scholarly journals Predicting the Extent of Resection of Motor-Eloquent Gliomas Based on TMS-Guided Fiber Tracking

2021 ◽  
Vol 11 (11) ◽  
pp. 1517
Author(s):  
Francesco Belotti ◽  
Mehmet Salih Tuncer ◽  
Tizian Rosenstock ◽  
Meltem Ivren ◽  
Peter Vajkoczy ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Intraoperative Monitoring ◽  
Corticospinal Tract ◽  
Risk Model ◽  
Motor Evoked Potential ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Resection Cavity ◽  
Risk Stratification Model ◽  
Motor Outcome

Background: Surgical planning with nTMS-based tractography is proven to increase safety during surgery. A preoperative risk stratification model has been published based on the M1 infiltration, RMT ratio, and tumor to corticospinal tract distance (TTD). The correlation of TTD with corticospinal tract to resection cavity distance (TRD) and outcome is needed to further evaluate the validity of the model. Aim of the study: To use the postop MRI-derived resection cavity to measure how closely the resection cavity approximated the preoperatively calculated corticospinal tract (CST) and how this correlates with the risk model and the outcome. Methods: We included 183 patients who underwent nTMS-based DTI and surgical resection for presumed motor-eloquent gliomas. TTD, TRD, and motor outcome were recorded and tested for correlations. The intraoperative monitoring documentation was available for a subgroup of 48 patients, whose responses were correlated to TTD and TRD. Results: As expected, TTD and TRD showed a good correlation (Spearman’s ρ = 0.67, p < 0.001). Both the TTD and the TRD correlated significantly with the motor outcome at three months (Kendall’s Tau-b 0.24 for TTD, 0.31 for TRD, p < 0.001). Interestingly, the TTD and TRD correlated only slightly with residual tumor volume, and only after correction for outliers related to termination of resection due to intraoperative monitoring events or the proximity of other eloquent structures (TTD ρ = 0.32, p < 0.001; TRD ρ = 0.19, p = 0.01). This reflects the fact that intraoperative monitoring (IOM) phenomena do not always correlate with preoperative structural analysis, and that additional factors influence the intraoperative decision to abort resection, such as the adjacency of other vulnerable structures. The TTD was also significantly correlated with variations in motor evoked potential (MEP) responses (no/reversible decrease vs. irreversible decrease; p = 0.03). Conclusions: The TTD approximates the TRD well, confirming the best predictive parameter and giving strength to the nTMS-based risk stratification model. Our analysis of TRD supports the use of the nTMS-based TTD measurement to estimate the resection preoperatively, also confirming the 8 mm cutoff. Nevertheless, the TRD proved to have a slightly stronger correlation with the outcome as the surgeon’s experience, anatomofunctional knowledge, and MEP observations influence the expected EOR.

Bicentric validation of the navigated transcranial magnetic stimulation motor risk stratification model

2021 ◽  
pp. 1-13
Author(s):  
Tizian Rosenstock ◽  
Levin Häni ◽  
Ulrike Grittner ◽  
Nicolas Schlinkmann ◽  
Meltem Ivren ◽  
...  
Keyword(s):  
Transcranial Magnetic Stimulation ◽  
Risk Stratification ◽  
Magnetic Stimulation ◽  
Corticospinal Tract ◽  
Fiber Tracking ◽  
Motor Deficit ◽  
Navigated Transcranial Magnetic Stimulation ◽  
Risk Stratification Model ◽  
Motor Outcome ◽  
Dti Fiber Tracking

OBJECTIVE The authors sought to validate the navigated transcranial magnetic stimulation (nTMS)–based risk stratification model. The postoperative motor outcome in glioma surgery may be preoperatively predicted based on data derived by nTMS. The tumor-to-tract distance (TTD) and the interhemispheric resting motor threshold (RMT) ratio (as a surrogate parameter for cortical excitability) emerged as major factors related to a new postoperative deficit. METHODS In this bicentric study, a consecutive prospectively collected cohort underwent nTMS mapping with diffusion tensor imaging (DTI) fiber tracking of the corticospinal tract prior to surgery of motor eloquent gliomas. The authors analyzed whether the following items were associated with the patient’s outcome: patient characteristics, TTD, RMT value, and diffusivity parameters (fractional anisotropy [FA] and apparent diffusion coefficient [ADC]). The authors assessed the validity of the published risk stratification model and derived a new model. RESULTS A new postoperative motor deficit occurred in 36 of 165 patients (22%), of whom 20 patients still had a deficit after 3 months (13%; n3 months = 152). nTMS-verified infiltration of the motor cortex as well as a TTD ≤ 8 mm were confirmed as risk factors. No new postoperative motor deficit occurred in patients with TTD > 8 mm. In contrast to the previous risk stratification, the RMT ratio was not substantially correlated with the motor outcome, but high RMT values of both the tumorous and healthy hemisphere were associated with worse motor outcome. The FA value was negatively associated with worsening of motor outcome. Accuracy analysis of the final model showed a high negative predictive value (NPV), so the preoperative application may accurately predict the preservation of motor function in particular (day of discharge: sensitivity 47.2%, specificity 90.7%, positive predictive value [PPV] 58.6%, NPV 86.0%; 3 months: sensitivity 85.0%, specificity 78.8%, PPV 37.8%, NPV 97.2%). CONCLUSIONS This bicentric validation analysis further improved the model by adding the FA value of the corticospinal tract, demonstrating the relevance of nTMS/nTMS-based DTI fiber tracking for clinical decision making.

