1. Lasocki A, Khoo C, Lau PKH, et al. High-resolution MRI demonstrates that more than 90% of small intracranial melanoma metastases develop in close relationship to the leptomeninges. Neuro Oncol 2020;22:423–32
Brain MR examinations of melanoma patients treated at a specialist oncology center from July 2015 to June 2017 were retrospectively reviewed. The MR examination on which intracranial melanoma metastases were first visible was identified, utilizing 1 mm volumetric postcontrast imaging prior to local therapy. Individual metastases (up to 10 per patient) were assessed for the presence of leptomeningeal contact, as well as their number, size, and morphology. Seventy-five patients had evidence of intracranial melanoma metastases. Fifteen patients had only lesion(s) measuring ≥10 mm at diagnosis, leaving 60 patients. One hundred ninety-two individual metastases were examined, 174 (91%) demonstrating leptomeningeal contact.
Classic radiological teaching is that intracranial metastases from solid organ metastases usually arise in the parenchyma, at the gray–white matter junction. Prior research, however, may have been inherently biased by grouping solid organ metastases together. For example, in one study assessing the pattern of intracranial metastases in 105 patients found that the majority developed at the gray–white matter junction. Only 3 patients in their series had melanoma, however, with the majority having a lung primary. Similarly, in another study assessing the location of 150 metastases in 28 patients, all patients had either a lung or breast primary. The proclivity of cells from a particular cancer type to preferentially metastasize to certain anatomical locations is well established. This is equally true regarding the distribution of metastases to the brain—for example, some primaries have a greater tendency to posterior fossa involvement.
They conclude that most intracranial melanoma metastases measuring between 2 and 9 mm in diameter are corticomeningeal nodules. These data raise the hypothesis that deeper parenchymal extension of intracranial melanoma metastases occurs secondarily. Further investigation of the underlying biology of this phenomenon may provide opportunities for novel therapeutic strategies for patients with intracranial melanoma metastases.
3 figures, 2 tables
2. Marenco-Hillembrand L, Wijesekera O, Suarez-Meade P, et al. Trends in glioblastoma: outcomes over time and type of intervention: a systematic evidence based analysis. J Neurooncol [Internet] 2020;147:297–307. Available from: https://doi.org/10.1007/s11060-020-03451-6
Glioblastoma is the most common and aggressive primary brain tumor. With an incidence rate of 3.19 per 100,000 a year carrying a grim prognosis. Today, the median overall survival is estimated to be ~ 15 months, a value that was originally reported by the landmark Stupp trial (2005) which established the current standard of care of radiotherapy and temozolomide for GBM. This happened over a decade ago and since then, new treatment strategies have become available or are underway in an effort to prolong the lifespan of GBM patients. The authors performed a systematic review was conducted according to PRISMA guidelines to identify articles of newly diagnosed glioblastoma from 1978 to 2018. 438 studies from 1979–2017 were analyzed, where 308 (70.3%) survival outcomes were from observational, 92 (21%) from one arm clinical trials, and 38 (8.6%) from two arm clinical trials. Studies included a total of 56,626 patients with a median of 70 patients per study.
The central tendency of median overall survival (MOS) was 13.5 months (2.3–29.6) and cumulative 5-year survival was 5.8% with a significant difference in survival between studies that predate versus postdate the implementation of temozolomide and radiation, (12.5 vs 15.6 months). Coadministration with radiotherapy and temozolomide provided a statistically significant increase in survival for patients suffering from glioblastoma. However, the natural history for GBM remains poor and GBM remains largely refractory to treatment.
