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75. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie

Prof. Dr. med.

Vorsitz

Dr. med. univ.

Prof. Dr.

PD Dr.

Epilepsy and neurocognition in patients with glioblastoma

Tumor

Epilepsie und Neurokognition bei Patienten mit Glioblastom

Epilepsy is a common symptom in patients with glioblastoma, often leading to first diagnosis. Many of these patients are treated with antiepileptic medication. However, especially for patients with very occasional, focal seizures the decision-making regarding anticonvulsive treatment remains a matter of discussion. Some studies suggest an impact of epilepsy and its treatment on neurocognition and mood. The aim of this study was to describe the prevalence and use of antiepileptic drugs before therapy and during the course of disease, and to analyse correlations with neurocognitive performance.226 patients with untreated glioblastomas underwent neurocognitive assessment composed of 11 subtests, complemented by a standard questionnaire to assess depression (Becks Depression Index). Moreover, information on epileptic history and the use of antiepileptic drugs were collected from the attending physicians before and after first surgery, and after 3 and 6 months. Neurocognitive data were normalised to percentile ranks. Pearson"s point-biserial correlations were calculated to examine relationships between neurocognitive performance and epilepsy as well as use of antiepileptic medication. Chi-squared tests were applied to evaluate the relationship between epilepsy (treatment) and binomial factors. Correction for multiple comparisons was applied.Preoperatively, 22% were reported to suffer from (mostly focal) epilepsy. 28% received antiepileptic treatment (84% levetiracetam-based medication). Seizures during the acute postoperative phase occurred overall in 3.6% of the patients, largely irrespective of preoperative epilepsy (4.8% vs. 3.5%; n.s.). The prevalence of epilepsy did not significantly change over time. Patients with epilepsy showed, overall, non-inferior neurocognitive test performance. Interestingly, they even showed better performance than non-epileptic patients in visuospatial processing (p=0.05), especially when under anticonvulsive medication (p=0.003). In contrast, we found no significant association of epilepsy with depression or the IDH mutation status. Of note, tumour volumes of epilepsy patients were not different from others (p=0.899).Our data showed no negative effect of epilepsy and related medical treatment on neurocognitive functions, and even support the hypothesis that the use of levetiracetam has a positive impact on visuospatial abilities. This seems worthy of consideration for clinical decision-making.

Abstractvortrag | Abstract talk

PD Dr. med.

Professor

Cognitive Reserve Index in neuro-oncological patients

Kognitive Reserve Index neuro-onkologischer Patienten

Neuro-oncological diseases often result in brain damage, leading to neurological deficits. The Cognitive Reserve Index Questionnaire (CRIq) is a validated tool that gauges cognitive reserve, reflecting the brain's resilience to neuropathological damage and its compensatory mechanisms. This study aims to conduct a comprehensive analysis of variations in CRIq scores and the underlying factors among diverse brain tumors.In this pilot series, all patients attending our neuro-oncology outpatient clinic over a 7-month period (October 2022 - April 2023) were requested to complete the CRIq questionnaire. Data analysis adhered to the established "Instructions for the administration of the CRIq" (Nucci et al., 2012) and was correlated with epidemiological data. Patients were categorized by age, marital and parental status, tumor malignancy, WHO Grading System, treatment modality and tumor localization. Statistical analyses were performed using Prism for Windows 10 (Version 8.4.2).The study encompassed a cohort of 173 neuro-oncological patients. Among them, 105 individuals (60.7%) fully completed the CRIq questionnaire, allowing for CRI calculation. Of these participants, 64 were female and 41 were male, with a mean age of 52.7 ± 14.43 years. Approximately 90.5% of patients had intracranial tumors, with 58% classified as malignant. CRI scores were distributed as follows: 0.95% low, 2.85% medium-low, 67.62% medium, 19.04% medium-high, and 9.52% high (as defined by Nucci et al.). Age and parental status had a statistically significant impact on CRI, while gender did not. Interestingly, a significant increase in CRI scores was observed in highly malignant diseases such as glioblastoma (mean CRI score of 116.63 ± 13.18) compared to less malignant ones like low-grade gliomas (mean CRI score of 99.57 ± 8.18) (two-tailed p-value of 0.0063, Mann-Whitney test).The utilization of the CRIq appears promising in assessing cognitive reserve in neuro-oncological patients. Interestingly, among intracranial gliomas, a discernible pattern emerged wherein CRI scores exhibited an upward trend relative to tumor grade. Specifically, patients with glioblastomas displayed a statistically significant increase in CRI scores compared to those with low-grade gliomas. Ongoing investigations involving cognitive testing and volumetric assessments are being conducted to elucidate the mechanisms driving this phenomenon and uncover its potential implications for disease prognosis.

