'An eye for an eye' therapeutic strategy for cavernous sinus dural arteriovenous fistula: a single-center experience.

BACKGROUND: In cavernous sinus dural arteriovenous fistulas (CS-DAVF), ophthalmological symptoms are usually the main clinical presentation, caused by abnormal drainage of the superior ophthalmic vein (SOV). Early opacification of the SOV during cerebral angiography inevitably signifies the fistula's shunt point at the confluence of the SOV and CS. We aimed to leverage this anatomical feature to achieve precise embolization, thereby enhancing the embolization success rate and preventing CS-related symptoms and complications resulting from overpacking. METHODS: This single-center, case series study was conducted between May 2017 and September 2023, and included the largest sample of CS-DAVF patients treated via the transfemoral vein-SOV approach. We retrospectively reviewed the data of 32 CS-DAVF patients with inferior petrosal sinus (IPS) occlusion. RESULTS: The study demonstrated an excellent immediate postoperative complete embolization rate (31/32, 97%). Only three patients (3/32, 9%) developed temporary endovascular treatment-related complications. The average operation time was 131.6±61.6 min, with an average of 1.2±1.1 coils and 1.8±1.2 mL Onyx glue used per patient. CS-DAVF-associated ophthalmological symptoms resolved in all patients. We also identified a rare anatomical variation, where 77% of the patients had a facial vein draining into the external jugular vein. CONCLUSIONS: Transfemoral vein-SOV embolization should be considered a crucial alternative approach in CS-DAVF patients with occluded IPS and predominantly SOV drainage. This approach showed an excellent immediate postoperative complete embolization rate and satisfactory long-term outcomes along with clinical safety. We therefore strongly advocate for this 'an eye for an eye' treatment strategy.

Novel subsets of peripheral immune cells associated with promoting stroke recovery in mice.

AIMS: Peripheral immune cells infiltrating into the brain trigger neuroinflammation after an ischemic stroke. Partial immune cells reprogram their function for neural repair. Which immune cells promote ischemic brain recovery needs further identification. METHODS: We performed single-cell transcriptomic profiling of CD45high immune cells isolated from the ischemic hemisphere at subacute (5 days) and chronic (14 days) stages after ischemic stroke. RESULTS: A subset of phagocytic macrophages was associated with neuron projection regeneration and tissue remodeling. We also identified a unique type of T cells with highly expressed macrophage markers, including C1q, Apoe, Hexb, and Fcer1g, which showed high abilities in tissue remodeling, myelination regulation, wound healing, and anti-neuroinflammation. Moreover, natural killer cells decreased cytotoxicity and increased energy and metabolic function in the chronic stage after ischemic stroke. Two subgroups of neutrophils upregulated CCL signals to recruit peripheral immune cells and released CXCL2 to keep self-recruiting at the chronic stage. CONCLUSIONS: We identified subsets of peripheral immune cells that may provide potential therapeutic targets for promoting poststroke recovery.

A novel phenotype of B cells associated with enhanced phagocytic capability and chemotactic function after ischemic stroke.

Accumulating evidence has demonstrated the involvement of B cells in neuroinflammation and neuroregeneration. However, the role of B cells in ischemic stroke remains unclear. In this study, we identified a novel phenotype of macrophage-like B cells in brain-infiltrating immune cells expressing a high level of CD45. Macrophage-like B cells characterized by co-expression of B-cell and macrophage markers, showed stronger phagocytic and chemotactic functions compared with other B cells and showed upregulated expression of phagocytosis-related genes. Gene Ontology analysis found that the expression of genes associated with phagocytosis, including phagosome- and lysosome-related genes, was upregulated in macrophage-like B cells. The phagocytic activity of macrophage-like B cells was verified by immunostaining and three-dimensional reconstruction, in which TREM2-labeled macrophage-like B cells enwrapped and internalized myelin debris after cerebral ischemia. Cell-cell interaction analysis revealed that macrophage-like B cells released multiple chemokines to recruit peripheral immune cells mainly via CCL pathways. Single-cell RNA sequencing showed that the transdifferentiation to macrophage-like B cells may be induced by specific upregulation of the transcription factor CEBP family to the myeloid lineage and/or by downregulation of the transcription factor Pax5 to the lymphoid lineage. Furthermore, this distinct B cell phenotype was detected in brain tissues from mice or patients with traumatic brain injury, Alzheimer's disease, and glioblastoma. Overall, these results provide a new perspective on the phagocytic capability and chemotactic function of B cells in the ischemic brain. These cells may serve as an immunotherapeutic target for regulating the immune response of ischemic stroke.

