The clinicopathological features of ganglioglioma with CD34 expression and BRAF mutation in patients with epilepsy.

Objective: The aim of the study was to evaluate the clinicopathological features, as well as the surgical prognosis, of epilepsy-associated gangliogliomas (GG) with CD34 expression and BRAFV600E mutation. Methods: Clinical data of patients who underwent epilepsy surgery for GG were retrospectively studied. Univariate and multivariate analyses were performed to evaluate the correlations of clinical and pathological factors with molecular markers of CD34 expression and BRAFV600E mutation in GG. Results: A total of 208 patients with GG had immunohistochemical detection of CD34 expression (positive/negative: 184/24), and among them, 89 patients had immunohistochemical detection of BRAFV600E mutation (positive/negative: 54/35). By univariate and multivariate analyses, seizure aura (p = 0.025), concordance of ictal electroencephalogram (EEG) findings (p = 0.045) and medial temporal tumor (p = 0.030) were found to be related to CD34 expression, but only hospitalization time (p = 0.042) was different for BRAF-mutated status. In addition, drug-resistant epilepsy (p = 0.040) and concordance of interictal EEG findings (p = 0.009) were found to be associated with tumor progression-free survival (PFS) in univariate analysis, but only concordance of interictal EEG findings was with significance in multivariate analysis. However, CD34 expression or BRAFV600E mutation in GG was not found to be associated with surgical outcomes of seizure control and tumor PFS. Conclusion: The CD34 expression or BRAFV600E mutation in GG may partly influence the distribution of clinicopathological features of patients with epilepsy, but they may be not able to predict the surgical prognosis of seizure outcome and tumor recurrence.

The cognitive functions and seizure outcomes of patients with low-grade epilepsy-associated neuroepithelial tumors.

PURPOSE: The aim of the study was to evaluate the cognitive functions and seizure outcomes of patients with low-grade epilepsy-associated neuroepithelial tumors (LEATs). METHODS: We retrospectively reviewed the clinical data of patients who underwent preoperative neuropsychological evaluations and subsequent epilepsy surgery for LEATs. The neuropsychological results of full-scaled intelligence quotient (FSIQ) and full-scaled memory quotient (FSMQ) were analyzed, as well as the postoperative seizure outcomes. RESULTS: Of the 138 patients included in the study, 59 patients (40.4%) were female and 47 (36.6%) patients were children. Preoperatively, 138 patients received FSIQ assessments and 30 patients (21.7%) had an intellectual deficit (FSIQ < 80 scores); 124 patients received FSMQ assessments and 32 patients (25.8%) had a memory deficit (FSMQ < 80 scores). Younger age at seizure onset (OR 0.93; P = 0.035) and discordant ictal electroencephalography (EEG) findings (OR 5.26; P = 0.001) were found to predict intellectual deficits, while abnormal hippocampus (OR 2.36; P = 0.051) as well as discordant ictal EEG findings (OR 4.03; P = 0.007) tended to cause memory deficits. During postoperative follow-up, 123 patients (90.7%) were followed up at least 12 months, and among them, 105 patients (85.4%) got seizure-free (Engel class I), while 18 patients (14.6%) were not (Engel class II-IV); longer duration of epilepsy (OR 1.01; P < 0.001) and discordant interictal EEG findings (OR 5.91; P = 0.005) were found to be related to poor seizure outcomes in patients with LEATs. CONCLUSION: Cognitive deficits commonly occur in patients with LEATs, especially in patients with early or childhood seizures. Early surgical intervention, however, could prevent most of patients from repeated seizure onsets and thus cognitive impairments.

The long-term surgical outcomes of low-grade epilepsy-associated neuroepithelial tumors.

OBJECTIVE: This study aimed to evaluate the surgical outcomes and relevant prognostic factors in patients with low-grade epilepsy-associated neuroepithelial tumors (LEAT) and, especially, to develop a scoring system to predict postoperative seizure outcomes. METHODS: The clinical data of patients who underwent epilepsy surgery for LEAT were retrospectively studied. The surgical outcomes of seizure and neurological statuses in patients were evaluated using Engel classification and modified Rankin Scale (mRS) scoring, respectively. A scoring system of seizure outcomes was constructed based on the weight of the ß-coefficient estimate of each predictor in the final multivariate predicting model of seizure outcomes. RESULTS: Of the 287 patients (106 female) enrolled, the median age was 19 years at surgery and 10 years at seizure onset, with a median duration of epilepsy of 60 months. Among 258 patients who were followed up for at least 12 months, 215 (83.3%) patients had a favorable seizure outcome (Engel class I) after surgery, and 43 (16.7%) patients had an unfavorable seizure outcome; longer duration of epilepsy, discordant magnetoencephalography (MEG) findings, and acute postoperative seizures were significantly included in the scoring system to predict unfavorable seizure outcomes, and in the scoring system, accumulated scoring of 0-19 scores was recorded, which were finally grouped into three risk levels: low risk (risk < 30%), medium risk (30% ≤ risk < 70%), and high risk (risk ≥ 70%). In addition, favorable neurological outcomes (mRS score 0-1) were recorded in 187 (72.5%) patients, while unfavorable neurological outcomes were recorded in 71 (27.5%) patients, which were significantly related to poor seizure control, older age at surgery, and longer duration of epilepsy and hospitalization time. SIGNIFICANCE: The long-term surgical outcomes of LEAT after surgery were satisfactory. A scoring system for predicting unfavorable seizure outcomes with different risk levels was developed, which could partly guide clinical treatments of LEAT.

