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11C-methionine-18F-FDG dual-PET-tracer–based target delineation of malignant glioma: evaluation of its geometrical and clinical features for planning radiation therapy

Takero Hirata, Manabu Kinoshita, Keisuke Tamari, Yuji Seo, Osamu Suzuki, Nobuhide Wakai, Takamune Achiha, Toru Umehara, Hideyuki Arita, Naoki Kagawa, Yonehiro Kanemura, Eku Shimosegawa, Naoya Hashimoto, Jun Hatazawa, Haruhiko Kishima, Teruki Teshima and Kazuhiko Ogawa

OBJECTIVE

It is important to correctly and precisely define the target volume for radiotherapy (RT) of malignant glioma. 11C-methionine (MET) positron emission tomography (PET) holds promise for detecting areas of glioma cell infiltration: the authors’ previous research showed that the magnitude of disruption of MET and 18F-fluorodeoxyglucose (FDG) uptake correlation (decoupling score [DS]) precisely reflects glioma cell invasion. The purpose of the present study was to analyze volumetric and geometrical properties of RT target delineation based on DS and compare them with those based on MRI.

METHODS

Twenty-five patients with a diagnosis of malignant glioma were included in this study. Three target volumes were compared: 1) contrast-enhancing core lesions identified by contrast-enhanced T1-weighted images (T1Gd), 2) high-intensity lesions on T2-weighted images, and 3) lesions showing high DS (DS ≥ 3; hDS). The geometrical differences of these target volumes were assessed by calculating the probabilities of overlap and one encompassing the other. The correlation of geometrical features of RT planning and recurrence patterns was further analyzed.

RESULTS

The analysis revealed that T1Gd with a 2.0-cm margin was able to cover the entire high DS area only in 6 (24%) patients, which indicates that microscopic invasion of glioma cells often extended more than 2.0 cm beyond a Gd-enhanced core lesion. Insufficient coverage of high DS regions with RT target volumes was suggested to be a risk for out-of-field recurrence. Higher coverage of hDS by T1Gd with a 2-cm margin (i.e., higher values of “[T1Gd + 2 cm]/hDS”) had a trend to positively impact overall and progression-free survival. Cox regression analysis demonstrated that low coverage of hDS by T1Gd with a 2-cm margin was predictive of disease recurrence outside the Gd-enhanced core lesion, indicative of out-of-field reoccurrence.

CONCLUSIONS

The findings of this study indicate that MRI is inadequate for target delineation for RT in malignant glioma treatment. Expanding the treated margins substantially beyond the MRI-based target volume may reduce the risk of undertreatment, but it may also result in unnecessary irradiation of uninvolved regions. As MET/FDG PET-DS seems to provide more accurate information for target delineation than MRI in malignant glioma treatment, this method should be further evaluated on a larger scale.

In Journal of Neurosurgery Volume 131: Issue 3 (Sep 2019): Pages 657-991

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Clip-first policy versus coil-first policy for the exclusion of middle cerebral artery aneurysms

David Hassanein Berro, Vincent L’Allinec, Anne Pasco-Papon, Evelyne Emery, Mada Berro, Charlotte Barbier, Henri-Dominique Fournier and Thomas Gaberel

OBJECTIVE

Middle cerebral artery (MCA) aneurysms are a particular subset of intracranial aneurysms that can be excluded by clipping or coiling. A comparison of the results between these two methods is often limited by a selection bias in which wide-neck and large aneurysms are frequently treated with surgery. Here, the authors report the results of two centers using opposing policies in the management of MCA aneurysms: one center used a clip-first policy while the other used a coil-first policy, which limited the selection bias and ensured a good comparison of these two treatment modalities.

METHODS

All patients treated for either ruptured or unruptured MCA aneurysms at one of two institutions between January 2012 and December 2015 were eligible for inclusion in this study. At one center a clip-first policy was applied, whereas the other applied a coil-first policy. The authors retrospectively reviewed the medical records of these patients and compared their clinical and radiological outcomes.

RESULTS

A total of 187 aneurysms were treated during the inclusion period; 88 aneurysms were treated by coiling and 99 aneurysms by clipping. The baseline patient and radiological characteristics were similar between the two groups, but the clinical presentation of the ruptured aneurysm cohort differed slightly. In the ruptured cohort (n = 90), although patients in the coiling group had a higher rate of additional surgery, the complication rate, functional outcome, and risk of death were similar between the two treatment groups. In the unruptured cohort (n = 97), the complication rate, functional outcome, and risk of death were also similar between the two treatment groups, although the risk of discomfort related to the temporal muscle atrophy was higher in the surgical group. Overall, the rate of complete occlusion was higher in the clipping group (84.2%) than in the coiling group (31%), which led to a higher risk in the coiling group of aneurysm retreatment within the first 2 years (p = 0.04).

