Laser Interstitial Thermal Therapy in Glioblastoma

Laser interstitial thermal therapy is a minimally invasive ablative technique that continues to gain popularity in treatment of a variety of intracranial and spinal disorders. In the field of neuro-oncology it continues to be used for treatment of a variety of intracranial neoplasms, including glioblastoma—the most common malignant primary brain tumor. Maximizing the extent of resection in patients with glioblastoma was shown to prolong patient survival. Many patients present, however, with tumors that are nonresectable due to proximity to eloquent cortical or subcortical areas, or involvement of deep brain structures. LITT procedure, on the other hand, is minimally invasive and involves placing a laser catheter under stereotactic guidance and monitoring the size of the lesion produced as a result of laser ablation using MR thermography in real time. Therefore, a number of studies explored the potential of laser ablation to accomplish significant cytoreduction and thus potentially improve patient’s outcomes and prolong survival. The following chapter will review the principles of laser ablation and its current role in treatment of glioblastoma

Laser Interstitial Thermal Therapy for Posterior Fossa Lesions: An Initial Experience

© 2018 Elsevier Inc. Background: The application of laser interstitial thermal therapy (LITT) for intracranial lesions in the posterior fossa tumors remains challenging due to the smaller size of this compartment as well as the thickness and angle of the occipital bone. In this study, we reviewed our experience with this treatment modality for posterior fossa lesions. Methods: We retrospectively reviewed our series of 8 patients with posterior fossa tumors treated with LITT from an Institutional Review Board–approved brain tumor database (2012–2017) of more than 200 cases at our institution. Results: The 8 patients underwent LITT targeting 3 metastases, 2 pilocytic astrocytomas, 2 zones of radiation necrosis after radiosurgery, and 1 glioblastoma (GBM). The mean preoperative lesion volume was 4.35 cm3. A 6 months postsurgery, the mean lesion volume had decreased from 9.64 cm3 to 5.72 cm3. Two of the tumors (the GBM and a metastatic adenocarcinoma) progressed after 8.5 and 7.5 months, respectively, with mortality after 1.1 and 1.6 years, respectively. Surgical resection was performed in a patient with metastatic adenocarcinoma tumor at 7.7 months after LITT. All other lesions remained stable or were diminished at a median follow-up of 14.8 months (range, 0.4–37.5 months). Magnetic resonance imaging (MRI) on the first postoperative day, showed an increase in mean tumor-related edema volume from 9.45 cm3 to 14.10 cm3. After a postoperative follow-up of at least 1 month, this mean decreased to 8.70 cm3. One case each of transient partial unilateral sixth cranial nerve palsy, superficial wound infection, and a late obstructive hydrocephalus were noted postoperatively. No mortality was associated with the procedure. Conclusions: LITT is a safe and feasible treatment modality even in challenging locations like the posterior fossa. However, surgical indications should be tailored for each individual patient based on the size and location of tumor

Laser Interstitial Thermal Therapy for Posterior Fossa Lesions: A Systematic Review and Analysis of Multi-Institutional Outcomes

Background: Laser interstitial thermal therapy (LITT) has emerged as a treatment option for deep-seated primary and metastatic brain lesions; however, hardly any data exist regarding LITT for lesions of the posterior fossa. Methods: A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), Scopus, and Cochrane electronic bibliographic databases. Inclusion criteria were studies assessing LITT on posterior fossa tumors. Results: 16 studies comprising 150 patients (76.1% female) with a mean age of 56.47 years between 2014 and 2021 were systematically reviewed for treatment outcomes and efficacy. Morbidity and mortality data could be extracted for 131 of the 150 patients. Death attributed to treatment failure, disease progression, recurrence, or postoperative complications occurred in 6.87% (9/131) of the pooled sample. Procedure-related complications, usually including new neurologic deficits, occurred in approximately 14.5% (19/131) of the pooled sample. Neurologic deficits improved with time in most cases, and 78.6% (103/131) of the pooled sample experienced no complications and progression-free survival at the time of last follow-up. Conclusions: LITT for lesions of the posterior fossa continues to show promising data. Future clinical cohort studies are required to further direct treatment recommendations

The Impact of Microelectrode Recording on Lead Location in Deep Brain Stimulation for the Treatment of Movement Disorders