scholarly journals Performance of the recommended ESC/EASD cardiovascular risk stratification model in comparison to SCORE and NT-proBNP as a single biomarker for risk prediction in type 2 diabetes mellitus

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Suriya Prausmüller ◽  
Michael Resl ◽  
Henrike Arfsten ◽  
Georg Spinka ◽  
Raphael Wurm ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Risk Stratification ◽  
Risk Model ◽  
Risk Stratification Model ◽  
Score Risk ◽  
Unselected Cohort

Abstract Background Recently, the European Society of Cardiology (ESC) and European Association for the Society of Diabetes (EASD) introduced a new cardiovascular disease (CVD) risk stratification model to aid further treatment decisions in individuals with diabetes. Our study aimed to investigate the prognostic performance of the ESC/EASD risk model in comparison to the Systematic COronary Risk Evaluation (SCORE) risk model and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in an unselected cohort of type 2 diabetes mellitus (T2DM). Methods and results A total of 1690 T2DM patients with a 10-year follow up for fatal CVD and all-cause death and a 5-year follow up for CVD and all-cause hospitalizations were analyzed. According to ESC/EASD risk criteria 25 (1.5%) patients were classified as moderate, 252 (14.9%) high, 1125 (66.6%) very high risk and 288 (17.0%) were not classifiable. Both NT-proBNP and SCORE risk model were associated with 10-year CVD and all-cause death and 5-year CVD and all-cause hospitalizations while the ESC/EASD model was only associated with 10-year all-cause death and 5-year all-cause hospitalizations. NT-proBNP and SCORE showed significantly higher C-indices than the ESC/EASD risk model for CVD death [0.80 vs. 0.53, p < 0.001; 0.64 vs. 0.53, p = 0.001] and all-cause death [0.73, 0.66 vs. 0.52, p < 0.001 for both]. The performance of SCORE improved in a subgroup without CVD aged 40–64 years compared to the unselected cohort, while NT-proBNP performance was robust across all groups. Conclusion The new introduced ESC/EASD risk stratification model performed limited compared to SCORE and single NT-proBNP assessment for predicting 10-year CVD and all-cause fatal events in individuals with T2DM.

scholarly journals Performance of NT-proBNP as a single biomarker in comparison to SCORE and the recommended ESC/EASD cardiovascular risk stratification model for risk prediction in type 2 diabetes mellitus

2020 ◽  
Author(s):  
Suriya Prausmüller ◽  
Michael Resl ◽  
Henrike Arfsten ◽  
Georg Spinka ◽  
Raphael Wurm ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Risk Stratification ◽  
Risk Model ◽  
Risk Stratification Model ◽  
Score Risk ◽  
Unselected Cohort

Abstract Background. Recently, the European Society of Cardiology (ESC) and European Association for the Society of Diabetes (EASD) introduced a new cardiovascular (CV) risk stratification model to aid further treatment decisions in individuals with diabetes. Our study aimed to investigate the prognostic performance of NT-proBNP and the Systematic COronary Risk Evaluation (SCORE) compared to the ESC/EASD risk model in an unselected cohort of type 2 diabetes mellitus (T2DM).Methods & Results. A total of 1690 T2DM patients with a 10-year follow up for fatal CV and all-cause death and a 5-year follow up for CV and all-cause hospitalizations were analyzed. According to ESC/EASD risk criteria 25 (1.5%) patients were classified as moderate, 252 (14.9%) high, 1125 (66.6%) very high risk and 288 (17.0%) were not classifiable. NT-proBNP, the ESC/EASD and SCORE risk model were all associated with 10-year CV and all-cause death and 5-year CV and all-cause hospitalizations. NT-proBNP showed significantly higher C-indices than the ESC/EASD and SCORE risk model for CV death [0.80 vs 0.53 vs 0.64, p<0.001] and all-cause death [0.73 vs 0.52 vs 0.66, p<0.001]. The performance of SCORE improved in a subgroup without CV disease aged 40-64 years compared to the unselected cohort, whilst performance of NT-proBNP was robust across all groups. Conclusion. NT-proBNP is a high-performing biomarker for CV risk assessment in T2DM. Single NT-proBNP is superior compared to SCORE and the multiparameter ESC/EASD risk stratification model for predicting 10-year CV and all-cause fatal events.

