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Purpose:To explore a prognostic or predictive role of MRI and O-(2–18F-fluoroethyl)-L-tyrosine (18FET) PET parameters for outcome in the randomized multicenter trial ARTE that compared bevacizumab plus radiotherapy with radiotherpay alone in elderly patients with glioblastoma.Patients and Methods:Patients with isocitrate dehydrogenase wild-type glioblastoma ages 65 years or older were included in this post hoc analysis. Tumor volumetric and apparent diffusion coefficient (ADC) analyses of serial MRI scans from 67 patients and serial 18FET-PET tumor-to-brain intensity ratios (TBRs) from 31 patients were analyzed blinded for treatment arm and outcome. Multivariate Cox regression analysis was done to account for established prognostic factors and treatment arm.Results:Overall survival benefit from bevacizumab plus radiotherapy compared with radiotherapy alone was observed for larger pretreatment MRI contrast-enhancing tumor [HR per cm3 0.94; 95% confidence interval (CI), 0.89–0.99] and for higher ADC (HR 0.18; CI, 0.05–0.66). Higher 18FET-TBR on pretreatment PET scans was associated with inferior overall survival in both arms. Response assessed by standard MRI-based Response Assessment in Neuro-Oncology criteria was associated with overall survival in the bevacizumab plus radiotherapy arm by trend only (P = 0.09). High 18FET-TBR of noncontrast-enhancing tumor portions during bevacizumab therapy was associated with inferior overall survival on multivariate analysis (HR 5.97; CI, 1.16–30.8).Conclusions:Large pretreatment contrast-enhancing tumor mass and higher ADCs identify patients who may experience a survival benefit from bevacizumab plus radiotherapy. Persistent 18FET-PET signal of no longer contrast-enhancing tumor after concomitant bevacizumab plus radiotherapy suggests pseudoresponse and predicts poor outcome.

Note S1, Figure S1-S4, Table S1-S3

Zusammenfassung. In der Neurologie als Disziplin finden sich klare Überschneidungen mit der Palliative Care. Dennoch findet eine frühe Integration von palliativer Versorgung begleitend zur neurologischen Behandlung eher selten statt, und weiterhin bestehen Missverständnisse in Bezug auf den Zeitpunkt des Einbezugs von Palliative Care und deren Rolle jenseits der oft verwechselten reinen «End-of-Life Care» und Hospizpflege. Ein weiterer Ausbau und die Nutzung der Synergien sollte in den kommenden Jahren integraler Bestandteil beider Disziplinen werden und eine entsprechende Schulung insbesondere junger ärztlicher Kolleginnen und Kollegen im Fokus der Ausbildung stehen.

To analyze the increase in diameter of the nerve roots C5 and C6 in early childhood.The nerve roots of 56 children aged 0 days to 10 years (47 younger than 2 years) were examined by high-resolution ultrasound imaging. The correlation of diameter and age was statistically tested and a logarithmic regression analysis was performed to develop a logarithmic growth model.The increase in nerve root diameter is greatest during the first 2 years of life and then the growth rate decreases steadily. The relationship between age and diameter follows a logarithmic curve (p 10The main increase in the diameter of the nerve roots happens in the first 2 years of life. Comparing data from a previous study, our data also suggest that the maturation of the proximal part of the median nerve is comparable to the maturation of its distal segments. This suggests a synchronous maturation of the axons and myelin sheath for the whole extent of the nerve, from the radix to its very distal part.Normative values for the size of the cervical nerve roots C5 and C6; an insight into the maturation of the proximal parts of the peripheral nervous system; and the correlation between age and cervical root diameter.

Aim: Immune checkpoint inhibitor-induced encephalitis (ICI-iE) is a rare but life-threatening toxicity of immune checkpoint inhibitor treatment. We aim to identify the characteristics of ICI-iE and describe factors that discriminate it from herpes simplex virus (HSV)-1 encephalitis and anti-leucine-rich glioma-inactivated 1 (anti-LGI1) encephalitis, as two alternative entities of encephalitis. Methods: In this retrospective multicentre cohort study, we collected patients with ICI-iE reported to the Side Effect Registry Immuno-Oncology from January 2015 to September 2021 and compared their clinical features and outcome with 46 consecutive patients with HSV-1 or anti-LGI1 encephalitis who were treated at a German neurological referral centre. Results: Thirty cases of ICI-iE, 25 cases of HSV-1 encephalitis and 21 cases of anti-LGI1 encephalitis were included. Clinical presentation of ICI-iE was highly variable and resembled that of HSV-1 encephalitis, while impairment of consciousness (66% vs. 5%, p = .007), confusion (83% vs. 43%; p = .02), disorientation (83% vs. 29%; p = .007) and aphasia (43% vs. 0%; p = .007) were more common in ICI-iE than in anti-LGI1 encephalitis. Antineuronal antibodies (17/18, 94%) and MRI (18/30, 60%) were mostly negative in ICI-iE, but cerebrospinal fluid (CSF) showed pleocytosis and/or elevated protein levels in almost all patients (28/29, 97%). Three patients (10%) died of ICI-iE. Early immunosuppressive treatment was associated with better outcome (r = 0.43). Conclusions: ICI-iE is a heterogeneous entity without specific clinical features. CSF analysis has the highest diagnostic value, as it reveals inflammatory changes in most patients and enables the exclusion of infection. Early treatment of ICI-iE is essential to prevent sequelae and death.

Introduction: The evaluation of symptom burden, performance status, and neurological function is still challenging in glioblastoma (GBM) patients. Patients may suffer from a wide spectrum of neurological symptoms like cognitive deficits, aphasia, or hemiparesis, which interfere to report to comprehensive questionnaires. However, an integrated and reliable neuro-oncological assessment is the key in the clinical management and in the evaluation of treatment benefits for GBM patients. Methods: We implemented an easy-to-use clinical toolkit for the prospective assessment and follow-up evaluation of GBM patients using the Karnofsky performance status (KPS), the National Institute of Health Stroke Scale (NIH-SS), and simple scores for the evaluation of key symptoms like fatigue, depression, and headache. Results: We prospectively followed 50 patients. The composite score (headache, depression, and fatigue), fatigue alone, the NIHSS, and the KPS were suitable biomarkers to evaluate symptom burden in GBM patients and indicate clinical disease progression. Discussion/Conclusion: The proposed clinical toolkit seems feasible in routine clinical practice and reflects changes in symptom burden in different stages of the postsurgical course of GBM patients in this monocentric clinical pilot trial.

