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PurposePatients diagnosed with High Grade Gliomas (HGG) generally tend to have a relatively negative prognosis with a high risk of early tumor recurrence (TR) after post-operative radio-chemotherapy. The assessment of the pre-operative risk of early versus delayed TR can be crucial to develop a personalized surgical approach. The purpose of this article is to predict TR using MRI radiomic analysis.MethodsData were retrospectively collected from a database. A total of 248 patients were included based on the availability of 6-month TR results: 188 were used to train the model, the others to externally validate it. After manual segmentation of the tumor, Radiomic features were extracted and different machine learning models were implemented considering a combination of T1 and T2 weighted MR sequences. Receiver Operating Characteristic (ROC) curve was calculated with relative model performance metrics (accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)) at the best threshold based on the Youden Index.ResultsModels performance were evaluated based on test set results. The best model resulted to be the XGBoost, with an area under ROC curve of 0.72 (95% CI: 0.56 - 0.87). At the best threshold, the model exhibits 0.75 (95% CI: 0.63 - 0.75) as accuracy, 0.62 (95% CI: 0.38 - 0.83) as sensitivity 0.80 (95% CI: 0.66 - 0.89 as specificity, 0.53 (95% CI: 0.31 - 0.73) as PPV, 0.88 (95% CI: 0.72 - 0.94) as NPV.ConclusionMRI radiomic analysis represents a powerful tool to predict late HGG recurrence, which can be useful to plan personalized surgical treatments and to offer pertinent patient pre-operative counseling.

BackgroundRegarding brain tumor-related epilepsy (BTRE), there is an increasing number of evidence about a relationship between epileptogenesis and oncogenesis. A recent study suggests a role of post-surgery seizure outcome on the survival of patients with low-grade glioma (LGG), underlying the need for a targeted and aggressive epilepsy treatment.ObjectiveThis study aims at investigating the possible correlation between pre- and post-surgical seizure control and tumor progression in patients who underwent surgery for LGG.MethodsWe performed a retrospective analysis of patients affected by LGGs and BTRE, in a single high-volume neurosurgical center. Seizure control was assessed before surgery and at 3 years of follow-up. Patients with histological progression in high-grade glioma (HGG) have been evaluated. Clinical features, pre-surgical electroencephalograms (EEGs), and electrocorticography (ECoG) have been analyzed.ResultsAmong 154 subjects, we collected 32 patients who presented a tumor progression in HGG during the follow-up period. The majority had poor seizure control both pre- and post-surgery, never being in Engel class Ia throughout the whole history of their disease. Almost all patients with poor seizure control had pathological ECoG recording. Clinical features of seizures did not correlate with seizure outcome. On the univariate analysis, the age, the post-operative Engel class, and the extent of resection (EOR) were the prognostic factors significantly associated with oncological outcome; nevertheless, on multivariate analysis, Engel class significance was not confirmed, and the only predicting factor were age and EOR.ConclusionsAlthough not confirmed on multivariate analysis, post-surgical seizure control could be a relevant factor to consider during follow-up of BRTE, in particular, when gross total resection is not achieved. Pathological findings on the ECoG may suggest a “hidden” propensity to malignant progression, strictly related to the persistent neuronal hyper-excitability. Further studies with longer follow-up period are needed to confirm our observations.

Background: The risk of surgery in eloquent areas is related to neuropsychological dysfunctions. Maximizing the extent of resection increases the overall survival. The onco-functional balance is mandatory when surgery involves cognitive areas, and maximal information on the cognitive status of patients during awake surgery is needed. This can be achieved using direct cortical stimulation mapping and, in addition to this, a neuropsychological monitoring technique called real-time neuropsychological testing (RTNT). The RTNT includes testing protocols based on the area where the surgery is performed. We reported on tests used for left temporal lobe surgery and our RTNT decision tree.Case Report: We reported our RTNT experience with a 25-year-old right-handed man with 13 years of schooling. He reported daily partial seizures. MRI revealed the presence of a low-grade glioma involving the temporo-insular cortex. The neuropsychological status presurgery which was within the normal range was combined with functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) information. Awake surgery plus RTNT was performed. Direct electrical stimulation during object naming elicited a motor speech arrest. Resection was continuously accompanied by the RTNT. The RTNT provided enriched information to the surgeon. Performance never dropped. A slight decrement in accuracy emerged for pseudoword repetition, short-term memory and working memory, phonological processing, and verbal comprehension. Total resection was performed, and the histological examination confirmed the nature of the lesion. Immediate postsurgery performance was within the normal range as it was the fMRI and DTI assessment.Conclusion: The RTNT provides essential information that can be used online, during surgery, for clinical aims to provide the surgeon with useful feedback on the cognitive status of patients.

