Supratentorial Gliomas Research Articles

Mismatch repair-deficient glioma with spatially distinct IDH-mutant and IDH-wild type components arising in the setting of Lynch syndrome.

Pathogenic mutations in MLH1, MSH2, PMS2, and MSH6 compromise DNA mismatch repair mechanisms and in the heterozygous state result in Lynch syndrome, which is typified by a predisposition to endometrial, ovarian, colorectal, gastric, breast, hematologic, and soft tissue cancers. Rarely, germline pathogenic aberrations in these genes are associated with the development of primary central nervous system tumors. We present a report of an adult female with no prior cancer history who presented with a multicentric, infiltrative supratentorial glioma involving both the left anterior temporal horn and left precentral gyrus. Surgical treatment and neuropathological/molecular evaluation of these lesions revealed discordant isocitrate dehydrogenase (IDH) status and histologic grade at these spatially distinct disease sites. A frameshift alteration within the MLH1 gene (p.R217fs*12, c.648delT) was identified in both lesions and subsequently identified in germline testing of a blood sample, consistent with Lynch syndrome. Despite distinct histopathologic features and divergent IDH status of the patient's tumors, the molecular findings suggest that both sites of intracranial neoplasia may have developed as a consequence of underlying monoallelic germline mismatch repair deficiency. This case illustrates the importance of characterizing the genetic profile of multicentric gliomas and highlights the oncogenic potential of germline mismatch repair gene pathogenic alterations within central nervous system gliomas.

Applied Fence-Post Techniques Using Deep Electrodes Instead of Catheters for Resection of Glioma Complicated with Frequent Epileptic Seizures: A Case Report

Fence-post catheter techniques are used to use tumor margins when resecting gliomas. In the present study, deep electrodes instead of catheters were used as fence-posts. The case of a 25-year-old female patient whose magnetic resonance images (MRI) revealed a tumor in the left cingulate gyrus is presented in this study. She underwent daily seizures without loss of consciousness under the administration of anti-seizure medications. Despite video electroencephalography (EEG) monitoring, the scalp inter-ictal EEG did not show obvious epileptiform discharges. We were consequently uncertain whether such frequent seizures were epileptic seizures or not. As a result, deep electrodes were used as fence-posts: three deep electrodes were inserted into the tumor's anterior, lateral, and posterior margins using a navigation-guided method. The highest epileptic discharge was detected from the anterior deep electrode. As a result, ahead of the tumor was extendedly resected, and epileptic discharges were eliminated using EEG. The postoperative MRI revealed that the tumor was resected. The patient has never experienced seizures after the surgery. In conclusion, when supratentorial gliomas complicated by frequent seizures are resected, intraoperative EEG monitoring using deep electrodes as fence-posts is useful for estimating epileptogenic areas.

MicroRNAs in the Diagnosis of Malignancy of Supratentorial Brain Gliomas and Prognosis of Disease Progression.

The study of brain tumors has shown that microRNAs can act as both oncogenes and tumor suppressors and, consequently, can be used as biomarkers for the diagnosis and prognosis of such tumors. Thus, big interest arises in the role of microRNA and its part in oncogenesis in the human brain to find key molecules that can act as tumor markers for diagnostic and prognostic purposes, as well as potential therapeutic agents. The sim of this study was to assess histological, molecular, and genetic metrics in patients with supratentorial gliomas, and indicate diagnostic and prognostic abilities of microRNA usage as biomarkers of the grade of malignancy of the tumor. Clinical and genetic studies were performed in 107 operated patients with supratentorial gliomas of different malignancies. The expression levels of 10 microRNAs (-16, -21¸ -31, -124, - 125b, -181b, -191, -221, -223, and -451) were analyzed using real-time polymerase chain reaction (PCR). The results were analyzed statistically using Statistica 12.0 (Statistica, Hamburg, Germany) and GraphPad Prism 9 software (GraphPad Software Inc., Boston, Massachusetts, United States). Based on a comprehensive statistical analysis involving the database of the clinical results of treatment of all 107 patients (combined treatment methods, quality of life, and survival) and microRNA expression levels, specific profiles of microRNA expression typical of different histotypes of gliomas of different malignancy were identified, the prognostic significance of the studied microRNAs as potential predictors of survival in patients with brain gliomas was determined, and microRNAs with the highest prognostic value were identified among them.

Predictive Value of Preoperative Diffusion Tensor Imaging for Evaluating Postoperative Outcomes of Supratentorial Glioma in the Motor Function Area.

This study aimed to assess the predictive value of preoperative diffusion tensor imaging (DTI) data for surgical outcomes of patients with supratentorial glioma in the motor function area. This is a retrospective study of 43 patients receiving navigation-guided surgery for histopathologically demonstrated supratentorial glioma in the motor function area. All patients underwent preoperative 3 Tesla magnetic resonance imaging examinations with conventional and DTI sequences. Data on preoperative imaging and pre- and postoperative clinical characteristics of patients were retrospectively collected. Univariate and multivariate linear regressions were applied to analyze the relationships between preoperative parameters and pre- and postoperative muscle strength and the Karnofsky Performance Status (KPS) score. Fourteen patients had low-grade gliomas and 29 had high-grade gliomas. Although the corticospinal tract (CST) score did not differ significantly between tumor grades, edema and deviation were common in low-grade gliomas (64.3%), while destroyed and infiltrated lesions were common in high-grade gliomas (58.6%). Muscle strength improved after surgery in the deviated tract group (40%) more than in the infiltrated tract group (33.3%). Two independent indices, preoperative muscle strength (p =0.000) and glioma-to-CST distance (p =0.001), were linearly related to postoperative muscle strength. The preoperative KPS score was the only indicator that affected the postoperative KPS score (p =0.000). DTI should be considered in surgical management of supratentorial gliomas in the motor function area to determine the appropriate surgical strategy and predict the nature of the tumor and postoperative motor function.

Feasibility of predicting the evolution of cerebral gliomas based on study of microRNA expression levels in blood plasma and saliva

The management of cerebral glioma (CG) remains challenging. Recently, methods based on the study of the expression levels of miRNAs in blood plasma have proven to be promising. The volume of tumor tissue is known to correlate with increased expression levels of microRNA-21 and -210. MicroRNA-15, -16, -34, -126 and -342 are involved in the regulation of tumor proliferative potential, and microRNA-128 is involved in the regulation of metabolic activity.The aim of the study was to evaluate the extended protocol for assessing the expression of microRNA-15, -16, -21, -34, -126, -128, -210, and -342 in the plasma and saliva of CG patients.Material and Methods. The study group consisted of 24 patients with supratentorial glioma (8 men and 16 women aged 41 to 71 years, mean age: 56 years). The control group consisted of 30 volunteers. MicroRNA expression was studied in plasma and saliva according to the StemLoop-RealTime protocol, using fluorescently labeled samples with small miRNA U6 as a reference gene. Statistical analysis was carried out using nonparametric methods.Results. The lack of CG stabilization and the most probable progression of the tumor with a poor prognosis was related to an increase in microRNA-21 and -210 expression levels and decrease in microRNA-128 expression and at least four of microRNA 15, -16, -34, -126, and -342. Stabilization of CG with a high probability of progression was associated with an increase in microRNA-21 or microRNA210 expression levels, decrease in no more than three of microRNA-15, -16, -34, -126, -342 expression levels as well as decrease in microRNA-128 expression. Stabilization of the tumor with a low probability of progression was associated with a decrease in the expression of microRNA-21 and -210 and in no more than one of miRNA-15, -16, -34, -126, -342 below the reference level, with a simultaneous increase in miRNA-128 expression.Conclusion. The determination of microRNA expression in blood plasma and saliva can be one of the important criteria for assessing the prognosis of CG.

