Publications by authors named "Arianna Rustici"

18 Publications

  • Page 1 of 1

Comparison of prostate cancer detection rate at targeted biopsy of hub and spoke centers mpMRI: experience matters.

Minerva Urol Nephrol 2022 Jun 29. Epub 2022 Jun 29.

Division of Urology, IRCCS University Hospital of Bologna, Bologna, Italy.

Background: Latest changes in European guidelines on prostate cancer determined a widespread of multiparametric magnetic resonance imaging (mpMRI) even in less experienced centers due to an increased demand. This could decrease diagnostic accuracy of targeted biopsy (TB) since image interpretation can be challenging and requires adequate and supervised training. Therefore we aimed to evaluate the PCa detection rate on TB according to mpMRI center's volume and experience.

Methods: We retrospectively analyzed data of 737 patients who underwent mpMRI-TB at our institution. Patients were stratified according to mpMRI center: Hub (high volume>100 exams/year with dedicated radiologists and supervised training) and Spoke center (low volume<100 exams/year without dedicated radiologists and/or supervised training). Detection rate of PCa at TB and possible predictors of clinically significant PCa (csPCa) at TB. Differences in detection rate were explored using Chi-square test. Predictors of csPCa were evaluated through uni and multivariable logistic regression. The adjustment for casemix included: age, PSA, mpMRI center,lesion's location, PSA density, PI-RADS score and index lesion's size.

Results: 449 (60.9%) and 288 (39.1%) patients underwent mpMRI at a Hub or Spoke center, respectively. Hub group had higher detection rate for both any (60.3% vs 48.1%) and csPCa (46.9% vs 38.7%; all p≤0.001). After stratifying for PI-RADS score, Hub group had higher detection rate for PI-RADS score 3 (csPCA 25.2% vs. 15.7%; p 0.04) and 4 (csPCa 65.7% vs. 45.7%; p 0.001). At multivariable analyses, receiving an mpMRI scan at a Spoke center was an independent predictor for csPCa on TB (OR 0.65; p 0.04).

Conclusions: mpMRI performed in Hub centers provided a significantly higher PCa yield on TB. A dedicated team of experienced radiologist, a supervised training for mpMRI and a central revision of mpMRI performed in non-experienced centres are essential to avoid unnecessary and potentially harmful procedures.
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http://dx.doi.org/10.23736/S2724-6051.22.04932-1DOI Listing
June 2022

Improving visualization of three-dimensional aneurysm features via segmentation with upsampled resolution and gradient enhancement (SURGE).

J Neurointerv Surg 2022 Jun 21. Epub 2022 Jun 21.

Department of Mechanical & Industrial Engineering, University of Toronto, Toronto, Ontario, Canada

Background: Intracranial aneurysm neck width tends to be overestimated when measured with three-dimensional rotational angiography (3DRA) compared with two-dimensional digital subtraction angiography (2D-DSA), owing to high curvature at the neck. This may affect morphological and hemodynamic analysis in support of treatment planning. We present and validate a method for extracting high curvature features, such as aneurysm ostia, during segmentation of 3DRA images.

Methods: In our novel SURGE (segmentation with upsampled resolution and gradient enhancement) approach, the gradient of an upsampled image is sharpened before gradient-based watershed segmentation. Neck measurements were performed for both standard and SURGE segmentations of 3DRA for 60 consecutive patients and compared with those from 2D-DSA. Those segmentations were also qualitatively compared for surface topology and morphology.

Results: Compared with the standard watershed method, SURGE reduced neck measurement error relative to 2D-DSA by >60%: median error was 0.49 mm versus 0.17 mm for SURGE, which is less than the average pixel resolution (~0.33 mm) of the 3DRA dataset. SURGE reduced neck width overestimations >1 mm from 13/60 to 5/60 cases. Relative to 2D-DSA, standard segmentations were overestimated by 16% and 93% at median and 95th percentiles, respectively, compared with only 6% and 37%, respectively, for SURGE.

