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BackgroundThe glioblastoma's bad prognosis is primarily due to intra-tumor heterogeneity, demonstrated from several studies that collected molecular biology, cytogenetic data and more recently radiomic features for a better prognostic stratification. The GLIFA project (GLIoblastoma Feature Analysis) is a multicentric project planned to investigate the role of radiomic analysis in GB management, to verify if radiomic features in the tissue around the resection cavity may guide the radiation target volume delineation. Materials and methodsWe retrospectively analyze from three centers radiomic features extracted from 90 patients with total or near total resection, who completed the standard adjuvant treatment and for whom we had post-operative images available for features extraction. The Manual segmentation was performed on post gadolinium T1w MRI sequence by 2 radiation oncologists and reviewed by a neuroradiologist, both with at least 10 years of experience. The Regions of interest (ROI) considered for the analysis were: the surgical cavity +/- post-surgical residual mass (CTV_cavity); the CTV a margin of 1.5 cm added to CTV_cavity and the volume resulting from subtracting the CTV_cavity from the CTV was defined as CTV_Ring. Radiomic analysis and modeling were conducted in RStudio. Z-score normalization was applied to each radiomic feature. A radiomic model was generated using features extracted from the Ring to perform a binary classification and predict the PFS at 6 months. A 3-fold cross-validation repeated five times was implemented for internal validation of the model. ResultsTwo-hundred and seventy ROIs were contoured. The proposed radiomic model was given by the best fitting logistic regression model, and included the following 3 features: F_cm_merged.contrast, F_cm_merged.info.corr.2, F_rlm_merged.rlnu. A good agreement between model predicted probabilities and observed outcome probabilities was obtained (p-value of 0.49 by Hosmer and Lemeshow statistical te

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Background: Although anterior cervical discectomy and fusion (ACDF) represents a standardized procedure for surgical treatment of a cervical herniated disc, several variables could affect patients' clinical and radiological outcome. We evaluated the impact of sex, age, body mass index (BMI), myelopathy, one-or two-level ACDF, and the use of postoperative collars on functional and radiological outcomes in a large series of patients operated for ACDF. Materials and Methods: Databases of three institutions were searched, resulting in the enrollment of 234 patients submitted to one-or two-level ACDF from January 2013 to December 2017 and followed as outpatients at 6-and 12-month follow-up. The impact of variables on functional and radiological outcomes was evaluated using univariate and multivariate logistic regression analysis. Results: At univariate analysis, female sex, higher BMI, two-level ACDF, and postoperative collar correlated with a significantly worse early and late Neck Disability Index (NDI). Multivariate analysis showed that male patients had a lower risk of worse early (P = 0.01) and late NDIs (P = 0.009). Patients with myelopathy showed better early NDI (P = 0.004). Cervical collar negatively influenced both early and late NDIs (P < 0.0001), with a higher risk of early nonfusion (P = 0.001) but a lower risk of late nonfusion (P = 0.01). Patients operated for two-level ACDF have a worse early NDI (P = 0.005), a worse late NDI (P = 0.01), and a higher risk of early nonfusion (P = 0.048). BMI and age did not influence outcome. Conclusions: Female sex, two-level surgery, and the use of postoperative collars significantly correlate with worse functional outcomes after one-or two-level ACDF.

Pr5-ALA has been well-established for use in intraoperative fluorescence-guided resection of malignant glioma. It is not as strongly supported for use with low-grade gliomas (LGG) because only a few of these, less than 20%, have visible porphyrin accumulation, which is useful for 5-ALA-guided surgery. We report here our experience with 5-ALA uptake in a case of suspected relapse of anaplastic oligodendroglioma, IDH-mutant and 1p/19q-codeleted.