scholarly journals Improved risk-stratification for posterior fossa ependymoma of childhood considering clinical, histological and genetic features – a retrospective analysis of the HIT ependymoma trial cohort

2019 ◽  
Vol 7 (1) ◽  
Author(s):  
Stephanie T. Jünger ◽  
Martin Mynarek ◽  
Inken Wohlers ◽  
Evelyn Dörner ◽  
Anja zur Mühlen ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Mitotic Activity ◽  
Posterior Fossa ◽  
Cox Regression ◽  
Residual Tumor ◽  
Histological Features ◽  
Chromosome 1Q ◽  
Risk Stratification Model ◽  
Vascular Proliferation ◽  
1Q Gain

Abstract Introduction Risk stratification of children with ependymomas of the posterior fossa in current therapeutic protocols is mainly based on clinical criteria. We aimed to identify independent outcome predictors for this disease entity by a systematic integrated analysis of clinical, histological and genetic information in a defined cohort of patients treated according to the German HIT protocols. Methods Tumor samples of 134 patients aged 0.2–15.9 years treated between 1999 and 2010 according to HIT protocols were analyzed for histological features including mitotic activity, necrosis and vascular proliferation and genomic alterations by SNP and molecular inversion probe analysis. Survival analysis was performed by Kaplan-Meier method with log rank test and multivariate Cox regression analysis. Results Residual tumor after surgery, chromosome 1q gain and structural genomic alterations were identified as predictors of significantly shorter event-free (EFS) and overall survival (OS). Furthermore, specific histological features including vascular proliferation, necrosis and high mitotic activity were predictive for shorter OS. Multivariate Cox regression revealed residual tumor, chromosome 1q gain and mitotic activity as independent predictors of both EFS and OS. Using these independent predictors of outcome, we were able to build a 3-tiered risk stratification model that separates patients with standard, intermediate and high risk, and which outperforms current stratification procedures. Conclusion The integration of defined clinical, histological and genetic parameters led to an improved risk-stratification model for posterior fossa ependymoma of childhood. After validation in independent cohorts this model may provide the basis for risk-adapted treatment of children with ependymomas of the posterior fossa.

Comparison of Motor Outcome in Patients Undergoing Awake vs General Anesthesia Surgery for Brain Tumors Located Within or Adjacent to the Motor Pathways

Neurosurgery ◽  
2019 ◽  
Vol 85 (3) ◽  
pp. E470-E476 ◽  
Author(s):  
Roni Zelitzki ◽  
Akiva Korn ◽  
Eti Arial ◽  
Carmit Ben-Harosh ◽  
Zvi Ram ◽  
...  
Keyword(s):  
Motor Cortex ◽  
Brain Tumors ◽  
General Anesthesia ◽  
Tumor Resection ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Awake Craniotomy ◽  
Motor Deficits ◽  
Surgical Removal ◽  
Motor Outcome

Abstract BACKGROUND Surgical removal of intra-axial brain tumors aims at maximal tumor resection while preserving function. The potential benefit of awake craniotomy over craniotomy under general anesthesia (GA) for motor preservation is yet unknown. OBJECTIVE To compare the clinical outcomes of patients who underwent surgery for perirolandic tumors while either awake or under GA. METHODS Between 2004 and 2015, 1126 patients underwent surgical resection of newly diagnosed intra-axial tumors in a single institution. Data from 85 patients (44 awake, 41 GA) with full dataset who underwent resections for perirolandic tumors were retrospectively analyzed. RESULTS Identification of the motor cortex required significantly higher stimulation thresholds in anesthetized patients (9.1 ± 4 vs 6.2 ± 2.7 mA for awake patients, P = .0008). There was no group difference in the subcortical threshold for motor response used to assess the proximity of the lesion to the corticospinal (pyramidal) tract. High-grade gliomas were the most commonly treated pathology. The extent of resection and residual tumor volume were not different between groups. Postoperative motor deficits were more common in the anesthetized patients at 1 wk (P = .046), but no difference between the groups was detected at 3 mo. Patients in the GA group had a longer mean length of hospitalization (10.3 vs 6.7 d for the awake group, P = .003). CONCLUSION Awake craniotomy results in a better early postoperative motor outcome and shorter hospitalization compared with patients who underwent the same surgery under GA. The finding of higher cortical thresholds for the identification of the motor cortex in anesthetized patients may suggest an inhibitory effect of anesthetic agents on motor function.