Conclusion: SURGE provides operators with high-level control of the image gradient, allowing recovery of high-curvature features such as aneurysm ostia from 3DRA where conventional algorithms may fail. Compared with standard segmentation and tedious manual editing, SURGE provides a faster, easier, and more objective method for assessing aneurysm ostia and morphology.
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http://dx.doi.org/10.1136/neurintsurg-2022-018912DOI Listing
June 2022

Infra-Temporal and Pterygo-Palatine Fossae Tumors: A Frontier in Endoscopic Endonasal Surgery-Description of the Surgical Anatomy of the Approach and Report of Illustrative Cases.

Int J Environ Res Public Health 2022 05 25;19(11). Epub 2022 May 25.

Programma Neurochirurgia Ipofisi-Pituitary Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy.

Infratemporal and pterygopalatine fossae (ITF and PPF) represent two complex paramedian skull base areas, which can be defined as jewelry boxes, containing a large number of neurovascular and osteomuscular structures of primary importance. They are in close communication with many craniofacial areas, such as nasal/paranasal sinuses, orbit, middle cranial fossa, and oral cavities. Therefore, they can be involved by tumoral, infective or inflammatory lesions spreading from these spaces. Moreover, they can be the primary site of the development of some primitive tumors. For the deep-seated location of ITF and PPF lesions and their close relationship with the surrounding functional neuro-vascular structures, their surgery represents a challenge. In the last decades, the introduction of the endoscope in skull base surgery has favored the development of an innovative anterior endonasal approach for ITF and PPF tumors: the transmaxillary-pterygoid, which gives a direct and straightforward route for these areas. It has demonstrated that it is effective and safe for the treatment of a large number of benign and malignant neoplasms, located in these fossae, avoiding extensive bone drilling, soft tissue demolition, possibly unaesthetic scars, and reducing the risk of neurological deficits. However, some limits, especially for vascular tumors or lesions with lateral extension, are still present. Based on the experience of our multidisciplinary team, we present our operative technique, surgical indications, and pre- and post-operative management protocol for patients with ITF and PPF tumors.
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http://dx.doi.org/10.3390/ijerph19116413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9180479PMC
May 2022

Vessel Wall MRI: clinical implementation in cerebrovascular disorders-technical aspects.

Radiol Med 2022 Jun 2;127(6):645-651. Epub 2022 Apr 2.

Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.

Vessel Wall MRI (VW-MRI) is an emerging MR sequence used for diagnosis, characterization, and treatment planning of cerebrovascular diseases. Although VW-MRI is not yet routinely used, most papers have emphasized its role in several aspects of the management of cerebrovascular diseases. Nowadays, no VW-MRI sequence optimized for the intracranial imaging is commercially available, thus the Spin Echo sequences are the more effective sequences for this purpose. Moreover, as one of the principal technical requirements for intracranial VW-MR imaging is to achieve both the suppression of blood in vessel lumen and of the outer cerebrospinal fluid, different suppression techniques have been developed. This short report provides the technical parameters of our VW-MR sequence developed over 3-years' experience.
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http://dx.doi.org/10.1007/s11547-022-01484-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9130152PMC
June 2022

Bilateral antererior circulation stroke: A rare but threatening consequence of pituitary apoplexy. Case report and systematic literature review.

Neuroradiol J 2022 Mar 27:19714009221083146. Epub 2022 Mar 27.

Programma Neurochirurgia Ipofisi- Pituitary Unit, 419170IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy.

Background: Brain stroke is a rare, life-threatening condition associated with pituitary apoplexy (PA), resulting from direct arterial occlusion due to mechanical compression secondary to the sudden enlargement of the pituitary adenoma, or to vessel vasospasm, induced by tumor hemorrhage.

Case Report: We report the case of a 64-year-old woman with PA complicated by bilateral anterior circulation stroke due to critical stenosis of both anterior cerebral arteries (ACA). Despite the quick surgical decompression and consequent blood flow restoration, the neurological conditions of the patient did not improve and she died 18 days later. Ten other cases of anterior circulation stroke due to PA were retrieved in a systematic review of literature. Clinical and neuroradiological features of these patients and treatment outcome were assessed to suggest the most proper management.

