Wat te doen bij rugpijn? Voor deze ‘kwaal van de eeuw’ wordt een brede waaier aan oplossingen aangeboden. Om door het bos de bomen te helpen zien, publiceerde het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) in mei reeds een klinische richtlijn, gebaseerd op het meest recente wetenschappelijke bewijs. Vandaag gaat het op de ingeslagen weg verder met een ‘zorgpad’, dat voor elk type rugpatiënt bepaalt welke onderzoeken best worden uitgevoerd en welke de optimale behandeling is. Het is de eerste keer in ons land dat een zorgpad werd ontwikkeld in samenwerking met alle betrokken zorgdisciplines en de patiënten. Het omvat zowel lumbale (eenvoudige rugpijn) als radiculaire (type ischias) pijn. En voor een groter gebruiksgemak ontwikkelde het KCE een interactieve, online tool (www.lagerugpijn.kce.be).

1 INTRODUCTION.12 -- 1.1 BACKGROUND: A FREQUENT PROBLEM WITH HIGH SOCIETAL IMPACT 12 -- 1.2 STUDY OBJECTIVES AND RESEARCH QUESTIONS.13 -- 1.3 DEFINITION OF CONCEPTS 13 -- 1.3.1 Definition of low back and radicular pain .13 -- 1.3.2 Definition of clinical pathway 14 -- 1.4 STUDY PROCESS.14 -- 2 A SYSTEMATIC REVIEW OF LITERATURE .15 -- 2.1 RESEARCH OBJECTIVE 15 -- 2.2 METHODS 15 -- 2.3 RESULTS 16 -- 2.4 LIMITATIONS 22 -- 3 INTERNATIONAL COMPARISON OF PATHWAYS 22 -- 3.1 RESEARCH OBJECTIVE 22 -- 3.2 METHODS 22 -- 3.2.1 Identification of eligible pathways and countries 22 -- 3.2.2 Identification of variables relevant to the quality, efficacy, feasibility and applicability of low back pain care pathways .23 -- 3.2.3 Data collection 23 -- 3.2.4 Processing and analysis of the data 24 -- 3.3 RESULTS 24 -- 3.3.1 Number of identified pathways 24 -- 3.3.2 Characteristics of retrieved pathways26 -- 3.3.3 Pathway components related to quality and efficiency.38 -- 3.3.4 Key interventions and building elements for LBP pathways 38 -- 3.3.5 Organizational challenges in the development of LBP pathways 39 -- 3.4 LIMITATIONS 40 -- 4 THE BELGIAN CONTEXT.41 -- 4.1 RESEARCH OBJECTIVE 41 -- 4.2 METHODS 41 -- 4.3 RESULTS41 -- 4.3.1 Structural initiatives for managing pain.41 -- 4.3.2 A variety in initiatives for the patients.45 -- 4.3.3 Initiatives regarding work ability and work conditions. 45 -- 4.4 LIMITATIONS46 -- 5 DESCRIPTION OF SOME BELGIAN INITIATIVES OF PATHWAYS 46 -- 5.1 RESEARCH OBJECTIVE 46 -- 5.2 METHODS 46 -- 5.3 RESULTS 47 -- 5.3.1 Characteristics of the Belgian pathway initiatives 47 -- 5.3.2 Key interventions and building elements .56 -- 5.4 LIMITATIONS59 -- 6 HEALTHCARE PROVIDERS PERCEPTION - NOMINAL GROUPS.60 -- 6.1 RESEARCH OBJECTIVE 60 -- 6.2 METHODS 60 -- 6.3 RESULTS60 -- 6.3.1 First contact and Triage 63 -- 6.3.2 Diagnostic 64 -- 6.3.3 Treatment.64 -- 6.3.4 Return to work 66 -- 6.4 LIMITATIONS66 -- 7 PATIENTS PERCEPTION – FOCUS GROUPS.67 -- 7.1 RESEARCH OBJECTIVE 67 -- 7.2 METHODS 67 -- 7.3 RESULTS 68 -- 7.3.1 Decision to consult 69 -- 7.3.2 First contact: “I felt not taken seriously” 70 -- 7.3.3 Triage: a long process of trial and error 70 -- 7.3.4 (Lack of) Diagnosis and “learn to accept your condition”.72 -- 7.3.5 Treatment.73 -- 7.3.6 Impact on patients’ life 77 -- 7.3.7 Professional life and Return to work 