Efficacy and histopathological effects of self-assembling peptides RADA16 and IEIK13 in neurosurgical hemostasis.

There is a continued need for effective hemostatic agents that are safe for neurosurgical use. Self-assembling peptide hydrogels have been suggested as novel hemostatic agents. They offer some advantages for neurosurgical hemostasis (e.g., transparency), but their efficacy and safety for neurosurgery have not been established. In this paper, the efficacy and safety of two self-assembling peptides, RADA16 and IEIK13, are explored for hemostasis of oozing bleeding on the rat cerebral cortex (n = 56). Chronic safety was evaluated by neuropathological evaluation at one, four, and twelve weeks after craniotomy (n = 32). An inactive control and oxidized cellulose served as comparators. Mean time-to-hemostasis was significantly shorter for RADA16 and IEIK13 compared to controls, while safety evaluation yielded similar results. Histopathological response consisted primarily of macrophage infiltration at the lesion site in all groups. This study confirms the hemostatic potential and safety of RADA16 and IEIK13 for hemostasis in the rat brain.

Time trends in the risk of delayed cerebral ischemia after subarachnoid hemorrhage: a meta-analysis of randomized controlled trials.

OBJECTIVE: Delayed cerebral ischemia (DCI) contributes to morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Continuous improvement in the management of these patients, such as neurocritical care and aneurysm repair, may decrease the prevalence of DCI. In this study, the authors aimed to investigate potential time trends in the prevalence of DCI in clinical studies of DCI within the last 20 years. METHODS: PubMed, Embase, and the Cochrane library were searched from 2000 to 2020. Randomized controlled trials that reported clinical (and radiological) DCI in patients with aSAH who were randomized to a control group receiving standard care were included. DCI prevalence was estimated by means of random-effects meta-analysis, and subgroup analyses were performed for the DCI sum score, Fisher grade, clinical grade on admission, and aneurysm treatment method. Time trends were evaluated by meta-regression. RESULTS: The search strategy yielded 5931 records, of which 58 randomized controlled trials were included. A total of 4424 patients in the control arm were included. The overall prevalence of DCI was 0.29 (95% CI 0.26-0.32). The event rate for prevalence of DCI among the high-quality studies was 0.30 (95% CI 0.25-0.34) and did not decrease over time (0.25% decline per year; 95% CI -2.49% to 1.99%, p = 0.819). DCI prevalence was higher in studies that included only higher clinical or Fisher grades, and in studies that included only clipping as the treatment modality. CONCLUSIONS: Overall DCI prevalence in patients with aSAH was 0.29 (95% CI 0.26-0.32) and did not decrease over time in the control groups of the included randomized controlled trials.

Ruptured blood blister like aneurysm: does the best therapeutic option really exist?

Our study aimed to evaluate the outcome of patients with ruptured blood-blister like aneurysm (BBLA) in our institution by comparing microsurgical selective treatment to endovascular treatment using flow-diverter stent (FD). Our study included 18 consecutive patients treated for BBLA between 2004 and 2020. Until 2014, microsurgery was preferred in all patients with BBLA (n = 10). Significant postoperative morbi-mortality was recorded at this time and led us to change therapeutic strategy and to favor FD as first-line treatment in all patients (n = 8). Postprocedural complications and BBLA occlusion were recorded. High WFNS score (> 2) was noted in 6 patients of microsurgical group and in 2 of endovascular group. In microsurgical group, ischemic lesions were noted in 6 patients and led to death in 3 patients. Immediate BBLA occlusion was obtained in all patients. Favorable outcome after 3 months (mRS < 3) was recorded in 4 of the 7 survivors. In endovascular group, ischemic lesions were noted in 4 patients. One patient died from early postprocedural BBLA rebleeding. Scarpa hematoma was noted in 3 patients with surgical evacuation in 1. Persistent BBLA at 3 months was recorded in 4 patients without rebleeding, but further FD was required in 1 with growing BBLA. Favorable outcome was noted in 6 of the 7 survivors. Although, rate of morbi-mortality appear lower in patients treated with FD, neurological presentation was better and BBLA diagnosis remains questionable in this group. Moreover, persistent BBLA imaging with potential risk of rebleeding after FD deserves to be discussed.

Vessel territory mapping after cerebral revascularization surgery using selective angiographic flat detector perfusion imaging.

