Perfusion Computed Tomography as a Screening Tool for Pending Delayed Cerebral Ischemia in Comatose Patients After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is frequently complicated by delayed cerebral ischemia (DCI), leading to poor outcomes. Early diagnosis of DCI is crucial for improving survival and outcomes but remains challenging in comatose patients. In this study, we aimed to evaluate computed tomography with angiography and perfusion (P-CT) as a screening modality on postictal days four and eight for impending DCI after aSAH in comatose patients using vasospasm with hypoperfusion (hVS) as a surrogate and DCI-related infarction as an outcome measure. Two objectives were set: (1) to evaluate the screening's ability to accurately risk stratify patients and (2) to assess the validity of P-CT screening. METHODS: We conducted a retrospective review of the records of comatose patients with aSAH from January 2019 to December 2021 who were monitored with P-CT scans on days four and eight. The event rates of DCI-related infarction, hVS, and endovascular rescue therapy (ERT) were analyzed, and the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for DCI were calculated. DCI-related infarction was defined as new secondary cerebral infarction > 48 h < 6 weeks post aSAH not attributable to other causes, and hVS was defined as arterial narrowing with corresponding hypoperfusion on P-CT. RESULTS: Fifty-six comatose patients were included, and 98 P-CT scans were performed. The incidence of DCI-related infarction was 40%. Screening P-CT on days four and eight found vasospasm in 23% of all patients, including 11% with hVS. A positive hVS on day four or eight revealed a relative risk of 2.4 [95% confidence interval (CI) 1.13-5.11, p = 0.03], sensitivity of 23% (95% CI 8-45, p = 0.03), specificity of 95% (95% CI 36-100, p = 0.03), PPV of 0.83 (95% CI 0.36-1.00, p = 0.03), and NPV of 0.65 (95% CI 0.50-0.78). Six positive P-CT scans led to digital subtraction angiography in five patients, three of whom received ERT. All ERT-intervened patients developed DCI-related infarction. CONCLUSIONS: P-CT resulted in few interventions and often resulted in late detection of DCI at an irreversible stage. Although a positive P-CT result accurately predicts impending DCI-related infarction, screening on days four and eight alone in comatose patients with aSAH often fails to timely detect impending DCI. Based on our analysis, we cannot recommend P-CT as a screening modality. P-CT is likely best used as a confirmatory test prior to invasive interventions when guided by continuous multimodal monitoring; however, prospective studies with comparison groups are warranted. The need for a reliable continuous screening modality is evident because of the high rate of deterioration and narrow treatment window.

Magnetic resonance elastography in normal pressure hydrocephalus-a scoping review.

BACKGROUND: Magnetic resonance elastography (MRE) of the brain allows quantitative measurement of tissue mechanics. Multiple studies are exploring possible applications in normal pressure hydrocephalus (NPH) in clinical and paraclinical contexts. This is of great interest in neurological surgery due to challenges related to diagnosis and prediction of treatment effects. In this scoping review, we present a topical overview and discuss the current literature, with particular attention to clinical implications and current challenges. METHODS: The protocol was based on the PRISMA extension for scoping reviews. After a systematic database search (PubMed, Embase, and Web of Science), the articles were screened for relevance. Thirty articles were subject to detailed screening, and key technical and clinical data items were extracted. The inclusion criteria included the use of MRE on human subjects with NPH. RESULTS: Seven articles were included in the final study. These studies had various objectives including the role of MRE in the assessment of regional elastic changes in NPH, shunt effect, and evaluation of NPH symptoms. MRE revealed patterns of mechanical changes in NPH that differed from other dementias. Regional MRE changes were associated with specific NPH signs and symptoms. Neurosurgical shunting caused partial normalization in tissue scaffold parameters. The studies were highly heterogeneous in technical aspects and design. CONCLUSION: MRE studies in NPH are still limited by few participants, variable cohorts, inconsistent methodologies, and technical challenges, but the approach shows great potential for future clinical application.

Multiple formin proteins participate in glioblastoma migration.