78 -- 7.4 LIMITATION 80 -- 8 TRANSVERSAL ANALYSIS 80 -- 8.1 FINDING 1: CURRENT TRAJECTORIES ARE HETEROGENEOUS.80 -- 8.1.1 The first contact with the healthcare system is not so early 81 -- 8.1.2 A large heterogeneity of professionals can be involved in the first contact 81 -- 8.1.3 The search for a solution is a trial and error process.81 -- 8.1.4 Professionals and patients have not the same perception of ‘the trajectories’ heterogeneity .82 -- 8.2 FINDING 2: DIAGNOSTIC AND CAUSE ARE UNCERTAIN 82 -- 8.2.1 Rarely there are underlying severe pathologies 82 -- 8.2.2 Radicular pain should be distinguished from low back pain 84 -- 8.2.3 Imaging does not improve diagnosis .85 -- 8.2.4 Follow-up is important to reassure the patient and the care provider 86 -- 8.3 FINDING 3: THE BIO-PSYCHO-SOCIAL PERSPECTIVE: A NEW APPROACH FOR SOME .86 -- 8.3.1 The obsolete biomechanical model still used 86 -- 8.3.2 A risk assessment of the bio-psycho-social factors is possible 89 -- 8.3.3 Stratifying care according to the risk assessment can be useful for LBP93 -- 8.3.4 Multidisciplinary rehabilitation since the subacute phase if needed 93 -- 8.4 FINDING 4: PATIENT-CENTERED CARE IS NOT SO EASY 95 -- 8.4.1 Not all patients’ needs and expectations can be satisfied 95 -- 8.4.2 Patients’ empowerment is a challenge .97 -- 8.5 FINDING 5: WORK AND SOCIAL ACTIVITIES ARE PART OF THE MANAGEMENT .99 -- 8.5.1 The risk for long term absence can be assessed 99 -- 8.5.2 Healthcare providers have a role for maintaining the patient in the work environment.100 -- 8.5.3 The continuation of social activities, outside the work, should also be promoted 102 -- 8.6 FINDING 6: A STEPWISE PROCESS PROVIDES A ROLE TO EACH TYPE OF HEALTHCARE PROVIDER 103 -- 8.6.1 The primary care should be reinforced 103 -- 8.6.2 The referral to the secondary care could be improved 107 -- 8.6.3 Coordination of care is not optimal 108 -- 8.7 FINDING 7: GATHERING DATA AND MONITORING SHOULD BE FORESEEN BEFORE THE PATHWAY IMPLEMENTATION 110 -- 8.7.1 The COMI questionnaire 111 -- 8.7.2 The ICHOM set of measures 112 -- 9 BELGIAN PATHWAYS.115 -- 10 CONCLUSION 118 -- 10.1 ORGANISATIONAL ASPECTS TO BE TAKEN INTO ACCOUNT.118 -- 10.1.1 Importance of healthcare professionals training 118 -- 10.1.2 Improvement of communication between professionals 118 -- 10.1.3 Change within population and patients 119 -- 10.1.4 Incentives for healthcare providers 120 -- 10.1.5 Respect of local initiatives.120 -- 10.1.6 Monitoring/evaluation 120 -- 10.1.7 Research questions .121 -- 10.1.8 Prevention of low back pain is important although out of the scope of this project .121 -- 10.1.9 Electronic tools to support the pathway .121 -- 10.2 DIFFUSION OF THE BELGIAN PATHWAYS 122 -- 10.2.1 Target users .122 -- 10.2.2 Ways for disseminating 122 -- REFERENCES 123

