Early Detection of Underlying Cavernomas in Patients with Spontaneous Acute Intracerebral Hematomas

BACKGROUND AND PURPOSE

Early identification of the etiology of spontaneous acute intracerebral hemorrhage is essential for appropriate management. This study aimed to develop an imaging model to identify cavernoma-related hematomas.

MATERIALS AND METHODS

Patients 1-55 years of age with acute (≤7 days) spontaneous intracerebral hemorrhage were included. Two neuroradiologists reviewed CT and MR imaging data and assessed the characteristics of hematomas, including their shape (spherical/ovoid or not), their regular or irregular margins, and associated abnormalities including extralesional hemorrhage and peripheral rim enhancement. Imaging findings were correlated with etiology. The study population was randomly split to provide a training sample (50%) and a validation sample (50%). From the training sample, univariate and multivariate logistic regression was performed to identify factors predictive of cavernomas, and a decision tree was built. Its performance was assessed using the validation sample.

RESULTS

Four hundred seventy-eight patients were included, of whom 85 had hemorrhagic cavernomas. In multivariate analysis, cavernoma-related hematomas were associated with spherical/ovoid shape (P < .001), regular margins (P = .009), absence of extralesional hemorrhage (P = .01), and absence of peripheral rim enhancement (P = .002). These criteria were included in the decision tree model. The validation sample (n = 239) had the following performance: diagnostic accuracy of 96.1% (95% CI, 92.2%-98.4%), sensitivity of 97.95% (95% CI, 95.8%-98.9%), specificity of 89.5% (95% CI, 75.2%-97.0%), positive predictive value of 97.7% (95% CI, 94.3%-99.1%), and negative predictive value of 94.4% (95% CI, 81.0%-98.5%).

CONCLUSIONS

An imaging model including ovoid/spherical shape, regular margins, absence of extralesional hemorrhage, and absence of peripheral rim enhancement accurately identifies cavernoma-related acute spontaneous cerebral hematomas in young patients.

Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial

OBJECTIVE

The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries.

METHODS

Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2.

RESULTS

From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%).

CONCLUSIONS

Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

Intraoperative cerebral blood flow monitoring in neurosurgery: A review of contemporary technologies and emerging perspectives

Intraoperative monitoring of cerebral blood flow (CBF) has become an invaluable adjunct to vascular and oncological neurosurgery, reducing the risk of postoperative morbidity and mortality. Several technologies have been developed during the last two decades, including laser-based techniques, videomicroscopy, intraoperative MRI, indocyanine green angiography, and thermography. Although these technologies have been thoroughly studied and clinically applied outside the operative room, current practice lacks an optimal technology that perfectly fits the workflow within the neurosurgical operative room. The different available technologies have specific strengths but suffer several drawbacks, mainly including limited spatial and/or temporal resolution. An optimal CBF monitoring technology should meet particular criteria for intraoperative use: excellent spatial and temporal resolution, integration in the operative workflow, real-time quantitative monitoring, ease of use, and non-contact technique. We here review the main contemporary technologies for intraoperative CBF monitoring and their current and potential future applications in neurosurgery.

Petroclival meningiomas: update of current treatment and consensus by the EANS skull base section

BACKGROUND

The optimal management of petroclival meningiomas (PCMs) continues to be debated along with several controversies that persist.

METHODS

A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the management of these tumors. To achieve this, the task force reviewed in detail the literature in this field and had formal discussions within the group.

RESULTS

The constituted task force dealt with the existing definitions and classifications, pre-operative radiological investigations, management of small and asymptomatic PCMs, radiosurgery, optimal surgical strategies, multimodal treatment, decision-making, and patient's counselling.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the management of PCMs.

OS5.4 Characteristics of adult diffuse H3K27M-mutant gliomas at recurrence

BACKGROUND

Adult diffuse H3K27M-mutant gliomas are rare and associated with a poor prognosis but could benefit in the next future from specific therapeutic strategies. In this context, the aim of the present study was to describe the characteristics of these tumors at recurrence.

MATERIAL AND METHODS

We retrospectively analyzed the characteristics of a series of 27 adult diffuse H3K27M-mutant gliomas at recurrence

RESULTS

Median age at diagnosis was 37 years. Initial treatment consisted of temozolomide radiochemotherapy (n=17, 62%), radiotherapy alone (n=1, 4%), chemotherapy alone (n=4, 15%), wait and see (n=1, 4%) and palliative care (n=4, 15%). Median PFS and median OS were 11 and 22 months in the whole series and 15 and 29 months in the patients who were treated with temozolomide radiochemotherapy. The pattern of recurrence could be analyzed in 19 patients. Ten patients (50%) demonstrated a local recurrence, five patients a local and distant recurrence (25%), two patients only a distant recurrence (10%) and two patients a leptomeningeal progression (10%). At recurrence, 15 patients received an oncological treatment that consisted of an alkylating chemotherapy (n=5), a bevacizumab based chemotherapy regimen (n=9) and of radiotherapy (n=1). Median PFS and OS after first recurrence in these patients were 6 and 14 months, respectively. An activating FGFR1 mutation was identified in 4 out of the 9 patients in whom it was assessed.