Conclusion: The onset of neurological symptoms suggestive for brain stroke in patients with PA requires performing an emergency Magnetic Resonance Imaging (MRI), including Diffusion-weighted and angiographic MR-sequences. The role of surgery in these cases is debated, however, transsphenoidal adenomectomy would permit us to decompress the ACA and restore blood flow in their territories. Although the prognosis of PA-induced anterior circulation stroke is generally poor, a timely diagnosis and treatment would be paramount for improving patient outcome.
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http://dx.doi.org/10.1177/19714009221083146DOI Listing
March 2022

Vessel-wall MRI in primary headaches: The role of neurogenic inflammation.

Headache 2022 Feb 8. Epub 2022 Feb 8.

Programma di Neuroimmagini Funzionali e Molecolari, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.

Objective: The purpose of this study was to investigate if vessel-wall magnetic resonance imaging (VW-MRI) could differentiate among primary headaches disorders, such as migraine and cluster headache (CH), and detect the presence of neurogenic inflammation.

Background: The pathophysiology of primary headaches disorders is complex and not completely clarified. The activation of nociceptive trigeminal afferents through the release of vasoactive neuropeptides, termed "neurogenic inflammation," has been hypothesized. VW-MRI can identify vessel wall changes, reflecting the inflammatory remodeling of the vessel walls despite different etiologies.

Methods: In this case series, we enrolled seven patients with migraine and eight patients with CH. They underwent a VW-MRI study before and after the intravenous administration of contrast medium, during and outside a migraine attack or cluster period. Two expert neuroradiologists analyzed the magnetic resonance imaging (MRI) studies to identify the presence of vessel wall enhancement or other vascular abnormalities.

Results: Fourteen out of 15 patients had no enhancement. One out of 15, with migraine, showed a focal parietal enhancement in the intracranial portion of a vertebral artery, unmodified during and outside the attack, thus attributable to atherosclerosis. No contrast enhancement attributable to neurogenic inflammation was observed in VW-MRI, both during and outside the attack/cluster in all patients. Moreover, MRI angiography registered slight diffuse vasoconstriction in one of seven patients with migraine during the attack and in one of eight patients with cluster headache during the cluster period; both patients had taken triptans as symptomatic therapy for pain.

Conclusions: These preliminary results suggest that VW-MRI studies are negative in patients with primary headache disorders even during migraine attacks or cluster periods. The VW-MRI studies did not detect signs of neurogenic inflammation in the intracranial intradural vessels of patients with migraine or CH.
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http://dx.doi.org/10.1111/head.14253DOI Listing
February 2022

PI-RADS version 2.1 for the evaluation of transition zone lesions: a practical guide for radiologists.

Br J Radiol 2022 Mar 11;95(1131):20210916. Epub 2022 Feb 11.

Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

Multiparametric MRI has been established as the most accurate non-invasive diagnostic imaging tool for detecting prostate cancer (PCa) in both the peripheral zone and the transition zone (TZ) using the PI-RADS (Prostate Imaging Reporting and Data System) v. 2.1 released in 2019 as a guideline to reporting. TZ PCa remains the most difficult to diagnose due to a markedly heterogeneous background and a wide variety of atypical imaging presentations as well as other anatomical and pathological processes mimicking PCa. The aim of this paper was to present a spectrum of PCa in the TZ, as a guide for radiologists.
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http://dx.doi.org/10.1259/bjr.20210916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8978244PMC
March 2022

Evaluating the performance of clinical and radiological data in predicting prostate cancer in prostate imaging reporting and data system version 2.1 category 3 lesions of the peripheral and the transition zones.

Int Urol Nephrol 2022 Feb 25;54(2):263-271. Epub 2021 Nov 25.

Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy.

Purpose: To define the value of clinical and radiological data, using multiparametric magnetic resonance imaging (mpMRI), to predict prostate cancer (PCa) in prostate imaging reporting and data system version 2.1 (PIRADSv2.1) 3 lesions of the peripheral and the transition zones (PZ and TZ).