Purpose: To explore a prognostic or predictive role of MRI and O-(2–18F-fluoroethyl)-L-tyrosine (18FET) PET parameters for outcome in the randomized multicenter trial ARTE that compared bevacizumab plus radiotherapy with radiotherpay alone in elderly patients with glioblastoma. Patients and Methods: Patients with isocitrate dehydrogenase wild-type glioblastoma ages 65 years or older were included in this post hoc analysis. Tumor volumetric and apparent diffusion coefficient (ADC) analyses of serial MRI scans from 67 patients and serial 18FET-PET tumor-to-brain intensity ratios (TBRs) from 31 patients were analyzed blinded for treatment arm and outcome. Multivariate Cox regression analysis was done to account for established prognostic factors and treatment arm. Results: Overall survival benefit from bevacizumab plus radiotherapy compared with radiotherapy alone was observed for larger pretreatment MRI contrast-enhancing tumor [HR per cm3 0.94; 95% confidence interval (CI), 0.89–0.99] and for higher ADC (HR 0.18; CI, 0.05–0.66). Higher 18FET-TBR on pretreatment PET scans was associated with inferior overall survival in both arms. Response assessed by standard MRI-based Response Assessment in Neuro-Oncology criteria was associated with overall survival in the bevacizumab plus radiotherapy arm by trend only (P = 0.09). High 18FET-TBR of noncontrast-enhancing tumor portions during bevacizumab therapy was associated with inferior overall survival on multivariate analysis (HR 5.97; CI, 1.16–30.8). Conclusions: Large pretreatment contrast-enhancing tumor mass and higher ADCs identify patients who may experience a survival benefit from bevacizumab plus radiotherapy. Persistent 18FET-PET signal of no longer contrast-enhancing tumor after concomitant bevacizumab plus radiotherapy suggests pseudoresponse and predicts poor outcome.

AimTo analyse the increase in diameter of the nerve roots C5 and C6 in early childhood.MethodsThe nerve roots of 56 children subjects aged 0 days to 10 years (47 younger than 2 years) were examined by high-resolution ultrasound imaging. The correlation of diameter and age was statistically tested and a logarithmic regression analysis was performed to develop a logarithmic growth model.ResultsThe increase in nerve root diameter is greatest during the first two years of life and then the growth rate decreases steadily. The relationship between age and diameter follows a logarithmic curve (p < 10−8).InterpretationThe main increase in the diameter of the nerve roots happens in the first two years of life. Comparing data from a previous study, our data also suggest that the maturation of the proximal part of the median nerve is comparable to the maturation of its distal segments. This suggests a synchronous maturation of the axons and myelin sheath for the whole extent of the nerve, from the radix to its very distal part.What this paper addsNormative values for the size of the cervical nerve roots C5 and C6, an insight into the maturation of the proximal parts of the peripheral nervous system, and the correlation between age and cervical root diameter.Highlights-Maturation of the nerve roots C5 and C6 in children from 0 to two years of age.-Reference values from the diameter of the C5 and C6 nerve roots of children up to two years.

As the COVID-19 pandemic progresses, reports of neurological manifestations are increasing. However, despite a high number of case reports and case series on COVID-19 and Guillain-Barré-Syndrome (GBS), a causal association is still highly debated, due to the lack of case-control studies. In this opinion paper, we focus on a few clinically relevant questions regarding the possible link between GBS and SARS-CoV-2 infection or vaccination based on our personal clinical experience and literature review.

Objective: The aim of this study was to examine neurocognitive course over time among people with well treated HIV. Design: The Neurocognitive Assessment in the Metabolic and Aging Cohort (NAMACO) study is an ongoing, prospective, longitudinal, multicenter and multilingual study within the Swiss HIV Cohort Study (SHCS). Participants undergo neuropsychological assessment at baseline and two-yearly follow-up. Setting: Seven SHCS centres. Participants: Patients aged at least 45 years enrolled in the SHCS with fluency in the local language (French, German or Italian) and agreeing to participate in the NAMACO study: 981 participants at baseline, 720 at 2-year follow-up of whom 644 had complete data sets. Intervention: Standardized neuropsychological assessment at baseline and 2-year follow-up. Main outcome measure: Neurocognitive performance using Frascati criteria and mean z-scores. Results: Four participants (of 644, 0.6%) had plasma HIV-1 RNA more than 50 copies/ml; median CD4+ cell count was 660 cells/μl. According to Frascati criteria, 204 participants (31.7%) had neurocognitive impairment (NCI) at baseline. NCI severity in these participants changed little over 2 years and comprehensive models based on Frascati criteria were not feasible. Examining mean z-scores, however, we observed neurocognitive stability or improvement over two years in five of seven neurocognitive domains assessed. Age at least 65 years (P = 0.02) and cognitive complaints (P = 0.004) were associated with neurocognitive decline, while black race (P = 0.01) and dolutegravir treatment (P = 0.002) were associated with improvement. Conclusion: Frascati criteria were less sensitive in measuring NCI change and therefore unsuitable for following neurocognitive course in our cohort of people with well treated HIV. Examining neurocognitive course by mean z-score change, we observed stability or improvement.

Palliative Care in Neurology

INTRODUCTION The CeTeG/NOA-09 trial demonstrated superior median overall survival (mOS, 48.1 months) in MGMT-methylated glioblastoma treated with lomustine/temozolomide compared to temozolomide. We retrospectively analyzed an off-study cohort of patients treated with lomustine/temozolomide to gather real-world data on this new regimen. METHODS Adult patients from 20 centers in Germany, Austria and Switzerland were included. Inclusion criteria were MGMT-methylated IDHwt glioblastoma newly diagnosed prior to end of 2020, and lomustine/temozolomide treatment as part of first-line therapy. RESULTS 321 patients with a median age of 57 years (range, 21-78) and a median follow-up of 19.9 months were included. In the whole cohort, mOS was 41.0 months (95%CI, 33.0 – not reached). In patients starting lomustine/temozolomide immediately upon initiation of radiotherapy strictly following the CeTeG protocol (88%), mOS was 52.8 months (35.8 – not reached) as compared to 24.6 months (17.6 – not reached) in patients starting lomustine/temozolomide after completion of radiotherapy/concomitant temozolomide (12%, logrank test: p = 0.06). Patients with a KPS < 80 had a shorter mOS of 19.7 months (95%CI, 16.6 – not reached) compared to 41.0 months (33.0 – not reached, p = 0.009) in KPS 80-100. Gross total resection (GTR, 53.9%) was associated with longer mOS (52.8 months, 95%CI 24.1 – not reached) compared to partial resection/biopsy (30.5 months, 95%CI 36.8 – not reached, p=0.004). Multivariable Cox regression analysis confirmed GTR (HR 0.66, p = 0.033) and younger age ( ≤ 50 years: HR 0.42, p = 0.001), but not KPS (80-100 vs. lower: HR 0.66, p = 0.12) as independent prognostic factors. DISCUSSION In this real-world multicenter cohort, survival was similar to the promising results of CeTeG/NOA-09. Further analyses should investigate a potentially reduced benefit from lomustine/temozolomide in patients with low KPS/no GTR and a possible detrimental effect from deferred lomustine/temozolomide initiation. The median follow-up is admittedly short, updated data will be presented.

