Tomáš Belšán

Subtypes of autism by cluster analysis based on structural MRI data

The aim of our study was to subcategorize Autistic Spectrum Disorders (ASD) using a multidisciplinary approach. Sixty four autistic patients (mean age 9.4±5.6 years) were entered into a cluster analysis. The clustering analysis was based on MRI data. The clusters obtained did not differ significantly in the overall severity of autistic symptomatology as measured by the total score on the Childhood Autism Rating Scale (CARS). The clusters could be characterized as showing significant differences: Cluster 1: showed the largest sizes of the genu and splenium of the corpus callosum (CC), the lowest pregnancy order and the lowest frequency of facial dysmorphic features. Cluster 2: showed the largest sizes of the amygdala and hippocampus (HPC), the least abnormal visual response on the CARS, the lowest frequency of epilepsy and the least frequent abnormal psychomotor development during the first year of life. Cluster 3: showed the largest sizes of the caput of the nucleus caudatus (NC), the smallest sizes of the HPC and facial dysmorphic features were always present. Cluster 4: showed the smallest sizes of the genu and splenium of the CC, as well as the amygdala, and caput of the NC, the most abnormal visual response on the CARS, the highest frequency of epilepsy, the highest pregnancy order, abnormal psychomotor development during the first year of life was always present and facial dysmorphic features were always present. This multidisciplinary approach seems to be a promising method for subtyping autism.

One Year Experience with 3.0 T Intraoperative MRI in Pituitary Surgery

A multifunctional surgical suite with intraoperative 3.0 T MRI (ioMRI) has been operating at the Central Military Hospital, Prague since April 2008. Our experiences over the past year and the effect of ioMRI on the extent of pituitary adenoma resection are evaluated. Eighty-six pituitary adenoma resections were performed in 85 patients with ioMRI in the first year of the ioMRI service. Pituitary adenoma suprasellar extension was present in 60 cases, invasion into cavernous sinus in 49 cases, and retrosellar growth in one case. The surgical goal was set before surgery: either a radical resection (49 cases) or a partial resection (37 cases). In the group of patients where a decision for a radical resection was taken the results are as follows: ioMRI confirmed radical resection in 69.4% of the cases; ioMRI disclosed unexpected adenoma residuum and further resection led to radical resection in 22.4%. In the group of patients where a decision for a partial resection was taken, the results are as follows: no further resection was perfomed after ioMRI in 51.3% of the cases and further resection was performed after ioMRI in 48.7% of the cases. ioMRI seems to be a valuable tool to increase the extent of pituitary adenoma resection.

Hysteroscopy after uterine fibroid embolization: Evaluation of intrauterine findings in 127 patients

Aim:  Several atypical hysteroscopy findings have been described in association with uterine artery embolization (UAE). The purpose of this study was to evaluate the types and frequency of these findings in the largest published series of patients.

The MRI volumetry of the posterior fossa and its substructures in trigeminal neuralgia: a validated study

PurposeOur aim was to determine whether the anatomical configuration of the posterior fossa and its substructures might represent a predisposition factor for the occurrence of clinical neurovascular conflict in trigeminal neuralgia (TN).MethodsWe used MRI volumetry in 18 patients with TN and 15 controls. The volume of the pontomesencephalic cistern, Meckel’s cave and the trigeminal nerve on the clinical and non-affected sides was compared. The reliability has been assessed in all measurements.ResultsThe posterior fossa volume was not different in the clinical and control groups; there was no difference between the affected and non-affected sides when measuring the pontomesencephalic cistern and Meckel’s cave volume either. The volume of the clinically affected trigeminal nerve was significantly reduced, but with a higher error of measurement.ConclusionsWe did not find any association between the clinical neurovascular conflict (NVC) and the size of the posterior fossa and its substructures. MRI volumetry may show the atrophy of the affected trigeminal nerve in clinical NVC.

Comparison of 3 fusion techniques in the treatment of the degenerative cervical spine disease. Is stand-alone autograft really the "gold standard?": prospective study with 2-year follow-up.