Methods: The mpMRI of patients with PIRADSv2.1 3 lesions who had undergone fusion targeted biopsy was reviewed. Morphological pattern, diffusion parameters and vascularisation were evaluated. The radiological/histopathological data of benign and malignant lesions, between the PZ and TZ were compared. Univariate and multivariate analyses were carried out to identify the clinical and radiological data capable of predicting PCa.

Results: One hundred and twenty-three lesions were assessed, 93 (76%) in the PZ and 30 (24%) in the TZ. Of these, 56 (46%) were PCa and 67 (54%) were benign. The majority of the PCas were Grade Group System (GGS) 1 (38%) and GGS 2 (39%); tumours having a GGS ≥ 3 were more frequently in the TZ (p = 0.02). Univariate analysis showed a significant correlation between PCa and prostate volume, prostate-specific antigen (PSA) density, lesion zone and the apparent diffusion coefficient. At multivariate logistic regression PSA density > 0.15 ng/ml/ml {Odds ratio [OR] 2.38; p = 0.001} and lesion zone (i.e. TZ OR 7.55) were independent predictors of PCa (all p ≤ 0.04).

Conclusion: In solitary PIRADSv2.1 3 lesions, the most important predictive factor was the location zone, with a much greater risk for TZ lesions.
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http://dx.doi.org/10.1007/s11255-021-03071-7DOI Listing
February 2022

Is There a Role for Surgical Resection of Multifocal Glioblastoma? A Retrospective Analysis of 100 Patients.

Neurosurgery 2021 11;89(6):1042-1051

Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Italy.

Background: Glioblastoma with multiple localizations (mGBMs) can be defined as multifocal, where enhancing lesions present a connection visible on magnetic resonance imaging fluid-attenuated inversion recovery imaging, or multicentric, in the absence of a clear dissemination pathway.

Objective: To evaluate the role of the extent of resection (EOR) in the treatment of mGBMs and its correlation with overall survival (OS) and progression free survival (PFS).

Methods: One hundred patients with mGBMs were treated at our Institution between 2009 and 2019. Clinical, radiological, and follow-up data were collected. EOR of the contrast-enhancing part of lesions was classified as gross total resection (GTR, absence of tumor remnant), subtotal resection (STR, residual tumor < 30% of the initial mass), partial resection (PR, residual tumor > 30% of the initial mass), and needle or open biopsy (residual tumor > 75% of the initial mass).

Results: Approximately 15% of patients underwent GTR, 14% STR, 32% PR, and 39% biopsy. Median OS was 17 mo for GTR, 11 mo for STR, 7 mo for PR, and 5 mo for biopsy. Greater EOR was associated with a significantly longer OS than biopsy. GTR and STR were associated with a longer PFS in Kaplan-Meier survival analyses. After adjusting for age, Karnofsky performance status (KPS), number of lesions, and adjunctive therapy in multivariable Cox regression analyses, GTR, STR, and PR were still associated with OS, but only GTR remained associated with PFS.

Conclusion: Our study suggests that EOR may positively influence survival of patients with mGBM. Surgical resection can be a reasonable option when performance and access to adjuvant treatment can be preserved.
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http://dx.doi.org/10.1093/neuros/nyab345DOI Listing
November 2021

Machine learning-based clinical outcome prediction in surgery for acromegaly.

Endocrine 2022 Feb 12;75(2):508-515. Epub 2021 Oct 12.

Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Purpose: Biochemical remission (BR), gross total resection (GTR), and intraoperative cerebrospinal fluid (CSF) leaks are important metrics in transsphenoidal surgery for acromegaly, and prediction of their likelihood using machine learning would be clinically advantageous. We aim to develop and externally validate clinical prediction models for outcomes after transsphenoidal surgery for acromegaly.

Methods: Using data from two registries, we develop and externally validate machine learning models for GTR, BR, and CSF leaks after endoscopic transsphenoidal surgery in acromegalic patients. For the model development a registry from Bologna, Italy was used. External validation was then performed using data from Zurich, Switzerland. Gender, age, prior surgery, as well as Hardy and Knosp classification were used as input features. Discrimination and calibration metrics were assessed.

