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Cureus Apr 2024Cavernous malformations (CM) are rare intracerebral vascular lesions occurring in the brain, or less commonly in the spine, with an annual bleeding risk of up to...
Cavernous malformations (CM) are rare intracerebral vascular lesions occurring in the brain, or less commonly in the spine, with an annual bleeding risk of up to 1.1%. These lesions can be occult or present to signs and symptoms based on location or, more frequently, are a result of hemorrhagic events. The most challenging aspect of managing these cases is weighing the risks and benefits of surgical treatment and intervening before the onset of a devastating hemorrhagic event. Here, we present the second case of CM haemorrhage following the cerebrospinal fluid (CSF) diversion procedure with a literature review of theories explaining this phenomenon. We present a 37-year-old female who has a known case of brainstem cavernoma and underwent left sub-temporal resection with stable residual since 2011, then was managed conservatively due to patient preference till she had a deterioration in December 2021 manifested as confusion, diplopia, dysarthria, and significant left sided weakness leaving her wheelchair bound. CT showed supratentorial hydrocephalus with extensive periventricular transependymal edema and no clear haemorrhage. A ventriculoperitoneal (VP) shunt was inserted, with no intraoperative complications. A few hours post-VP shunt insertion, she experienced a worsening in her mental status, hemiparesis, and dysarthria. Subsequent imaging found evidence of acute haemorrhage in the location of the previously noted residual. She was managed by supportive care. Causative factors of CM haemorrhage are poorly understood, and current data only suggest that prior haemorrhage and CM location could increase bleeding risk. Only one case of CM bleeding post-shunt insertion was reported; however, studies on other types of intracranial vascular lesions suggest that alterations in transmural pressure (including cerebrospinal fluid diversion procedures) can increase the risk of haemorrhage by changing the hemodynamic flow in these abnormally formed and weak vascular structures.
PubMed: 38774181
DOI: 10.7759/cureus.58689 -
Orphanet Journal of Rare Diseases May 2024Brain injury in hereditary hemoglobinopathies is commonly attributed to anemia-related relative hypoperfusion in terms of impaired oxygen blood supply. Supratentorial...
BACKGROUND
Brain injury in hereditary hemoglobinopathies is commonly attributed to anemia-related relative hypoperfusion in terms of impaired oxygen blood supply. Supratentorial and infratentorial vascular watershed regions seem to be especially vulnerable, but data are very scarce.
AIMS
We investigated a large beta-thalassemia sample with arterial spin labeling in order to characterize regional perfusion changes and their correlation with phenotype and anemia severity.
METHODS
We performed a multicenter single-scanner cross-sectional 3T-MRI study analyzing non-invasively the brain perfusion in 54 transfusion-dependent thalassemia (TDT), 23 non-transfusion-dependent thalassemia (NTDT) patients and 56 Healthy Controls (HC). Age, hemoglobin levels, and cognitive functioning were recorded.
RESULTS
Both TDT and NTDT patients showed globally increased brain perfusion values compared to healthy controls, while no difference was found between patient subgroups. Using age and sex as covariates and scaling the perfusion maps for the global cerebral blood flow, beta-thalassemia patients showed relative hyperperfusion in supratentorial/infratentorial watershed regions. Perfusion changes correlated with hemoglobin levels (p = 0.013) and were not observed in the less severely anemic patients (hemoglobin level > 9.5 g/dL). In the hyperperfused regions, white matter density was significantly decreased (p = 0.0003) in both patient subgroups vs. HC. In NTDT, white matter density changes correlated inversely with full-scale Intelligence Quotient (p = 0.007) while in TDT no correlation was found.
CONCLUSION
Relative hyperperfusion of watershed territories represents a hemodynamic hallmark of beta-thalassemia anemia challenging previous hypotheses of brain injury in hereditary anemias. A careful management of anemia severity might be crucial for preventing structural white matter changes and subsequent long-term cognitive impairment.
Topics: Humans; beta-Thalassemia; Male; Female; Adult; Magnetic Resonance Imaging; Cross-Sectional Studies; Brain; Young Adult; Cerebrovascular Circulation; Adolescent; Middle Aged; Child
PubMed: 38773534
DOI: 10.1186/s13023-024-03194-x -
La Clinica Terapeutica 2024We assessed the value of histogram analysis (HA) of apparent diffusion coefficient (ADC) maps for grading low-grade (LGG) and high-grade (HGG) gliomas. (Comparative Study)
Comparative Study Observational Study
OBJECTIVES
We assessed the value of histogram analysis (HA) of apparent diffusion coefficient (ADC) maps for grading low-grade (LGG) and high-grade (HGG) gliomas.