BACKGROUND The 2007 WHO classification of brain tumors first encompassed two new entities of glioneuronal tumors, including papillary glioneuronal tumors (PGNT) and rosette-forming glioneuronal tumours. The reviewed version of the 2016 WHO classification additionally included diffuse leptomeningeal glioneuronal tumours. The histopathological, genetic, and clinical understanding of glioneuronal tumors is currently evolving, however there are no guidelines for diagnostic and clinical management yet. MATERIAL AND METHODS We report two male patients with glioneuronal tumors and performed a review of literature. RESULTS The first patient was diagnosed with a PGNT (MIB-1 proliferation index = 5%) located in the right parietal lobe at the age of 33 years and received surgical resection. Two years later, the tumor recurred in the same location. A second tumor resection was performed followed by concomitant radiochemotherapy with temozolomide (60/2 Gray). A next-generation sequencing gene panel (Oncomine) confirmed the initial diagnosis of a PGNT. The patient has remained in remission for the past 10 years. The second patient developed complex partial seizures which were first misdiagnosed as anxiety disorder at the age of 26 years. An MRI scan revealed a contrast-enhancing bifrontal cystic lesions 5 years later and he received a gross total tumor resection. The diagnosis of a glioneuronal tumor was made, however molecular pathology and methylation analysis were not able to classify the tumor entity further. There was no evidence of tumor recurrence one year after surgery and he remained seizure-free with antiepileptic treatment. CONCLUSION Glioneuronal tumors encompass rare and heterogenous tumor entities which primarily present in young patients and often show a favorable clinical course. Although the increasing number of reports in the literature have improved our understanding of these tumors, uncertainty remains in diagnostic challenging cases and patients with progressive disease after surgery. The value of next-generation sequencing and the choice of adjuvant treatment modalities have not been systematically evaluated in this patient group.

OBJECTIVE The management of brain tumour patients who would like to resume driving is complex, and needs multidisciplinary input and a consensus among treating physicians. The Swiss Neuro-Oncology Society (SwissNOS) and the Swiss Society for Legal Medicine (SGRM) aim to provide guidance on how to assess “fitness-to-drive” of glioblastoma patients and to harmonise the relevant procedures in Switzerland. METHODS At several meetings, Swiss neuro-oncologists discussed common practices on how to advise patients with a stable, i.e., non-progressive, glioblastoma, who wish to resume driving after the initial standard tumour treatment. All participants of the SwissNOS meetings were invited twice to return a questionnaire (modified Delphi process) on specific tools/procedures they commonly use to assess “fitness-to-drive” of their patients. Answers were analysed to formulate a tentative consensus for a structured and reasonable approach. RESULTS Consensus on minimum requirements for a “fitness-to-drive”programme for glioblastoma patients could be reached among Swiss neuro-oncologists. The recommendations were based on existing guidelines and expert opinions regarding patients with seizures, visual disturbances, cognitive impairment or focal deficits for safe driving. At this point in time, the Swiss neuro-oncologists agreed on the following requirements for glioblastoma patients after the initial standard therapy and without a seizure for at least 12 months: (1) stable cranial magnetic resonance imaging (MRI) according to Response Assessment in Neuro-Oncology (RANO) criteria, to be repeated every 3 months; (2) thorough medical history, including current or new medication, a comprehensive neurological examination at baseline (T0) and every 3 months thereafter, optionally an electrocencephalogram (EEG) at baseline; (3) ophthalmological examination including visual acuity and intact visual fields; and (4) optional neuropsychological assessment with a focus on safe driving. Test results have to be compatible with safe driving at any time-point. Patients should be informed about test results and optionally sign a document. CONCLUSIONS We propose regular thorough clinical neurological examination and brain MRI, optional EEG, neuropsychological and visual assessments to confirm “fitness-to-drive” for glioblastoma patients after initial tumour-directed therapy. The proposed “fitness-to-drive” assessments for glioblastoma patients serves as the basis for a prospective Swiss Pilot Project GLIODRIVE (BASEC ProjectID 2020-00365) to test feasibility, adherence and safety in a structured manner for patients who wish to resume driving. Research will focus on confirming the usefulness of the proposed tools in predicting “fitness-to-drive” and match results with events obtained from the road traffic registry (Strassenverkehrsamt).

Background Early diagnosis is of substantial benefit for patients with Pompe disease. Yet underdiagnosing and substantial diagnostic delay are still frequent and the determinants of this are unknown. This study is the first to systematically investigate the diagnostic odyssey in Pompe disease from patients', parents', and physicians' perspectives. Methods Patients with infantile or late onset Pompe disease, their parents as well as their metabolic experts were invited to fill in respective surveys. The survey addressed perceived disease symptoms at onset and during the course of the disease, specialties of involved physicians, activities of patient-initiated search for diagnosis and the perceived impact of time to diagnosis on outcome. Results of experts' and patients'/parents' surveys were compared and expressed by descriptive statistics. Results and Discussion We collected data on 15 males and 17 females including 9 infantile and 23 late onset Pompe patients. All received the correct diagnosis at a metabolic or musculoskeletal expert center. Patients with direct referral to the expert center had the lowest diagnostic delay, while patients who were seen by several physicians, received the correct diagnosis after 44%-200% longer delay. The proportion of direct referral varied strongly between pediatricians (57%) and other disciplines (18%-36%). Conclusion Our study highlights a substantially larger diagnostic delay in Pompe patients that are not directly referred to expert centers for diagnostic work. Our findings may be used to develop more successful strategies for early diagnosis. Synopsis Diagnostic delay in Pompe disease is substantial particularly in patients that are not directly referred to expert centers for diagnostic workup, so facilitating direct referral may be a new strategy for early diagnosis.

A 57-year-old female presented at the emergency room with acute onset aphasia but unremarkable cCT (incl. angiography and perfusion). Suspecting an ischemic stroke, she received thrombolysis with quick recovery of aphasia. Afterwards, myoclonic jerks of the face and right arm occurred leading to anticonvulsant therapy. Follow-up cMRI surprisingly demonstrated swollen T2w-hyperintense and Gd-enhancing left limbic, temporal and frontal lobes. Suspected herpes-simplex-encephalitis was treated with aciclovir despite unremarkable CSF results (no pleocytosis, no BBB disruption, negative HSV-PCR) on day 2 and follow-up (day 5). Due to persisting cognitive deficits, autoimmune limbic encephalitis was suspected, and intravenous immunoglobulin therapy was added. Three weeks later, she experienced new neurological symptoms (weakness, blurred vision, vomiting, headache). Follow-up brain MRI demonstrated a massive increase of multifocal Gd-enhancing lesions. Partial resection revealed the diagnosis of an IDH-wildtype glioblastoma (GB). Next generation oncogene panel testing demonstrated a GOPC-ROS1 fusion which is rarely found in GB. Due to the gliomatosis-like infiltration of both hemispheres, radiotherapy was deemed to be too toxic. Instead, she received two cycles of lomustine in absence of a MGMT-promotor methylation. Two months later cMRI showed a symptomatic second multilocular progression. 2nd-line therapy with a ROS-inhibitor was rejected, whereupon she died five weeks later. Our case is in several aspects peculiar: It demonstrates that rare GB-mimics (i.e. HSV- and autoimmune limbic encephalitis) can only be ruled out in a fast manner by brain biopsy. Watchful waiting may neglect fast progression of GB leading to the inability to provide optimal treatment (i.e. radiotherapy). Thrombolysis is strictly contraindicated in primary brain tumors, but was unharmful in our case most probably to the early tumor stage without relevant neoangiogenesis. Rare genetic abnormalities like ROS1-fusions which are reported mostly in childhood glioblastoma may be present and serve as a therapeutic target also in adult GB.