Results: The derivation cohort consisted of 307 patients (43.3% male; mean [SD] age, 47.2 [12.7] years). GTR was achieved in 226 (73.6%) and BR in 245 (79.8%) patients. In the external validation cohort with 46 patients, 31 (75.6%) achieved GTR and 31 (77.5%) achieved BR. Area under the curve (AUC) at external validation was 0.75 (95% confidence interval: 0.59-0.88) for GTR, 0.63 (0.40-0.82) for BR, as well as 0.77 (0.62-0.91) for intraoperative CSF leaks. While prior surgery was the most important variable for prediction of GTR, age, and Hardy grading contributed most to the predictions of BR and CSF leaks, respectively.

Conclusions: Gross total resection, biochemical remission, and CSF leaks remain hard to predict, but machine learning offers potential in helping to tailor surgical therapy. We demonstrate the feasibility of developing and externally validating clinical prediction models for these outcomes after surgery for acromegaly and lay the groundwork for development of a multicenter model with more robust generalization.
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http://dx.doi.org/10.1007/s12020-021-02890-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8816764PMC
February 2022

Interpreting nephrometry scores with three-dimensional virtual modelling for better planning of robotic partial nephrectomy and predicting complications.

Urol Oncol 2021 12 14;39(12):836.e1-836.e9. Epub 2021 Sep 14.

Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Laboratory of Bioengineering, University of Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.

Objective: 3D models are increasingly used as additional preoperative tools for renal surgery. We aim to evaluate the impact of 3D renal models in the assessment of PADUA, RENAL, Contact Surface Area (CSA) and Arterial Based Complexity (ABC) for the prediction of complications after Robot assisted Partial Nephrectomy (RAPN).

Methods And Materials: Overall, 57 patients with T1 and 1 patient with T2 renal mass referred to RAPN, were prospectively enrolled. 3D virtual modelling was obtained from 2D computed tomography (CT). Two radiologists recorded PADUA, RENAL, CSA and ABC by evaluation of 2D images; two bioengineers recorded PADUA, RENAL CSA and ABC by evaluation of the 3D model, using MeshMixer software. To evaluate the concordance between 2D and 3D nephrometry scores, Cohen's j coefficient was calculated. Receiver-operating characteristic (ROC) curves were generated to evaluate the accuracy of 3D and 2D nephrometry scores to predict overall complications. Finally, the impact of 3D model on clamping approach during RAPN was compared to 2D imaging.

Results: PADUA, RENAL CSA and ABC scores had a significant different distribution compared to PADUA, RENAL, CSA and ABC (all p≤0.03). 2D nephrometry scores may be unchanged, reduced or increased after assessment by 3D models: CSA, PADUA, RENAL and ABC were reduced in14%, 26%, 29% and 16% and increased in 16%, 36%, 38% and 29% of cases, respectively. At ROC curve analysis, PADUA, RENAL and ABC showed were significantly better accuracy to predict complications compared to PADUA, RENAL and ABC. PADUA (OR: 1.66), RENAL (OR: 1.69) and ABC (OR: 2.44) revealed a significant correlation with postoperative complications (all P ≤0.03).

Conclusion: Nephrometry scores calculated via 3D models predict complications after RAPN with higher accuracy than conventional 2D imaging.
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http://dx.doi.org/10.1016/j.urolonc.2021.07.024DOI Listing
December 2021

Novel Volumetric and Morphological Parameters Derived from Three-dimensional Virtual Modeling to Improve Comprehension of Tumor's Anatomy in Patients with Renal Cancer.

Eur Urol Focus 2021 Aug 21. Epub 2021 Aug 21.

Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Università degli studi di Bologna, Bologna, Italy.

Background: Three-dimensional (3D) models improve the comprehension of renal anatomy.

Objective: To evaluate the impact of novel 3D-derived parameters, to predict surgical outcomes after robot-assisted partial nephrectomy (RAPN).

