1
|
Broggi M, Ferroli P, Schiavolin S, Zattra C, Schiariti M, Acerbi F, Caldiroli D, Raggi A, Vetrano I, Falco J, de Laurentis C, Broggi G. Surgical Complexity and Complications: The Need for a Common Language. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:1-12. [PMID: 37548717 DOI: 10.1007/978-3-030-12887-6_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Quality measurement and outcome assessment have recently caught an attention of the neurosurgical community, but lack of standardized definitions and methodology significantly complicates these tasks. OBJECTIVE To identify a uniform definition of neurosurgical complications, to classify them according to etiology, and to evaluate them comprehensively in cases of intracranial tumor removal in order to establish a new, easy, and practical grading system capable of predicting the risk of postoperative clinical worsening of the patient condition. METHODS A retrospective analysis was conducted on all elective surgeries directed at removal of intracranial tumor in the authors' institution during 2-year study period. All sociodemographic, clinical, and surgical factors were extracted from prospectively compiled comprehensive patient registry. Data on all complications, defined as any deviation from the ideal postoperative course occurring within 30 days of the procedure, were collected with consideration of the required treatment and etiology. A logistic regression model was created for identification of independent factors associated with worsening of the Karnofsky Performance Scale (KPS) score at discharge after surgery in comparison with preoperative period. For each identified statistically significant independent predictor of the postoperative worsening, corresponding score was defined, and grading system, subsequently named Milan Complexity Scale (MCS), was formed. RESULTS Overall, 746 cases of surgeries for removal of intracranial tumor were analyzed. Postoperative complications of any kind were observed in 311 patients (41.7%). In 223 cases (29.9%), worsening of the KPS score at the time of discharge in comparison with preoperative period was noted. It was independently associated with 5 predictive factors-major brain vessel manipulation, surgery in the posterior fossa, cranial nerve manipulation, surgery in the eloquent area, tumor size >4 cm-which comprised MCS with a range of the total score from 0 to 8 (higher score indicates more complex clinical situations). Patients who demonstrated KPS worsening after surgery had significantly higher total MCS scores in comparison with individuals whose clinical status at discharge was improved or unchanged (3.24 ± 1.55 versus 1.47 ± 1.58; P < 0.001). CONCLUSION It is reasonable to define neurosurgical complication as any deviation from the ideal postoperative course occurring within 30 days of the procedure. Suggested MCS allows for standardized assessment of surgical complexity before intervention and for estimating the risk of clinical worsening after removal of intracranial tumor. Collection of data on surgical complexity, occurrence of complications, and postoperative outcomes, using standardized prospectively maintained comprehensive patient registries seems very important for quality measurement and should be attained in all neurosurgical centers.
Collapse
Affiliation(s)
- Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Silvia Schiavolin
- Neurology, Public Health and Disability Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Costanza Zattra
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Dario Caldiroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit - Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ignazio Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Camilla de Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giovanni Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| |
Collapse
|
2
|
Whiteman AS, Bartsch AJ, Kang J, Johnson TD. Bayesian inference for brain activity from functional magnetic resonance imaging collected at two spatial resolutions. Ann Appl Stat 2022; 16:2626-2647. [DOI: 10.1214/22-aoas1606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrew S. Whiteman
- Department of Biostatistics, University of Michigan School of Public Health
| | - Andreas J. Bartsch
- Radiologie Bamberg and Department of Neuroradiology, University of Heidelberg
| | - Jian Kang
- Department of Biostatistics, University of Michigan School of Public Health
| | - Timothy D. Johnson
- Department of Biostatistics, University of Michigan School of Public Health
| |
Collapse
|
3
|
Carrabba G, Fiore G, Di Cristofori A, Bana C, Borellini L, Zarino B, Conte G, Triulzi F, Rocca A, Giussani C, Caroli M, Locatelli M, Bertani G. Diffusion tensor imaging, intra-operative neurophysiological monitoring and small craniotomy: Results in a consecutive series of 103 gliomas. Front Oncol 2022; 12:897147. [PMID: 36176387 PMCID: PMC9513471 DOI: 10.3389/fonc.2022.897147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
Diffusion tensor imaging (DTI) allows visualization of the main white matter tracts while intraoperative neurophysiological monitoring (IONM) represents the gold standard for surgical resection of gliomas. In recent years, the use of small craniotomies has gained popularity thanks to neuronavigation and to the low morbidity rates associated with shorter surgical procedures. The aim of this study was to review a series of patients operated for glioma using DTI, IONM, and tumor-targeted craniotomies. The retrospective analysis included patients with supratentorial glioma who met the following inclusion criteria: preoperative DTI, intraoperative IONM, tumor-targeted craniotomy, pre- and postoperative MRI, and complete clinical charts. The DTI was performed on a 3T scanner. The IONM included electroencephalography (EEG), transcranial (TC) and/or cortical motor-evoked potentials (MEP), electrocorticography (ECoG), and direct electrical stimulation (DES). Outcomes included postoperative neurological deficits, volumetric extent of resection (EOR), and overall survival (OS). One hundred and three patients (61 men, 42 women; mean age 54 ± 14 years) were included and presented the following WHO histologies: 65 grade IV, 19 grade III, and 19 grade II gliomas. After 3 months, only three patients had new neurological deficits. The median postoperative volume was 0cc (IQR 3). The median OS for grade IV gliomas was 15 months, while for low-grade gliomas it was not reached. In our experience, a small craniotomy and a tumor resection supported by IONM and DTI permitted to achieve satisfactory results in terms of neurological outcomes, EOR, and OS for glioma patients.
