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Neurofibromatosis type 1 (NF1) is a phenotypically heterogenous multisystem cancer predisposition syndrome manifesting in childhood and adolescents. Central nervous system (CNS) manifestations include structural, neurodevelopmental, and neoplastic disease. We aimed to (1) characterize the spectrum of CNS manifestations of NF1 in a paediatric population, (2) explore radiological features in the CNS by image analyses, and (3) correlate genotype with phenotypic expression for those with a genetic diagnosis. We performed a database search in the hospital information system covering the period between January 2017 and December 2020. We evaluated the phenotype by retrospective chart review and imaging analysis. 59 patients were diagnosed with NF1 [median age 10.6 years (range, 1.1–22.6); 31 female] at last follow-up, pathogenic NF1 variants were identified in 26/29. 49/59 patients presented with neurological manifestations including 28 with structural and neurodevelopmental findings, 16 with neurodevelopmental, and 5 with structural findings only. Focal areas of signal intensity (FASI) were identified in 29/39, cerebrovascular anomalies in 4/39. Neurodevelopmental delay was reported in 27/59 patients, learning difficulties in 19/59. Optic pathway gliomas (OPG) were diagnosed in 18/59 patients, 13/59 had low-grade gliomas outside the visual pathways. 12 patients received chemotherapy. Beside the established NF1 microdeletion, neither genotype nor FASI were associated with the neurological phenotype. NF1 was associated with a spectrum of CNS manifestations in at least 83.0% of patients. Regular neuropsychological assessment complementing frequent clinical and ophthalmologic testing for OPG is necessary in the care of each child with NF1.

Objective To analyze trends and differences of endovascular, surgical and hybrid revascularization approaches and the impact of comorbidity on characteristics, costs, and outcome of in-patients with peripheral artery disease (PAD) of the lower extremity. Methods Analyzing data provided by the Research Data Center of the German Federal Statistical Office, we included all hospitalizations due to PAD Fontaine IIb (Rutherford 2–3) or higher in Germany between 2009–2011 and 2016–2018. According to the individually performed procedures encoded by the Operation and Procedure Classification System, we divided hospitalizations by revascularization procedures into sole endovascular, sole surgical, hybrid, two-step and no revascularization. Patient’s comorbidity was assessed using the linear van Walraven comorbidity score (vWs). Results 1,067,671 hospitalizations (mean age 71.3 ± 11.1 years; 60.1% male) were analyzed. Between 2009–2011 and 2016–2018, reimbursement costs rose by 28.0% from €2.72 billion (€5,350/case) to €3.49 billion (€6,238/case). The share of hospitalizations with any revascularization increased by 8.9% (67.7–73.7%) driven by an increase in two-step (+ 63.3%), hybrid (+ 58.2%) and sole endovascular revascularizations (+ 32.6%), while sole surgical approaches declined (− 18.2%). Hospitalizations of more comorbid patients (vWs ≥ 20) rose by 46.8% (21,444–31,478 cases), showed an overproportionate increase in costs of 124.6% (+ €1,750/case) and were associated with more individual procedures (+ 90.6%). Conclusions In-patient treatment of PAD patients shows increasing numbers of hybrid and sole endovascular revascularizations and more patients with higher comorbidity, while sole surgical interventions and in-hospital mortality decrease. Consequently, associated costs are surging especially in more comorbid patients due to an increasing number of performed procedures and escalation of therapy.

Objectives To assess epicardial adipose tissue (EAT) volume and attenuation of different virtual non-contrast (VNC) reconstructions derived from coronary CTA (CCTA) datasets of a photon-counting detector (PCD) CT-system to replace true non-contrast (TNC) series. Methods Consecutive patients (n = 42) with clinically indicated CCTA and coronary TNC were included. Two VNC series were reconstructed, using a conventional (VNCConv) and a novel calcium-preserving (VNCPC) algorithm. EAT was segmented on TNC, VNCConv, VNCPC, and CCTA (CTA-30) series using thresholds of −190 to −30 HU and an additional segmentation on the CCTA series with an upper threshold of 0 HU (CTA0). EAT volumes and their histograms were assessed for each series. Linear regression was used to correlate EAT volumes and the Euclidian distance for histograms. The paired t-test and the Wilcoxon signed-rank test were used to assess differences for parametric and non-parametric data. Results EAT volumes from VNC and CCTA series showed significant differences compared to TNC (all p < .05), but excellent correlation (all R2 > 0.9). Measurements on the novel VNCPC series showed the best correlation (R2 = 0.99) and only minor absolute differences compared to TNC values. Mean volume differences were −12%, −3%, −13%, and +10% for VNCConv, VNCPC, CTA-30, and CTA0 compared to TNC. Distribution of CT values on VNCPC showed less difference to TNC than on VNCConv (mean attenuation difference +7% vs. +2%; Euclidean distance of histograms 0.029 vs. 0.016). Conclusions VNCPC-reconstructions of PCD-CCTA datasets can be used to reliably assess EAT volume with a high accuracy and only minor differences in CT values compared to TNC. Substitution of TNC would significantly decrease patient’s radiation dose. Key points • Measurement of epicardial adipose tissue (EAT) volume and attenuation are feasible on virtual non-contrast (VNC) series with excellent correlation to true non-contrast series (all R2>0.9). • Differences in VNC algorithms have a significant impact on EAT volume and CT attenuation values. • A novel VNC algorithm (VNCPC) enables reliable assessment of EAT volume and attenuation with superior accuracy compared to measurements on conventional VNC- and CCTA-series.