Design, Setting, And Participants: Sixty-nine patients with cT1-T2 renal mass scheduled for RAPN were included. Three-dimensional virtual modeling was achieved from computed tomography. The following volumetric and morphological 3D parameters were calculated: V (volume of the tumor); V/V (ratio between tumor volume and kidney volume); CSA (ie, contact surface area); UCS (contact to the urinary collecting system); Tumor-Artery: tumor's blood supply by tertiary segmental arteries (score = 1), secondary segmental artery (score = 2), or primary segmental/main renal artery (scoren = 3); S (tumor's sphericity); Conv (tumor's convexity); and Endophyticity (ratio between the CSA and the global tumor surface).

Intervention: RAPN with a 3D model.

Outcome Measurements And Statistical Analysis: Three-dimensional parameters were compared between patients with and without complications. Univariate logistic regression was used to predict overall complications and type of clamping; linear regression was used to predict operative time, warm ischemia time, and estimated blood loss.

Results And Limitations: Overall, 11 (15%) individuals experienced overall complications (7.2% had Clavien ≥3 complications). Patients with urinary collecting system (UCS) involvement at 3D model (UCS = 2), tumor with blood supply by primary or secondary segmentary arteries (Tumor-Artery = 1 and 2), and high Endophyticity values had significantly higher rates of overall complications (all p ≤ 0.03). At univariate analysis, UCS, Tumor-Artery, and Endophyticity are significantly associated with overall complications; CSA and Endophyticity were associated with warm ischemia time; and CSA was associated with selective clamping (all p ≤ 0.03). Sample size and the lack of interobserver variability are the main limits.

Conclusions: Three-dimensional modeling provides novel volumetric and morphological parameters to predict surgical outcomes after RAPN.

Patient Summary: Novel morphological and volumetric parameters can be derived from a three-dimensional model to describe surgical complexity of renal mass and to predict surgical outcomes after robot-assisted partial nephrectomy.
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http://dx.doi.org/10.1016/j.euf.2021.08.002DOI Listing
August 2021

Texture Analysis on Ultrasound: The Effect of Time Gain Compensation on Histogram Metrics and Gray-Level Matrices.

J Med Phys 2020 Oct-Dec;45(4):249-255. Epub 2021 Feb 2.

Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.

Aims: Texture analysis (TA) is becoming an increasingly used tool in radiological research. Some papers have been published on its use in ultrasound (US), but the way in which the machine settings affect the features has not yet been fully explored. With this research, we analyze how the time gain compensation (TGC) influences the features of the gray-level matrices in the abdominal US setting.

Subjects And Methods: We analyzed the images acquired from the hepatorenal acoustic window of a healthy 29-year-old volunteer acquired with different TGC settings. TA was carried out using the LifeX software.

Results: Several both 1 and 2 order gray-level matrices features showed a strong correlation with TGC settings.

Conclusions: TGC settings must be accounted for when carrying out further TA studies.
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http://dx.doi.org/10.4103/jmp.JMP_82_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074715PMC
February 2021

Vessel-wall MRI in thunderclap headache: A useful tool to answer the riddle?

Interv Neuroradiol 2021 Apr 10;27(2):219-224. Epub 2020 Dec 10.

Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy.

Background: Finding an intracranial aneurysm (IA) during a thunderclap headache (TCH) attack, represents a problem because it is necessary to distinguish whether the aneurysm is responsible for the headache as a warning leak or as an incidental finding. High-Resolution Vessel-Wall (HRVW) MRI sequences have been proposed to assess the stability of the wall, as it permits to detect the presence of aneurysmal wall enhancement (AWE). In fact, AWE has been confirmed due to inflammation, recognizable preceding rupture.Case 1: A 37-year-old woman with a migraine more intense than her usual. A CTA revealed a 10 mm AComA aneurysm without subarachnoid hemorrhage (SAH) and HRVW-MRI excluded AWE. The patient's headache improved, and therefore, the aneurysm was considered an incidental finding, and the headache diagnosed as TCH attack. Subsequently, the aneurysm was surgically clipped, and typical migraine relapsed was reported at follow-up (FU).Case 2: A 67-year-old woman with no history of headaches underwent CTA for an abrupt onset of headache. A 7 mm right carotid-ophthalmic aneurysm with no sign of SAH was discovered. HRVW-MRI demonstrated AWE and thus, a TCH attack for a warning leak of an unstable wall was suspected. Endovascular coiling was immediately performed and at FU any further headache attack was reported.