CONCLUSIONS

Clipping and coiling for MCA aneurysm treatment provide the same clinical outcome for ruptured and unruptured aneurysms. However, clipping provides higher short- and long-term rates of complete exclusion, which in turn decreases the risk of aneurysm retreatment. Whether this lower occlusion rate can have a clinical impact in the long-term must be further evaluated.

In Journal of Neurosurgery Publish Before Print

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Developing a 3D composite training model for cranial remodeling

Du Cheng, Melissa Yuan, Imali Perera, Ashley O’Connor, Alexander I. Evins, Thomas Imahiyerobo, Mark Souweidane and Caitlin Hoffman

OBJECTIVE

Craniosynostosis correction, including cranial vault remodeling, fronto-orbital advancement (FOA), and endoscopic suturectomy, requires practical experience with complex anatomy and tools. The infrequent exposure to complex neurosurgical procedures such as these during residency limits extraoperative training. Lack of cadaveric teaching tools given the pediatric nature of synostosis compounds this challenge. The authors sought to create lifelike 3D printed models based on actual cases of craniosynostosis in infants and incorporate them into a practical course for endoscopic and open correction. The authors hypothesized that this training tool would increase extraoperative facility and familiarity with cranial vault reconstruction to better prepare surgeons for in vivo procedures.

METHODS

The authors utilized representative craniosynostosis patient scans to create 3D printed models of the calvaria, soft tissues, and cranial contents. Two annual courses implementing these models were held, and surveys were completed by participants (n = 18, 5 attending physicians, 4 fellows, 9 residents) on the day of the course. These participants were surveyed during the course and 1 year later to assess the impact of this training tool. A comparable cohort of trainees who did not participate in the course (n = 11) was also surveyed at the time of the 1-year follow-up to assess their preparation and confidence with performing craniosynostosis surgeries.

RESULTS

An iterative process using multiple materials and the various printing parameters was used to create representative models. Participants performed all major surgical steps, and we quantified the fidelity and utility of the model through surveys. All attendees reported that the model was a valuable training tool for open reconstruction (n = 18/18 [100%]) and endoscopic suturectomy (n = 17/18 [94%]). In the first year, 83% of course participants (n = 14/17) agreed or strongly agreed that the skin and bone materials were realistic and appropriately detailed; the second year, 100% (n = 16/16) agreed or strongly agreed that the skin material was realistic and appropriately detailed, and 88% (n = 14/16) agreed or strongly agreed that the bone material was realistic and appropriately detailed. All participants responded that they would use the models for their own personal training and the training of residents and fellows in their programs.

CONCLUSIONS

The authors have developed realistic 3D printed models of craniosynostosis including soft tissues that allow for surgical practice simulation. The use of these models in surgical simulation provides a level of preparedness that exceeds what currently exists through traditional resident training experience. Employing practical modules using such models as part of a standardized resident curriculum is a logical evolution in neurosurgical education and training.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Editorial. Clipping versus coiling for the treatment of middle cerebral artery aneurysms: which modality should be considered first?

Tyler Scullen, Mansour Mathkour, John D. Nerva, Aaron S. Dumont and Peter S. Amenta

In Journal of Neurosurgery Publish Before Print

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Evaluation and treatment of children with radiation-induced cerebral vasculopathy

David S. Hersh, Kenneth Moore, Vincent Nguyen, Lucas Elijovich, Asim F. Choudhri, Jorge A. Lee-Diaz, Raja B. Khan, Brandy Vaughn and Paul Klimo Jr.

OBJECTIVE

Stenoocclusive cerebral vasculopathy is an infrequent delayed complication of ionizing radiation. It has been well described with photon-based radiation therapy but less so following proton-beam radiotherapy. The authors report their recent institutional experience in evaluating and treating children with radiation-induced cerebral vasculopathy.

METHODS

Eligible patients were age 21 years or younger who had a history of cranial radiation and subsequently developed vascular narrowing detected by MR arteriography that was significant enough to warrant cerebral angiography, with or without ischemic symptoms. The study period was January 2011 to March 2019.

RESULTS

Thirty-one patients met the study inclusion criteria. Their median age was 12 years, and 18 (58%) were male. Proton-beam radiation therapy was used in 20 patients (64.5%) and photon-based radiation therapy was used in 11 patients (35.5%). Patients were most commonly referred for workup as a result of incidental findings on surveillance tumor imaging (n = 23; 74.2%). Proton-beam patients had a shorter median time from radiotherapy to catheter angiography (24.1 months [IQR 16.8–35.4 months]) than patients who underwent photon-based radiation therapy (48.2 months [IQR 26.6–61.1 months]; p = 0.04). Eighteen hemispheres were revascularized in 15 patients. One surgical patient suffered a contralateral hemispheric infarct 2 weeks after revascularization; no child treated medically (aspirin) has had a stroke to date. The median follow-up duration was 29.2 months (IQR 21.8–54.0 months) from the date of the first catheter angiogram to last clinic visit.