Monitoring cognition in neurological rehabilitation: Feasibility and validity of a new screening test (BLTT®) in a larger group of brain damaged patients

Trauma und Neurointensiv 

Überwachung der Kognition in der neurologischen Rehabilitation: Durchführbarkeit und Validität eines neuen Screening Tests (BLTT ®) in einer größeren Gruppe von Patienten mit Hirnschädigung

Objective: To evaluate the feasibility and validity of the Brain Lesion Tracking Test (BLTT), a neuropsychological screening tool for the assessment and outcome control of older patients with acquired brain lesions undergoing neurological rehabilitation.Methods: A consecutive cohort of 376 patients was screened with the BLTT at the beginning and after 4-17 weeks of rehabilitation. The test is standardized for repeated assessment and addresses episodic, semantic memory and executive functions bypassing visual or hand functions. The BLTT was complemented by a figural recognition test, the Extended Barthel Index (EBI) and the Singer scale, an ICF (International Classification of Functioning, Disability, and Health) oriented rating tool.Results: Application of the BLTT was possible in majority of the patients (82%). Mild aphasia, hemineglect, hemiplegia, psychomotor slowing or visual impairments including hemianopsia did not exclude testing. With 30 minutes, testing took longer than in controls. 88% showed baseline an impaired total scale, 38% to 71% subscale deficits. Singer and EBI indicated 96% and 48% impaired. Cognitive improvement was evident in 31-37%, EBI and Singer improved in 27% and 49%. Cognitive worsening was seen in 11-17% (mostly memory), in the EBI and Singer in 2% and 0%. BLTT, figural memory, EBI and Singer correlated at baseline at best with r = 0.39, whereas pre- to post changes did not correlate. Different outcomes dependent on lesion type and side, presence of epilepsy, a previous hit, gender, education and duration of rehabilitation proved the clinical validity of the assessments.Conclusion: The BLTT, a time-efficient screening tool appears suitable and valid in patients with acquired brain injury of various etiologies. In light of these findings, the test is highly appropriate for repetitive neurocognitive monitoring of neurosurgical patients in both perioperative and postoperative settings. Its application is currently underway.

Practice variation in the treatment of recurrent glioblastoma: A nationwide survey among German neuro-oncology specialists

Behandlungsunterschiede bei Glioblastom-Rezidiven: Eine Umfrage unter deutschen neuroonkologischen Spezialisten

The treatment of newly diagnosed glioblastomas follows standardized recommendations based on guidelines. Despite close interdisciplinary collaboration within the neuro-oncological tumor boards, there is uncertainty regarding the optimal treatment modality in patients with a recurrent glioblastoma due to limited evidence. This study aimed to investigate practice variation between neuro-oncology specialists and to identify patient characteristics that determine specific therapies.We conducted an online survey using a structured questionnaire via the e-mail distribution lists of the German Society for Neurosurgery (DGNC), the Neurooncological Working Group (NOA) and the German Society for Radiooncology (DEGRO). Six recurrent glioblastoma cases with different patient characteristics were presented to neurosurgeons, neuro-oncologists, medical oncologists and radiation oncologists. In addition, we asked for practice characteristics of the participants.The survey was filled in by 180 respondents of which 74 (41%) were neurosurgeons, 15 (8%) neuro-oncologists, 3 (2%) medical oncologists and 88 (49%) radiation oncologists. 49% of the participants were from university centres. 78% of the hospitals had participated in clinical oncology studies in the last 2 years. In the case of recurrence in young and clinical intact patients, most respondents were in favour of another tumour resection (88%) and of further adjuvant therapy (89%). There was no difference between the underlying specialties (89% of neurosurgeons, 88% of radiation oncologists, 93% of neurologists opted for another resection). However, there was substantial practice variation regarding the choice of adjuvant therapy (radiation vs. type of chemotherapy vs. experimental treatment options) between cases and specialties, but even within specialties. The clinical condition of the patient had the strongest influence on the decision to have another resection (only 53% were in favour of another resection in patients with low Karnofsky Performance Index), followed by age (only 70% were in favour with another resection in patients with higher age).Our data show that the majority of specialists opts for re-resection and adjuvant therapy in recurrent glioblastoma in young patients without neurologic deficits. However, with regard to adjuvant therapy there was a high degree of treatment heterogeneity. This underlines the need for new evidence-based treatment standards.