Background For recurrent glioblastoma (GB) patients, several therapy options have been established over the last years such as more aggressive surgery, re-irradiation or chemotherapy. Age and the Karnofsky Performance Status Scale (KPSS) are used to make decisions for these patients as these are established as prognostic factors in the initial diagnosis of GB. This study’s aim was to evaluate preoperative patient comorbidities by using the age-adjusted Charlson Comorbidity Index (ACCI) as a prognostic factor for recurrent GB patients. Methods In this retrospective analysis we could include 123 patients with surgery for primary recurrence of GB from January 2007 until December 2016 (43 females, 80 males, mean age 57 years (range 21–80 years)). Preoperative age, sex, ACCI, KPSS and adjuvant treatment regimes were recorded for each patient. Extent of resection (EOR) was recorded as a complete/incomplete resection of the contrast-enhancing tumor part. Results Median overall survival (OS) was 9.0 months (95% CI 7.1–10.9 months) after first re-resection. Preoperative KPSS > 80% (P P = 0.013) were associated with significantly improved survival in univariate analysis. Including these factors in multivariate analysis, preoperative KPSS P = 0.004) and EOR are the only significant prognostic factor (HR 1.611 [95% CI: 1.036–2.505], P = 0.034). ACCI was not shown as a prognostic factor in univariate and multivariate analyses. Conclusion For patients with surgery for recurrent glioblastoma, the ACCI does not add further information about patient’s prognosis besides the well-established KPSS and extent of resection.

See also the editorial by Dodd and MacDermott in this issue.

To analyze the quantitative and qualitative image quality of low-dose CT scans of the abdomen on a novel photon-counting detector CT (PCD-CT) in comparison with a traditional energy-integrating detector CT (EID-CT).Consecutive patients with clinically indicated low-dose CT were scanned on a PCD-CT and compared with a BMI-matched EID-CT-cohort scanned during the same timeframe. Radiation dose, image noise, and signal-to-noise ratio (SNR) were measured for each patient. Furthermore, image quality and conspicuity of abdominal structures (adrenal glands, mesenteric vessels, ureters, and renal pelvis) were assessed on 5-point Likert-scales (1 = very poor quality/not detectable; 5 = excellent quality/differentiability).Twenty patients (mean age 46.2 [range: 19-77]; 13 men) were included. Image noise was significantly lower (24.9 ± 3.3 vs. 31.4 ± 5.6 SD HU, p 0.001) and SNR significantly higher (2.1 ± 0.3 vs. 1.5 ± 0.4; p 0.001) on the PCD-CT. Subjective image quality was substantially higher (4.0 ± 0.3 vs. 3.1 ± 0.6; p 0.001) and conspicuity better for the renal pelvis, ureters, and mesenteric vessels on the PCD-CT. There was no significant difference in the conspicuity of the adrenal glands. With increasing BMI (1Low-dose CT scans of the abdomen performed on a novel PCD-CT exhibit reduced noise, higher SNR, increased subjective image quality, and superior conspicuity of abdominal fine structures compared to scans in comparable patients on an EID-CT.

Transsphenoidal surgery provides a minimal invasive treatment for pituitary adenoma. Our aim is to evaluate the endocrinological outcomes after adenoma resection focusing on the corticotroph function, and to identify prognostic factors for an impaired hypothalamic-pituitary-adrenal-axis function (HPA) and the reliability of postoperative early morning serum cortisol measurements. We performed a retrospective analysis of all patients treated for pituitary adenoma from April 2006 to January 2019 in our neurosurgical department. Pituitary function was assessed pre- and postoperatively as well as at 6 weeks to 12 weeks and at 1-year follow-up. Two hundred eleven patients were included. Nine percent of the patients recovered from a preoperative adrenal insufficiency, 10.4% developed a new need for hormone substitution, and a long-term deficiency of the hypothalamic-pituitary-adrenal-axis was observed in 30.9%. Cortisol measurements 5 days after surgery had a lower area under the curve (AUC) than cortisol levels detected after 6 to 12 weeks (AUC 0.740 vs. AUC 0.808) in predicting an intact corticotrope function. The cut-off value determined for cortisol measured after 6 weeks was 6.95 µg/dl (sensitivity of 94%, specificity of 68%). Postoperative early morning cortisol levels seem to be less sensitive and specific in predicting long-term corticotroph function than measurements after 6 weeks and 1 year, emphasizing the importance of endocrine follow-up testing.

