Preoperative Grading System Research Articles

P11.04.B ASSESSMENT OF TUMOR ELOQUENCE IN GLIOMA RESECTIONS: A SYSTEMATIC REVIEW

Abstract BACKGROUND Tumor location and eloquence are two crucial factors when deciding on the optimal surgical strategy in glioma management. Consensus is currently lacking on the assessment and definition of eloquent areas. This systematic review aims to evaluate the existing definitions and assessment methods of eloquent areas used in current clinical practice. MATERIAL AND METHODS A computer-aided search of Embase, Medline (OvidSP), and Google Scholar was performed to identify relevant studies. This review includes articles describing preoperative definitions of eloquence in the study’s Methods section. These definitions were compared and categorized by anatomical structure. Additionally, various techniques to preoperatively assess tumor eloquence were extracted, along with their benefits, drawbacks and ease of use. RESULTS This review covers 98 articles including 12,714 participants. Evaluation of these studies indicated considerable variability in defining eloquence. Categorization of these definitions yielded a list of 32 brain regions that were considered eloquent. The most commonly used methods to preoperatively determine tumor eloquence were anatomical classification systems and structural MRI, followed by DTI-FT, functional MRI and nTMS. CONCLUSION None of the definitions or techniques to define eloquence described in the articles are entirely satisfactory as an objective, quantifiable, preoperative factor in glioma treatment and surgical decision-making. Therefore, we propose the development of a new, easily applicable and interpretable anatomical preoperative grading system to assess tumor eloquence. This may aid neurosurgeons in their perioperative decision-making to improve surgical outcomes on an individual patient level and to facilitate the execution and interpretation of multicenter studies.

Intraoperative Scoring System to Assess the Difficult Laparoscopic Cholecystectomy: A Prospective Study From a Tertiary Care Centre.

Background In comparison to a traditional cholecystectomy (open), the laparoscopic cholecystectomy approach provides a number of benefits and has been demonstrated in some studies to have a greater complication rate. The conversion rate from laparoscopic to open surgery ranged between 2% and 15%. A preoperative scoring or grading system (based on age, sex, history, clinical examination, laboratory, and sonographic results)was developed byNassar et al., to anticipate the challenge of laparoscopic cholecystectomy. So, we conducted this study to assess the degree of difficulty in faced during laparoscopic cholecystectomy using an intraoperative scoring system and validate the same using the preoperative scoring system. Methods We conducted this study in the department of General Surgery among 105 patients who underwent laparoscopic cholecystectomy during the defined study period of one year. We performed the preoperative workup for all patients. A preoperative scoring or grading system developed by Nassar et al., in 2020was used. In our study, laparoscopic cholecystectomy was performed by surgeons having a minimum of eight years of hands-on experience in laparoscopic surgeries. An intraoperative scoring or grading system for the degree of difficulty during laparoscopic cholecystectomy, developed by Sugrue et al., in 2015 was used. The Chi-square test was applied to assess the association between preoperative variables and the intraoperative score grading. We have also performed the receiver operating characteristic (ROC) curve analysis to validate the preoperative score in predicting the intraoperative findings. All tests were considered statically significant if the p-value was < 0.05. Results In our study, a total of 105 patients were included in the study and the mean age of patients was 57.6±16.4 years. The male patients were 58.1% and the remaining 41.9% were females. The primary diagnosis was cholecystitis among 44.8% of patients and 2.9% of patients were diagnosed with pancreatitis. Among enrolled patients, laparoscopic cholecystectomy was done on an emergency basis among 2.9% of subjects. During the laparoscopic cholecystectomy, among 21.0% and 30.5% of patients, there was a severe and extreme degree of difficulty respectively. In our study, the conversion rate from laparoscopic to open cholecystectomy was 8.6%. In our study, we found that at a preoperative score of 6, the sensitivity and specificity for predicting easy cases were 88.2% and 73.8%, respectively, and had an accuracy of 88.6% for easy cases and 68.5% for difficult cases. Conclusion When grading the difficulties of doing a laparoscopic cholecystectomy and determining the severity of cholecystitis, this intraoperative scoring system is effective and accurate. Additionally, it signifies the need for conversion from laparoscopic to open cholecystectomyin cases of severe cholecystitis.