Spatial distribution of supratentorial diffuse gliomas: A retrospective study of 990 cases.

Gliomas distribute unevenly in the supratentorial brain space. Many factors were linked to tumor locations. This study aims to describe a more detailed distributing pattern of these tumors with age and pathological factors concerned. A consecutive series of 990 adult patients with newly-diagnosed supratentorial diffuse gliomas who underwent resection in Beijing Tiantan Hospital between January 2013 and January 2017 were retrospectively reviewed. For each patient, the anatomic locations were identified by the preoperative MRI, and the pathological subtypes were reviewed for histological grade and molecular status (if any) from his medical record. The MNI template was manually segmented to measure each anatomic location's volume, and its invaded ratio was then adjusted by the volume to calculate the frequency density. Factors of age and pathological subtypes were also compared among locations. The insulae, hippocampi, and corpus callosum were locations of the densest frequencies. The frequency density decreased from the anterior to posterior (frontal - motor region - sensory region - parietal - occipital), while the grade (p < 0.0001) and the proportion of IDH-wt (p < 0.0001) increased. More tumors invading the right basal ganglion were MGMT-mt (p = 0.0007), and more of those invading the left frontal were TERT-wt (p = 0.0256). Age varied among locations and pathological subtypes. This study demonstrated more detailed spatial disproportions of supratentorial gliomas. There are potential interactions among age, pathological subtypes, and tumor locations.

Clinical factors affecting post-operative seizure control after supratentorial low-grade glioma resection in adults.

Up to 88% of patients with low grade glioma (LGG) experience seizures during the course of their disease. In patients who undergo surgery for supratentorial low grade glioma (SLGG), post-operative seizures can impact their quality of life and complicate the post-operative management course. Evidence suggests that epileptic activity can be related to tumour progression. In addition to the extent of resection, recent studies have investigated the possible patient and tumour factors which can influence post-operative seizure control in patients with SLGG.

Haemostatic technique in malignant gliomas.

Haemostasis in brain surgery is mandatory to avoid postoperative re-bleeding and a poor outcome. Postoperative intra-cavity haemorrhage is a frequent complication, especially in surgery of malignant gliomas because of the fragility of pathological vessels. In this technical note, we describe our 'compression' technique used to achieve haemostasis in adult patients who underwent surgery for supratentorial malignant gliomas (GBM) at our Institute from January 2019 to January 2022. Peri-operative work-up included clinical status, laboratory data and contrast brain CT, performed at 24 hours after surgery, or earlier for patients with neurological worsening. A total of 82 patients was included in this study, 46 males (57%) and 36 females (43%). A post-operative intra-cavity haemorrhage was documented by postoperative CT-scan in 3/82 patients (3.65%), and the mean surgical time was 3.66 hours. No late bleeding was observed 48 hours after surgery. We have documented the good results of our technique to achieve haemostasis in patients operated for malignant glioma (GBM). The technique described in this study seems to be safe and useful to avoid post-operative bleeding in the surgery of cerebral GBM.

Cerebellar High-Grade Glioma: A Translationally Oriented Review of the Literature.

World Health Organization (WHO) grade 4 gliomas of the cerebellum are rare entities whose understanding trails that of their supratentorial counterparts. Like supratentorial high-grade gliomas (sHGG), cerebellar high-grade gliomas (cHGG) preferentially affect males and prognosis is bleak; however, they are more common in a younger population. While current therapy for cerebellar and supratentorial HGG is the same, recent molecular analyses have identified features and subclasses of cerebellar tumors that may merit individualized targeting. One recent series of cHGG included the subclasses of (1) high-grade astrocytoma with piloid features (HGAP, ~31% of tumors); (2) H3K27M diffuse midline glioma (~8%); and (3) isocitrate dehydrogenase (IDH) wildtype glioblastoma (~43%). The latter had an unusually low-frequency of epidermal growth factor receptor (EGFR) and high-frequency of platelet-derived growth factor receptor alpha (PDGFRA) amplification, reflecting a different composition of methylation classes compared to supratentorial IDH-wildtype tumors. These new classifications have begun to reveal insights into the pathogenesis of HGG in the cerebellum and lead toward individualized treatment targeted toward the appropriate subclass of cHGG. Emerging therapeutic strategies include targeting the mitogen-activated protein kinases (MAPK) pathway and PDGFRA, oncolytic virotherapy, and immunotherapy. HGGs of the cerebellum exhibit biological differences compared to sHGG, and improved understanding of their molecular subclasses has the potential to advance treatment.