Radiomic Features of the Edema Region May Contribute to Grading Meningiomas With Peritumoral Edema.

BACKGROUND: Meningiomas are frequently accompanied by peritumoral edema (PTE). The potential value of radiomic features of edema region in meningioma grading has not been investigated. PURPOSE: To investigate whether radiomic features of edema region contribute to grading meningiomas with PTE. STUDY TYPE: Retrospective. POPULATION: A total of 444 patients including 196 grade II and 248 WHO grade I meningiomas: 356 patients for training, 88 for validation. FIELD STRENGTH/SEQUENCE: A 1.5-T/3.0-T, noncontrast T1-weighted (T1WI), T2-weighted (T2WI), contrast-enhanced T1-weighted (T1CE) spin echo sequences. ASSESSMENT: A total of 851 radiomic features were extracted from each sequence on each region (tumor and edema region). These features were integrated by region respectively. Three subsets of clinical-radiomic features were constructed by joining clinical information (sex, age, tumor volume, and edema volume) and radiomic features of three regions: tumor, edema, and combined subsets. For each subset, features were filtered by the least absolute shrinkage and selection operator (LASSO) and Random Forest algorithm. Top 20 features of each subset were finally selected. STATISTICAL TESTS: Stochastic Gradient Boosting, Random Forest, and Bagged AdaBoost predictive models were built based on each subset. Discriminative abilities of models were quantified using receiver operating characteristics (ROC) and the area under the curve (AUC). A P value < 0.05 was considered statistically significant. RESULTS: Random Forest model based on combined subset (AUC [95% CI] = 0.880 [0.807-0.953]) had the best discriminative ability in grading meningiomas among the final models. The best model of edema subset and tumor subset were Random Forest model (AUC [95% CI] = 0.864 [0.791-0.938]) and Stochastic Gradient Boosting model (AUC [95% CI] = 0.844 [0.760-0.928]), respectively. DATA CONCLUSION: Radiomic features of edema region may contribute to grading meningiomas with PTE. The Random Forest model based on combined subset surpasses the best model based on tumor or edema subset regarding grading meningiomas with PTE. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 3.

Safety and Efficacy of Tirofiban in Severe Ischemic Stroke Patients Undergoing Mechanical Thrombectomy.

Tirofiban has recently shown encouraging efficacy and safety among acute ischemic stroke (AIS) patients with mechanical thrombectomy (MT). However, the benefits of tirofiban varied among studies depending on the patient's condition, which was often not well analyzed. This study aimed to identify the characteristics of patients who may obtain the largest benefits from tirofiban. The efficacy endpoint was a favorable outcome defined as a modified Rankin Scale (mRS) score of 0~2 at 90 days. The safety endpoints were intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Adjusted logistic regression analysis and subgroup analyses were utilized to investigate the factors associated with tirofiban and the outcome. All of 285 patients fit the inclusion criteria. Tirofiban was associated with a higher rate of favorable outcome (aOR 2.033, 95% CI, 1.002~4.123, p = 0.043) but not with an increased risk of ICH, sICH or mortality (p > 0.05). Moreover, subgroup analyses revealed that tirofiban was associated with favorable outcomes in patients with NIHSS > 14 (aOR 2.778, 95% CI 1.056~7.356, p = 0.038) but not in patients with NIHSS ≤ 14 (aOR 1.719, 95% CI 0.646~4.578, p = 0.278). No significant heterogeneity was found in the effect of tirofiban across the subgroups of age, sex, ASPECTS, time from onset to puncture, use of t-PA or stroke etiology (p for interaction > 0.05). The administration of tirofiban was associated with favorable outcomes in severe ischemic stroke patients, and further studies are needed to confirm this finding.

