Tectal Plate Glioma: A Clinical and Radiologic Analysis of Progression and Management in Adults

BACKGROUND

Tectal plate gliomas (TPGs) are a heterogeneous group of uncommon brain tumors. TPGs are considered indolent and are usually managed conservatively but they have the potential to transform into higher-grade tumors. The aims of this study were to investigate the natural history of adult TPG, treatment outcomes, and overall survival.

METHODS

A retrospective cohort analysis was performed of adult patients with TPG between 1993 and 2021. Baseline clinical, radiologic, and management characteristics were collected. The primary outcome was tumor progression, defined as increasing size on radiologic assessment or new gadolinium contrast enhancement. Secondary outcomes included management and mortality.

RESULTS

Thirty-nine patients were included, of whom 23 (52.2%) were men. Median age at diagnosis was 35 years (interquartile range, 27-53). Radiologic tumor progression was observed in 8 patients (20.5%). The 10-year progression-free survival was 72.6% (95% confidence interval [CI], 0.58-0.91). The 10-year overall survival was 86.5% (95% confidence interval, 0.75-1.0). Cerebrospinal fluid diversion procedures were used in 62% of the cohort (n = 24). Seventeen patients (43.6%) underwent at least 1 endoscopic third ventriculostomy, whereas only 6 patients (15.4%) underwent at least 1 ventriculoperitoneal shunt.

CONCLUSIONS

TPG has an overall favorable clinical prognosis, although progression occurs in 1 in 5 patients. Showing accurate factors by which patients with TPG may be risk stratified should be a key area of further research. A follow-up duration of 10 years would be a reasonable window based on the radiologic progression rates in this study; however, larger cohort studies are needed to answer both questions definitively.

Health-related quality of life following cranioplasty - a systematic review

Cranioplasty is a neurosurgical procedure that repairs a defect in the skull Coupled with the underlying pathology cranioplasty associated morbidity can have a large impact on patient quality of life, which is often poorly explored. The objective of this systematic review was to identify patient-reported outcomes evaluating health-related quality of life following cranioplasty. The review protocol was registered on PROSPERO (CRD42021251543) and a systematic review was conducted in accordance with the PRISMA statement. PubMed, Embase, CINAHL Plus, and the Cochrane databases were searched from inception to 1 May 2022. All studies reporting HRQoL following cranioplasty were included. Reporting was assessed using the ISOQOL checklist and risk of bias was assessed using the Newcastle-Ottawa Scale or the Johanna-Briggs Institute Scale, as appropriate. A total of 25 studies were included of which 20 were cross-sectional and 2 longitudinal. Most studies utilized study specific questionnaires and Likert scales to assess HRQoL. The studies found a significant improvement in physical functioning, social functioning, cosmetic outcome, and overall HRQoL following cranioplasty. Further longitudinal studies utilising validated measurement tools are required to better understand the effect of cranioplasty at a patient level.

Tranexamic acid use in meningioma surgery - A systematic review and meta-analysis

Tranexamic Acid (TXA) has been used in medical and surgical practice to reduce haemorrhage. The aim of this review was to evaluate the effect of TXA use on intraoperative and postoperative outcomes of meningioma surgery. A systematic review and meta-analysis was conducted in accordance with the PRISMA statement and registered in PROSPERO (CRD42021292157). Six databases were searched up to November 2021 for phase 2-4 control trials or cohort studies, in the English language, examining TXA use during meningioma surgery. Studies ran outside of dedicated neurosurgical departments or centres were excluded. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Random effects meta-analysis were performed to delineate differences in operative and postoperative outcomes. Four studies (281 patients) were included. TXA use significantly reduced intraoperative blood loss (mean difference 315.7 mls [95% confidence interval [CI] -532.8, -98.5]). Factors not affected by TXA use were transfusion requirement (odds ratio = 0.52; 95% CI 0.27, 0.98), operation time (mean difference = -0.2 h; 95% CI -0.8, 0.4), postoperative seizures (Odds Ratio [OR] = 0.88; 95% CI 0.31, 2.53), hospital stay (mean difference = -1.2; 95% CI -3.4, 0.9) and disability after surgery (OR = 0.50; 95% CI 0.23, 1.06). The key limitations of this review were the small sample size, limited data for secondary outcomes and a lack of standardised method for measuring blood loss. TXA use reduces blood loss in meningioma surgery, but not transfusion requirement or postoperative complications. Larger trials are required to investigate the impact of TXA on patient-reported postoperative outcomes.

