Postoperative ischemic changes following resection of newly diagnosed and recurrent gliomas and their clinical relevance

Clinical article

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Object

The aim of surgical treatment of glioma is the complete resection of tumor tissue with preservation of neurological function. Inclusion of diffusion-weighted imaging (DWI) in the postoperative MRI protocol could improve the delineation of ischemia-associated postoperative neurological deficits. The present study aims to assess the incidence of infarctions following resection of newly diagnosed gliomas in comparison with recurrent gliomas and the influence on neurological function.

Methods

Patients who underwent glioma resection for newly diagnosed or recurrent gliomas had early postoperative MRI, including DWI and apparent diffusion coefficient (ADC) maps. Postoperative areas of restricted diffusion were classified as arterial territorial infarctions, terminal branch infarctions, or venous infarctions. Tumor entity, location, and neurological function were recorded.

Results

New postoperative ischemic lesions were identified in 26 (31%) of 84 patients with newly diagnosed gliomas and 20 (80%) of 25 patients with recurrent gliomas (p < 0.01). New permanent and transient neurological deficits were more frequent in patients with recurrent gliomas than in patients with newly diagnosed tumors. Patients with neurological deficits had a significantly higher rate of ischemic lesions.

Conclusions

Postoperative infarctions occur frequently in patients with newly diagnosed and recurrent gliomas and do have an impact on postoperative neurological function. In this patient cohort there was a higher risk for ischemic lesions and for deterioration of neurological function after resection of recurrent tumors. Radiogenic and postoperative tissue changes could contribute to the higher risk of an ischemic infarction in patients with recurrent tumors.

Abbreviations used in this paper:ACA = anterior cerebral artery; ADC = apparent diffusion coefficient; DWI = diffusion-weighted imaging; HGG = high-grade glioma; LGG = low-grade glioma; MCA = middle cerebral artery; PCA = posterior cerebral artery.

Article Information

* Drs. Gempt and Förschler contributed equally to this work.

Address correspondence to: Florian Ringel, M.D., Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675 München, Germany. email: florian.ringel@lrz.tum.de.

Please include this information when citing this paper: published online February 1, 2013; DOI: 10.3171/2012.12.JNS12125.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A and B: Images obtained in a 76-year-old female patient after resection of a left temporodorsal glioblastoma. Early postoperative DWI (A) and an ADC map (B) display an ischemic lesion classified as an arterial territorial infarction (AT) related to the territory of the ramus occipitotemporalis (PCA) with distinct hyperintensity on DWI and hypointensity on the ADC map. C and D: Early postoperative MR images obtained in a 28-year-old female patient with a left frontal glioblastoma. A wedge-shaped area of restricted diffusion is clearly visible on the DWI (C) as well as on the ADC map (D) indicating an ischemic lesion, which was classified as terminal branch infarction.

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    A–C: Early postoperative images obtained in a 41-year-old male patient after resection of a right cingular oligodendroglioma (WHO Grade II). An area of DWI hyperintensity (A) is clearly visible, with corresponding hypointensity on the ADC map (C). The T2-weighted MR image (B) also displays a slight perifocal edema and bleeding inside the ischemic lesion. The ischemic lesion, which does not follow arterial territories was classified as other/venous infarction (V). D–F: Early postoperative images obtained in a 28-year-old patient after resection of a right frontal diffuse astrocytoma (WHO Grade II). An area of hyperintensity is visible only along the resection border on DWI (D) with a slight corresponding hypointensity on the ADC map (E). On T1-weighted MRI (F), hyperintense blood products are clearly visible, indicating that there is no infarction.

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    Flowchart showing the numbers of LGGs and HGGs in the newly diagnosed and recurrent glioma groups and the absolute and relative incidence of postoperative ischemic lesions in DWI.

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    Bar graph showing the incidence of infarctions after resection of newly diagnosed HGG or LGG. There is no statistically significant difference in the incidence of ischemic lesions between the 2 groups. n.s. = not significant.

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    Bar graph showing the incidence of infarctions following resection of newly diagnosed versus recurrent gliomas. The incidence is significantly higher in patients undergoing resection of recurrent tumors (occurring in 31% of patients with newly diagnosed gliomas and 80% of those with recurrent tumors).

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    Bar graph showing the proportions of patients with transient or permanent new neurological deficits after resection of newly diagnosed or recurrent gliomas.

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    Bar graph showing the incidence of ischemic lesions in patients with and without new postoperative deficits (transient or permanent) after resection of newly diagnosed gliomas. There is a significantly higher number of ischemic lesions in patients with new postoperative deficits.

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    Bar graph showing the proportion of new postoperative deficits in patients with newly diagnosed gliomas with and without DWI abnormalities resembling ischemic lesions. There is a significantly higher incidence of new deficits in patients with new infarctions.

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