BACKGROUND Natural ghrelin, a peptide growth hormone secretagogue, has a therapeutic potential in cachexia. We designed a dose-finding trial of subcutaneous natural ghrelin to improve nutritional intake (NI) in advanced cancer patients. METHODS Advanced cancer patients with cachexia management (symptom management, physiotherapy, nutritional, and psychosocial support) started with ghrelin at 32 μg/kg body weight, followed by 50% dose increases. Patients self-injected ghrelin twice daily for 4 days followed by a wash-out period. After reaching the primary endpoint, maximal NI (minimal dose for maximal NI), a maintenance period followed during which patients injected 10 doses of ghrelin per week. Safety parameters, NI, and cachexia outcomes (symptoms, narratives, muscle mass, and strength) were measured over 6 weeks. RESULTS Ten patients with metastatic solid tumours were included, and six (100% male, mean age 61.8 ± 8.5 SD) received ghrelin. Minimal dose for maximal NI was reached in four patients. Three patients reached the end-of study visit. Ghrelin was well tolerated with variable results on appetite and eating-related symptoms but a positive effect in the narratives. Mean Functional Assessment of Appetite & Cachexia Therapy score was 6.8 points lower at final measurement compared with baseline, t(5) = 5.98, P

Pompe disease is a lysosomal multisystem disorder with predominant proximal myopathy. Treatment with enzyme replacement therapy (ERT) is available requiring life-long biweekly infusions of recombinant α-glucosidase. To minimize the burden of ERT patients ask for home infusion therapy.Pompe disease experts from Germany, Austria, and Switzerland discussed in two consensus meetings in 2019 and 2020 requirements for home infusion therapy, adequate execution of treatment, and the legal situation for delegating physicians.Home infusion therapy is principally feasible for patients with Pompe disease if certain preconditions are fulfilled, but the decision to implement has to be made on an individual basis. The treating physician delegates the execution of ERTDer Morbus Pompe ist eine lysosomale Multisystemerkrankung mit prädominanter Myopathie, für die eine Enzymersatztherapie (EET) mit rekombinanter α-Glucosidase verfügbar ist. Diese muss aktuell zweiwöchentlich lebenslang erfolgen. Um die Belastung durch diese Behandlungsform gering zu halten, besteht bei vielen Betroffenen der Wunsch, die EET zu Hause als sog. Heiminfusionstherapie durchzuführen.Im Rahmen zweier Deutsch-Österreichisch-Schweizerischer Konsensus-Expertentreffen in den Jahren 2019 und 2020 wurde diskutiert, welche Voraussetzungen gegeben sein müssen, damit eine Heiminfusionstherapie medizinisch vertretbar erfolgen kann, wie diese sachgemäß durchzuführen ist und wie die Rechtslage für delegierende Ärzte aussieht.Prinzipiell ist bei Patienten mit Morbus Pompe eine Heiminfusionstherapie möglich, wenn bestimmte Voraussetzungen erfüllt sind. Die Entscheidung muss für jeden Patienten individuell getroffen werden. Der behandelnde Arzt delegiert die Durchführung der Heiminfusionstherapie ad

Immune checkpoint inhibitors (ICIs) are emerging as the new standard of care for treating various metastatic cancers. It is known that effective anti-tumor immune responses are associated with a stronger presence of tumor-infiltrating lymphocytes (TILs) in solid tumor tissue. Cancer patients with relapsing–remitting multiple sclerosis (RRMS) are often under continuous treatment with fingolimod, an immune-modulating drug that inhibits lymphocyte egress from secondary lymphatic organs. Little is known about the effect of fingolimod on ICI cancer therapy, as fingolimod may limit the number of TILs. Here we present three patients with RRMS, who developed various cancers during fingolimod treatment. Histology of all tumors consistently showed low numbers of TILs. A second biopsy taken from one of the tumors, a melanoma, revealed a significant increase of TILs after stopping fingolimod and starting pembrolizumab, indicating a surge in the number and re-invigoration of T cells. Our study suggests that fingolimod limits the number of TILs in solid tumors and may, thus, inhibit anti-cancer immune responses.

Gliomas are intrinsic brain tumours, which are classified by the World Health Organization (WHO) into different grades of malignancy, with glioblastoma being the most frequent and most malignant subtype (WHO grade IV). Mutations in the isocitrate dehydrogenase (IDH) 1 or 2 genes are frequent in lower (WHO II/III) grade tumours but typically absent in classical glioblastoma. IDH mutations are associated with a better prognosis compared with IDH wild-type tumours of the same WHO grade. Following detection of a tumour mass by imaging, maximum safe surgery as feasible is commonly performed to reduce mass effect and to obtain tissue allowing histopathological diagnosis and molecular assessment. Radiotherapy has been the mainstay in the treatment of diffuse gliomas for several decades. It provides improved local control, but is not curative. Furthermore, several randomised trials have shown that the addition of alkylating chemotherapy, either temozolomide or nitrosourea-based regimens, to radiotherapy results in prolonged survival. Tumour-treating fields (TTFields) have emerged as an additional treatment option in combination with maintenance temozolomide treatment for patients with newly diagnosed glioblastoma. Treatment at recurrence is less standardised and depends on the patient’s performance status, symptom burden and prior treatments. Bevacizumab prolongs progression-free survival in newly diagnosed and recurrent glioblastoma, but does not impact overall survival. However, in Switzerland and some other countries, it is still considered a valuable treatment option to reduce clinical symptom burden. Given the generally poor outcome for these patients, various novel treatment approaches are currently being explored within clinical trials including immunotherapeutic strategies such as immune checkpoint inhibition and the brain-penetrant proteasome inhibitor marizomib.

To explore a prognostic or predictive role of MRI and O-(2-Patients with isocitrate dehydrogenase wild-type glioblastoma ages 65 years or older were included in thisOverall survival benefit from bevacizumab plus radiotherapy compared with radiotherapy alone was observed for larger pretreatment MRI contrast-enhancing tumor [HR per cmLarge pretreatment contrast-enhancing tumor mass and higher ADCs identify patients who may experience a survival benefit from bevacizumab plus radiotherapy. Persistent

Ein 28-jahriger Koch beschrieb drei Tage nach einer «downhill»-Fahrradtour vor allem Schmerzen am Handgelenk beim aktiven Faustschluss und Kribbelparasthesien.

