The safety and use of perioperative dexamethasone in the perioperative management of primary sporadic supratentorial meningiomas.

Objective: Despite the lack of prospective evidence for the perioperative use of dexamethasone in meningioma surgery, its use is well established in the daily routine of several centers. The present study evaluates the effect of dexamethasone on postoperative complications, peritumoral T2/FLAIR hyperintensity, and progression-free survival in patients with supratentorial meningiomas undergoing resection. Methods: A total of 148 patients who underwent resection of a primary sporadic supratentorial meningioma at the authors' institution between 2018 and 2020 were included in this retrospective cohort. Safety criteria were side effects of dexamethasone (e.g. hyperglycemia), surgical morbidities, length of stay, and mortality. The individual Karnofsky Performance Scales (KPS) were evaluated regarding the individual development and the delta of KPS at 3- and 12-months compared to baseline KPS was calculated. Longitudinal assessment of the peritumoral T2-/FLAIR hyperintensity changes was performed. Results: The use of both pre- and postoperative dexamethasone did not influence the incidence rates of wound infections, infarctions, postoperative seizures, pulmonary embolism, postoperative hemorrhage, mortality, length of stay, new-onset hyperglycemia and new neurological deficits. Perioperative Dexamethasone use was associated with an improved Karnofsky performance development at 3- (delta of KPS 3.3 vs. -1.9, p=0.001) and 12-months (delta of KPS 3.8 vs. -1.1, p=0.008) compared to the preoperative Karnofsky performance status. Multivariable analysis revealed that perioperative dexamethasone use enhances the KPS improvement (OR: 3.65, 95% CI: 1.01-13.18, p=0.048). Persistent peritumoral T2/FLAIR hyperintensity changes were observed in 35 cases of 70 patients with available follow-up images and a baseline edema (50.0%). Perioperative dexamethasone use enhanced the reduction of the preoperative peritumoral T2-/FLAIR hyperintensity changes (mean reduction of maximum diameter: 1.8 cm vs. 1.1 cm, p=0.023). Perioperative dexamethasone use was independently associated with a lower risk for persistent peritumoral T2-/FLAIR hyperintensity changes (OR: 3.77, 95% CI: 1.05-13.54, p=0.042) The perioperative use of dexamethasone did not influence the progression-free survival time in Simpson grade I or II resected WHO grade 1 meningiomas (log-rank test: p=0.27). Conclusion: Perioperative dexamethasone use seems to be safe in surgery for primary supratentorial meningiomas. Dexamethasone use might enhance the functionality by reducing postoperative peritumoral T2-/FLAIR hyperintensities. These findings highlight the need for prospective data.

CDKN2A/B deletions are strongly associated with meningioma progression: a meta-analysis of individual patient data.

Homozygous CDKN2A/B deletion has been associated with an increased risk of recurrence in meningiomas. However, the evidence is confined to a limited number of studies, and the importance of heterozygous CDKN2A/B deletions remains insufficiently investigated. Hence, the present meta-analysis reconstructs individual patient data (IPD) and reconstructs the probabilities of progression-free survival (PFS) stratified by CDKN2A/B status. IPD of PFS rates were extracted from published Kaplan-Meier plots using the R package IPDfromKM in R studio (RStudio, Boston, MA, USA). Reconstructed Kaplan-Meier Plots of the pooled IPD data were created. One-stage and two-stage meta-analyses were performed. Hazard ratios (HR) were used as effective measures. Of 181 records screened, four articles with 2521 participants were included. The prevalence of homozygous CDKN2A/B deletions in the included studies was 0.049 (95% CI 0.040-0.057), with higher tumor grades associated with a significantly greater proportion of CDKN2A/B deletions. The reconstructed PFS curves for the pooled cohort showed that the median PFS time of patients with a CDKN2A/B wild-type status, heterozygous or homozygous CDKN2A/B deletion was 180.0 (95% CI 145.7-214.3), 26.1 (95% CI 23.3-29.0), and 11.00 (95% CI 8.6-13.3) months, respectively (p < 0.0001). Both hetero- or homozygous CDKN2A/B deletions were significantly associated with shortened time to meningioma progression. One-stage meta-analysis showed that hetero- (HR: 5.5, 95% CI 4.0-7.6, p < 0.00001) and homozygous CDKN2A/B deletions (HR: 8.4, 95% CI 6.4-11.0, p < 0.00001) are significantly associated with shortened time to meningioma progression. Multivariable Cox regression analysis of progression in a subgroup with available covariates (age, sex, WHO grade, and TERT status) and also two-stage meta-analysis confirmed and validated the results of the one-stage analysis that both heterozygous and homozygous CDKN2A/B deletions are of prognostic importance. Further large-scale studies of WHO grade 2 and 3 meningiomas are needed to validate the importance of heterozygous CDKN2A/B deletions with consideration of established factors.

Hippocampal GABA levels correlate with retrieval performance in an associative learning paradigm.