4 figures
3. Angevine PD, Bray D, Cloney M, et al. Uncertainty in the relationship between sagittal alignment and patient-reported outcomes. Neurosurgery [Internet] 2020;86:485–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/31264701
4. Pennington Z, Sciubba DM. Commentary: uncertainty in the relationship between sagittal alignment and patient-reported outcomes. Neurosurgery [Internet] 2020;86:E383–84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/31340018
Previous studies have reported correlations and precise quantitative relationships between sagittal spine alignment and health-related quality-of-life (HRQOL) scores. To explore the uncertainty in the overall relationships between sagittal alignment and HRQOL and in the predictions of individual patient pain and disability. A retrospective analysis of all new adult patients with long-cassette radiographs and complete outcomes questionnaires presenting to the senior author from 2012 to 2014 was performed and a bunch of complicated statistics were applied.
A total of 134 patients satisfied inclusion criteria and were included. For Oswestry Disability Index (ODI) vs pelvic incidence-lumbar lordosis (LL), the 90% high-density probability interval ranged from –0.04 to 0.23, indicating that both the magnitude and direction of the relationship were uncertain. For both ODI vs sagittal vertical axis and ODI vs LL, there was uncertainty in the magnitude of the slope. Wide regions of uncertainty were also seen for predicting individual patient scores.
This study supports 2 main conclusions. First, uncertainty in the mean relationships between sagittal alignment and patient-reported outcome measures is potentially substantial and, in some cases, includes both the direction and the magnitude of the relationship. Second, patients with similar sagittal alignment may have widely different patient-reported outcome measures, highlighting the difficulty of predicting clinical status based on radiographic measurements. Radiographic treatment goals derived from similar studies should be considered to be general recommendations, and assumptions regarding a patient’s clinical status based solely or primarily on radiographic measurements must be made very carefully.
2 figures, 4 tables
5. Mazya MV, Berglund A, Ahmed N, et al. Implementation of a prehospital stroke triage system using symptom severity and teleconsultation in the Stockholm Stroke Triage Study. JAMA Neurol [Internet] 2020;77:691–99. Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/2763539
Studies have shown shorter times (median difference, >90 minutes) from stroke onset to the start of EVT (onset-to-puncture time [OPT]) for patients arriving directly at a comprehensive stroke center (CSC), compared with those transferred to a CSC from a primary stroke center (PSC) following receiving an imaging proof of a large artery occlusion (LAO). This emphasizes the need for improved decision-making in prehospital stroke triage to identify patients with a high probability of requiring EVT. On October 10, 2017, the novel Stockholm Stroke Triage System (SSTS) was implemented in the entire region. The SSTS used a hemiparalysis severity rule to guide ambulance staff to either teleconsult the comprehensive stroke center stroke physician regarding primary stroke center bypass eligibility or to prenotify the nearest primary stroke center.
In this cohort study of 2905 patients undergoing code-stroke ambulance transport within the Stockholm region (Sweden), the new triage system had an overall accuracy in predicting large-artery occlusion stroke of 87% (positive predictive value, 41%; negative predictive value, 93%). The median onset-to-puncture time for thrombectomy was 137 minutes vs 206 minutes in the previous year, while onset-to-needle time for intravenous thrombolysis was unchanged at a median of 115 minutes. The conclude that combining a symptom-based prehospital triage algorithm with ambulance-to-hospital teleconsultation may result in markedly reduced delivery times for thrombectomy without delaying intravenous thrombolysis.
2 figures, 3 tables
6. Sollmann N, Fratini A, Zhang H, et al. Associations between clinical outcome and tractography based on navigated transcranial magnetic stimulation in patients with language-eloquent brain lesions. J Neurosurg [Internet] 2019;132:1–10. Available from: https://thejns.org/view/journals/j-neurosurg/132/4/article-p1033.xml
The aim of this study was to establish navigated transcranial magnetic stimulation (nTMS)-based DTI FT for preoperative risk stratification by evaluating associations between lesion-to-tract distances (LTDs) and aphasia and by determining a cut-off LTD value to prevent surgery-related permanent aphasia.