AIMS Recurrent glioblastoma (GBM) is a disease with poor prognosis. Although several therapeutic approaches such as chemotherapy, irradiation or surgery have been investigated, there is no established standard therapy. A recent survey among Swiss neuro-oncology centres has shown considerable controversy in the treatment recommendations for any specific scenario of recurrent GBM. In view of the cost differences of the available treatment alternatives, the aim of our study was assess the financial impact of different institutional therapeutic strategies for recurrent GBM in Switzerland. METHODS We created a decision analytic model for each of the eight centres participating in the initial study with a centre-specific treatment algorithm to evaluate the average treatment cost per patient. The probability of decision criteria was varied by univariate and probabilistic sensitivity analysis over a wide range to account for the high level of uncertainty. Treatment costs were calculated from the perspective of the Swiss healthcare payer. RESULTS Mean treatment costs per patient calculated on the basis of the institutional treatment algorithms ranged from CHF 13,748 to CHF 22,072 depending on the probability of individual decision criteria. The most influential decision factors for the mean treatment costs were the probability of fit patients and the proportion of patients with resectable tumour recurrences. There was a significant correlation between the complexity of treatment algorithms in a centre and the resulting mean treatment costs. CONCLUSIONS Institutional treatment algorithms can be used to estimate the average treatment costs per patient, which are, however, highly sensitive to probability changes of individual decision criteria. Our study demonstrates a high variability in treatment costs for recurrent GBM among eight Swiss neuro-oncology centres based on individual institutional treatment algorithms.

Background: Medical decision-making is complex and involves a variety of decision criteria, many of which are universally recognised. However, decision-making analyses have demonstrated that certain decision criteria are not used uniformly among clinicians. Aim: We describe decision criteria, which for various contexts are only used by a minority of decision makers. For these, we introduce and define the term “insular criteria”. Methods: 19 studies analysing clinical decision-making based on decision trees were included in our study. All studies were screened for decision-making criteria that were mentioned by less than three local decision makers in studies involving 8–26 participants. Results: 14 out of the 19 included studies reported insular criteria. We identified 42 individual insular criteria. They could be intuitively allocated to seven major groups, these were: comorbidities, treatment, patients’ characteristics/preferences, caretaker, scores, laboratory and tumour properties/staging. Conclusion: Insular criteria are commonly used in clinical decision-making, yet, the individual decision makers may not be aware of them. With this analysis, we demonstrate the existence of insular criteria and their variety. In daily practice and clinical studies, awareness of insular criteria is important.

Background The addition of bevacizumab to temozolomide-based chemoradiotherapy (TMZ/RT → TMZ) did not prolong overall survival (OS) in patients with newly diagnosed glioblastoma in phase III trials. Elderly and frail patients are underrepresented in clinical trials, but early reports suggested preferential benefit in this population. Patients and methods ARTE was a 2 : 1 randomized, multi-center, open-label, non-comparative phase II trial of hypofractionated RT (40 Gy in 15 fractions) with bevacizumab (10 mg/kg×14 days) (arm A, N = 50) or without bevacizumab (arm B, N = 25) in patients with newly diagnosed glioblastoma aged ≥65 years. The primary objective was to obtain evidence for prolongation of median OS by the addition of bevacizumab to RT. Response was assessed by RANO criteria. Quality of life (QoL) was monitored by the EORTC QLQ-C30/BN20 modules. Exploratory studies included molecular subtyping by 450k whole methylome and gene expression analyses. Results Median PFS was longer in arm A than in arm B (7.6 and 4.8 months, P = 0.003), but OS was similar (12.1 and 12.2 months, P = 0.77). Clinical deterioration was delayed and more patients came off steroids in arm A. Prolonged PFS in arm A was confined to tumors with the receptor tyrosine kinase (RTK) I methylation subtype (HR 0.25, P = 0.014) and proneural gene expression (HR 0.29, P = 0.025). In a Cox model of OS controlling for established prognostic factors, associations with more favorable outcome were identified for age

Zusammenfassung. Wir berichten über eine 72-jährige Patientin, die nach einer elektiven Koronarangiografie über plötzlich einsetzende stärkste Kopfschmerzen klagte. Klinisch bestand eine dysphasische Aphasie, die sich rasch progredient zu einer globalen Aphasie und einem deliranten Zustandsbild entwickelte. Nach dem Ausschluss alternativer Differenzialdiagnosen gingen wir von der seltenen Komplikation einer kontrastmittelinduzierten Enzephalopathie nach Koronarangiografie aus.

Zusammenfassung. Wir stellen den Fall einer 81-jährigen Patientin mit Fieber unklarer Ursache bei bekannter chronisch inflammatorischer demyelinisierender Polyneuropathie (CIDP) und monoklonaler Gammopathie unklarer Signifikanz vor. Nach langer Hospitalisation konnte die Diagnose eines diffus grosszelligen B-Zell-Lymphoms erst nach einer Splenektomie gestellt werden. Die Abklärungen bei Diagnosestellung und die Nachsorgeuntersuchungen bei einer monoklonalen Gammopathie werden diskutiert.

TPS2068 Background: Lisavanbulin (BAL101553, prodrug of BAL27862) is a novel tumor checkpoint controller that promotes tumor cell death by modulating the spindle assembly checkpoint. BAL27862 is a lipophilic, small molecule (MW 387) shown in rodents to penetrate the brain (1:1 plasma ratio) with promising antitumor activity in orthotopic models of glioblastoma (GB) as monotherapy or in combination with radiotherapy (RT) ± chemotherapy. In a completed phase 1 study (Lopez et al. ESMO 2020, NCT02490800) with daily oral lisavanbulin in patients with recurrent GB or high-grade glioma, the RP2D was determined at 25 mg/day. In this phase 1 study, two patients (out of 20 patients) with GB show a long-lasting (> 2 years) clinical benefit with improvement in clinical symptoms and in target and/or non-target GB lesions as per RANO criteria. Both patients show strong end-binding protein 1 (EB1) expression in their GB tissues as assessed by immunohistochemistry staining. EB1, a protein located on the plus-ends of microtubules, is involved in microtubule (MT) function and has been associated with stemness of glioma cells and a more aggressive disease. Data from GB mouse models suggest that EB1 is a predictive marker for response to lisavanbulin. The prevalence of EB1-positivity in GB is estimated at ̃5%. This ongoing phase 2 study is an extension of the completed Phase 1 study and is conducted to confirm prospectively whether EB1 is a response-predictive biomarker for lisavanbulin in GB. Methods: This is an ongoing multicenter, open-label, phase 2 study using a Simon Two-Stage design to assess the efficacy of lisavanbulin in patients with recurrent GB. The study is being performed in the UK, Switzerland and Germany. Patients with histologically-confirmed GB and recurrent disease after prior RT with alkylating chemotherapy (de-novo/primary GB) or after prior chemotherapy or RT (secondary GB), are eligible for enrollment if their GB archival tumor tissue is EB1-positive. EB1-positivity is defined as moderate to strong EB1-staining in at least 70% of GB tumor cells using a CE-marked immunohistochemistry Clinical Trial Assay (Targos Molecular Pathology GmbH). The primary study objective is the overall response rate by RANO, with MRI scans being performed every 8 weeks. Secondary endpoints include progression-free survival and overall survival. Adverse events are assessed using CTCAEv5. To develop a potential RNA-based response signature, molecular profiling of tumor tissue is performed using whole transcriptome sequencing (RNAseq) in each patient enrolled in the study to define the genomic expression profiles in patients with EB1-positive GB. Nine evaluable patients are to be enrolled in Stage 1, and an additional 10 patients will be enrolled in stage 2 if at least 2 objective responses per RANO criteria are observed in stage 1. Clinical trial information: 02490800.