Assessing rupture risk by hemodynamics, morphology and plasma concentrations of the soluble form of tyrosine kinase receptor Axl in unruptured intracranial aneurysms.

OBJECTIVE: This study investigated the relationship between morphology, hemodynamic parameters, and plasma concentrations of the soluble form of tyrosine kinase receptor Axl (sAxl) and their potential role in assessing the intracranial aneurysm rupture risk. METHODS: Thirty-nine patients were retrospectively recruited and these patients were divided into low and high rupture risk groups based on the PHASES score. Plasma levels of sAxl were measured using an enzyme-linked immunosorbent assay-based method. Computational fluid dynamics were used to calculate the morphological and hemodynamic parameters. Differences between clinical data, morphological-hemodynamic parameters and sAxl level were initially determined using univariate analysis. The variables (p ＜ 0.05) were included in a logistic regression model, and the specificity and sensitivity of the selected parameters were evaluated both graphically and statistically using receiver operating characteristic (ROC) curve methods. RESULTS: Aneurysm size ratio (p = 0.023), and normalized wall shear stress (WSS) (p = 0.02) showed significant differences between the two groups. Plasma concentrations of sAXL with a high rupture risk were significantly higher than the low rupture risk (8.47 ± 4.43 ng/ml vs. 5.37 ± 3.21 ng/ml; p = 0.016). Binary logistic regression analysis indicated that the concentration of sAxl was an independent determinant of high rupture risk (odds ratio=1.41, 95%CI=1.08-1.83, p = 0.011). The combination of sAxl + size ration (SR) + WSS achieved the highest area under the curve (0.849) for predicting rupture risk. CONCLUSIONS: Unruptured intracranial aneurysms with a higher rupture risk had a larger SR, lower WSS, and higher plasma sAxl concentration. Combining sAxl, SR, and WSS could help estimate the rupture risk of intracranial saccular aneurysm.

Changes of FSTL1 and MMP-9 levels in patients with acute cerebral infarction and its relationship with hemorrhagic transformation.

BACKGROUND: hemorrhagic transformation is a serious complication of acute ischemic stroke, which may lead to poor prognosis and delayed use of anticoagulant therapy. METHODS: 125 patients with cerebral infarction from December 2019 to December 2020 in the Second Affiliated Hospital of Zhejiang University were selected. All patients did not receive intravascular therapy, intravenous thrombolysis and other reperfusion treatment; and the relevant laboratory data were collected within 24 h after admission. At the same time, 15 healthy subjects were selected as the research objects for prospective analysis. Hemorrhagic transformation (HT) was defined as a condition in which computed tomography (CT) did not indicate bleeding at admission, but follow-up magnetic resonance imaging (MRI) or CT showed hemorrhage. The patients were divided into HT group (n = 50) and non-HT group (n = 75) according to whether there was HT after admission. The concentrations of FSTL1 and MMP-9 in peripheral blood of the two groups were detected. RESULTS: The concentrations of FSTL1 and MMP-9 in acute cerebral infarction (ACI) group were significantly higher than those in control group. However the HT group had a higher concentration of FSTL1 and MMP-9 than the non-HT group. The serum FSTL1 and MMP-9 were independent risk factors for hemorrhagic transformation. The area under the ROC curve of FSTL1 and MMP-9 in diagnosis of HT was 0.809 and 0.856 respectively, and their combined value was 0.923. CONCLUSION: The high levels of FSTL1 and MMP-9 had strong correlation with HT in ACI patients.

Can Tirofiban Improve the Outcome of Patients With Acute Ischemic Stroke: A Propensity Score Matching Analysis.