Objective: During deep brain stimulation (DBS) surgery, microelectrode recording (MER) leads to target refinement from the initial plan in 30% to 47% of hemispheres; however, it is unclear whether the DBS lead ultimately resides within the MER-optimized target in relation to initial radiographic target coordinates in these hemispheres. This study aimed to determine the frequency of discordance between radiographic and neurophysiologic nucleus and whether target optimization with MER leads to a significant change in DBS lead location away from initial target. Methods: Consecutive cases of DBS surgery with MER using intraoperative computed tomography were included. Coordinates of initial anatomic target (AT), MER-optimized target (MER-O) and DBS lead were obtained. Hemispheres were categorized as “discordant” (D) if there was a suboptimal neurophysiologic signal despite accurate targeting of AT. Hemispheres where the first MER pass was satisfactory were deemed “concordant” (C). Coordinates and radial distances between 1) AT/MER-O; 2) MER-O/DBS; and 3) AT/DBS were calculated and compared. Results: Of the 273 hemispheres analyzed, 143 (52%) were D, and 130 (48%) were C. In C hemispheres, DBS lead placement error (mean ± standard error of the mean) was 0.88 ± 0.07 mm. In D hemispheres, MER resulted in significant migration of DBS lead (mean AT-DBS error 2.11 ± 0.07 mm), and this distance was significantly greater than the distance between MER-O and DBS (2.11 vs. 1.09 mm, P < 0.05). Directional assessment revealed that the DBS lead migrated in the intended direction as determined by MER-O in D hemispheres, except when the intended direction was anterolateral. Conclusions: Discordance between radiographic and neurophysiologic target was seen in 52% of hemispheres, and MER resulted in appropriate deviation of the DBS lead toward the appropriate target. The actual value of the deviation, when compared with DBS lead placement error in C hemispheres, was, on average, small

Combined use of minimal access craniotomy, intraoperative magnetic resonance imaging, and awake functional mapping for the resection of gliomas in 61 patients

©AANS 2020. OBJECTIVE Current management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts. METHODS The authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed. RESULTS A total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p \u3c 0.001). Seventeen of 62 cases achieved an increased EOR \u3c 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months. CONCLUSIONS In this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection

The effect of Gamma Knife radiosurgery on large posterior fossa metastases and the associated mass effect from peritumoral edema

©AANS 2021, except where prohibited by US copyright law OBJECTIVE Gamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM. METHODS The authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome. RESULTS Fifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4–21.1 cm3), 14.98 cm3 (range 0.6–71.8 cm3), and 1.23 cm3 (range 0.3–3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0–5.07 cm). The median follow-up time was 7.3 months (range 1.6–57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range −96.95% to +48.69%, p \u3c 0.001), median PTE decreased by 78.10% (range −99.92% to +198.35%, p \u3c 0.001), and the fourth ventricle increased by 24.97% (range −37.96% to +545.6%, p \u3c 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment. CONCLUSIONS In this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p \u3c 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates

Recurrent Cushing Disease: An Extensive Review on Pros and Cons of Different Therapeutic Approaches

Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission. We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020. We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60–0.70), 0.57 (95% CI 0.51–0.63), and 0.75 (95% CI 0.60–0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60–0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28). Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range

The quality of care index for low back pain: a systematic analysis of the global burden of disease study 1990–2017

Abstract Background . Low back pain is one of the major causes of morbidity worldwide. Studies on low back pain quality of care are limited. This study aimed to evaluate the quality of care of low back pain worldwide and compare gender, age, and socioeconomic groups. Methods . This study used GBD data from 1990 to 2017 from the Institute for Health Metrics and Evaluation (IHME) website. Extracted data included low back pain incidence, prevalence, disability-adjusted life years (DALYs), and years lived with disability (YLDs). DALYs to prevalence ratio and prevalence to incidence ratio were calculated and used in the principal component analysis (PCA) to make a proxy of the quality-of-care index (QCI). Age groups, genders, and countries with different socioeconomic statuses regarding low back pain care quality from 1990 to 2017 were compared. Results The proxy of QCI showed a slight decrease from 36.44 in 1990 to 35.20 in 2017. High- and upper-middle-income countries showed a decrease in the quality of care from 43.17 to 41.57 and from 36.37 to 36.00, respectively, from 1990 to 2017. On the other hand, low and low-middle-income countries improved, from a proxy of QCI of 20.99 to 27.89 and 27.74 to 29.36, respectively. Conclusion . Despite improvements in the quality of care for low back pain in low and lower-middle-income countries between 1990 and 2017, there is still a large gap between these countries and higher-income countries. Continued steps must be taken to reduce healthcare barriers in these countries

The effect of Gamma Knife radiosurgery on large posterior fossa metastases and the associated mass effect from peritumoral edema

©AANS 2021, except where prohibited by US copyright law OBJECTIVE Gamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM. METHODS The authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome. RESULTS Fifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4–21.1 cm3), 14.98 cm3 (range 0.6–71.8 cm3), and 1.23 cm3 (range 0.3–3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0–5.07 cm). The median follow-up time was 7.3 months (range 1.6–57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range −96.95% to +48.69%, p \u3c 0.001), median PTE decreased by 78.10% (range −99.92% to +198.35%, p \u3c 0.001), and the fourth ventricle increased by 24.97% (range −37.96% to +545.6%, p \u3c 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment. CONCLUSIONS In this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p \u3c 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates