The association of thromboembolic complications and the use of tranexamic acid during resection of intracranial meningiomas: systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Antifibrinolytics, such as tranexamic acid (TXA), have been shown to decrease intraoperative blood loss across multiple surgical disciplines. However, they carry the theoretical risk of thromboembolic events secondary to induced hypercoagulability. Therefore, the aim of this study was to systematically review the available literature and perform a meta-analysis on the use of TXA in meningioma resection to assess thromboembolic risks.

METHODS

The PubMed, Web of Science, and Google Scholar databases were reviewed for all randomized controlled trials presenting primary data on TXA use during resection of intracranial meningiomas. Data were gathered on operative duration, venous thromboembolic complications, deep venous thrombosis, use of allogeneic blood transfusion, estimated blood loss (EBL), and postoperative hemoglobin. Patients who received TXA were compared with controls who did not receive TXA intraoperatively using random-effects models.

RESULTS

A total of 508 unique articles were identified, of which 493 underwent full-text review. Ultimately, 6 studies with 381 total patients (190 receiving TXA) were included in the final analysis. All 6 trials were randomized, blinded, and placebo controlled with a TXA administration rate of a 20-mg/kg load followed by a 1-mg/kg/hr infusion. All studies were performed in lower-middle-income countries. There were no reported instances of venous thromboembolism (VTE) in the TXA and non-TXA cohorts. Patients receiving TXA exhibited fewer allogeneic transfusions (21.5% vs 41.6% [OR 0.26, 95% CI 0.09-0.77], p = 0.02) and lower EBL (MD -282.48 mL [95% CI -367.77 to -197.20 mL], p < 0.001) compared with patients who did not receive TXA, and they also had lower rates of perioperative complications (10.7% vs 19.9% [OR 0.47, 95% CI 0.2-0.95], p = 0.04).

CONCLUSIONS

Current literature suggests that TXA is not associated with increased risk for VTE when administered during resection of intracranial meningioma. TXA appears to decrease intraoperative blood loss and allogeneic transfusion requirements during meningioma resection and thus may improve the safety of surgical management of this pathology.

In vivo C6 glioma models: an update and a guide toward a more effective preclinical evaluation of potential anti-glioblastoma drugs

Glioblastoma multiform (GBM) is the most common primary brain tumor with a poor prognosis and few therapeutic choices. In vivo, tumor models are useful for enhancing knowledge of underlying GBM pathology and developing more effective therapies/agents at the preclinical level, as they recapitulate human brain tumors. The C6 glioma cell line has been one of the most widely used cell lines in neuro-oncology research as they produce tumors that share the most similarities with human GBM regarding genetic, invasion, and expansion profiles and characteristics. This review provides an overview of the distinctive features and the different animal models produced by the C6 cell line. We also highlight specific applications of various C6 in vivo models according to the purpose of the study and offer some technical notes for more convenient/repeatable modeling. This work also includes novel findings discovered in our laboratory, which would further enhance the feasibility of the model in preclinical GBM investigations.

Endoscopic transsphenoidal approach in resection of intracranial clivus chondrosarcoma: A case report

Intracranial primary chondrosarcomas are rare, accounting for <0.15% of all intracranial tumors, but exhibit a high risk of recurrence. Due to the rarity of this condition, it has proven difficult to establish efficacy-based treatment guidelines. The present study details a case of clivus chondrosarcoma exhibiting no recurrence following surgical resection using an endoscopic transsphenoidal approach and postoperative adjuvant radiotherapy. A 41-year-old female presented with primary symptoms of left eye esotropia, scotoma of the left nasal visual field and double vision. Preoperative cranial magnetic resonance imaging revealed a lesion on the clivus, which was initially diagnosed as chordoma. However, clivus chondrosarcoma was ultimately diagnosed based on intraoperative findings and postoperative histopathology. The tumor was totally resected and 25 doses of adjuvant radiotherapy with planning gross tumor volume (60 Gy) and planning clinical target volume (50 Gy) were administered for 5 weeks. The patient was discharged at 12 days post-surgery with no obvious postoperative complications. Over the 28-month follow-up period, there was no evidence of recurrence, which may be due to the successful use of combined gross total resection and adjuvant radiotherapy. Therefore, surgical resection using an endoscopic transsphenoidal approach and postoperative adjuvant radiotherapy is an effective method for treating intracranial clivus chondrosarcoma.

MRI Findings of Desmoplastic Infantile Ganglioglioma: A Case Report and Analysis

Desmoplastic infantile gangliogliomas (DIG) are rare intracranial tumors that predominantly affect children. They are characterized by a mixture of glial and neuronal components interspersed with abundant fibrous stroma and are typically located on the surface of the cerebral hemispheres. In this case report, we present a seven-year-old male child with a late presentation of DIG, which is typically diagnosed between zero and 60 months of age. We discuss the MRI findings, clinical symptoms, and differential diagnosis of DIG in patients with this central nervous system tumor.

Infantile (congenital) anaplastic intracranial solitary fibrous tumor/hemangiopericytoma-A case report with brief literature review

Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare primary central nervous system (CNS) tumor, included in the World Health Organization (WHO) 2016 classification. Very few cases have been described in the literature so far, especially the infantile type. It is a mesenchymal tumor of the fibroblastic type, characterized by the fusion of NAB 2 and STAT 6 genes. A 10-month-old boy presented to our neurosurgery department with complaints of increasing head circumference since 1 month of age. The magnetic resonance imaging (MRI) showed a space-occupying lesion measuring 8.2 cm × 7 cm × 6.9 cm in the fronto-temporo-parietal region with a clinical diagnosis of glioma/atypical teratoid rhabdoid tumor (ATRT). The microscopy revealed a spindle cell tumor arranged in a patternless pattern with variable cellularity, increased mitosis, and areas of coagulative necrosis. The immunohistochemistry showed vimentin, CD 34, STAT6, CD99 positivity whereas Glial fibrillary acidic protein, Epithelial membrane antigen, and S-100 negativity. Hence, a diagnosis of anaplastic SFT/HPC (grade-III) was rendered. The patient improved after gross total resection (GTR). The primary intracranial congenital SFT/HPC are extremely rare, often a clinico-radiologically misdiagnosed entity. Thus, the immunohistochemistry/molecular study in addition to histology is mandatory for accurate diagnosis.

Risk factors of intraoperative blood transfusion in pediatric craniotomy for intracranial tumor resection: a 10-year analysis

OBJECTIVE

A pediatric craniotomy for intracranial tumor removal brings both high bleeding and blood transfusion risks. The aim of this study was to identify the risk factors for intraoperative blood transfusion in this procedure. The secondary outcome was to investigate postoperative complications and clinical outcomes related to blood transfusion.

METHODS

A retrospective analysis was performed among children who underwent a craniotomy for brain tumor resection at a tertiary hospital over a 10-year period. The pre- and intraoperative variables were examined and compared between the transfusion and nontransfusion groups.

RESULTS

One hundred seventy-two patients (58%) received intraoperative blood transfusions among a total of 295 craniotomies in 284 children. Factors associated with blood transfusion were body weight ≤ 20 kg (adjusted odds ratio [AOR] 5.286, 95% confidence interval [CI] 2.892-9.661; p < 0.001), American Society of Anesthesiologists (ASA) physical status III-IV (AOR 6.860, 95% CI 1.434-32.811; p = 0.016), preoperative hemoglobin ≤ 11 g/dl (AOR 3.610, 95% CI 1.406-9.265; p = 0.008), tumor size ≥ 45 mm (AOR 2.117, 95% CI 1.214-3.693; p = 0.008), and duration of operation ≥ 6 hours (AOR 3.816, 95% CI 1.736-8.385; p = 0.001). Postoperative infection of other systems, other complications, duration of mechanical ventilation, and intensive care unit and hospital length of stay were found to be significantly higher in the transfusion group.

CONCLUSIONS

Lower body weight, higher ASA physical status, preoperative anemia, large tumor size, and prolonged duration of surgery were found to be significant factors for predicting intraoperative blood transfusion in pediatric craniotomy. The identification and modification of risks from intraoperative blood transfusion can be beneficial in reducing the probability of transfusion and improving allocation efficiency of limited blood component resources.