The Role of Clinical Picture of Supratentorial Glioma on the Outcome of Surgery

The Role of Clinical Picture of Supratentorial Glioma on the Outcome of Surgery

Cortical mapping in glioma surgery: correlation of fMRI and direct electrical stimulation with Human Connectome Project parcellations.

Noninvasive brain mapping with functional MRI (fMRI) and mapping with direct electrical stimulation (DES) are important tools in glioma surgery, but the evidence is inconclusive regarding the sensitivity and specificity of fMRI. The Human Connectome Project (HCP) proposed a new cortical parcellation that has not been thoroughly tested in a clinical setting. The main goal of this study was to evaluate the correlation of fMRI and DES mapping with HCP areas in a clinical setting, and to evaluate the performance of fMRI mapping in motor and language tasks in patients with glioma, using DES as the gold standard. Forty patients with supratentorial gliomas were examined using preoperative fMRI and underwent awake craniotomy with DES. Functional activation maps were visualized on a 3D representation of the cortex, classified according to HCP areas, and compared with surgical mapping. Functional MRI was successful in identifying language and motor HCP areas in most cases, including novel areas such as 55b and the superior longitudinal fasciculus (SLF). Functional MRI had a sensitivity and specificity of 100% and 71%, respectively, for motor function in HCP area 4. Sensitivity and specificity were different according to the area and fMRI protocol; i.e., semantic protocols performed better in Brodmann area (BA) 55b/peri-sylvian language areas with 100% sensitivity and 20% specificity, and word production protocols in BAs 44 and 45 with 70% sensitivity and 80% specificity. Some compensation patterns could be observed, such as motor activation of the postcentral gyrus in precentral gliomas. HCP areas can be detected in clinical scenarios of glioma surgery. These areas appear relatively stable across patients, but compensation patterns seem to differ, allowing occasional resection of activating areas. Newly described areas such as 55b and SLF can act as critical areas in language networks. Surgical planning should account for these parcellations.

Effect of intraoperative goal-directed fluid therapy on the postoperative brain edema in patients undergoing high-grade glioma resections: a study protocol of randomized control trial

IntroductionBrain edema is the most frequent postoperative complication after brain tumor resection, especially in patients with high-grade glioma. However, the effect of SVV-based goal-directed fluid therapy (GDFT) on postoperative brain edema and the prognosis remain unclear.Methods and analysisThis is a prospective, randomized, double-blinded, parallel-controlled trial aiming to observe whether stroke volume variation (SVV)-based GDFT could improve the postoperative brain edema in patients undergoing supratentorial high-grade gliomas compared with traditional fluid therapy. The patient will be given 3 ml/kg hydroxyethyl starch solution when the SVV is greater than 15% continuously for more than 5 min intraoperatively. The primary outcome will be postoperative cerebral edema volume on brain CT within 24 h.Ethics and disseminationThis trial has been registered at ClinicalTrials.gov (NCT03323580) and approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (reference number: KY2017-067-02). The findings will be disseminated in peer-reviewed journals and presented at national or international conferences relevant to the subject fields.Trial registrationClinicalTrials.gov NCT03323580 (First posted: October 27, 2017; Last update posted: February 11, 2022).

SURG-29. CAN NEOADJUVANT CHEMOTHERAPY INCREASE EXTENT OF RESECTION IN DIFFUSE LOWER-GRADE GLIOMA?