CONCLUSION

At recurrence, adult diffuse H3K27M-mutant gliomas are associated with a high rate of distant locations. A subset of patients harbor targetable FGFR1 activating mutations.

P14.13 Incidence of pseudoprogression in high-grade IDH-mutant gliomas

BACKGROUND

Pseudoprogression (PsP) is a well-known concern in IDH-wildtype glioblastomas. The aim of the present study was to describe its incidence in high-grade IDH-mutant gliomas.

MATERIAL AND METHODS

We retrospectively analyzed the characteristics of a consecutive series of high-grade IDH-mutant gliomas treated with radiotherapy (RT) with or without chemotherapy between March 2009 and September 2017. PsP was defined as a new enhanced lesion that occurred after RT and subsequently disappeared or remained stable during follow-up for a least 6 months.

RESULTS

The study population consisted of 38 anaplastic IDH-mutant and 1p/19q codeleted oligodendrogliomas, 34 IDH-mutant anaplastic astrocytomas and 18 IDH-mutant glioblastomas. Treatment consisted of radiotherapy alone (n=8, 9%), radiotherapy and PCV chemotherapy (n=63, 70%) and temozolomide radiochemotherapy (n=19, 21%). After a median follow-up of 3.5 years (range 1–8 years), 24 patients (28%) presented a PsP that occurred after a median delay of 10 months after radiotherapy (2 to 32 months). PsP was more frequent in patients treated with RT+PCV than in those treated with RT+TMZ (34% vs 10%, p=0.05). During the first two years after RT completion, 19 patients (21%) presented a PsP and 15 patients (17%) a true progression. At last follow-up, 1 patient (4%) in the PsP group had died compared to 10 patients (16%) in the group of patients without PsP.

CONCLUSION

PsP is a frequent issue in IDH-mutant high-grade gliomas. Its timing of onset is delayed compared to the timing of PsP onset reported in IDH-wildtype glioblastomas. The association between the use of PCV chemotherapy and PsP requires validation in an independent series.

OS8.4 Impact of brain invasion assessment on outcome in intracranial grade II meningiomas

BACKGROUND

Brain invasion has already been identified as an independent criterion of meningioma recurrence by Jääskaläinen’s in 1986. While it was only suggested that meningiomas harbouring brain invasion could be staged as grade II in the 2007 WHO Classification of Tumours of the Central Nervous System, brain invasion was clearly listed as a grade II atypical meningioma criterion for the first time in the 2016 version. Since 2007, brain invasion has been carefully screened during the histopathological characterisation of meningiomas in our centre thanks to specific training of the neuropathology department staff. Furthermore, neurosurgeons are asked to provide well-preserved and grossly orientable tumours borders whenever possible. The aim of the present study was to compare the characteristics of patients diagnosed with grade II meningiomas before and after this change of practices.

MATERIAL AND METHODS

We retrospectively reviewed the characteristics of 125 patients with grade II meningiomas diagnosed between 2011 and 2014 (group A) and compared them to those of 166 patients with grade II meningiomas diagnosed between 1998 and 2005 (group B).

RESULTS

Tumour location and socio-demographic parameters were comparable in group A and B with a median age of 62 years in both groups (p=0.18). There were more de novo meningiomas in group A (84% vs 68.7%, p=0.004). Brain invasion was found in 59% in group A and 9% in group B (p=0.00001) while median Ki67 labelling was of 8.4% in group A and 10.5% in group B (p=0.04). Consistently, tumour borders were irregular in 52% in group A and 29% in group B (p=0.0002). Progression free survival was similar in the two groups (65 vs 66 months, p=0.92) but grade progression was more frequently observed in group B (18.9% vs 0%, p=0.006). In group A, meningiomas that were classified as grade II exclusively based on brain infiltration (n=33, group A-bi) had a similar progression rate compared to meningiomas with other criteria of atypia (27% vs 25%, p=0.98) and a similar time to progression (32 vs 32 months, p=0.74). The median time to progression of group A-bi meningiomas was also comparable to that of the other 258 pooled meningiomas (32 vs 40 months, p=0.40).

CONCLUSION

In accordance with the 2016 WHO Classification of Tumours of the Central Nervous System, the outcome of meningiomas defined as atypical solely based on brain infiltration seems to be comparable to that of meningiomas with other criteria of atypia. Appropriate coordination between neurosurgeons and neuropathologists is mandatory to optimally assess this criterion.

