Search

Background Awake craniotomy is used to resect tumor while preserving language. However, differences between patients in post-operative speech/language outcome are observed despite careful intra-operative monitoring. Literature describes improved performance in language tasks during cognitive tests in musicians. Moreover increased white matter connectivity properties in the corpus callosum are described in musicians compared to non-musicians. We hypothesize better recovery of language in musical patients after awake glioma surgery, caused by higher connectivity properties from the corpus callosum. Material and Methods Adult patients undergoing resection for glioma with an awake resection procedure at two neurosurgical centers were prospectively included. Patients without standardized language tests at pre- and post-operative level, with a glioblastoma multiforme (WHO grade 4) or undergoing re-resection were excluded. Language was assessed with the Diagnostic Instrument for Mild Aphasia (DIMA) and corrected for age and education years from a healthy population. The patients’ musical skill was assessed through questionnaires, and divided in groups based on the Musical Expertise Criterion (MEC) which defines musicality based the duration and intensity of musical training. Volumetric measures of the corpus callosum, corrected for total brain volumes, was calculated of each included patient based on the pre-operative structural MRI. Results Forty-six patients, enrolled between June 2015 and September 2019, were followed-up (mean/SD; 240/174 days after craniotomy) and divided in: non-musician (41.3%, n = 19), amateur-musician (34.8%, n=16) and trained-musician (23.9%, n = 11). Overall a decrease in language was observed after craniotomy (mean/SD) of -0.361/0.771. Musical abilities correlated with less decrease in language (mean/SD) when comparing non-musicians (-0.543/0.683) to amateur (-0.272/0.910) and trained (-0.176/0.693) musicians. An increased but non-significant trend (p=0.28) between musicality and corpus callosum / brain ratio (mean/SD) was observed in non-musicians (0.763, 0.718;0.808), amateur musicians (0.792, 0.745;0.838) and trained musicians (0.835, 0.778;0.891). Conclusion Musicality seemed to improve language outcome after awake glioma surgery, possibly attributed due to a higher white matter connectivity in the corpus callosum. Future studies with larger sample sizes are needed to confirm our findings.

Background IDH1/2 wildtype (IDHwt) glioma WHO grade 2 and 3 patients with pTERT mutation and/or EGFR amplification and/or +7/−10 chromosome gain/loss have a similar overall survival time as IDHwt glioblastoma patients, and are both considered glioblastoma IDHwt according to the WHO 2021 classification. However, differences in seizure onset have been observed. This study aimed to compare the course of epilepsy in the two glioblastoma subtypes. Material and Methods We analyzed epilepsy data of an existing cohort including IDHwt histologically lower-grade glioma WHO grade 2 and 3 with molecular glioblastoma-like profile (IDHwt hLGG) and IDHwt glioblastoma patients. Primary outcome was the incidence proportion of epilepsy during the disease course. Major secondary outcomes included onset of epilepsy, number of seizure days and antiepileptic drug (AED) polytherapy. Results Out of 254 patients, 78% (50/64) IDHwt hLGG and 68% (129/190) IDHwt glioblastoma patients developed epilepsy during the disease course (p=0.121). Epilepsy onset before histopathological diagnosis occurred more frequently in IDHwt hLGG compared to IDHwt glioblastoma patients (90% versus 60%, p Conclusion Although the incidence proportion of epilepsy during the entire disease course is similar, IDHwt hLGG patients show a significantly higher incidence of epilepsy before diagnosis and a significantly longer median time between first seizure and diagnosis compared to IDHwt glioblastoma patients, indicating a distinct clinical course.

Surgical perfection takes years of training and a learning curve to optimize outcomes. This creates an ethical dilemma: although healthcare systems benefit from training new surgeons, the learning curve may cause suboptimal outcomes for the first patients a resident operates on. Can collective interest for the betterment of healthcare be combined with the wellbeing of the individual patient? We argue that this is possible under controlled circumstances. Residency programmes can optimize the learning curve of the trainee by active and extensive supervision: the 'See one, do one' mentality is outdated, even in relatively simple procedures. Residents can improve their skills by using hands-on training on animals or cadavers, or by re-watching their own procedures. It is possible that despite all preventative measures, the effect of the learning curve on surgical outcomes is inevitable and necessary where new surgeons are trained within regular healthcare systems. Ultimately, practice makes perfect.