Objective: To evaluate the efficacy and safety of tirofiban for patients with acute ischemic stroke (AIS), especially posterior circulation stroke (PCS). Methods: We enrolled consecutive patients with AIS who suffered large artery occlusion (LAO) and underwent mechanical thrombectomy (MT) between January 2016 and May 2020. Patients were divided into two groups according to whether tirofiban was used during MT. The primary efficacy outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-2 at 3 months. The safety outcomes were the rate of mortality at 3 months and the presence of intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH). Cohorts were balanced using 1:1 propensity score matching (PSM). Subgroup analysis was further performed to compare the efficacy and safety of tirofiban between the anterior circulation stroke (ACS) and PCS groups. Results: A total of 292 patients were eligible for this study and divided into the tirofiban group (n = 51) and the no-tirofiban group (n = 241). In the propensity-score-matched cohort, the tirofiban group had a higher rate of favorable outcomes than the no-tirofiban group (49.0 vs. 25.5%, p = 0.014), and the mortality at 3 months showed a greater downward trend in the tirofiban group than the no-tirofiban group (15.6 vs. 33.3% p = 0.064). The risk of sICH and ICH was the same between the tirofiban and control groups (17.6 vs. 27.4% p = 0.236, 31.3 vs. 45.1% p = 0.154, respectively). Tirofiban use was predictive of favorable outcomes [adjusted odds ratio (aOR) = 2.87, 95% confidence interval (CI) 1.52-6.44, p = 0.043] after multiple logistic regression analysis. Subgroup analysis revealed that tirofiban use was significantly associated with favorable outcomes in ACS (aOR = 3.66, 95% CI 1.24-5.22, p = 0.019) but not in PCS (aOR = 1.12, 95% CI 0.47-7.52, p = 0.570). Conclusion: We demonstrated that tirofiban may be associated with improving favorable outcome for the AIS patients who underwent MT, without increasing ICH or sICH. Furthermore, our results indicated that for PCS patients tirofiban may not be associated with favorable outcome, and more comprehensive randomized controlled trials are needed to confirm this finding.

Endovascular treatment for ruptured vertebral dissecting aneurysms involving PICA: Reconstruction or deconstruction? Experience from 16 patients.

OBJECTIVE: Ruptured vertebral dissecting aneurysms (VDAs) with posterior inferior cerebellar artery (PICA) involved require an optimal method to isolate the dissection and prevent the symptomatic infraction. This study aims to present our experience with both parent artery occlusion (PAO) and stent-assisted coiling (SAC), and provide a favorable strategy to the management of ruptured VDAs with PICA involved. METHODS: We retrospectively reviewed patients with subarachnoid hemorrhage in our database from March 2013 to December 2018, suffering from dissecting aneurysms of the intradural vertebral arteries and endovascularly treated. A total of 16 cases with PICA involved were included. Basic information, aneurysm characteristics, procedure related complications and outcomes of patients were analyzed. RESULTS: 10 (62.5%) aneurysms were managed with PAO containing 3 proximal occlusion and 8 targeted-trapping preserved the PICA. 5 (31.3%) aneurysms were treated with SAC and one 6.3%) treated with vertebral artery to PICA stenting and trapping. Two (12.5%) patients died in the acute phase. Good clinical outcomes (modified Rankin Scale 0 to 3) were observed in 13(81.5%) cases in 30 days follow-up. PICA territory infraction was happened in one patient without any dysfunction. Favorable occlusion was observed in 9 of 12 (75%) which were free of further treatment. CONCLUSIONS: For patients with good contralateral circulation, PAO could be a first line management for ruptured VDAs with PICA involved. Targeted-trapping with either reserved PICA or proximal occlusion with moderate coiling in aneurysm are promising modalities to prevent severe PICA infraction.

In vivo measurement of cytoplasmic organelle water fraction using diffusion-weighted imaging: Application in the malignant grading and differential diagnosis of gliomas.