The technical feasibility and diagnostic potential of angiographic flat-detector perfusion imaging technique, combining digital subtraction angiography with a flat-detector computed tomography steady-state perfusion imaging, was explored in patients treated with direct or indirect revascularization surgery. This short communication is about an imaging modality with great potential for evaluation, comparison and grading of vascular perfusion territory areas and anatomical location selectively perfused by direct and indirect cerebral bypasses.

Iron chelators for acute stroke.

BACKGROUND: Stroke is the second leading cause of death and a major cause of morbidity worldwide. Retrospective clinical and animal studies have demonstrated neuroprotective effects of iron chelators in people with haemorrhagic or ischaemic stroke. This is the first update of the original Cochrane Review published in 2012. OBJECTIVES: To evaluate the effectiveness and safety of iron-chelating drugs in people with acute stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (2 September 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2019, Issue 9; 2 September 2019), MEDLINE Ovid (2 September 2019), Embase Ovid (2 September 2019), and Science Citation Index (2 September 2019). We also searched ongoing trials registers. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of iron chelators versus no iron chelators or placebo for the treatment of acute stroke, including subarachnoid haemorrhage. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results. We obtained the full texts of potentially relevant studies and evaluated them for eligibility. We assessed risk of bias using the Cochrane 'Risk of bias' tool, and the certainty of evidence using the GRADE approach. MAIN RESULTS: Two RCTs (333 participants) were eligible for inclusion; both compared the iron-chelating agent deferoxamine against placebo. Both studies evaluated participants with spontaneous intracerebral haemorrhage. We assessed one study to have a low risk of bias; the other study had potential sources of bias. The limited and heterogeneous data did not allow for meta-analysis of the outcome parameters. The evidence suggests that administration of deferoxamine may result in little to no difference in deaths (8% in placebo vs 8% in deferoxamine at 180 days; 1 RCT, 291 participants; low-certainty evidence). These RCTs suggest that there may be little to no difference in good functional outcome (modified Rankin Scale score 0 to 2) between groups at 30, 90 and 180 days (placebo vs deferoxamine: 67% vs 57% at 30 days and 36% vs 45% at 180 days; 2 RCTs, 333 participants; low-certainty evidence). One RCT suggests that administration of deferoxamine may not increase the number of serious adverse events or deaths (placebo vs deferoxamine: 33% vs 27% at 180 days; risk ratio 0.81, 95 % confidence interval 0.57 to 1.16; 1 RCT, 291 participants; low-certainty evidence). No data were available on any deaths within the treatment period. Deferoxamine may result in little to no difference in the evolution of National Institute of Health Stroke Scale scores from baseline to 90 days (placebo vs deferoxamine: 13 to 4 vs 13 to 3; P = 0.37; 2 RCTs, 333 participants; low-certainty evidence). Deferoxamine may slightly reduce relative oedema surrounding intracerebral haemorrhage at 15 days (placebo vs deferoxamine: 1.91 vs 10.26; P = 0.042; 2 RCTs, 333 participants; low-certainty evidence). Neither study reported quality of life. AUTHORS' CONCLUSIONS: We identified two eligible RCTs for assessment. We could not demonstrate any benefit for the use of iron chelators in spontaneous intracerebral haemorrhage. The added value of iron-chelating therapy in people with ischaemic stroke or subarachnoid haemorrhage remains unknown.

How I do it: operative nuances of multiple burr hole surgery for moyamoya disease and syndrome.

BACKGROUND: Burr hole surgery for moyamoya disease and moyamoya syndrome is known to be an effective, versatile, and relatively simple revascularization technique. We will focus on the technical operative aspects of multiple burr hole surgery as we perform it in our center. METHODS: Periosteal flaps are prepared and placed in a burr hole with beveled edge, after opening the dura and arachnoid membrane, in order to facilitate neovascularization into the ischemic cortex. CONCLUSIONS: Burr hole surgery is a versatile treatment modality for moyamoya and moyamoya-like disease. Success can be maximized by having a meticulous operative technique.

Protective STA-MCA bypass to prevent brain ischemia during high-flow bypass surgery: case series of 10 patients.