Study Design. A prospective study. Objective. The aim of this study was to compare the 3 different methods of interbody fusion of the cervical spine—autograft in stand-alone technique, autograft with anterior plate, and polyetheretherketone cage supported by anterior plate. The clinical and radiological data obtained were analyzed and discussed. Summary of Background Data. Although degenerative cervical spine disease has been treated by an anterior approach for more than 50 years, there is not one generally accepted operative approach. There is a very low-quality evidence of little or no difference in pain relief between each of the techniques. Iliac crest autograft still seems to be the “gold standard” for interbody fusion. Methods. Prospective study collecting clinical and radiological data of 81 patients undergoing anterior cervical interbody fusion, in which the interbody fusion of 1 or 2 motion segments from C3 to C7 was done by any of the 3 techniques–-stand-alone insertion of autograft (group 1: 28 patients), autograft and anterior plate (group 2: 18 patients), and polyetheretherketone cage filled with beta-tricalcium phosphate and plate (group 3: 29 patients). Patients were followed for 2 years after surgery. Results. Significant interaction of relative height in the segment and time was found (P < 0.001). The values of the relative height of stand-alone autograft dropped below 95% of initial height and the values of the other 2 groups remained above 105%. Significant interaction of time and group was found for Cobb S angles (P < 0.001). Values of group 1 decreased substantially and remained significantly lower than values of other 2 groups. Fusion rate was 100% in all groups. Neck Disability Index group and time interaction was found (P = 0.023). During postoperative follow-up, group 1 scored in all controls higher than the other 2 groups, but differences were not significant. Visual analogue scale showed effect of time (P < 0.001). This was due to a smaller improvement of patients in group 1 during the whole follow-up in comparison with the other 2 groups. Highest proportion of unsatisfied patients was in group 1 compared with the other 2 groups after 2 years (P = 0.034). Conclusion. Significantly worse radiological and clinical results after 2 years of follow-up were achieved using stand-alone autograft technique in comparison with autograft supported by anterior plating similarly as in comparison with cage implant and anterior plating. Using artificial fusion substrate together with plate and cage can offer the same clinical and radiological results such as iliac autograft and plating. Anterior plating seems to be an important factor influencing the postoperative cervical spine alignment and also the clinical outcome.

Intraoperative Magnetic Resonance Imaging During Endoscopic Transsphenoidal Surgery of Growth Hormone-Secreting Pituitary Adenomas

BACKGROUND The effect of intraoperative magnetic resonance imaging (iMRI) on the extent of sellar region tumors treated endonasally has been described in previous research. However, the effects of iMRI on endocrinologic outcome of growth hormone-secreting adenomas have been studied in only a few small cohort studies. METHODS Inclusion criteria were primary transsphenoidal surgery for growth hormone-secreting adenoma from January 2009 to December 2014, a minimum follow-up of 1 year, complete endocrinologic data, at least 1 iMRI, and at least 2 postoperative magnetic resonance images. The cohort consisted of 105 patients (54 females, 51 males) with a mean age of 48.3 years (range, 7-77 years). There were 16 microadenomas and 89 macroadenomas. RESULTS Endocrinologic remission in the whole cohort was achieved in 64 of the patients (60.9%). Resection after iMRI was attempted in 22 of the cases (20.9%). Resection after iMRI led to hormonal remission in 9 cases (8.6%). Endocrinologic postoperative deficit was observed in 10 cases (12.5%). Postoperative cerebrospinal fluid leakage indicated the necessity to reoperate in 3 cases (3.8%). No neurologic deterioration was observed. CONCLUSIONS iMRI influences not only the morphologic extent of pituitary adenomas resection but also the endocrinologic results. We encourage the routine application of iMRI in pituitary adenoma surgery, including hormone-secreting pituitary tumors.

Intraoperative MR imaging in a case of a cervical spinal cord lesion

The aim of this article is to describe the feasibility of performing intraoperative MR imaging in patients with spinal cord lesions and the potential value of this technique. The authors report a case involving a 28-year-old man who presented with chronic cervical pain and pain along the ulnar side of the forearms during neck flexion. Findings on clinical examination were normal, but MR imaging revealed a multicystic cervical spinal cord lesion. Surgery was undertaken to open the cysts, evacuate old blood, and search for pathological tissue. Intraoperative MR imaging showed that the caudal cyst was not opened, and surgery was therefore continued. The caudal cyst was fenestrated and a suspected small cavernous malformation was removed. Electrophysiological monitoring was performed both before and after the intraoperative MR imaging. The use of intraoperative MR imaging changed the strategy of the procedure and helped the surgeon to safely enter all the cysts in the cervical cord.