Conclusions: HRVW-MRI is useful in case of finding aneurysm as the cause of headaches, particularly the TCH attack. In fact, HRVW-MRI could assess the stability of the aneurysms wall, allowing different patient management and eventually the aneurysmal treatment.
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http://dx.doi.org/10.1177/1591019920979496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050527PMC
April 2021

Management of sellar and parasellar tumors becoming symptomatic during pregnancy: a practical algorithm based on multi-center experience and systematic literature review.

Pituitary 2021 Apr 17;24(2):269-283. Epub 2020 Nov 17.

Pituitary Unit, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy.

Introduction: Sellar/parasellar tumors (SPTs) very rarely become symptomatic during pregnancy. No specific guidelines exist for their management, that is extremely challenging as mother and fetus health can be jeopardized.

Materials And Methods: Data of patients with SPTs becoming symptomatic during pregnancy treated at two Italian referral Centers were retrospectively collected. Systematic literature review was also performed.

Results: Our series consisted of 6 cases, 3 meningiomas, 1 ACTH-secreting adenoma, 1 pituicytoma and 1 craniopharyngioma. Mean age at presentation was 33.6 ± 6.0 years. Five patients complained of visual disturbances, associated with headache in one case, that occurred between gestation week (GW) 22 and 34. In 5 cases, pregnancy was uneventful with the delivery of a healthy baby between GW 33 and 35, followed by endoscopic surgical tumor exeresis (n = 4) or proton bean therapy (n = 1). Another patient presented with stigmata typical of Cushing's syndrome and rapidly worsening pre-eclampsia, that required pregnancy interruption and adenomectomy. Based on personal and literature cases, a practical algorithm was proposed to help clinicians dealing with these patients.

Conclusions: SPTs becoming symptomatic in pregnancy deserve careful monitoring and multidisciplinary management. Overall, wait-and-see approach is suggested, reserving surgery to patients with rapidly progressive/life-threatening situations, significant risk of permanent neurological impairment or malignant lesions.
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http://dx.doi.org/10.1007/s11102-020-01107-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7966198PMC
April 2021

Machine learning-based prediction of outcomes of the endoscopic endonasal approach in Cushing disease: is the future coming?

Neurosurg Focus 2020 06;48(6):E5

1Pituitary Unit, Center for the Diagnosis and Treatment of Hypothalamic-Pituitary Diseases, IRCCS Institute of Neurological Sciences of Bologna.

Objective: Machine learning (ML) is an innovative method to analyze large and complex data sets. The aim of this study was to evaluate the use of ML to identify predictors of early postsurgical and long-term outcomes in patients treated for Cushing disease (CD).

Methods: All consecutive patients in our center who underwent surgery for CD through the endoscopic endonasal approach were retrospectively reviewed. Study endpoints were gross-tumor removal (GTR), postsurgical remission, and long-term control of disease. Several demographic, radiological, and histological factors were assessed as potential predictors. For ML-based modeling, data were randomly divided into 2 sets with an 80% to 20% ratio for bootstrapped training and testing, respectively. Several algorithms were tested and tuned for the area under the curve (AUC).

Results: The study included 151 patients. GTR was achieved in 137 patients (91%), and postsurgical hypersecretion remission was achieved in 133 patients (88%). At last follow-up, 116 patients (77%) were still in remission after surgery and in 21 patients (14%), CD was controlled with complementary treatment (overall, of 131 cases, 87% were under control at follow-up). At internal validation, the endpoints were predicted with AUCs of 0.81-1.00, accuracy of 81%-100%, and Brier scores of 0.035-0.151. Tumor size and invasiveness and histological confirmation of adrenocorticotropic hormone (ACTH)-secreting cells were the main predictors for the 3 endpoints of interest.

Conclusions: ML algorithms were used to train and internally validate robust models for all the endpoints, giving accurate outcome predictions in CD cases. This analytical method seems promising for potentially improving future patient care and counseling; however, careful clinical interpretation of the results remains necessary before any clinical adoption of ML. Moreover, further studies and increased sample sizes are definitely required before the widespread adoption of ML to the study of CD.
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http://dx.doi.org/10.3171/2020.3.FOCUS2060DOI Listing
June 2020

Endoscopic approaches to orbital lesions: case series and systematic literature review.

