Monocyte Count on Admission Is Predictive of Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage.

The authors sought to evaluate whether immunologic counts on admission were associated with shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage. A retrospective analysis of 143 consecutive patients with aneurysmal subarachnoid hemorrhage over a 9-year period was performed. A stepwise algorithm was followed for external ventricular drain weaning and determining the necessity of shunt placement. Data were compared between patients with and without shunt-dependent hydrocephalus. Overall, 11.19% of the cohort developed shunt-dependent hydrocephalus. On multivariate logistic regression analysis, acute hydrocephalus (OR: 61.027, 95% CI: 3.890-957.327; p = 0.003) and monocyte count on admission (OR: 3.362, 95% CI: 1.024-11.037; p = 0.046) were found to be independent predictors for shunt dependence. Receiver operating characteristic curve analysis for the prediction of shunt-dependent hydrocephalus confirmed that monocyte count exhibited an acceptable area under the curve (AUC = 0.737, 95% CI: 0.601-0.872; p < 0.001). The best predictive cutoff value to discriminate between successful external ventricular drain weaning and shunt-dependent hydrocephalus was identified as a monocyte count ≥0.80 × 103/uL at initial presentation. These preliminary data demonstrate that a monocyte count ≥0.80 × 103/uL at admission predicts shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage; however, further large-scale prospective trials and validation are necessary to confirm these findings.

Case Report: Metastatic Bronchopulmonary Carcinoid Tumor to the Pineal Region.

Intracranial spread of a systemic malignancy is common in advanced staged cancers; however, metastasis specifically to the pineal gland is a relatively rare occurrence. A number of primary lesions have been reported to metastasize to the pineal gland, the most common of which is lung. However, metastasis of a bronchial neuroendocrine tumor to the pineal gland is a seldom-reported entity. Here, we present a 53-year-old female who presented with worsening headaches and drowsiness. MRI brain revealed a heterogeneously enhancing partially cystic mass in the pineal region. The patient had an extensive oncologic history consisting of remote stage IIA invasive breast ductal carcinoma as well as a more recently diagnosed atypical bronchopulmonary neuroendocrine tumor with lymph node metastases. She underwent microsurgical volumetric resection of the large pineal mass and a gross total removal of the tumor was achieved. Histopathology confirmed a metastatic tumor of neuroendocrine origin and the immunohistochemical profile was identical to the primary bronchopulmonary carcinoid tumor. Eight weeks after surgery, she underwent stereotactic radiosurgical treatment to the resection cavity. At 1-year follow-up, the patient remains clinically stable without any new focal neurological deficits and without any evidence of residual or recurrent disease on postoperative MRI. Metastatic neuroendocrine tumors should be considered in the differential diagnosis of pineal region tumors and aggressive surgical resection should be considered in selected patients. Gross total tumor resection may afford excellent local disease control. We discuss the relevant literature on neuroendocrine tumors and current treatment strategies for intracranial metastases of neuroendocrine origin.

Factors affecting R01 grant funding among academic neurosurgeons over the last decade.

BACKGROUND: Recent studies have reported a gender and medical degree disparity for those receiving Research Project Grants in surgical specialties. The aim of the present study is to analyze factors among academics neurosurgeons that correlate to higher amounts of R01 grant monies awarded. MATERIALS AND METHODS: The National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Results database was queried for neurosurgery funding between 2008 and 2018. Grant recipients were categorized among type of degree, secondary degree(s), professorship, gender, and h - index. Statistical analysis was performed. RESULTS: The National Institutes of Health awarded 480 R01 grants totaling $182,482,644 to 81 allopathic neurosurgeons between 2008 and 2018. No osteopathic neurosurgeons were awarded an R01 grant during this timeframe. There was a significant difference for type of professorship on the total awarded amount at the p < 0.05 level for the three types of professorship [F (2,78) = 4.85, p < 0.01)]. There was a significant difference for magnitude of h - index on total R01 monies (p < 0.00001). Males accounted for the majority of R01 monies (93.99%); however, no significant difference between average amount awarded and gender was identified (p = 0.86). A secondary degree was without significant difference for R01 amount awarded (p = 0.75). CONCLUSIONS: The present study establishes a medical degree disparity for academic neurosurgeons who receive an R01 grant. Statistically significant factors found to affect amount of R01 grant monies awarded were limited to type of professorship and magnitude of h - index.

Spontaneous necrotizing granuloma of the cerebellum: a case report.