1. COMPOSITION OF EXPERTS GROUPS 8 -- 1.1. LIST OF PARTICIPANTS TO THE WORKING GROUPS 8 -- 1.2. COMPOSITION OF THE STAKEHOLDERS GROUP 10 -- 1.3. COMPOSITION OF THE SUBCONTRACTOR’S EXPERT TEAM (KULEUVEN) 11 -- 1.4. COMPOSITION OF THE KCE EXPERT TEAM 11 -- 2. LITERATURE REVIEW 12 -- 2.1. DATABASES AND DATE LIMITS 12 -- 2.2. SEARCH STRATEGIES 12 -- 3. EXTRACTS OF THE LIME SURVEY 27 -- 4. DESCRIPTION OF THE PATHWAYS (INTERNATIONAL COMPARISON) 29 -- 4.1. GRONINGEN, THE NETHERLANDS 29 -- 4.1.1. Demographic information 29 -- 4.1.2. Identification and organizational items 29 -- 4.1.3. Patient Selection: 29 -- 4.1.4. Team composition and team members role 30 -- 4.1.5. Evidence and implementation process 31 -- 4.1.6. Triage and diagnosis 31 -- 4.1.7. Therapeutic actions 31 -- 4.1.8. Additional patient items 33 -- 4.1.9. Additional caregiver items 33 -- 4.1.10. Pathway monitoring 33 -- 4.2. NIJMEGEN, THE NETHERLANDS 34 -- 4.2.1. Demographic information 34 -- 4.2.2. Identification and organizational items 34 -- 4.2.3. Patient Selection: 34 -- 4.2.4. Team composition and team members role 35 -- 4.2.5. Evidence and implementation process 36 -- 4.2.6. Triage and diagnosis 36 -- 4.2.7. Therapeutic actions 36 -- 4.2.8. Additional patient items 38 -- 4.2.9. Additional caregiver items 38 -- 4.2.10. Pathway monitoring 38 -- 4.3. MAASTRICHT, THE NETHERLANDS 39 -- 4.3.1. Demographic information 39 -- 4.3.2. Identification and organizational items 39 -- 4.3.3. Patient Selection: 39 -- 4.3.4. Team composition and team members role 39 -- 4.3.5. Evidence and implementation process 40 -- 4.3.6. Triage and diagnosis 40 -- 4.3.7. Therapeutic actions 40 -- 4.3.8. Additional patient items 42 -- 4.3.9. Additional caregiver items 42 -- 4.3.10. Pathway monitoring 42 -- 4.4. SASKATCHEWAN, CANADA 43 -- 4.4.1. Demographic information 43 -- 4.4.2. Patient Selection: 43 -- 4.4.3. Team composition and team members role 43 -- 4.4.4. Evidence and implementation process 44 -- 4.4.5. Triage and diagnosis 44 -- 4.4.6. Therapeutic actions 45 -- 4.4.7. Additional patient items 45 -- 4.4.8. Additional caregiver items 45 -- 4.4.9. Pathway monitoring 45 -- 4.5. TORONTO, CANADA 46 -- 4.5.1. Demographic information 46 -- 4.5.2. Identification and organizational items 46 -- 4.5.3. Patient Selection: 46 -- 4.5.4. Team composition and team members role 47 -- 4.5.5. Evidence and implementation process 48 -- 4.5.6. Triage and diagnosis 48 -- 4.5.7. Therapeutic actions 48 -- 4.5.8. Additional patient items 49 -- 4.5.9. Additional caregiver items 49 -- 4.5.10. Pathway monitoring 49 -- 4.6. NORTH-EAST ENGLAND, UK 50 -- 4.6.1. Demographic information 50 -- 4.6.2. Patient Selection: 50 -- 4.6.3. Team composition and team members role 50 -- 4.6.4. Evidence and implementation process 51 -- 4.6.5. Triage and diagnosis 51 -- 4.6.6. Therapeutic actions 52 -- 4.6.7. Additional patient items 52 -- 4.6.8. Additional caregiver items 52 -- 4.6.9. Pathway monitoring 52 -- 4.7. LONDON (IMPLEMENTATION OF THE BRITISH PAIN SOCIETY PATHWAY), UK 53 -- 4.7.1. Demographic information 53 -- 4.7.2. Patient Selection: 53 -- 4.7.3. Team composition and team members role 53 -- 4.7.4. Evidence and implementation process 54 -- 4.7.5. Triage and diagnosis 54 -- 4.7.6. Therapeutic actions 55 -- 4.7.7. Additional patient items 56 -- 4.7.8. Additional caregiver items 56 -- 4.7.9. Pathway monitoring 56 -- 4.8. IRELAND, WATERFORD 57 -- 4.8.1. Demographic information 57 -- 4.8.2. Identification and organizational items 57 -- 4.8.3. Patient Selection: 57 -- 4.8.4. Team composition and team members role 57 -- 4.8.5. Evidence and implementation process 58 -- 4.8.6. Triage and diagnosis 58 -- 4.8.7. Therapeutic actions 58 -- 4.8.8. Additional patient items 59 -- 4.8.9. Additional caregiver items 59 -- 4.8.10. Pathway monitoring 59 -- 4.9. LAUSANNE, SWITZERLAND 60 -- 4.9.1. Demographic information 60 -- 4.9.2. Identification and organizational items 60 -- 4.9.3. Patient Selection: 60 -- 4.9.4. Team composition and team members role 60 -- 4.9.5. Evidence and implementation process 61 -- 4.9.6. Triage and diagnosis 61 -- 4.9.7. Therapeutic actions 62 -- 4.9.8. Additional patient items 63 -- 4.9.9. Additional caregiver items 63 -- 4.9.10. Pathway monitoring 64 -- 4.10. NÜRNBERG, GERMANY 64 -- 4.10.1. Demographic information 64 -- 4.10.2. Identification and organizational items 64 -- 4.10.3. Patient Selection: 64 -- 4.10.4. Team composition and team members role 64 -- 4.10.5. Evidence and implementation process 65 -- 4.10.6. Triage and diagnosis 65 -- 4.10.7. Therapeutic actions 66 -- 4.10.8. Additional patient items 67 -- 4.10.9. Additional caregiver items 67 -- 4.10.10. Pathway monitoring 67 -- 4.11. PLYMOUTH, UNITED STATES 68 -- 4.11.1. Demographic information 68 -- 4.11.2. Identification and organizational items 68 -- 4.11.3. Patient Selection: 68 -- 4.11.4. Team composition and team members role 68 -- 4.11.5. Evidence and implementation process 70 -- 4.11.6. Triage and diagnosis 70 -- 4.11.7. Therapeutic actions 70 -- 4.11.8. Additional patient items 70 -- 4.11.9. Additional caregiver items 70 -- 4.11.10. Pathway monitoring 71 -- 5. PATHWAYS FLOWCHARTS (INTERNATIONAL COMPARISON) 72 -- 6. BELGIAN INITIATIVES IN FLOWCHARTS 81 -- 7. FOCUS GROUPS MATERIAL 87 -- 7.1. FLYERS FOR PATIENTS 87 -- 7.2. INTERVIEW GUIDE 89

BACKGROUND:Motor cortex stimulation (MCS) was introduced in the early 1990s by Tsubokawa and his group for patients diagnosed with drug-resistant, central neuropathic pain. Inconsistencies concerning the details of this therapy and its outcomes and poor methodology of most clinical essays divide the neuromodulation society worldwide into "believers" and "nonbelievers." A European expert meeting was organized in Brussels, Belgium by the Benelux Neuromodulation Society in order to develop uniform MCS protocols in the preoperative, intraoperative, and postoperative courses. METHODS:An expert meeting was organized, and a questionnaire was sent out to all the invited participants before this expert meeting. An extensive literature research was conducted in order to enrich the results. RESULTS:Topics that were addressed during the expert meeting were 1) inclusion and exclusion criteria, 2) targeting and methods of stimulation, 3) effects of MCS, and 4) results from the questionnaire. CONCLUSIONS:Substantial commonalities but also important methodologic divergencies emerged from the discussion of MCS experts from 7 European Centers. From this meeting and questionnaire, all participants concluded that there is a need for more homogenous standardized protocols for MCS regarding patient selection, implantation procedure, stimulation parameters, and follow-up-course.