CONCLUSIONS

All children who receive cranial radiation therapy from any source, particularly if the parasellar region was involved and the child was young at the time of treatment, require close surveillance for the development of vasculopathy. A structured and detailed evaluation is necessary to determine optimal treatment.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Incidence of nonaccidental head trauma in infants: a call to revisit prevention strategies

LaVerne W. Thompson, Kathryn D. Bass, Justice O. Agyei, Hibbut-Ur-Rauf Naseem, Elizabeth Borngraber, Jiefei Wang and Renée M. Reynolds

OBJECTIVE

Traumatic brain injury is a major sequela of nonaccidental trauma (NAT) that disproportionately affects young children and can have lasting sequelae. Considering the potentially devastating effects, many hospitals develop parent education programs to prevent NAT. Despite these efforts, NAT is still common in Western New York. The authors studied the incidence of NAT following the implementation of the Western New York Shaken Baby Syndrome Education Program in 1998.

METHODS

The authors performed a retrospective chart review of children admitted to our pediatric hospital between 1999 and 2016 with ICD-9-CM and ICD-10-CM codes for types of child abuse and intracranial hemorrhage. Data were also provided by the Safe Babies New York program, which tracks NAT in Western New York. Children with a diagnosis of abuse at 0–24 months old were included in the study. Children who suffered a genuine accidental trauma or those with insufficient corroborating evidence to support the NAT diagnosis were excluded.

RESULTS

A total of 107 children were included in the study. There was a statistically significant rise in both the incidence of NAT (p = 0.0086) and the incidence rate of NAT (p = 0.0235) during the study period. There was no significant difference in trendlines for annual NAT incidence between sexes (y-intercept p = 0.5270, slope p = 0.5263). When stratified by age and sex, each age group had a distinct and statistically significant incidence of NAT (y-intercept p = 0.0069, slope p = 0.0374).

CONCLUSIONS

Despite educational interventions targeted at preventing NAT, there is a significant rise in the trend of newly reported cases of NAT, indicating a great need for better injury prevention programming.

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Intraoperative electrostimulation for awake brain mapping: how many positive interference responses are required for reliability?

Franck-Emmanuel Roux, Imène Djidjeli, Romain Quéhan, Emilie Réhault, Carlo Giussani and Jean-Baptiste Durand

OBJECTIVE

The purpose of this study was to characterize the reproducibility of language trials within and between brain mapping sessions.

METHODS

Brain mapping and baseline testing data from 200 adult patients who underwent resection of left-hemisphere tumors were evaluated. Data from 11 additional patients who underwent a second resection for recurrence were analyzed separately to investigate reproducibility over time. In all cases, a specific protocol of electrostimulation brain mapping with a controlled naming task was used to detect language areas, and the results were statistically compared with preoperative and intraoperative baseline naming error rates. All patients had normal preoperative error rates, controlled for educational level and age (mean 8.92%, range 0%–16.25%). Intraoperative baseline error rates within the normal range were highly correlated with preoperative ones (r = 0.74, p < 10−10), although intraoperative rates were usually higher (mean 13.30%, range 0%–26.67%). Initially, 3 electrostimulation trials were performed in each cortical area. If 2 of 3 trials showed language interference, 1 or 2 additional trials were performed (depending on results).

RESULTS

In the main group of 200 patients, there were 82 single interferences (i.e., positive results in 1 of 3 trials), 227 double interferences (2/3), and 312 full interferences (3/3). Binomial statistics revealed that full interferences were statistically significant (vs intraoperative baseline) in 92.7% of patients, while double interferences were significant only in 38.5% of patients, those with the lowest error rates. On further testing, one-third of the 2/3 trials became 2/4 trials, which was significant in only one-quarter of patients. Double interference could be considered significant for most patients (> 90%) when confirmed by 2 subsequent positive trials (4/5). In the 11 patients who were operated on twice, only 26% of areas that tested positive in the initial operation tested positive in the second and showed the same type of interference and the same current threshold (i.e., met all 3 criteria).

CONCLUSIONS

Electrostimulation trials in awake brain mapping produced graded patterns of positive reproducibility levels, and their significance varied with the baseline error rates. The results suggest that caution is warranted when 2 of 3 trials are positive, although the need for additional trials depends on the individual patients’ baseline error rates. Reproducibility issues should be considered in the interpretation of data from awake brain mapping.

In Journal of Neurosurgery Publish Before Print

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Letter to the Editor. Arachnoid cyst prevalence

Cormac O. Maher

In Journal of Neurosurgery: Pediatrics Publish Before Print

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Operculoinsular cortectomy for refractory epilepsy. Part 1: Is it effective?