Multifunctional Surgical Suite (MFSS) with 3.0 T iMRI: 17 Months of Experience

The 3T ioMRI in Prague is composed of two independent suites: the operating theatre and the 3T MR suite, both of which can and do work independently. They are connected by a double door and a special transportation system. The whole operating table is moved on rails to and from the MR gantry. Anaesthesiological equipment is built from paramagnetic material, which is also moved to and from the MR suite. The integral parts of the multifunctional surgical suite (MFSS) are the neuronavigation system, electrophysiological monitoring, surgical microscope with availability of indocyanin green angiography and fluorescence-guided glioma resection technique and endoscopy equipment. The operating theatre is equipped in a normal fashion with the exception of a head holder that is paramagnetic. MR radiologist and MR assistants are alerted approximately 30 min before the requested intraoperative and out-patient service is interrupted to clean the MR suite. The ioMRI takes 15-20 min and immediately after the door closes the out patient activity is resumed. Intraoperative MR was performed in 332 surgeries in the first 17 months of operation. The most frequent indications were pituitary adenomas, followed by gliomas. Other indications were less frequent and included meningiomas, cavernomas, aneurysms, epilepsy surgery, intramedullary lesions, non-pituitary sellar lesions, metastases and various other surgeries. In 332 cases no technical or medical complication connected with ioMRI was encountered.

Magnetic resonance imaging and histology correlation in Cushing's disease

INTRODUCTION We continuously look for new techniques to improve the radicality of resection and to eliminate the negative effects of surgery. One of the methods that has been implemented in the perioperative management of Cushings disease was the combination of three magnetic resonance imaging (MRI) sequences: SE, SPGR and fSPGR. MATERIAL AND METHODS We enrolled 41 patients (11 males, 30 females) diagnosed with Cushings disease. A 3D tumour model with a navigation console was developed using each SPGR, fSPGR and SE sequence. The largest model was then used. In all cases, a standard four-handed, bi-nostril endoscopic endonasal technique was used. Endocrinological follow-up evaluation using morning cortisol sampling was performed for 6-34 months in our study. RESULTS In total, 36 patients (88%) were disease-free following surgery. Our results indicate we achieved 100% sensitivity of MR. Overall, the conformity of at least one donor site, as compared with the places designated on MR, was in 78% of patients. We searched the place of compliance in individual locations. There is a consensus in individual locations in 63 of the 123 cases (or 56%). The correlation gamma function at a 5% significance level was then 0.27. DISCUSSION The combination of MR sequences (SE, SPGR, fSPGR), neuronavigation system and iMRI led to increased sensitivity of up to 100%. Specificity reached 56% in our study. CONCLUSION We found a high success rate in surgical procedure in terms of the correlation between MR findings and histology, which leads to remission of Cushings disease.

O38: Subcortical mapping and intraoperative diffusion tensor tractography 3.0T of the corticospinal tract in supratentorial intrinsic tumor surgery. Reliability study

Question: What is the agreement in spindle scoring within, between and among experts? How does spindle scoring by humans compare to automated spindle scoring algorithms? Methods: We crowd-sourced the collection of spindle scorings from 24 experts in a large and varied dataset of EEG (C3-M2) from 110 middle-aged sleeping subjects. Epochs were scored by an average of 5.3 unique experts. Two experts scored parts of the dataset multiple times. We developed a simple method to build a large gold standard by establishing group consensus among expert scorers. We tested the performance of six previously published automated spindle detectors against the gold standard and refined methods of performance analysis for event detection. Results: We found an interrater agreement (F1-score) of 61±6% (Cohen’s Kappa (κ): 0.52±0.07) averaged over 24 expert pairs and an intrarater agreement of 72±7% (κ: 0.66±0.07) averaged over two experts. We tested the performance of individual experts to a gold standard compiled from all the expert scorers and found average agreement of 75±6% (κ: 0.68) over the 24 experts. We recompiled the gold standard and excluded the single expert whose performance was being assessed, and found an average agreement of 67±7% (κ: 0.59). Overall, we found the performance of human experts to be significantly better than the automated sleep spindle detectors we tested (maximum F1-score of detectors: 52%). Conclusions: Sleep spindle characteristics between subjects are very diverse which makes the scoring task difficult. The low interrater reliability suggests using more than one expert when scoring a dataset.