Abstract INTRODUCTION Maximal safe surgical resection remains front-line treatment for diffuse lower-grade gliomas (DLGGs). Greater extent of resection (EOR) can delay transformation, control seizures, and improve survival. EOR is limited by the infiltrative nature of DLGGs and eloquent brain location preponderance. We investigated the role of neoadjuvant chemotherapy in tumour volume reduction (TVR) for cases in which a meaningful EOR was deemed unachievable. METHODS Retrospective review (2000-2020) of patients in a large tertiary UK brain tumor centre who serendipitously underwent management that did or could mimic a neoadjuvant chemotherapy pathway. Inclusion criteria: &amp;gt;18 years at diagnosis; histologically-proven WHO grade 2 supratentorial glioma; received chemotherapy alone after biopsy then +/- debulking. Tumour volume delta +/- EOR were calculated on serial MRI T2/FLAIR sequences using a semi-automated quantitative analysis tool (Smartbrush, BrainLab® AG). RESULTS Group 1 (neoadjuvant chemotherapy and then surgery, n=4): debulking was considered unachievable initially but then possible post-chemotherapy. Median TVR post-chemotherapy was 16.90% (range 0.45–64.90%). Mean EOR was 68.67% (33.72–100%). Median overall survival (OS) and progression free survival (PFS) were 85 (18–154) and 62 (13–153) months, respectively. Group 2 (biopsy followed by chemotherapy alone, n=7): debulking was considered unachievable initially. Median TVR post-chemotherapy was 25.68% (-294.95–46.02%, one patient progressed during chemotherapy). Median OS and PFS were 92 (6–135) and 27 (3–80) months, respectively. On re-review, and based on Group 1 results, some Group 2 patients may have been able to undergo debulking with meaningful EOR post-chemotherapy. CONCLUSIONS Chemotherapy can have a significant impact on reducing tumour volumes, such that cases initially deemed unsuitable for debulking may be converted into those in which a meaningful EOR can be achieved. Larger, multicentre, retrospective studies, and prospective trials are needed to determine the role of chemotherapy as a neoadjuvant tool in the management of DLGGs.

DDEL-11. DETERMINING THE DOSE OF REGADENOSON MOST LIKELY TO TRANSIENTLY ALTER THE INTEGRITY OF THE BLOOD-BRAIN BARRIER IN PATIENTS WITH GLIOMAS

Abstract BACKGROUND The blood brain barrier (BBB) is a major obstacle to the delivery of chemotherapy to the CNS. Regadenoson is an FDA approved adenosine A2 agonist used for cardiac stress tests. In murine models, it transiently increases BBB permeability to a 70KD dextran. This multi-institutional, NIH funded, Adult Brain Tumor Consortium trial was designed to discover a dose of regadenoson that substantially increases vascular permeability in normal appearing white matter (NAWM) where drug delivery is particularly challenging. METHODS Adults ages 18-45 with supratentorial gliomas at low-risk for regadenoson complications were recruited (n = 7). One patient was treated at each of seven dose levels (from 0.05 to 1.4 mg) that are known to be safe in humans. The primary outcome measure is change in vascular permeability via dynamic contrast enhanced (DCE) perfusion MRI estimates of Ktrans. The primary outcome measure was a 10-fold higher Ktrans in NAWM than reported in literature (Ktrans &amp;gt; 0.04 min-1). Contrast-enhanced T1 subtraction map estimates of change in contrast enhancement and other measurements in normal brain and non-enhancing tumor were quantified. RESULTS Ktrans measures in NAWM averaged 1.13x10-3 ± 0.44x10-3 (SEM) min-1, lower than the target of 0.04 min-1. Normalized, contrast enhanced T1-weighted MR signal intensity in NAWM increased an average of 74.0 ± 22.4% min-1 (SEM) min-1, which was significantly higher than zero (P = 0.0163). Data available from this limited sample failed to meet the target goal in Ktrans increase or change in contrast enhancing signal intensity. CONCLUSION Administration of regadenoson at seven different doses did not significantly elevate Ktrans for gadolinium in NAWM. This data suggests that single doses of regadenoson are unlikely to substantially increase the delivery of therapeutic agents in non-enhancing brain tissue. This trial design is appropriate for further human testing of other regadenoson schedules and other novel approaches aimed at transiently modifying BBB permeability.

