Postsurgical Magnetic Resonance Imaging Research Articles

Diffusion-weighted imaging does not seem to be a predictor of consistency in pituitary adenomas.

To prospectively evaluate the usefulness of T1-weighted imaging (T1WI) and diffusion-weighted imaging (DWI) sequences in predicting the consistency of macroadenomas. In addition, to determine their values ​​as prognostic factors of surgical outcomes. Patients with pituitary macroadenoma and surgical indication were included. All patients underwent pre-surgical magnetic resonance imaging (MRI) that included the sequences T1WI before and after contrast administration and DWI with the apparent diffusion coefficient (ADC) map. Post-surgical MRI was performed at least 3months after surgery. The consistency of the macroadenomas was evaluated at surgery, and they were grouped into soft and intermediate/hard adenomas. Mean ADC values, signal on T1WI and the ratio of tumor ADC values ​​to pons (ADCR) were compared with tumor consistency and grade of surgical resection. A total of 80 patients were included. A softened consistency was found at surgery in 53 patients and hardened in 27 patients. The median ADC in the soft consistency group was 0.532 × 10-3 mm2/sec (0.306-1.096 × 10-3 mm2/sec), and in the intermediate/hard consistency group was 0.509 × 10-3 mm2/sec (0.308-0.818 × 10-3 mm2/sec). There was no significant difference between the median values ​​of ADC, ADCR and signal on T1W between the soft and hard tumor groups, or between patients with and without tumor residue. Our results did not show usefulness of the DWI and T1WI for assessing the consistency of pituitary macroadenomas, nor as a predictor of the degree of surgical resection.

RANO 2.0: Update to the Response Assessment in Neuro-Oncology Criteria for High- and Low-Grade Gliomas in Adults.

The Response Assessment in Neuro-Oncology (RANO) criteria for high-grade gliomas (RANO-HGG) and low-grade gliomas (RANO-LGG) were developed to improve reliability of response assessment in glioma trials. Over time, some limitations of these criteria were identified, and challenges emerged regarding integrating features of the modified RANO (mRANO) or the immunotherapy RANO (iRANO) criteria. Informed by data from studies evaluating the different criteria, updates to the RANO criteria are proposed (RANO 2.0). We recommend a standard set of criteria for both high- and low-grade gliomas, to be used for all trials regardless of the treatment modalities being evaluated. In the newly diagnosed setting, the postradiotherapy magnetic resonance imaging (MRI), rather than the postsurgical MRI, will be used as the baseline for comparison with subsequent scans. Since the incidence of pseudoprogression is high in the 12 weeks after radiotherapy, continuation of treatment and confirmation of progression during this period with a repeat MRI, or histopathologic evidence of unequivocal recurrent tumor, are required to define tumor progression. However, confirmation scans are not mandatory after this period nor for the evaluation of treatment for recurrent tumors. For treatments with a high likelihood of pseudoprogression, mandatory confirmation of progression with a repeat MRI is highly recommended. The primary measurement remains the maximum cross-sectional area of tumor (two-dimensional) but volumetric measurements are an option. For IDH wild-type glioblastoma, the nonenhancing disease will no longer be evaluated except when assessing response to antiangiogenic agents. In IDH-mutated tumors with a significant nonenhancing component, clinical trials may require evaluating both the enhancing and nonenhancing tumor components for response assessment. The revised RANO 2.0 criteria refine response assessment in gliomas.

Machine Learning-Derived Multimodal Neuroimaging of Presurgical Target Area to Predict Individual's Seizure Outcomes After Epilepsy Surgery.