Intraparenchymal cerebellar capillary hemangioma in a 32-year-old man: a case report

The authors present an unusual case of a 32-year-old adult male with a capillary hemangioma, which developed within the left cerebellar parenchyma. The histopathological examination reveals a mass mostly formed by the proliferation of capillaries, lined by a layer of flat-plump endothelial cells, some branching and dilating large capillaries, forming a lobulated structure separated by fibrocollagenous connective tissue. Immunohistochemistry examination with CD31 and S100 was positive on the endothelial and stromal cells, respectively, and negative S100 on the endothelial cells. Although rare, capillary hemangioma should be one of the differential diagnoses for diagnosing intra-axial lesions in the cerebellar region. Confirmation of the histopathological characteristic is necessary to determine the diagnosis of capillary hemangioma and exclude other differential diagnoses.

Comparison of supratentorial meningioma resection outcomes by dural reconstruction technique

OBJECTIVE

Excision of intracranial meningiomas often requires resection or coagulation of the dura mater. The choice of dural closure technique is individualized and based on surgeon preference. The objective of this study was to determine outcomes following various dural closure techniques for supratentorial meningiomas.

METHODS

A retrospective, single-center cohort study was performed for patients who underwent excision of supratentorial meningiomas from 2000 to 2019. Outcomes including operative time, postoperative in-hospital complications, readmission, causes of readmission including surgical site infection, pseudomeningocele, need for shunt surgery, and imaging appearance of pseudomeningocele on long-term follow-up imaging were compared. Univariate and multivariable analyses were conducted.

RESULTS

A total of 353 patients who had complete clinical and operative data available for review were included. Of these patients, 227 (64.3%) had nonsutured dural graft reconstruction and 126 (35.7%) had sutured dural repair, including primary closure, artificial dura, or pericranial graft. There was significant variability in using nonsutured dural reconstruction compared with sutured dural repair technique among surgeons (p < 0.001). Tumors with sagittal sinus involvement were more likely to undergo nonsutured closure (n = 79, 34.8%) than dural repair (n = 26, 20.6%) (p = 0.003). There were no other differences in preoperative imaging findings or WHO grade. Frequency of surgical site infection and pseudomeningocele, need for shunt surgery, and recurrence were similar between those undergoing nonsutured and those undergoing sutured dural repair. The mean operative time for the study cohort was 234.9 (SD 106.6) minutes. The nonsutured dural reconstruction group had a significantly shorter mean operative time (223.9 [SD 99.7] minutes) than the sutured dural repair group (254.5 [SD 115.8] minutes) (p = 0.015). In a multivariable linear regression analysis, after controlling for tumor size and sinus involvement, nonsutured dural graft reconstruction was associated with a 36.8-minute reduction (95% CI -60.3 to -13.2 minutes; p = 0.002) in operative time.

CONCLUSIONS

Dural reconstruction using a nonsutured graft and sutured dural repair exhibit similar postoperative outcomes for patients undergoing resection for supratentorial meningiomas. Although sutured grafts may sometimes be necessary, nonsutured graft reconstruction for most supratentorial meningioma resections may suffice. The decreased operative time associated with nonsutured grafts may ultimately result in cost savings. These findings should be taken into consideration when selecting a dural reconstruction technique for supratentorial meningioma.

Liver Metastasis From Intracranial Hemangiopericytoma 8 Years After Initial Resection: Case Report

Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare intracranial tumor that arises from pericytes surrounding the blood vessels. Solitary fibrous tumor/hemangiopericytoma accounts for less than 1% of primary brain tumors and is classified as grades I, II, or III based on mitotic count. These tumors often masquerade as meningiomas. Histologically, SFT/HPC is vascular with high cellularity and often surrounded by connective tissue. Immunohistochemistry is positive for stat 6, vimentin, and CD34. Although aggressive surgical resection is the mainstay of treatment, close long-term follow-up is necessary as recurrence or extra cranial metastasis can present several years after resection.

Malignant transformation of a cerebral dermoid cyst into a squamous cell carcinoma with malignant intraperitoneal spreading along a ventriculoperitoneal shunt: illustrative case

BACKGROUND

Malignant progression of intracranial dermoid cysts into squamous cell carcinoma is extremely rare with only three reports published so far. Intracranial dermoid cysts are uncommon benign tumors lined by stratified squamous epithelium of embryonic ectodermal origin.

OBSERVATIONS

Here, the authors present the case of a 64-year-old female with a recurrent temporal dermoid cyst. After surgery for the recurrent dermoid cyst, once in the early 1990s and another 16 years later, the patient presented with headache and nausea due to hydrocephalus. After implantation of a ventriculoperitoneal shunt, she deteriorated rapidly and died only 60 days after admission. Autopsy revealed malignant transformation of the epithelial lining of the dermoid cyst into a squamous cell carcinoma resulting in neoplastic meningiosis and intraperitoneal tumor spread along a previously implanted ventriculoperitoneal shunt.

LESSONS

Malignant transformation should be considered in patients with dermoid cyst who show new leptomeningeal contrast enhancement. In the case of hydrocephalus, alternatives to peritoneal shunting should be considered.

Perioperative Hypercoagulability in Free Flap Reconstructions Performed for Intracranial Tumors

OBJECTIVE(S)

Patients with intracranial tumors have a higher risk of thromboembolic events. This risk increases at the time of surgical intervention. We have noted an anecdotal increase in perioperative flap thrombosis in patients undergoing free tissue transfer for intracranial tumor resection. This study aims to formally evaluate this risk.

METHODS

A multi-institutional retrospective chart review was performed of patients who underwent free tissue transfer for scalp/cranial reconstruction. Perioperative thrombosis and free flap outcomes were evaluated.

RESULTS

The 209 patients who underwent 246 free tissue transfers were included in the study. The 28 free flap scalp reconstructions were associated with intracranial tumors, 19 were performed following composite cranial resections with associated dural resection/reconstruction, and 199 were performed in the absence of intracranial tumors (control group). There was a significantly higher incidence of perioperative flap thrombosis in the intracranial tumor group (11/28, 39%) when compared to controls (38/199, 19%) (p = 0.0287). This was not seen when scalp tumors extended to the dura alone (4/19, 21%, p = 0.83). Therapeutic anticoagulation used for perioperative thrombosis (defined as intraoperative or in the immediate postoperative phase up to 5 days) was associated with a lower risk of flap failure, although this was not statistically significant (p = 0.148). Flap survival rates were equivalent between flaps performed for intracranial pathology (93.3%) and controls (95%).

CONCLUSION

There is an increase in perioperative flap thrombosis in patients with intracranial tumors undergoing free tissue scalp reconstruction. Anticoagulation appears to mitigate this risk.

LEVEL OF EVIDENCE

This recommendation is based on level 3 evidence (retrospective case-control studies, systematic review of retrospective studies, and case reports) Laryngoscope, 2022.

Intracranial tumors mimicking benign paroxysmal positional vertigo: A case series

Background

A few intracranial lesions may present only with positional vertigo which are very easy to misdiagnose as benign paroxysmal positional vertigo (BPPV); the clinicians should pay more attention to this disease.

Objectives

To analyze the clinical characteristics of 6 patients with intracranial tumors who only presented with positional vertigo to avoid misdiagnosing the disease.

Material and methods

Six patients with intracranial tumors who only presented with positional vertigo treated in our clinic between May 2015 to May 2019 were reviewed, and the clinical symptoms, features of nystagmus, imaging presentation, and final diagnosis of the patients were evaluated.

Results

All patients presented with positional vertigo and positional nystagmus induced by the changes in head position or posture, including one case with downbeating nystagmus in a positional test, two cases with left-beating nystagmus, one case with apogeotropic nystagmus in a roll test, one case with right-beating nystagmus, and one case with left-beating and upbeating nystagmus. Brain MRI showed the regions of the tumors were in the vermis of the cerebellum, the fourth ventricle, the lateral ventricle, and the cerebellar hemisphere.

Expression of L-type amino acid transporter 1 in canine and feline intracranial tumors

L-type amino acid transporter 1 (LAT1) is upregulated in various malignant tumors in humans. LAT1 expression correlates with the grade of cancer and prognosis. LAT1 is responsible for the supply of many essential amino acids to cancer cells. Inhibition of LAT1 reduces the amino acids that enter the cell and inhibits cancer cell growth. Therefore, novel anticancer drugs targeting LAT1 have attracted much attention in recent years. In this study, to explore the applicability of using LAT1 expression in intracranial tumors as a prognostic factor and therapeutic target, we investigated the expression of LAT1 in surgically resected primary and secondary intracranial tumor tissues from dogs and cats. Immunohistochemical analysis of LAT1 was performed on intracranial tumor tissue from 14 dogs and 3 cats. Primary intracranial tumors were seen in 10 dogs and included meningiomas, histiocytic sarcomas, pituitary tumors, and gliomas, and 9 out of 10 cases were positive for LAT1. Primary intracranial tumors were seen in 2 cats and included meningioma and lymphoma; both cases were positive for LAT1. Secondary intracranial tumors were positive for LAT1 in 3 out of 4 cases in dogs and 1 out of 1 in cats. Since the majority of intracranial tumors in dogs and cats were positive for LAT1, immunostaining for LAT1 is expected to be a prognostic indicator and therapeutic target in the future.