Recently, we have proposed a theoretical modified tri-exponential model for multi-b-value diffusion-weighted imaging (DWI) to measure the cytoplasmic organelle water fraction (COWF). This study aims to investigate whether COWF maps are effective in evaluating the malignant degree of gliomas and distinguishing primary central nervous system lymphomas (PCNSL) from gliomas.We performed this retrospective study based on our prospectively collected data. All patients underwent preoperative multi-b-value DWI. Parametric maps were derived from multi-b-value DWI maps using the modified tri-exponential model. Receiver operating characteristic analyses were used to assess the diagnostic accuracy of the parameter maps. Pearson correlation coefficients were calculated to investigate the correlations between the parameters and the Ki-67 proliferation index.A total of 66 patients were enrolled, including 16 low-grade gliomas (LGG), 45 high-grade gliomas (HGG), and 5 PCNSL. The mean COWF values were significantly different among LGG (3.1 ±â€Š1.4%), HGG (6.9 ±â€Š2.8%), and PCNSL (14.0 ±â€Š2.2%) (P < .001). The areas under the curves of the mean COWF value in distinguishing HGG from LGG and distinguishing PCNSL from gliomas were 0.899 and 0.980, respectively. The mean COWF value had a moderate correlation with the Ki-67 proliferation index (r = 0.647).The COWF map is useful in malignant grading of gliomas, and may be helpful in distinguishing PCNSL from gliomas.

Bright Edge Sign on High b-Value Diffusion-Weighted Imaging as a New Imaging Biomarker to Predict Poor Prognosis in Glioma Patients: A Retrospective Pilot Study.

Purpose: To investigate the prognostic value of bright edge sign observed on high b-value diffusion-weighted imaging (DWI) map in glioma patients. Methods: We retrospectively reviewed our prospectively collected database for gliomas. Bright edge sign was defined as the presence of extremely high signal in tumor margin on high b-value DWI map (b = 3,000 s/mm2) with the signal intensity higher than those in contralateral normal white matter and tumor central region. Extremely poor prognosis was defined as overall survival time < 9 months. Survival analyses were conducted by using the Cox regression for both the univariable and multivariable analyses. Results: A total of 52 patients were enrolled (WHO IV, 25; WHO III, 13; WHO II, 14). Bright edge sign presented in 10 (19.2%) patients (WHO IV, 5; WHO III, 3; WHO II, 2). Nine (90.0%) patients with bright edge sign had extremely poor prognosis, while only 1 (2.4 %) patient without bright edge sign had extremely poor prognosis. The sensitivity and specificity of bright edge sign in determining extremely poor prognosis were 90 and 97.7%, respectively. Bright edge sign (HR [95% CI] = 25.11 [7.26-86.81], p < 0.001) was an independent predictor of poor prognosis after adjustment. Conclusion: Bright edge sign on high b-value DWI may be an accurate predictor of extremely poor prognosis in glioma patients, regardless of pathologic grades.

A Modified Tri-Exponential Model for Multi-b-value Diffusion-Weighted Imaging: A Method to Detect the Strictly Diffusion-Limited Compartment in Brain.

Purpose: To present a new modified tri-exponential model for diffusion-weighted imaging (DWI) to detect the strictly diffusion-limited compartment, and to compare it with the conventional bi- and tri-exponential models. Methods: Multi-b-value diffusion-weighted imaging (DWI) with 17 b-values up to 8,000 s/mm2 were performed on six volunteers. The corrected Akaike information criterions (AICc) and squared predicted errors (SPE) were calculated to compare these three models. Results: The mean f0 values were ranging 11.9-18.7% in white matter ROIs and 1.2-2.7% in gray matter ROIs. In all white matter ROIs: the AICcs of the modified tri-exponential model were the lowest (p < 0.05 for five ROIs), indicating the new model has the best fit among these models; the SPEs of the bi-exponential model were the highest (p < 0.05), suggesting the bi-exponential model is unable to predict the signal intensity at ultra-high b-value. The mean ADCvery-slow values were extremely low in white matter (1-7 × 10-6 mm2/s), but not in gray matter (251-445 × 10-6 mm2/s), indicating that the conventional tri-exponential model fails to represent a special compartment. Conclusions: The strictly diffusion-limited compartment may be an important component in white matter. The new model fits better than the other two models, and may provide additional information.

