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76. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie

Vorsitz | Chair

Prof. Dr.

PD Dr.

Dr. med.

Spatial characterization of tumor growth pattern and facial outcome in vestibular schwannoma surgery

Schädelbasis

Räumliche Charakterisierung des Tumorwachstumsmusters und des fazialen Outcomes nach der Resektion von Vestibularisschwannomen

Tumor size is the most important predictor of postoperative facial function outcome (FFO) in vestibular schwannoma (VS) surgery. However, there is increasing evidence that the growth pattern (i.e., elongated tumors anterior to the internal auditory canal) is also affecting the FFO. The present study explores the relationship between tumor growth pattern and FFO using voxel-based lesion symptom mapping (VLSM).We enrolled 140 consecutive patients with VS who underwent primary gross-total resection via a retrosigmoidal approach. Preoperative MRI data were normalized to the standard MNI space and the tumor was segmented semi-automatically. Tumor volume (TV) was determined and categorized by the KOOS classification. Facial nerve function was assessed preoperatively as well after 1 year of follow-up using the House-Brackmann (HB) grading scale. VLSM with a multiple regression analysis was employed to correlate lesion location, tumor size, and postoperative facial nerve outcomes.Mean TV was 4.2±5.2 ml. There was a good correlation between TV and KOOS classification (r=0.87, pSpatial analysis highlighted that resections involving specific voxel clusters adjacent to the REZ of the facial nerve were predictive of unfavorable outcomes. This might be attributed to the vulnerability of the facial nerve due to the transition of central to peripheral myelination. Tumor size remains a significant predictor of postoperative FFO, but the precise resection-related anatomy plays a pivotal role.

Abstractvortrag | Abstract talk

Prof. Dr. med.

Molecular landscape and clinical associations of petroclival meningiomas

Molekulare Landschaft und klinische Korrelation petroclivaler Meningeome

Petroclival meningiomas (PCM), comprising 2% of all meningiomas, pose significant surgical challenges due to their location and consistency, often leading to neurological deficits. This study examines the relationship between the clinical characteristics, radiological features, and molecular profiles of PCMWe performed whole-genome sequencing on 46 PCM samples collected from a single center, focusing on known meningioma-driver genes. We compared the molecular data with the clinical features of the tumors. Patient and tumor data, including age, sex, tumor consistency, and volume, were retrospectively collected. In addition, patient survival was analyzedThe study cohort comprised 36 females (78.3%) and 10 males (21.7%), with a median age at diagnosis of 61 years (range 19-88 years). The majority of tumors (78.3%, n=36) were classified as WHO grade 1, and the remaining 21.7% as grade 2 meningiomas. Known driver mutations were found in 87% of patients (n=40). The most common mutations were found in the TRAF7 (n=15, 32.6%) and NF2 (n= 14, 30.4%) genes, which occurred mutually exclusive. Further frequently detected mutations were KLF4K409Q (n= 13, 28.2%, all co-mutant with TRAF7) and AKT1E17K (n= 8, 17.4%, including five co-mutant with TRAF7), followed by mutations in POLR2AQ403K (n= 5), SMARCB1 (n= 2), SMO (n=2), and PTCH1 (n=1). In seven patients, no known meningioma driver mutations were detectable. The most common histological subtype was meningothelial in 28 cases (60%) with no correlation between histology and mutational profile of PCMs. The median tumor volume at diagnosis was 11.9 cm3. Among tumors with known driver mutations, NF2-mutant PCMs presented with the largest median volume (45.6 cm3), whereas AKT1- and TRAF7/KLF4-mutations were associated with the smallest tumor volumes (10.5 cm3 and 9.6 cm3, respectively). We then correlated the molecular profile with tumor intraoperative consistency, with 10 being firm and 36 of soft tumors. No significant correlation between tumor consistency and molecular features was foundDistinct molecular subgroups of PCM were identified, with NF2-mutant tumors associated with larger volumes and potentially more aggressive behavior. Similarly, other subgroups, such as those with TRAF7/KLF4 mutations, demonstrated smaller volumes, suggesting less aggressive growth patterns. These findings highlight the value of molecular diagnostics in improving preoperative planning and enabling personalized treatment strategies

Prediction of postoperative hearing and facial nerve function in vestibular schwannoma surgery: Results from a prospective randomized controlled trial.