Despite recent discoveries in genetics and molecular fields, glioblastoma (GBM) prognosis still remains unfavorable with less than 10% of patients alive 5 years after diagnosis. Numerous studies have focused on the research of biological biomarkers to stratify GBM patients. We addressed this issue in our study by using clinical/molecular and image data, which is generally available to Neurosurgical Departments in order to create a prognostic score that can be useful to stratify GBM patients undergoing surgical resection. By using the random forest approach [CART analysis (classification and regression tree)] on Survival time data of 465 cases, we developed a new prediction score resulting in 10 groups based on extent of resection (EOR), age, tumor volumetric features, intraoperative protocols and tumor molecular classes. The resulting tree was trimmed according to similarities in the relative hazard ratios amongst groups, giving rise to a 5-group classification tree. These 5 groups were different in terms of overall survival (OS) (p < 0.000). The score performance in predicting death was defined by a Harrell’s c-index of 0.79 (95% confidence interval [0.76–0.81]). The proposed score could be useful in a clinical setting to refine the prognosis of GBM patients after surgery and prior to postoperative treatment.

BACKGROUND: The survival benefit in maximizing resection in glioblastomas (GBMs) has been demonstrated by numerous studies. The true limit of infiltration of GBMs has been an overwhelming obstacle, and several technological advances have been introduced to improve the identification of residual tumors. OBJECTIVE: To evaluate whether the integration of 5-aminolevulinic acid (5-ALA) with microbubble contrast-enhanced ultrasound (CEUS) improves residual tumor identification and has an impact on the extent of resection (EOR), overall survival (OS), and progression-free survival (PFS). METHODS: A total of 230 GBM procedures were retrospectively studied. Cases were stratified according to the surgical procedure into 4 groups: 5-ALA- and CEUS-guided surgeries, 5-ALA-guided surgeries, CEUS-guided surgeries, and conventional microsurgical procedures. RESULTS: Patients undergoing conventional microsurgical procedures showed the worst EORs compared to the assisted techniques (5-ALA and CEUS procedures). Both 5-ALA and CEUS techniques improved the EOR compared to conventional microsurgical procedures. However, their combination gave the best results in terms of the EOR (P = .0003). The median EOR% and the number of supramarginal resections are hence superior in the 5-ALA + CEUS + group compared to the others; this observation had consequences on PFS and OS in our series. CONCLUSION: In terms of the EOR, the best results can be achieved through a combination of both techniques, where the 5-ALA-guided procedure is followed by a final survey with CEUS. Compared with other intraoperative imaging techniques, CEUS is a real-time, readily repeatable, safe, and inexpensive technique that provides valuable information to the surgeon before, during, and after resection.

Objective: We studied the correlation of magnetic resonance imaging (MRI) findings with the prognosis of patients with multiple sclerosis (MS)-related trigeminal neuralgia (TN) who had undergone percutaneous balloon compression (PBC). To the best of our knowledge, no studies have previously reported on this topic. We also performed a review of pertinent studies. Methods: From a surgical series of 82 patients with TN who had undergone PBC from January 2013 to June 2017, we identified 16 patients with MS (mean age, 54.81 ± 8.51 years; mean follow-up, 38.12 ± 19.86 months). Using brain MRI, we evaluated the presence of a lesion in the trigeminal nerve root entry zone and trigeminal nuclei. With other clinical and procedure-related factors, we studied its effect on acute pain relief (pain free at hospital discharge) and pain-free survival (PFS). Results: Of the 16 patients, 15 (93.75%) reported acute pain relief; 8 patients (50.00%) experienced a recurrence of pain. At the latest follow-up visit, an excellent outcome (Barrow Neurological Institute grade 1–2) was obtained for 75% of patients and a good outcome (Barrow Neurological Institute grade 3) for 25%. No patient experienced uncontrolled pain. The presence of a pear-like balloon shape during surgery (P = 0.0053) and a MRI detectable lesion in the trigeminal pathway (P = 0.049) were associated with greater PFS. Conclusions: PBC can be efficient in treating MS-related TN. Some factors, such as a pear-like balloon shape during surgery and evidence of a MRI-detectable lesion in the trigeminal pathway were associated with longer PFS.

Cavernous malformations (CM) are benign, low-flow vascular lesions that account for 5% - 13% of all cerebrovascular malformations. Surgery remains the most important treatment strategy, and many different approaches have been developed. We present here our institutional experience with 68 cases using a transcortical neuronavigation approach with some technical nuances to improve navigation accuracy during resection. The technique and clinical outcomes are discussed, with a specific focus on seizure sequels. Demographic data were collected, along with information on clinical and seizure characteristics at presentation, localization and size of CM, presence of multiple localizations, evidence of recent CM-related bleeding on MRI, intervention features, postoperative complications, prescription of anti-epileptic drugs at discharge and seizure outcome. We assume that surgery through a narrow well-defined working corridor would limit brain exposure and manipulation, and hence could significantly affect not only general complications, but also seizure control. The technique is feasible and associated with relatively low rates of minor and major procedure-related complications. It is also a valid method for surgeons in training since the trajectory is planned preoperatively with a senior consultant and the working corridor always follows the catheter, which directly leads to the cavernoma.