The value of radiomics based on dual-energy CT for differentiating benign from malignant solitary pulmonary nodules.

OBJECTIVE: To investigate the value of monochromatic dual-energy CT (DECT) images based on radiomics in differentiating benign from malignant solitary pulmonary nodules. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board, and informed consent was waived. Pathologically confirmed lung nodules smaller than 3 cm with integrated arterial phase and venous phase (AP and VP) gemstone spectral imaging were retrospectively identified. After extracting the radiomic features of each case, principal component analysis (PCA) was used for feature selection, and after training with the logistic regression method, three classification models (ModelAP, ModelVP and ModelCombination) were constructed. The performance was assessed by the area under the receiver operating curve (AUC), and the efficacy of the models was validated using an independent cohort. RESULTS: A total of 153 patients were included and divided into a training cohort (n = 107) and a validation cohort (n = 46). A total of 1130 radiomic features were extracted from each case. The PCA method selected 22, 25 and 35 principal components to construct the three models. The diagnostic accuracy of ModelAP, ModelVP and ModelCombination was 0.8043, 0.6739, and 0.7826 in the validation set, with AUCs of 0.8148 (95% CI 0.682-0.948), 0.7485 (95% CI 0.602-0.895), and 0.8772 (95% CI 0.780-0.974), respectively. The DeLong test showed that there were significant differences in the AUCs between ModelAP and ModelCombination (P = 0.0396) and between ModelVP and ModelCombination (P = 0.0465). However, the difference in AUCs between ModelAP and ModelVP was not significant (P = 0.5061). These results demonstrate that ModelCombination shows a better performance than the other models. Decision curve analysis proved the clinical utility of this model. CONCLUSIONS: We developed a radiomics model based on monochromatic DECT images to identify solitary pulmonary nodules. This model could serve as an effective tool for discriminating benign from malignant pulmonary nodules in patients. The combination of arterial phase and venous phase imaging could significantly improve the model performance.

Effect of puncture sites on pneumothorax after lung CT-guided biopsy.

To determine the influence of puncture site on aspiration in dealing with pneumothorax following CT-guided lung biopsy.Two hundred thirty-six pneumothorax patients after CT guided lung biopsies were retrospective analyzed from January 2013 to December 2018. Patients with minor asymptomatic pneumothorax were treated conservatively with monitoring of vital signs and follow-up CT to confirm stability. Ninety of the 236 pneumothorax patients, who underwent manual aspiration, were included in this analysis. In first manual aspiration, the needle from the lesion was retracted back into the pleural space after biopsy, and then aspiration treatment was performed. If the treatment is of unsatisfied result, a second attempt aspiration treatment, which puncture site away from initial biopsy one, was conducted. The efficacy of simple manual aspiration and the new method, changing puncture site for re-aspiration was observed.Immediate success was obtained in 62 out of the 90 patients in the first attempt. The effective rate and failure rate were 68.9% (62/90) and 31.1% (28/90), respectively. Twenty-eight patients in whom first attempt simple aspiration were unsuccessful underwent a second attempt aspiration, which puncture site away from initial biopsy one, was successful in 13 patients with 15 patients undergoing chest tube placement. The effective rate and failure rate were 46.4% (13/28) and 53.6% (15/28), respectively. Applying the modified procedure, total effective rate of aspiration elevated significantly from 68.9% (62/90) to 83.3% (75/90) (P < .05). No serious side effects were detected in the period of aspiration procedure.Manual aspiration with puncture site away from initial biopsy one is worth trying to deal with post-biopsy pneumothorax. This modified procedure improved the efficiency of treatment significantly, and reduced the rate of pneumothorax requiring chest tube placement.

Surgical Management and Functional Outcomes of Cavernous Malformations Involving the Medulla Oblongata.