Dear Sirs, Multiple myeloma (MM) is characterized by the accumulation of monoclonal plasma cells [12], with common nervous system involvement including peripheral neuropathy and epidural compression [2]. In contrast, intraparenchymal lesions and infiltration of cerebrospinal fluid (CSF) and leptomeninges (meningeal myelomatosis) are rare; CSF infiltration occurs in 1% of MM patients [4], which is less common than in solid tumours (1–5%) and much less than in lymphoma and leukaemia (5–15%) [1, 7]. We present a MM patient with progressive and stepwise, multifocal neurological symptoms. Craniospinal MRI was normal, but CSF examination confirmed the diagnosis of meningeal myelomatosis. A 63-year-old male visited the emergency department with double vision and repetitive short-lasting episodes of light-headedness and headache when standing up without loss of consciousness. Nine months earlier he had been diagnosed with Durie-Salmon stage IIIA (International Scoring System stage 3) IgA-kappa MM, with bone lesions (skull, spine, long bones) and an extramedullary left psoas muscle mass. Three cycles of induction chemotherapy with thalidomide, doxorubicine, and dexamethasone were followed by melphalan with stem cell rescue. Four months later, he experienced a relapse with reoccurrence of the psoas lesion and new extramedullary (paranasal sinuses and paravertebral) lesions, for which lenalidomide, dexamethasone and radiotherapy of the psoas lesion was initiated. At the time of presentation in the emergency department, just after initiation of lenalidomide and dexamethasone, no abnormalities of ocular motility could be found although the patient still experienced double vision. A mild paresis of the right peroneus muscle, hypoesthesia of the first to third right toes, and absent achilles tendon reflexes were noted. Differential diagnosis was broad (Table 1). Electrocardiography, laboratory investigations and gadolinium-enhanced brain MRI (Fig. 1a1) were normal. Table 1 Differential diagnosis of neurological complications of multiple myeloma and suggested ancillary investigations for each of these diagnoses [2, 8, 9, 13] Fig. 1 Studies from presented patient. a T1-weighted gadolinium-enhanced MRI of a1 brain and a2 lumbosacral spine. Pathologically enhancing multiple myeloma lesions are visible in the sphenoid sinus (asterisk, a1) and lumbar vertebrae (arrows, a2). No pathological ... One week later, the double vision and light-headedness had disappeared, but the patient had developed a mild paresis of the right biceps and triceps muscles with normal tendon reflexes. Because of the multifocal neurological deficits, the revised differential diagnosis (Table 1) included cervical epidural MM localization and meningeal myelomatosis. However, CT of the neck and cervical spine MRI were normal. Right arm electromyography revealed signs consistent with a C5 or C6 radiculopathy. Another week later, the patient developed a slight dysarthria and severe weakness of the left anterior tibial muscle. Lumbar epidural compression, meningeal myelomatosis or infection were considered, but gadolinium-enhanced lumbar spine MRI was normal (Fig. 1a2). However, CSF examination showed 133×106 leucocytes/L and an elevated total protein level of 0.63 g/L; flow cytometry demonstrated 92% monoclonal plasma cells (Fig. 1b, c). We concluded that the patient’s multifocal neurological abnormalities were due to meningeal myelomatosis. He was treated with biweekly intrathecal methotrexate and prednisone. After two courses, no more plasma cells could be detected in the CSF, CSF leukocyte count (1×106/L) and total protein level (0.34 g/L) normalised and his neurological symptoms had improved. Three months later the patient died from progressive systemic disease. Autopsy confirmed the diagnosis of meningeal myelomatosis. In this MM patient, the uncommon occurrence of meningeal myelomatosis was associated with negative craniospinal MRI. This patient’s history stresses that, in cases with a high clinical suspicion of meningeal myelomatosis, a normal MRI should be followed by CSF examination. Symptoms and signs of meningeal myelomatosis are usually multifocal, including non-specific prodromes, cranial nerve neuropathy and radiculopathy (all present in our case) and may vary greatly according to involved structures. Contrast-enhanced MRI is often used to diagnose neoplastic meningitis, but sensitivity is much lower for hematologic malignancies (20–37% for leukaemia and lymphoma) than for solid tumours (85%) [10]. In contrast, MRI was false-negative in only 8% of a group of myelomatous meningitis patients [8, 9]. There is no standardized treatment for meningeal myelomatosis. Treatment options include craniospinal radiation or intrathecal chemotherapy, often accompanied by systemic chemotherapy [2, 8, 11, 13], but survival is generally short [6, 8, 13]. In conclusion, meningeal myelomatosis, although rare, should be considered in MM patients with progressive multifocal neurological deficits, even when MRI is normal. CSF investigation is mandatory in an early stage to prevent delay in diagnosis and treatment.