Classifying the Severity of Cubital Tunnel Syndrome: A Preoperative Grading System Incorporating Electrodiagnostic Parameters.

Current classifications for cubital tunnel syndrome have not been shown to reliably predict postoperative outcomes. In this article, the authors introduce a new classification that incorporates clinical and electrodiagnostic parameters, including compound muscle action potential amplitude, to classify the preoperative severity of cubital tunnel syndrome. The authors compare this to established classifications and evaluate its association with patient-rated improvement. The authors reviewed 44 patients who were treated surgically for cubital tunnel syndrome. Patients were retrospectively classified using their proposed classification and the Akahori, McGowan-Goldberg, Dellon, and Gu classifications. Correlation of grades was assessed by Spearman coefficients and agreement was assessed by weighted kappa coefficients. Patient-reported impairment was assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire before and after surgery. The classifications tended to grade patients in a similar way, with Spearman coefficients of 0.60 to 0.85 ( p < 0.0001) and weighted kappa coefficients of 0.46 to 0.71 ( p < 0.0001). Preoperative Disabilities of the Arm, Shoulder, and Hand scores increased with severity grade for most classifications. In multivariable analysis, the authors' classification predicted postoperative Disabilities of the Arm, Shoulder, and Hand score improvement, whereas established classifications did not. Established classifications are imperfect indicators of preoperative severity. The authors introduce a preoperative classification for cubital tunnel syndrome that incorporates electrodiagnostic findings in addition to classic signs and symptoms. Diagnostic, III.

Clinical outcomes for patients with lateral lumbar radiculopathy treated by percutaneous endoscopic transforaminal discectomy versus tubular microdiscectomy: A retrospective review

BackgroundSurgical management of lateral lumbar radiculopathy is evolving. TMD (Tubular microdiscectomy) and TELD (Transforaminal endoscopic lumbar discectomy) have emerged as viable MIS treatments. We aim to compare clinical outcomes of both techniques for the treatment of lateral lumbar radiculopathy in relation to pre-operative lumbar foraminal stenosis grade (LFS). MethodsRetrospective observational cohort study of patients with back and leg pain from single level foraminal nerve root compression that underwent TMD or TELD. Data analyzed included pre- and post-operative VAS leg and back pain, MacNab clinical outcome scores, hospital length of stay, complication rates, and operative time. Outcomes were correlated with a pre-operative MRI grading system for LFS. Results109 patients were enrolled (71 TELD and 38 TMD). Back and leg VAS pain scores improved in TELD and TMD (p < 0.0001). Patients with grade III stenosis showed significantly higher VAS scores (p < 0.01), and worse functional outcomes at latest follow-up compared with grade I/II LFS. Overall, there was no difference in outcome between procedure groups except that TMD VAS back pain scores were lower than TELD at last follow up (p < 0.05). Clinical outcome comparisons between procedures relating to LFS grade showed higher correlation of LFS to TELD (Spearman’s rho (ρ)= 0.342 for TMD and 0.606 TELD). Regression analyses demonstrated correlation between higher-grade foraminal stenosis and poorer outcomes in TELD and TMD. ConclusionsBoth TELD and TMD are viable for treating lateral lumbar radiculopathy. Higher-grade foraminal stenosis can be indicative of poorer outcomes regardless of procedure type, however, the severity of pre-operative LFS correlates with clinical outcomes in TELD more significantly than TMD.

Validation and Application for the Berlin Grading System of Moyamoya Disease in Adult Patients.