Vorhersage der postoperativen Hör- und Facialisfunktion bei Operationen von Vestibularisschwannomen: Ergebnisse einer prospektiven randomisierten kontrollierten Studie.

Preservation of hearing and facial nerve function remains a significant challenge in the treatment of vestibular schwannoma (VS). The aim of this study was to identify predictors of postoperative hearing and facial nerve function in a cohort from a prospective randomized controlled trial (RCT).70 patients with hearing function classified as Gardner-Robertson (GR) Grades I-III and facial function House and Brackmann (HB) Grade I underwent VS resection via a retrosigmoid approach within a RCT. As sub-analysis of this trial, pre- and perioperative patient and electrophysiological findings, as well as tumor resection status were evaluated in relation to outcomes at discharge and at 3-month follow-up.Tumor size (Hannover classification) was: T1 (1.6%), T2 (32.8%), T3 (43.8%) and T4 (21.9%). Gross total tumor resection (GTR) was achieved in 92.1%. Surgery was stopped with a subtotal resection (STR) in 7.9% to preserve the facial nerve.Hearing was preserved in 51.9% with T1-T3a and 24.1% with T3b-T4b VS (p=0.032). Worse outcomes were seen in cases with intraoperative auditory evoked potentials (AEP) amplitude reduction >80% (AUC=0.763) and latency reduction >50% (AUC=0.760). Binary logistic regression identified preoperative audiometric hearing function (p=0.04, OR=3.5) and perioperative AEP deterioration (p=0.007, OR=1.5) as independent predictors of postoperative hearing function.Facial palsy at discharge was associated with larger preoperative tumor size (p=0.006) and a perioperative drop in motor evoked potentials (MEP) (p=0.04). Patients who underwent STR had worse HB grades compared to those who had GTR (p=0.002).Tumor size (p=0.033, OR=5.1) was the only independent predictor of facial nerve function at discharge. However, this improved to HB I or II in 84.9% of cases until the 3 month follow-up. STR (which however is triggered by intraoperative worsening of facial nerve electrophysiology) was also predictive of impaired facial nerve function at discharge and 3-months follow-up.In this RCT, preoperative hearing function and intraoperative AEP changes were strong predictors for the functional hearing outcome after VS surgery. Preoperative tumor size was a predictor for facial nerve function at discharge, but this resolved until the 3 month follow-up by good nerve recovery. These high-quality data of a RCT might guide preoperative counseling, help inform patient expectations, and assist in perioperative decision-making.

Prof.

Routine postoperative health-related quality of life assessment (PROMIS) following pituitary tumor surgery reveals entity-associated impairment.

Die routinemäßige Erfassung der Lebensqualität (PROMIS) nach hypophysärer Tumorresektion ergibt Entitäts-assoziierte Einschränkungen.