Dural arteriovenous fistulas misdiagnosed as intracranial neoplasms: illustrative case.

Dural arteriovenous fistulas (dAVF) may induce imaging findings attributable to various disease entities including malignant neoplasms. In these cases, diagnosis and adequate treatment are often delayed and patients may be exposed to spurious treatments in addition to the risks inherent to an untreated dAVF with cortical venous drainage. The authors report a case of a patient referred for surgical treatment of a supratentorial high-grade glioma. Thorough review of imaging data challenged the initial radiological diagnosis and led to proper angiographic workup. As a result, a high-grade dAVF was confirmed and successfully embolized. In addition to this case, we provide an extensive literature review on dAVF initially diagnosed as cerebral neoplasms, including clinical, imaging and follow-up data. The literature provides diagnostic criteria for dAVF on magnetic resonance imaging; however, those criteria may be only partly applicable in many cases. Misdiagnosis of a neoplasm due to dAVF has been reported but remains rare, especially in supratentorial lesions. Digital subtraction angiography should be pursued to rule out an underlying vascular pathology if any doubt. This may prevent unnecessary interventions such as biopsies, pharmacological treatment and a delay in dAVF treatment, given its associated risk of hemorrhage and nonhemorrhagic neurological deficits.

Brain and Brainstem Necrosis after Re-Irradiation for Recurrent Childhood Central Nervous System (CNS) Tumors: A Report from the Pediatric Normal Tissue Effects in the Clinic (PENTEC) Task Force

<h3>Purpose/Objective(s)</h3> Re-irradiation is increasingly used in children, adolescents and young adults (AYA) with recurrent CNS tumors. The PENTEC re-irradiation task force reports the results on the risk of symptomatic necrosis following cranial re-irradiation, and its dependence on cumulative dose. <h3>Materials/Methods</h3> A systematic literature search for peer-reviewed articles 1975 to 2021 identified 1183 studies on re-irradiation and 92 studies on re-irradiation for recurrent CNS tumors. Studies on predominantly adult populations and re-irradiation for secondary neoplasms were excluded (n=49). Data from the remaining 43 studies were captured. 17 studies (n=449), reporting brain and brainstem necrosis were used for analysis. While all studies mentioned techniques and range of doses used for re-irradiation, they lacked details on significant dose-volume metrics (e.g., percentage of re-irradiation treatment volume overlapping with primary radiotherapy, mean and maximum cumulative equivalent dose in 2Gy fractions, with alpha-beta ratio=2 (EQD2/2) to organs at risk) necessary for a dose-response modelling. We, therefore, estimated the incidence of necrosis with an exact 95% confidence interval (CI) and provided a qualitative description of the data. <h3>Results</h3> Treated cancers included ependymoma (n=279;7 studies), medulloblastoma (n=98; 6 studies), any CNS tumors (n=62: 3 studies) and supratentorial high-grade gliomas (n=10: 1 study). The median interval between initial and re-irradiation was 2.3 years (range 1.2-4.75). The median cumulative EQD2/2 prescription dose was 103.8 Gy (range 79.7-141.3). Among 449 children/AYA treated with re-irradiation, 22 (4.9%, 95% CI 3.1-7.3%) developed brain necrosis and 14 (3.1%, 95% CI 1.7-5.2%) brainstem necrosis. The median cumulative prescription EQD2/2 was 111.4 Gy (range 79.7-141.3) for development of any necrosis, 107.7 Gy (range 79.7-141.3) for brain necrosis and 112.1 Gy (range 100.2-117) for brainstem necrosis. In 6 studies (n=176) of conventionally fractionated (≤2 Gy per fractions) re-irradiation, 7 patients developed brain necrosis (3.9%) and 4 brainstem necrosis (1.7). In the 5 studies (n=160) of hypofractionated (4-24 Gy per fraction) re-irradiation, 9 patients developed brain necrosis (5.6%) and 10 brainstem necrosis (6.9%). Though there were more necroses in the hypofractionated group, it was not statistically significant (Fisher's exact test 2-tailed p value=0.4664). The remaining six studies (n=113) used a range of fraction size (1.8-24 Gy). No studies reported cumulative dosing for individual organs at risk. <h3>Conclusion</h3> Existing literature suggests that in children and AYA with recurrent brain tumors, re-irradiation results in less than 5-7% incidence of brain/brainstem necrosis with conventional prescription doses after a median follow-up of 2.3 years. A uniform approach for reporting dosimetric endpoints is recommended to derive a robust predictive model of late toxicities following re-irradiation.