Traditional moyamoya disease (MMD) classification relies on morphological digital subtraction angiography (DSA) assessment, which do not reflect hemodynamic status, clinical symptoms, or surgical treatment outcome. To (1) validate the new Berlin MMD preoperative symptomatology grading system and (2) determine the clinical application of the grading system in predicting radiological and clinical outcomes after surgical revascularization. Ninety-six MMD patients (192 hemispheres) with all 3 investigations (DSA, magnetic resonance imaging [MRI], Xenon-CT) performed preoperatively at our institution (2007-2013) were included. Two clinicians independently graded the imaging findings according to the proposed criteria. Patients' modified Rankin Score (mRS) scores (preoperative, postoperative, last follow-up), postoperative infarct (radiological, clinical) were collected and statistical correlations performed. One hundred fifty-seven direct superficial temporal artery-middle cerebral artery bypasses were performed on 96 patients (66 female, mean age 41 yr, mean follow-up 4.3 yr). DSA, MRI, and cerebrovascular reserve capacity were independent factors associated hemispheric symptomatology (when analyzed individually or in the combined grading system). Mild (grade I), moderate (grade II), severe (grade III) were graded in 45, 71, and 76 hemispheres respectively; of which, clinical symptoms were found in 33% of grade I, 92% of grade II, 100% of grade III hemispheres (P<.0001). Two percent of grade I, 11% of grade II, 20% of grade III hemispheres showed postoperative radiological diffusion weighted image-positive ischemic changes or hemorrhage on MRI (P=.018). Clinical postoperative stroke was observed in 1.4% of grade II, 6.6% of grade III hemispheres (P=.077). The grading system also correlated well to dichotomized mRS postoperative outcome. The Berlin MMD grading system is able to stratify preoperative hemispheric symptomatology. Furthermore, it correlated with postoperative new ischemic changes on MRI, and showed a strong trend in predicting clinical postoperative stroke.

Masseteric-to-Facial Nerve Transfer and Selective Neurectomy for Rehabilitation of the Synkinetic Smile

Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive. To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile. In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified. Masseteric-to-facial nerve transfer. Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side). Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant. This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. This study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality. 4.

Interrater reliability of a method to assess hypothalamic involvement in pediatric adamantinomatous craniopharyngioma.

Pediatric adamantinomatous craniopharyngiomas (ACPs) are histologically benign brain tumors that confer significant neuroendocrine morbidity. Previous studies have demonstrated that injury to the hypothalamus is associated with worsened quality of life and a shorter lifespan. This insight helps many surgeons define the goals of surgery for patients with ACP. Puget and colleagues proposed a 3-tiered preoperative and postoperative grading system based on the degree of hypothalamic involvement identified on MRI. In a prospective cohort from their institution, the authors found that use of the system to guide operative goals was associated with decreased morbidity. To date, however, the Puget system has not been externally validated. Here, the authors present an interrater reliability study that assesses the generalizability of this system for surgeons planning initial operative intervention for children with craniopharyngiomas. A panel of 6 experts, consisting of pediatric neurosurgeons and pediatric neuroradiologists, graded 30 preoperative and postoperative MRI scans according to the Puget system. Interrater reliability was calculated using Fleiss' κ and Krippendorff's α statistics. Interrater reliability in the preoperative context demonstrated moderate agreement (κ = 0.50, α = 0.51). Interrater reliability in the postoperative context was 0.27 for both methods of statistical evaluation. Interrater reliability for the system as defined is moderate. Slight refinements of the Puget MRI grading system, such as collapsing the 3 grades into 2, may improve its reliability, making the system more generalizable.

A retrospective study of canine cervical disk herniation and the beneficial effects of rehabilitation therapy after ventral slot decompression