Transsphenoidal surgery provides a minimal invasive treatment for pituitary adenoma. Our aim is to evaluate the endocrinological outcomes after adenoma resection focusing on the corticotroph function, and to identify prognostic factors for an impaired hypothalamic–pituitary–adrenal-axis function (HPA) and the reliability of postoperative early morning serum cortisol measurements. We performed a retrospective analysis of all patients treated for pituitary adenoma from April 2006 to January 2019 in our neurosurgical department. Pituitary function was assessed pre- and postoperatively as well as at 6 weeks to 12 weeks and at 1-year follow-up. Two hundred eleven patients were included. Nine percent of the patients recovered from a preoperative adrenal insufficiency, 10.4% developed a new need for hormone substitution, and a long-term deficiency of the hypothalamic–pituitary–adrenal-axis was observed in 30.9%. Cortisol measurements 5 days after surgery had a lower area under the curve (AUC) than cortisol levels detected after 6 to 12 weeks (AUC 0.740 vs. AUC 0.808) in predicting an intact corticotrope function. The cut-off value determined for cortisol measured after 6 weeks was 6.95 µg/dl (sensitivity of 94%, specificity of 68%). Postoperative early morning cortisol levels seem to be less sensitive and specific in predicting long-term corticotroph function than measurements after 6 weeks and 1 year, emphasizing the importance of endocrine follow-up testing.

Purpose: Median overall survival (OS) after diagnosis of glioblastoma (GBM) remains 15 months amongst patients receiving aggressive surgical resection, chemotherapy and irradiation. Treatment of patients with a poor preoperative Karnofsky Performance Status Scale (KPSS) is still controversial. Therefore, we retrospectively assessed the outcome after surgical treatment in patients with a KPSS of ≤ 60%.Methods: We retrospectively included patients with a de-novo glioblastoma WHO °IV and preoperative KPSS ≤ 60%, who underwent surgery at two neurosurgical centres between September 2006 and March 2016. We recorded pre- and postoperative tumour volume, pre- and postoperative KPSS, OS, age and MGMT promoter status.Results: 123 patients (58 females/65 males, mean age 67.4 ± 13.4 years) met the inclusion criteria. 75 of the 123 patients (61%) underwent surgical resection. 48/123 patients (39%) received a biopsy. The median preoperative and postoperative tumour volume of all patients was 33.0 ± 31.3 cm3 (IR 15.0–56.5cm3) and 3.1 ± 23.8 cm3 (IR 0.2–15.0 cm3), respectively. The median KPSS was 60% (range 20–60%) preoperatively and 50% (range 0–80%) postoperatively. The median OS was 123 ± 220 days (IR 52–395 days). Age (pConclusion: Patients with a preoperative KPSS of ≤ 60% benefit from low postoperative residual tumour volumes. Age and MGMT-methylation status were also significant prognostic parameters in this patient cohort.

Transsphenoidal surgery (TSS) represents the gold standard of pituitary adenoma resection, providing a safe and minimal invasive treatment for patients suffering from symptoms of mass effect. The aim of this study is to analyze the postoperative improvement of visual function after adenoma resection and to identify prognostic factors for the postoperative clinical recovery. We performed a retrospective analysis of all consecutive patients treated via a transsphenoidal approach for pituitary adenomas from April 2006 to December 2019 in a high-volume neurosurgical department. Our primary outcome was postoperative visual acuity and visual field impairment; the clinical findings were followed up to 3 months after surgery and correlated with clinical and radiographic findings. In total, 440 surgeries were performed in our department for tumors of the sella region in a time period of 13 years via transsphenoidal approach, and 191 patients included in the analysis. Mean age was 55 years, and 98% were macroadenomas. Mean preoperative visual acuity in patients with preoperative impairment (n = 133) improved significantly from 0.64/0.65 to 0.72/0.75 and 0.76/0.8 (right eye R/left eye L) postoperatively and at 3 months follow-up (p

Purpose: Seizures related to tumor growth are common in glioma patients, especially in low-grade glioma patients this is often the first tumor manifestation. We hypothesize that there are associations between preoperative seizures and morphologic features (e.g., tumor size, location) and histogram features in patients with glioblastoma (GB). Methods: Retrospectively, 160 consecutive patients with initial diagnosis and surgery of GB (WHO IV) and preoperative MRI were analyzed. Preoperative MRI sequences were co-registered (T2-FLAIR, T1-contrast, DTI) and tumors were segmented by a neuroradiologist using the software ITK-snap blinded to the clinical data. Tumor volume (FLAIR, T1-contrast) and histogram analyses of ADC- and FA-maps were recorded in the contrast enhancing tumor part (CET) and the non-enhancing peritumoral edema (FLAIR). Location was determined after co-registration of the data with an atlas. Permutation-based multiple-testing adjusted t statistics were calculated to compare imaging variables between patients with and without seizures. Results: Patients with seizures showed significantly smaller tumors (CET, adj. p = 0.029) than patients without preoperative seizures. Less seizures were observed in patients with tumor location in the right cingulate gyrus (adj. p = 0.048) and in the right caudate nucleus (adj. p = 0.009). Significant differences of histogram analyses of FA in the contrast enhancing tumor part were observed between patients with and without seizures considering also tumor location and size. Conclusion: Preoperative seizures in GB patients are associated with lower preoperative tumor volume. The different histogram analyses suggest that there might be microstructural differences in the contrast enhancing tumor part of patients with seizures measured by fractional anisotropy. Higher variance of GB presenting without seizures might indicate a more aggressive growth of these tumors.