Pontine Myopericytoma: Case Report and Literature Review

Myopericytoma (MPC) is a benign soft tissue tumor that develops from perivascular myoid cells and is part of the perivascular tumor group. MPC most commonly occurs in the subcutaneous soft tissues of the extremities, while intracranial MPC is remarkably rare. Herein, we report the case of a 45-year-old woman with myopericytoma who had a 2-week history of recurrent dizziness. Magnetic resonance imaging (MRI) revealed an irregular mass in the pons, with nodular enhancement of the mass on contrast-enhanced scans. The mass was considered a vascular lesion and was highly suspected to be a hemangioblastoma, prompting surgical intervention for the patient. The postoperative pathological report corrected the initial diagnosis, hemangioblastoma, to MPC. Intracranial MPC is extremely rare and there are no detailed imaging sources for this condition; furthermore, MPC occurrence in the pons has not been reported previously. This report presents the etiological characteristics intracranial MPC as visualized through MRI data alongside a comparative discussion on other reported diagnoses that resemble MPC. The case findings will provide a more widespread understanding for radiologists regarding the differential diagnosis of intracranial blood-rich supply lesions.

Management of Childhood-onset Craniopharyngioma in Italy: A Multicenter, 7-Year Follow-up Study of 145 Patients

CONTEXT

Nationwide data on children diagnosed with craniopharyngioma (CP) are not available in Italy.

OBJECTIVE

This work aimed to identify patients' characteristics, type of surgical approach, complications and recurrences, number of pituitary deficits, and number of patients starting growth hormone (GH) treatment.

METHODS

A retrospective multicenter collection took place of 145 patients aged 0 to 18 years who underwent surgery for CP between 2000 and 2018, and followed up in 17 Italian centers of pediatric endocrinology.

RESULTS

Age at diagnosis was 8.4 ± 4.1 years. Duration of symptoms was 10.8 ± 12.5 months and headache was most frequent (54%), followed by impaired growth (48%) and visual disturbances (44%). Most lesions were suprasellar (85%), and histology was adamantinomatous in all cases but two. Surgical approach was transcranial (TC) in 67.5% of cases and transsphenoidal (TS) in 31.%. The TC approach was prevalent in all age groups. Postsurgery complications occurred in 53% of cases, with water-electrolyte disturbances most frequent. Radiotherapy was used in 39% of cases. All patients but one presented with at least one hormone pituitary deficiency, with thyrotropin deficiency most frequent (98.3%), followed by adrenocorticotropin (96.8%), arginine vasopressin (91.1%), and GH (77.4%). Body mass index (BMI) significantly increased over time. A hypothalamic disturbance was present in 55% of cases. GH therapy was started during follow-up in 112 patients at a mean age of 10.6 years, and 54 developed a recurrence or regrowth of the residual lesion.

CONCLUSION

CP is often diagnosed late in Italy, with TC more frequent than the TS surgical approach. Postsurgery complications were not rare, and hypopituitarism developed almost in all cases. BMI shows a tendency to increase overtime.

The different structure-function correlation as measured by OCT and octopus perimetry cluster analysis in intracranial tumor and glaucoma patients

BACKGROUND

To explore the correlation between visual field (VF) defect values and retinal nerve fiber layer (RNFL) thickness for intracranial tumor and glaucoma patients.

METHODS

Retrospective analysis is performed for the intracranial and glaucoma patients, whose VF defect values were measured with Octopus perimeter cluster analysis, RNFL thickness, ganglion cell layer (GCL) thickness, and optic disk parameters measured with swept-source OCT. The differences between VF and RNFL (including the data of optic disc) are calculated. The correlation between VF defect values and RNFL and GCL thickness are explored.

RESULTS

In total 43 eyes of 29 patients with intracranial tumor and 31 eyes of 19 patients with glaucoma were enrolled. The thickness of RNFL not only for the whole (360°), but also for the four quadrants was thinner in the glaucoma group than those of the intracranial tumor group (p<0.05), and similar to the thickness of GCL without significance (p>). There is no significant difference in VF for those two groups except glaucoma having lower sLV (p<0.05). A stronger correlation for mean deviations (MD)s of VF ten clusters and RNFL thickness of OCT twelve sectors is found in the glaucoma patients, but few in the intracranial tumor patients. Logistic regression also shows the loss of RNFL or increasing of vertical CDR and cup volume tending to the diagnosis of glaucoma and the irregular VF damage is inclined to the diagnosis of intracranial tumor.

CONCLUSIONS

Intracranial tumor has a weak correlation between the RNFL thickness and Octopus VF MD, compared with that of glaucoma. OCT and Octopus VF might provide more helpful information for the differential diagnosis of intracranial tumor and glaucoma.

Glycation Interferes with the Expression of Sialyltransferases in Meningiomas

Meningiomas are the most common non-malignant intracranial tumors and prefer, like most tumors, anaerobic glycolysis for energy production (Warburg effect). This anaerobic glycolysis leads to an increased synthesis of the metabolite methylglyoxal (MGO) or glyoxal (GO), which is known to react with amino groups of proteins. This reaction is called glycation, thereby building advanced glycation end products (AGEs). In this study, we investigated the influence of glycation on sialylation in two meningioma cell lines, representing the WHO grade I (BEN-MEN-1) and the WHO grade III (IOMM-Lee). In the benign meningioma cell line, glycation led to differences in expression of sialyltransferases (ST3GAL1/2/3/5/6, ST6GAL1/2, ST6GALNAC2/6, and ST8SIA1/2), which are known to play a role in tumor progression. We could show that glycation of BEN-MEN-1 cells led to decreased expression of ST3Gal5. This resulted in decreased synthesis of the ganglioside GM3, the product of ST3Gal5. In the malignant meningioma cell line, we observed changes in expression of sialyltransferases (ST3GAL1/2/3, ST6GALNAC5, and ST8SIA1) after glycation, which correlates with less aggressive behavior.

Receptor Tyrosine Kinases as Candidate Prognostic Biomarkers and Therapeutic Targets in Meningioma

Meningioma (MGM) is the most common type of intracranial tumor in adults. The validation of novel prognostic biomarkers to better inform tumor stratification and clinical prognosis is urgently needed. Many molecular and cellular alterations have been described in MGM tumors over the past few years, providing a rational basis for the identification of biomarkers and therapeutic targets. The role of receptor tyrosine kinases (RTKs) as oncogenes, including those of the ErbB family of receptors, has been well established in several cancer types. Here, we review histological, molecular, and clinical evidence suggesting that RTKs, including the epidermal growth factor receptor (EGFR, ErbB1), as well as other members of the ErbB family, may be useful as biomarkers and therapeutic targets in MGM.

The Role of Mfsd2a in Nervous System Diseases

Major facilitator superfamily (MFS) is the maximum and most diversified membrane transporter, acting as uniporters, symporters and antiporters. MFS is considered to have a good development potential in the transport of drugs for the treatment of brain diseases. The major facilitator superfamily domain containing protein 2a (Mfsd2a) is a member of MFS. Mfsd2a-knockout mice have shown a marked decrease of docosahexaenoic acid (DHA) level in brain, exhibiting neuron loss, microcephaly and cognitive deficits, as DHA acts essentially in brain growth and integrity. Mfsd2a has attracted more and more attention in the study of nervous system diseases because of its critical role in maintaining the integrity of the blood-brain barrier (BBB) and transporting DHA, including inhibiting cell transport in central nervous system endothelial cells, alleviating BBB injury, avoiding BBB injury in cerebral hemorrhage model, acting as a carrier etc. Up to now, the clinical research of Mfsd2a in nervous system diseases is rare. This article reviewed the current research progress of Mfsd2a in nervous system diseases. It summarized the physiological functions of Mfsd2a in the occurrence and development of intracranial hemorrhage (ICH), Alzheimer's disease (AD), sepsis-associated encephalopathy (SAE), autosomal recessive primary microcephaly (MCPH) and intracranial tumor, aiming to provide ideas for the basic research and clinical application of Mfsd2a.