BACKGROUND: The prognosis of glioblastoma remains poor, related to its diffuse spread within the brain. There is an ongoing search for molecular regulators of this particularly invasive behavior. One approach is to look for actin regulating proteins that might be targeted by future anti-cancer therapy. The formin family of proteins orchestrates rearrangement of the actin cytoskeleton in multiple cellular processes. Recently, the formin proteins mDia1 and mDia2 were shown to be expressed in glioblastoma in vitro, and their function could be modified by small molecule agonists. This finding implies that the formins could be future therapeutic targets in glioblastoma. METHODS: In cell studies, we investigated the changes in expression of the 15 human formins in primary glioblastoma cells and commercially available glioblastoma cell lines during differentiation from spheroids to migrating cells using transcriptomic analysis and qRT-PCR. siRNA mediated knockdown of selected formins was performed to investigate whether their expression affects glioblastoma migration. Using immunohistochemistry, we studied the expression of two formins, FHOD1 and INF2, in tissue samples from 93 IDH-wildtype glioblastomas. Associated clinicopathological parameters and follow-up data were utilized to test whether formin expression correlates with survival or has prognostic value. RESULTS: We found that multiple formins were upregulated during migration. Knockdown of individual formins mDia1, mDia2, FHOD1 and INF2 significantly reduced migration in most studied cell lines. Among the studied formins, knockdown of INF2 generated the greatest reduction in motility in vitro. Using immunohistochemistry, we demonstrated expression of formin proteins FHOD1 and INF2 in glioblastoma tissues. Importantly, we found that moderate/high expression of INF2 was associated with significantly impaired prognosis. CONCLUSIONS: Formins FHOD1 and INF2 participate in glioblastoma cell migration. Moderate/high expression of INF2 in glioblastoma tissue is associated with worse outcome. Taken together, our in vitro and tissue studies suggest a pivotal role for INF2 in glioblastoma. When specific inhibiting compounds become available, INF2 could be a target in the search for novel glioblastoma therapies.

Shift of microRNA profile upon glioma cell migration using patient-derived spheroids and serum-free conditions.

Glioblastoma multiforme (GBM) is the most frequent malignant primary brain tumor. A major reason for the overall median survival being only 14.6 months is migrating tumor cells left behind after surgery. Another major reason is tumor cells having a so-called cancer stem cell phenotype being therefore resistant towards traditional chemo- and radiotherapy. A group of novel molecular targets are microRNAs (miRNAs). MiRNAs are small non-coding RNAs exerting post-transcriptional regulation of gene expression. The aim of this study was to identify differentially expressed miRNAs in migrating GBM cells using serum-free stem cell conditions. We used patient-derived GBM spheroid cultures for a novel serum-free migration assay. MiRNA expression of migrating tumor cells isolated at maximum migration speed was compared with corresponding spheroids using an OpenArray Real-Time PCR System. The miRNA profiling revealed 30 miRNAs to be differentially expressed. In total 13 miRNAs were upregulated and 17 downregulated in migrating cells compared to corresponding spheroids. The three most deregulated miRNAs, miR-1227 (up-regulated), miR-32 (down-regulated) and miR-222 (down-regulated), were experimentally overexpressed. A non-significantly increased migration rate was observed after miR-1227 overexpression. A significantly reduced migration rate was observed after miR-32 and miR-222 overexpression. In conclusion a shift in microRNA profile upon glioma cell migration was identified using an assay avoiding serum-induced migration. Both the miRNA profiling and the functional validation suggested that miR-1227 may be associated with increased migration and miR-32 and miR-222 with decreased migration. These miRNAs may represent potential novel targets in migrating glioma cells.

Migrating glioma cells express stem cell markers and give rise to new tumors upon xenografting.