OBJECTIVE: The aim of this study was to evaluate the clinical features, surgical complications, and functional outcomes of the surgical treatment of patients with cavernous malformations (CMs) involving the medulla oblongata. METHODS: The charts of 69 patients undergoing surgical treatment of CMs in the medulla oblongata, pontomedullary, and cervicomedullary junctions between 2011 and 2017 were retrospectively reviewed. Patient demographics, lesion characteristics, operative documents, and patient outcomes were examined. RESULTS: Of the 69 patients, the male-to-female ratio was 1.3. The mean patient age was 32.6 years, and the mean mRS score was 2.7 on admission. Postoperatively, 21 patients (30.4%) had deficits of cough reflexes, and 6 patients (8.7%) experienced respiratory rhythm disorder and dyspnea. The mean follow-up duration was 35.3 months. At the last follow-up evaluation, the mean mRS score was 1.8, and 53 patients (80.3%) had favorable outcomes, with mRS scores ≤2. The conditions of the patients improved in 45 cases (68.2%), remained unchanged in 11 cases (16.7%), and worsened in 10 cases (15.1%) relative to their preoperative baseline. The independent adverse factors for long-term functional outcome were increased age, multiple hemorrhages, presence of developmental venous anomalies, and lack of perilesional edema. CONCLUSIONS: Respiratory dysfunction and deficits of cough reflexes can commonly occur during the early postoperative period for surgical resection of CMs involving the medulla oblongata. Favorable functional outcomes can be achieved by surgery, especially for younger patients who experience fewer hemorrhages and have lesions with perilesional edema and the absence of developmental venous anomalies.

Surgical Management and Risk Factors of Postoperative Respiratory Dysfunction of Cavernous Malformations Involving the Medulla Oblongata.

OBJECTIVE: To evaluate surgical management of cavernous malformations (CMs) involving the medulla oblongata and to predict risk factors of postoperative respiratory dysfunction (RDF). METHODS: Patient data from individuals who underwent surgical treatment for CMs involving the medulla oblongata were retrospectively reviewed. Patients with postoperative RDF and/or deficits of the cough reflex (CR, ≥7 days) were deemed as having bad respiratory statuses. A binary logistic regression analysis tested the association of preoperative predictors with bad postoperative respiratory status. RESULTS: The study consisted of 69 patients. Preoperatively, 9 patients (13.0%) had dyspnea, and 4 (5.8%) had hypoxemia. Postoperatively, 11 patients (15.9%) had bad respiratory statuses, including RDF as a respiratory rhythm disorder and/or dyspnea in 6 patients, and ≥7 days of CR deficits in 5 patients. With a mean follow-up duration of 35.3 months, the neurologic status improved in 45 patients (68.2%), remained unchanged in 11 (16.7%), and worsened in 10 (15.1%) relative to the preoperative baseline. A multivariate logistic regression analysis identified that the independent adverse factors of bad postoperative respiratory status were multiple preoperative hemorrhages, large lesion size, and surgical intervention during the chronic period (>8 weeks). CONCLUSIONS: Postoperative RDF and CR deficits could commonly occur in patients with CMs involving the medulla oblongata. However, patients with fewer preoperative hemorrhages, small lesion size, and operation within 8 weeks of the last bleeding are prone to be associated with a reduced possibility of bad postoperative respiratory status.

Surgical Treatment of the Medullary Cavernous Malformations: 53 Cases.

OBJECTIVE: The aim of this study was to investigate patient clinical features, surgical complications and outcomes, and the prognostic risk factors of surgical treatment of cavernous malformations (CMs) involving the medulla oblongata. METHODS: The charts of 53 patients who underwent surgical treatment for CMs involving the medulla oblongata between 2011 and 2017 were reviewed retrospectively. Patient demographics, lesion characteristics, operative documents, and patient outcomes were examined. RESULTS: The study population consisted of 53 patients, with a male/female ratio of 1.4 and a mean age of 32.6 years. Eighteen patients (34.0%) had respiratory dysfunction, and 2 patients (3.8%) had cardiac instabilities, preoperatively. The mean modified Rankin Scale score was 2.7 on admission. Gross total resection was achieved in 52 patients (98.1%). Postoperatively, 23 patients (43.4%) had respiratory dysfunction, and 16 patients (30.2%) had dysphagia or cough. The mean follow-up duration was 35.7 months. At the last follow-up evaluation, the mean modified Rankin Scale score was 1.7, and 42 patients (84%) had favorable outcomes, with mRS scores ≤2. The conditions of the patients improved in 34 cases (68%), remained unchanged in 10 cases (20%), and worsened in 6 cases (12%) relative to the preoperative baseline. The independent adverse factors for long-term outcome were age ≥50 years and increased time of reservation of tracheal intubation after surgery. CONCLUSIONS: Surgical treatment of CMs involving the medulla oblongata was challenging, notably, perioperative respiratory dysfunction, with which patients tend to have unfavorable long-term outcomes, especially for elder patients.

Manual aspiration in the biopsy-side down position to deal with delayed pneumothorax after lung biopsy.