BACKGROUND: High-flow extracranial-intracranial bypass is associated with a significant risk of ischemic stroke. The goal of this study is to evaluate the effectiveness of STA-MCA bypass preceding a high-flow bypass as a means of protecting the brain from ischemia during the high-flow bypass anastomosis in patients with otherwise untreatable aneurysms. MATERIALS AND METHOD: This prospective study included 10 consecutive patients treated for complex/giant aneurysm using a previous combined STA-MCA bypass and high-flow EC-IC bypass between June 2016 and January 2018 when classical endovascular or microsurgical exclusion was estimated too risky. Early cranial Doppler, MRI, CT scan, and conventional angiography were performed in each patient to confirm patency of bypasses, measure flow in the anastomoses, detect any ischemic lesions, and evaluate exclusion of the aneurysm. RESULTS: The mean age at treatment was 55 years (range 34 to 67). The mean time of microsurgical procedure was 11 h (range 9 to 12). In all patients, the high-flow bypass was patent intraoperatively and complete occlusion of aneurysm was obtained. No ischemic lesions were noted on early MRI. One patient died from a large hemispheric infarction related to a common carotid artery dissection 10 days after the microsurgical procedure and immediate postoperative epidural hematoma was noted in one other patient. CONCLUSION: In this study, we described the use of a protective STA-MCA bypass, performed prior to the high-flow bypass, in order to reduce the risk of perioperative ischemic lesions without increasing the morbidity of the surgical procedure. This treatment paradigm was feasible in all ten patients without complications related to the STA-MCA anastomosis.

Is There an Advantage to Minimizing Surgery in Scaphocephaly? A Study on Extended Strip Craniectomy Versus Extensive Cranial Vault Remodeling.

BACKGROUND: Different techniques have been described to correct scaphocephaly. In authors' institution, total cranial vault remodeling (TCVR) was the standard of care. To limit the extent of surgery and the need for transfusion, the technique was minimized to extended strip craniectomy (ESC) without helmet therapy. This retrospective study compares outcome and morbidity between ESC and TCVR. METHODS: Twenty-seven scaphocephalic patients were included. The ESC was performed in 9 patients between 2012 and 2014, and TCVR in 17 patients between 2008 and 2016. Data on blood loss and transfusion rate, duration of surgery, length of hospital stay (LOS), head circumference, and cephalic index (CI) were collected retrospectively. A cosmetic outcome score (COS) was developed to rate esthetic outcome since CI is a limited and crude measurement of cosmetic outcome. RESULTS: The LOS was identical in both groups, but duration of surgery was significantly shorter in ESC (P < 0.0001). Transfusion rate appeared higher in the TCVR group, but differences were not significant (P = 0.11). Cosmetic outcome appeared slightly worse in the ESC group, but results were not significantly different (P = 0.66). There was, however, a significant improvement in postoperative CI in the TCVR group (P < 0.0001). CONCLUSION: The only advantage of ESC was the reduced duration of surgery, but this could not prevent the need for transfusion in this group of patients. The improvement of the CI was significantly less pronounced after ESC, but the COS was not significantly worse in the ESC group. The scar and LOS were similar in both groups. Therefore, our findings indicate that minimizing TCVR to ESC without helmet therapy does not provide significant advantages.

A contemporary and a historical patient with an ectopic meningioma.

Introduction: Ectopic meningiomas are rare tumors which can be encountered by all surgical specialties. Patients and methods: We report on two different cases, a contemporary one and a historical one, highlighting the diversity of clinical presentations and prognoses of these lesions. Furthermore epidemiological aspects, clinical features, and diagnostic and therapeutic work-up in patients with an ectopic meningioma are reviewed. Results: Typically, ectopic meningiomas present as gradually expanding lesions, causing a variety of symptoms by their mass effect. Diagnosis is based on histological characteristics, which are similar to those of intracranial meningiomas. Treatment is primarily surgical. Conclusions: The cases we report are at different ends of the clinical and prognostic spectrum. Therapeutic options for different clinical scenarios are discussed.

Occipital nerve stimulation in fibromyalgia: a double-blind placebo-controlled pilot study with a six-month follow-up.