Glioblastoma (GBM) is the most frequent and malignant brain tumor with an overall survival of only 14.6 months. Although these tumors are treated with surgery, radiation and chemotherapy, recurrence is inevitable. A critical population of tumor cells in terms of therapy, the so-called cancer stem cells (CSCs), has been identified in gliomas and many other cancers. These tumor cells have a stem cell-like phenotype and are suggested to be responsible for tumor growth, chemo- and radio-resistance as well as recurrence. However, functional evidence for migrating glioma cells having a stem cell-like phenotype is currently lacking. In the present study, the aim was to characterize the phenotype of migrating tumor cells using a novel migration assay based on serum-free stem cell medium and patient-derived spheroid cultures. The results showed pronounced migration of five different GBM spheroid cultures, but not of the commercial cell line U87MG. An in vitro limiting dilution assay showed preserved but reduced spheroid formation capacity of migrating cells. Orthotopic xenografting in mice showed preserved but reduced tumorigenic capacity. Profiling of mRNAs revealed no significant deregulation of 16 predefined CSC-related genes and the HOX-gene list in migrating cells compared to spheroids. Determination of GBM molecular subtypes revealed that subtypes of spheroids and migrating cells were identical. In conclusion, migrating tumor cells preserve expression of stem cell markers and functional CSC characteristics. Since CSCs are reported to be highly resistant to therapy, these results emphasize that the CSC phenotype should be taken into consideration in future treatment of GBMs.

Shift of microRNA profile upon orthotopic xenografting of glioblastoma spheroid cultures.

Glioblastomas always recur despite surgery, radiotherapy and chemotherapy. A key player in the therapeutic resistance may be immature tumor cells with stem-like properties (TSCs) escaping conventional treatment. A group of promising molecular targets are microRNAs (miRs). miRs are small non-coding RNAs exerting post-transcriptional regulation of gene expression. In this study we aimed to identify over-expressed TSC-related miRs potentially amenable for therapeutic targeting. We used non-differentiated glioblastoma spheroid cultures (GSCs) containing TSCs and compared these to xenografts using a NanoString nCounter platform. This revealed 19 over-expressed miRs in the non-differentiated GSCs. Additionally, non-differentiated GSCs were compared to neural stem cells (NSCs) using a microarray platform. This revealed four significantly over-expressed miRs in the non-differentiated GSCs in comparison to the NSCs. The three most over-expressed miRs in the non-differentiated GSCs compared to xenografts were miR-126, -137 and -128. KEGG pathway analysis suggested the main biological function of these over-expressed miRs to be cell-cycle arrest and diminished proliferation. To functionally validate the profiling results suggesting association of these miRs with stem-like properties, experimental over-expression of miR-128 was performed. A consecutive limiting dilution assay confirmed a significantly elevated spheroid formation in the miR-128 over-expressing cells. This may provide potential therapeutic targets for anti-miRs to identify novel treatment options for GBM patients.

High levels of c-Met is associated with poor prognosis in glioblastoma.

The tyrosine kinase receptor c-Met has been suggested to be involved in crucial parts of glioma biology like tumor stemness, growth and invasion. The aim of this study was to investigate the prognostic value of c-Met in a population-based glioma patient cohort. Tissue samples from 238 patients with WHO grade I, II, III and IV tumors were analyzed using immunohistochemical staining and advanced image analysis. Strong c-Met expression was found in tumor cells, blood vessels, and peri-necrotic areas. At the subcellular level, c-Met was identified in the cytoplasm and in the cell membrane. Measurements of high c-Met intensity correlated with high WHO grade (p = 0.006) but no association with survival was observed in patients with WHO grade II (p = 0.09) or III (p = 0.17) tumors. High expression of c-Met was associated with shorter overall survival in patients with glioblastoma multiforme (p = 0.03). However the prognostic effect of c-Met in glioblastomas was time-dependent and only observed in patients who survived more than 8.5 months, and not within the first 8.5 months after diagnosis. This was significant in multivariate analysis (HR 1.99, 95 % CI 1.29-3.08, p = 0.002) adjusted for treatment and the clinical variables age (HR 1.01, 95 % CI 0.99-1.03, p = 0.30), performance status (HR 1.34, 95 % CI 1.17-1.53, p < 0.001), and tumor crossing midline (HR 1.28, 95 % CI 0.79-2.07, p = 0.29). In conclusion, this study showed that high levels of c-Met holds unfavorable prognostic value in glioblastomas.

Idiopathic normal pressure hydrocephalus: Validation of the DESH score as a prognostic tool for shunt surgery response.