Fifty patients with left-hemispheric, language-eloquent brain tumors underwent preoperative navigated transcranial magnetic stimulation language mapping and nTMS-based DTI FT, followed by tumor resection. The arcuate fascicle (AF), superior longitudinal fascicle (SLF), inferior longitudinal fascicle (ILF), uncinate fascicle (UC), and frontooccipital fascicle (FoF) were identified in nTMS-based tractography, and minimum lesion-to-tract distance were measured between the lesion and the AF and between the lesion and the closest other subcortical language related pathway.
A significant difference in lesion-to-tract distances was observed between patients with no or only surgery-related transient impairment and those who developed surgery-related permanent aphasia with regard to the AF as well as the closest other subcortical language-related pathway.
nTMS-based DTI FT of subcortical language-related pathways seems suitable for risk stratification and prediction in patients suffering from language-eloquent brain tumors. Thus, the current role of nTMS-based DTI FT might be expanded, going beyond the level of being a mere tool for surgical planning and resection guidance.
2 figures, 2 tables, including MR
7. Spetzler RF, McDougall CG, Zabramski JM, et al. Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg 2020;132:771–76
8. Spetzler RF, Albuquerque FC, Zabramski JM, et al. Response to editorials: saccular aneurysms in the Barrow Ruptured Aneurysm Trial: 10 years later. J Neurosurg 2020;132:768–70
In the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist.
There was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling.
From the comment response:
The final question that Dr. Cockroft poses is, “then this would suggest that if you have your ruptured aneurysm treated with open craniotomy and clipping by arguably one of the best cerebrovascular surgeons in the country, if not the world, at a facility known for its surgical prowess, your best hope at 10 years is that you will have the same chance of a poor outcome as someone who had their aneurysm coiled with what is now 15-year-old technology. If that is the case, then why in this day and age would anyone choose to have their aneurysm clipped?” Dr. Spetzler replies that all aneurysms in the anterior circulation that are treated with clipping are associated with the same risk; that clipping, unlike coiling, does not require retreatment in almost 20% of cases; that clipping is associated with much better long-term occlusion rates than coiling; and finally, that the risks of bleeding and death from rerupture associated with clipping are statistically superior to those associated with coiling.
9. Willeke VM, Anderson MP, Mahadevan A, et al. Epstein Barr virus associated smooth muscle tumors in the central nervous system: a case report and systematic review of the literature. J Neurooncol [Internet] 2020;147:247–60. Available from: https://doi.org/10.1007/s11060-020-03426-7
It is known that Epstein-Barr virus (EBV) can be associated with various neoplasms. These include: Non-Hodgkin lymphoma, Burkitt lymphoma, Hodgkin’s disease, nasopharyngeal carcinoma and gastric carcinoma. In the 1990’s it was discovered that there is also an association between EBV infections and the occurrence of certain smooth muscle tumors (SMT). These uncommon tumors carrying EBV are mainly found in immunosuppressed patients, especially in HIV-positive and posttransplant individuals. So this is a case report and review of the literature on this rare topic, which in this case had intracranial tumor that mimicked a meningioma.
EBV-associated SMT appear to have a more favorable prognosis than sporadic LMS. EBV-associated SMT intracranial lesions in post-transplant patients seem to have the poorest prognosis. It has been postulated, that the individual immune status predominately determines the aggressiveness of SMTs. Accordingly, mortality in this patient subgroup seems rarely to be due to the EBV-associated SMT itself, but more frequently patients die because of their underlying primary disease. Improvement of the immune status depending on the underlying disease should be at least one component of the therapy.
Bonus:
10. Makin JG, Moses DA, Chang EF. Machine translation of cortical activity to text with an encoder–decoder framework. Nat Neurosci [Internet] 2020;23:575–82. Available from: http://dx.doi.org/10.1038/s41593-020-0608-8
The authors show that spoken speech can be decoded reliably from electrocorticogram data, with word error rates as low as 3% on datasets with 250-word vocabularies, but the speech to be decoded was limited to 30–50 sentences. They trained a recurrent neural network to encode each sentence-length sequence of neural activity into an abstract representation, and then to decode this representation, word by word, into an English sentence.
7 figures, 1 table, and many equations