Collapse
Affiliation(s)
- Giorgio Carrabba
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
- *Correspondence: Giorgio Carrabba,
| | - Giorgio Fiore
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Andrea Di Cristofori
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
| | - Cristina Bana
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Linda Borellini
- Neurophysiopathology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy
| | - Barbara Zarino
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giorgio Conte
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Fabio Triulzi
- Neuroradiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Alessandra Rocca
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Carlo Giussani
- Neurosugery, Azienda Socio Sanitaria Territoriale Monza - Ospedale San Gerardo di Monza, Monza, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Manuela Caroli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Marco Locatelli
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
- Department of Medical-Surgical Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Giulio Bertani
- Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
4
|
Transcranial versus Direct Cortical Stimulation for Motor-Evoked Potentials during Resection of Supratentorial Tumors under General Anesthesia (The TRANSEKT-Trial): Study Protocol for a Randomized Controlled Trial. Biomedicines 2021; 9:biomedicines9101490. [PMID: 34680607 PMCID: PMC8533079 DOI: 10.3390/biomedicines9101490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/08/2021] [Accepted: 10/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Monitoring of motor function during surgery for supratentorial tumors under general anesthesia applies either transcranial electrical stimulation (TES) or direct cortical stimulation (DCS) to elicit motor-evoked potentials. To date, there is no guideline that favor one method over the other. Therefore, we designed this randomized study to compare between both methods regarding the prediction of postoperative motor deficits and extent of tumor resection. Methods: This is a multicenter (six centers in Germany and one in Switzerland), double blind, parallel group, exploratory, randomized controlled clinical trial. Patients without or with mild paresis, who are scheduled for surgical resection of motor-eloquent brain tumors under general anesthesia will be randomized to surgical resection under TES or surgical resection under DCS. The primary endpoint is sensitivity and specificity in prognosis of motor function 7 days after surgery. The main secondary endpoint is the extent of tumor resection. The study is planned to include 120 patients within 2 years. Discussion: The present exploratory study should compare TES and DCS regarding sensitivity and specificity in predicting postoperative motor deficit and extent of tumor resection to calculate the required number of patients in a confirmatory trial to test the superiority of one method over the other.
Collapse
|
5
|
Luna LP, Sherbaf FG, Sair HI, Mukherjee D, Oliveira IB, Köhler CA. Can Preoperative Mapping with Functional MRI Reduce Morbidity in Brain Tumor Resection? A Systematic Review and Meta-Analysis of 68 Observational Studies. Radiology 2021; 300:338-349. [PMID: 34060940 DOI: 10.1148/radiol.2021204723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Preoperative functional MRI (fMRI) is one of several techniques developed to localize critical brain structures and brain tumors. However, the usefulness of fMRI for preoperative surgical planning and its potential effect on neurologic outcomes remain unclear. Purpose To assess the overall postoperative morbidity among patients with brain tumors by using preoperative fMRI versus surgery without this tool or with use of standard (nonfunctional) neuronavigation. Materials and Methods A systematic review and meta-analysis of studies across major databases from 1946 to June 20, 2020, were conducted. Inclusion criteria were original studies that (a) included patients with brain tumors, (b) performed preoperative neuroimaging workup with fMRI, (c) investigated the usefulness of a preoperative or intraoperative functional neuroimaging technique and used that technique to resect cerebral tumors, and (d) reported postoperative clinical measures. Pooled estimates for adverse event rate (ER) effect size (log ER, log odds ratio, or Hedges g) with 95% CIs were computed by using a random-effects model. Results Sixty-eight studies met eligibility criteria (3280 participants; 58.9% men [1555 of 2641]; mean age, 46 years ± 8 [standard deviation]). Functional deterioration after surgical procedure was less likely to occur when fMRI mapping was performed before the operation (odds ratio, 0.25; 95% CI: 0.12, 0.53; P < .001]), and postsurgical Karnofsky performance status scores were higher in patients who underwent fMRI mapping (Hedges g, 0.66; 95% CI: 0.21, 1.11; P = .004]). Craniotomies for tumor resection performed with preoperative fMRI were associated with a pooled adverse ER of 11% (95% CI: 8.4, 13.1), compared with a 21.0% ER (95% CI: 12.2, 33.5) in patients who did not undergo fMRI mapping. Conclusion From the currently available data, the benefit of preoperative functional MRI planning for the resection of brain tumors appears to reduce postsurgical morbidity, especially when used with other advanced imaging techniques, such as diffusion-tensor imaging, intraoperative MRI, or cortical stimulation. © RSNA, 2021 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Licia P Luna
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Farzaneh Ghazi Sherbaf
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Haris I Sair
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Debraj Mukherjee
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Isabella Bezerra Oliveira
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| | - Cristiano André Köhler
- From the Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, Johns Hopkins Hospital, 600 N Wolfe St, Phipps B100F, Baltimore, MD 21287 (L.P.L., F.G.S., H.I.S.); Department of Neurosurgery, Johns Hopkins University, Baltimore, Md (D.M.); Department of Radiology, Hospital Geral de Fortaleza, Fortaleza, Brazil (I.B.O.); and Medical Sciences Post-Graduation Program, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Brazil (C.A.K.)