Optimization of high-grade glioma resection using 5-ALA fluorescence-guided surgery: A literature review and practical recommendations from the neuro-oncology club of the French society of neurosurgery

BACKGROUND

When feasible, the surgical resection is the standard first step of the management of high-grade gliomas. 5-ALA fluorescence-guided-surgery (5-ALA-FGS) was developed to ease the intra-operative delineation of tumor borders in order to maximize the extent of resection.

METHODS

A Medline electronic database search was conducted. English language studies from January 1998 until July 2018 were included, following the PRISMA guidelines.

RESULTS

5-ALA can be considered as a specific tool for the detection of tumor remnant but has a weaker sensibility (level 2). 5-ALA-FGS is associated with a significant increase in the rate of gross total resection reaching more than 90% in some series (level 1). Consistently, 5-ALAFGS improves progression-free survival (level 1). However, the gain in overall survival is more debated. The use of 5-ALA-FGS in eloquent areas is feasible but requires simultaneous intraoperative electrophysiologic functional brain monitoring to precisely locate and preserve eloquent areas (level 2). 5-ALA is usable during the first resection of a glioma but also at recurrence (level 2). From a practical standpoint, 5-ALA is orally administered 3 hours before the induction of anesthesia, the recommended dose being 20 mg/kg. Intra-operatively, the procedure is performed as usually with a central debulking and a peripheral dissection during which the surgeon switches from white to blue light. Provided that some precautions are observed, the technique does not expose the patient to particular complications.

CONCLUSION

Although 5-ALA-FGS contributes to improve gliomas management, there are still some limitations. Future methods will be developed to improve the sensibility of 5-ALA-FGS.

DIABETES INSIPIDUS IN A PATIENT WITH BRONCHOGENIC CARCINOMA AND SECONDARIES TO THE HYPOTHALAMUS - CASE REPORT

We present a middle-aged man with features of diabetes insipidus, visual and mental impairments as a result of metastases from bronchogenic carcinoma. This case is being presented because it is uncommon; high index of suspicion and the relevant imaging techniques are required for diagnosis. Surgical resection of the pituitary secondaries with post-operative chemo-radiation brought resolution of symptoms.

CONCLUSION

In conclusion, hypothalamic metastases are uncommon and are often associated with compression of the pituitary gland and optic chiasma leading to diabetes insipidus, visual impairment and mental defects. MRI for diagnosis and surgical resection followed with chemoradiation lead to improvement of symptoms but mortality is high.

Headholders' - complications in neurosurgery: A review of the literature and recommendations for its use

Several types of headholders are routinely used in neurosurgical practice to secure the head in a precise position, providing better security during surgical dissection as well as an absence of eye compression during prone positions. Nevertheless, potentially lethal complications might occur. We performed a review of the literature via PubMed and Google Scholar using the terms "Mayfield skull clamp", "Sugita headholders", "headholder complications" and "skull clamp complications". Twenty-six complications directly related to the use of headholders were identified through 19 papers published from 1981 to 2014: mainly skull fractures with or without a dural laceration (50%), epidural hematomas (23.8%), skull fractures with or without a dural laceration (50%), and air embolism (9.5%). The authors propose recommendations for the safe use of headholders.

Primary pituitary lymphoma: an update of the literature

Primary intracranial lymphomas (Weller et al. in Neuro Oncol 14(12):1481-1484, 2012) are an emerging disease and an isolated localization in the pituitary gland i.e. primary pituitary lymphoma (PPL) represents a rare condition. We present an update of the most recent evidence for PPL through a systematic review of the literature. A systematic literature review was conducted using PubMed database up to October 2015. The population was defined as immunocompetent patients with a pathologically confirmed diagnosis of PPL. Patients' characteristics, clinical presentation, radiological features, pathology reports, adjuvant treatment and follow-up data were analyzed. We reported one case of PPL and included our data in this analysis. A total of 33 cases of PPL were identified, including ours. A slight not significant female prevalence was evident, with a mean age of 59 years at diagnosis. Visual troubles and headaches were the most common presenting symptoms. About 80 % of patients presented a cranial nerve (CN) deficit. The most frequently involved were the II and III CN. Anterior hypopituitarism was present in 70 % of cases and a diabetes insipidus in 36 % of cases. PPL was rarely limited to the sella and most often extended to the suprasellar and parasellar space. 70 % of cases underwent resection, 21 % a biopsy. A B-cell lymphoma was isolated in 82 % of cases, a T-cell lymphoma in 15 % and a NK/T cell lymphoma in one case. Overall mean survival rate was 14.4 months (95 % confidence interval 9.0-19.8 months) and there was no difference in terms of survival rates when patients were stratified according to the treatment they received. PPL is an emerging clinical entity. Literature data are too scarce to allow the definition of specific protocols of treatment and the management is based on the guidelines present for PCNSL. The role of surgery aiming at a complete resection of PPL should be reevaluated in wider studies including only this category of patients, to establish the real role of each therapeutic strategy.