Objectives: Half of the patients who have tailored resection of the suspected epileptogenic zone for drug-resistant epilepsy have recurrent postoperative seizures. Although neuroimaging has become an indispensable part of delineating the epileptogenic zone, no validated method uses neuroimaging of presurgical target area to predict an individual’s post-surgery seizure outcome. We aimed to develop and validate a machine learning-powered approach incorporating multimodal neuroimaging of a presurgical target area to predict an individual’s post-surgery seizure outcome in patients with drug-resistant focal epilepsy. Materials and Methods: One hundred and forty-one patients with drug-resistant focal epilepsy were classified either as having seizure-free (Engel class I) or seizure-recurrence (Engel class II through IV) at least 1 year after surgery. The presurgical magnetic resonance imaging, positron emission tomography, computed tomography, and postsurgical magnetic resonance imaging were co-registered for surgical target volume of interest (VOI) segmentation; all VOIs were decomposed into nine fixed views, then were inputted into the deep residual network (DRN) that was pretrained on Tiny-ImageNet dataset to extract and transfer deep features. A multi-kernel support vector machine (MKSVM) was used to integrate multiple views of feature sets and to predict seizure outcomes of the targeted VOIs. Leave-one-out validation was applied to develop a model for verifying the prediction. In the end, performance using this approach was assessed by calculating accuracy, sensitivity, and specificity. Receiver operating characteristic curves were generated, and the optimal area under the receiver operating characteristic curve (AUC) was calculated as a metric for classifying outcomes. Results: Application of DRN–MKSVM model based on presurgical target area neuroimaging demonstrated good performance in predicting seizure outcomes. The AUC ranged from 0.799 to 0.952. Importantly, the classification performance DRN–MKSVM model using data from multiple neuroimaging showed an accuracy of 91.5%, a sensitivity of 96.2%, a specificity of 85.5%, and AUCs of 0.95, which were significantly better than any other single-modal neuroimaging (all p ˂ 0.05). Conclusion: DRN–MKSVM, using multimodal compared with unimodal neuroimaging from the surgical target area, accurately predicted postsurgical outcomes. The preoperative individualized prediction of seizure outcomes in patients who have been judged eligible for epilepsy surgery could be conveniently facilitated. This may aid epileptologists in presurgical evaluation by providing a tool to explore various surgical options, offering complementary information to existing clinical techniques.

Postsurgical geometrical variations of tumor bed and brainstem during photon and proton therapy for pediatric tumors of the posterior fossa: dosimetric impact and predictive factors.

Brainstem radionecrosis is an important issue during the irradiation of tumors of the posterior fossa. The aim of the present study is to analyze postsurgical geometrical variations of tumor bed (TB) and brainstem (BS) and their impact on dosimetry. Retrospective collection of data from pediatric patients treated at asingle institution. Availability of presurgical magnetic resonance imaging (MRI) was verified; availability of at least two postsurgical MRIs was considered afurther inclusion criterion. The following metrics were analyzed: total volume, Dice similarity coefficient (DSC), and Haudsdorff distances (HD). Fourteen patients were available for the quantification of major postsurgical geometrical variations of TB. DSC, HD max, and HD average values were 0.47 (range: 0.08;0.76), 11.3mm (7.7;24.5), and 2.6mm (0.7;6.7) between the first and the second postoperative MRI, respectively. Postsurgical geometrical variations of the BS were also observed. Coverage to the TB was reduced in one patient (D95: -2.9 Gy), while D2 to the BS was increased for the majority of patients. Overall, predictive factors for significant geometrical changes were presurgical gross tumor volume (GTV) > 33 mL, hydrocephaly at diagnosis, Luschka foramen involvement, and younger age (≤ 8years). Major volume changes were observed in this cohort, with some dosimetric impact. The use of arecent co-registration MRI is advised. The 2-3 mm HD average observed should be considered in the planning target volume/planning organ at risk volume (PTV/PRV) margin and/or robust optimization planning. Results from wider efforts are needed to verify our findings.

Acute changes in diffusion tensor-derived metrics and its correlation with the motor outcome in gliomas adjacent to the corticospinal tract.