| |
Collapse
|
6
|
Ferroli P, Vetrano IG, Schiavolin S, Acerbi F, Zattra CM, Schiariti M, Leonardi M, Broggi M. Brain Tumor Resection in Elderly Patients: Potential Factors of Postoperative Worsening in a Predictive Outcome Model. Cancers (Basel) 2021; 13:cancers13102320. [PMID: 34065990 PMCID: PMC8151018 DOI: 10.3390/cancers13102320] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/28/2021] [Accepted: 05/10/2021] [Indexed: 12/05/2022] Open
Abstract
Simple Summary Brain tumor surgery in older patients is becoming more relevant, considering that the proportion of older adults being treated for cancer is rising, whereas some pivotal studies in neuro-oncology comprised young patients only. The knowledge of possible predictors of outcome should be included in the preoperative assessment to make the best possible decision in terms of management. We present a case series of 143 patients older than 65 years, intending to identify the possible factors predicting the risk of clinical worsening after elective surgical resection of intracranial tumors in elderly patients. We found that postoperative complications occurrence and preoperative surgical complexity significantly influence the outcome in this subgroup of patients, whereas postoperative complications were the only factor with an impact also at long-term follow-up. Abstract The decision of whether to operate on elderly patients with brain tumors is complex, and influenced by pathology-related and patient-specific factors. This retrospective cohort study, based on a prospectively collected surgical database, aims at identifying possible factors predicting clinical worsening after elective neuro-oncological surgery in elderly patients. Therefore, all patients ≥65 years old who underwent BT resection at a tertiary referral center between 01/2018 and 12/2019 were included. Age, smoking, previous radiotherapy, hypertension, preoperative functional status, complications occurrence, surgical complexity and the presence of comorbidities were prospectively collected and analyzed at discharge and the 3-month follow-up. The series included 143 patients (mean 71 years, range 65–86). Sixty-five patients (46%) had at least one neurosurgical complication, whereas 48/65 (74%) complications did not require invasive treatment. Forty-two patients (29.4%) worsened at discharge; these patients had a greater number of complications compared to patients with unchanged/improved performance status. A persistent worsening at three months of follow-up was noted in 20.3% of patients; again, this subgroup presented more complications than patients who remained equal or improved. Therefore, postoperative complications and surgical complexity seem to influence significantly the early outcome in elderly patients undergoing brain tumor surgery. In contrast, postoperative complications alone are the only factor with an impact on the 3-month follow-up.
Collapse
Affiliation(s)
- Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (P.F.); (F.A.); (C.M.Z.); (M.S.); (M.B.)
| | - Ignazio Gaspare Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (P.F.); (F.A.); (C.M.Z.); (M.S.); (M.B.)
- Correspondence:
| | - Silvia Schiavolin
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (S.S.); (M.L.)
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (P.F.); (F.A.); (C.M.Z.); (M.S.); (M.B.)
| | - Costanza Maria Zattra
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (P.F.); (F.A.); (C.M.Z.); (M.S.); (M.B.)
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (P.F.); (F.A.); (C.M.Z.); (M.S.); (M.B.)
| | - Matilde Leonardi
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (S.S.); (M.L.)