BACKGROUND:There is evidence in the literature supporting that fluorescent tissue signal in fluorescence-guided surgery extends farther than tissue highlighted in gadolinium in T1 sequence magnetic resonance imaging (MRI), which is the standard to quantify the extent of resection.OBJECTIVE:To study whether the presence of residual fluorescent tissue after surgery carries a different prognosis for glioblastoma (GBM) cases with complete resection confirmed by MRI.METHODS:A retrospective review in our center found 118 consecutive patients with high-grade gliomas operated on with the use of fluorescence-guided surgery with 5-aminolevulinic acid. Within that series, the 52 patients with newly diagnosed GBM and complete resection of enhancing tumor (CRET) in early MRI were selected for analysis. We studied the influence of residual fluorescence in the surgical field on overall survival and neurological complication rate. Multivariate analysis included potential relevant factors: age, Karnofsky Performance Scale, O-methylguanine methyltransferase methylation promoter status, tumor eloquent location, preoperative tumor volume, and adjuvant therapy.RESULTS:The median overall survival was 27.0 months (confidence interval = 22.4-31.6) in patients with nonresidual fluorescence (n = 25) and 17.5 months (confidence interval = 12.5-22.5) for the group with residual fluorescence (n = 27) (P = .015). The influence of residual fluorescence was maintained in the multivariate analysis with all covariables, hazard ratio = 2.5 (P = .041). The neurological complication rate was 18.5% in patients with nonresidual fluorescence and 8% for the group with residual fluorescence (P = .267).CONCLUSION:GBM patients with CRET in early MRI and no fluorescent residual tissue had longer overall survival than patients with CRET and residual fluorescent tissue.

For most cancers, PET is essentially a diagnostic tool. For brain tumors, PET has got its main contribution at the level of the therapeutic management. Indeed, specific reasons render the therapeutic management of brain tumors, especially gliomas, a real challenge. Although some gliomas may appear well-delineated on conventional neuroimaging such as CT and MRI, they are by nature infiltrating neoplasms and the interface between tumor and normal brain tissue may not be accurately defined. Moreover, gliomas may present as ill-defined lesions for which various MRI sequences combination does not provide a unique contour for tumor delineation. Also, gliomas are often histologically heterogeneous with anaplastic areas evolving within a low-grade tumor, and contrast-enhancement on CT or MRI does not represent a good marker for anaplastic tissue detection. Finally, assessment of tumor residue, recurrence, or progression, may be altered by different signals related to inflammation or adjuvant therapies, and contrast enhancement on CT and MRI is not an appropriate marker at the postoperative or posttherapeutic stage. These limitations of conventional neuroimaging in detecting tumor tissue, delineating tumor extent and evidencing anaplastic changes, lead to potential inaccuracy in lesion targeting at different steps of the management (diagnostic, surgical, postoperative, and posttherapeutic stages). Molecular information provided by PET has proved helpful to supplement morphological imaging data in this context. F-18 FDG and amino-acid tracers such as C-11 methionine (C-11 MET) provide complementary metabolic data that are independent from the anatomical MR information. These tracers help in the definition of glioma extension, detection of anaplastic areas, and postoperative follow-up. Additionally, PET data have a prognostic value independently of histology. To take advantage of PET data in glioma treatment, PET might be integrated in the planning of image-guided biopsy, resection, and radiosurgery.

We present a novel method, corticokinetic coher ence, for functional motor mapping by computing coherence between cortical magnetoencephalographic (MEG) signals and the kinetics of voluntary movements. Six subjects performed during an MEG recording self-paced flexion–extensions of the right-hand fingers at about 3 Hz, with a 3-axis accelerometer attached to the index finger. Cumulant density and coherence spectra were computed between the MEG and accelerometer signals.

Anterolateral meningiomas of the foramen magnum (FMMs) represent a neurosurgical challenge because they grow in close contact with osteoarticular, nervous, and vascular structures that cannot be sacrificed or retracted.To evaluate our strategy and results in 26 patients with FMMs and analyze factors affecting the decision-making process, resection, and outcome.Among 26 consecutive symptomatic FMM (10 anterior, 16 lateral) patients (16 women, 10 men, ages 28-82 years), 4 older than 70 years of age were untreated. Twenty-two were operated on using a posterolateral approach, with the vertebral artery transposed in 19 and the occipital condyle drilled in 10. We analyzed the characteristics and outcome of untreated cases, the utility of THE occipital condyle drilled, the difficulties of microdissection, morbidity and total removal rates, the outcome of tumor residues, and the literature on radiosurgery.Three of 4 untreated patients remained clinically stable at 2 to 5 years. After systematic vertebral artery medial transposition and occipital condyle drilled in 6 cases, our technique evolved with experience in the next 16 (vertebral artery transposed in 13 of 16; occipital condyle drilled in 4 of 13) for dissecting anteriorly beyond midline (anterior FMMs). Retrocondylar access was sufficient for lateral FMMs. Tumors were totally removed in 16 of 22 (73%). One patient died, and 4 had permanent deficits. Follow-up of more than 5 years in 12 patients showed no C0-1 instability, and slight increase of tumor residue size 7 years after surgery. In the literature, 15 FMMs treated with radiosurgery are reported, 13 at diagnosis and 2 at recurrence, with short-term clinical and radiological safety and efficacy.We currently recommend (1) aiming for subtotal removal in difficult cases, (2) remaining conservative in asymptomatic or elderly patients with mild symptoms, and (3) considering radiosurgery at diagnosis for small (<30 mm) symptomatic FMMs or as an adjunct for evolving residues/recurrences in poor candidates for resection.

