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A New Scoring System for Predicting Extent of Resection in Medial Wang et al. Chinese Neurosurgical Journal (2020) 6:35 https://doi.org/10.1186/s41016-020-00214-0 中华医学会神经外科学分会 CHINESE MEDICAL ASSOCIATION CHINESE NEUROSURGICAL SOCIETY RESEARCH Open Access A new scoring system for predicting extent of resection in medial sphenoid wing meningiomas based on three-dimensional multimodality fusion imaging Zilan Wang1†, Xiaolong Liang2†, Yanbo Yang1, Bixi Gao1, Ling Wang3, Wanchun You1, Zhouqing Chen1* and Zhong Wang1* Abstract Background: Three-dimensional (3D) fusion imaging has been proved to be a promising neurosurgical tool for presurgical evaluation of tumor removal. We aim to develop a scoring system based on this new tool to predict the resection grade of medial sphenoid wing meningiomas (mSWM) intuitively. Methods: We included 46 patients treated for mSWM from 2014 to 2019 to evaluate their tumors’ location, volume, cavernous sinus involvement, vascular encasement, and bone invasion by 3D multimodality fusion imaging. A scoring system based on the significant parameters detected by statistical analysis was created and evaluated. Results: The tumor volumes ranged from 0.8 cm3 to 171.9 cm3. A total of 39 (84.8%) patients had arterial involvement. Cavernous sinus (CS) involvement was observed in 23 patients (50.0%) and bone invasion was noted in 10 patients (21.7%). Simpson I resection was achieved in 10 patients (21.7%) and Simpson II resection was achieved in 17 patients (37.0%). Fifteen patients (32.6%) underwent Simpson III resection and 4 patients (8.7%) underwent Simpson IV resections. A scoring system was created. The score ranged from 1 to 10 and the mean score of our patients was 5.3 ± 2.8. Strong positive monotonic correlation existed between the score and resection grade (Rs =0.772,P < 0.001). The scoring system had good predictive capacity with an accuracy of 69.60%. Conclusions: We described a scoring system that enabled neurosurgeons to predict extent of resection and outcomes for mSWM preoperatively with 3D multimodality fusion imaging. Trial registration: Retrospectively registered Keywords: Brain tumor, Sphenoid wing meningioma, Scoring system, Fusion imaging, 3D reconstruction * Correspondence: [email protected]; [email protected] †Zilan Wang and Xiaolong Liang contributed equally to this work. 1Department of Neurosurgery, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou 215006, Jiangsu Province, China Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wang et al. Chinese Neurosurgical Journal (2020) 6:35 Page 2 of 10 PACS picture archiving and communication system Company, Leuven, Belgium). Firstly, we created a SD Standard deviation mask of the imaging data to extract the targeted SWM Sphenoid wing meningiomas structure by determining the region of interest and 3D Three-dimensional adjusting the thresholding. Skull was delineated from CT. Blood vessels were delineated from MRA/CTA. Background Tumor was delineated from the T1-weighted of MRI Sphenoid wing meningiomas (SWM) make up approxi- with contrast. Then, edits were done on the masks mately 10–15% of total cranial meningiomas [14]. Med- and the unclear margins were outlined manually. Fi- ial sphenoid wing meningiomas (mSWM) present a nally, all the targeted structures were integrated into surgical challenge because they can grow into the cav- the same space and manually adjusted to the exact ernous sinus (CS), encircle the anterior circulation arter- place to generate the 3D multimodality fusion im- ies, affect the cranial nerves, and even invade the bone aging data. Tumors were set as transparent to assess [16, 25]. The intricate location of medial sphenoid wing the arteries inside. Tumor location, volume, CS in- meningiomas (mSWM) increases the risk of surgery, volvement, vascular encasement, and bone invasion leading to higher morbidity and even mortality. It is cru- were evaluated. All the images were evaluated by a cial to study preoperative imaging to predict which ex- neuroradiologist and a young neurosurgeon, without tent of resection can be achieved and decide whether to knowledge of any patients’ clinical data. manage total resection for lower recurrence rate or par- The volume of the tumor was calculated