OBJECTIVE: The goal of this study is to evaluate the effectiveness of occipital nerve stimulation (ONS) as a surgical treatment for fibromyalgia in a placebo-controlled design. MATERIALS AND METHODS: Eleven patients were selected based on the American College of Rheumatology-90 criteria and implanted with an occipital nerve trial-lead stimulator. Baseline scores for pain, mood, and fatigue were acquired, and patients were randomized in a ten-week double-blinded crossover design with placebo and effective subsensory threshold stimulation (no paresthesias). After finalizing the trial, nine patients were implanted permanently; evaluation was performed prior to surgery and at six months after surgery for pain, fatigue, and mood of the number of trigger points and overall morbidity. RESULTS: Significant results were found during the trial for a decrease in pain intensity (39.74%) on visual analogue scale (VAS; p < 0.001) and pain catastrophizing scale (PCS) during effective stimulation. A total of 9/11 patients responded to trial treatment; however, in two patients, this might be a placebo effect, recognizable due to the study design. Six months after permanent implantation, pain intensity remained decreased (44.01%) on VAS (p < 0.05). Besides the VAS, significant changes were noted for PCS, fatigue (modified fatigue impact scale), the number of trigger points, and overall morbidity (fibromyalgia impact questionnaire). There were no serious adverse events. CONCLUSIONS: Our data strongly suggest that ONS is beneficial in the treatment of fibromyalgia. The beneficial effects are stable at six months after permanent implantation. Subsensory threshold stimulation is feasible in designing a placebo-controlled trial.

Anatomical Variations and Anomalies of the Anterior Communicating Artery Complex.

BACKGROUND: Intracranial arteries have a high rate of variation, but a clear schematic overview is lacking. In this pictorial review we classify and depict all variations and anomalies within the anterior communicating artery complex. METHODS: PubMed was searched with the terms "Anterior Communicating Artery" AND "Variations" OR "Anomalies." Articles were selected based on their description of variants. Cross-referencing was used to broaden the range of variations. Surgical view during pterional craniotomy and transsylvian approach was used as a baseline for schematic drawings of the variations. RESULTS: A total of 42 variants were identified, schematically drawn and classified into A1-A2 segment, anterior communicating artery, and the recurrent artery of Heubner. CONCLUSIONS: The anterior communicating artery complex consists of the anterior cerebral artery, anterior communicating artery and the recurrent artery of Heubner. An overview of these variations may be helpful in distinguishing pathology from anatomical variations, assist neurosurgeons during clipping of cerebral aneurysms, and support interventional radiologists during endovascular treatments. This article summarizes the current knowledge of anatomical variations within the anterior communicating artery complex, their prevalence and clinical relevance. A total of 42 variants were identified and schematically depicted. We encourage all who diagnose, treat, and study the anterior communicating artery complex to use this overview for a uniform and better understanding of its anatomy.

The auricula as a new surgical landmark for the transverse-sigmoid-sinus-transition.

Introduction: The transverse-sigmoid-sinus-transition constitutes an important landmark during a retrosigmoid craniotomy. Due to anatomical variations, the location is highly variable. Landmarks for identification of the anterior border of the sigmoid sinus have been described extensively, such as the mastoid notch, digastric point, external auditory meatus and crux of the helix curvature. There is a paucity of landmarks for the identification of the posterior border, however. Research question: We examined the relationship between the transverse-sigmoid-sinus-transition and the most-posterior-part-of-the-auricula. Material and methods: We performed a retrospective analysis of one-hundred patients (38 males and 62 females) who underwent cerebral MRI examinations at Antwerp University Hospital (Belgium). Using Brainlab®, the transverse-sigmoid-sinus-transition and most-posterior-part-of-the-auricula coordinates were calculated and compared. Left and right sides were compared in both the anteroposterior and craniocaudal axis. Results: Mean age was 56.4 ± 16.1 years. Mean MPPA-TSST-distance in the anteroposterior direction was -1.93 mm (right) and -1.96 mm (left). Mean MPPA-TSST-distance in the craniocaudal direction was -5.16 mm (right) and -5.04 mm (left). Discussion and conclusion: The transverse-sigmoid-sinus-transition seems to be located more anterior and caudal with respect to the most-posterior-part-of-the-auricula, meaning that it can be considered a save landmark. A correction of five mm needs to be applied in order to identify the inferior border of the transverse sinus. Left/right and gender had no significant influence. The most-posterior-part-of-the-auricula can be considered a fast and practical anatomical landmark for identification of the transverse-sigmoid-sinus-transition, without affecting operative fluency, especially during an emergency craniotomy.

Anatomical Variations and Anomalies of the Middle Cerebral Artery.