Background: This study involves analysis of the relationship between variables obtained using diffusion tensor imaging (DTI) and motor outcome in gliomas adjacent to the corticospinal tract (CST).Methods: Histologically confirmed glioma patients who were to undergo surgery between January 2018 and December 2019 were prospectively enrolled. All patients had a preoperative magnetic resonance imaging (MRI) study that included DTI, a tumor 2 cm or less from the CST, and postsurgical control within 48 h. Patients with MRI that was performed at other center, tumors with primary and premotor cortex invasion, postsurgical complications directly affecting motor outcome and tumor progression <6 months were excluded in the study. In pre- and post-surgical MRI, we measured the following DTI-derived metrics: fractional anisotropy (FA), mean diffusivity, axial diffusivity, and radial diffusivity of the entire CST and peritumoral CST regions and in the contralateral hemisphere. The motor outcome was assessed at 1, 3, and 6 months using the Medical Research Council scale.Results: Eleven patients were analyzed, and six corresponded to high-grade gliomas and five to low-grade gliomas. Four patients had previous motor impairment and seven patients had postsurgical motor deficits (four transient and three permanent). An FA ratio of 0.8 between peritumoral CST regions and the contralateral hemisphere was found to be the cutoff, and lower values were obtained in patients with permanent motor deficits.Conclusion: Quantitative analysis of DTI that was performed in the immediate postsurgery period can provide valuable information about the motor prognosis after surgery for gliomas near the CST.

HEMANGIOMA CAPILAR INTRADURAL EXTRAMEDULAR EN PACIENTE DE 03 MESES DE VIDA: REPORTE DE CASO

Introduction: Capillary hemangioma is an extremely rare endothelial cell neoplasm as an extramedullary intradural tumor. Its presentation in infants is anecdotal and only 2 cases have been previously reported in the literature. Clinical case: a 03-month-old infant with severe abrupt-onset paraparesis. Spinal magnetic resonance imaging (MRI) showed an intraspinal tumor at the T7, T8, and T9 levels, which captures contrast. A T7-T9 laminectomy and microsurgical resection of the extramedullary spinal tumor were performed. The pathology was reported as lobulated angiomatous proliferation with focal vascular thrombus, with positive immunohistochemistry for CD 31 and 34, compatible with capillary hemangioma. The neurological evolution was favorable. Post-surgical MRI and spinal angiography showed little residual tumor and hydrosyringomyelia in remission. Conclusion: Capillary hemangioma is a rare pathology in infants, this case being the 3rd case reported. Its diagnosis and surgical resection are important since most patients present an improvement in the neurological deficit after surgery. Surgical treatment avoids the risk of acute bleeding Keywords: Hemangioma, Capillary, Spinal Cord Neoplasms, Infant, Laminectomy. (Source: MeSH NLM)

Impact of Early Reoperation on the Prognosis of Patients Operated on for Glioblastoma

The prognosis for patients with glioblastoma depends particularly on the degree of tumor resection. Patients with tumor remnants in postsurgical magnetic resonance imaging (<72 hours) may benefit from early reoperation. We present our results concerning the impact on overall survival (OS) and progression-free survival (PFS) of reoperation in patients who have already undergone surgery for glioblastoma. This study included all patients who had undergone surgery for glioblastoma with control magnetic resonance imaging, who received adjuvant therapy as per the Stupp protocol, with a minimum follow-up of 24 months. We recorded the number of complete resections, partial resections, and early reoperations. We determined the impact on OS and PFS of the early reoperations and the functional status. We considered complete resection when the volume of the residual tumor was 0 cm3. A total of 112 patients were diagnosed with glioblastoma between March 2014 and March 2017. The study included 58 patients who fulfilled all the inclusion criteria. Complete resection was achieved in 24 patients (41.4%) and partial resection in 34 (58.6%). Of these 34 patients, 11 (32.35%) underwent early reoperation. The final result was complete resection in 58.62% of the patients. In the patients who underwent reoperation, OS and PFS were 30.3 months and 16.6 months compared with 12.7 months and 6.75 months in those without reoperation (P= 0.013 and P= 0.012). The functional prognosis was similar between the 2 groups. Early reoperation in patients with residual tumor improved OS and PFS without increasing the number of complications compared with the patients who did not undergo reoperation.

Diffusion tensor imaging of microstructural alterations in the trigeminal nerve due to neurovascular contact/compression.