Glioma infiltration sign on high b-value diffusion-weighted imaging in gliomas and its prognostic value.

BACKGROUND: Glioma cells may infiltrate beyond the tumor margins revealed on conventional structural images. PURPOSE: To investigate whether the presence of a glioma infiltration sign on high b-value diffusion-weighted imaging (DWI) can predict the prognosis of gliomas. STUDY TYPE: Retrospective cohort. SUBJECTS: Fifty-two patients with gliomas (14 WHO grade II; 13 WHO grade III; 25 WHO grade IV). FIELD STRENGTH/SEQUENCE: 3.0T, including a T1 -weighted contrast-enhanced (T1 w-CE) sequence, contrast-enhanced T2 -flair sequence, and a DWI sequence. ASSESSMENT: T1 w-CE images and contrast-enhanced T2 -flair images were used for identifying the tumor region for enhancing and nonenhancing gliomas, respectively. The glioma infiltration sign was defined as the presence of a peritumoral abnormal high signal region on DWI map, which was adjacent to the tumor region and had higher signal than surrounding areas. This sign was assessed on a high b-value DWI map with b = 3000 s/mm2 . For patients with glioma infiltration sign, DWI3000max , DWI1000max , ADC3000min , and ADC1000min were measured by drawing a region of interest over the peritumoral abnormal high signal region. STATISTICAL TESTS: Survival analysis was conducted by using Cox regression. RESULTS: Glioma infiltration sign was observed in 28 (53.8%) patients. The occurrence rate of this sign was 92.0% in grade IV gliomas, 30.8% in grade III gliomas, and 7.1% in grade II gliomas. The glioma infiltration sign could independently predict both the progression-free survival (hazard ratio [HR], 95% confidence interval [CI] = 8.58 [3.19-23.03], P < 0.001) and overall survival (HR, 95% CI = 11.90 [3.41-41.55], P < 0.001) after adjustment. For patients with glioma infiltration sign, DWI3000max (P = 0.005) and ADC3000min (P = 0.008) were both independent predictors of overall survival after adjustment, while DWI1000max and ADC1000min were not. DATA CONCLUSION: The glioma infiltration sign on high b-value DWI is an independent predictor of poor prognosis in glioma patients. High b-value DWI might be a convenient method to detect glioma infiltration. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018.

Apparent diffusion coefficient maps obtained from high b value diffusion-weighted imaging in the preoperative evaluation of gliomas at 3T: comparison with standard b value diffusion-weighted imaging.

OBJECTIVE: To assess whether ADC maps obtained from high b value DWI were more valuable in preoperatively evaluating the grade, Ki-67 index and outcome of gliomas. METHODS: Sixty-three patients with gliomas, who underwent preoperative multi b value DWI at 3 T, were enrolled. The ADC1000, ADC2000 and ADC3000 maps were generated. Receiver operating characteristic analyses were conducted to determine the area under the curve (AUC) in differentiating high-grade gliomas (HGG) from low-grade gliomas (LGG). Pearson correlation coefficients (R value) were calculated to investigate the correlation between parameters with the Ki-67 proliferation index. Survival analysis was conducted by using Cox regression. RESULTS: The AUC of the mean ADC1000 value (0.820) was lower than that of the mean ADC2000 value (0.847) and mean ADC3000 value (0.875) in differentiating HGG from LGG. The R value of the mean ADC1000 value (-0.499) was less negative than that of the mean ADC2000 value (-0.530) and mean ADC3000 value (-0.567). The mean ADC3000 value was an independent prognosis factor for gliomas (p = 0.008), while the mean ADC1000 and ADC2000 values were not. CONCLUSION: ADC maps obtained from high b value DWI might be a better imaging biomarker in the preoperative evaluation of gliomas. KEY POINTS: • ADC 3000 maps could improve the differentiation between HGG and LGG. • The mean ADC 3000 value had a closer correlation with the Ki-67 index. • The mean ADC 3000 value was an independent prognosis factor for gliomas.