after we tial resection for preservation of encased neurovascular established the 3D model of the tumor by Mimics structures. We have not yet had a widely accepted classi- software. Volume < 20 cm3 was categorized into grade fication system of mSWM to predict the extent of resec- 1, volume between 20 and 50 cm3 was categorized tion in clinical practice. Recently, application of three- into grade 2, and volume >50cm3 was categorized dimensional (3D) multimodality fusion imaging has into grade 3. Grade of arterial encasement was deter- greatly contributed to the understanding of anatomical mined as follows: involvement of any artery was given structures and has been proved to be a promising neuro- one point, and an additional point was given for each surgical tool for brain tumors [7, 17, 21]. So, our object- of the following features as shown in Fig. 1:com- ive is to develop a scoring system based on the pletely encircling (360°) the artery, involving more preoperative 3D multimodality fusion imaging to predict than one artery, and narrowing the lumen of the ar- the grade of tumor resection. tery. The grade ranged from 0 to 4. CS involvement was defined as infiltration of the tumor into the cav- Methods ernous sinus as shown in Fig. 2. Bone invasion was Patients and study design observed by the 3D reconstruction of the skull. The inclusion criteria for the study were the presence of medial sphenoid wing meningiomas based on radiologic, Microsurgical technique intraoperative, and pathologic findings from 2014 to Three neurosurgeons performed these surgeries and 2019. Meningiomas originating in the tuberculum sellae, each neurosurgeon performed 27 (58.7%), 11 (23.9%), orbital roof, cavernous sinus, or middle or lateral aspects and 8 (17.4%) cases, respectively. For microsurgical of the sphenoid wing were excluded. Each patient in- tumor removal, pterional approach was performed on 45 cluded needed a preoperative computed tomography patients (98%) and lateral supraorbital approach was per- (CT), magnetic resonance imaging (MRI) with and with- formed on 1 patient (2%). A high-speed pneumatic drill out contrast, and magnetic resonance angiography was used to remove any thickened bony prominence of (MRA)/computed tomography angiography (CTA). The the lesser and greater sphenoid wings. After opening the study was approved by the local ethics committee as a dura, the operating microscope was used, and the tumor retrospective study (Institutional Review Board No. was approached through the sylvian fissure. The basal 2019117). As this article is a retrospective study, ethics dural attachment of the tumor on the sphenoid ridge committees have been granted exemption of patient in- was coagulated to decrease the tumor’s blood supply formed consent. and detach it from the dura. The capsule of the tumor was then opened, and the tumor was resected piecemeal. Image processing After resection of the tumor, the dura attachment was The Digital Imaging and Communications in Medi- coagulated. cine (DICOM) data format of images was imported from our institution’s Picture Archiving and Commu- Extent of tumor resection nication System (PACS) (Neusoft Corp., Shenyang, The extent of tumor resection was categorized according China) into Mimics Medical 15.0 (Materialise to the Simpson grade of resection [23]: grade I, total Wang et al. Chinese Neurosurgical Journal (2020) 6:35 Page 3 of 10 Fig. 1 Three-dimensional multimodality medical fusion imaging demonstrating the arterial involvement and cavernous sinus involvement. a The tumor partially encircling the M1 segment of the middle cerebral artery (MCA) without narrowing the lumen, with a score of 1. b The tumor completely (360°) encircling the internal carotid artery (ICA) without narrowing the lumen, with a score of 2. c The tumor completely encircling and narrowing the M1 segment of the MCA, with a score of 3. d The tumor completely encircling and narrowing the ICA and M1 segment of the MCA, with a score of 4 tumor resection with excision of its dural attachment, 2 is a good outcome with improvement of symptoms. and any abnormal bone; grade II, total tumor resection Patients with grade 3 show an excellent outcome with and coagulation of dural attachments; grade III,
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