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (P.F.); (F.A.); (C.M.Z.); (M.S.); (M.B.)
| |
Collapse
|
7
|
de Laurentis C, Höhne J, Cavallo C, Restelli F, Falco J, Broggi M, Bosio L, Vetrano IG, Schiariti M, Zattra CM, Ferroli P, Schebesch KM, Acerbi F. The impact of fluorescein-guided technique in the surgical removal of CNS tumors in a pediatric population: results from a multicentric observational study. J Neurosurg Sci 2019; 63:679-687. [PMID: 31037934 DOI: 10.23736/s0390-5616.19.04601-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Surgery has a fundamental role in central nervous system (CNS) tumors in the pediatric population, as aggressive resection correlates with prognosis. Due to its accumulation in areas with damaged blood brain barrier, sodium fluorescein (SF) could be a valid tool to improve the extent of resection in tumors enhancing at preoperative MRI. This study is aimed to systematically assess the utility of SF in a pediatric population. METHODS Patient data were collected in two centers, one in Italy and the other in Germany. At the induction of anesthesia, SF was administered intravenously (5 mg/kg). Surgery was performed using a YELLOW560 filter. Fluorescence intensity was graduated as bright, moderate or absent based on surgeon's opinion; furthermore, SF use was judged as "helpful," "not helpful" or "not essential" in tumor removal. RESULTS Twenty-four patients for 27 surgical procedures were identified. In 21 of 27 (77.8%) procedures fluorescence was reported as bright or moderate, in two of 27 (7.4%) absent and in four of 27 (14.8%) data were unavailable. Intraoperative fluorescence was reported in 21 of 25 (84%) surgeries whose corresponding preoperative MRI had shown contrast enhancement. In 14 of 27 (51.8%) surgical procedures SF was considered "helpful"; in two of 27 (7.4%) not "helpful"; in seven of 27 (25.9%) "not essential." In four of 27 (14.8%) data were unavailable. No adverse effect to SF was registered. CONCLUSIONS SF could be considered a valid and safe tool to improve visualization of tumors enhancing at preoperative MRI also in pediatric patients. Future prospective studies are needed to confirm these preliminary data.
Collapse
Affiliation(s)
- Camilla de Laurentis
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Julius Höhne
- Department of Neuropathology and Neurosurgery, Regensburg University Hospital, Regensburg, Germany
| | - Claudio Cavallo
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy.,Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Francesco Restelli
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Lorenzo Bosio
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Ignazio G Vetrano
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Costanza M Zattra
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Karl-Michael Schebesch
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Carlo Besta Institute of Neurology, IRCCS and Foundation, Milan, Italy -
| |
Collapse
|
8
|
Zhang N, Shang Z, Wang Z, Meng X, Li Z, Tian H, Huang D, Yin X, Zheng B, Zhang X. Molecular pathological expression in malignant gliomas resected by fluorescein sodium-guiding under the YELLOW 560 nm surgical microscope filter. World J Surg Oncol 2018; 16:195. [PMID: 30285781 PMCID: PMC6167783 DOI: 10.1186/s12957-018-1495-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 09/20/2018] [Indexed: 12/05/2022] Open
Abstract
Background This study aimed to analyze the relationship between molecular pathologic expression of GFAP and Ki-67 and fluorescence levels, and to provide molecular pathological basis for the removal of malignant gliomas (MG) by Fluorescein Sodium (FLS) navigation under the YELLOW 560 nm surgical microscope filter. Methods A retrospective analysis of clinical data of 18 MG cases confirmed by the postoperative pathology was performed. All cases were resected by FLS guiding under the YELLOW 560 nm filter. Hematoxylin-eosin (HE) staining, molecular pathology markers GFAP, and Ki-67 immunohistochemical staining of the specimens were performed. The relationship between fluorescence staining levels and GFAP positive rate, Ki-67 proliferation index, and WHO grades was studied. Results There were 69 pathological specimens with fluorescence levels of “bright” fluorescence (n = 32), “low” fluorescence (n = 18), and “no” fluorescence (n = 19). Immunohistochemical staining showed GFAP-positive expression in both tumor cells and normal glial cells. The staining levels of the specimens in the fluorescence regions were higher than that in the non-fluorescence regions. GFAP expression was positive in 61 specimens and negative in 8 specimens. Comparison of Ki-67 proliferation index using chi-square test showed different fluorescence levels had different Ki-67 proliferation indexes (χ2 = 14.678, p = 0.005). With high proliferation index of specimens, fluorescence level was brighter. WHO grade had no correlation with fluorescence levels (χ2 = 3.531, p = 0.171). Conclusion FLS-guided resection of MG is safe and effective. In the boundary area of MG, fluorescence levels and Ki-67 proliferation index showed correlation. FLS-guided resection achieved the function of “reducing tumor cell,” thus reducing the proliferation index in the lesion area.