J Neurosurg 2020 Jan 3:1-13. Epub 2020 Jan 3.

1Center for the Diagnosis and Treatment of Hypothalamic-Pituitary Diseases, Pituitary Unit, and.

Objective: Surgical treatment of orbital lesions is challenging because complex approaches with a high risk of postoperative sequelae are required. Recently, minimally invasive endoscopic approaches through endonasal (EEA) and transpalpebral (ETP) routes have been proposed. The objective of this study was to assess outcomes of EEA and ETP in the authors' series of patients with orbital lesions.

Methods: Data from all patients who underwent operations for an orbital tumor through an endoscopic approach at the authors' institution from 2002 to 2018 were retrospectively collected. All patients underwent preoperative MRI and ophthalmological evaluation, which was repeated 3 months after surgery and then at regular follow-up intervals. A systematic review of the literature was also performed using Medline, Embase, and Web of Science databases.

Results: The series includes 23 patients (14 males); the mean patient age was 48 ± 23.9 years. Most of the lesions were intraconal (n = 19, 83%). The more frequent histotype was cavernous hemangioma (n = 5, 22%). Exophthalmos was the most common symptom (21 of 23 patients). EEA was performed in 16 cases (70%) and ETP in 7 (30%). The aim of the surgery was achieved in 94% of the cases after an EEA (successful biopsy in 5 of 6 cases and radical resection in all 10 remaining patients), and in 86% after an ETP (successful biopsy in 2 cases and radical tumor resection in 4 of 5 cases). Complications consisted of 3 cases (13%) of transitory diplopia. One recurrence (4%) was observed at follow-up (mean 59 ± 55 months).

Conclusions: The EEA and ETP have demonstrated to be safe and effective for tumors located respectively in medial and lateral quadrants, permitting one to approach orbital lesions endoscopically at 360°. Innovative surgical tools, including intraoperative ultrasonography, may be useful to potentially reduce surgical morbidity. Larger series are needed to validate these preliminary suggestions.
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http://dx.doi.org/10.3171/2019.10.JNS192138DOI Listing
January 2020

The influence of clinical and radiological parameters in treatment of ruptured intracranial aneurysms: a single center 7-year retrospective cohort study.

J Neurosurg Sci 2021 Apr 10;65(2):181-189. Epub 2018 Oct 10.

Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy -

Background: In many clinical trials endovascular procedures are suggested as the treatment of choice for aneurysmal Subarachnoid Hemorrhage (aSAH) whenever possible. However, in clinical practice this management is often controversial. The aim of this study was to analyze factors involved in this decision.

Methods: Our study included 317 consecutive cases of aSAH between 2010 and 2016, assessing clinical and neuroradiological features to evaluate their role in this choice.

Results: In our series coiling was preferred in 119 (37.6%) patients, while 198 (62.4%) were treated surgically. On univariate analysis location of aneurysms (P<0.001), GCS score on admission (P=0.105), degree of midline shift (P=0.015), Fisher' score (P=0.002) and presence of vessels in the aneurysmal neck (P=0.071) proved the most relevant factors in the choice. Also, multivariate analysis confirmed the location and Fisher' grade as influential factors. Conversely, other radiological parameters, such as morphology, aspect and dome-neck ratio, presence of pre-operative vasospasm or hydrocephalus were not associated with this decision.

Conclusions: The decision process in aSAH requires a multidisciplinary team, to singularly evaluate each patient. We found that the location of aneurysms in vertebro-basilar circulation, PcomA and ICA, greater GCS score, absence of vessels in the aneurysmal neck, lower midline shift and Fisher' score are factors influencing in choosing coiling. Conversely, morphology, Aspect and Dome-Neck ratio proved not relevant to this decision, due to technological improvement and increasing skills in the endovascular treatment.
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http://dx.doi.org/10.23736/S0390-5616.18.04430-2DOI Listing
April 2021
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