OBJECTIVE: Several radiological markers have been linked to clinical improvement after shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). However, iNPH has no pathognomonic feature, and patients are still diagnosed as probable, possible, or unlikely cases based on clinical symptoms, imaging findings, and invasive supplementary tests. The predictive value of the disproportionately enlarged subarachnoid space hydrocephalus (DESH) score is not yet conclusively determined, but it might offer a more accurate diagnostic method. The aim of the present retrospective cohort study was to validate the predictive power of the DESH score for clinical improvement after shunt surgery in iNPH patients. METHODS: We retrospectively obtained presurgical MRI and/or CT scans from 71 patients with iNPH who underwent ventriculoperitoneal shunt surgery. Radiological images were evaluated for Evans index (EI), corpus callosal angle (CA), tight high convexity (THC), Sylvian fissure dilation, and focal sulci dilation. These markers were aggregated to determine the DESH score. Patient journal entries were used to subjectively determine the extent of improvement in gait function, urinary incontinence, and/or cognition as a measure of shunt surgery response. RESULTS: Multiple logistic regression analysis, controlling for age and sex (α = 0.05), showed that DESH score was significantly correlated (OR 1.77) with subjective shunt-surgery response at a minimum of 1-month follow-up. Patients with higher DESH scores were more likely to have a favorable response to shunt surgery. CONCLUSION: Aggregating radiological markers into the DESH score is useful for predicting shunt responders among iNPH patients and can aid the selection of patients for surgery. These findings provide further support for the DESH score as a diagnostic tool for iNPH.

Ventriculosinus shunt: a pilot study to investigate new technology to treat hydrocephalus and mimic physiological principles of cerebrospinal fluid drainage.

OBJECTIVE: Devices draining CSF to the intracranial venous sinus for the treatment of hydrocephalus have been tested in the past, and while clinically effective, have not shown efficacy in the long term. The majority of these devices become obstructed within 3 months due to endothelial overgrowth. In this study, the authors investigated a newly developed ventriculosinus (VS) shunt outlet device with the objective of showing it would remain patent for at least 6 months. METHODS: Twelve patients in need of shunting for hydrocephalus underwent an operation using the investigational device and were followed for 6 months to record patency of the shunt. RESULTS: In 10 patients, the shunt was patent at 6 months, with the outlet device remaining unobstructed. In the remaining 2 patients, one died just before reaching the 6-month endpoint, and in the other the outlet was misplaced during surgery and therefore ceased to function after 3 months. No occlusion of the internal jugular vein or thrombus formation was noted in any of the 12 cases. CONCLUSIONS: These findings indicate that the outlet device can remain patent and has the capability to mimic physiological drainage by diverting CSF to the intracranial sinus. Additional confirmation of its potential as part of a new VS shunt system and ultimately as a viable alternative for ventriculoperitoneal and ventriculoatrial shunting to reduce complication rates requires further clinical trials.

Idiopathic normal pressure hydrocephalus; treatment and outcome in the Region of Southern Denmark.

OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) is a prevalent and cost-effective disease to treat. However, no gold standard exists to confidently select patients for shunt surgery. The aim of this study was to investigate how patients with suspected iNPH at our center responded to shunt surgery and to compare pre-surgical variables between shunt responders and non-responders. METHODS: Preoperative baseline characteristics, MRI and/or CT scans were retrospectively obtained in 55 shunt-operated iNPH patients. Evan's index, third ventricle diameter, dilation of Sylvian fissures, tight high convexity, focal sulci, callosal angle, Rout value, MMSE score, CSF phosphorylated tau, CSF tau, and a combination of radiologic findings (DESH score) were compared according to whether or not patients expressed satisfactory response to shunt treatment at 1-month follow-up. RESULTS: Multiple logistic regression controlling for age and gender (α = 0.05) showed that tight high convexity, dilated Sylvian fissures, focal sulci, CSF tau, CSF phosphorylated tau, and DESH score correlated significantly with subjective shunt response at 1-month follow-up. CONCLUSION: In line with current literature, Shunt responders had lower levels of CSF tau and CSF phosphorylated tau compared to non-responders. While commonly used radiologic markers are of value, they can be aggregated into a score for better selection of shunt candidates.

Small ruptured intracranial aneurysms are overrepresented at the anterior and posterior communicating artery: Results of a multiple regression analysis.