Despite aggressive multimodality treatment of glioblastoma, outcome remains poor and patients mostly die of local recurrences. Besides reoperation and occasionally reirradiation, systemic treatment of recurrent glioblastoma consists of alkylating chemotherapy (lomustine, temozolomide), bevacizumab and combinations thereof. Unfortunately, antiangiogenic agents failed to improve survival either as a monotherapy or in combination treatments. This review provides current insights into tumor-derived escape mechanisms and other areas of treatment failure of antiangiogenic agents in glioblastoma. Areas covered: We summarize the current literature on antiangiogenic agents in the treatment of glioblastoma, with a focus on recurrent disease. A literature search was performed using the terms 'glioblastoma', 'bevacizumab', 'antiangiogenic', 'angiogenesis', 'resistance', 'radiotherapy', 'chemotherapy' and derivations thereof. Expert commentary: New insights in glioma neoangiogenesis, increasing understanding of vascular pathway escape mechanisms, and upcoming immunotherapy approaches might revitalize the therapeutic potential of antiangiogenic agents against glioblastoma, although with a different treatment intention. The combination of antiangiogenic approaches with or without radiotherapy might still hold promise to complement the therapeutic armamentarium of fighting glioblastoma.

Zusammenfassung. Das Glioblastom rezidiviert regelmässig trotz multimodaler Erstlinientherapie innerhalb weniger Monate nach der Diagnose. Für diese Situation ist bislang noch kein Therapiestandard etabliert. Bevacizumab, ein Antikörper gegen den vaskulären endothelialen Wachstumsfaktor, weckte grosse Hoffnungen in der Therapie des Glioblastoms. Zwei Phase-III-Studien zeigten allerdings nur eine Verzögerung der Krankheitsprogression, nicht aber des Gesamtüberlebens, durch die Kombination der Standarderstlinientherapie mit Bevcizumab. Gleiches ergab die EORTC 26101-Rezidivtherapiestudie mit einer Kombination von Lomustin/Bevacizumab gegenüber einer Lomustin-Monotherapie. Zudem existieren widersprüchliche Beobachtungen zur Lebensqualität und Neurokognition. Trotz der insgesamt enttäuschenden Studienlage wird Bevacizumab aufgrund seines sehr guten palliativen Effektes von den Schweizer neuro-onkologischen Zentren als zugelassene Therapieoption in der Rezidivtherapie häufig eingesetzt. Vakzinierungs- und Immuntherapien eröffnen neue Einsatzmöglichkeiten für Bevacizumab in der Behandlung primärer Hirntumoren.

Pompe disease is a rare autosomal-recessive disorder characterised by limb-girdle myopathy and respiratory weakness in the late-onset form (LOPD). Various mutations in the acid alpha-glucosidase gene lead to toxic lysosomal and extra-lysosomal glycogen accumulation in all organs due to ineffective glycogen clearance by the encoded enzyme. Only one randomized trial demonstrated beneficial effects of respiratory function and meters walked in the 6-min walking test with enzyme replacement therapy (ERT). These results were confirmed in several retrospective and prospective observations and in meta-analyses. Due to a potential lifelong therapy, moderate efficacy and high treatment costs time of ERT initiation and cessation is an ongoing matter of debate. So far, several national and international recommendations have been published with different criteria concerning diagnosis, initiation and cessation of ERT in LOPD. We therefore formally analysed recent published recommendations and consensus statements of LOPD using diagnostic nodes (DODES) as a special software tool. With DODES, an objective analysis becomes possible if the content of the recommendations is represented as algorithms using cross-compatible elements. This analysis formally disclosed both, areas of great heterogeneity and concordance for the diagnosis and management of LOPD and paved the way for a Pompe disease burden scale focussing on ERT initiation. According to this investigation further clinical research should concentrate on ERT in pre-symptomatic and severely affected LOPD patients and on cessation criteria for ERT as these issues are areas of international uncertainty and discordance.

Introduction: The additional value of peripheral nerve ultrasound in acquired immune-mediated neuropathies has recently been reported. Its impact in vasculitic neuropathy is yet to be defined. We report electrophysiological and nerve ultrasound studies in a patient with nonsystemic vasculitic neuropathy at first diagnosis and in response to immunosuppression. Case Report: A 44-year-old female presented with painful neuropathy and weakness of the intrinsic hand muscles. Electrodiagnostic studies revealed severe axonal neuropathy of the nerves of the left arm. On nerve ultrasound, massive and patchy swelling of these nerves was detected. Clinical, laboratory, and radiological evidence of nonneuromuscular involvement and systemic vasculitic diseases was absent. Hence, nonsystemic vasculitic neuropathy was diagnosed without the possibility of histological verification. After 6 months of systemic immunosuppression with steroids and cyclophosphamide, clinical symptoms improved in parallel with neurosonography. In contrast, electrophysiological studies remained pathological despite clinical improvement. Conclusions: Neurosonography studies in nonsystemic vasculitic neuropathy are rare but might be an ancillary technique to guide noninvasive diagnosis and therapeutic monitoring. Morphological analysis of nerves and changes in response to treatment could be well visualized. Additionally, neurosonography might be useful to target nerve biopsy.

Zusammenfassung. Meningeome sind die häufigsten hirneigenen Tumoren und haben eine medizinische Relevanz in der Hausarztmedizin. Diese Tumoren sind überwiegend gutartig (WHO-Grad I) und können entweder beobachtet oder operiert werden. Bei einer kompletten Tumorentfernung ist das Rückfallrisiko gering. Höher-gradige Meningeome (WHO-Grad II/III) bedürfen meist einer multimodalen Therapie mit Operation und Strahlentherapie, auch wenn hierzu keine kontrollierten Studien vorliegen. Das Rezidivrisiko dieser Meningeome ist wesentlich höher, sodass engmaschiger mittels kranialer Magnetresonanztomografie nachuntersucht werden muss, um Rezidive früh zu entdecken. Neue Systemtherapien mit gezieltem Wirkmechanismus («targeted drugs») erweitern das therapeutische Spektrum und kommen zum Einsatz, wenn die lokalen Therapieverfahren versagen (z.B. Bevacizumab, Sunitinib). Bei Meningeomen aller WHO-Grade empfiehlt sich die Festlegung einer therapeutischen Strategie im Rahmen eines interdisziplinären Tumorboards.