Objective: The number of diagnosed fatal encephalitis cases in humans caused by the classical Borna disease virus (BoDV-1) has been increasing, ever since it was proved that BoDV-1 can cause human infections. However, awareness of this entity is low, and a specific imaging pattern has not yet been identified. We therefore provide the first comprehensive description of the morphology of human BoDV-1 encephalitis, with histopathological verification of imaging abnormalities. Methods: In an institutional review board-approved multicenter study, we carried out a retrospective analysis of 55 magnetic resonance imaging (MRI) examinations of 19 patients with confirmed BoDV-1 encephalitis. Fifty brain regions were analyzed systematically (T1w, T2w, T2*w, T1w + Gd, and DWI), in order to discern a specific pattern of inflammation. Histopathological analysis of 25 locations in one patient served as correlation for MRI abnormalities. Results: Baseline imaging, acquired at a mean of 11 ± 10 days after symptom onset, in addition to follow-up scans of 16 patients, revealed characteristic T2 hyperintensities with a predilection for the head of the caudate nucleus, insula, and cortical spread to the limbic system, whereas the occipital lobes and cerebellar hemispheres were unaffected. This gradient was confirmed by histology. Nine patients (47.4%) developed T1 hyperintensities of the basal ganglia, corresponding to accumulated lipid phagocytes on histology and typical for late-stage necrosis. Interpretation: BoDV-1 encephalitis shows a distinct pattern of inflammation in both the early and late stages of the disease. Its appearance can mimic sporadic Creutzfeldt–Jakob disease on MRI and should be considered a differential diagnosis in the case of atypical clinical presentation.

This study aimed to assess perioperative neurocognitive functions in patients with surgery for intracranial neuroepithelial tumors. Seventy-one patients [38 male, 33 female, mean age 47.2 years (range 18 to 81)] with surgery for an intracranial neuroepithelial tumor were included in this prospective single-center study. Mini-mental status examination (MMSE) and extensive neurocognitive testing (divided into the categories attention, memory, and executive functions and adjusted for age, sex, and education) were performed pre-(t0) and early postoperatively (t1). Part of the patient cohort (n = 32) also underwent neurocognitive testing during follow-up (t2). The Karnofsky Performance Status Scale (KPS) was used to assess patients’ functional independence. Patients’ quality of life was recorded by the Short Form 36 (SF 36) pre- and postoperatively in a part of the patient cohort. Pre- and postoperative comparisons were performed using the Wilcoxon-test for paired samples. Post hoc Bonferroni correction was performed to adjust for multiple testing. To assess the influence of risk factors on neurocognitive functions, Spearman correlations and the chi-squared test were performed. Subgroup analyses for patients with low-grade and high-grade tumors were performed. Postoperative deterioration was observed in 5 of 39 subtests of extensive neurocognitive testing in all 3 categories, whereas no improvement was shown. Patients with WHO Grade I tumors showed no deterioration of cognitive functions. Patients with WHO Grade II and III tumors showed significantly worse results in the executive functions category patients with WHO Grade IV tumors showed deterioration in the attention category. Significantly worse functional independence was recorded postoperatively and during follow-up (P

Objective An increasing demographic aging of the general population results in a rising incidence of octogenarians and nonagenarians with spine disease. Patients older than 65 years represent the majority of patients with degenerative lumbar spine disease in our daily clinical routine. Surgical treatment is undertaken reluctantly because of an increased rate of comorbidities. We therefore assessed complication rates of lumbar decompression in regard to neurological outcome and medical conditions in patients age 80 years or older in a retrospective single-center series. Methods Data for 244 patients (124 female, 120 male; mean age, 83.1 ± 3 years; age range, 80–95 years) who underwent decompressive surgery for lumbar spinal stenosis or disc herniation between April 2007 and February 2016 were assessed retrospectively. Age at surgery, neurologic deficits (preoperative and postoperative), relevant medical comorbidities and previous lumbar decompression, intraoperative and postoperative complications (e.g., surgery-related, medical), duration of surgery, length of hospital stay, and rate of revision surgeries were recorded. Results Surgery was performed for lumbar stenosis (184 patients; 75.4%), lumbar disc herniation (13 patients; 5.3%) or both (47 patients; 19.3%). Seventy-six patients (31.3%) patients experienced preoperative neurologic deficits; 48 (63.2%) of these patients improved, 28 (36.8%) of them were unchanged after surgery, and none deteriorated. New transient, postoperative, neurologic deficits occurred in 6 patients (2.5%). All 55 (22.5%) intraoperative complications were mild to moderate, and no severe surgical complications occurred. Two hundred fifteen patients (88%) had relevant medical disorders. Nineteen (7.7%) postoperative medical complications were reported in 17 patients (7%), of which 14 (73.7%) were severe and 5 (26.3%) were mild (4 pulmonary embolisms, 6 pneumonias, 3 myocardial infarctions, 1 postoperative renal failure, 5 urinary tract infections). Medical complications that necessitated intensive care unit treatment and resulted in lethal outcome were seen in 2 patients (0.8%). Conclusion Despite their age, the vast majority of octogenarians and nonagenarians benefited from lumbar decompression surgery. Mild to moderate intraoperative complications were relatively frequent, whereas severe intraoperative complications did not occur. The majority of medical complications was severe, but the incidence was acceptable, and the postoperative outcome was still favorable in most patients.