scholarly journals Performance of the recommended ESC/EASD cardiovascular risk stratification model in comparison to SCORE and NT-proBNP as a single biomarker for risk prediction in type 2 diabetes mellitus

2021 ◽  
Author(s):  
Suriya Prausmüller ◽  
Michael Resl ◽  
Henrike Arfsten ◽  
Georg Spinka ◽  
Raphael Wurm ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Risk Stratification ◽  
Risk Model ◽  
Risk Stratification Model ◽  
Score Risk ◽  
Unselected Cohort

Abstract Background. Recently, the European Society of Cardiology (ESC) and European Association for the Society of Diabetes (EASD) introduced a new cardiovascular disease (CVD) risk stratification model to aid further treatment decisions in individuals with diabetes. Our study aimed to investigate the prognostic performance of the ESC/EASD risk model in comparison to the Systematic COronary Risk Evaluation (SCORE) risk model and NT-proBNP in an unselected cohort of type 2 diabetes mellitus (T2DM).Methods & Results. A total of 1690 T2DM patients with a 10-year follow up for fatal CVD and all-cause death and a 5-year follow up for CVD and all-cause hospitalizations were analyzed. According to ESC/EASD risk criteria 25 (1.5%) patients were classified as moderate, 252 (14.9%) high, 1125 (66.6%) very high risk and 288 (17.0%) were not classifiable. Both, NT-proBNP and SCORE risk model were associated with 10-year CVD and all-cause death and 5-year CVD and all-cause hospitalizations while the ESC/EASD model was only associated with 10-year all-cause death and 5-year all-cause hospitalizations. NT-proBNP and SCORE showed significantly higher C-indices than the ESC/EASD risk model for CVD death [0.80 vs 0.53, p<0.001; 0.64 vs 0.53, p=0.001] and all-cause death [0.73, 0.66 vs 0.52, p<0.001 for both].The performance of SCORE improved in a subgroup without CVD aged 40-64 years compared to the unselected cohort, while NT-proBNP performance was robust across all groups.Conclusion. The new introduced ESC/EASD risk stratification model performed limited compared to SCORE and single NT-proBNP assessment for predicting 10-year CVD and all-cause fatal events in individuals with T2DM.

scholarly journals Performance of the recommended ESC/EASD cardiovascular risk stratification model and SCORE in comparison to NT-proBNP as a single biomarker for risk prediction in type 2 diabetes mellitus

2020 ◽  
Author(s):  
Suriya Prausmüller ◽  
Michael Resl ◽  
Henrike Arfsten ◽  
Georg Spinka ◽  
Raphael Wurm ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Risk Stratification ◽  
Risk Model ◽  
Risk Stratification Model ◽  
Score Risk ◽  
Unselected Cohort

Abstract Background. Recently, the European Society of Cardiology (ESC) and European Association for the Society of Diabetes (EASD) introduced a new cardiovascular disease (CVD) risk stratification model to aid further treatment decisions in individuals with diabetes. Our study aimed to investigate the prognostic performance of the ESC/EASD risk model and the Systematic COronary Risk Evaluation (SCORE) in comparison to NT-proBNP in an unselected cohort of type 2 diabetes mellitus (T2DM).Methods & Results. A total of 1690 T2DM patients with a 10-year follow up for fatal CVD and all-cause death and a 5-year follow up for CVD and all-cause hospitalizations were analyzed. According to ESC/EASD risk criteria 25 (1.5%) patients were classified as moderate, 252 (14.9%) high, 1125 (66.6%) very high risk and 288 (17.0%) were not classifiable. Both, NT-proBNP and SCORE risk model were associated with 10-year CVD and all-cause death and 5-year CVD and all-cause hospitalizations while the ESC/EASD model was only associated with 10-year all-cause death and 5-year all-cause hospitalizations. NT-proBNP showed significantly higher C-indices than the ESC/EASD and SCORE risk model for CVD death [0.80 vs 0.53 vs 0.64, p<0.001] and all-cause death [0.73 vs 0.52 vs 0.66, p<0.001]. The performance of SCORE improved in a subgroup without CVD aged 40-64 years compared to the unselected cohort, while NT-proBNP performance was robust across all groups.Conclusion. The new introduced ESC/EASD risk stratification model performed limited compared to SCORE and single NT-proBNP assessment for predicting 10-year CVD and all-cause fatal events in individuals with T2DM.