Background: Anterior communicating artery (AcomA) represents the most common location for ruptured intracranial aneurysms (rIAs). Approximately 50% of all rIAs are smaller than 7 mm, but factors that lead to rupture are multifactorial. The study investigates whether AcomA location represents an independent risk factor for small size at time of rupture (<7 mm) in a cohort of aneurysmal subarachnoid hemorrhage (aSAH) when controlling for known risk factors. Methods: The aSAH cohort was retrospectively searched from our institution charts. The cohort was dichotomized into small aneurysms (<7 mm) or large aneurysms (≥7 mm). Risk factors for rupture were identified according to the unruptured intracranial aneurysm treatment score (UIATS). These were sex, age, location, smoking, hypertension, alcohol abuse, aneurysm morphology, multiplicity, previous SAH, and family history. With size as independent variable, a multiple regression analysis was performed including UIATS risk factors. Results: One-hundred and seventy-six patients were included in the study. About 49.4% of the aneurysms were <7 mm. Multiple regression analysis demonstrated that aneurysms located at AcomA and posterior communicating artery (PcomA) was significantly more frequent smaller than 7 mm, compared to middle cerebral artery (P = 0.006), internal carotid artery (other than PcomA) (P = 0.013), and posterior circulation (P = 0.017), when controlling for risk factors. Conclusion: Ruptured AcomA and PcomA aneurysms are more frequent smaller than 7 mm compared to other locations. Patients with unruptured UIA at either AcomA or PcomA may be at increased risk of rupture even if the size of the aneurysm is small. Further studies are needed to confirm this finding.

Magnetic Resonance Elastography in Intracranial Neoplasms: A Scoping Review.

BACKGROUND: Magnetic resonance elastography (MRE) allows noninvasive assessment of intracranial tumor mechanics and may thus be predictive of intraoperative conditions. Variations in the use of technical terms complicate reading of current literature, and there is need of a review using consolidated nomenclature. OBJECTIVES: We present an overview of current literature on MRE relating to human intracranial neoplasms using standardized nomenclature suggested by the MRE guidelines committee. We then discuss the implications of the findings, and suggest approaches for future research. METHOD: We performed a systematic literature search in PubMed, Embase, and Web of Science; the articles were screened for relevance and then subjected to full text review. Technical terms were consolidated. RESULTS: We identified 12 studies on MRE in patients with intracranial tumors, including meningiomas, glial tumors including glioblastomas, vestibular schwannomas, hemangiopericytoma, central nervous system lymphoma, pituitary macroadenomas, and brain metastases. The studies had varying objectives that included prediction of intraoperative consistency, histological separation, prediction of adhesiveness, and exploration of the mechanobiology of tumor invasiveness and malignancy. The technical terms were translated using standardized nomenclature. The literature was highly heterogeneous in terms of image acquisition techniques, post-processing, and study design and was generally limited by small and variable cohorts. CONCLUSIONS: MRE shows potential in predicting tumor consistency, adhesion, and mechanical homogeneity. Furthermore, MRE provides insight into malignant tumor behavior and its relation to tissue mechanics. MRE is still at a preclinical stage, but technical advances, improved understanding of soft tissue rheological impact, and larger samples are likely to enable future clinical introduction.

An increased potential for organ donors may be found among patients with out-of-hospital cardiac arrest.