Occurrence, Risk Factors, and Consequences of Postoperative Ischemia After Glioma Resection: A Retrospective Study.

Postoperative ischemia can lead to neurological deficits and is a known complication of glioma resection. There is inconsistency in documented incidence of ischemia after glioma resection, and the precise cause of ischemia is often unknown. To assess the incidence of postoperative ischemia and neurological deficits after glioma resection and to evaluate their association with potential risk factors. One hundred thirty-nine patients with 144 surgeries between January 2012 and September 2014 for World Health Organization (WHO) 2016 grade II-IV diffuse supratentorial gliomas with postoperative MRI within 72 hours were retrospectively included. Patient, tumor, and perioperative data were extracted from the electronic patient records. Occurrence of postoperative confluent ischemia, defined as new confluent areas of diffusion restriction, and new or worsened neurological deficits were analyzed univariably and multivariably using logistic regression models. Postoperative confluent ischemia was found in 64.6% of the cases. Occurrence of confluent ischemia was associated with an insular location ( P = .042) and intraoperative administration of vasopressors ( P = .024) in multivariable analysis. Glioma location in the temporal lobe was related to an absence of confluent ischemia ( P = .01). Any new or worsened neurological deficits occurred in 30.6% and 20.9% at discharge from the hospital and at first follow-up, respectively. Occurrence of ischemia was significantly associated with the presence of novel neurological deficits at discharge ( P = .013) and after 3 months ( P = .024). Postoperative ischemia and neurological deficit were significantly correlated. Intraoperative administration of vasopressors, insular glioma involvement, and absence of temporal lobe involvement were significantly associated with postoperative ischemia.

Role of Magnetic Resonance Imaging (MRI) in grading gliomas comparable with pathology: A cross-sectional study from Syria.

ObjectiveGliomas are one of the most common brain tumors in adults with a poor prognosis in most patients. Magnetic Resonance Imaging (MRI) plays a critical role in the diagnosis, management, and follow-up of gliomas. The aim of this study is to assess the sensitivity and specificity of MRI in the preoperative grading of supratentorial gliomas in comparison to histopathology.MethodsA cross-sectional study included 39 patients, aged between 40 and 75 years with histologically diagnosed supratentorial gliomas who underwent conventional MR imaging, which included T1, T2, and FLAIR sequences from November 2018–December 2019 in the Department of Neurosurgery, Tishreen University Hospital, Lattakia. The histopathological typing and grading of the tumor were done by using 2016 WHO classification. The sensitivity, specificity, predictive value, and accuracy of MRI in determining tumor grade were calculated. The comparison was done between MRI findings and WHO histopathological grading.ResultsThe overall sensitivity and specificity of MRI findings in the assessment of high-grade gliomas were 100% and 91% respectively. The positive predictive value (PPV) was 66.6%, and the negative predictive value (NPV) was 100%. The overall accuracy was 94.9%. The agreement between histopathological and MRI findings was 72%.ConclusionsMRI plays an essential role in the initial diagnosis and grading of supratentorial gliomas with high sensitivity and specificity. It is considered a non-invasive method and is useful in cases where the biopsy procedure is a contraindication or rejected by the patient.