Dr. med.

Stratification of rehabilitation potential after resection of diffuse glioma by changes of language pathway integrity – Preliminary results

Stratifizierung des Rehabilitationspotentials nach Resektion diffuser Gliome durch Veränderungen der Integrität von Sprachtrakten - vorläufige Resultate

Diffuse glioma is a potentially devastating disease whose prognosis is largely dependent on the extent of resection. This is only outweighed by prevention of permanent neurological deficits. However, distinction between permanent and temporary neurological deficits remains difficult, as does risk stratification before and estimation of rehabilitation potential after surgery.We retrospectively analyzed 50 right-handed patients with diffuse glioma (WHO-grade 2, 3, or 4) and applied a tractography workflow before and after surgery including eddy correction, coregistration and tract segmentation within DSI Studio for the arcuate fascicle (AF), the frontal aslant tract (FAT), and the uncinate fascicle (UF). The patients were 34 % female and 60 ± 2 years old. Follow-up aphasia score (0–3) after three months could be recorded in 46 patients with 0.48 ± 0.13. Linear regression analysis of mean fractional anisotropy (FA) in the segmented tracts for the occurence of aphasia at follow-up revealed independent significant correlation of the preoperative left AF (0.41 ± 0.01 versus 0.34 ± 0.02). Calculation of an FA quotient postoperative / preoperative was possible in 12 patients and resulted in independent significant correlation of changed right AF FA (96 ± 4 % versus 101 ± 3 %), and changed right UF FA (107 ± 2 % versus 98 ± 1 %) with aphasia at follow-up. These preliminary results confirm the important role of the arcuate fascicle in the dominant hemisphere. Further, in surgery of diffuse glioma, preservation and postoperative integrity of other pathways seem important for lasting speech performance, which may indicate reorganisation of the language network after glioma surgery and entails a need for further investigation.

Prospective longitudinal assessment of health-related quality of life and psycho-oncological burden in meningioma patients after tumor resection

Prospektive longitudinale Erhebung der Gesundheits-bezogenen Lebensqualität und psychoonkologischen Belastung von Meningeom-Patienten nach einer Tumorresektion

From the practitioners" perspective, intracranial meningioma is often considered a benign disease with long-term disease control after tumor resection. However, the patients" psycho-oncological burden and health-related quality of life (HRQOL) are still poorly defined and may be subject to changes over time due to burdensome treatment and fear of progression. Here, we prospectively assessed psycho-oncological burden and HRQOL before and after surgery.Since 02/2019, patients with a suspected or recurrent intracranial meningioma scheduled for resection were prospectively enrolled in this study. Psycho-oncological burden and HRQOL were assessed with standardized self-assessment questionnaires (HADS-D, EORTC-QLQ-C30, EORTC-QLQ-BN20) at four different time points: before (T1) as well as 3 (T3), 12 (T12) and 24 (T24) months after surgery. Results were compared intra-individually by pairwise t-tests and to normative data from the German general population.Until 12/2022, 142 patients (mean age 55.7 years; 75.4% females) were enrolled with longitudinal assessment available for 115 patients at T3, 96 patients at T12 and 40 patients at T24. 94.4% underwent Simpson grade 1-3 resection and 2.8% received adjuvant radiotherapy, because of high-grade or recurrent meningioma. When compared to the general population, the frequency of patients reporting anxiety or depression was higher at all time points. At intra-individual comparison, the frequency of patients reporting anxiety remained stable over time while the number of patients reporting depression dropped from T1 to T12 (p=0.012). Concerning HRQOL, patients fared worse on all function and symptom scales of EORTC-QLQ-C30 than the general population. Over time, only few significant changes in HRQOL were noted: global health improved from T1 to T12 (p=0.018) while emotional functioning and future uncertainty improved from T1 to T3, T12 and T24 (p<0.01 each). Patients constantly complained of itchy skin at all time points after surgery. In this prospective analysis, psycho-oncological burden was higher and HRQOL was lower in meningioma patients at all time points before and after tumor resection than in the general population. Over time, HRQOL improved in only few (but meaningful) domains such as global health, emotional functioning, and future uncertainty. This study underlines a high need for psycho-oncological support in meningioma patients also at later stages after surgery.

Session 17
Tumor – Gliome und Neurokognition

Appointment

Vorsitz

Programme

Session 17Tumor – Gliome und Neurokognition

Appointment

Vorsitz

Programme

Session 17
Tumor – Gliome und Neurokognition