The objective of this study was to evaluate the clinical outcome of ventral slot decompression and rehabilitation therapy in dogs with cervical intervertebral disc herniation (IVDH). Surgical decompression was performed in dogs with IVDH using the ventral slot procedure. After surgery, physiotherapeutic rehabilitation consisted of a combination of electrotherapy, infrared therapy and mechanical massage; treadmill exercise was started when the animal could stand up. A total of 58 dogs were selected from the hospital and included in two groups: rehabilitated group (RG, n = 34) and non-rehabilitated group (NRG, n = 24). Dogs of each group were subdivided into five groups based on a pre-operative clinical grading system. Grade 1 designated spinal pain only, grade 2 designated ambulatory paraparesis, grade 3 designated non-ambulatory paraparesis, grade 4 designated paraplegia with deep-pain perception intact and grade 5 designated paraplegia without deep-pain perception. Post-operative changes of both groups were evaluated and compared, including time until unassisted standing and walking after surgery and the success rate. Overall, 79.41% (27/34) of dogs had a successful neurologic outcome in the RG group, which was significantly (P &amp;lt; 0.05) higher than the NRG group 62.50% (15/24). Interestingly, the success rate differed when the preoperative grading system was considered. The success rates of grades 1, 2, 3, 4 and 5 were 100% (9/9), 100% (7/7), 75% (3/4), 53.85% (7/13) and 100% (1/1), respectively, in the rehabilitated groups, whereas in the non-rehabilitated groups success rates were 100% (5/5), 83.33% (5/6), 60.00% (3/5), 28.57% (2/7) and 0% (0/1), respectively. The differences in success rates between the two groups according to grading were 0, 16.67, 15, 25.57 and 100%, respectively. The proposed rehabilitation therapy after surgical decompression of cervical IVDH can improve the success rate when the preoperative pathological condition is severe.

Canine thoracolumbar intervertebral disk herniation and rehabilitation therapy after surgical decompression: A retrospective study.

Objective:The purpose of this study was to evaluate the clinical outcome of surgical decompression and rehabilitation therapy in dogs with thoracolumbar intervertebral disk herniation (IVDH).Materials and Methods:After surgery, physiotherapeutic rehabilitation was performed by a combination of electrotherapy, infrared therapy, training for standing, deep tendon reflex, and aquatic treadmill exercise. A total of 186 dogs were selected from the hospital records and included in two groups: the rehabilitated group (RG, n = 96) and non-rehabilitated group (NRG, n = 90). Dogs in each group were subdivided into three groups based on a pre-operative clinical severity grading system and those in grades 2–4 were included in this study. Post-operative neurologic functions, unassisted standing, walking, and the success rate of both groups were evaluated and comparedResults:Overall, 86.46% (83/96) of dogs had a successful neurologic outcome in the RG group, which was significantly (p < 0.01) higher than the NRG group 52.22% (47/90). Interestingly, the success rate differed when the preoperative grading system was considered. The success rates of grades 2, 3, and 4 were 97.14% (34/35), 97.33% (42/45), and 43.75% (7/16), respectively, in the rehabilitated groups, whereas in the non-rehabilitated groups, success rates were 82.35% (28/34), 51.85% (14/27), and 17.24% (5/29), respectively. The differences in success rates among the groups according to grading were 14.79%, 41.48%, and 26.51%, respectively, indicating that the proposed rehabilitation therapy is remarkably advantageous for increasing the success rate.Conclusion:Rehabilitation therapy after surgical decompression of thoracolumbar IVDH improves neurologic functions and increases the success rate, especially when the preoperative pathological condition is severe.

Cranial Chordoma: A New Preoperative Grading System.

BACKGROUNDChordomas are rare but challenging neoplasms involving the skull base. A preoperative grading system will be useful to identify both areas for treatment and risk factors, and correlate to the degree of resection, complications, and recurrence.OBJECTIVETo propose a new grading system for cranial chordomas designed by the senior author. Its purpose is to enable comparison of different tumors with a similar pathology to clivus chordoma, and statistically correlate with postoperative outcomes.METHODSThe numerical grading system included tumor size, site of the tumor, vascular encasement, intradural extension, brainstem invasion, and recurrence of the tumor either after surgery or radiotherapy with a range of 2 to 25 points; it was used in 42 patients with cranial chordoma. The grading system was correlated with number of operations for resection, degree of resection, number and type of complications, recurrence, and survival.RESULTSWe found 3 groups: low-risk 0 to 7 points, intermediate-risk 8 to 12 points, and high-risk ≥13 points in the grading system. The 3 groups were correlated with the following: extent of resection (partial, subtotal, or complete; P < .002); number of operative stages to achieve removal (P < .014); tumor recurrence (P = .03); postoperative Karnofsky Performance Status (P < .001); and with successful outcome (P = .005). The grading system itself correlated with the outcome (P = .005).CONCLUSIONThe proposed chordoma grading system can help surgeons to predict the difficulty of the case and know which areas of the skull base will need attention to plan further therapy.