2520 Background: Bevacizumab failed to demonstrate overall survival benefit despite markedly prolonged progression-free survival in glioblastoma patients. Reasons for this divergence may include suboptimal patient selection and delayed diagnosis of progression on MRI scans under bevacizumab. Imaging analyses of retrospective and uncontrolled clinical trial cohorts suggest MRI diffusion mapping as a predictor of benefit from bevacizumab. Moreover, amino acid PET has been proposed by the RANO working group for the differentiation of tumor versus edema or gliosis based on proof-of-principle studies demonstrating earlier detection of progression with PET compared to MRI. Methods: ARTE (NCT01443676) was a 2:1 randomized, multi-center, open-label trial of hypofractionated radiotherapy in combination with intravenous bevacizumab every 2 weeks (BEV/RT) versus RT alone in patients with newly diagnosed glioblastoma aged 65 years or older. Patients with histologically and molecularly confirmed IDH wildtype glioblastoma aged 65 years or older were analyzed. MRI was available from 67 and serial 18FET PET from 30 patients in this post hoc analysis. 18FET PET intensity ratios and herein reported MRI parameters including tumor volumetric analyses and ADC were analyzed blinded for outcome and study arm. Results: Demographic, clinical and molecular parameters were balanced between treatment arms. Overall survival benefit from bevacizumab was observed for larger contrast-enhancing tumor volumes (hazard ratio [HR] per cm3 0.94, 95% CI 0.89-0.99, p = 0.032) and higher ADC (HR 0.18, 95% CI 0.05-0.66, p = 0.025) on pre-treatment MRI. Response in the BEV/RT arm by the standard MRI-based RANO criteria was associated with overall survival by trend (HR 0.56, 95% CI 0.30-1.10, time-dependent p = 0.094). In a multivariate model controlling for established risk factors, 18FET tumor-to-brain uptake ratios (TBR) of non-contrast-enhancing tumor portions predicted inferior overall survival specifically in the BEV/RT arm (HR [per 0.1 18FET TBR] 1.50, 95% CI 1.05-2.13, time-dependent p = 0.025). Controlling for 18FET TBR at first follow-up identified benefit from BEV/RT by trend (HR 0.41, 95% CI 0.16-1.07, p = 0.069). Conclusions: Large contrast-enhancing tumor mass and high ADC identify patients with overall survival benefit from bevacizumab. Under bevacizumab, non-contrast enhancing tumor portions can be adequately monitored by amino acid PET.

Although not curative, enzyme replacement therapy (ERT) with recombinant human acid alpha-glucosidase enzyme has shown to be effective in the treatment of late-onset Pompe disease (LOPD). For this potentially life-long treatment, little is known on the clinical effect of cessation and resuming ERT. Due to a Swiss supreme court decision on ERT reimbursement, a temporary stop of ERT occurred in our study population. The aim of this study was to report the 36-months follow-up assessments after resuming ERT. After resuming ERT, seven patients suffering from genetically and enzymatically confirmed LOPD had periodic, mandatory, prospective assessments of pulmonary function tests, muscle strength summary scores, distances walked in timed walking tests, and patient-reported questionnaires. Data were statistically analyzed for significant differences between time points at ERT cessation, at ERT resuming, and 36 months thereafter. After resuming ERT forced vital capacity (p = 0.007) and distance walked in the 6 min walk test (6-MWT, p = 0.011) significantly increased at 36 months. Compared to before ERT cessation, distance walked in 6-MWT at 36 months still remained significantly lower (p = 0.005). Self-reported scores in the fatigue severity scale significantly declined at 36 months after resuming ERT (p = 0.019). No other functional or reported parameter significantly changed at 36 months after resuming ERT. Our data suggests that long-term interruption of ERT in LOPD may lead to deterioration of clinical meaningful parameters and quality of life. In addition, a clinical restoration after ERT cessation is possible for most of the LOPD patients within a 36 months follow-up.

Immune checkpoint inhibitors represent a major step forward in the field of oncologic immunotherapy these last years and have significantly increased survival of cancer patients in an ever-growing number of indications. These agents block specific immune checkpoint molecules (programmed cell death protein 1 and its ligand as well as cytotoxic T-lymphocyte-associated antigen 4) that normally downregulate the immune response. These new agents show a specific range of adverse effects induced by abnormal immunologic activation. Many different neurologic adverse events have been described, including encephalitis, myelopathy, aseptic meningitis, meningoradiculitis, Guillain-Barre-like syndrome, peripheral neuropathy (including mononeuropathy, mononeuritis multiplex, and polyneuropathy) as well as myasthenic syndrome. Immune checkpoint inhibitors have shown promising results in cancer but can possibly induce autoimmune disorders. Although rare, neurological adverse events require prompt recognition and treatment to avoid substantial morbidity.

The addition of bevacizumab to temozolomide-based chemoradiotherapy (TMZ/RT→TMZ) prolonged progression-free survival (PFS), but not overall survival (OS) in patients with newly diagnosed glioblastoma in two double-blind phase III trials. Elderly and frail patients are underrepresented in most clinical trials, but early reports of bevacizumab in glioblastoma suggested preferential benefit in this population. ARTE was a 2:1 randomized, multi-center, open-label trial of hypofractionated RT (40 Gy in 15 fractions) in combination with bevacizumab (10 mg/kg x 14 days) (arm A, N=50) versus RT alone (arm B, N=25) in patients with newly diagnosed glioblastoma aged >65 years. The primary endpoint was median OS. Quality of life (QoL) was monitored by the EORTC QLQ-C30/BN20 modules. Response was assessed by RANO criteria. Exploratory studies included 18F-fluoro-ethyltyrosine positron emission tomography (FET-PET, N=34), as well as whole methylome (N=57) and nanostring gene expression (N=54) analyses. Median PFS was longer in arm A versus arm B (7.6 vs. 4.8 months, p=0.003), but OS was similar (12.1 vs 12.2 months, p=0.8). Clinical deterioration was delayed and more patients came off steroids in arm A versus arm B. Longer PFS in arm A versus arm B was confined to the receptor tyrosine kinase (RTK) I methylation subtype and to the proneural gene expression subtype, but was not observed for patients with RTK II, classical or mesenchymal subtype glioblastoma. Applying a Cox model to OS that controlled for established prognostic factors, we detected an association with age and KPS. Exploration of imaging predictors of OS in this model identified the presence of non-enhancing tumor detected by FET-PET (HR 0.31, p=0.02) as an important prognostic factor. Efficacy outcomes and exploratory analyses of ARTE do not support the notion that bevacizumab generally prolongs survival in elderly glioblastoma patients. However, novel molecular and imaging biomarkers may identify patients with preferential benefit from bevacizumab.

