggesting an inferior outcomes in young adults (< 45yo) with newly diagnosed, IDH-WT GBM. At the same time, our group were considering the dimension of this subpopulation treated in our centre, and we performed the same analysis, comparing datas with affected elderly adults.

METHODS

We explore the prognostic impact of EGFR expression status in young adults with IDH-WT GBM, and compare this impact with the affected elderly adults. We therefore analyzed clinical characteristics, tumor genetics, and clinical outcomes in a cohort of adults aged 18-45 years with newly diagnosed WT GBM. We selected a total of 146 patients affected by newly diagnosed IDH-WT GBM who underwent surgery, radiation, and chemotherapy in our Institution in the period ranging between January 2014 and December 2016. We focused primarily on the prognostic impact of EGFR expression.

RESULTS

We confirmed through a Bivariate Analysis that the Age of the Patients, the Volume of the lesions, were statistically strongly associated with the survival parameters; The general OS of the cohort presented a breakthrough point between the patients who were respectively younger and older than 45 years, EGFR mutation was per se not associated to a survival reduction in all the cohort patients. When analyzing exclusively the Survival parameters of the patients whose age was under 40, it was possible to outline a non statistically significant trend towards a lesser OS in younger patients harboring an EGFR expression.

CONCLUSIONS

Once again the main difference in terms of OS in GBM is shown in a EOR and in Age. To our knowledge, ours is the second study (Hoffman et al., J Neurooncol 145: 321-328, 2019) to evaluate the prognostic impact of EGFR CN gain specifically in young adults with IDH-WT GBM and in the era of modern radiation and Temozolomide, but is the first one to compares this impact with a population of adults over 45, and correlates this date with clinical onset, dimension and localization of disease between this groups. We suggest other centers to evaluate this important finding with a larger number of patients and we are inclined to accept collaborations to increase the power of this study.

Long Term Survival in Patients Suffering from Glio-blastoma Multiforme: A Single-Center Observational Cohort Study

Background: Glioblastomas (GBM) are generally burdened, to date, by a dismal prognosis, although long term survivors have a relatively significant incidence. Our specific aim was to determine the exact impact of many surgery-, patient- and tumor-related variables on survival parameters. Methods: The surgical, radiological and clinical outcomes of patients have been retrospectively reviewed for the present study. All the patients have been operated on in our institution and classified according their overall survival in long term survivors (LTS) and short term survivors (STS). A thorough review of our surgical series was conducted to compare the oncologic results of the patients in regard to: (1) surgical-(2) molecular and (3) treatment-related features. Results: A total of 177 patients were included in the final cohort. Extensive statistical analysis by means of univariate, multivariate and survival analyses disclosed a survival advantage for patients presenting a younger age, a smaller lesion and a better functional status at presentation. From the histochemical point of view, Ki67 (%) was the strongest predictor of better oncologic outcomes. A stepwise analysis of variance outlines the existence of eight prognostic subgroups according to the molecular patterns of Ki67 overexpression and epidermal growth factor receptor (EGFR), p53 and isocitrate dehydrogenase (IDH) mutations. Conclusions: On the grounds of our statistical analyses we can affirm that the following factors were significant predictors of survival advantage: Karnofsky performance status (KPS), age, volume of the lesion, motor disorder at presentation and/or a Ki67 overexpression. In our experience, LTS is associated with a gross total resection (GTR) of tumor correlated with EGFR and p53 mutations with regardless of localization, and poorly correlated to dimension. We suppose that performing a standard molecular analysis (IDH, EGFR, p53 and Ki67) is not sufficient to predict the behavior of a GBM in regards to overall survival (OS), nor to provide a deeper understanding of the meaning of the different genetic alterations in the DNA of cancer cells. A fine molecular profiling is feasible to precisely stratify the prognosis of GBM patients.

The Role and Real Effect of an Iterative Surgical Approach for the Management of Recurrent High-Grade Glioma: An Observational Analytic Cohort Study

BACKGROUND

The benefits of multiple interventions on the recurrence of high-grade gliomas are renowned. However, the real effect of repeated operations on the survival parameters does not seem to have been assessed. The aim of the present study was to determine whether reoperation for selected patients is safe and feasible.

METHODS

A total of 78 patients with high-grade glioma had undergone surgery from 2004 to 2014. All the patients had met the following inclusion criteria: American Society of Anesthesiologists score 1-3, Karnofsky performance scale score >60, and reintervention ≥4 months after the first surgery. The following parameters were evaluated: overall survival (OS) after diagnosis and reintervention, progression-free survival (PFS) after reintervention, number of surgical procedures, and OS of patients who had undergone surgery >2 times. The results were compared with those of 78 patients with high-grade glioma who had undergone adjuvant chemotherapy.

RESULTS

OS at 1 year was 100%. At 2 years, OS was 39.4% for those with glioblastoma and 58.3% for those with anaplastic astrocytoma. PFS after 6 months was 53.03% for glioblastoma and 75.0% for anaplastic astrocytoma. Of the 78 patients, 55 had undergone reoperation, with 15 requiring a third intervention and 8 requiring 4. Major complications developed in only 2 patients. Statistical analysis revealed no significant differences in complications or worsening neurological status.

CONCLUSIONS

These data showed excellent outcomes in terms of OS and PFS and clinical conditions after multiple surgical procedures. Therefore, reintervention appears to be a feasible and safe solution for selected patients.