OBJECTIVE: Intracranial arteries have a high rate of variation, but a clear schematic overview is lacking. In this pictorial review we classify and depict all the variations and anomalies within the middle cerebral artery (MCA). METHODS: PubMed was searched with the MeSH-term "Middle Cerebral Artery." Articles were selected based on their description of variants within the MCA. Cross-referencing was used to broaden the range of articles. The anatomical variants were then schematically drawn using the anteroposterior and lateral view during angiography of the internal carotid artery. RESULTS: A total of 29 unique medical illustrations were made, depicting variation in number of vessels; variation in vessel origin; and variation in morphology. CONCLUSIONS: The MCA provides vital blood supply to the frontal, parietal, temporal, and central brain structures. An overview of these variations is important to diagnose and treat patients with MCA-related pathology correctly and safely. They can aid in distinguishing pathology from normal anatomical variance; aid neurosurgeons during aneurysmal clipping or arteriovenous malformation resections; and aid interventional radiologists during thrombectomy or coiling. This article provides a summary regarding current knowledge of anatomical variations within the MCA, their prevalence and clinical relevance. A total of 29 unique illustrations were made, depicting currently known variants. We encourage all who diagnose, treat, and study the MCA to use this overview for a uniform and better understanding of its anatomy.

Posterior Cerebral Artery-to-Superior Cerebellar Artery Side-to-Side Bypass via Extreme Lateral Supracerebellar Infratentorial Approach: Technical Note.

BACKGROUND: Difficult-to-treat aneurysms of the distal posterior cerebral artery (PCA) can often be treated by parent artery occlusion. A cerebrovascular bypass can complement PCA occlusion to curb the risk of ischemic complications. An in situ bypass may be considered when the occipital artery or superficial temporal artery cannot serve as a bypass donor. This article describes the use of a side-to-side bypass of superior cerebellar artery as a donor to the PCA via an extreme lateral supracerebellar infratentorial approach (ELSCIT). This bypass approach can be a useful surgical strategy for PCA revascularization. METHODS: A 40-year-old woman underwent a side-to-side PCA-superior cerebellar artery bypass via the ELSCIT approach for to treat a complex and previously coiled PCA aneurysm. The bypass was followed by endovascular aneurysm and parent artery occlusion. RESULTS: Postoperatively, the patient experienced transient, partial trochlear nerve palsy of the left eye without ischemic lesions on magnetic resonance imaging. The clinical condition was stable, and angiography showed a patent bypass and complete aneurysm occlusion 12 months after surgery. CONCLUSIONS: The ELSCIT approach offers access to the medial and distal PCA that is suitable for a side-to-side PCA-superior cerebellar artery bypass. This type of approach and bypass may be of value when revascularization of a P2-P3 portion of the PCA is needed, but a suitable occipital artery or superficial temporal artery is not available.

Transforaminal epidural steroid injection for radiculopathy and the evolution to surgical treatment: a pragmatic prospective observational multicenter study.

Aim: The aim of this study is to analyze the real-world outcomes of transforaminal epidural steroid injections (TFESIs) in all patients with radiculopathy and their long-term outcomes. Methods: Patients with radiculopathy and failure of conservative treatment were included in a prospective, multicenter, observational cohort study. Results: In total, 117 patients were treated with one or two TFESIs. The mean duration of follow-up was 116 (±14) weeks. In total 19,6% (95% CI: 12.9-28.0%) patients were treated with surgery after insufficient symptom improvement. The evolution to surgery was not associated with etiology, symptom duration or previous spine surgery. Conclusion: Real-world data confirms that TFESIs is an effective treatment with satisfactory results in about 80% of patients for a period of 2 years.

This study focusses on evaluating the real-world effectiveness of transforaminal epidural steroid injections (TFESIs) in treating radiculopathy, a condition characterized by back and leg pain due to compressed spinal nerves. This nerve compression can originate from different problems.A total of 117 patients with radiating leg pain were included in this study. The infiltrations were administered, and the primary outcome was the need for spinal surgery within 2 years. The findings revealed that approximately 20% of patients eventually required surgery due to unsatisfactory results after injections. However, for patients with satisfactory outcomes, there was a notable reduction in back and leg pain, disability and pain medication usage, along with an improved quality of life.Importantly, the results suggested that TFESIs could be considered as a treatment option in daily clinical practice, also after a prolonged duration of symptoms.Despite certain limitations, such as the absence of a control group undergoing immediate surgical treatment, the real-world data supported the effectiveness of TFESIs in treating radiculopathy. This information provides valuable insights for spine surgeons and pain physicians in understanding the prognosis of TFESIs across diverse patient scenarios.