In Reply: Cranial Chordoma: A New Preoperative Grading System.

In Reply: Cranial Chordoma: A New Preoperative Grading System.

In Reply: Cranial Chordoma: A New Preoperative Grading System.

In Reply: Cranial Chordoma: A New Preoperative Grading System.

Preoperative Grading System versus Intraoperative Grading System as Predictors for Difficult Laparoscopic Cholecystectomy: A Comparative Validation Study

Preoperative Grading System versus Intraoperative Grading System as Predictors for Difficult Laparoscopic Cholecystectomy: A Comparative Validation Study

Prognostic value with intervertebral herniation disk disease in dogs

Objective: The objective of this retrospective study was to evaluate the preoperative clinical characteristics to predict postoperative neurologic recovery in dogs with intervertebral herniated disk disease (IVDD). Materials and Methods : The dogs were classified according to postoperative neurologic recovery from clinical history of the hospital e-book. Excellent when dogs (n=13) were neurologically normal; good (n=8) when postoperative neurologic grade was improved from preoperative condition had improved sufficiently to require no or minor therapy after discharge; fair (n=4) is considered when postoperative neurologic status was unchanged from preoperative condition and poor (n=5) when major postoperative complication developed as a consequences neurologic grade had worsened at discharge than their preoperative score or the patient died. The evaluated preoperative clinical characteristics in all groups are breed, age, sex, duration of clinical sings appearance (DCSA), preoperative neurologic grading system (PNGS), compression rate (pre and post-operative) in MRI and CT scan, housefield unit (HU), type of IVDD and surgical procedures, and compared with excellent group. Results : no definitive relationship was found between the clinical characteristics and neurologic recovery, except, DCSA and preclinical neurologic pathological condition. The DCSA were 73.54±15.00, 117.63±31.58, 171.25±99.56 and 175.00±94.83 ( P <0.05), respectively. The PNGS were 3±0, 3±0, 4±0 and 4±0 ( P <0.01), respectively. Conclusion : Finally based on this clinical study, it is recommended that postoperative recovery greatly depends on DCSA and PNGS in IVDD dogs. http://doi.org/10.5455/javar.2018.e261

Optimizing a machine learning based glioma grading system using multi-parametric MRI histogram and texture features.

Current machine learning techniques provide the opportunity to develop noninvasive and automated glioma grading tools, by utilizing quantitative parameters derived from multi-modal magnetic resonance imaging (MRI) data. However, the efficacies of different machine learning methods in glioma grading have not been investigated.A comprehensive comparison of varied machine learning methods in differentiating low-grade gliomas (LGGs) and high-grade gliomas (HGGs) as well as WHO grade II, III and IV gliomas based on multi-parametric MRI images was proposed in the current study. The parametric histogram and image texture attributes of 120 glioma patients were extracted from the perfusion, diffusion and permeability parametric maps of preoperative MRI. Then, 25 commonly used machine learning classifiers combined with 8 independent attribute selection methods were applied and evaluated using leave-one-out cross validation (LOOCV) strategy. Besides, the influences of parameter selection on the classifying performances were investigated. We found that support vector machine (SVM) exhibited superior performance to other classifiers. By combining all tumor attributes with synthetic minority over-sampling technique (SMOTE), the highest classifying accuracy of 0.945 or 0.961 for LGG and HGG or grade II, III and IV gliomas was achieved. Application of Recursive Feature Elimination (RFE) attribute selection strategy further improved the classifying accuracies. Besides, the performances of LibSVM, SMO, IBk classifiers were influenced by some key parameters such as kernel type, c, gama, K, etc. SVM is a promising tool in developing automated preoperative glioma grading system, especially when being combined with RFE strategy. Model parameters should be considered in glioma grading model optimization.

A Novel Biomarker-Based Preoperative Prognostic Grading System for Predicting Survival After Surgery for Intrahepatic Cholangiocarcinoma.