Several recent studies have focused on microstructural changes in the trigeminal nerve in trigeminal neuralgia using diffusion tensor imaging (DTI). However, alterations after microvascular decompression (MVD) have rarely been investigated. Furthermore, the trigeminal nerve of asymptomatic individuals also presenting with neurovascular contact/compression (NVC) has not yet been studied. Thirty-four patients suffering from trigeminal neuralgia and 34 healthy age-matched controls, who were identified as having unilateral NVC signs, underwent both DTI and high-resolution magnetic resonance imaging (MRI) for comparison. All trigeminal neuralgia patients underwent a post-surgical MRI scan after 7days and a follow-up MRI scan within 6-8months after surgery. The apparent diffusion coefficients (ADCs) and fractional anisotropy (FA) values were measured from coronal images in which the nerves from the root exit point to the distal segment were clearly shown. In 34 trigeminal neuralgia patients, the absolute FA value was significantly lower on the affected side (mean FA, 0.34 ± 0.03) than on the unaffected side (mean FA, 0.37 ± 0.05, p < 0.001). The FA ratio was also significantly different between the trigeminal neuralgia group (RsFA, 0.92 ± 0.06) and the control group (RsFA, 0.99 ± 0.09) (p = 0.001). The absolute ADC value between the two sides in patients and the ratios of ADC between the trigeminal neuralgia and control groups did not show any significant differences (p = 0.21 and 0.29, respectively). However, in 34 healthy subjects presenting with signs of NVC, neither the FA value nor the ADC showed a difference between sides (p > 0.05). The FA ratio of patients showed a significant increase on two follow-up MRI scans compared to the preoperative FA (p = 0.02 and 0.002, respectively), while the ADC ratio showed a significant decrease at 6months after MVD (p = 0.004). This study of trigeminal neuralgia due to NVC found that DTI indexes could reflect alterations in the affected trigeminal nerve. Furthermore, a reversible change after MVD surgery could be potentially valuable for monitoring the change in white matter of the trigeminal nerve.

Assessment of the extent of pituitary macroadenomas resection in immediate postoperative MRI

ObjectiveTo evaluate if it is possible to determine the extent of pituitary macroadenomas resection in the immediate postoperative pituitary magnetic resonance imaging (MRI). Material and methodsMRI of patient with pituitary macroadenomas from January 2010 until October 2014 were reviewed. Those patients who had diagnostic MRI, immediate post-surgical MRI and at least one MRI control were included. We evaluate if the findings between the immediate postsurgical MRI and the subsequent MRI were concordant. Cases which did not have evolutionary controls and those who were reoperation for recurrence were excluded. The degree of tumor resection was divided into groups: total resection, partial resection and doubtful. All MRI studies were performed on a 1.5T machine following the same protocol sequences for all cases. One morphological part, a dynamic contrast IV and late contrast part. ResultsOf the 73 cases included, immediate postoperative pituitary MRI was interpreted as total resection in 38 cases and tumoral rest in 28 cases, uncertainty among rest or inflammatory changes in 7 cases. Follow-up MRI identified 41 cases total resection and tumoral rest in 32. Sensitivity and specificity of 0.78 and 0.82 and positive and negative predictive value (PPV and NPV) 0.89 and 0.89 respectively were calculated. ConclusionImmediate post-surgery pituitary MRI is useful for assessing the degree of tumor resection and is a good predictor of the final degree of real resection compared with the following MRI studies. It allows us to decide the most appropriate treatment at an early stage.

A review of Cushing's disease treatment by the Department of Neuroendocrinology of the Brazilian Society of Endocrinology and Metabolism.

