Brain Activity Foreshadows Stock Price Dynamics.

Successful investing is challenging since stock prices are difficult to consistently forecast. Recent neuroimaging evidence suggests, however, that activity in brain regions associated with anticipatory affect may not only predict individual choice, but also forecast aggregate behavior out-of-sample. Thus, in two experiments, we specifically tested whether anticipatory affective brain activity in healthy humans could forecast aggregate changes in stock prices. Using functional magnetic resonance imaging, we found in a first experiment (n = 34, 6 females; 140 trials/subject) that nucleus accumbens activity forecast stock price direction, whereas anterior insula (AIns) activity forecast stock price inflections. In a second preregistered replication experiment (n = 39, 7 females) that included different subjects and stocks, AIns activity still forecast stock price inflections. Importantly, AIns activity forecast stock price movement even when choice behavior and conventional stock indicators did not (e.g., previous stock price movements), and classifier analysis indicated that forecasts based on brain activity should generalize to other markets. By demonstrating that AIns activity might serve as a leading indicator of stock price inflections, these findings imply that neural activity associated with anticipatory affect may extend to forecasting aggregate choice in dynamic and competitive environments such as stock markets.SIGNIFICANCE STATEMENT Many try but fail to consistently forecast changes in stock prices. New evidence, however, suggests that anticipatory affective brain activity may not only predict individual choice, but also may forecast aggregate choice. Assuming that stock prices index collective choice, we tested whether brain activity sampled during the assessment of stock prices could forecast subsequent changes in the prices of those stocks. In two neuroimaging experiments, a combination of previous stock price movements and brain activity in a region implicated in processing uncertainty and arousal forecast next-day stock price changes-even when behavior did not. These findings challenge traditional assumptions of market efficiency by implying that neuroimaging data might reveal "hidden information" capable of foreshadowing stock price dynamics.

Posterior fossa ICP monitoring: a tale of two compartments.

AIM: Measuring the intracranial pressure (ICP) of the infra-tentorial, posterior fossa compartment has long been avoided due to a lack of precedent and interpretability, as well as concern of damage to the underlying vital structures. In cases of posterior fossa insults however, the supra-tentorial compartment ICPs can be falsely reassuring. We aimed to measure the posterior fossa ICP in such a case and analyse the resulting data. METHODS: We present a case of posterior fossa ICP monitoring and discuss its safety profile, rationale and possible indications. RESULTS: Our comparison of the supra and infra-tentorial ICPs showed that there was a statistically significant difference in the two compartments. The infra-tentorial compartment had ICPs averaging 11.02 ± 2.24 mmHg whilst the supra-tentorial compartment averaged 4.94 ± 1.80 mmHg in the first 72 hours post-op (p < .01 on paired t-testing). After 72 hours, the pressures seemed to equilibrate and were 4.71 ± 2.6 and 3.88 ± 2.89 for the infra and supra-tentorial compartments respectively. CONCLUSION: We propose that where a patient with a posterior fossa insult exhibits signs and symptoms consistent with raised ICP but the supra-tentorial readings are normal, posterior fossa ICP monitoring can be considered.

Effects of institutional caseload of subarachnoid hemorrhage on mortality: a secondary analysis of administrative data.

BACKGROUND AND PURPOSE: Procedures requiring specific skill sets often have been shown to depend on institutional volume, that is, centers receiving a higher volume observe better outcomes in those patients. This relationship recently has been shown to exist for subarachnoid hemorrhage(SAH) patients in a large study in the United States. We aim to examine this relationship for SAH patients in England, restricting analysis to specialist neurosurgical units. METHODS: Aggregate counts of patients with SAH in 25 specialist neuroscience centers in England, from 2005 to 2011, were obtained from the Hospital Episode Statistics database maintained by the National Health Service Information Center. These data were linked with national mortality statistics to obtain counts of deaths. Poisson regression was used to investigate the relationship between institutional caseload of SAH and 6-month mortality from any cause. Six-month mortality rates and mortality ratios were computed. RESULTS: Annual institutional caseload of admissions with SAH was inversely related to 6-month mortality (P=0.009; r(2)=0.26). Each 100-patient increase in annual patient volume was associated with a 24% reduction in mortality (adjusted mortality ratio, 0.76; confidence interval, 0.67-0.87). This relationship was consistent across the entire range of annual institutional caseloads examined (29-367 cases for the lowest and highest volumes seen in a single center in 1 year). CONCLUSIONS: Our results provide support for management of SAH at high-volume centers and suggest that health care policy in this setting should pursue regionalization while ensuring an adequate geographic spread of access to care.