Although treatment strategies for intrahepatic cholangiocarcinoma (ICC) are shifting towards multidisciplinary approaches, preoperative radiographic methods for identifying patients requiring further therapy are unclear. This study was designed to establish a prognostic grading system using preoperatively available objective biomarkers. A novel preoperative prognostic grading system for predicting survival after surgery for ICC was developed from multivariate analysis of 134 ICC patients who underwent surgery between 1996 and 2015 using preoperatively available biomarkers. The median overall survival time and 3- and 5year survival rates were 33.3months, 48, and 38%, respectively. Of the preoperative biomarkers, the neutrophil-to-lymphocyte ratio (≥5), and C-reactive protein (≥5mg/L) and carbohydrate antigen 19-9 (≥500IU/mL) levels were independently associated with poor overall survival. Based on the presence of these factors, the preoperative prognostic grades were defined as follows: grade 1, no factor; grade 2, one factor; and grade 3, two or three factors. The median overall survival time and 3- and 5year survival rates of patients with grade 1 (70.3months, 66, and 53%, respectively) were higher than those of patients with grade 2 (23.4months, 37, and 30%, respectively; P=0.004) and grade 3 (8.8months, 5% both; 2 vs. 3, P<0.001). Multivariable analysis revealed that the preoperative prognostic grading system independently predicted survival after adjusting for known prognostic factors. A novel biomarker-based preoperative prognostic grading system for ICC significantly stratifies survival after surgery and may identify patients requiring further treatment.

Surgical treatment of congenital aural atresia – is it still justified?

Conclusion: Surgery candidacy based on the surgical accessibility of the middle ear seems more valuable than the use of a preoperative grading system. Also patients with severe malformations can benefit from surgical reconstruction. Objective: To evaluate the long-term results of the primary surgical treatment of patients with congenital auricular atresia (CAA). Methods: One hundred patients with CAA underwent surgical reconstruction between 1985 and 2010. The mean follow-up time was 40 months. All patients were retrospectively scored using the Jahrsdoerfer grading scale and divided into two groups according to the grade of their malformation. Group 1 included 20 patients with scores of 4–6 and group 2 included 80 patients with scores of 7–10. Pre- and postoperative air conduction (AC), bone conduction (BC), pure-tone average ‘air–bone gap’ (PTA4-ABG), surgical findings, postoperative complications, and revision surgeries performed were determined and compared between the two groups. Results: For 90% of the patients in group 1 and 79% of the patients in group 2, the postoperative ABG was within 0 and 30 dB. The most common complications were recurrent infection, lateralization of the tympanic membrane, and restenosis of the ear canal.

Surgical management of spinal meningiomas: A retrospective case analysis based on preoperative surgical grade.

Background:Although spinal meningiomas respond favorably to surgical excision, their surgical management is impacted by several factors. This study utilized a surgery-based grading system to discuss the optimal surgical strategy.Methods:Twenty-three consecutive patients who underwent surgery for spinal meningiomas were included in this retrospective study. The patients’ neurological condition was assessed using the modified McCormick functional schema (mMFS) and sensory pain scale (SPS), and tumor removal was assessed using Simpson grade. Major factors contributing to surgical difficulty included; tumor size, extent/severity of cord compression, location of tumor attachment, spinal level, and anatomical relationships plus tumor extending in a dumbbell shape and local postoperative recurrence.Results:Fifteen cases were classified as ventral attachment (65.2%). There were two dumbbell-shaped tumors and three local recurrences at the primary site. Simpson grade 1 or 2 resections were performed in 18 of 20 cases (90%) with preoperative surgical grades 0 to 3. Simpson grade 4 resections were achieved in all three cases with preoperative surgical grades 4 to 5. Overall neurological assessment after surgery revealed the satisfactory or acceptable recovery on mMFS and SPS analysis.Conclusions:Lower preoperative grade yielded better results, while the higher the preoperative grade, the more likely tumor was insufficiently removed. A preoperative surgical grading system appeared to be helpful when considering the surgical strategy. Ventral meningiomas could be safely resected via the posterolateral or lateral approach using technical modifications. Recurrent tumors, especially with ventral attachment, were hard to resolve, and primary surgery appears to be important.