The treatment objectives for a patient with Cushing's disease (CD) are remission of hypercortisolism, adequate management of co-morbidities, restoration of the hypothalamic-pituitary-adrenal axis, preservation of fertility and pituitary function, and improvement of visual defects in cases of macroadenomas with suprasellar extension. Transsphenoidal pituitary surgery is the main treatment option for the majority of cases, even in macroadenomas with low probability of remission. In cases of surgical failure, another subsequent pituitary surgery might be indicated in cases with persistent tumor imaging at post surgical magnetic resonance imaging (MRI) and/or pathology analysis of adrenocorticotropic hormone-positive (ACTH+) positive pituitary adenoma in the first procedure. Medical treatment, radiotherapy and adrenalectomy are the other options when transsphenoidal pituitary surgery fails. There are several options of medical treatment, although cabergoline and ketoconazole are the most commonly used alone or in combination. Novel treatments are also addressed in this review. Different therapeutic approaches are frequently needed on an individual basis, both before and, particularly, after surgery, and they should be individualized. The objective of the present review is to provide the necessary information to achieve a more effective treatment for CD. It is recommended that patients with CD be followed at tertiary care centers with experience in treating this condition.

Valoración del grado de resección de los macroadenomas hipofisarios en la resonancia magnética posquirúrgica inmediata

ObjectiveTo evaluate if it is possible to determine the extent of pituitary macroadenomas resection in the immediate postoperative pituitary magnetic resonance imaging (MRI). Material and methodsMRI of patient with pituitary macroadenomas from January 2010 until October 2014 were reviewed. Those patients who had diagnostic MRI, immediate post-surgical MRI and at least one MRI control were included. We evaluate if the findings between the immediate postsurgical MRI and the subsequent MRI were concordant. Cases which didn’t have evolutionary controls and those who were reoperation for recurrence were excluded. The degree of tumor resection was divided into groups: total resection, partial resection and doubtful. All MRI studies were performed on a1.5T machine following the same protocol sequences for all cases. One morphological part, a dynamic contrast iv and late contrast part. ResultsOf the 73 cases included, immediate postoperative pituitary MRI was interpreted as total resection in 38 cases and tumoral rest in 28 cases, uncertainty among rest or inflammatory changes in 7 cases. Follow- up MRI identified 41 cases total resection and tumoral rest in 32. Sensitivity and specificity of 0.78 and 0.82 and positive and negative predictive value (PPV and NPV) 0.89 and 0.89 respectively were calculated. ConclusionImmediate post-surgery pituitary MRI is useful for assessing the degree of tumor resection and is a good predictor of the final degree of real resection compared with the following MRI studies. It allows us to decide the most appropriate treatment at an early stage.

Is Mean Radiation Dose to the Subventricular Zone a Prognostic Indicator?

It has been postulated that the capability of glioblastoma (GBM) to withstand multi-modality treatment is driven by a niche of mutated neural progenitor cells (NPCs) called cancer stem cells (CSCs) residing in the subventricular zone (SVZ). Previous studies suggest that increased radiation dose to the SVZ is associated with improved outcomes while others have not found this association and underline the importance of NPC preservation during radiation therapy (RT). Given this conflicting data, we examined the relationship between dose to the SVZ and treatment outcomes in GBM patients treated with surgery followed by RT- Temozolomide (TMZ). Patients with GBM who completed a course of RT-TMZ at single institution between 2010 and 2016 were included. All patients were >18 years old, underwent surgery followed by intensity modulated radiation therapy (IMRT) to 60 Gy in 30 fractions with concomitant TMZ, and had a minimum of 6 month follow-up. Time to tumor recurrence was defined as the date that tumor progression on Magnetic Resonance Imaging (MRI) was documented by both the neuro-radiologist and treating neuro-oncologist. Dates of patients’ deaths were obtained from medical records and the Social Security Death Index. SVZ contours were delineated on the fused computed tomography simulation and post-surgical MRI T1-weighted images and defined as the lateral wall of the lateral ventricles using a 5-mm brush. Mean doses were calculated for ipsilateral, contralateral and bilateral SVZ regions. Log Rank tests, cox regression and backward stepwise model selection were employed for data analyses. 109 patients (median age 62 years) were identified. 45.9% underwent gross total resection, 43.1% subtotal resection, and 11% biopsy. At diagnosis, 18.3% of patients were RPA Class III, 47% RPA Class IV, 16% Class V. 66.1% of patients had tumor in contact with the SVZ. The median ipsilateral, contralateral, and bilateral mean doses were 57.8 Gy, 37.5 Gy, and 47.1 Gy, respectively. At a median follow up of 14.4 months, the 1 and 2-year progression-free survival (PFS) and overall survival (OS) rates were 27.5%, 6.4%, 67.0% and 21.1%, respectively. There was a trend of worse OS with higher mean ipsilateral SVZ dose in patients who received >57.8 Gy (14.5 vs 19.4 months, p=0.06). Lack of SVZ involvement at diagnosis was associated with an OS benefit on univariate analysis (16.8 vs 13.8 months, p=0.03). On multivariate analysis, lower RPA class and greater extent of resection were associated with improved PFS. Younger age, higher performance status, greater extent of resection, and MGMT methylation were associated with improved OS. This study suggests a trend towards worse OS with higher mean ipsilateral SVZ doses and significantly worse OS with SVZ involvement. Additionally, our study continues to underline the importance of RPA class, age, performance status, resection type and MGMT status as the most important prognostic indicators of survival outcomes.