Endovascular revascularization of chronically occluded common carotid artery for symptomatic cerebral hypoperfusion.

Endovascular recanalization is increasingly being utilized in symptomatic patients with chronically occluded carotid arteries.1 In carefully selected patients, endovascular recanalization has shown to lower the risk of ischemic events when compared to medical management alone.1 However, successful endovascular revascularization is technically challenging and not without risk.1, 2 In this video, we demonstrate a case of a 64-year-old woman who presented with recurrent transient ischemic attacks. On imaging she was found to have a chronic total occlusion of the common carotid artery from the arch. After obtaining informed consent, the patient underwent a successful endovascular recanalization and stenting of a chronically occluded left common carotid artery with aid from an intravascular guided re-entry catheter. Post operatively the patient developed a neck hematoma which improved and she returned to her neurological baseline. She reported no further symptoms on her three month follow up.

Contemporary Management of Cranial Dural Arteriovenous Fistulas.

Cranial dural arteriovenous fistulas (dAVFs) are rare acquired neurovascular disorders that have the potential to profoundly alter the local and global cerebral venous drainage. Factors such as location, angioarchitecture, degree of shunting, and mode of presentation all appear to have some bearing on the natural history of dAVFs, which can vary from almost entirely benign to life-threatening. Accurate and evidence-based risk stratification is, therefore, key to informing important management decisions. The treatment strategies are nuanced and, for an already rare entity, can vary tremendously from 1 fistula to another. It is only through a thorough understanding of their behavior and the treatment options available that we will be able to deliver tailored treatment to the correct dAVF and the correct patient. We aimed to provide an up-to-date summary of the reported data on the natural history and predictors of aggressive behavior for cranial dAVFs in general, followed by site-specific management considerations.

Transvenous embolization of a cerebrospinal fluid-venous fistula for the treatment of spontaneous intracranial hypotension.

Cerebrospinal fluid-venous fistula is an increasingly recognized cause of spontaneous intracranial hypotension.1 The site of the leak is between the dural sleeve around a spinal nerve root and the surrounding foraminal veins. In appropriately investigated patients, transvenous embolization of the draining foraminal and paraspinal veins has been shown to be an effective way of treating the disease, with low periprocedural morbidity, improvement in symptoms and radiological appearances.2 Video 1 shows the technique employed in a typical case using Onyx (Medtronic, Minnesota, USA) to embolize a CSF-venous fistula at the right T10 neural foramen. neurintsurg;14/9/948/V1F1V1Video 1Video showing the technique for trans-venous embolization of a right T10 CSF-venous fistula for the treatment of spontaneous intracranial hypotension. The first section covers patient selection and work up, before then focusing on the technical aspects of navigating through the azygos system to the target foramen and completely occluding the pathway for CSF outflow.

Combined CSF-venous Fistula and middle meningeal artery embolization for treatment of spontaneous intracranial hypotension.

Transvenous Onyx embolization was recently described as an effective treatment of spontaneous intracranial hypotension caused by CSF-venous fistulas. Patients with CSF-venous fistulas can present with a wide spectrum of clinical and imaging findings, sometimes including spontaneous subdural hematomas, subdural hygromas, or a combination of both. Here, we describe four patients with spontaneous intracranial hypotension complicated by subdural fluid collections caused by CSF-venous fistulas. The patients were treated with transvenous Onyx embolization of their CSF-venous fistulas and transarterial particle embolization of the bilateral middle meningeal arteries, with both procedures performed in a single treatment session. All four patients had clinical improvement and decreased size or resolution of their subdural fluid collections. Based on our findings, we believe that middle meningeal embolization could be a useful adjunct to CSF-venous fistula embolization. A case-control study comparing patients who did or did not undergo middle meningeal embolization will be necessary to validate this supposition.

Serum albumin and survival in glioblastoma multiforme.

Serum albumin is an established predictor of survival in numerous cancers but its prognostic value in central nervous system tumours has not been established. Here we have examined prognostic factors in 685 patients with histologically proven glioblastoma multiforme (GBM), the majority of which (n = 549) had pre-operative serum albumin assayed. Mean serum albumin was 34.7 g/l (SD 5.2). Post-operative survival was significantly less for patients with hypoalbuminaemia (<30 g/l, n = 82) than for patients with normal albumin level (median 2.3 vs. 5.6 months, P < 0.001 Log-rank test). Furthermore, patients with lower normal albumin (30-40 g/l, n = 371) had significantly shorter survival compared against patients with albumin in the upper normal range (40-50 g/l, n = 96; median 5.1 vs. 8.8 months, P < 0.001). Multivariate Cox regression showed the independent predictors of survival were age, debulking surgery, chemoradiotherapy, and serum albumin (Hazard Ratio 0.97 per g/l, P < 0.005). This study suggests pre-operative serum albumin level is a significant predictor of survival in patients with GBM. Further studies are needed to examine the relationship between albumin and other known prognostic factors, and to determine if pre-operative serum albumin is a clinically useful predictor of survival.