Epidemiologic Study of Primary Brain Tumors in Miyazaki Prefecture: A Regional 10-year Survey in Southern Japan

The increased use of neuroimaging and the aging of society have changed the incidence and proportion of histological types of intracranial tumors in Japan. A population-based epidemiological survey has been reported only from Kumamoto Prefecture. We performed a 10-year survey in Miyazaki Prefecture to compare our findings with the incidence rate (IR) of primary intracranial tumors (PIT) reported in the Kumamoto survey. Our study included 1915 new cases of PIT diagnosed in Miyazaki Prefecture between 2007 and 2016. The crude IR was 16.97/100000/year. The most common tumor was meningioma (46.3%), followed by glioma (17.1%), pituitary adenoma (13.1%), schwannoma (8.2%), and malignant lymphoma (3.8%). The age-specific IR of all PITs and of meningiomas, gliomas, pituitary adenomas, schwannomas, lymphomas, and germ cell tumors was similar in both prefectures. To directly compare with the age-adjusted IRs reported in the Kumamoto survey, we calculated the IR for the two prefectures. The age-adjusted IR of primary brain tumors in Miyazaki Prefecture was 14.65/100000/year, which was slightly higher than in the Kumamoto survey (14.09/100000/year between 1989 and 2008). The age-adjusted IR of glioma, schwannoma, and malignant lymphoma showed only a small difference between Miyazaki and Kumamoto. However, the age-adjusted IR of meningiomas was higher in Miyazaki than Kumamoto (6.15- vs. 4.97/100000/year), but the IR of pituitary adenoma was higher in Kumamoto than Miyazaki (2.66- vs. 2.13/100000/year). Although there were some differences between the two surveys, the IR of PIT showed a similar pattern in Kumamoto and Miyazaki, which are neighboring districts on Kyushu Island.

Predictors of Survival in Atypical Meningiomas

Simple Summary

Meningiomas are the most common intracranial tumor [1] and are classified by the World Health Organization (WHO) as grade I (benign), grade II (atypical), or grade III (anaplastic) [2]. Regarding atypical meningiomas, predictors of overall survival (OS) and progression-free survival (PFS) are less well documented compared to their benign counterparts. Moreover, one of the most critical aspects of meningiomas is tumor relapse/progression that may also take place after the complete removal of the lesion. Recurrent lesions pose the question whether it is reasonable to perform second surgery. Alternative approaches include radiotherapy (RT) (stereotactic radiosurgery or conventional fractionated RT). We investigated 77 consecutive patients who underwent craniotomy for intracranial atypical meningiomas to evaluate predictors of OS and retreatment-free survival, and to assess the benefits of surgical retreatment for subsequent recurrences. We concluded that gross total resection (GTR) significantly prolonged retreatment-free survival but had no significant impact on OS. GTR was also associated with improved/stable neurological outcomes at 6–12 months. Age at surgery, preoperative Karnofsky performance scale (KPS), and retreatment were all strong prognostic factors of OS. Time-to-retreatment did not decrease significantly in patients requiring repeated surgical excision.

Abstract

Introduction: Predictors of survival and progression of disease in atypical meningiomas are less well documented in the literature compared to benign meningiomas. Higher grade meningiomas tend to recur often and one of the most critical aspects is how to best deal with relapses. Methods: A total of 77 consecutive patients who underwent craniotomy for atypical meningioma between 1990–2010 at Oslo University Hospital (OUH) were reviewed. Results: Median age at surgery was 62.21 [interquartile range (IQR): 22.87] years. Fifty-one patients (66.2%) had neurological deficits at presentation. Fifty-four patients (70.1%) underwent gross total resection (GTR). Thirty-nine patients (50.7%) had improved/stable neurological outcomes at 6–12 months. Twenty-two patients (28.6%) underwent retreatment, of whom 20 (26.0%) were subjected to resection followed by adjuvant radiotherapy. Overall survival (OS) was significantly longer in patients <65 years (p < 0.001), with preoperative Karnofsky performance scale (KPS) score of ≥ 70 (p = 0.006), and who required no retreatment (p = 0.033). GTR significantly prolonged the retreatment-free survival rate (p < 0.001). STR carried almost a six-fold greater risk of neurological outcome deterioration (p = 0.044). Conclusions: GTR significantly prolonged retreatment-free survival but had no significant impact on OS. STR was a significant risk factor for deteriorated neurological outcome. Age, preoperative KPS, and retreatment were all strong predictors of OS. Median time-to-retreatment (TTR) did not shorten significantly throughout repeated surgeries.

Predictors of Survival in Subtotally Resected WHO Grade I Skull Base Meningiomas

BACKGROUND

Although gross total resection (GTR) is the goal in meningioma surgery, this can sometimes be difficult to achieve in skull base meningiomas. We analyzed clinical outcomes and predictors of survival for subtotally resected benign meningiomas.

METHODS

A total of 212 consecutive patients who underwent subtotal resection (STR) for benign skull base meningioma between 1990-2010 were investigated.

RESULTS

Median age was 57.7 [IQR 18.8] years, median preoperative Karnofsky performance status (KPS) was 80.0 [IQR 20.0], 75 patients (35.4%) had posterior fossa meningioma. After a median follow-up of 6.2 [IQR 7.9] years, retreatment (either radiotherapy or repeated surgery) rate was 16% at 1-year, 27% at 3-years, 34% at 5-years, and 38% at 10-years. Ten patients (4.7%) died perioperatively, 9 (3.5%) had postoperative hematomas, and 2 (0.8%) had postoperative infections. Neurological outcome at final visit was improved/stable in 122 patients (70%). Multivariable analysis identified advanced age and preoperative KPS < 70 as negative predictors for overall survival (OS). Patients who underwent retreatment had no significant reduction of OS.

CONCLUSIONS

Advanced age and preoperative KPS were independent predictors of OS. Retreatments did not prolong nor shorten the OS. Clinical outcomes in STR skull base meningiomas were generally worse compared to cohorts with high rates of GTR.

Glycation of benign meningioma cells leads to increased invasion

Meningiomas are the most common non-malignant intracranial tumors. Like most tumors, meningiomas prefer anaerobic glycolysis for energy production (Warburg effect). This leads to an increased synthesis of the metabolite methylglyoxal (MGO). This metabolite is known to react with amino groups of proteins. This reaction is called glycation, thereby building advanced glycation endproducts (AGEs). In this study, we investigated the influence of glycation on two meningioma cell lines, representing the WHO grade I (BEN-MEN-1) and the WHO grade III (IOMM-Lee). Increasing MGO concentrations led to the formation of AGEs and decreased growth in both cell lines. When analyzing the influence of glycation on adhesion, chemotaxis and invasion, we could show that the glycation of meningioma cells resulted in increased invasive potential of the benign meningioma cell line, whereas the invasive potential of the malignant cell line was reduced. In addition, glycation increased the E-cadherin- and decreased the N-cadherin-expression in BEN-MEN-1 cells, but did not affect the cadherin-expression in IOMM-Lee cells.

Presenting Psychiatric and Neurological Symptoms and Signs of Brain Tumors before Diagnosis: A Systematic Review

Brain tumors can present with various psychiatric symptoms, with or without neurological symptoms, an aspect that complicates the clinical picture. However, no systematic description of symptoms that should prompt a neurological investigation has been provided. This review aims to summarize available case reports describing patients with brain tumors showing psychiatric symptoms before brain tumor diagnosis, in order to provide a comprehensive description of these symptoms as well as their potential relationship with delay in the diagnosis. A systematic literature review on case reports of brain tumors and psychiatric symptoms from 1970 to 2020 was conducted on PubMed, Ovid, Psych Info, and MEDLINE. Exclusion criteria comprised tumors not included in the World Health Organization (WHO) Classification 4th edition and cases in which psychiatric symptoms were absent or followed the diagnosis. A total of 165 case reports were analyzed. In a subset of patients with brain tumors, psychiatric symptoms can be the only manifestation or precede focal neurological signs by months or even years. The appearance of focal or generalized neurological symptoms after, rather than along with, psychiatric symptoms was associated with a significant delay in the diagnosis in adults. A timely assessment of psychiatric symptoms might help to improve early diagnosis of brain tumors.

Secondary stabbing headache associated with intracranial tumors, aneurysms, and arteriovenous malformation: An alarming warning sign

BACKGROUND

Stabbing headache (SH) is considered as a pure primary headache, but according to a few clinical observations it could also be secondary. Over the past decades, we have been observing the complaint of SH in patients with intracranial vascular and neoplastic lesions.