Diffusion tensor imaging, intra-operative neurophysiological monitoring and small craniotomy: Results in a consecutive series of 103 gliomas.

Diffusion tensor imaging (DTI) allows visualization of the main white matter tracts while intraoperative neurophysiological monitoring (IONM) represents the gold standard for surgical resection of gliomas. In recent years, the use of small craniotomies has gained popularity thanks to neuronavigation and to the low morbidity rates associated with shorter surgical procedures. The aim of this study was to review a series of patients operated for glioma using DTI, IONM, and tumor-targeted craniotomies. The retrospective analysis included patients with supratentorial glioma who met the following inclusion criteria: preoperative DTI, intraoperative IONM, tumor-targeted craniotomy, pre- and postoperative MRI, and complete clinical charts. The DTI was performed on a 3T scanner. The IONM included electroencephalography (EEG), transcranial (TC) and/or cortical motor-evoked potentials (MEP), electrocorticography (ECoG), and direct electrical stimulation (DES). Outcomes included postoperative neurological deficits, volumetric extent of resection (EOR), and overall survival (OS). One hundred and three patients (61 men, 42 women; mean age 54 ± 14 years) were included and presented the following WHO histologies: 65 grade IV, 19 grade III, and 19 grade II gliomas. After 3 months, only three patients had new neurological deficits. The median postoperative volume was 0cc (IQR 3). The median OS for grade IV gliomas was 15 months, while for low-grade gliomas it was not reached. In our experience, a small craniotomy and a tumor resection supported by IONM and DTI permitted to achieve satisfactory results in terms of neurological outcomes, EOR, and OS for glioma patients.

Full-course resection control strategy in glioma surgery using both intraoperative ultrasound and intraoperative MRI.

BackgroundIntraoperative ultrasound(iUS) and intraoperative MRI (iMRI) are effective ways to perform resection control during glioma surgery. However, most published studies employed only one modality. Few studies have used both during surgery. How to combine these two techniques reasonably, and what advantages they could have for glioma surgery are still open questions.MethodsWe retrospectively reviewed a series of consecutive patients who underwent initial surgical treatment of supratentorial gliomas in our center. We utilized a full-course resection control strategy to combine iUS and iMRI: IUS for pre-resection assessment and intermediate resection control; iMRI for final resection control. The basic patient characteristics, surgical results, iMRI/iUS findings, and their impacts on surgical procedures were evaluated and reported.ResultsA total of 40 patients were included. The extent of resection was 95.43 ± 10.37%, and the gross total resection rate was 72.5%. The median residual tumor size was 6.39 cm3 (range 1.06–16.23 cm3). 5% (2/40) of patients had permanent neurological deficits after surgery. 17.5% (7/40) of patients received further resection after the first iMRI scan, resulting in four (10%) more patients achieving gross total resection. The number of iMRI scans per patient was 1.18 ± 0.38. The surgical time was 4.5 ± 3.6 hours. The pre-resection iUS scan revealed that an average of 3.8 borders of the tumor were beside sulci in 75% (30/40) patients. Intermediate resection control was utilized in 67.5% (27/40) of patients. In 37.5% (15/40) of patients, the surgical procedures were changed intraoperatively based on the iUS findings. Compared with iMRI, the sensitivity and specificity of iUS for residual tumors were 46% and 96%, respectively.ConclusionThe full-course resection control strategy by combining iUS and iMRI could be successfully implemented with good surgical results in initial glioma surgeries. This strategy might stabilize resection control quality and provide the surgeon with more intraoperative information to tailor the surgical strategy. Compared with iMRI-assisted glioma surgery, this strategy might improve efficiency by reducing the number of iMRI scans and shortening surgery time.