Vessel Wall Imaging After Subarachnoid Hemorrhage in Patients with Multiple Intracranial Aneurysms: A Cautionary Case.

BACKGROUND: Almost 30% of patients with subarachnoid hemorrhage (SAH) are found to have multiple aneurysms. This can potentially present a serious management dilemma when planning treatment. Magnetic resonance imaging vessel wall imaging (VWI) has been proposed as a reliable technique in differentiating between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms who present with SAH. Expert consensus now supports this as a possible use for the technique. CASE DESCRIPTION: Here we present a patient presenting a particular clinical dilemma with SAH and a left third nerve palsy and transient speech disturbance who had circumferential enhancement in the left larger 3.5-mm irregular middle cerebral artery aneurysm and no detectable enhancement in what was angiographically either a 1.5-mm smooth noncompressive left posterior communicating artery aneurysm or infundibulum, but was proved at surgery to be the culprit aneurysm. CONCLUSION: Although a case of concurrent false positive and false negative in the same patient has not previously been reported, the positive predictive value of VWI for rupture status is known to be much lower than its negative predictive value, and a case like this might be expected to occur in 0.6% of patients. Therefore, whereas VWI is a valuable tool, it should be used in conjunction with, and not in lieu of, traditional indicators of aneurysm rupture.

Apparent Effects of Opioid Use on Neural Responses to Reward in Chronic Pain.

Neural responses to incentives are altered in chronic pain and by opioid use. To understand how opioid use modulates the neural response to reward/value in chronic pain, we compared brain functional magnetic resonance imaging (fMRI) responses to a monetary incentive delay (MID) task in patients with fibromyalgia taking opioids (N = 17), patients with fibromyalgia not taking opioids (N = 17), and healthy controls (N = 15). Both groups of patients with fibromyalgia taking and not taking opioids had similar levels of pain, psychological measures, and clinical symptoms. Neural responses in the nucleus accumbens to anticipated reward and non-loss outcomes did not differ from healthy controls in either fibromyalgia group. However, neural responses in the medial prefrontal cortex differed, such that patients with fibromyalgia not taking opioids demonstrated significantly altered responses to anticipated rewards and non-loss outcomes compared to healthy controls, but patients with fibromyalgia taking opioids did not. Despite limitations including the use of additional non-opioid medications by fibromyalgia patients taking opioids, these preliminary findings suggest relatively "normalized" neural responses to monetary incentives in chronic pain patients who take opioids versus those who do not.

Altered prefrontal correlates of monetary anticipation and outcome in chronic pain.

Chronic pain may alter both affect- and value-related behaviors, which represents a potentially treatable aspect of chronic pain experience. Current understanding of how chronic pain influences the function of brain reward systems, however, is limited. Using a monetary incentive delay task and functional magnetic resonance imaging (fMRI), we measured neural correlates of reward anticipation and outcomes in female participants with the chronic pain condition of fibromyalgia (N = 17) and age-matched, pain-free, female controls (N = 15). We hypothesized that patients would demonstrate lower positive arousal, as well as altered reward anticipation and outcome activity within corticostriatal circuits implicated in reward processing. Patients demonstrated lower arousal ratings as compared with controls, but no group differences were observed for valence, positive arousal, or negative arousal ratings. Group fMRI analyses were conducted to determine predetermined region of interest, nucleus accumbens (NAcc) and medial prefrontal cortex (mPFC), responses to potential gains, potential losses, reward outcomes, and punishment outcomes. Compared with controls, patients demonstrated similar, although slightly reduced, NAcc activity during gain anticipation. Conversely, patients demonstrated dramatically reduced mPFC activity during gain anticipation-possibly related to lower estimated reward probabilities. Further, patients demonstrated normal mPFC activity to reward outcomes, but dramatically heightened mPFC activity to no-loss (nonpunishment) outcomes. In parallel to NAcc and mPFC responses, patients demonstrated slightly reduced activity during reward anticipation in other brain regions, which included the ventral tegmental area, anterior cingulate cortex, and anterior insular cortex. Together, these results implicate altered corticostriatal processing of monetary rewards in chronic pain.