OBJECTIVE

To describe a series of patients with intracranial lesions who experienced SH.

METHODS

This is a cross-sectional, retrospective study of 34 patients with intracranial lesions associated with SH, admitted at Hospital das Clínicas, Federal University of Pernambuco, Brazil.

RESULTS

In this series of 34 patients [29 women, 44 ± 12 years (mean ± SD)] with secondary SH, the causes were intracranial neoplasms (n = 31), cerebral aneurysms (n = 2), or arteriovenous malformation (n = 1). Pituitary tumor (n = 18), meningioma (n = 6), and vestibular schwannomas (n = 4) were the most prevalent types of intracranial neoplasms. All these lesions had intimate contact with the dura mater, including an oligodendroglioma, the only intra-axial tumor in the series. A characteristic in the secondary SH is the crescendo pattern (12/34, 35%), progressing from infrequent attacks to recurrent crises occurring several times a day. The SH lasted from 5 days to 60 months (15 ± 18 months, mean ± SD) until the correct diagnosis [16/34 (47%) of the patients ≤6 months]. The SH was triggered by the movement of the head (5/34, 15%) or Valsalva maneuver (1/34). After surgery, suppression of the SH was observed. In a few of the patients to whom dexamethasone was prescribed, the SH subsided within a few days.

CONCLUSION

This study was able to identify clinical red flags associated with intracranial lesions and secondary SH, for example, recent onset of SH, exclusively unilateral (ipsilateral) at the same location, crescendo pattern, triggered by head movements, or Valsalva maneuver.

CovidNeuroOnc: A UK multicenter, prospective cohort study of the impact of the COVID-19 pandemic on the neuro-oncology service

BACKGROUND

The COVID-19 pandemic has profoundly affected cancer services. Our objective was to determine the effect of the COVID-19 pandemic on decision making and the resulting outcomes for patients with newly diagnosed or recurrent intracranial tumors.

METHODS

We performed a multicenter prospective study of all adult patients discussed in weekly neuro-oncology and skull base multidisciplinary team meetings who had a newly diagnosed or recurrent intracranial (excluding pituitary) tumor between 01 April and 31 May 2020. All patients had at least 30-day follow-up data. Descriptive statistical reporting was used.

RESULTS

There were 1357 referrals for newly diagnosed or recurrent intracranial tumors across 15 neuro-oncology centers. Of centers with all intracranial tumors, a change in initial management was reported in 8.6% of cases (n = 104/1210). Decisions to change the management plan reduced over time from a peak of 19% referrals at the start of the study to 0% by the end of the study period. Changes in management were reported in 16% (n = 75/466) of cases previously recommended for surgery and 28% of cases previously recommended for chemotherapy (n = 20/72). The reported SARS-CoV-2 infection rate was similar in surgical and non-surgical patients (2.6% vs. 2.4%, P > .9).

CONCLUSIONS

Disruption to neuro-oncology services in the UK caused by the COVID-19 pandemic was most marked in the first month, affecting all diagnoses. Patients considered for chemotherapy were most affected. In those recommended surgical treatment this was successfully completed. Longer-term outcome data will evaluate oncological treatments received by these patients and overall survival.

Predictive diagnostic and/or prognostic biomarkers obtained from routine blood biochemistry in patients with solitary intracranial tumor

Background

Radiological and/or laboratory tests may be sometimes inadequate distinguishing glioblastoma from metastatic brain tumors. The aim of this study was to find possible predictive biomarkers produced from routine blood biochemistry analysis results evaluated preoperatively in each patient with solitary brain tumor in distinguishing glioblastoma from metastatic brain tumors as well as revealing short-term prognosis.

Methods

Patients admitted to neurosurgery clinic between January 2015 and September 2018 were included in this study and they were divided into GLIOMA (n=12) and METASTASIS (n=17) groups. Patients' data consisted of age, gender, Glasgow Coma Scale scores, duration of stay in hospital, Glasgow Outcome Scale (GOS) scores and histopathological examination reports, hemoglobin level, leukocyte, neutrophil, lymphocyte, monocyte, eosinophil, basophil and platelet count results, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio values, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were evaluated preoperatively.

Results

The CRP levels of METASTASIS group (143.10 mg/L) were higher than those of GLIOMA group (23.90 mg/L); and it was 82% sensitive and 75% specific in distinguishing metastatic brain tumor from glioblastoma if CRP value was >55.00 mg/L. A positive correlation was determined between GOS score and hemoglobin level and between ESR and CRP values. However, GOS scores were negatively correlated with the ESR level and duration of stay in hospital.

Conclusions

Study results demonstrated that CRP values could be predictive biomarker in distinguishing metastatic brain tumor from glioblastoma. In addition, ESR, CRP, hemoglobin levels and duration of stay in hospital could be prognostic biomarkers in predicting short-term prognosis of patients with solitary brain tumor.

Pleiotropic Role of Tenascin-C in Central Nervous System Diseases: From Basic to Clinical Applications

The extracellular matrix is composed of a variety of macromolecular substances secreted by cells, which form a complex network that supports and connects tissue structures, regulates the morphogenesis of tissues, and maintains the physiological activities of cells. Tenascin-C, a secreted extracellular matrix glycoprotein, is abundantly expressed after exposure to pathological stimuli. It plays an important regulatory role in brain tumors, vascular diseases, and neurodegenerative diseases by mediating inflammatory responses, inducing brain damage, and promoting cell proliferation, migration, and angiogenesis through multiple signaling pathways. Therefore, tenascin-C may become a potential therapeutic target for intracranial diseases. Here, we review and discuss the latest literature regarding tenascin-C, and we comprehensively explain the role and clinical significance of tenascin-C in intracranial diseases.

Intracranial Tumors: A Nurse-Led Intervention for Educating and Supporting Patients and Their Caregivers

BACKGROUND

Behavioral symptoms among postoperative patients with intracranial tumors and distress among caregivers are common.

OBJECTIVES

This article aimed to assess the effectiveness of a brief nurse-led intervention on behavioral symptoms of postoperative patients with intracranial tumors and distress of their caregivers.

METHODS

A randomized controlled trial was conducted on 80 patients with intracranial tumors and their family caregivers in a tertiary care institute in India. A brief nurse-led intervention was provided in the form of individual counseling, and a pamphlet was given to patients and caregivers in the experimental group at the time of discharge. Behavioral symptoms of patients and distress of caregivers were assessed.

FINDINGS

Patients in the experimental group had significantly fewer behavioral symptoms and less severity of behavioral symptoms as compared to the control group. Caregivers in the experimental group had significantly less severity of distress as compared to the control group.

Correlation of changes in serum S100β, NSE and inflammatory factor levels with MMSE and MoCA in intracranial tumor patients with cognitive impairment

Changes in serum neuron-specific enolase (NSE) level, S100β protein concentration and inflammatory factor levels and their correlations with cognitive impairment Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in intracranial tumor patients with cognitive impairment were explored. Seventy patients diagnosed with intracranial tumor based on clinical symptoms and computed tomography (CT) images were selected and divided into non-cognitive impairment group (MoCA score ≥26 points, n=44) and cognitive impairment group (MoCA score <26 points, n=26) in accordance with the comprehensive cognitive function evaluation scores. Next, the serum NSE level, S100β protein concentration and inflammatory factor levels were detected, and their relationships with MMSE and MoCA scores were analyzed via Pearsons correlation analysis. The MoCA and MMSE scores in non-cognitive impairment group were higher than those in cognitive impairment group (P<0.05). NSE and S100β levels were higher in non-cognitive impairment group compared with cognitive impairment group (P<0.05). In addition, the levels of interleukin-6 (IL-6), IL-8 and tumor necrosis factor-α (TNF-α) were higher in cognitive impairment group than those in non-cognitive impairment group (P<0.05). The levels of patient's serum NSE, S100β protein and inflammatory factors were negatively related to MMSE and MoCA scores (P<0.05). The changes in serum NSE, S100β protein and inflammatory factor levels in patients with cognitive impairment can reflect the severity of the disease to a certain extent and are directly related to cognitive impairment. Accurate and comprehensive assessment of cognitive function of patients and early development of effective and targeted cognitive interventions are of certain clinical practical value for the improvement of prognosis.

Case of Clear Cell Ependymoma Successfully Treated with Preoperative Embolization

Objective

Clear cell ependymoma (CCE) is known to be very similar to hemangioblastoma (HB) in regards to neuroimaging and histopathology. We report a rare case of CCE in which successfully underwent preoperative embolization with a prior diagnosis of HB.