BACKGROUND: Anterolateral meningiomas of the foramen magnum (FMMs) represent a neurosurgical challenge because they grow in close contact with osteoarticular, nervous, and vascular structures that cannot be sacrificed or retracted. OBJECTIVE: To evaluate our strategy and results in 26 patients with FMMs and analyze factors affecting the decision-making process, resection, and outcome. METHODS: Among 26 consecutive symptomatic FMM (10 anterior, 16 lateral) patients (16 women, 10 men, ages 28-82 years), 4 older than 70 years of age were untreated. Twenty-two were operated on using a posterolateral approach, with the vertebral artery transposed in 19 and the occipital condyle drilled in 10. We analyzed the characteristics and outcome of untreated cases, the utility of THE occipital condyle drilled, the difficulties of microdissection, morbidity and total removal rates, the outcome of tumor residues, and the literature on radiosurgery. RESULTS: Three of 4 untreated patients remained clinically stable at 2 to 5 years. After systematic vertebral artery medial transposition and occipital condyle drilled in 6 cases, our technique evolved with experience in the next 16 (vertebral artery transposed in 13 of 16; occipital condyle drilled in 4 of 13) for dissecting anteriorly beyond midline (anterior FMMs). Retrocondylar access was sufficient for lateral FMMs. Tumors were totally removed in 16 of 22 (73%). One patient died, and 4 had permanent deficits. Follow-up of more than 5 years in 12 patients showed no C0-1 instability, and slight increase of tumor residue size 7 years after surgery. In the literature, 15 FMMs treated with radiosurgery are reported, 13 at diagnosis and 2 at recurrence, with short-term clinical and radiological safety and efficacy. CONCLUSION: We currently recommend (1) aiming for subtotal removal in difficult cases, (2) remaining conservative in asymptomatic or elderly patients with mild symptoms, and (3) considering radiosurgery at diagnosis for small (<30 mm) symptomatic FMMs or as an adjunct for evolving residues/recurrences in poor candidates for resection.

OBJECT In this paper, the authors' goal was to evaluate the impact of PET data on the clinical management of incidental brain lesions in children. METHODS Between 1995 and 2007, 442 children with a newly diagnosed brain lesion were referred to the authors' department. Of these, 55 presented with an incidental brain lesion and were selected for study because MR imaging sequences revealed limitations in assessing the tumor, its evolving nature, and/or the malignant potential of the lesion diagnosed. Thirteen children were studied using FDG-PET and 42 with L-(methyl-(11)C)-methionine (MET)-PET; 3 children underwent both FDG-PET and MET-PET but only the MET-PET results were used in the analysis. The PET and MR images were combined in image fusion navigation planning. Drawing on their experience with PET in adults, the authors proposed the following treatment plans: 1) surgery in children with imaging evidence of increased PET tracer uptake, which is highly specific of tumor and/or malignant tumor tissue; or 2) conservative treatment in children in whom there was little or no tracer uptake on PET. The authors compared the PET data with the MR imaging-based diagnosis and either 1) the results of histological examination in surgically treated cases, or 2) the long-term outcome in untreated cases. They studied PET and MR imaging sensitivity and specificity in detecting tumor and malignant tissues, and evaluated whether PET data altered their clinical management. RESULTS Seventeen children had increased PET tracer uptake and underwent surgery. Tumor diagnosis was confirmed in all cases (that is, there were no false-positive findings). Cases in which there was little or no PET tracer uptake supported conservative treatment in 38 children. However, because PET was under evaluation, 16 of 38 lesions that were judged accessible for resection were surgically treated. Histological examination results demonstrated neither malignant nor evolving tumor tissue but yielded 9 indolent tumors (6 dysembryoplastic neuroectodermal tumors, 2 low-grade astrocytomas, and 1 low-grade astrocytoma and dysplasia) and 7 nontumoral lesions (3 cases of vasculitis, 3 of gliosis, and 1 of sarcoidosis). In 22 of the untreated 38 children, stable disease was noted during follow-up (range 18-136 months). Although an absence of PET tracer uptake might not exclude tumor tissue, PET did not reveal any false-negative findings in malignant or evolving tumor tissue detection in cases in which MR imaging showed false-positive and -negative cases in > 35 and 25% of the cases, respectively. CONCLUSIONS These data confirmed the high sensitivity and specificity of PET to detect tumor as well as malignant tissue. Regarding the treatment of the incidental brain lesions, the PET findings enabled the authors to make more appropriate decisions regarding treatment than those made on MR imaging findings alone. Therefore, the risk of surgically treating a nontumoral lesion was reduced as well as that for conservatively managing a malignant tumor. Nowadays, it is estimated that these data justify conservative management in incidental lesions with low or absent PET tracer uptake.