Association of Neural Responses to Drug Cues With Subsequent Relapse to Stimulant Use.

Importance: Although chronic relapse is a characteristic of addiction to stimulants, conventional measures (eg, clinical, demographic, and self-report) do not robustly identify which individuals are most vulnerable to relapse. Objectives: To test whether drug cues are associated with increased mesolimbic neural activity in patients undergoing treatment for stimulant use disorder and whether this activity is associated with risk for subsequent relapse. Design, Setting, and Participants: This prospective cohort study of 76 participants included a control group for baseline group comparisons. Veteran patients (n = 36) with stimulant use disorders were recruited from a 28-day residential treatment program at the Veterans Affairs Palo Alto Health Care System. Healthy controls (n = 40) were recruited from the surrounding community. Baseline data were collected between September 21, 2015, and January 26, 2018, from patients and healthy controls using functional magnetic resonance imaging during a performance of a reward cue task. Patients' stimulant use was subsequently assessed after treatment discharge (at approximately 1, 3, and 6 months) to assess relapse outcomes. Main Outcomes and Measures: Primary measures included neural responses to drug and food cues in estimated mesolimbic volumes of interest, including the medial prefrontal cortex, nucleus accumbens (NAcc), and ventral tegmental area. The primary outcome variable was relapse (defined as any stimulant use), assessed both dichotomously (3 months after discharge) and continuously (days to relapse). Brain activity measures were contrasted between groups to validate neural measures of drug cue reactivity, which were then used to estimate relapse outcomes of patients. Results: Relative to controls (n = 40; 16 women and 24 men; mean [SD] age, 32.0 [11.6] years), patients (n = 36; 2 women and 34 men; mean [SD] age, 43.4 [13.3] years) showed increased mesolimbic activity in response to drug cues (medial prefrontal cortex, t74 = 2.90, P = .005, Cohen d = 0.66; NAcc, t74 = 2.39, P = .02, Cohen d = 0.54; and ventral tegmental area, t74 = 4.04, P < .001, Cohen d = 0.92). In patients, increased drug cue response in the NAcc (but not other volumes of interest) was associated with time to relapse months later (Cox proportional hazards regression hazard ratio, 2.30; 95% CI, 1.40-3.79). After controlling for age, NAcc response to drug cues classified relapsers (12 patients; 1 woman and 11 men; mean [SD] age, 49.3 [14.1] years) and abstainers (21 patients; 1 woman and 20 men; mean [SD] age, 39.3 [12.3] years) at 3 months with 75.8% classification accuracy. Model comparison further indicated that NAcc responses to drug cues were associated with relapse above and beyond estimations of relapse according to conventional measures. Conclusions and Relevance: Responses in the NAcc to stimulant cues appear to be associated with relapse in humans. Identification of neural markers may eventually help target interventions to the most vulnerable individuals.

Striatal dopamine deficits predict reductions in striatal functional connectivity in major depression: a concurrent 11C-raclopride positron emission tomography and functional magnetic resonance imaging investigation.

Major depressive disorder (MDD) is characterized by the altered integration of reward histories and reduced responding of the striatum. We have posited that this reduced striatal activation in MDD is due to tonically decreased stimulation of striatal dopamine synapses which results in decremented propagation of information along the cortico-striatal-pallido-thalamic (CSPT) spiral. In the present investigation, we tested predictions of this formulation by conducting concurrent functional magnetic resonance imaging (fMRI) and 11C-raclopride positron emission tomography (PET) in depressed and control (CTL) participants. We scanned 16 depressed and 14 CTL participants with simultaneous fMRI and 11C-raclopride PET. We estimated raclopride binding potential (BPND), voxel-wise, and compared MDD and CTL samples with respect to BPND in the striatum. Using striatal regions that showed significant between-group BPND differences as seeds, we conducted whole-brain functional connectivity analysis using the fMRI data and identified brain regions in each group in which connectivity with striatal seed regions scaled linearly with BPND from these regions. We observed increased BPND in the ventral striatum, bilaterally, and in the right dorsal striatum in the depressed participants. Further, we found that as BPND increased in both the left ventral striatum and right dorsal striatum in MDD, connectivity with the cortical targets of these regions (default-mode network and salience network, respectively) decreased. Deficits in stimulation of striatal dopamine receptors in MDD could account in part for the failure of transfer of information up the CSPT circuit in the pathophysiology of this disorder.