Case Presentation

A 58-year-old woman presented with vertigo for several months. MRI showed the right cerebellar tumor mimicking solid HB. DSA revealed the hypervascular tumor supplied by branches of the posterior inferior cerebellar artery (PICA). To reduce intraoperative bleeding, preoperative embolization was performed using n-butyl-2-cyanoacrylate (NBCA). A flow-guided microcatheter was guided to the proper feeders, and diluted NBCA was injected. Sufficient devascularization was achieved. The tumor was totally resected with minimal blood loss the next day. Postoperative pathological diagnosis was CCE.

Conclusion

This is the first report that preoperative embolization was performed to CCE with careful techniques and recent advanced devices. Since CCE has a poorer prognosis, preoperative embolization for safety total resection may be more important.

Mesenchymal Chondrosarcoma of the Brain with Metastasis: A Case Report with Literature Review

Mesenchymal chondrosarcoma of the brain is one of the rarest tumors with dismal prognosis. A 26-year-old man presented with headache, vomiting, and diplopia. On evaluation, a moderately enhancing extra-axial lesion was seen in right temporal region involving right greater wing of sphenoid, adjacent right maxillary sinus, and lateral wall of right orbit. Patient underwent magnetic resonance imaging of the spine and computed tomography (CT) of the chest for possible metastasis which showed lesion in lumbar vertebrae and left lung. Patient was planned for CT-guided lung biopsy which proved inconclusive. The patient was further planned for craniotomy and underwent craniotomy with microscopic excision of the mass. Histoimmunochemistry was suggestive of extraskeletal mesenchymal chondrosarcoma. Mesenchymal chondrosarcoma of the brain is highly aggressive tumors which are difficult to differentiate radiologically. Radical excision followed by chemoradiotherapy is optimal treatment of choice.

Incidence and Risk Factors for Venous Thromboembolism Following Craniotomy for Intracranial Tumors: A Cohort Study

Context:

Venous thromboembolism (VTE) is a devastating complication of intracranial tumor surgery. The present study helps identify patients at the greatest risk of developing VTE.

Aims:

The aim of the study was to evaluate the incidence of and risk factors for VTE following craniotomy for intracranial tumors.

Setting and Designs:

This was a retrospective cohort study.

Methods:

Data from the institutional database (between January 2017 and December 2018) were reviewed. Consecutive patients with intracranial tumors who underwent craniotomy were included.

Statistical Analysis Used:

Patient characteristics were reported as descriptive data, and factors associated with VTE development were analyzed by the Cox regression model.

Results:

The study identified 177 patients. The incidence of VTE was 10.2% (deep-vein thrombosis [DVT], 8.5%; pulmonary embolism [PE] 1.7%; and simultaneous DVT and PE, 1.7%). In univariate analysis, VTE development was associated with diabetes mellitus (DM), operative duration of >420 min, blood transfusion, and new-onset postoperative motor deficits. DM and new-onset postoperative motor deficits were statistically significant factors in multivariable analysis, with hazard ratios of 4.52 (95% confidence interval [CI] = 1.38–14.82) and 3.46 (95% CI = 1.17–10.23), respectively.

Conclusions:

Postcraniotomy VTE was detected in 10.2% of patients with intracranial tumors. Risk factors for VTE included DM and new-onset postoperative motor deficits. Hence, intracranial tumor patients with these risk factors are the most likely to require VTE prophylaxis with an anticoagulant.

A retrospective survey on canine intracranial tumors between 2007 and 2017

To clarify the prevalence of canine intracranial tumors in Japan, a retrospective study was performed using data on 186 canine intracranial tumors. Of 186 cases, 159 cases (85.5%) were primary and 27 cases (14.5%) were secondary intracranial tumors. Among primary intracranial tumors, meningioma (50.9%) was the most common, followed by glial tumors (21.4%) and primary intracranial histiocytic sarcoma (12.6%). These 3 tumors were most frequently found in middle-aged to elderly dogs without any sex predilection. Regarding glial tumors, the incidence of oligodendroglial tumors (79.4%) was higher than that of astrocytic tumors (17.6%). A significant breed predisposition (P<0.05) was observed for meningioma in Rough Collie, Golden Retriever, Miniature Schnauzer, and Scottish Terrier; for glial tumors in Bouvier de Flandres, French Bulldog, Newfoundland, Bulldog, and Boxer; for primary intracranial histiocytic sarcoma in Pembroke Welsh Corgi, Siberian Husky, and Miniature Schnauzer. The high incidence of oligodendroglial tumors in dogs and the breed predisposition for primary intracranial histiocytic sarcoma in Pembroke Welsh Corgi have not been reported in previous epidemiological studies on canine tumors. Since the incidence of intracranial tumors was vary among dog breeds, the present results demonstrate the uniqueness of the canine breed population in Japan.

The Use of Imaging to Detect Intracranial Tumors in Idiopathic Olfactory Dysfunction: A Systematic Review

Objectives

To review the literature regarding the use of intracranial imaging as a screening tool for idiopathic olfactory loss (IOL) and to review the incidence of identifying a sinonasal or intracranial neoplasm as a result of intracranial imaging.

Methods

A systematic review of published English-language literature was performed using PubMed, Ovid MEDLINE, Scopus, and Cochrane databases.

Results

Of the 694 available abstracts, 5 met inclusion criteria for this review. Out of 470 eligible patients, intracranial imaging identified tumors causing IOL in 8 patients (1.7%). Tumor detection rates ranged from 0% to 4.9%. Of the 470 eligible patients, intracranial imaging detected intracranial or sinonasal pathology, excluding tumors, causing IOL in 53 patients (11%). The findings ranged from 0.77% to 23%. Of the 604 eligible IOL patients, 470 (81%) underwent intracranial imaging, ranging from 53% to 100%.

Conclusions

In most cases, diagnostic imaging in IOL patients is frequently ordered. This study finds computed tomography or magnetic resonance imaging to be an important recommendation given to all patients with IOL. Although the overall rate of detecting tumor from diagnostic imaging is low, it is important to offer diagnostic imaging to this subset of patients to avoid missing tumors at an early stage.

The importance of social relationships for brain tumor patients' quality of life: A case for the inclusion of the concept of disclosure in psycho-oncological care

Purpose: Interpersonal factors are of major importance for cancer patients' physical and mental health. Brain tumor patients rank amongst those cancer patients with the highest psychosocial burden. Changes in language, cognition, and personality pose specific risk factors for impeding interpersonal functioning in this patient group. Despite this, role and relevance of social support including both supportive (e.g., emotional support) and detrimental interactions causing distress (e.g., critical remarks) are not well understood. Aims of this study were thus (1) to investigate the association of social support and patients' Health Related Quality of Life (HRQoL) and (2) to assess whether this relationship is mediated by the patients' disclosure behavior.Methods: Seventy-four ambulatory brain tumor patients (mean age 54 years; 58% women) completed the following self-report questionnaires: Illness-specific Social Support Scale (SSUK) for assessment of positive support and detrimental interactions, the Disclosure of Trauma Questionnaire (DTQ) for assessment of patients' disclosure behavior, and the Short-Form Health Survey (SF-8) for assessment of QoL.Findings: Detrimental social interactions were significantly related to patients' mental and physical well-being while positive support was not. Our results support a model in which patients perceiving detrimental social interactions show more difficulties in talking about illness-specific contents in a functional manner. This, in turn, was associated with a lower physical and mental HRQoL.Conclusions: This was the first study in which the close associations of detrimental social interactions, brain tumor patients' dysfunctional disclosure behavior and patients' mental as well as physical well-being were empiricially validated. Thus, dysfunctional disclosure behavior might pose a relevant therapeutic target when offering psycho-oncological support for brain tumor patients and their families.

Prenatal Presentation of Medulloepithelioma: Case and Literature Review

Congenital brain tumors (CBTs) are extremely rare and account for only 0.5%-1.9% of all pediatric brain tumors. Medulloepithelioma is one of the rare tumors with an incidence of about 1% among all CBTs with a very dismal prognosis and typically diagnosed at the median age of 24 months. The objective is reporting medulloepithelioma presenting in the intrauterine period with very few prior cases being reported in the prenatal period, and to add to the limited existing literature on medulloepithelioma. We present a rare case of medulloepithelioma referred to us in the antenatal period at 27 weeks and subsequently causing intrauterine fetal demise. Prenatal MRI of the fetal brain and postnatal histopathological findings on autopsy were suggestive of intracranial medulloepithelioma.