Melatonin attenuates neuronal apoptosis through up-regulation of K(+) -Cl(-) cotransporter KCC2 expression following traumatic brain injury in rats.

Traumatic brain injury (TBI) initiates a complex cascade of neurochemical and signaling changes that leads to neuronal apoptosis, which contributes to poor outcomes for patients with TBI. The neuron-specific K(+) -Cl(-) cotransporter-2 (KCC2), the principal Cl(-) extruder in adult neurons, plays an important role in Cl(-) homeostasis and neuronal function. This present study was designed to investigate the expression pattern of KCC2 following TBI and to evaluate whether or not melatonin is able to prevent neuronal apoptosis by modulating KCC2 expression in a Sprague Dawley rat controlled cortical impact model of TBI. The time course study showed decreased mRNA and protein expression of KCC2 in the ipsilateral peri-core parietal cortex after TBI. Double immunofluorescence staining demonstrated that KCC2 is located in the plasma membrane of neurons. In addition, melatonin (10 mg/kg) was injected intraperitoneally at 5 minutes and repeated at 1, 2, 3, and 4 hours after brain trauma, and brain samples were extracted 24 hours after TBI. Compared to the vehicle group, melatonin treatment altered the down-regulation of KCC2 expression in both mRNA and protein levels after TBI. Also, melatonin treatment increased the protein levels of brain-derived neurotrophic factor (BDNF) and phosphorylated extracellular signal-regulated kinase (p-ERK). Simultaneously, melatonin administration ameliorated cortical neuronal apoptosis, reduced brain edema, and attenuated neurological deficits after TBI. In conclusion, our findings suggested that melatonin restores KCC2 expression, inhibits neuronal apoptosis and attenuates secondary brain injury after TBI, partially through activation of BDNF/ERK pathway.

[Pterional keyhole approach in surgical treatment of ruptured anterior circulation intracranial aneurysm: a report of 313 cases].

OBJECTIVE: To review the surgical modality with pterional keyhole approach in treatment of anterior circulation aneurysm. METHODS: Three hundred and thirteen patients with ruptured anterior circulation intracranial aneurysm treated surgically with pterional keyhole approach between January 2009 and June 2014 in Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, were included in the analysis. Complete occlusion rate of aneurysms and incidence of major complications including delayed cerebral ischemia and chronic hydrocephalus were documented. Surgical outcomes at 6-month follow up were assessed by modified Rankin Scale. RESULTS: Totally 348 aneurysms were treated with pterional keyhole approach, 326 aneurysms were completely clipped, 16 aneurysms were partly clipped, and 6 aneurysms were wrapped with gauze material. Among 313 patients, 15 patients (4.79%) suffered from delayed cerebral ischemia, and 10 patients (3.19%) suffered from hydrocephalus. At the 6-month follow up, the rate of good outcome was 66.77% (209/313). CONCLUSIONS: The pterional keyhole approach can be used to clip most of anterior circulation aneurysms, and it seems to have advantages over the traditional approaches with lower incidence of complications and similar outcomes.

Mirror-image arachnoid cysts in a pair of monozygotic twins: a case report and review of the literature.

Mirror-imaging of arachnoid cysts (ACs) in monozygotic twins (MZ) is extremely rare. We describe a pair of MZ who developed mirror-imaging of ACs in the temporal fossas, and we also review the literature. Brain computer tomography (CT) and Magnetic Resonance Imaging (MRI) of the MZ revealed mirror-imaging of vast lesions of cerebrospinal fluid intensity in their temporal fossas. This is the second ever report of such a case according to the available literature. Unlike the prior case, our patients were 14 months, which is a much younger age than the patients of the previous report. Consequently, our case is better in supporting a genetic origin in the pathogenesis of AC. The findings in our case indicate that early neuroimaging is mandatory in the counterpart of the symptomatic patient with AC, irrespective of the absence of symptoms.