ZusammenfassungDie Bildgebung bei intrakraniellen Malignomen hat sich in den vergangenen beiden Jahrzehnten erheblich gewandelt. Dieser Übersichtsartikel beschreibt den aktuellen Stand der bildgebenden Diagnostik für die drei häufigsten Entitäten, die Gliome, Metastasen und Meningeome und geht dabei sowohl auf technische Grundlagen als auch auf die Anwendung in der Diagnostik, Therapieplanung und im Follow-Up ein.

OBJECTIVERecent studies have indicated that a signal intensity increase of the fluid within the resection cavity on FLAIR images may predict tumor recurrence after glioma surgery. The aim of this study was to assess the increase in FLAIR signal intensity in a large patient cohort and in subgroups to assess its prognostic value for early tumor recurrence in glioma patients.METHODSA total of 212 patients (213 cases) who had undergone surgery for an intracranial glioma (WHO Grade IV [n = 103], WHO Grade III [n = 57], and WHO Grade II [n = 53]) were included in this retrospective study. FLAIR signal within the resection cavity at the time of tumor recurrence/last contact and on the previous MRI study was assessed qualitatively and quantitatively. Appearance of FLAIR signal increase was studied over time using Kaplan-Meier estimates in subgroups.RESULTSPatients with WHO Grade II glioma and connection of the resection cavity to CSF who did not undergo radiotherapy did not regularly develop this sign and were excluded from further analysis. For the remaining 87 cases, FLAIR signal intensity increase was observed in 27 cases. Recurrent disease was found in 26 of these 27 cases, resulting in a specificity of 80.0%, a sensitivity of 31.7%, and positive and negative predictive values of 96.3% and 6.7%, respectively. In 4 cases this sign had been observed prior (range 2.8–8.5 months) to tumor recurrence defined by standard criteria. Quantitative analysis underlined the results of qualitative analysis, but it did not add a diagnostic value.CONCLUSIONSSignal intensity increase of the fluid within the resection cavity on FLAIR images is a rare but highly specific and early sign for tumor recurrence/tumor progression in completely and incompletely resected high-grade glioma without connection of the resection cavity to CSF and with radiotherapy.

Background Cement-augmented pedicle screw instrumentation (CAPSI) of the thoracolumbar spine is indicated in osteoporosis or osteopenia to improve pullout strength and biomechanical stability of pedicle screws (PS). Only a few studies report on the incidence of pulmonary cement embolism or other complications associated with CAPSI. Purpose The aim of this retrospective study was to assess the rate of CAPSI-associated complications. Study Design Retrospective cohort study. Patient Sample Patients who underwent CAPSI due to spinal tumors or degenerative spine disease. Outcome Measures Cement leakage, pulmonary cement embolism (PCE), mortality rate. Methods Our clinical database was reviewed for patients who underwent CAPSI between January 2012 and June 2015. A total of 165 patients (mean age 71±11.2; range: 46 to 93 years; m=62, f=103) were included. Indications were osteoporotic fractures (n=40), spinal metastases (n=57), degenerative (n=49) or infectious spine disease (n=5), and traumatic vertebral fractures (n=14) with an associated osteoporosis. Every patient received between 2 and 21 (mean 8±3.3) cement-augmented pedicle screws in the thoracolumbar and lumbosacral spine. Both intraoperative cement leakage in prevertebral veins, the inferior vena cava, and/or pulmonary arteries, and leakage detected on postoperative imaging were evaluated. We assessed the incidence of clinically symptomatic and asymptomatic events. Results In 29 of 31 patients with intraoperative suspicion of cement leakage into prevertebral veins or the inferior vena cava on lateral fluoroscopy, which were without hemodynamic relevance, cement extrusion was confirmed on postoperative X-ray or computed tomography (CT) scan. In three of eight patients with suspicion of PCE, PCE was verified on thoracic CT. Four patients experienced life-threatening intraoperative hemodynamic reactions, either due to cement embolism (n=2; 1.2%) or anaphylactic shock (n=2; 1.2%) with need for intraoperative cardiopulmonary resuscitation in three cases. Two patients died due to fulminant PCE. Three patients with dyspnea 1 day after surgery were also confirmed with PCE on chest CT. In five patients, an asymptomatic PCE was found incidentally on postoperative imaging. In addition, 68 patients with cement leakage into prevertebral veins or the ascending cava vein were found incidentally on postoperative spine X-ray or CT. Two of 10 patients with intraspinal epidural cement leakage required revision surgery. One hundred ten of 165 patients (66.7%) had clinically asymptomatic cement leakage. Thirteen patients had PCE (7.9%), of whom five (3.0%) were symptomatic. Two patients experienced intraoperative cement-induced anaphylaxis (1.2%). The overall symptomatic complication rate was 5.5% (n=9). The 30-day mortality rate was 1.8% (n=3). Conclusions CAPSI bears a high risk of asymptomatic cement leakage. The risk for associated severe complications was also relatively high and probably underestimated considering the retrospective nature of the present study. A strict indication for cement augmentation, especially in patients with cardiac predisposition, should be the consequence. We doubt that technical aspects of cement application and/or different types of cement are capable of reducing the risk of these complications substantially.