C2 subcutaneous stimulation for failed back surgery syndrome: a case report.

OBJECTIVE: Failed back surgery syndrome (FBSS) is a term embracing a constellation of conditions that describes persistent or recurring low back pain, with or without sciatica following one or more spine surgeries. It has been shown in animals that electrical stimulation of the high cervical C2 area can suppress pain stimuli derived from the L5-S1 dermatome. It is unknown whether C2 electrical stimulation in humans can be used to treat pain derived from the L5-S1 area, and a case is reported in which subcutaneous C2 is applied to treat FBSS. CASE: A patient presents to the neuromodulation clinic because of FBSS (after three lumbar diskectomies) and noninvasive neuromodulation is performed consisting of transcutaneous electrical nerve stimulation (TENS) at C2. The C2 TENS stimulation is successful in improving pain. It induces paresthesias in the C2 dermatome above a certain amplitude threshold, but does not generate paresthesias in the pain area. However, the patient becomes allergic to the skin-applied TENS electrodes and therefore a new treatment strategy is discussed with the patient. A subcutaneous C2 electrode is inserted under local anesthesia, and attached to an external pulse generator. METHODS: Three stimulation designs are tested: a classical tonic stimulation, consisting of 40 Hz stimulation, a placebo, and a burst stimulation, consisting of 40 Hz burst mode, with five spikes delivered at 500 Hz at 1000 µsec pulse width and 1000 µsec interspike interval. RESULTS: The patient's stimulation results demonstrate that burst mode is superior to placebo and tonic mode, and she receives a fully implanted C2 electrode connected to an internal pulse generator via an extension wire. CONCLUSION: The burst design is capable of both suppressing the least and worst pain effectively, and she has remained almost pain-free for over three years.

Unraveling cerebral saccular aneurysm mimics: Case report and review of the literature.

Introduction: Aneurysm mimics, such as an occluded cerebral artery, vascular loops or infundibular dilatations, should be beard in mind when planning a craniotomy for the treatment of an aneurysm. Although ischemic stroke caused by clot migration from an aneurysmal cavity has been described, an ischemic event should raise awareness of potential MCA branch occlusion instead of an aneurysm. Research question: We provided a scaffold that could be used to differentiate other saccular aneurysm mimics. We explored the current literature concerning ACM segment occlusions initially misdiagnosed as a saccular aneurysm. Material and methods: We present the case of a 58 year old female who experienced a subarachnoid hemorrhage. CT angiography could not reveal an underlying aneurysm. She had a medical history of right carotid artery occlusion with secondary ischemic stroke and left spastic hemiparesis. An aneurysm of the right MCA was suspected and she was scheduled for explorative craniotomy. Results: Peroperatively we did not encounter an aneurysm, although a thrombosed branch of the right MCA was noted. The most proximal part of the branch was still patent, mimicking a saccular aneurysm on angiographic records. Discussion and conclusion: Aneurysm mimics can potentially expose patients to unnecessary exploratory craniotomies in the presumptive diagnosis of a saccular aneurysm. MRI 3D-CISS can be a helpful adjunct, since MRA and DSA are frequently not sufficient. Although ischemic stroke can be caused by clot migration from an aneurysmal cavity, an ischemic event should raise awareness of potential cerebral artery occlusion.

Patient profiling and outcome assessment in spinal cord stimulation for chronic back and/or leg pain (the PROSTIM study): a study protocol.

Spinal cord stimulation (SCS) is a well-established treatment option in the multidisciplinary approach to chronic back and leg pain. Nevertheless, careful patient selection remains crucial to provide the most optimal treatment and prevent treatment failure. We report the protocol for the PROSTIM study, an ongoing prospective, multicentric and observational clinical study (NCT05349695) that aims to identify different patient clusters and their outcomes after SCS. Patients are recruited in different centers in Europe. Analysis focuses on identifying significant patient clusters based on different health domains and the changes in biopsychosocial variables 6 weeks, 3 and 12 months after implantation. This study is the first to include a biopsychosocial cluster analysis to identify significant patient groups and their response to treatment with SCS.