Background: Brain metastases from laryngeal squamous cell carcinoma (SCC) are rare, and there are no standardized treatments. Here we reported on a case of brain metastasis from laryngeal SCC and performed a literature review on these cases. Moreover, by plotting Kaplan-Meier curves, we carried out a survival analysis to provide an estimation of overall survival (OS) and to find possible prognostic factors. Case Description: A 65-year-old male was admitted to our department with a large left occipital lesion. Three years ago, the patient had undergone total laryngectomy with bilateral neck dissection with a diagnosis of a poor differentiated SCC. The occipital lesion was totally removed. A diagnosis of a brain metastasis from laryngeal SCC was made. The patient was submitted to adjuvant chemotherapy and radiation therapy. He is in good clinical conditions at 7-month follow-up with a still ongoing chemotherapy. From survival analysis, we have found that surgery and/or radiochemotherapy increase the OS of these patients compared with untreated cases. Moreover, Karnofsky performance status (KPS) score ≥70 and recursive partitioning analysis (RPA) classes I and II were associated with better OS in these patients. Conclusion: Brain metastases from laryngeal SCC are rare. This is the first study in which a survival analysis of these cases has been performed. Surgery and/or radio-chemotherapy increase the survival of these patients compared with untreated cases. Moreover, KPS score and RPA class affect the outcome of these patients.

OBJECTIVE: The orbital cavity is an anatomically complex region and an area of interest of many specialists, each of whom is familiar with specific surgical approaches. METHODS: We retrospectively reviewed clinical and outcome data of 70 patients who underwent surgery for resection of an orbital tumor with a mean follow-up of 111.9 ± 79.6 months. The clinical outcome was reported and the role of sex, age, histology, tumor location, tumor size, and surgical approach on the extent of tumor removal was assessed. RESULTS: Total removal was achieved in 74.3%, subtotal removal in 20%, and partial removal in 5.7% of patients. A fronto-orbital craniotomy was used in 57.1% of cases, frontal approach in 17.1%, fronto-orbit-zygomatic approach in 10%, and endoscopic endonasal approach in 11.4%. Complications included visual acuity decrease (4.3%), cerebrospinal fluid leak (4.3%), nerve palsy (10%; supra-orbital nerve 4.3%; frontal branches of facial nerve 2.9%, third cranial nerve 2.9%), and enophthalmos (1.4%). Lateral orbitotomy, combined fronto-orbital and maxillotomy, and trans-eyelid approaches were used in the remaining cases. The fronto-orbital, frontal, and lateral orbitotomy approaches were associated with greater rates of total resection as compared with the fronto-orbit-zygomatic approach, which was used in difficult cases in which the tumor involved several regions. CONCLUSIONS: We recommend, 1) the endoscopic endonasal approach for primary orbital tumors located in the medial or inferior orbital walls without extra-orbital extension; 2) the trans-eyelid approach for tumors of the upper and upper-lateral quadrants extraconally located, and 3) the fronto-orbital approach for intraconally located tumors involving more than one quadrant.

Treatment options for recurrent glioblastoma are scarce; targeted therapy trials were disappointing, probably due to enrollment of patients without molecular selection. We treated with bevacizumab and erlotinib a 66-year-old male suffering from recurrent glioblastoma, IDH-wildtype and MGMT unmethylated, after three neurosurgeries. Treatment was tailored on molecular profile of recurrent tumor-namely, EGFRvIII positivity, VEGF overexpression, normal PTEN, low total VEGF and VEGF-121 mRNA-and resulted in complete, exceptionally durable response (51-month progression-free survival). Notably, histology of further recurrence after therapy was reminiscent of sarcoma. We suggest a thorough molecular screening for personalization of targeted therapy in recurrent glioblastoma