OBJECT:In this paper, the authors' goal was to evaluate the impact of PET information on brain tumor surgery in children.METHODS:Between 1995 and 2007, 442 children were referred to the authors' institution for a newly diagnosed brain lesion. Of these, 85 were studied with FDG-PET and/or L-(methyl-(11)C)-methionine -PET in cases in which MR images were unable to assist in selecting accurate biopsy targets (35 patients) or to delineate tumors for maximal resection (50 patients). In surgical cases, PET and MR images were combined in image fusion planning for stereotactic biopsies or navigation-based resections. The preoperative planning images were compared postoperatively with MR imaging and PET findings and histological data for evaluating the clinical impact on the diagnostic yield and tumor resection.RESULTS:The PET data influenced surgical decisions or procedures in all cases. The use of PET helped to better differentiate indolent from active components in complex lesions (in 12 patients); improved target selection and diagnostic yield of stereotactic biopsies without increasing the sampling; provided additional prognostic information; reduced the amount of tissue needed for biopsy sampling in brainstem lesions (in 20 cases); better delineated lesions that were poorly delineated on MR imaging and that infiltrated functional cortex (in 50 cases); significantly increased the amount of tumor tissue removed in cases in which total resection influenced survival (in 20 cases); guided resection in hypermetabolic areas (in 15 cases); improved early postoperative detection of residual tumor (in 20 cases); avoided unnecessary reoperation (in 5 cases); and supported the decision to undertake early second-look resection (in 8 cases).CONCLUSIONS:The authors found that PET has a significant impact on the surgical decisions and procedures for managing pediatric brain tumors. Further studies may demonstrate whether PET improves outcomes in children.

To compare the contribution of the tracers [C-11]methionine (met) and [f-18]-fluorodeoxyglucose (fdg) in positron emission tomography (pet)-guided stereotactic brain biopsy. Forty-five patients underwent combined Met-Pet-, fdg-pet- associated with computerized tomography (ct)- or magnetic resonance (mr)-guided stereotactic biopsy. The patients presented a lesion that was in close relationship with the cortical or subcortical grey matter. Met-pet and fdg-pet images were analyzed to determine which tracer offers the best information to guide at least one stereotactic biopsy trajectory. Histological diagnosis was obtained in all patients (39 tumors / 6 non tumor lesions). All tumors were biopsied under pet-guidance. Fdg was used for target definition when tumor uptake was higher than in the grey matter (18 tumors). Met was used for target definition when fdg uptake was absent or equivalent to that of the grey matter (21 tumors). Parallel review of all histological and imaging data showed that all tumors had an area of abnormal Met uptake and 33 of them had an abnormal fdg uptake. All 6 non tumor lesions had no Met uptake and were biopsied under ct- or mr-guidance only. All tumor trajectories had an area of abnormal met uptake; all non-diagnostic trajectories in tumors had no abnormal met uptake. When fdg shows limitations for target selection, met is a good alternative, because of its high specificity in tumors. Moreover, in the perspective of a single-tracer procedure and regardless of fdg uptake, met is a better choice for the pet-guidance of neurosurgical procedures.