Collapse
Affiliation(s)
- Ningning Zhang
- Department of Neurosurgery, Shandong University Qilu Hospital, Qingdao, Shandong, China. .,Department of Neurosurgery, Affiliated Hospital of Taishan Medical University, Tai An, Shandong, China.
| | - Zhende Shang
- Department of Neurosurgery, Affiliated Hospital of Taishan Medical University, Tai An, Shandong, China
| | - Zhigang Wang
- Department of Neurosurgery, Shandong University Qilu Hospital, Qingdao, Shandong, China
| | - Xianbing Meng
- Department of Neurosurgery, Affiliated Hospital of Taishan Medical University, Tai An, Shandong, China
| | - Zheng Li
- Department of Neurosurgery, Affiliated Hospital of Taishan Medical University, Tai An, Shandong, China
| | - Hailong Tian
- Department of Neurosurgery, Shandong University Qilu Hospital, Qingdao, Shandong, China
| | - Dezhang Huang
- Department of Neurosurgery, Shandong University Qilu Hospital, Qingdao, Shandong, China
| | - Xin Yin
- Department of Neurosurgery, Shandong University Qilu Hospital, Qingdao, Shandong, China
| | - Bin Zheng
- Department of Neurosurgery, Affiliated Hospital of Taishan Medical University, Tai An, Shandong, China
| | - Xinhua Zhang
- Department of Neurosurgery, Affiliated Hospital of Taishan Medical University, Tai An, Shandong, China.
| |
Collapse
|
9
|
Cavallo C, De Laurentis C, Vetrano IG, Falco J, Broggi M, Schiariti M, Ferroli P, Acerbi F. The utilization of fluorescein in brain tumor surgery: a systematic review. J Neurosurg Sci 2018; 62:690-703. [PMID: 29790725 DOI: 10.23736/s0390-5616.18.04480-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Sodium fluorescein (SF) is a green, water-soluble dye with the capacity to accumulate in cerebral areas as a result of damaged blood-brain barrier (BBB); this property allows SF to concentrate specifically at the tumor site of various types of brain neoplasms, making the tumor tissue more clearly visible. EVIDENCE ACQUISITION A literature search (1947-2018) was conducted with the keywords "fluorescein neurosurgery," "YELLOW neurosurgery," "fluorescein brain tumor," "YELLOW brain tumor." We included clinical studies, clinical trials, observational studies, only conducted on humans and concerning surgery; in addition, we have included 3 articles derived from the analysis of the references of other papers. Ultimately, 57 articles were included for further analysis. EVIDENCE SYNTHESIS Fluorescein as a fluorescent tracer in neuro-oncology is gaining a wider acceptance in the neurosurgical literature: until February 1st, 2018, at least 1099 neuro-oncological patients have been operated through fluorescein-assistance, mostly only after 2012. The most important application remains the aim to improve tumor visualization and extent of resection for high-grade gliomas (HGG), but the nonspecific mechanism of action is the theoretical base for its use also for tumors different from HGG. Nevertheless, no homogenous protocol of fluorescein utilization in neurosurgical oncology can be found in literature. CONCLUSIONS Fluorescein-guided surgery is a safe and effective technique to improve visualization and resection of different CNS tumors and conditions, based on BBB alteration, with a growing evidence-based background.
Collapse
Affiliation(s)
- Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph Hospital and Medical Center, Phoenix, AZ, USA
| | - Camilla De Laurentis
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Ignazio G Vetrano
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Jacopo Falco
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Morgan Broggi
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Marco Schiariti
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Paolo Ferroli
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy
| | - Francesco Acerbi
- Neurosurgical Unit II, Department of Neurosurgery, IRCCS "Istituto Neurologico C. Besta" Foundation, Milan, Italy -
| |
Collapse
|
10
|
Sodium Fluorescein-Guided Resection under the YELLOW 560 nm Surgical Microscope Filter in Malignant Gliomas: Our First 38 Cases Experience. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7865747. [PMID: 29124069 PMCID: PMC5662847 DOI: 10.1155/2017/7865747] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/01/2017] [Accepted: 09/10/2017] [Indexed: 11/18/2022]
Abstract
Objective Sodium fluorescein (FL) had been safely used in fluorescence-guided microsurgery for imaging various brain tumors. Under the YELLOW 560 nm surgical microscope filter, low-dose FL as a fluorescent dye helps in visualization. Our study investigated the safety and efficacy of this innovative technique in malignant glioma (MG) patients. Patients and Method 38 patients suffering from MGs confirmed by pathology underwent FL-guided resection under YELLOW 560 nm surgical microscope filter. We retrospectively analyzed the clinical characters, microsurgery procedure, extent of resection, pathology of MGs, progression-free survival (PFS), and overall survival (OS). Results Thirty-eight patients had MGs (10 WHO grade III, 28 WHO grade IV). With YELLOW 560 nm surgical microscope filter combined with neuronavigation, sodium fluorescein-guided gross total resection (GTR) was achieved in 35 (92.1%) patients and subtotal resection in 3 (7.69%). The sensitivity and specificity of FL were 94.4% and 88.6% regardless of radiographic localization. Intraoperatively, 10 biopsies (10/28 FL[+]) showed “low” or “high” fluorescence in non-contrast-enhancement region and are also confirmed by pathology. Our data showed 6-month PFS of 92.3% and median survival of 11 months. Conclusion FL-guided resection of MGs under the YELLOW 560 nm surgical microscope filter combined with neuronavigation was safe and effective, especially in non-contrast-MRI regions. It is feasible for improving the extent of resection in MGs especially during emergency cases.