Imaging of intracranial neoplasms has significantly changed over the past two decades. This overview discusses the current state of diagnostic imaging for the three most common tumor types, namely gliomas, metastases and meningiomas, and describes the underlying technical principles as well as their application in diagnosis, treatment planning and follow-up.

Conventional MRI, the gold standard in structural brain imaging, alone has its limitations in pre-operative tumour grading, biopsy targeting, determination of accurate tumour margins prior to surgical resection/radiation therapy, detection of tumour recurrence and determination of early therapeutic response. The aim was to introduce and review two of the recently most discussed adjunct modalities for molecular imaging in glioma: PET and MRS, and the combination of both. A PubMed search with a combination of the terms “MRS”, “glioma” and “glioblastoma”, “brain tumour”, “positron emission” and “PET” was carried out. These results were complemented with a search of the authors’ own files. Preclinical in vitro studies as well as animal studies were excluded. Published single modality data show that 1H-MRS and PET perform similarly in answering clinical questions, which cannot be adequately answered by conventional MR imaging alone. Original articles including patients with gliomas and combining the PET and MRS modalities within the same study were scarce and resulted in 17 research papers. These articles especially point to a spatial correlation between 1H-MRS metabolic ratios and amino acid uptake and a positive relationship with histologically proven cell proliferation markers, indicating diagnostic improvement in the differentiation between glioma and benign lesions, in the delineation of brain tumours and in the differentiation between treatment-related changes and tumour progression. PET and 1H-MRS have shown their value in the non-invasive diagnosis of gliomas delivering metabolic tumour information in addition to pure structural information from conventional MRI or CT alone. The very few studies, which were conducted evaluating 1H-MRS and PET in combination, indicate a diagnostic benefit from a combined imaging approach in glioma and encourage more systematic investigation—ideally carried out in multicentric settings, in experienced neuroimaging centres (with access to integrated PET/MRI scanners), using standardized imaging- and analysis protocols.

This study was designed to assess risk factors for neurocognitive impairment in patients with benign intracranial lesions including tumors and vascular lesions. 74 patients (29 m, 51 f, mean age 54.4 years) with surgery for benign intracranial lesions were included in this prospective single-center study. Extensive neuropsychological testing was performed preoperatively, including tests for attention, memory and executive functions. Furthermore, headache and depression were assessed using the german version of the HDI (IBK) and the BDI-II. Multiple linear regression analyses of the percentile ranks (adjusted for age, sex and education) including the parameters age, Karnofsky Performance Status Scale (KPS), mood, pain and lesion size were performed to identify risk factors for cognitive impairment. Using the Mann-Whitney U test, the influence of hemisphere and type of lesion (tumor/vascular) was assessed. Posthoc Bonferroni correction was performed. Poorer neurocognitive functions were observed only in the category attention in patients with higher age (divided attention, WMS) and reduced KPS (WMS). Lesion volume, mood, pain, hemisphere or the type of the lesion (tumor, vascular) were not identified as risk factors for poorer neurocognitive functions in patients with benign intracranial lesions. Age and KPS are the main risk factors for poorer neurocognitive functions in the category attention in patients with benign intracranial lesions. Knowledge of these risk factors might be important to find appropriate therapy regimes to improve cognitive functions and quality of life.

Modern medicine requires tight multidisciplinary collaboration and communication among several technical disciplines. Nevertheless, multidisciplinary medical courses are rare and even less often scientifically evaluated. The aim was to evaluate an innovative neuro-oncology course for medical students (MED) and students of science, technology, engineering, and mathematics (STEM) so that they learn and practice mutual understanding, communication and cooperation. 10 MED and 9 STEM were trained together during a one-week-course on the topic of "brain tumor" in imaging, surgical planning, surgery, pathological diagnosis, and adjuvant therapy. Evaluation was undertaken via focus groups and accompanying questionnaires about motivation, course acceptance, and multidisciplinary attitude. Students evaluated course structure, content, and multidisciplinary setting positively and showed high intrinsic motivation. However, the students sensed an "artificial dividing line" between both groups, which was conceptually encouraged by the deliberate temporary subdivision into "monodisciplinary" seminars and during the preparation of presentations. Students' opinion of the concept was generally positive as they learned about the challenges in finding a "common scientific language". Nevertheless, some criticisms were raised concerning the dividing line between the disciplines, which in part led to organizational changes. Even though the current reality may be reflected here, the goal of future interprofessional courses should definitely be to dissolve this dividing line.