The minimally invasive endoscopic management of septated chronic subdural hematomas: surgical technique

BACKGROUND

Fibrin membranes and compartmentalization within the subdural space are a frequent cause of failure in the treatment of chronic subdural hematomas (CSH). This specific subtype of CSH classically requires craniotomy, which carries significant morbidity and mortality rates, particularly in elderly patients. In this work, we describe a minimally invasive endoscopic alternative.

METHODS

Under local scalp anesthesia, a rigid endoscope is inserted through a parietal burr hole in the subdural space to collapse fibrin septa and cut the internal membrane. It also allows cauterization of active bleedings and the placement of a drain under direct visualization.

CONCLUSIONS

The endoscopic treatment of septated CSH represents a minimally invasive alternative to craniotomy especially for the internal membranectomy.

[Interest of optic nerve sheath diameter ultrasonography in dectecting non-invasively raised intracranial pressure]

Intracranial hypertension is an emergency suspected from clinical symptoms, imaging data and ophthalomologic signs. Intracranial hypertension is confirmed by invasive intracranial monitoring, which is the gold standard technique to measure intracranial pressure (ICP). Because of complications, hemorrhage or infection, non-invasive methods have been developed such as neuroimaging, transcranial Doppler sonography and optic nerve sheath diameter (ONSD) ultrasonography. We have reviewed ONSD technique that detects intracranial hypertension related volume variations of subarachnoid space along the retro bulbar segment of the optic nerve. Technique, indications and prospects are discussed.

[Shifting paradigm in skull base surgery: Roots, current state of the art and future trends of endonasal endoscopic approaches]

During the last two decades, endoscopic endonasal approach has completed the minimally invasive skull base surgery armamentarium. Endoscopic endonasal skull base surgery (EESBS) was initially developed in the field of pituitary adenomas, and gained an increasing place for the treatment of a wide variety of skull base pathologies, extending on the midline from crista galli process to the occipitocervical junction and laterally to the parasellar areas and petroclival apex. Until now, most studies are retrospective and lack sufficient methodological quality to confirm whether the endoscopic endonasal pituitary surgery has better results than the microsurgical trans-sphenoidal classical approach. The impressions of the expert teams show a trend toward better results for some pituitary adenomas with the endoscopic endonasal route, in terms of gross total resection rate and probably more comfortable postoperative course for the patient. Excepting intra- and suprasellar pituitary adenomas, EESBS seems useful for selected lesions extending onto the cavernous sinus and Meckel's cave but also for clival pathologies. Nevertheless, this infatuation toward endoscopic endonasal approaches has to be balanced with the critical issue of cerebrospinal fluid leaks, which constitutes actually the main limit of this approach. Through their experience and a review of the literature, the authors aim to present the state of the art of this approach as well as its limits.

[Surgical management of solitary eosinophilic granuloma of the calvaria. Two case reports]

Langerhans cell histiocytosis is a systemic disease resulting from the oligoclonal proliferation of Langerhans cells, occurring most commonly in children and young adults. The focal form of the disease, also known as eosinophilic granuloma, most frequently involves the calvaria. We present two cases of calvarial eosinophilic granulomas that were surgically removed. These tumors are reputed to have an excellent prognosis, even if local recurrences and systemic dissemination can occur during the follow-up. The authors discuss the pathogenesis and the evolutive profile but also the therapeutic management of solitary eosinophilic granuloma of the calvaria.

Calcified pilocytic astrocytoma of the medulla mimicking a brainstem "stone"

Brainstem gliomas are a heterogeneous group of tumours commonly found in children, comprising about 10% of central nervous system tumours in paediatric patients, but less than 2% in adults. Pilocytic astrocytomas usually involve the midbrain and the medulla, and their surgical resection, when feasible, is generally curative. Thin calcifications can be normally found within low grade gliomas, but densely calcified pilocytic astrocytomas of the brainstem have been only rarely reported. We present the case of a young man presenting with a large brainstem calcification involving the medulla, which was subtotally resected using a posterior suboccipital approach. The definitive pathological diagnosis was calcified pilocytic astrocytoma.

Hémangiopéricytome sellaire

Primary central nervous system hemangiopericytoma is rare, accounting for less than 1% of primary central nervous system tumors. Diagnosis is histological. Treatment is surgical excision, followed by radiotherapy. Long-term follow-up is mandatory for these tumors with a high potential for recurrence and metastasis. The sellar location is very rare, and can be confused with pituitary adenoma. We report the case of a patient presenting a sellar hemangiopericytoma, who underwent surgery via a transsphenoidal approach, then right frontal craniotomy followed by radiotherapy. There was no recurrence at one year follow-up.