What Makes New Ischemic Lesions Symptomatic after Aortic Valve Replacement?

Acute cerebral infarctions on diffusion-weighted magnetic resonance imaging (MRI) are common after cardiothoracic surgery. However, most are asymptomatic and we aimed to identify features associated with clinical stroke symptoms. Patients over 65 years of age undergoing surgical aortic valve replacement (AVR) for calcific stenosis were prospectively recruited (N = 196). All patients underwent neurological evaluation preoperatively and on postoperative days 1, 3, and 7, and MRI on planned postoperative day 5. Among those with new postoperative DWI lesions, we performed univariate and multivariable analyses to identify clinical, demographic, surgical, and imaging factors associated with clinical stroke symptoms. Of the 129 patients who completed a postsurgical MRI, 79 (61%) had DWI lesions and 17 (21.5%) of these had new stroke symptoms concordant with the infarct distribution. In an exploratory multivariable analysis, focal neurological symptoms were associated with increased age, a longer bypass duration, and a larger pre-existing lesion burden on fluid-attenuated inversion recovery. Limiting the analysis to the 61 patients with analyzable volume and location data, logistic regression failed to identify any location-related determinant of symptomatic lesions. New DWI lesions are common after AVR, but most are asymptomatic. Patients are more likely to have symptoms with longer bypass durations, increasing age, and larger pre-existing lesion burdens.

Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine

To examine the prevalence and impact of athletic pubalgia (AP) surgery in elite American football athletes participating in the National Football League (NFL) Combine. Results from 1,311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with a history of AP repair were identified using the NFL Combine Database. Athlete history and available imaging was reviewed. NFL performance based on draft status, games played, games started, and current status in the NFL was gathered using publicly available databases. Statistical analysis was performed to detect for significant associations between athlete history and NFL performance in the presence of AP repair and pelvic pathology on postsurgical magnetic resonance imaging (MRI). AP repair was identified in 4.2% (n=55) of athletes. MRI was performed in 35% (n= 19 of 55) with AP repair, of which 53% (n= 10 of 19) had positive pathology. Athletes with repair were not at risk of playing (P= .87) or starting (P= .45) fewer regular season games, going undrafted (P= .27), or not being on an active NFL roster (P= .51). Compared with athletes with negative imaging findings, positive pathology on MRI did not have a significant impact on games played (P= .74), games started (P= .48), draft status (P= .26), or being on an active roster (P= .74). Offensive linemen (P= .005) and athletes with a history of repair within 1year of the Combine (P= .03) had a significantly higher risk of possessing positive pathology on MRI. Athletes with a history of successful AP surgery invited to the NFL Combine and those with persistent pathology on MRI are not at increased risk for diminished performance in the NFL. Offensive linemen and athletes less than 1year out from surgery have a higher risk for positive MRI findings at the pubic symphysis. Level IV, prognostic study-case series.

Astroblastoma in a Young Female Patient: A Case Report and Literature Review of Clinicopathological, Radiological and Prognostic Characteristics and Current Treatment Strategies.