Collapse
|
11
|
Acerbi F, Broggi M, Schebesch KM, Höhne J, Cavallo C, De Laurentis C, Eoli M, Anghileri E, Servida M, Boffano C, Pollo B, Schiariti M, Visintini S, Montomoli C, Bosio L, La Corte E, Broggi G, Brawanski A, Ferroli P. Fluorescein-Guided Surgery for Resection of High-Grade Gliomas: A Multicentric Prospective Phase II Study (FLUOGLIO). Clin Cancer Res 2017; 24:52-61. [PMID: 29018053 DOI: 10.1158/1078-0432.ccr-17-1184] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/05/2017] [Accepted: 10/05/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Sodium fluorescein is a dye that, intravenously injected, selectively accumulates in high-grade glioma (HGG) tissue through a damaged blood-brain barrier. In this article, the final results of a multicentric prospective phase II trial (FLUOGLIO) on fluorescein-guided HGG resection through a dedicated filter on the surgical microscope were reported.Methods: Patients with suspected HGGs considered suitable for removal were eligible to participate in this trial. Fluorescein was intravenously injected at a dose of 5 to 10 mg/kg. The primary endpoint was the percentage of patients with histologically confirmed HGGs, without contrast-enhancing tumor at the immediate postoperative MRI. Secondary endpoints were PFS, residual tumor on postoperative MRI, overall survival, neurologic deficits, and fluorescein-related toxicity. The sensitivity and specificity of fluorescein in identifying tumor tissue were estimated by fluorescent and nonfluorescent biopsies at the tumor margin. The study was registered on the European Regulatory Authorities website (EudraCT 2011-002527-18).Results: Fifty-seven patients aged 45 to 75 years were screened for participation, and 46 were considered for primary and secondary endpoints. Mean preoperative tumor volume was 28.75 cm3 (range, 1.3-87.8 cm3). Thirty-eight patients (82.6%) underwent a complete tumor removal. Median follow-up was 11 months. PFS-6 and PFS-12 were 56.6% and 15.2%. Median survival was 12 months. No adverse reaction related to SF administration was recorded. The sensitivity and specificity of fluorescein in identifying tumor tissue were respectively 80.8% and 79.1%.Conclusions: Fluorescein-guided technique with a dedicated filter on the surgical microscope is safe and enables a high percentage of contrast-enhancing tumor in patients with HGGs. Clin Cancer Res; 24(1); 52-61. ©2017 AACR.
Collapse
Affiliation(s)
- Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy.
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Karl-Michael Schebesch
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Julius Höhne
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Claudio Cavallo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Camilla De Laurentis
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marica Eoli
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Elena Anghileri
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Maura Servida
- Department of Molecular Neuro-Oncology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Carlo Boffano
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Bianca Pollo
- Department of Neuropathology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Sergio Visintini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Cristina Montomoli
- Department of Public Health, Forensic and Experimental Medicine, Unit of Biostatistic and Clinic Epidemiology, University of Pavia, Pavia, Italy
| | - Lorenzo Bosio
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Emanuele La Corte
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Giovanni Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Alexander Brawanski
- Department of Neuropathology and Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| |
Collapse
|
12
|
Continuous physical examination during subcortical resection in awake craniotomy patients: Its usefulness and surgical outcome. Clin Neurol Neurosurg 2016; 147:34-8. [PMID: 27267754 DOI: 10.1016/j.clineuro.2016.05.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/20/2016] [Accepted: 05/22/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the value of physical examination as a monitoring tool during subcortical resection in awake craniotomy patients and surgical outcomes. PATIENTS AND METHODS Authors reviewed medical records of patients underwent awake craniotomy with continuous physical examination for pathology adjacent to the eloquent area. RESULTS Between January 2006 and August 2015, there were 37 patients underwent awake craniotomy with continuous physical examination. Pathology was located in the left cerebral hemisphere in 28 patients (75.7%). Thirty patients (81.1%) had neuroepithelial tumors. Degree of resections were defined as total, subtotal, and partial in 16 (43.2%), 11 (29.7%) and 10 (27.0%) patients, respectively. Median follow up duration was 14 months. The reasons for termination of subcortical resection were divided into 3 groups as follows: 1) by anatomical landmark with the aid of neuronavigation in 20 patients (54%), 2) by reaching subcortical stimulation threshold in 8 patients (21.6%), and 3) by abnormal physical examination in 9 patients (24.3%). Among these 3 groups, there were statistically significant differences in the intraoperative (p=0.002) and early postoperative neurological deficit (p=0.005) with the lowest deficit in neuronavigation group. However, there were no differences in neurological outcome at later follow up (3-months p=0.103; 6-months p=0.285). There were no differences in the degree of resection among the groups. CONCLUSION Continuous physical examination has shown to be of value as an additional layer of monitoring of subcortical white matter during resection and combining several methods may help increase the efficacy of mapping and monitoring of subcortical functions.