Neural plasticity is a complex process dependent on neurochemical underpinnings. Next to the glutamatergic system which contributes to memory formation via long-term potentiation (LTP) and long-term depression (LTD), the main inhibitory neurotransmitter, GABA is crucially involved in neuroplastic processes. Hence, we investigated changes in glutamate and GABA levels in the brain in healthy participants performing an associative learning paradigm. Twenty healthy participants (10 female, 25 ±â€¯5 years) underwent paired multi-voxel magnetic resonance spectroscopy imaging before and after completing 21 days of a facial associative learning paradigm in a longitudinal study design. Changes of GABA and glutamate were compared to retrieval success in the hippocampus, insula and thalamus. No changes in GABA and glutamate concentration were found after 21 days of associative learning. However, baseline hippocampal GABA levels were significantly correlated with initial retrieval success (pcor = 0.013, r = 0.690). In contrast to the thalamus and insula (pcor>0.1), higher baseline GABA levels in the hippocampus were associated with better retrieval performance in an associative learning paradigm. Therefore, our findings support the importance of hippocampal GABA levels in memory formation in the human brain in vivo.

Intrameningioma Metastasis: A Wolf in Sheep's Clothing? Experience from a Series of 7 Cases.

BACKGROUND: Intrameningioma metastasis is a rare differential diagnosis. The clinical implications of these lesions are poorly understood. We screened our database to identify all patients who had been undergone surgery between January 2000 and December 2018 and had been diagnosed with intrameningioma metastasis. Medical charts and radiographic images were reviewed. Brain edema was related to tumor size on preoperative T2-weighted magnetic resonance imaging and classified as little (i.e., less than the tumor size), moderate (i.e., less than triple the size of the tumor), and extensive (i.e., more than triple the size of the tumor). CASE DESCRIPTIONS: We identified 7 patients (3 men and 4 women) with a median age of 61 years (range, 33-63 years). A systemic cancer had been diagnosed preoperatively in all patients (lung adenocarcinoma, n = 5; breast adenocarcinoma, n = 1; pancreas adenocarcinoma, n = 1). Mean time interval between diagnosis of the systemic cancer and the intracranial dural mass was 32 months (SD 23.05). The preoperative working diagnosis was meningioma in 5 patients, and metastasis in 2 patients. All patients were symptomatic at the time of diagnosis with a short history of headache (n = 2), nausea (n = 1), and dizziness (n = 1), and 5 patients harbored neurologic deficits, including hemiparesis (n = 2), hemihypesthesia (n = 2), and paresthesia (n = 1). Preoperative images showed brain edema in all patients (extensive, n = 4; moderate, n = 3). CONCLUSIONS: Intrameningioma metastases show an aggressive clinical behavior prompting early surgical intervention. Clinicians should be aware of this rare entity when counseling patients.

Long-Term Clinical and Computed Tomography Angiographic Follow-up After Totally Endoscopic Coronary Artery Bypass Grafting.

OBJECTIVE: Totally endoscopic coronary artery bypass grafting was shown to be feasible and safe, with excellent clinical and angiographic mid-term results. Data on long-term outcome are lacking. Therefore, we aimed to investigate the long-term rate of major adverse cardiac and cerebrovascular events and left internal mammary artery patency rate in patients undergoing arrested heart totally endoscopic coronary artery bypass grafting. METHODS: From 2001 to 2012, a total of 208 arrested heart-totally endoscopic coronary artery bypass grafting patients were prospectively included. Mean ± SD age was 58.8 ± 9.4 years, and mean ± SD Society of Thoracic Surgeons score was 0.5 ± 0.5%. Major adverse cardiac and cerebrovascular events were defined as a composite of death, myocardial infarction, stroke, re-percutaneous coronary intervention, re-coronary artery bypass graft, and target vessel revascularization. Left internal mammary artery patency was assessed using cardiac computed tomography and depicted according to the established Fitzgibbon classification. Mean ± SD follow-up was 6.9 ± 2.3 years. RESULTS: At 1, 5, and 10 years, survival rate was 100%, 98.3%, and 95.8%, respectively. The freedom from clinical events at 1, 5, and 10 years were major adverse cardiac and cerebrovascular events (93.5%, 85.9%, and 83.0%), myocardial infarction (99.0%, 97.4%, and 95.9%), target vessel revascularization (96.0%, 94.3%, and 91.7%), re-percutaneous coronary intervention (94.5%, 91.6%, and 84.2%), and re-coronary artery bypass graft (100%, 99.5%, and 99.5%), respectively. Left internal mammary artery patency rate at 1, 5, and 10 years was 100%, 94.9%, and 88.1%, respectively. CONCLUSIONS: Arrested heart-totally endoscopic coronary artery bypass grafting shows excellent clinical long-term results with a left internal mammary artery patency rate comparable with conventional coronary artery bypass graft at 10 years after surgery.