What is the study about? Spinal cord stimulation (SCS) is a treatment for chronic back and leg pain, in which an electrical stimulation is delivered to the spinal cord in order to reduce pain experience. It is important to choose the right patients to make sure the treatment works well. The PROSTIM study is a research project in which we study patients selected to be treated with SCS. We want to understand how different groups of patients selected for this treatment do after getting SCS. The study includes patients in different European centers, following them for 6 weeks, 3 months and 1 year after getting SCS. This study is the first one to use a cluster analysis to group patients based on different aspects of their psychological and physical health and see how they respond differently to SCS treatment. Clinical Trial Registration: NCT05349695 (ClinicalTrials.gov).

Can angiographic Flat Detector Computed Tomography blood volume measurement be used to predict final infarct size in acute ischemic stroke?

INTRODUCTION AND PURPOSE: Flat detector computed tomography (FD-CT) technology is becoming more widely available in the angiography suites of comprehensive stroke centers. In patients with acute ischemic stroke (AIS), who are referred for endovascular therapy (EVT), FD-CT generates cerebral pooled blood volume (PBV) maps, which might help in predicting the final infarct area. We retrospectively analyzed pre- and post-recanalization therapy quantitative PBV measurements in both the infarcted and hypoperfused brain areas of AIS patients referred for EVT. MATERIALS AND METHODS: We included AIS patients with large vessel occlusion in the anterior circulation referred for EVT from primary stroke centers to our comprehensive stroke center. The pre- and post-recanalization FD-CT regional relative PBV (rPBV) values were measured between ipsilateral lesional and contralateral non-lesional areas based on final infarct area on post EVT follow-up cross-sectional imaging. Statistical analysis was performed to identify differences in PBV values between infarcted and non-infarcted, recanalized brain areas. RESULTS: We included 20 AIS patients. Mean age was 63 years (ranging from 36 to 86 years). The mean pre- EVT rPBV value was 0.57 (±0.40) for infarcted areas and 0.75 (±0.43) for hypoperfusion areas. The mean differences (Δ) between pre- and post-EVT rPBV values for infarcted and hypoperfused areas were respectively 0.69 (±0.59) and 0.69 (±0.90). We found no significant differences (p > 0.05) between pre-EVT rPBV and ΔrPBV values of infarct areas and hypoperfusion areas. CONCLUSION: Angiographic PBV mapping is useful for the detection of cerebral perfusion deficits, especially in combination with the fill run images. However, we were not able to distinguish irreversibly infarcted tissue from potentially salvageable, hypoperfused brain tissue based on quantitative PBV measurement in AIS patients.

Diffusion tensor imaging provides an insight into the microstructure of meningiomas, high-grade gliomas, and peritumoral edema.

OBJECTIVE: Fractional anisotropy (FA) is a measure for the degree of microstructural organization. Several studies have used FA values to assess microstructural organization of brain tumors and peritumoral edema. The purpose of our study was to validate FA and apparent diffusion constant (ADC) values in the diagnosis of meningiomas versus high-grade glial tumors, with the focus on the ability of diffusion tensor imaging (DTI) to reveal tumor ultrastructure. Our hypothesis was that FA and ADC values significantly differ between high-grade gliomas and meningiomas, and in the peritumoral edema. METHODS: Diffusion tensor imaging values were obtained from 20 patients with meningiomas (21 tumors) and 15 patients with high-grade gliomas. Regions of interest were outlined in FA and ADC maps for solid-enhancing tumor tissue and peritumoral edema. Fractional anisotropy and ADC values were normalized by comparison to normal-appearing white matter (NAWM) in the contralateral hemisphere. Differences between meningiomas and high-grade gliomas were statistically analyzed. RESULTS: Meningiomas showed a significantly higher FA tumor/FA NAWM ratio (P = 0.0001) and lower ADC tumor/ADC NAWM ratio (P = 0.0008) compared to high-grade gliomas. On average, meningiomas also showed higher FA values in peritumoral edema than high-grade gliomas (P = 0.016). Apparent diffusion constant values of peritumoral edema for the 2 tumor groups did not differ significantly (P = 0.5). CONCLUSIONS: Diffusion tensor imaging can be used to reveal microstructural differences between meningiomas and high-grade gliomas and may contribute toward predicting the histopathology of intracranial tumors. We advocate that diffusion tensor imaging should be included in the standard imaging protocol for patients with intracranial tumors.