scholarly journals Risk stratification in motor area–related glioma surgery based on navigated transcranial magnetic stimulation data

2017 ◽  
Vol 126 (4) ◽  
pp. 1227-1237 ◽  
Author(s):  
Tizian Rosenstock ◽  
Ulrike Grittner ◽  
Güliz Acker ◽  
Vera Schwarzer ◽  
Nataliia Kulchytska ◽  
...  
Keyword(s):  
Transcranial Magnetic Stimulation ◽  
Risk Stratification ◽  
Magnetic Stimulation ◽  
Motor Deficit ◽  
Precentral Gyrus ◽  
Navigated Transcranial Magnetic Stimulation ◽  
Glioma Surgery ◽  
Risk Stratification Model ◽  
Resting Motor Threshold ◽  
Motor Outcome

OBJECTIVE Navigated transcranial magnetic stimulation (nTMS) is a noninvasive method for preoperatively localizing functional areas in patients with tumors in presumed motor eloquent areas. The aim of this study was to establish an nTMS-based risk stratification model by examining whether the results of nTMS mapping and its neurophysiological data predict postoperative motor outcome in glioma surgery. METHODS Included in this study were prospectively collected data for 113 patients undergoing bihemispheric nTMS examination prior to surgery for gliomas in presumed motor eloquent locations. Multiple ordinal logistic regression analysis was performed to test for any association between preoperative nTMS-related variables and postoperative motor outcome. RESULTS A new motor deficit or deterioration due to a preexisting deficit was observed in 20% of cases after 7 days and in 22% after 3 months. In terms of tumor location, no new permanent deficit was observed when the distance between tumor and corticospinal tract was greater than 8 mm and the precentral gyrus was not infiltrated (p = 0.014). New postoperative deficits on Day 7 were associated with a pathological excitability of the motor cortices (interhemispheric resting motor threshold [RMT] ratio < 90% or > 110%, p = 0.031). Interestingly, motor function never improved when the RMT was significantly higher in the tumorous hemisphere than in the healthy hemisphere (RMT ratio > 110%). CONCLUSIONS The proposed risk stratification model, based on objective functional-anatomical and neurophysiological measures, enables one to counsel patients about the risk of functional deterioration or the potential for recovery.

Estimating Risk of Pituitary Apoplexy after Resection of Giant Pituitary Adenomas

2021 ◽  
Author(s):  
John T. Butterfield ◽  
Takako Araki ◽  
Daniel Guillaume ◽  
Ramachandra Tummala ◽  
Emiro Caicedo-Granados ◽  
...  
Keyword(s):  
Pituitary Adenomas ◽  
Pituitary Apoplexy ◽  
Residual Tumor ◽  
Extent Of Resection ◽  
Morbidity And Mortality ◽  
Surgical Approaches ◽  
Subtotal Resection ◽  
Advantages And Disadvantages ◽  
Cranial Nerve Palsies ◽  
Giant Pituitary Adenomas

Abstract Background Pituitary apoplexy after resection of giant pituitary adenomas is a rare but often cited morbidity associated with devastating outcomes. It presents as hemorrhage and/or infarction of residual tumor in the postoperative period. Because of its rarity, its incidence and consequences remain ill defined. Objective The aim of this study is to estimate the rate of postoperative pituitary apoplexy after resection of giant pituitary adenomas and assess the morbidity and mortality associated with apoplexy. Methods A systematic review of literature was performed to examine extent of resection in giant pituitary adenomas based on surgical approach, rate of postoperative apoplexy, morbidities, and mortality. Advantages and disadvantages of each approach were compared. Results Seventeen studies were included in quantitative analysis describing 1,031 cases of resection of giant pituitary adenomas. The overall rate of subtotal resection (<90%) for all surgical approaches combined was 35.6% (95% confidence interval: 28.0–43.1). Postoperative pituitary apoplexy developed in 5.65% (n = 19) of subtotal resections, often within 24 hours and with a mortality of 42.1% (n = 8). Resulting morbidities included visual deficits, altered consciousness, cranial nerve palsies, and convulsions. Conclusion Postoperative pituitary apoplexy is uncommon but is associated with high rates of morbidity and mortality in subtotal resection cases. These findings highlight the importance in achieving a maximal resection in a time sensitive fashion to mitigate the severe consequences of postoperative apoplexy.

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