BACKGROUND: The endovascular treatment of intracranial aneurysms can be hampered by the tortuosity of extracranial vessels. Percutaneous or surgical vessel puncture can resolve the problem of inaccessibility.OBJECTIVE: We describe rerouting of a kinked vertebral artery (VA) to restore transfemoral endovascular access to an aneurysm.CASE REPORT: A 63-year-old woman presented with progressive hemiparesis. Magnetic resonance imaging demonstrated a left fusiform vertebrobasilar aneurysm with mass effect on the brainstem. The patient was found to have a dominant left VA on angiography with a severe kink in its V1 segment. Tight loops of this segment prevented catheter progression past V1 during endovascular treatment.INTERVENTION: The left VA was rerouted from its subclavian origin to the C5 transverse foramen through a combined lateral and supraclavicular approach. Release of the VA off the C6 transverse process and C6 and C7 cranial nerve roots permitted unfolding of the VA. The excess length of the VA, initially present between the subclavian artery and the C6 transverse process, was spread over a longer distance. The tight angles present preoperatively were converted into a harmonious curvature. The rerouted VA was attached to surrounding soft tissue to maintain its position. The patient's postoperative course was uneventful. Endovascular treatment of the aneurysm was performed 15 days later.CONCLUSION: The VA rerouting technique can be used successfully in patients in whom tight loops in the VA prevent endovascular access to intracranial vessels.

Meningiomas account for approximately 13–19% of all intracranial tumors. Meningiomas of the skull base locations constitute 40% of all intracranial meningiomas. Of these, about one half occur in the sphenoid wing.1–3 Sphenoid wing meningiomas then account for more or less 20% of intra-cranial meningiomas and represent a real surgical challenge due to their invasion of the bone and their proximity to main arteries and cranial nerves. Anatomically, the sphenoid wing extends from the anterior clinoid process to the pterion with the greater wing constituting the outer third and the lesser wing the inner two thirds. The greater wing and the lateral half of the lesser wing represent the lateral and middle portions of the sphenoid wing.2–7

Integrating positron emission tomographic (PET) images into the image-guided resection of high-grade gliomas (HGG) has shown that metabolic information on tumor heterogeneity and distribution are useful for planning surgery, improve tumor delineation, and provide a final target contour different from that obtained with magnetic resonance imaging (MRI) alone in about 80% of the procedures. Moreover, PET guidance helps to increase the amount of tumor removed and to target image-guided resection to anaplastic tissue areas. The present study aims to evaluate whether PET-guided volumetric resection (VR) in supratentorial HGG might add benefit to the patient's outcome.PET images using [18F]fluorodeoxyglucose (n=23) and [11C]methionine (n=43) were combined with MRI scans in the planning of VR procedures performed at the initial stage in 66 consecutive patients (43 M/23 F) with supratentorial HGG according to the technique previously described. In all cases (35 anaplastic gliomas [20 astrocytomas, 10 oligoastrocytomas, 5 oligodendrogliomas] and 31 glioblastomas [GBM]), level and distribution of PET tracer uptake were analyzed to define a PET contour projected on MRI scans to define a final target contour for VR. Maximal tumor resection was accomplished in each case, with the intention to remove the entire abnormal metabolic area comprised in the surgical planning. Early postoperative MRI and PET assessed tumor resection. Survival analysis was performed separately in anaplastic gliomas and glioblastoma multiforme according to the presence or absence of residual tracer uptake on postoperative PET and according to the presence or absence of residual contrast enhancement on postoperative MRI.Preoperatively, metabolic information helped the surgical planning. In all procedures, PET contributed to define a final target contour different from that obtained with MRI alone. Postoperatively, 46 of 66 patients had no residual PET tracer uptake (total PET resection), 23 of 66 had no residual MRI contrast enhancement. No additional neurological morbidity due to the technique was reported. A total PET tracer uptake resection was associated with a significantly longer survival in anaplastic gliomas (P = 0.0071) and in glioblastoma multiforme (P = 0.0001), respectively. A total MRI contrast enhancement resection was not correlated with a significantly better survival, neither in anaplastic gliomas (P = 0.6089) nor in glioblastoma multiforme (P = 0.6806).Complete resection of the increased PET tracer uptake prolongs the survival of HGG patients. Because PET information represents a more specific marker than MRI enhancement for detecting anaplastic tumor tissue, PET-guidance increases the amount of anaplastic tissue removed in HGG.