METHODS
We compared the diagnostic performance of two region-of-interest (ROI) placement methods (ROI 1: the entire tumor; ROI 2: the tumor excluding cystic and necrotic portions). We retrospectively evaluated 54 patients with supratentorial gliomas (18 LGG and 36 HGG). All subjects underwent standard 3T contrast-enhanced magnetic resonance imaging. Histogram parameters of ADC maps calculated with the two segmentation methods comprised mean, median, maxi-mum, minimum, kurtosis, skewness, entropy, standard deviation (sd), mean of positive pixels (mpp), uniformity of positive pixels, and their ratios (r) between lesion and normal white matter. They were compared using the independent t-test, chi-square test, or Mann-Whitney U test. For statistically significant results, receiver operating characteristic curves were constructed, and the optimal cutoff value, sensitivity, and specificity were determined by maximizing Youden's index.
RESULTS
The ROI 1 method resulted in significantly higher rADC mean, rADC median, and rADC mpp for LGG than for HGG; these parameters had value for predicting the histological glioma grade with a cutoff (sensitivity, specificity) of 1.88 (77.8%, 61.1%), 2.25 (44.4%, 97.2%), and 1.88 (77.8%, 63.9%), respectively. The ROI 2 method resulted in significantly higher ADC mean, ADC median, ADC mpp, ADC sd, ADC max, rADC median, rADC mpp, rADC mean, rADC sd, and rADC max for LGG than for HGG, while skewness was lower for LGG than for HGG (0.27 [0.98] vs 0.91 [0.81], p = 0.014). In ROI 2, ADC median, ADC mpp, ADC mean, rADC median, rADC mpp, and rADC mean performed well in differentiating glioma grade with cutoffs (sensitivity, specificity) of 1.28 (77.8%, 88.9%), 1.28 (77.8%, 88.9%), 1.25 (77.8%, 91.7%), 1.81 (83.3%, 91.7%), 1.74 (83.3%, 91.7%), and 1.81 (83.3%, 91.7%), respectively.
CONCLUSIONS
HA parameters had value for grading gliomas. Ex-cluding cystic and necrotic portions of the tumor for measuring HA parameters was preferable to using the entire tumor as the ROI. In this segmentation, rADC median showed the highest performance in predicting histological glioma grade, followed by rADC mpp, rADC mean, ADC median, ADC mpp, and ADC mean.
Topics: Humans; Glioma; Female; Middle Aged; Retrospective Studies; Male; Neoplasm Grading; Adult; Diffusion Magnetic Resonance Imaging; Brain Neoplasms; Aged; Young Adult
PubMed: 38767069
DOI: 10.7417/CT.2024.5053 -
Lancet (London, England) Jun 2024It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to... (Randomized Controlled Trial)
Randomized Controlled Trial
Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial.
BACKGROUND
It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone.
METHODS
In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18-75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5-6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov, NCT02258919, and is completed.
FINDINGS
SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51-68), and the median haematoma volume 57 mL (IQR 44-74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5-6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] -13%, 95% CI -26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5-6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD -15%, 95% CI -28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment.
INTERPRETATION
SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups.
FUNDING
Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim.
Topics: Humans; Middle Aged; Male; Decompressive Craniectomy; Female; Cerebral Hemorrhage; Aged; Adult; Treatment Outcome; Combined Modality Therapy
PubMed: 38761811
DOI: 10.1016/S0140-6736(24)00702-5 -
BMJ Open May 2024Cardiopulmonary complications and cognitive impairment following craniotomy have a significantly impact on the general health of individuals with brain tumours....
INTRODUCTION
Cardiopulmonary complications and cognitive impairment following craniotomy have a significantly impact on the general health of individuals with brain tumours. Observational research indicates that engaging in walking is linked to better prognosis in patient after surgery. This trial aims to explore whether walking exercise prior to craniotomy in brain tumour patients can reduce the incidence of cardiopulmonary complications and preserve patients' cognitive function.
METHODS AND ANALYSIS
In this randomised controlled trial, 160 participants with supratentorial brain tumours aged 18-65 years, with a preoperative waiting time of more than 3-4 weeks and without conditions that would interfere with the trial such as cognitive impairment, will be randomly assigned in a ratio of 1:1 to either receive traditional treatment or additional combined with a period of 3-4 weeks of walking exercise of 10 000-15 000 steps per day. Wearable pedometer devices will be used to record step counts. The researchers will evaluate participants at enrolment, baseline, 14 days preoperatively, 3 days prior to surgery and 1 week after surgery or discharge (select which occurs first). The primary outcomes include the incidence of postoperative cardiopulmonary complications and changes in cognitive function (gauged by the Montreal Cognitive Assessment test). Secondary outcomes include the average length of hospital stay, postoperative pain, participant contentment, healthcare-associated costs and incidence of other postoperative surgery-related complications. We anticipate that short-term preoperative walking exercises will reduce the incidence of surgery-related complications in the short term after craniotomy, protect patients' cognitive function, aid patients' postoperative recovery and reduce the financial cost of treatment.