Astroblastoma is an uncommon glial tumor with predominant manifestation in the young age. Herein, we report a case of 18-year-old astroblastoma female patient who presented with history of two months headache. Magnetic resonance imaging (MRI) of the brain demonstrated well circumscribed, intra-axial abnormal signal intensity lesion (size=5×4 cm2) in the right parieto-occipital region of the brain. The patient underwent complete surgical resection of the gross tumor, as confirmed by an early post-surgical MRI (i.e., within 24 hours of surgery). Histopathological examination revealed neoplastic lesion exhibiting perivascular pseudo-rosettes with centrally hyalinized blood vessel and focal nuclear pleomorphism. Immunohistochemistry staining illustrated reactivity for glial fibrillary acidic protein and integrase interactor 1 (INI-1). These features rendered the diagnosis of astroblastoma. A comprehensive review of the current literature to summarize the clinicopathological and radiological characteristics, prognostic factors and current treatment strategies of astroblastomas is also presented. Our study would expand the pool of this uncommon tumor towards its better understanding and optimal treatment.

The Danish Neuro-Oncology Registry

Aim of databaseThe Danish Neuro-Oncology Registry (DNOR) was established by the Danish Neuro-Oncology Group as a national clinical database. It was established for the purpose of supporting research and development in adult patients with primary brain tumors in Denmark.Study populationDNOR has registered clinical data on diagnostics and treatment of all adult patients diagnosed with glioma since January 1, 2009, which numbers approximately 400 patients each year.Main variablesThe database contains information about symptoms, presurgical magnetic resonance imaging (MRI) characteristics, performance status, surgical procedures, residual tumor on postsurgical MRI, postsurgical complications, diagnostic and histology codes, radiotherapy, and chemotherapy.Descriptive dataDNOR publishes annual reports on descriptive data. During the period of registration, postoperative MRI is performed in a higher proportion of the patients (Indicator II), and a higher proportion of patients have no residual tumor after surgical resection of the primary tumor (Indicator IV). Further data are available in the annual reports. The indicators reflect only minor elements of handling brain tumor patients. Another advantage of reporting indicators is the related multidisciplinary discussions giving a better understanding of what actually is going on, thereby facilitating the work on adjusting the national guidelines in the Danish Neuro-Oncology Group.ConclusionThe establishment of DNOR has optimized the quality in handling primary brain tumor patients in Denmark by reporting indicators and facilitating a better multidisciplinary collaboration at a national level. DNOR provides a valuable resource for research.

Postoperative and postradiation head and neck: role of magnetic resonance imaging.

Interpretation of head and neck imaging after treatment for malignancy poses a challenge even for the experienced neuroradiologist. While computed tomography is often the preferred modality for assessment of the head and neck due to its faster acquisition, magnetic resonance imaging (MRI) is superior in the evaluation of nasopharyngeal, sinonasal and skull base tumors. In this article, we review pretherapy imaging protocols, common surgical approaches and reconstructions, postsurgical and postradiation MRI appearance and complications, MRI criteria for tumor recurrence and clinical applications of advanced MRI techniques as applicable to head and neck tumors.

Pelvic Osteomyelitis Presenting as Groin and Medial Thigh Pain: A Resident's Case Problem

Resident's case problem. Groin pain represents a diagnostic challenge and requires a diagnostic process that rules out life-threatening illness or disease processes. Osteomyelitis is a potential fatal disease process that requires accurate diagnosis and medical management. Osteomyelitis presents a problem for the outpatient physical therapist, as the described physical findings for the diagnosis of osteomyelitis are nonspecific. A 67-year-old man with groin and bilateral medial thigh pain was referred for physical therapy care to address right adductor weakness and generalized deconditioning. He had undergone extensive treatment for bladder cancer, with a recent radical cystoprostatectomy and cutaneous urinary diversion with an Indiana pouch. Postsurgical magnetic resonance imaging indicated normal findings, and the patient was currently being managed by an orthopaedic surgeon, who diagnosed the patient as having obturator nerve palsy. The physical therapist's examination produced findings inconsistent with this diagnosis. Subsequently, nuclear medicine studies revealed pubic symphysitis/osteomyelitis with secondary myositis, predominantly affecting the right adductor muscles. Osteomyelitis represents a difficult problem for the outpatient physical therapist. Careful consideration of red-flag symptoms and inconclusive physical testing indicate the need for further medical work-up. In this case, appropriate medical management led to improvement in patient function, highlighting the need for early diagnosis. Differential diagnosis, level 4.