Impact of intracranial hypertension on the short-term prognosis in dogs undergoing brain tumor surgery

The present study used data from anesthetic records to analyze variables of intracranial pressure (ICP) during brain tumor surgery or in the early postoperative period as prognostic indicators in dogs. Data from 17 dogs which were scheduled to undergo elective craniotomy for brain tumor surgery from 2009 to 2012 were included. Of these, five (29.4%) died during 14 days after the surgery because of respiratory failure following pneumonia (n=2), euthanasia due to difficulty in treatment of status epilepticus (n=1), tumor-bed hematoma (n=1), and unknown reason (n=1). In the 12 surviving dogs, neurological signs were improved or resolved at discharge. All dogs were administered midazolam and droperidol-fentanyl as premedication. General anesthesia was induced using propofol maintained on isoflurane and oxygen. Direct ICP was obtained via a Codman Microsensor strain gauge transducer. ICP hypertension (>13 mmHg) measured after 15 min of recovery from the moment after discontinuation of anesthesia by turning off the vaporizer dial was associated with poor prognosis (odds ratio, 20.00; 95% confidence interval, 1.39-287.60, P=0.028). This suggests that intracranial pressure influences the postoperative mortality rate in dogs undergoing brain tumor surgery.

Brain and Salivary Gland Tumors and Mobile Phone Use: Evaluating the Evidence from Various Epidemiological Study Designs

Mobile phones (MPs) are the most relevant source of radiofrequency electromagnetic field (RF-EMF) exposure to the brain and the salivary gland. Whether this exposure implies a cancer risk has been addressed in several case-control and few cohort studies. A meta-analysis of these studies does not show increased risks for meningioma, pituitary, and salivary gland tumors. For glioma and acoustic neuroma, the results are heterogeneous, with few case-control studies reporting substantially increased risks. However, these elevated risks are not coherent with observed incidence time trends, which are considered informative for this specific topic owing to the steep increase in MP use, the availability of virtually complete cancer registry data from many countries, and the limited number of known competing environmental risk factors. In conclusion, epidemiological studies do not suggest increased brain or salivary gland tumor risk with MP use, although some uncertainty remains regarding long latency periods (>15 years), rare brain tumor subtypes, and MP usage during childhood.

Treatment Outcome of Intracranial Tumor Embolization in Japan: Japanese Registry of NeuroEndovascular Therapy 3 (JR-NET3)

Embolization for intracranial tumor is performed as a standard endovascular treatment. A retrospective, multicenter, observational study was conducted to clarify the nature, frequency, and risk factors of complications in intracranial tumor embolization. Patients were derived from the Japanese Registry of NeuroEndovascular Therapy (JR-NET3) using data taken from January 2010 through December 2014 in Japan. A total of 40,169 patients were enrolled in JR-NET3, of which, 1,545 patients (3.85%) with intracranial tumors underwent embolization. The primary end point was the proportion of patients with a modified Rankin scale (mRS) score of 0–2 (independency) at 30 days after embolization. The secondary end point was the occurrence of complications related to the procedures. The risk factors of the development of complications were analyzed. The proportion of patients with mRS scores ≤2 at 30 days after procedure was 89.5%. Complications occurred in 57 of the 1544 patients (3.7%). Multivariate analysis showed that target vessels other than external carotid artery (ECA) (OR, 3.56; 95% CI, 2.03–6.25; P <0.001) and use of liquid material (OR, 2.65; 95% CI, 1.50–4.68; P <0.001) were significantly associated with the development of complications. In JR-NET3, the primary end point was 89.5%, and the procedure-related complication rate was 3.7%. Embolization from other than ECA was significant risk factor of the complications. In addition, increasing usage of liquid embolic material worsened the risk of complications.

A comparative pharmacokinetic study of PARP inhibitors demonstrates favorable properties for niraparib efficacy in preclinical tumor models

Niraparib is an orally bioavailable and selective poly (ADP-ribose) polymerase (PARP)-1/-2 inhibitor approved for maintenance treatment of both BRCA mutant (mut) and BRCA wildtype (wt) adult patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancers who have demonstrated a complete or partial response to platinum-based chemotherapy. In patients without germline BRCA mutations (non-gBRCAmut), niraparib improved progression-free survival (PFS) by 5.4 months, whereas another PARP inhibitor (PARPi) olaparib supplied only 1.9 months of improvement in a similar patient population. Previous studies revealed higher cell membrane permeability and volume of distribution (VD) as unique features of niraparib in comparison to other PARPi including olaparib. Here, we explore the potential correlation of these pharmacokinetic properties to preclinical antitumor effects in BRCAwt tumors. Our results show that at steady state, tumor exposure to niraparib is 3.3 times greater than plasma exposure in tumor xenograft mouse models. In comparison, the tumor exposure to olaparib is less than observed in plasma. In addition, niraparib crosses the blood-brain barrier and shows good sustainability in the brain, whereas sustained brain exposure to olaparib is not observed in the same models. Consistent with its favorable tumor and brain distribution, niraparib achieves more potent tumor growth inhibition than olaparib in BRCAwt models and an intracranial tumor model at maximum tolerated doses (MTD). These findings demonstrate favorable pharmacokinetic profiles and potent antitumor effects of niraparib in BRCAwt tumors, consistent with its broader clinical effect in patients with both BRCAmut and BRCAwt tumors.

Cerebral Bypass Surgery for Internal Carotid Artery Occlusion, Complex Supraclinoid Carotid Artery Aneurysm, and Tumors: A Report of Four Cases

Despite growing popularity of endovascular techniques, certain subsets of patients with cerebrovascular compromise may benefit from bypass surgery. We present four cases in which pending ischemic lesion was prevented by (1) A3 resection and reanastomosis following falx meningioma removal, (2) rescue superficial temporal artery–middle cerebral artery (STA-MCA) bypass after pituitary adenoma surgery, (3) STA-MCA bypass for chronic internal carotid artery occlusion, and (4) external carotid artery-MCA bypass using radial artery grafting. Following the procedure, there were no further clinical or radiological deteriorations and long-term patency was confirmed in all four cases.

Low-dose T1W DCE-MRI for early time points perfusion measurement in patients with intracranial tumors: A pilot study applying the microsphere model to measure absolute cerebral blood flow

BACKGROUND

Previous studies have measured cerebral blood flow (CBF) with DSC-MRI using an "early time points" (ET) method based on microsphere theory.

PURPOSE

To develop and assess a new ET method for absolute CBF estimation using low-dose high-temporal (LDHT) T1W-DCE-MRI.

STUDY TYPE

Retrospective cohort study.

SUBJECTS

Seven patients with sporadic vestibular schwannoma (VS) who underwent test-retest imaging; one patient with glioblastoma multiforme (GBM) imaged pretreatment; and 12 neurofibromatosis type 2 (NF2) patients undergoing bevacizumab treatment, imaged pre- and 90 days posttreatment.

FIELD STRENGTH/SEQUENCE

LDHT-DCE-MRI was performed at 1.5 and 3.0T, using 3D spoiled gradient echo with phase cycling. DSC-MRI performed in one patient, using 3D echo-shifted multi-shot echo-planar imaging (PRESTO) at 3T.

ASSESSMENT

Through Monte Carlo simulations, CBF estimation using three newly developed average contrast agent concentration (AC) -based methods (ACrPK, ACrMG, ACcomb), was compared against conventional maximum gradient (MG) approaches, at varying Rician noise levels. Reproducibility and applicability of the ACcomb method was assessed in our sporadic-VS/GBM/NF2 patient cohort, respectively.

STATISTICAL TESTS

Reproducibility was measured using test-retest coefficient of variation (CoV). Pre- and posttreatment CBF values were compared using paired t-test with Bonferroni correction.

RESULTS

Monte Carlo stimulations demonstrated that AC-based methods, particularly ACcomb, offered superior accuracy to conventional MG approaches. Overall test-retest CoV using the ACcomb method was 5.76 in normal-appearing white matter (NAWM). The new ACcomb method produced gray matter/white matter CBF estimates in the NF2 patient cohort of 55.9 ± 13.9/25.8 ± 3.5 on day 0; compared with 155.6 ± 17.2/128.4 ± 29.1 for the classical MG method. There was a moderate (10% using ACcomb and ACrPK) increase in CBF of NAWM 90 days post therapy (P = 0.03 and 0.005).