Purpose Increase in FLAIR signal of the fluid within the resection cavity is described as a highly specific and early sign for tumor recurrence in gliomas. The aim of this study was to assess the prognostic value of FLAIR signal increase in partially or completely resected brain metastases. Materials and Methods 209 cases of surgery for brain metastases were assessed. 41 cases with at least two follow-up MRIs were retrospectively included in this study. Quantitative and qualitative assessment of the FLAIR signal intensity of the fluid within the resection cavity was performed in the MRI examination at recurrent disease/last contact and in the previous MRI examination. Results 3 of 6 cases with local tumor recurrence showed a FLAIR signal increase (sensitivity 50.0 %, specificity 100.0 %). In one case, this sign was observed even about 3 months before tumor recurrence. The specificity of FLAIR signal increase for overall tumor recurrence (local and distant) was also 100.0 %, but with a lower sensitivity of 13.0 %. Quantitative analysis showed significant differences for signal intensity of the resection cavity as well as for the change of signal intensity of the resection cavity in cases with or without local tumor recurrence. Conclusion An increase in FLAIR signal of the fluid within the resection cavity might be a highly specific and early sign of local tumor recurrence/tumor progression also for brain metastases. Key points: Citation Format

Purpose Differentiating glioblastoma from brain metastases is important for therapy planning. Diffusion tensor imaging (DTI) was described as a promising tool, however with conflicting results. Aim of this study was to analyze the clinical utility of DTI for the differentiation of brain metastases and glioblastoma. Methods 294 patients (165 glioblastoma, 129 brain metastases) with preoperative DTI were included in this retrospective study. Fractional anisotropy (FA) was measured via regions of interest (ROIs) in the contrast-enhancing tumor, the necrosis and the FLAIR-hyperintense non-enhancing peritumoral region (NEPTR). Two neuroradiologists classified patient cases as glioblastoma or brain metastases without and with knowledge of FA values. Results Glioblastoma showed significantly higher FA contrast (median glioblastoma = 0.33, metastases = 0.23; P NEPTR (0.21 vs. 0.22; P = 0.28) and for FA necrosis (0.17 vs. 0.18, P = 0.37). FA improved diagnostic accuracy of the neuroradiologists significantly from an AUC of 0.84/0.85 (Reader1/Reader2) to 0.89/0.92. Conclusions Glioblastoma show significantly higher FA values in the contrast enhancing tumor part than brain metastases. Implementation of a ROI-based measurement of FA values and FA color maps in clinical routine helps to differentiate between glioblastoma and brain metastases.

Objective Postoperative magnetic resonance imaging (MRI) is recommended soon after glioma surgery to avoid reactive nonneoplastic contrast enhancement indistinguishable from tumor. The purpose of this study was to analyze these patterns of postoperative contrast enhancement at 3 T to define the optimal time frame for postoperative MRI. Methods MRI for 206 glioblastoma surgeries in 173 patients who underwent pre- and postoperative and at least 1 follow-up 3T MRI for each surgery were analyzed retrospectively. Postoperative MRI was assessed in consensus by 2 neuroradiologists, blinded to the time after surgery. Postoperative contrast enhancement marginal to the resection cavity was analyzed and classified as vascular, linear, or nodular. The cause of the contrast enhancement (ie, reactive vs. tumor) was assessed by comparing pre-, postoperative, and follow-up MRI. Results Within 45 hours after surgery, reactive enhancement appeared in 17.9% of cases. After 45 hours, the fraction of reactive changes increased to 34.1%. Linear enhancement was more often reactive (66.1%, 39/59 cases), whereas nodular enhancement was mainly residual tumor (93.2%, 68/73 cases). Specificity of nodular enhancement was high for tumor recurrence/tumor progression (91.5%). Conclusions To avoid an increasing number of MRIs with reactive contrast enhancement, postoperative MRI at 3 T should be performed within 45 hours after surgery. However, reactive contrast enhancement can occur at all time points. In these cases, the pattern of the contrast enhancement may help to differentiate its cause.

Objective O -(2-[18F]-fluoroethyl)-L-tyrosine positron emission tomography ( 18 F-FET-PET) imaging is applied for tumor grading, prognostic stratification, and diagnosis of tumor recurrence, especially in high-grade gliomas. Experience with 18 F-FET-PET imaging in low-grade gliomas is limited. Therefore, the objective of the present study was to assess 18 F-FET-PET tracer uptake in low-grade gliomas and to investigate possible correlations with contrast enhancement in magnetic resonance imaging (MRI) and histopathology. Methods A total of 65 patients (29 female, 36 male, median age 38 years) with newly diagnosed or recurrent low-grade gliomas for whom preoperative MRI and 18 F-FET-PET imaging were available were included. Tumor entity, tumor location, as well as histopathology (isocitrate dehydrogenase [IDH] 1/2 mutation, Ki67, p53, oligodendroglial differentiation, 1p19q codeletion), and progression-free survival were assessed. 18 F-FET-PET images were acquired and fused to MRI (T2-weighted fluid-attenuated inversion recovery) and tumor volume was measured in areas with a tumor-to-background ratio >1.3, >1.6, and >2.0 and in MRI. Results PET tracer uptake was observed in 78.5% of all World Health Organization Grade I and II tumors. 18 F-FET uptake showed a high negative predictive value for oligodendroglial components and for 1p19q codeletion. No further significant correlation between histologic features, progression-free survival, or IDH1/2 mutation status and tracer uptake was observed. Conclusions We found that 78.5% of low-grade gliomas do show elevated tracer uptake in 18 F-FET-PET imaging. Low-grade glioma without tracer uptake exclude oligodendroglial differentiation and 1p19q codeletion. Further differentiation between molecular subtypes is not possible with static 18 F-FET-PET. No correlation of progression-free survival to tracer uptake and IDH1/2-mutation status was observed.