Collapse
|
13
|
Ferroli P, Broggi M, Schiavolin S, Acerbi F, Bettamio V, Caldiroli D, Cusin A, La Corte E, Leonardi M, Raggi A, Schiariti M, Visintini S, Franzini A, Broggi G. Predicting functional impairment in brain tumor surgery: the Big Five and the Milan Complexity Scale. Neurosurg Focus 2015; 39:E14. [DOI: 10.3171/2015.9.focus15339] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The Milan Complexity Scale—a new practical grading scale designed to estimate the risk of neurological clinical worsening after performing surgery for tumor removal—is presented.
METHODS
A retrospective study was conducted on all elective consecutive surgical procedures for tumor resection between January 2012 and December 2014 at the Second Division of Neurosurgery at Fondazione IRCCS Istituto Neurologico Carlo Besta of Milan. A prospective database dedicated to reporting complications and all clinical and radiological data was retrospectively reviewed. The Karnofsky Performance Scale (KPS) was used to classify each patient’s health status. Complications were divided into major and minor and recorded based on etiology and required treatment. A logistic regression model was used to identify possible predictors of clinical worsening after surgery in terms of changes between the preoperative and discharge KPS scores. Statistically significant predictors were rated based on their odds ratios in order to build an ad hoc complexity scale. For each patient, a corresponding total score was calculated, and ANOVA was performed to compare the mean total scores between the improved/unchanged and worsened patients. Relative risk (RR) and chi-square statistics were employed to provide the risk of worsening after surgery for each total score.
RESULTS
The case series was composed of 746 patients (53.2% female; mean age 51.3 ± 17.1). The most common tumors were meningiomas (28.6%) and glioblastomas (24.1%). The mortality rate was 0.94%, the major complication rate was 9.1%, and the minor complication rate was 32.6%. Of 746 patients, 523 (70.1%) patients improved or remained unchanged, and 223 (29.9%) patients worsened. The following factors were found to be statistically significant predictors of the change in KPS scores: tumor size larger than 4 cm, cranial nerve manipulation, major brain vessel manipulation, posterior fossa location, and eloquent area involvement (Nagelkerke R2 = 0.286). A grading scale was obtained with scores ranging between 0 and 8. Worsened patients showed mean total scores that were significantly higher than the improved/unchanged scores (3.24 ± 1.55 vs 1.47 ± 1.58; p < 0.001). Finally, a grid was developed to show the risk of worsening after surgery for each total score: scores higher than 3 are suggestive of worse clinical outcome.
CONCLUSIONS
Through the evaluation of the 5 aforementioned parameters—the Big Five—the Milan Complexity Scale enables neurosurgeons to estimate the risk of a negative clinical course after brain tumor surgery and share these data with the patient. Furthermore, the Milan Complexity Scale could be used for research and educational purposes and better health system management.
Collapse
Affiliation(s)
| | | | - Silvia Schiavolin
- 2Neurology, Public Health, and Disability Unit—Scientific Directorate, and
| | | | - Valentina Bettamio
- 3Medical Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | | | | | | | - Matilde Leonardi
- 2Neurology, Public Health, and Disability Unit—Scientific Directorate, and
| | - Alberto Raggi
- 2Neurology, Public Health, and Disability Unit—Scientific Directorate, and
| | | | | | | | | |
Collapse
|
14
|
Okamoto E, Ishikawa E, Yamamoto T, Matsuda M, Nakai K, Matsushita A, Masuda Y, Akutsu H, Ayuzawa S, Sakamaki F, Matsumoto Y, Matsumura A. Variability in amplitude and stimulation threshold values in motor evoked potential (MEP) monitoring during the resection of brain lesions. Clin Neurophysiol 2015; 126:1271-1278. [DOI: 10.1016/j.clinph.2014.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 09/05/2014] [Accepted: 10/01/2014] [Indexed: 02/02/2023]
|
15
|
Stippich C, Blatow M, Garcia M. Task-Based Presurgical Functional MRI in Patients with Brain Tumors. CLINICAL FUNCTIONAL MRI 2015. [DOI: 10.1007/978-3-662-45123-6_4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
16
|
Acerbi F, Broggi M, Eoli M, Anghileri E, Cavallo C, Boffano C, Cordella R, Cuppini L, Pollo B, Schiariti M, Visintini S, Orsi C, La Corte E, Broggi G, Ferroli P. Is fluorescein-guided technique able to help in resection of high-grade gliomas? Neurosurg Focus 2014; 36:E5. [PMID: 24484258 DOI: 10.3171/2013.11.focus13487] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fluorescein, a dye that is widely used as a fluorescent tracer, accumulates in cerebral areas where the blood-brain barrier is damaged. This quality makes it an ideal dye for the intraoperative visualization of high-grade gliomas (HGGs). The authors report their experience with a new fluorescein-guided technique for the resection of HGGs using a dedicated filter on the surgical microscope. METHODS The authors