INTRODUCTION: A prehospital system where obvious futile cases may be terminated prehospitally by physicians may reduce unethical treatment of dying patients. Withholding treatment in futile cases may seem ethically sound but may keep dying patients from becoming organ donors. The objective of this study was to characterise the prehospital patients who underwent organ donation. The aim was to alert prehospital physicians to a potential for an increase in the organ donor pool by considering continued treatment even in some prehospital patients with obvious fatal lesions or illness. METHODS: This is a retrospective register-based study from the Region of Southern Denmark. The prehospital medical records from patients who underwent organ donation after prehospital care from 1st of January 2016-31st of December 2020 were screened for inclusion. The outcome measures were prehospital diagnosis, vital parameters, and critical interventions. RESULTS: In the five year period, one-hundred-and-fifty-one patients were entered into a donation process in the health region following prehospital care. Sixteen patients were excluded due to limitations in data availability. Of the 135 patients included, 36.3% had a stroke. 36.7% of these patients were intubated prehospitally. 15.6% had subarachnoideal haemorrhage. 66.7% of these were intubated prehospitally. 10.4% suffered from head trauma. 64.3% of these patients were intubated at the scene. In 21.5% of the patients, the prehospitally assigned tentative diagnosis was missing or included a diverse spectrum of medical and surgical emergencies. Twenty-two patients (16.3%) were resuscitated from cardiac arrest. 81.8% were intubated at the scene. CONCLUSION: The majority of the patients who became organ donors presented prehospitally with intracranial pathology. However, 30% of the patients that later underwent an organ donation process had other prehospital diagnoses. Among these, one patient in six had out-of-hospital cardiac arrest. Termination of treatment in patients with cardiac arrest is not uncommon in physician-manned prehospital emergency medical systems. An organ donation process cannot be initiated prehospitally but can be shut down if treatment is withheld or terminated. We contend that there is a potential for enlarging the donor pool if the decision processes in out-of-hospital cardiac arrest include considerations concerning future procurement of organ donors.

von Hippel-Lindau disease: Updated guideline for diagnosis and surveillance.

von Hippel Lindau disease (vHL) is caused by a hereditary predisposition to multiple neoplasms, especially hemangioblastomas in the retina and CNS, renal cell carcinomas (RCC), pheochromocytomas, neuroendocrine pancreatic tumours (PNET) and endolymphatic sac tumours. Evidence based approaches are needed to ensure an optimal clinical care, while minimizing the burden for the patients and their families. This guideline is based on evidence from the international vHL literature and extensive research of geno- and phenotypic characteristics, disease progression and surveillance effect in the national Danish vHL cohort. We included the views and preferences of the Danish vHL patients, ensured consensus among Danish experts and compared with international recommendations. RECOMMENDATIONS: vHL can be diagnosed on clinical criteria, only; however, in most cases the diagnosis can be supported by identification of a pathogenic or likely pathogenic variant in VHL. Surveillance should be initiated in childhood in persons with, or at risk of, vHL, and include regular examination of the retina, CNS, inner ear, kidneys, neuroendocrine glands, and pancreas. Treatment of vHL manifestations should be planned to optimize the chance of cure, without unnecessary sequelae. Most manifestations are currently treated by surgery. However, belzutifan, that targets HIF-2α was recently approved by the U.S. Food and Drug Administration (FDA) for adult patients with vHL-associated RCC, CNS hemangioblastomas, or PNETs, not requiring immediate surgery. Diagnostics, surveillance, and treatment of vHL can be undertaken successfully by experts collaborating in multidisciplinary teams. Systematic registration, collaboration with patient organisations, and research are fundamental for the continuous improvement of clinical care and optimization of outcome with minimal patient inconvenience.

Endoscopic third ventriculostomy for adults with hydrocephalus: creating a prognostic model for success: protocol for a retrospective multicentre study (Nordic ETV).

INTRODUCTION: Endoscopic third ventriculostomy (ETV) is becoming an increasingly widespread treatment for hydrocephalus, but research is primarily based on paediatric populations. In 2009, Kulkarni et al created the ETV Success score to predict the outcome of ETV in children. The purpose of this study is to create a prognostic model to predict the success of ETV for adult patients with hydrocephalus. The ability to predict who will benefit from an ETV will allow better primary patient selection both for ETV and shunting. This would reduce additional second procedures due to primary treatment failure. A success score specific for adults could also be used as a communication tool to provide better information and guidance to patients. METHODS AND ANALYSIS: The study will adhere to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis reporting guidelines and conducted as a retrospective chart review of all patients≥18 years of age treated with ETV at the participating centres between 1 January 2010 and 31 December 2018. Data collection is conducted locally in a standardised database. Univariate analysis will be used to identify several strong predictors to be included in a multivariate logistic regression model. The model will be validated using K-fold cross validation. Discrimination will be assessed using area under the receiver operating characteristic curve (AUROC) and calibration with calibration belt plots. ETHICS AND DISSEMINATION: The study is approved by appropriate ethics or patient safety boards in all participating countries. TRIAL REGISTRATION NUMBER: NCT04773938; Pre-results.