Perioperative infarction in brain tumor surgery occurs in about 30&ndash, 80% of cases and is strongly associated with poor patient outcomes and longer hospital stays. Risk factors contributing to postoperative brain infarction should be assessed. We retrospectively included all patients who underwent surgery for brain metastases between January 2015 and December 2017. Hemodynamic parameters were analyzed and then correlated to postoperative infarct volume and overall survival. Of 249 patients who underwent biopsy or resection of brain metastases during that time, we included 234 consecutive patients in this study. In total, 172/249 patients showed ischemic changes in postoperative magnet resonance imaging (MRI) (73%). Independent risk factors for postoperative brain infarction were perioperative blood loss (rho 0.189, p = 0.00587), blood glucose concentration (rho 0.206, p = 0.00358), blood lactate concentration (rho 0.176, p = 0.0136) and cumulative time of reduced PaCO2 (rho &minus, 0.142, p = 0.0445). Predictors for reduced overall survival were blood lactate (p = 0.007) and blood glucose levels (p = 0.032). Other hemodynamic parameters influenced neither infarct volume, nor overall survival. Intraoperative elevated lactate and glucose levels are independently associated with postoperative brain infarction in surgery of brain metastases. Furthermore, they might predict reduced overall survival after surgery. Blood loss during surgery also leads to more cerebral ischemic changes. Close perioperative monitoring of metabolism might reduce those complications.

Gliomas are primary brain tumors that present the majority of malignant adult brain tumors. Gliomas are subdivided into low- and high-grade tumors. Despite extensive research in recent years, the prognosis of malignant glioma patients remains poor. This is caused by naturally highly infiltrative capacities as well as high levels of radio- and chemoresistance. Additionally, it was shown that low linear energy transfer (LET) irradiation enhances migration and invasion of several glioma entities which might counteract today’s treatment concepts. However, this finding is discussed controversially. In the era of personalized medicine, this controversial data might be attributed to the patient-specific heterogeneity that ultimately could be used for treatment. Thus, current developments in glioma therapy should be seen in the context of intrinsic and radiation-enhanced migration and invasion. Due to the natural heterogeneity of glioma cells and different radiation responses, a personalized radiation treatment concept is suggested and alternative radiation concepts are discussed.

The aim of this study is to investigate the association between postoperative tumor volume and overall survival (OS) of O6-methylguanine DNA methyltransferase (MGMT)-unmethylated glioblastoma patients. One hundred-twenty-six patients with MGMT-unmethylated glioblastoma who were treated either with surgical resection or needle biopsy between 2006 and 2015 were included in this retrospective cohort. Pre- and postcontrast T1 weighted images were evaluated in order to determine pre- and postoperative contrast-enhancing tumor volumes (CE-TV). Cox regression models adjusted for other significant prognostic factors were used to investigate the association between postoperative tumor volume and survival. Complete resection of CE-TV was significantly associated with longer OS in the univariate analysis (HR 0.61; 95% CI 0.40–0.94; p = 0.02). However, this fact could not be confirmed after adjusting the model for other relevant prognostic factors (HR 1.01; 95% CI 0.65–1.55; p = 0.962). Postoperative CE-TV was significantly associated with survival in both univariate (HR: 1.04; 95% CI 1.025–1.055; p

This study aimed to assess the clinical applicability of MRI criteria for differentiation of pituitary adenomas and cystic pituitary lesions. One hundred ninety-eight consecutive patients with surgical resection of a pituitary adenoma/cystic pituitary lesion were retrospectively analyzed, blinded to clinical data and histopathological diagnosis. Different morphologic criteria were assessed: signal intensity in T2/T1w images, pattern of contrast enhancement, size, super-/infrasellar extension, and invasion of the cavernous sinus. For validation of the criteria, a second independent patient cohort (n = 102) was analyzed for diagnostic accuracy of the criteria. We identified differences between subtypes of pituitary adenomas regarding morphological MRI criteria. Especially, ACTH-producing adenomas and GH-producing adenomas showed partially specific imaging features. Application of our criteria on the second patient cohort (n = 102) did however not significantly improve diagnostic accuracy. Only differentiation between cystic pituitary lesions and adenomas was facilitated using these criteria, but did not reach statistical significance in this cohort (P = 0.352). MRI criteria might facilitate differentiation between pituitary adenomas and cystic pituitary lesions, but not between subtypes of pituitary adenomas. These subtypes show partially specific MR imaging features, however, due to a high variability knowledge of clinical symptoms and laboratory findings remain essential for the correct diagnosis.