initiated a prospective Phase II trial (FLUOGLIO) in September 2011 with the objective of evaluating the safety of fluorescein-guided surgery for HGGs and obtaining preliminary evidence regarding its efficacy for this purpose. To be eligible for participation in the study, a patient had to have suspected HGG amenable to complete resection of the contrast-enhancing area. The present report is based on the analysis of the short- and long-term results in 20 consecutive patients with HGGs (age range 45-74 years), enrolled in the study since September 2011. In all cases fluorescein (5-10 mg/kg) was injected intravenously after intubation. Tumor resection was performed with microsurgical technique and fluorescence visualization by means of BLUE 400 or YELLOW 560 filters on a Pentero microscope. RESULTS The median preoperative tumor volume was 30.3 cm(3) (range 2.4-87.8 cm(3)). There were no adverse reactions related to fluorescein administration. Complete removal of contrast-enhanced tumor was achieved in 80% of the patients. The median duration of follow-up was 10 months. The 6-months progression-free survival rate was 71.4% and the median survival was 11 months. CONCLUSIONS Analysis of these 20 cases suggested that fluorescein-guided technique with a dedicated filter on the surgical microscope is safe and allows a high rate of complete resection of contrast-enhanced tumor as determined on early postoperative MRI. Clinical trial registration no.: 2011-002527-18 (EudraCT).
Collapse
|
17
|
Rosazza C, Aquino D, D’Incerti L, Cordella R, Andronache A, Zacà D, Bruzzone MG, Tringali G, Minati L. Preoperative mapping of the sensorimotor cortex: comparative assessment of task-based and resting-state FMRI. PLoS One 2014; 9:e98860. [PMID: 24914775 PMCID: PMC4051640 DOI: 10.1371/journal.pone.0098860] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 05/08/2014] [Indexed: 11/18/2022] Open
Abstract
Resting state fMRI (rs-fMRI) has recently been considered as a possible complement or alternative to task-based fMRI (tb-fMRI) for presurgical mapping. However, evidence of its usefulness remains scant, because existing studies have investigated relatively small samples and focused primarily on qualitative evaluation. The aim of this study is to investigate the clinical usefulness of rs-fMRI in the context of presurgical mapping of motor functions, and in particular to determine the degree of correspondence with tb-fMRI which, while not a gold-standard, is commonly used in preoperative setting. A group of 13 patients with lesions close to the sensorimotor cortex underwent rs-fMRI and tb-fMRI to localize the hand, foot and mouth motor areas. We assessed quantitatively the degree of correspondence between multiple rs-fMRI analyses (independent-component and seed-based analyses) and tb-fMRI, with reference to sensitivity and specificity of rs-fMRI with respect to tb-fMRI, and centre-of-mass distances. Agreement with electro-cortical stimulation (ECS) was also investigated, and a traditional map thresholding approach based on agreement between two experienced operators was compared to an automatic threshold determination method. Rs-fMRI can localize the sensorimotor cortex successfully, providing anatomical specificity for hand, foot and mouth motor subregions, in particular with seed-based analyses. Agreement with tb-fMRI was only partial and rs-fMRI tended to provide larger patterns of correlated activity. With respect to the ECS data available, rs-fMRI and tb-fMRI performed comparably, even though the shortest distance to stimulation points was observed for the latter. Notably, the results of both were on the whole robust to thresholding procedure. Localization performed by rs-fMRI is not equivalent to tb-fMRI, hence rs-fMRI cannot be considered as an outright replacement for tb-fMRI. Nevertheless, since there is significant agreement between the two techniques, rs-fMRI can be considered with caution as a potential alternative to tb-fMRI when patients are unable to perform the task.
Collapse
Affiliation(s)
- Cristina Rosazza
- Neuroradiology Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
- Scientific Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
- * E-mail:
| | - Domenico Aquino
- Neuroradiology Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
| | - Ludovico D’Incerti
- Neuroradiology Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
| | - Roberto Cordella
- Neurosurgery Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
| | - Adrian Andronache
- Neuroradiology Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
| | - Domenico Zacà
- Center for Mind/Brain Sciences (CIMeC), University of Trento, Trento, Italy
| | - Maria Grazia Bruzzone
- Neuroradiology Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
| | - Giovanni Tringali
- Neurosurgery Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
| | - Ludovico Minati
- Scientific Department, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Milano, Italy
- Center for Mind/Brain Sciences (CIMeC), University of Trento, Trento, Italy
| |
Collapse
|