BACKGROUND: Intracranial necrotizing granulomatous space-occupying lesions are sparsely reported in literature. Variability in presenting symptomatology and radiographic features makes diagnostic work-up difficult. CASE PRESENTATION: This report presents the case of a 77-year-old female with sinusitis and fatigue who underwent an MRI revealing a posterior fossa lesion compressing the fourth ventricle. Subsequent contrast CT of the chest, abdomen, and pelvis was negative for primary malignancy. Histopathologic examination of the lesion following biopsy showed it to be a necrotizing granuloma in an antineutrophil cytoplasmic antibody (ANCA) negative patient. The most likely diagnosis was determined to be spontaneous necrotizing granuloma, a rare entity with only one previous report noted. CONCLUSIONS: Spontaneous necrotizing granuloma of the CNS is a rare entity that represents an important differential consideration in the work-up of space occupying lesions of the CNS.

Recurrent Cerebral Vasospasm and Delayed Cerebral Ischemia Weeks Subsequent to Elective Clipping of an Unruptured Middle Cerebral Artery Aneurysm.

BACKGROUND: Cerebral vasospasm and delayed ischemic neurologic deficits are well-known clinical aftereffects of subarachnoid hemorrhage due to rupture of an intracranial aneurysm. However, vasospasm with consequential ischemia after clipping of an unruptured aneurysm is an exceedingly rare sequela encountered in the reported neurosurgical literature. CASE DESCRIPTION: A 53-year-old woman had presented for elective craniotomy with microsurgical clipping of an unruptured left middle cerebral artery bifurcation saccular aneurysm, which was successfully treated without complications. Despite an initially benign clinical course, she experienced diffuse vasospasm with profound ischemic neurologic deficits on postoperative day 13 with a left middle cerebral artery distribution ischemic infarct. Moreover, she developed recurrent delayed spasm of the right posterior cerebral artery on postoperative day 26 and, consequentially, a left homonymous hemianopsia despite treatment with intra-arterial verapamil infusion. CONCLUSIONS: To the best of our knowledge, we have reported the first case of recurrent cerebral vasospasm and delayed ischemia neurologic deficits weeks subsequent to clipping of an unruptured aneurysm. The findings from the present case highlight the importance of considering delayed vasospasm as a cause of acute onset neurologic symptoms for patients who have recently undergone elective aneurysm surgery. We also reviewed the current data regarding the epidemiology, surgical factors, and proposed pathophysiologic mechanisms related to vasospasm after elective cases.

Corticosteroid-Induced Regression of Glioblastoma: A Radiographic Conundrum.

Corticosteroid-induced regression of lesion contrast enhancement on imaging studies is most commonly appreciated with primary central nervous system lymphoma; however, although exceedingly rare, a limited number of primary and metastatic intracranial lesions have been reported to exhibit similar radiographic changes subsequent to corticosteroid therapy. To date, there have been six cases of glioblastoma reported to exhibit such changes. Lesion transformation on repeat imaging after the initiation of steroids represents a diagnostic dilemma for clinicians when attempting to differentiate between a diagnosis of glioblastoma and lymphoma. Stereotactic biopsy may be inadvertently postponed due to high clinical suspicion for steroid-induced cytotoxicity traditionally seen with lymphomatous cells. To highlight this radiographic conundrum, we present a rare case of corticosteroid-induced regression of glioblastoma and discuss the relevant literature. To our knowledge, this is the first case report to describe the molecular profile of a glioblastoma that underwent corticosteroid-induced regression.

Rapidly fatal encephalitis associated with atypical lymphoid proliferations of the basal ganglia subsequent to aneurysmal subarachnoid hemorrhage.

Rapidly fatal encephalitis associated with atypical lymphoid proliferations after intracranial aneurysm rupture has not been reported. Here, we describe a 52-year-old female who presented to the emergency department with a severe headache. Imaging demonstrated aneurysmal subarachnoid hemorrhage due to a ruptured left posterior inferior cerebellar artery aneurysm, which was treated with endovascular embolization and subsequent external ventricular drain. She recovered without neurologic sequelae by day seven; however, five weeks later she represented with a severe headache associated with nausea and fever. Initial repeat imaging was unremarkable. She deteriorated quickly and was empirically treated for meningitis despite negative cerebrospinal fluid studies. Magnetic resonance imaging revealed diffuse cerebral edema within the basal ganglia and thalamus. Biopsy of the caudate nuclei revealed atypical lymphoid proliferations. She was treated accordingly with no significant improvement. This case highlights the necessity for a better understanding of the etiology, chronology, and natural history of atypical lymphoid proliferations.