[A growing complex cerebral artery aneurysm treated with cerebral bypass].

Fuciform, partly thrombosed giant middle cerebral artery (MCA) aneurysms constitute a relatively rare entity among intracranial aneurysms. Obliteration of these aneurysm poses a challenge for both neurosurgeons and neurointerventionalists. The present case report on a fuciform MCA aneurysm that continued to grow despite endovascular treatment. The aneurysm was successfully treated with an extracranial-to-intracranial bypass with trapping of the aneurysm. This case illustrates the continuous need for cerebral bypass techniques, even in the era of evolving endovascular techniques.

Mild trauma causing cervical fracture through transverse foramen leading to a vertebral arteriovenous fistula.

Vertebral arteriovenous fistula (vAVF) is an uncommon vascular disease defined as abnormal connections between the vertebral artery or its branches extracranially with nearby venous structures. This case report outlines the case of a man in his late 70s presenting with C1-C3 fractures after a mild trauma falling down a small staircase. CT angiogram (CTA) gave suspicion of vertebral artery dissection and pseudoaneurysm; however, digital subtraction angiography revealed a fracture-induced vAVF successfully treated endovascularly with coils. In conclusion, cervical fractures involving the transverse foramen regardless of trauma mechanism should result in a CTA. Endovascular treatment with ipsilateral vertebral artery closure is preferred due to its feasibility and safety.

[Endoscopic evacuation of deep intracerebral spontaneous haematoma].

Deep-seated intracerebral spontaneous haematomas (ICHs) pose a neurosurgical challenge in decision-making process as summarised in this review. No studies have been able to demonstrate a significant effect on surgical removal. The challenge to surgical removal is the damage the surgery causes to the healthy brain in connection with the surgical procedure. The application of minimally invasive techniques in the form of endoscopic removal of deep-seated ICHs, results in significantly less "trauma" to the healthy brain and hopefully a better prognosis for patients with deep-seated spontaneous ICHs.

Expression and prognostic value of the transcription factors EGR1 and EGR3 in gliomas.

Most glioblastoma patients have a dismal prognosis, although some survive several years. However, only few biomarkers are available to predict the disease course. EGR1 and EGR3 have been linked to glioblastoma stemness and tumour progression, and this study aimed to investigate their spatial expression and prognostic value in gliomas. Overall 207 gliomas including 190 glioblastomas were EGR1/EGR3 immunostained and quantified. A cohort of 21 glioblastomas with high P53 expression and available tissue from core and periphery was stained with double-immunofluorescence (P53-EGR1 and P53-EGR3) and quantified.EGR1 expression increased with WHO-grade, and declined by 18.9% in the tumour periphery vs. core (P = 0.01), while EGR3 expression increased by 13.8% in the periphery vs. core (P = 0.04). In patients with high EGR1 expression, 83% had methylated MGMT-promoters, while all patients with low EGR1 expression had un-methylated MGMT-promoters. High EGR3 expression in MGMT-methylated patients was associated with poor survival (HR = 1.98; 95%CI 1.22-3.22; P = 0.006), while EGR1 high/EGR3 high, was associated with poor survival vs. EGR1 high/EGR3 low (HR = 2.11; 95%CI 1.25-3.56; P = 0.005). EGR1 did not show prognostic value, but could be involved in MGMT-methylation. Importantly, EGR3 may be implicated in cell migration, while its expression levels seem to be prognostic in MGMT-methylated patients.

[Applications of cerebral bypass surgery in modern neurosurgery].

The indication for cerebral bypass has changed drastically within the latest two decades due to advances in medical therapy and endovascular treatment. In this review, we discuss the various types of cerebral bypass and their application in modern neurosurgery, from cerebral hypoperfusion including cerebral atherosclerosis and moyamoya disease, to the treatment of complex cerebral aneurysms and skull-base tumours. The number of Danish patients treated abroad with cerebral bypass over the latest decade warrants establishment of cerebral bypass surgery in Denmark.