Pituitary neuroendocrine tumours (PitNETs) are known to be associated with reduced health-related quality of life (HRQoL), even after successful surgical tumour resection, due to endocrine disorders or other limitations. However, standardized HRQoL assessment is rarely integrated into routine postoperative care. Here, we show the results of a prospective routine postoperative HRQoL assessment using the standardized, app-based Patient Reported Outcome Measurement Information System (PROMIS).A prospective HRQoL assessment was conducted in patients who underwent surgical tumour resection in the pituitary region over an average of 4.5 years, using an app-based PROMIS-29 tool. PROMIS T-scores were calculated, with 50 as the mean of the German PROMIS reference population and 10 as the standard deviation (SD) of that population.A total of 100 patients were included in the study, 42 with surgical resection of non-functioning pituitary adenomas (NFPA), 16 with acromegaly, 13 craniopharyngiomas, 10 prolactinomas, 4 Cushing's disease patients, and 15 patients with other pituitary tumors (e.g. meningiomas). Gross total resection (GTR) was achieved in 57%, while biochemical remission rates varied among hormonally active tumors. HRQoL outcomes revealed disparities across the six tumor entities. Patients with prolactinomas exhibited the best overall HRQoL, particularly in anxiety (51.2 ± 11.9), depression (48.9 ± 10.0) and social health (53.0 ± 11.8). In contrast, patients with Cushing"s disease displayed the lowest HRQoL, as indicated by elevated T-Scores in fatigue (54.9 ± 4.5) and pain interference (63.7 ± 6.5), along with the highest pain levels (5.0 ± 2.2) on the NRS-11. Craniopharyngioma patients reported highest mental health impairments, as evidenced by elevated T-Scores in depression (58.9 ± 7.1), anxiety (57.5 ± 8.8), and lower T-Scores in social health (44.8 ± 11.0).Regarding the postoperative HRQoL impairment as assessed by the app-based PROMIS, patients with both Cushing's disease and craniopharyngioma experienced the highest postoperative impairments. Referral to specialist centers, mental health support in postoperative care and standardized HRQoL assessments in clinical practice are recommended as essential steps for optimizing patient-centered treatment.

Technological Advances in Microvascular Decompression for Hemifacial Spasm: Enhancing Outcomes and Minimizing Complications

Technologische Fortschritte in der Mikrovaskulären Dekompression bei Hemispasmus Fazialis: Verbesserung der Ergebnisse und Minimierung von Komplikationen

Microvascular decompression (MVD) remains the only curative treatment for hemifacial spasm (HFS). With advancements in technology and surgical techniques, MVD has become safer and more effective. This study presents a spectrum of complications observed in a case series, explores their possible causes, and recommends strategies to minimize risks, emphasizing the role of modern technological improvements to classify spasm.The authors reviewed a prospectively maintained database for MVDs performed from 2005 to 2024 and extracted relevant data, including patient demographics, offending vessel(s), operative techniques, outcomes, and complications. Additionally, they developed a new grading system utilizing facial recognition and tracking technology.Data from 420 patients were included. 92.3% of the series with a minimum follow-up of 12 months had a favorable outcome. Facial tracking could grade the spasms into three grades (minimal, moderate clonic and sever tonic). Moderate clonic spasms had best cure rates following MVD. Immediate complications reached 18.8% (79/420). Complications persisted in only 7.14% of patients (30/420) including persistent hearing deficits (5.95%) and residual facial palsy (0.95%). Temporary complications included CSF leakage (3.10%), lower cranial nerve deficits (3.57%), meningitis (0.71%), and brainstem ischemia (0.24%). One patient died because of herpes encephalitis. Immediate disappearance of spasms and male gender are correlated with postoperative facial palsy, whereas combined vessel compressions involving the vertebral artery (VA) and anterior inferior cerebellar artery can predict postoperative hearing deterioration. VA compressions could predict postoperative lower cranial nerve deficits.A novel grading system utilizing facial tracking technology has demonstrated accuracy and may correlate with outcomes in MVD for HFS. Optimal patient positioning, precise arachnoid dissection, and enhanced endoscopic visualization, combined with continuous facial and auditory neurophysiological monitoring, are crucial strategies to minimize complication rates.