BACKGROUND: To assess the effect of aspiration in the biopsy-side down position to deal with delayed pneumothorax after computed tomography (CT)-guided lung biopsy. METHODS: A retrospective review was performed of the 236 delayed pneumothorax patients who underwent CT-guided transthoracic needle biopsies (TTNBs). Asymptomatic minimal pneumothorax patients were managed conservatively. Manual aspirations were applied for symptomatic cases with minimal pneumothorax and all cases with moderate to large pneumothorax. Patients were included into two groups: in group A (35 patients), aspiration was performed in the same position as the biopsy, while in group B (54 patients), patients were turned to the biopsy-side down position (from supine to prone or vice versa), and aspiration was conducted. The efficacy of two approaches was evaluated. RESULTS: One hundred forty-seven (62.3%) asymptomatic cases resolved without treatment. Distance between parietal and visceral pleura before and after aspiration were 4.24±1.87 and 1.93±2.33 cm for group A, 3.92±1.31 and 0.98±1.50 cm for group B, respectively. Volume of aspirated air in group A and group B were 735.4±231.8 and 434.8±320.3 mL, respectively. Complete lung expansion was detected in 28.6% (10/35) and 38.9% (21/54) for group A and group B, respectively. The overall effective rate and failure rate were 74.3% (26/35) and 25.7%(9/35) for group A, 92.6% (50/54) and 7.4%((4/54))for group B, respectively, which have significant statistic difference (P<0.05). CONCLUSIONS: Manual aspiration in biopsy-side down position demonstrates the safety and efficacy in treating delayed pneumothorax after CT-guided TTNBs. Thus reduce the rate of pneumothorax requiring drainage catheter placement.

Primary Intracranial Angioleiomyomas as Rare, Nonmalignant, and Distinct Neoplastic Entities: A Series of 8 Cases and a Literature Review.

OBJECTIVE: Primary intracranial angioleiomyoma is a rare and distinct neoplasm. Only 29 cases have been reported previously, and we aimed to investigate the clinical and radiopathologic features of these lesions. METHODS: Medical records and radiographs of 8 patients (7 male and 1 female; mean age: 48.7 years) at our institution were reviewed retrospectively. Patient follow-up and a literature review were performed. RESULTS: The most common preoperative symptom was a visual defect (n = 2), followed by diplopia (n = 1) and abducens paralysis (n = 1). Three patients were asymptomatic. The parasellar area (particularly the cavernous sinus) was the predilection site (n = 4; 50.0%). Radiographically, all lesions were solid without cystic degeneration. All lesions appeared with T1 hypointensity and T2 hyperintensity, and they were gradually heterogeneously enhanced after the administration of gadolinium. Complete resection was achieved in 7 patients (87.5%) without recurrence after 26.8 months of follow-up. Mitosis was rarely observed, and the Ki-67 labeling index was less than 1%; pathologically, the cavernous type was the most common. CONCLUSIONS: Primary intracranial angioleiomyomas were prevalent in middle-aged men, and they usually involved the cavernous sinus and were frequently pathologically identified as the cavernous type. Preoperative symptoms varied depending on lesion location. The preoperative diagnosis of primary intracranial angioleiomyomas is difficult without pathology. Digital subtraction angiography and preoperative embolization are useful for differential diagnosis and surgery. Given the indolent biology of these tumors, a favorable outcome can be achieved using total resection without recurrence. A larger sample size with long-term follow-up is needed to verify our findings.

Brainstem Cavernous Malformations: Surgical Indications Based on Natural History and Surgical Outcomes.

Cavernous malformations (CMs) are uncommon lesions occurring in the central nervous system, with an incidence of approximately 0.5% in the general population and constituting 5%-10% of all intracranial vascular malformations. Among CMs, prevalence within the brainstem as reported in the literature has ranged from 4% to 35%. With their precarious location and potentially devastating clinical events, brainstem CMs have attracted attention from neurosurgeons, and with these surgeons' unrelenting efforts, the microsurgical techniques to treat these lesions in the brainstem have greatly improved in recent decades. Although surgical outcomes reported in the literature have been satisfying, surgical intervention has become increasingly contraindicated because of the tendency for a benign clinical course in brainstem CMs, after weighing this fact against the high risk of surgical morbidity. Thus, it is advisable to operate on patients with symptomatic lesions abutting the pial or ependymal surface of the brainstem or where lesions are accessible to safe entry zones, which have caused more than 1 significantly symptomatic hemorrhage and can be defined as aggressive. However, treatment remains controversial for deep-seated lesions away from the surface of the brainstem or lesions that are inaccessible to safe entry zones. Other treatments, such as radiosurgery and medication, are still debatable, which might be as an alternative for lesions amenable to but at high risk with surgery.