Neoplastic Cerebral Aneurysm from Metastatic Lung Adenocarcinoma with Neuroendocrine Features.

BACKGROUND: Neoplastic cerebral aneurysms are exceedingly rare. We describe a case of a ruptured, distal middle cerebral artery aneurysm as the presenting symptom leading to the identification of metastatic lung cancer. CASE DESCRIPTION: The patient underwent an uncomplicated surgical trapping and ligation of the aneurysm. Histopathologic examination of the aneurysm confirmed the neoplastic cerebral aneurysm was due to a metastatic lung adenocarcinoma with neuroendocrine features. The patient subsequently underwent stereotactic radiosurgery to the resection cavity. CONCLUSIONS: Neoplastic cerebral aneurysms are rare, and there are insufficient data to support specific guidelines for management. This case is novel as the patient received adjuvant stereotactic radiosurgery to the operative bed, as well as systemic chemotherapy, and has maintained good functional status as of last follow-up at 6 months.

Beta 3 subunit of G-protein and its influence on autonomic nervous system in patients with vasovagal syncope.

OBJECTIVES: The aim of this prospective study was to investigate the impact of genetic polymorphisms of ß3 subunit of G-protein on the occurrence of vasovagal syncope, hemodynamic parameters and heart rate variability during head-up tilt test (HUT). BACKGROUND: G-proteins play an important role in the intracellular transmission of impulses in cardiovascular autonomic reflexes. METHODS: In 157 patients with suspected vasovagal syncope HUT was performed. Ninety-one patients (38 men, 53 women, mean age 48 ± 17 years) had positive HUT. Control group consisted of 109 subjects (69 men, 40 women, mean age 37 ± 16 years) with no history of syncope. Results of HUT, hemodynamic parameters and LF, HF, LF/HF, SDNN, RMSSD parameters of heart rate variability were compared in patients with different genotypes. C825T polymorphism of ß3 subunit of G-protein was determined in the study subjects. RESULTS: There was no significant difference in the distribution of genotypes between patients and control group. Also, there was no significant difference in hemodynamic parameters. A statistically significant difference was found between genotypes in LF/HF in the early HUT (mean rank CC: 48.68 vs CT: 35.51 vs TT: 34.14; p = 0.039) and at RMSSD at the time of syncope (mean rank CC: 32.38 vs CT: 42.74 vs TT: 18.50; p = 0.026). CONCLUSIONS: In this study, the relation of C825T polymorphism of ß3 subunit of G-protein to vasovagal syncope was not documented (Tab. 2, Fig. 4, Ref. 37).

Reduced baroreflex sensitivity in patients with vasovagal syncope.

OBJECTIVES: The evidence is conflicting regarding the role of baroreflex in patients with vasovagal syncope. The aim of the study was to measure baroreflex sensitivity (BRS) and hemodynamic parameters during head up tilt test (HUT) with nitroglycerine stimulation. METHODS: Nitroglycerine stimulated HUT was performed in 51 patients with the history of recurrent syncope (mean age 46±19 years, 18 men, 23 women). Cardiac output (CO), stroke volume (SV), left-ventricular ejection time (LVET) and total peripheral resistance (TPR) were assessed during HUT by volume-clamp method using a beat-to-beat photopletysmography. Spontaneous BRS sensitivity was computed using a sequential BRS calculation. RESULTS: HUT was positive after nitroglycerine administration in 28 patients and negative in 23 patients. BRS was lower at the time of syncope in HUT positive group compared to end-test values in HUT negative group (0.54±0.27 vs 0.72±0.35, p=0.03). At the time of syncope, CO was significantly lower in HUT positive patients compared to HUT negative patients (2.6±1.4 vs 4.3±1.4 l/min, p<0.0001), similarly as SV (34.7±14.7 vs 49.2±19 ml, p=0.005). LVET was significantly higher in syncopal patients (282.27±26.2 vs 240.5±58.8 ms, p=0.002) and TPR did not differ between two groups. CONCLUSIONS: Reduced BRS may contribute to the development of the vasovagal syncope by inability to adequately counteract hypotension resulting from decreased cardiac output at the time of syncope (Tab. 3, Ref. 18).