Objective: Bilateral globus pallidus internus deep brain stimulation (GPi-DBS) is an established and effective therapy for primary refractory dystonia. However, the comparison of frameless vs. frame-based DBS surgery technique is still controversial. This retrospective study aims to compare the clinical outcome of two GPi-DBS surgical techniques for patients affected by primary generalized or multi-segmental dystonia.Methods: For lead's stereotaxic placement, 10 patients underwent frame-based surgery and the other 10 subjects DBS surgery with a frameless technique. Clinical features were evaluated at baseline and 6 and 12 months after surgery by means of the Burke–Fahn–Marsden Dystonia Rating Scale.Results: Frame-based GPi-DBS and frameless stereotaxic group revealed a comparable clinical outcome with no surgical complications.Conclusions: Frameless technique is safe and well-tolerated by patients and showed similar effectiveness of the frame-based stereotaxic surgery during GPi-DBS for primary dystonia. Notably, it could be a valid alternative solution because of the great advantage in improving the patient's discomfort during awake surgery.

Background: Tracking the white matter principal tracts is routinely typically included during the pre-surgery planning examinations and has revealed to limit functional resection of low-grade gliomas (LGGs) in eloquent areas.Objective: We examined the integrity of the Superior Longitudinal Fasciculus (SLF) and Inferior Fronto-Occipital Fasciculus (IFOF), both known to be part of the language-related network in patients with LGGs involving the temporo-insular cortex. In a comparative approach, we contrasted the main quantitative fiber tracking values in the tumoral (T) and healthy (H) hemispheres to test whether or not this ratio could discriminate amongst patients with different post-operative outcomes.Methods: Twenty-six patients with LGGs were included. We obtained quantitative fiber tracking values in the tumoral and healthy hemispheres and calculated the ratio (HIFOF–TIFOF)/HIFOF and the ratio (HSLF–TSLF)/HSLF on the number of streamlines. We analyzed how these values varied between patients with and without post-operative neurological outcomes and between patients with different post-operative Engel classes.Results: The ratio for both IFOF and SLF significantly differed between patient with and without post-operative neurological language deficits. No associations were found between white matter structural changes and post-operative seizure outcomes.Conclusions: Calculating the ratio on the number of streamlines and fractional anisotropy between the tumoral and the healthy hemispheres resulted to be a useful approach, which can prove to be useful during the pre-operative planning examination, as it gives a glimpse on the potential clinical outcomes in patients with LGGs involving the left temporo-insular cortex.

Reading abilities and diffusion tensor imaging (DTI) parameters were retrospectively analyzed in a group of neurosurgical patients to investigate (Study 1) the role of white matter—in particular the arcuate fasciculus (AF)—in preserved vs. impaired reading; 4 months after surgery, we explored the plasticity processes (Study 2). Study 1 involved 40 patients with brain glioma (23 low-grade and 17 high-grade gliomas). We compared preoperative DTI parameters of language-related fascicles between patients who developed a reading impairment after surgery (n = 23) and patients with preserved reading (n = 17). Besides lower fractional anisotropy (FA), patients with impaired reading also displayed lower number and density of streamlines of a direct (i.e., directly connecting temporal and frontal lobes) AF segment. In Study 2, we longitudinally tested at follow-up-when reading performance had generally improved-13 patients diagnosed with low-grade glioma. The most relevant finding was a significant increase in length of streamlines of the direct AF segments in both hemispheres. From a neurosurgical perspective, our preliminary findings suggest the clinical importance of sparing direct AF segments for the involvement they showed in reading; however, the results also suggest the reorganization potential of these segments, possibly compensating of the right homologs as well.