NI-56 * FET-PET ADDS PREDICTIVE VALUE TO LOCALIZATION OF TREATMENT FAILURE IN HIGH GRADE GLIOMAS

PURPOSE: To evaluate if post-surgical magnetic resonance imaging (MRI) in combination with positron emission tomography (PET) is a better predictor for localization of treatment failure than MRI alone in patients with high grade gliomas. METHODS: Twenty-one patients with primary glioblastoma WHO grade IV were included in this retrospective study. Post-surgical, contrast-enhanced MRI was used to define the gross tumor volume (GTV-MR). In addition, 18F-fluoro-ethyltyrosine (FET) PET was performed, and the FET-positive volume was semi-automatically determined by including tissue with an uptake exceeding 1.6 times the uptake in normal appearing gray matter, and subsequently manually edited to exclude non-tumor. We defined GTV-MR in combination with FET as GTV-MRPET. Clinical target volume (CTV) was defined by adding a two centimeter margin to GTV-MR and modified to include the FET-volume. Patients were treated with surgery and subsequent chemo-radiation (RCX) to 60 Gy in 30 fractions to the CTV plus concurrent and adjuvant temozolomide (TMZ). Treatment failure volume (TFV) was defined as the earliest radiological evidence of residual or recurrent disease on post-therapeutic MRI. The maximum distances from GTV-MR and GTV-MRPET to encompass TFV, and the sensitivity as well as specificity between TV and TFV, were calculated and pairwise compared (Wilcoxon). RESULTS: The maximum distance to encompass TFV was significantly higher (p < 0.001) for GTV-MR (12.7 mm [3.20-73.6]) compared to GTV-MRPET (11.4 mm [3.15-73.6]). GTV-MRPET was significantly more sensitive in predicting the location of TFV (p < 0.001), however the specificity was significantly lower (p < 0.001). CONCLUSION: GTV-MRPET required smaller margin to encompass the TFV, was more sensitive but less specific than GTV-MR.

Social cognition in patients following surgery to the prefrontal cortex

Impaired social cognition, including emotion recognition, may explain dysfunctional emotional and social behaviour in patients with lesions to the ventromedial prefrontal cortex (VMPFC). However, the VMPFC is a large, poorly defined area that can be sub-divided into orbital and medial sectors. We sought to investigate social cognition in patients with discrete, surgically circumscribed prefrontal lesions. Twenty-seven patients between 1 and 12 months post-neurosurgery were divided into groups based on Brodmann areas resected, determined by post-surgical magnetic resonance imaging. We hypothesised that patients with lesions to the VMPFC (n=5), anterior cingulate cortex (n=4), orbitofrontal cortex (n=7) and dorsolateral prefrontal cortex (DLPFC, n=11) would perform worse than a control group of 26 extra-cerebral neurosurgery patients on measures of dynamic facial emotion recognition, theory of mind (ToM) and empathy. Results indicated the VMPFC-lesioned group performed significantly worse than the control group on the facial emotion recognition task overall, and for fear specifically, and performed worse on the ToM measure. The DLPFC group also performed worse on the ToM and empathy measures, but DLPFC lesion location was not a predictor of performance in hierarchical multiple regressions that accounted for other variables, including the reduced estimated verbal IQ in this group. It was concluded that isolated orbital or medial prefrontal lesions are not sufficient to produce impairments in social cognition. This is the first study to demonstrate that it is the combination of lesions to both areas that affect social cognition, irrespective of lesion volume. While group sizes were similar to other comparable studies that included patients with discrete, surgically circumscribed lesions to the prefrontal cortex, future large, multi-site studies are needed to collect larger samples and confirm these results.