Long standing overt ventriculomegaly in adults (LOVA): a systematic review and meta-analysis of endoscopic third ventriculostomy vs ventriculoperitoneal shunt as first line treatment

BACKGROUND

Long standing overt ventriculomegaly in adults (LOVA) is a heterogenous term describing forms of adult hydrocephalus. LOVA incidence is increasing, yet the optimal treatment strategy for symptomatic cases remains unclear. We compared the success and complication rates between Endoscopic Third Ventriculostomy (ETV) and Ventriculoperitoneal Shunt (VPS) as a first line treatment for LOVA.

METHODS

A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines (PROSPEROID CRD42021277542). Three databases were searched, and articles published from 2000 to October 2022 included (last search date 30^th September 2022). Success rates and complications of both ETV and VPS were compared using random effects models.

RESULTS

Of 895 articles identified, 22 studies were included in the analysis (556 patients- 346 treated with ETV, 210 VPS). Mean age was 44.8 years. The most common presenting symptoms were gait disturbance (N=178), headache (N=156), and cognitive decline (N=134). Combined success rates were 81.8% (N=283/346) in the ETV group and 86.7% (N=182/210) in the VPS group (median follow up 41 months). There was no difference in success rates between ETV and VPS groups (Odds Ratio [OR] 0.94, 95% CI 0.86-1.03, I² = 0%). Combined complication rates were 4.6% (N=16/346) in the ETV group and 27.1% (N=57/210) in the VPS group. ETV had a lower rate of postoperative complications (OR 0.22, 95% CI 0.11-0.33, I² = 0%).

CONCLUSIONS

Symptomatic LOVA can be successfully managed with surgical intervention. ETV and VPS have similar success rates when used as first line treatment. However, VPS has a higher complication rate.

Cranial meningioma with bone involvement: surgical strategies and clinical considerations

BACKGROUND

Intracranial meningioma with bone involvement and primary intraosseous meningioma is uncommon. There is currently no consensus for optimal management. This study aimed to describe the management strategy and outcomes for a 10-year illustrative cohort, and propose an algorithm to aid clinicians in selecting cranioplasty material in such patients.

METHODS

A single-centre, retrospective cohort study (January 2010-August 2021). All adult patients requiring cranial reconstruction due to meningioma with bone involvement or primary intraosseous meningioma were included. Baseline patient and meningioma characteristics, surgical strategy, and surgical morbidity were examined. Descriptive statistics were performed using SPSS v24.0. Data visualisation was performed using R v4.1.0.

RESULTS

Thirty-three patients were identified (mean age 56 years; SD 15) There were 19 females. Twenty-nine patients had secondary bone involvement (88%). Four had primary intraosseous meningioma (12%). Nineteen had gross total resection (GTR; 58%). Thirty had primary 'on-table' cranioplasty (91%). Cranioplasty materials included pre-fabricated polymethyl methacrylate (pPMMA) (n = 12; 36%), titanium mesh (n = 10; 30%), hand-moulded polymethyl methacrylate cement (hPMMA) (n = 4; 12%), pre-fabricated titanium plate (n = 4; 12%), hydroxyapatite (n = 2; 6%), and a single case combining titanium mesh with hPMMA cement (n = 1; 3%). Five patients required reoperation for a postoperative complication (15%).

CONCLUSION

Meningioma with bone involvement and primary intraosseous meningioma often requires cranial reconstruction, but this may not be evident prior to surgical resection. Our experience demonstrates that a wide variety of materials have been used successfully, but that pre-fabricated materials may be associated with fewer postoperative complications. Further research within this population is warranted to identify the most appropriate operative strategy.

Spinal fusion surgery - the need to follow the ‘BRAN’ toolkit (benefits, risks, alternatives, nothing): a case report

Failed back surgery syndrome is defined as increased or persistent pain following spinal surgery. Despite a relatively high incidence of failed back surgery syndrome (20%), patients may not be counselled regarding this complication pre-operatively. The Academy of Medical Royal Colleges has provided the Benefits, Risks, Alternatives and doing Nothing Toolkit to guide clinical discussions during the consent process. A 46-year-old female experiencing chronic lower back pain since 2003 suffered an exacerbation in 2015. Imaging identified non-compressive disc bulges. She was not put through the low back pain pathway as recommended by NICE and underwent spinal fusion in 2017. She continues to experience severe pain 54 months postsurgery. When considering spinal surgery, the risk of failed back surgery syndrome should be discussed with patients. Both clinicians and patients can use the BRAN toolkit to ensure open and transparent discussion prior to any intervention.