A proposed classification system that projects outcomes based on preoperative variables for adult patients with glioblastoma multiforme

Glioblastoma multiforme (GBM) is the most common and aggressive type of primary brain tumor in adults. Although the average survival is approximately 12 months, individual survival is heterogeneous. The ability to predict short- and long-term survivors is limited. Therefore, the aims of this study were to ascertain preoperative risk factors associated with survival, develop a preoperative prognostic grading system, and evaluate the utility of this grading system in predicting survival for patients undergoing resection of a primary intracranial GBM. Cases involving adult patients who underwent surgery for an intracranial primary (de novo) GBM between 1997 and 2007 at The Johns Hopkins Hospital, an academic tertiary-care institution, were retrospectively reviewed. Multivariate proportional hazards regression analysis was used to identify preoperative factors associated with survival, after controlling for extent of resection and adjuvant therapies. The identified associations with survival were then used to develop a grading system based on preoperative variables. Survival as a function of time was plotted using the Kaplan-Meier method, and survival rates were compared using Log-rank analysis. Associations with p < 0.05 were considered statistically significant. Of the 393 patients in this study, 310 (79%) had died as of most recent follow-up (median time from surgery to death 11.9 months). The preoperative factors, independent of extent of resection and adjuvant therapies (carmustine wafers, temozolomide, and radiation), found to be negatively associated with survival were: age > 60 years (p < 0.0001), Karnofsky performance status score < or = 80 (p < 0.0001), motor deficit (p = 0.02), language deficit (p = 0.001), and periventricular tumor location (p = 0.04). Patients possessing 0-1, 2, 3, and 4-5 of these variables were assigned a preoperative grade of 1, 2, 3, and 4, respectively. Patients with a preoperative grade of 1, 2, 3, and 4 had a median survival of 16.6, 10.2, 6.8, and 6.1 months, respectively. The present study found that older age, poor performance status, motor deficit, language deficit, and periventricular tumor location independently predicted poorer survival in patients undergoing GBM resection. A grading system based on these factors was able to identify 4 distinct groups of patients with different survival rates. This grading system, based only on preoperative variables, may provide patients and physicians with prognostic information that may guide medical and surgical therapy before any intervention is pursued.

Meningiomas de la base de cráneo. Un sistema predictivo para conocer las posibilidades de su extirpación y pronóstico

The aim of this study was to build a preoperative predictive system which could provide reliable information about: 1 degrees which skull base meningiomas can be total or partially removed, and 2 degrees their surgical outcome. Patient histories and imaging data were reviewed retrospectively from 85 consecutive skull base meningiomas patients who underwent surgery from 1990 and 2002. From the preoperative data, nine variables were selected for conventional statistical analysis as regards their relationship with: 1 degrees total vs partial tumor resection and 2 degrees with patients outcome according to the degree of tumour removal. From the nine variables analysed only two had a statistical association with the type of tumour resection performed (total vs partial) and the patient outcome: 1) arteries encasement and 2) cranial nerves involvement. Upon correlating these two variables with the type of tumour resection performed (total vs partial) and with the Karnofsky'scale to evaluate patients surgical outcome, the following grading groups were identified: Grade I: skull base meningiomas which did not involve cranial nerves or artery or only encased one artery or one cranial nerve. In these cases the incidence of gross tumour resection was 98.3% (p< 0.0001) and the perspective to reach 70 points in the Karnofsky'scale was of 96.5% ( p=0.001). Grade II: skull base meningiomas which involved one cranial nerve and encased, at least, two main cerebral arteries. In these cases, the frequency of total resection, decreased to 83.3% (p<0.0001) and the probability to reach 70 points in the Karnofsky'scale was 70.6% (p=0.001). Grade III: skull base meningiomas which involved two or more cranial nerves and encased several arteries In this group, the frequency of a total resection was of 42.9% (p<0.0001) and the probability of reaching 70 points in the Karnofsky'scale was only 60% (p=0.001). We propose a preoperative grading system for skull base meningiomas that helps predicting both whether total or partial tumor removal will be achieved during surgery and the immediate postsurgical outcome of the patient. In applying this predictive system we will be able to reduce surgical morbidity, to advance the possibility of a radiosurgical treatment and give a more precise information to the patients and their families about our surgical decision-making process.