We aimed to compare two different salvage treatment strategies for relapsed high-grade glioma (HGG) patients by means of a new prognostic model. A simplified version of the so-called HGG-Immuno RPA model estimates the prognosis of relapsed HGG patients and distinguishes three different prognostic classes (I = good, II = intermediate, III = poor). The model has been constructed with a cohort of 117 patients whose salvage treatment consisted of re-operation followed by dendritic cell vaccination (ReOP + DCV). However, using only the predictors histology, age and performance status, the simplified HGG-Immuno RPA model is basically independent from treatment. In the present study we applied the simplified model to the cohort used to construct the original HGG-Immuno RPA model and another cohort of 165 patients who underwent re-irradiation (ReRT) at relapse. Then, we compared the outcomes achieved by the two different salvage treatments in each prognostic class. The model predicted good, intermediate and poor prognosis for 11, 31 and 75 patients of the ReOP + DCV cohort and for 20, 39 and 106 patients of the ReRT cohort, respectively. Neither of the two strategies was superior to the other. In the groups with good, intermediate and poor prognosis 12-months survival rates were 73, 59 and 25 % after ReOP + DCV and 72, 36 and 23 % after ReRT, respectively. Being easy to handle and independent from treatment, the aforementioned model is useful for therapeutic decisions. ReRT and ReOP + DVC seem to be equally effective. The choice of salvage treatment should be based on the expected side effects.

PURPOSE: We aimed to validate a controversial prognostic model for the survival of relapsed malignant glioma patients after reirradiation with an independent, multicentric patient cohort.METHODS AND MATERIALS: A total of 165 malignant glioma patients underwent reirradiation at 4 different institutions between 1994 and 2012. Twenty-two patients had a good (score 1), 44 had a moderate (score 2), and 99 had a poor prognosis (score 3 or 4). Four statistical methods were used to validate the prognostic model: First, we compared survival according to prognostic group in the construction and the validation cohort by visual comparison of the respective Kaplan-Meier plots. Second, discrimination was quantified by calculating hazard ratios for death for each prognostic group, with the worst prognostic group serving as the reference. Calibration was assessed by a calibration plot for the time point 12 months after reirradiation. Finally, we compared the predictive performance of the score and a hypothetical prognostic model ignoring all predictor variables over time by means of a prediction error curve.RESULTS: On visual validation, the survival curves of the 3 patient groups with good, moderate, and poor prognoses nicely separated from each other. Median survival rates after reirradiation were 17.9, 9.0, and 7.7 months in the patient groups with good, moderate, and poor prognosis, respectively. Hazard ratios confirmed satisfactory discrimination. Calibration was satisfactory for all and most accurate for the worst prognostic group. The score improved the prognostic performance in comparison to the "zero-model."CONCLUSIONS: We successfully validated a prognostic model for the survival of malignant glioma patients after reirradiation with a multicentric, independent dataset. Being reliable and easy to handle, the model can be useful in personalized patient counseling and clinical decision-making.

In seltenen Fällen liegen der erworbenen Schädigung des Nervus peronaeus mit konsekutiver Lähmung der innervierten Muskulatur intraneurale Ganglien zugrunde. Diese können im Gegensatz zu den druckbedingten Kompressionen chirurgisch im Rahmen der Erstdiagnose behandelt werden. Eine sorgfältige Anamnese in Kombination mit einer klinischen und elektrophysiologischen Untersuchung ist hierbei zielführend. Häufig passen einzelne Befunde nicht zu der klassischen Präsentation einer Druckläsion am Fibulakopf. Ergänzend stellt die hochfrequente dynamische Nervensonographie des N. peronaeus eine sensitive und kostengünstige bildgebende Untersuchungsmethode dar, um diese besondere Pathologie aufzudecken. Nachfolgend werden drei Patienten mit Paresen des N. peronaeus beschrieben, bei denen die Nervensonographie zur Diagnose von intraneuralen Ganglien des N. peronaeus führte.

The objective is to prospectively investigate short- and mid-term changes of heart rate variability (HRV) in patients with relapsing–remitting multiple sclerosis (RRMS), being started on fingolimod. In this prospective clinical trial, patient (n = 33) with RRMS starting treatment with fingolimod underwent a time-domain-based analysis of HRV (breathing at rest, deep breath, and in response to the Valsalva maneuver) shortly before, 4.5 h and 3 months after first intake. Blood pressure changes after the Valsalva maneuver were used as a marker of the sympathetic noradrenergic system. We used a non-invasive continuous beat-to-beat heart rate and blood pressure monitoring. In addition, the Fatigue Severity Scale and the refined and abbreviated Composite Autonomic Symptom Score were applied. Significant changes in HRV in RRMS patients, following treatment with fingolimod, were detected. After an initial increase in HRV, measured 4.5 h after the first intake of fingolimod, a substantial decrease in HRV occurred within 3 months on continuous treatment. There is a growing body of evidence for short-term cardiovascular side effects in continuous treatment with fingolimod, driven by the ANS. The mechanisms and the clinical relevance of the observed changes in HRV need further evaluation, especially in longer and larger prospective studies.

Treatment evaluation of gliomas is performed by using the RANO criteria. They are based on cerebral MRI, steroid use, and neurological function. However, assessment of neurological function is neither defined nor standardized due to the lack of a validated measure. We used the NIH-SS to measure neurological function at baseline and follow-up in glioma patients in a standardized manner and compared the results with outcomes on MRI using the RANO criteria. Methods: Retrospective analysis of glioma patients (WHO grade II-IV; > 18 years) treated from 2008 to 2015 at the cantonal hospital St. Gallen with at least one follow up MRI including an NIH-SS assessment (0-42 points). Patients were identified by chart review. Results: We identified 61 patients (36 males, median age 52 years) with WHO grade II (10), grade III (21) and grade IV (30) gliomas who met the minimal inclusion criteria. During the observation period 45 (74%) patients progressed and 27 (44%) died. Median PFS and OS was 1.70 and 3.22 years, respectively. We evaluated 471 baseline and follow up assessments, with a median of 6 per patient (range, 2-22).Median baseline NIH-SS was 0 points (range, 0 to 7) and median change in NIH-SS was also 0 points (range,-4 to 9). Statistical analysis (Cohen’s kappa, Stuart-Maxwell-test) did not reveal an agreement of changes in NIH-SS and MRI-RANO criteria. Conclusion: Neurological follow up assessment using the NIH-SS was not a useful predictor of MRI findings in this retrospective cohort of glioma patients.