Alain Bouthillier, Alexander G. Weil, Laurence Martineau, Laurent Létourneau-Guillon and Dang Khoa Nguyen

OBJECTIVE

Patients with refractory epilepsy of operculoinsular origin are often denied potentially effective surgical treatment with operculoinsular cortectomy (also termed operculoinsulectomy) because of feared complications and the paucity of surgical series with a significant number of cases documenting seizure control outcome. The goal of this study was to document seizure control outcome after operculoinsular cortectomy in a group of patients investigated and treated by an epilepsy team with 20 years of experience with this specific technique.

METHODS

Clinical, imaging, surgical, and seizure control outcome data of all patients who underwent surgery for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Tumors and progressive encephalitis cases were excluded. Descriptive and uni- and multivariate analyses were done to determine seizure control outcome and predictors.

RESULTS

Forty-three patients with 44 operculoinsular cortectomies were studied. Kaplan-Meier estimates of complete seizure freedom (first seizure recurrence excluding auras) for years 0.5, 1, 2, and 5 were 70.2%, 70.2%, 65.0%, and 65.0%, respectively. With patients with more than 1 year of follow-up, seizure control outcome Engel class I was achieved in 76.9% (mean follow-up duration 5.8 years; range 1.25–20 years). With multivariate analysis, unfavorable seizure outcome predictors were frontal lobe–like seizure semiology, shorter duration of epilepsy, and the use of intracranial electrodes for invasive monitoring. Suspected causes of recurrent seizures were sparing of the language cortex part of the focus, subtotal resection of cortical dysplasia/polymicrogyria, bilateral epilepsy, and residual epileptic cortex with normal preoperative MRI studies (insula, frontal lobe, posterior parieto-temporal, orbitofrontal).

CONCLUSIONS

The surgical treatment of operculoinsular refractory epilepsy is as effective as epilepsy surgeries in other brain areas. These patients should be referred to centers with appropriate experience. A frontal lobe–like seizure semiology should command more sampling with invasive monitoring. Recordings with intracranial electrodes are not always required if the noninvasive investigation is conclusive. The complete resection of the epileptic zone is crucial to achieve good seizure control outcome.

In Journal of Neurosurgery Publish Before Print

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Operculoinsular cortectomy for refractory epilepsy. Part 2: Is it safe?

Alain Bouthillier, Alexander G. Weil, Laurence Martineau, Laurent Létourneau-Guillon and Dang Khoa Nguyen

OBJECTIVE

Operculoinsular cortectomy (also termed operculoinsulectomy) is increasingly recognized as a therapeutic option for perisylvian refractory epilepsy. However, most neurosurgeons are reluctant to perform the technique because of previously experienced or feared neurological complications. The goal of this study was to quantify the incidence of basic neurological complications (loss of primary nonneuropsychological functions) associated with operculoinsular cortectomies for refractory epilepsy, and to identify factors predicting these complications.

METHODS

Clinical, imaging, and surgical data of all patients investigated and surgically treated by our team for refractory epilepsy requiring an operculoinsular cortectomy were retrospectively reviewed. Patients with tumors and encephalitis were excluded. Logistic regression analysis was used for uni- and multivariate statistical analyses.

RESULTS

Forty-four operculoinsular cortectomies were performed in 43 patients. Although postoperative neurological deficits were frequent (54.5% of procedures), only 3 procedures were associated with a permanent significant neurological deficit. Out of the 3 permanent deficits, only 1 (2.3%; a sensorimotor hemisyndrome) was related to the technique of operculoinsular cortectomy (injury to a middle cerebral artery branch), while the other 2 (arm hypoesthesia and hemianopia) were attributed to cortical resection beyond the operculoinsular area. With multivariate analysis, a postoperative neurological deficit was associated with preoperative insular hypometabolism on PET scan. Postoperative motor deficit (29.6% of procedures) was correlated with fewer years of neurosurgical experience and frontal operculectomies, but not with corona radiata ischemic lesions. Ischemic lesions in the posterior two-thirds of the corona radiata (40.9% of procedures) were associated with parietal operculectomies, but not with posterior insulectomies.

CONCLUSIONS

Operculoinsular cortectomy for refractory epilepsy is a relatively safe therapeutic option but temporary neurological deficits after surgery are frequent. This study highlights the role of frontal/parietal opercula resections in postoperative complications. Corona radiata ischemic lesions are not clearly related to motor deficits. There were no obvious permanent neurological consequences of losing a part of an epileptic insula, including on the dominant side for language. A low complication rate can be achieved if the following conditions are met: 1) microsurgical technique is applied to spare cortical branches of the middle cerebral artery; 2) the resection of an opercula is done only if the opercula is part of the epileptic focus; and 3) the neurosurgeon involved has proper training and experience.

In Journal of Neurosurgery Publish Before Print