Vago-glossopharyngeal neuralgia: a comprehensive single-center study of pathophysiology and occurrence of vasomotor events

Vago-Glossopharyngealneuralgie: eine umfassende Einzelzentrumsstudie zur Pathophysiologie und zum Auftreten vasomotorischer Ereignisse

To analyse the correlation between morphological factors, clinical characteristics, and outcomes in patients with vago-glossopharyngeal neuralgia (VGN) who underwent microvascular decompression (MVD), with particular attention on the occurrence of vasomotor events.Eight patients with medically refractory VGN who underwent MVD over an 18-year period were identified. Preoperative imaging, intraoperative findings, and clinical outcomes were reviewed. Pain outcomes were measured using the modified Barrow Neurological Institute (BNI) pain scale. The severity of nerve deformation, compression patterns, presence of arachnoid membranes, and nerve rootlet involvement were assessed. Vasomotor events during surgery were recorded.The mean age was 56 years, with a mean pain duration of 4.3 years. The posterior inferior cerebellar artery was the most common compressing vessel (100%), followed by the vertebral artery (50%). Arachnoid scarring was present in 5 cases (62.5). Right-sided operations were associated with longer periods of bradycardia (47% vs 37.5%) and hypertension (30% vs 6%) compared to left-sided operations. At immediate postoperative evaluation, 6/8 patients achieved BNI I. At a mean long-term follow-up of 41 months, 3/8 patients presented with BNI I, one patient with BNI II, and another with BNI IIIa. Three patients experienced recurrence (BNI IV). Minor complications included transient dysphonia and dysphagia (12.5%) and transient tongue edema (12.5%).The pattern of neurovascular compression and affected side may influence the occurrence of vasomotor events during surgery, with right-sided operations showing higher rates of hypertension. These vasomotor events could be anticipated when performing MVD for VGN. MVD provides effective pain relief for VGN with minimal morbidity in experienced hands.

Rapid communication

PD Dr. med.

Endoscopic navigation assisted placement of cysto-ventricular catheters in craniopharyngioma

Endoskopische navigationsgestütze Implantation von zysto-ventrikulären Kathetern zur Therapie von zystischen Kraniopharyngeomen

Craniopharyngiomas are rare tumors located in the sella region, often characterized by large cystic compartments. This study aims to analyze the impact of placing a catheter within these cystic compartments to alleviate pressure on surrounding structures, as well as to assess the resulting effects on visual impairment and endocrine disorders.We conducted a retrospective analysis of patients with craniopharyngiomas who underwent surgical treatment between 2013 and 2024. MRI scans taken before and after surgery were evaluated to determine the presence of hydrocephalus, compression of the optic chiasm, and hypothalamic edema. Clinical reports were reviewed for signs of visual impairment, hypopituitarism, and diabetes insipidus.Out of 33 patients included in the study, a cysto-ventricular catheter (CVC) was placed in 14 (42%) cases at some point during treatment. Among these, 10 (71%) underwent endoscopic placement of the catheter, while in 3 (21%) cases, the catheter was placed using stereotactic techniques. The catheter was placed before resection in 7 cases. All patients showed improvement in visual function after CVC implantation. No new cases of hypopituitarism were observed following CVC placement. Additionally, in all cases, the size of the cyst decreased after CVC placement, and in 3 (43%) cases, hypothalamic edema was found to be regressing. Furthermore, the histopathological diagnosis was confirmed in all cases after endoscopic CVC placement.The use of cysto-ventricular catheters in the treatment of cystic craniopharyngiomas has shown promising results in select cases, as it can rapidly improve visual impairment and potentially reduce the impact of the tumor on surrounding tissues, thereby increasing the likelihood of complete removal during subsequent resections. Additionally, the endoscopic-assisted placement technique allows for biopsy collection and removal of crystalloid cyst fluid, which may help prevent aseptic meningitis. However, further studies are needed to identify the specific patient and tumor characteristics that would make this two-step approach preferable over other treatment options.

Session 3
Schädelbasis 1

Termin

Vorsitz | Chair

Thema

Programm

Session 3Schädelbasis 1

Termin

Vorsitz | Chair

Thema

Programm

Session 3
Schädelbasis 1