ETHICS AND DISSEMINATION
The study protocol has been approved by Ethics Committee of Xiangya Hospital of Central South University (approval number: 202305117). The findings of the research will be shared via publications that have been reviewed by experts in the field and through presentations at conferences.
TRIAL REGISTRATION NUMBER
NCT05930288.
Topics: Humans; Craniotomy; Walking; Adult; Middle Aged; Supratentorial Neoplasms; Female; Male; Aged; Preoperative Exercise; Prognosis; Randomized Controlled Trials as Topic; Young Adult; Postoperative Complications; Adolescent; Cognition
PubMed: 38754891
DOI: 10.1136/bmjopen-2023-080787 -
Frontiers in Oncology 2024Surgical resection of motor eloquent tumors poses the risk of causing postoperative motor deficits which leads to reduced quality of life in these patients. Currently,...
OBJECTIVE
Surgical resection of motor eloquent tumors poses the risk of causing postoperative motor deficits which leads to reduced quality of life in these patients. Currently, rehabilitative procedures are limited with physical therapy being the main treatment option. This study investigated the efficacy of repetitive navigated transcranial magnetic stimulation (rTMS) for treatment of motor deficits after supratentorial tumor resection.
METHODS
This randomized, double-blind, sham-controlled trial (DRKS00010043) recruited patients with a postoperatively worsened upper extremity motor function immediately postoperatively. They were randomly assigned to receive rTMS (1Hz, 110% RMT, 15 minutes, 7 days) or sham stimulation to the motor cortex contralateral to the injury followed by physical therapy. Motor and neurological function as well as quality of life were assessed directly after the intervention, one month and three months postoperatively.
RESULTS
Thirty patients were recruited for this study. There was no significant difference between both groups in the primary outcome, the Fugl Meyer score three months postoperatively [Group difference (95%-CI): 5.05 (-16.0; 26.1); p=0.631]. Patients in the rTMS group presented with better hand motor function one month postoperatively. Additionally, a subgroup of patients with motor eloquent ischemia showed lower NIHSS scores at all timepoints.
CONCLUSIONS
Low-frequency rTMS facilitated the recovery process in stimulated hand muscles, but with limited generalization to other functional deficits. Long-term motor deficits were not impacted by rTMS. Given the reduced life expectancy in these patients a shortened recovery duration of deficits can still be of high significance.
CLINICAL TRIAL REGISTRATION
https://drks.de/DRKS00010043.
PubMed: 38737898
DOI: 10.3389/fonc.2024.1368924 -
Cureus Apr 2024Infective endocarditis (IE) often presents with various signs and/or symptoms. However, at times, IE can present without outstanding clinical evidence but may carry...
Infective endocarditis (IE) often presents with various signs and/or symptoms. However, at times, IE can present without outstanding clinical evidence but may carry devastating consequences if not detected and treated. We present a case of an 81-year-old female with paroxysmal atrial fibrillation who presented to the emergency department with slurred speech. Her National Institutes of Health Stroke Scale (NIHSS) score was one, and her physical examination was unremarkable. Brain imaging revealed bilateral multiple acute supratentorial and infratentorial infarcts. The patient was fully compliant on apixaban and had a dual-chamber pacemaker placed years earlier at an outside facility for unclear reasons. Although initially suspected to have experienced anticoagulation failure (ACF), transesophageal echocardiography (TEE) was ordered to evaluate for possible left atrial appendage closure procedure, which disclosed a mobile, echo-bright structure on the mitral valve consistent with IE. Blood cultures returned positive, the patient was treated with IV antibiotics, and apixaban was resumed. It can be challenging to suspect IE clinically, especially in deceptive or insidious cases with no signs/symptoms. Still, ACF is a diagnosis of exclusion, and all sources of embolic stroke (such as IE) must be thoroughly worked up before assuming treatment failure.
PubMed: 38715991
DOI: 10.7759/cureus.57741 -
Brain & Spine 2024Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM...
INTRODUCTION
Intraoperative Neurophysiological Monitoring (IOM) is widely used in neurosurgery but specific guidelines are lacking. Therefore, we can assume differences in IOM application between Neurosurgical centers.
RESEARCH QUESTION
The section of Functional Neurosurgery of the Italian Society of Neurosurgery realized a survey aiming to obtain general data on the current practice of IOM in Italy.