DATA CONCLUSION

Our new AC-based method of CBF estimation offers excellent reproducibility, and displays more accuracy in both Monte Carlo analysis and clinical data application, than conventional MG-based approaches.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 4 J. MAGN. RESON. IMAGING 2018;48:543-557.

Dural Arteriovenous Fistula Associated With a Vestibular Tumor: An Unusual Case and Review of the Literature

Intracranial dural arteriovenous fistulae (DAVF) are rare vascular malformations. They are generally considered to be acquired lesions, often attributed to dural sinus thrombosis and intracranial venous hypertension. The authors encountered a case of DAVF associated with an octreotide-positive vestibular schwannoma. A 46-year-old female had symptoms of right ear congestion accompanied by pulsatile tinnitus and mild hearing loss. Magnetic resonance imaging (MRI) identified a lobulated mass centered at the cerebellopontine angle. Preoperatively, on cerebral angiography, there was an incidental discovery of a DAVF in the right posterior fossa. The decision was made to proceed with resection of the tumor in a staged fashion. Her latest follow-up MRI showed no evidence of recurrent tumor. This is the second reported case of DAVF associated with an intracranial schwannoma. Findings are discussed along with a thorough review of the literature. This case, combined with the data from the literature review, led us to believe that tumor-related angiogenesis might contribute to DAVF formation.

Global and Targeted Pathway Impact of Gliomas on White Matter Integrity Based on Lobar Localization

Primary brain tumors comprise 28% of all tumors and 80% of malignant tumors. Pathophysiology of high-grade gliomas includes significant distortion of white matter architecture, necrosis, the breakdown of the blood brain barrier, and increased intracranial pressure. Diffusion tensor imaging (DTI), a diffusion weighted imaging technique, can be used to assess white matter architecture. Use of DTI as a non-invasive pathophysiological tool to analyze glioma impact on white matter microstructure has yet to be fully explored. Preliminary assessment of DTI tractography was done as a measure of intracranial tumor impact on white matter architecture. Specifically, we addressed three questions: 1) whether glioma differentially affects local white matter structure compared to metastasis, 2) whether glioma affects tract integrity of major white matter bundles, 3) whether glioma lobe localization affects tract integrity of different white matter bundles. In this study, we retrospectively investigated preoperative DTI scans from 24 patients undergoing tumor resection. Fiber tractography was estimated using a deterministic fiber tracking algorithm in DSI (diffusion spectrum imaging) Studio. The automatic anatomical labeling (AAL) atlas was used to define the left and right (L/R) hemisphere regions of interest (ROI). In addition, the John Hopkins University (JHU) White Matter Atlas was used to auto-segment major white matter bundle ROIs. For all tracts derived from ROI seed targets, we computed the following parameters: tract number, tract length, fractional anisotropy (FA), axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD). The DTI tractography analysis revealed that white matter integrity in the hemisphere ipsilateral to intracranial tumor was significantly compromised compared to the control contralateral hemisphere. No differences were observed between high vs low-grade gliomas, however, gliomas induced significantly greater white matter degradation than metastases. In addition, targeted analysis of major white matter bundles important for sensory/motor function (i.e., corticospinal tract and superior longitudinal fasciculus) revealed tract-parameter specific susceptibility due to the presence of the tumor. Finally, major tract bundles were differentially affected based on lobar localization of the glioma. These DTI-based tractographic analyses complement findings from gross histopathological examination of glioma impact on neural tissue. Global and focal white matter architecture, ipsilateral to glioma, shows higher rates of degradation or edema - based on DTI tractographic metrics - in comparison to normal brain or metastases. Gliomas, which arise in the parietal lobe, also have a higher negative impact (potentially due to increased edema) on white matter integrity of the superior longitudinal fasciculus(SLF) than those which arise in the frontal lobe. Future studies will focus on using preoperative and postoperative tractography to predict functional deficits following resective surgery.

The impact of presurgical comorbidities on discharge disposition and length of hospitalization following craniotomy for brain tumor

Background:

Identifying risk factors for negative postoperative outcomes is an important part of providing quality care. Here, we build machine learning (ML) ensembles to model the independent impact of presurgical comorbidities on discharge disposition and length of stay (LOS) following brain tumor resection from the HCUP National Inpatient Sample (NIS).

Methods:

We performed a retrospective cohort study of 41,222 patients who underwent craniotomy for brain tumors during 2002–2011 and were registered in the NIS. Twenty-six ML algorithms were trained on prehospitalization variables to predict nonhome discharge and extended LOS (>7 days), and the most predictive algorithms combined to create ensemble models. Models were validated to demonstrate generalizability. Analysis was done to identify which and how specific comorbidities influence ensemble predictions.

Results:

Receiver operating curve analysis showed area under the curve of 0.796 and 0.824 for the disposition and LOS ensembles, respectively. The disposition ensemble was most strongly influenced by preoperative paralysis and fluid/electrolyte abnormalities, which independently increased the risk of nonhome discharge in craniotomy patients by 35.4% and 13.9%, respectively. The LOS ensemble was most strongly influenced by the presence of preoperative paralysis, fluid/electrolyte abnormalities, and other nonparalysis neurological deficits, which independently increased the risk of extended LOS in craniotomy patients by 20.4%, 22.5%, and 38.3%, respectively.

Conclusions:

In this study, we used ML ensembles to identify preoperative comorbidities that increased the risk of nonhome discharge and extended LOS following craniotomy for brain tumor. Recognizing these risk factors for poor postsurgical outcomes can improve patient counseling and offer opportunities for quality improvement.

Comparison of multileaf collimator and conventional circular collimator systems in Cyberknife stereotactic radiotherapy

Multileaf collimator (MLC) technology has been newly introduced with the Cyberknife system. This study investigated the advantages of this system compared with the conventional circular collimator (CC) system. Dosimetric comparisons of MLC and CC plans were carried out. First, to investigate suitable target sizes for the MLC mode, MLC and CC plans were generated using computed tomography (CT) images from 5 patients for 1, 3, 5 and 7 cm diameter targets. Second, MLC and CC plans were compared in 10 patients, each with liver and prostate targets. For brain targets, doses to the brain could be spared in MLC plans better than in CC plans (P ≤ 0.02). The MLC mode also achieved more uniform dose delivery to the targets. The conformity index in MLC plans was stable, irrespective of the target size (P = 0.5). For patients with liver tumors, the MLC mode achieved higher target coverage than the CC mode (P = 0.04). For prostate tumors, doses to the rectum and the conformity index were lowered in MLC plans compared with in CC plans (P ≤ 0.04). In all target plans, treatment times in MLC plans were shorter than those in CC plans (P < 0.001). The newly introduced MLC technology can reduce treatment time and provide favorable or comparable dose distribution for 1-7 cm targets. In particular, the MLC mode has dosimetric advantage for targets near organs at risk. Therefore, the MLC mode is recommended as the first option in stereotactic body radiotherapy.

Masson's tumor of the pineal region: case report

Intracranial intravascular papillary endothelial hyperplasia (IPEH), also referred to as Masson's tumor, is a condition that rarely occurs in the nervous system. IPEH most frequently occurs extracranially in the skin of the face, skull, neck, and trunk and can easily be mistaken clinically, radiologically, and histologically for angiosarcoma, organizing hematoma, or other vascular malformations. IPEH accounts for roughly 2% of all vascular tumors and is extremely rare intracranially, with only 23 reported cases compared with more than 300 cases of IPEH occurring in the skin and subcutaneous tissue. To date, it has never been reported to occur in the pineal region. The authors report the case of a patient with an IPEH in the pineal region who underwent complex resection and experienced reversal of neurological symptoms.

Classical intracranial chondrosarcoma: A case report

Intracranial chondrosarcoma is a rare malignant cartilage-forming tumor, with only a small number of cases in the posterior cranial fossa reported previously. The present study reports the case of a 40-year-old male patient who was admitted to Tianjin Huanhu Hospital with a progressive headache and dizziness that had lasted for 2 years. Physical and neurological examinations were normal. Radiography of the skull identified an opaque lesion in the left frontal region of the brain. Cranial computed tomography and magnetic resonance imaging revealed a lesion with calcification and homogenous contrast enhancement in the left frontal region. Subsequently, the patient underwent bicoronal craniotomy and gross total resection of the tumor. Pathological examination confirmed the diagnosis of classical intracranial chondrosarcoma. The patient was discharged 10 days after surgery, with no neurological deficit. One month after initial discharge, the patient underwent γ-knife treatment. A follow-up examination 9 months after surgery revealed that the patient was still alive and had returned to work, with no obvious symptoms or evidence of recurrence.