MATERIALS AND METHODS
A 22-item questionnaire was designed focusing on: volume procedures, indications, awake surgery, experience, organization and equipe. The questionnaire has been sent to Italian Neurosurgery centers.
RESULTS
A total of 54 centers completed the survey. The annual volume of surgeries range from 300 to 2000, and IOM is used in 10-20% of the procedures. In 46% of the cases is a neurologist or a neurophysiologist who performs IOM. For supra-tentorial pathology, almost all perform MEPs (94%) SSEPs (89%), direct cortical stimulation (85%). All centers perform IOM in spinal surgery and 95% in posterior fossa surgery. Among the 50% that perform peripheral nerve surgery, all use IOM. Awake surgery is performed by 70% of centers. The neurosurgeon is the only responsible for IOM in 35% of centers. In 83% of cases IOM implementation is adequate to the request.
DISCUSSION AND CONCLUSIONS
The Italian Neurosurgical centers perform IOM with high level of specialization, but differences exist in organization, techniques, and expertise. Our survey provides a snapshot of the state of the art in Italy and it could be a starting point to implement a consensus on the practice of IOM.
PubMed: 38698806
DOI: 10.1016/j.bas.2024.102796 -
Archives of Iranian Medicine Mar 2024Methanol-poisoning can be a challenging cause of mortality. Identifying the epidemiological, clinical, and para-clinical determinants of outcome in methanol-poisoning...
BACKGROUND
Methanol-poisoning can be a challenging cause of mortality. Identifying the epidemiological, clinical, and para-clinical determinants of outcome in methanol-poisoning patients could be a step forward to its management.
METHODS
In this hospital-based cohort study, 123 methanol-poisoning patients were included. Data on background variables, details of methanol consumption, and laboratory assessments were recorded for each patient. Patients underwent brain CT scans without contrast. We evaluated the association of all gathered clinical and para-clinical data with patients' outcome and length of hospital stay (LOS). Independent association of potential determinants of death, and LOS were modeled applying multivariable logistic, and Ordinary Least Square regressions, respectively. Odds ratio (OR), and regression coefficient (RC), and their 95% confidence intervals (CIs) were estimated.
RESULTS
Most of the study population were male (n=107/123). The mean age of the participants was 30.3±9.1 years. Ninety patients (73.2%) were reported as being conscious on admission, and 34.3% of patients were identified with at least one abnormality in their CT scan. Level of consciousness (LOC) (OR: 42.2; 95% CI: 2.35-756.50), and blood pH (OR: 0.37; 95% CI: 0.22-0.65) were associated with death. Supratentorial edema (RC: 17.55; 95% CI: 16.95-18.16) were associated with LOS.
CONCLUSION
Besides LOC, patients with any abnormality in their brain CT scan on admission were found to be at higher risk of death, and patients with supratentorial edema were at risk of longer LOS. Brain CT-scan on admission should be considered as a part of the routine procedure during the management of methanol-poisoning.
Topics: Humans; Male; Methanol; Female; Adult; Prognosis; Length of Stay; Tomography, X-Ray Computed; Young Adult; Poisoning; Iran; Logistic Models; Middle Aged; Cohort Studies; Brain
PubMed: 38685837
DOI: 10.34172/aim.2024.20 -
BMJ Case Reports Apr 2024A man in his late 40s with no known past medical history was unresponsive for an unknown period of time. Crushed pills and white residue were found on a nearby table. On...
A man in his late 40s with no known past medical history was unresponsive for an unknown period of time. Crushed pills and white residue were found on a nearby table. On presentation he was obtunded and unresponsive to verbal commands but withdrawing to painful stimuli. The initial urine drug screen was negative, but a urine fentanyl screen was subsequently positive with a level of 137.3 ng/mL. MRI of the brain showed reduced diffusivity and fluid attenuated inversion recovery (FLAIR) hyperintensity symmetrically in the bilateral supratentorial white matter, cerebellum and globus pallidus. Alternative diagnoses such as infection were considered, but ultimately the history and workup led to a diagnosis of fentanyl-induced leukoencephalopathy. Three days after admission the patient became able to track, respond to voice and follow basic one-step commands. The patient does not recall the mechanism of inhalation. While there are case reports of heroin-induced leukoencephalopathy following inhaled heroin use and many routes of fentanyl, this is the first reported case of a similar phenomenon due to fentanyl inhalation.
Topics: Humans; Fentanyl; Male; Leukoencephalopathies; Adult; Magnetic Resonance Imaging; Administration, Inhalation; Analgesics, Opioid; Brain
PubMed: 38684340
DOI: 10.1136/bcr-2023-258395