Intraluminal assessment of inflammatory factors in patients with intracranial aneurysms.

BACKGROUND: The formation, growth, and rupture of intracranial aneurysms (IA) are due to several pathophysiological mechanisms, including focal hemodynamic injury and inflammation of the arterial wall. We investigated the differences between venous, parent artery, and intra-aneurysmal blood by measuring inflammatory factors and antibodies in patients with ruptured (rIA) or unruptured intracranial aneurysms (uIA). METHOD: A prospective study was performed in patients who presented with IA and required endovascular treatment. Blood was drawn from the lumen of the aneurysm sac, the parent artery, and the peripheral veins, to determine the serum concentrations of complement factors C3, C4, IgG, IgM, IgA antibodies, and C-reactive protein (CRP). RESULTS: Thirty-six patients (15 with uIA and 21 with rIA) were enrolled in the study. In both groups, C3, C4, IgM, IgG, and IgA showed a gradual decrease from venous to intra-aneurysmal samples, but only IgG in the parent artery and intra-aneurysmal samples reached a significant decrease in uIA compared with venous samples. Accordingly, C3 and IgG concentrations in the intra-aneurysmal samples showed a significant decrease in rIA compared with venous samples. A significant increase in CRP concentrations was observed in parent artery and intra-aneurysmal samples from patients with rIA compared with patients with uIA; a significant increase in C3 concentrations was observed in parent artery samples from patients with rIA compared with patients with uIA, and a significant decrease in IgM concentrations was observed in venous, parent artery, and intra-aneurysmal samples from patients with rIA compared with patients with uIA. CONCLUSIONS: A decrease in C3 and IgG in the aneurysm sac indicates activation of the complement system in the arterial wall. CRP in the aneurysm sac and lumen of the parent artery was significantly increased in ruptured compared with unruptured aneurysms, whereas venous, parent artery, and intra-aneurysmal IgM were decreased in ruptured compared with unruptured aneurysms. These results argue for the role of an ongoing inflammatory process in aneurysms leading to their growth and rupture.

Effects of COVID-19 on the admissions of aneurysmal subarachnoid hemorrhage: the West Greece experience.

BACKGROUND: Acute subarachnoid hemorrhage (SAH) due to aneurysmal rupture is a devastating vascular disease accounting for 5% of strokes. COVID-19 pandemic resulted in a decrease in elective and emergency admissions in the majority of neurosurgical centers. The main hypothesis was that fear of COVID-19 may have prevented patients with critical medical or surgical emergencies from actively presenting in emergency departments and outpatient clinics. METHODS: We conducted a single-center, retrospective, observational study searching our institutional data regarding the incidence of spontaneous subarachnoid hemorrhage (SAH) and compare the admissions in two different periods: the pre COVID-19 with the COVID-19 period. RESULTS: The study cohort was comprised of a total of 99 patients. The mean (SD) weekly case rate of patients with SAH was 1.1 (1.1) during the pre-COVID-19 period, compared to 1.7 (1.4) during the COVID-19 period. Analysis revealed that the volume of admitted patients with SAH was 1.5-fold higher during the COVID period compared to the pre-COVID period and this was statistically significant (ExpB = 1.5, CI 95% 1-2.3, p = 0.044). Difference in mortality did not reach any statistical significance between the two periods (p = 0.097), as well as patients' length of stay (p = 0.193). CONCLUSIONS: The presented data cover a more extended time period than so far published reports; it is reasonable that our recent experience may well be demonstrating a general realistic trend of overall increase in aneurysmal rupture rates during lockdown. Hospitalization of patients with SAH cannot afford any reductions in facilities, equipment, or personnel if optimum outcomes are desirable.

Review of current treatment modalities and clinical outcome of giant saccular aneurysms of the basilar apex.

Introduction: Giant aneurysms of the basilar apex represent formidable challenges as the high rupture rate of untreated lesions must be balanced against the technical complexity and potential morbidity of intervention. Research question: Review of treatment modalities and outcomes of patients harboring giant (>2.5 cm) basilar apex saccular aneurysms, in an effort to refine treatment decision-making. Material and methods: A systematic literature review through the PubMed and Scopus databases was performed according to the PRISMA guidelines to identify cases of giant basilar apex saccular aneurysms treated either microsurgically or endovascularly. Patients' demographics, aneurysm size, preoperative and postoperative neurologic status, angiographic and clinical outcomes as well as follow-up information were obtained. Results: Data from 32 studies fulfilling the inclusion criteria, including 49 patients (32 treated surgically and 17 endovascularly) was obtained. Mean patient age at presentation was 51.69 years, with a male-to-female ratio of 1:2. Mean maximum aneurysm diameter was 30.57 mm. A favorable outcome (mRS 0-2) was reported on 70.6% of endovascular and 56.3% of open surgical cases. Complete aneurysm occlusion was achieved in 55.6% of the open and 23.5% of the endovascular cases. Death rate was 33% for endovascular and 15.6% for open cases; the higher mortality of endovascular treatment is mainly attributed to the mass effect from continued brainstem compression after treatment. Discussion and conclusion: Higher rates of complete occlusion but higher morbidity are associated with microsurgery compared to endovascular modalities. Severe, clinically apparent brainstem mass effect may require decompression associated with microsurgery, when technically feasible.

Assessment of organ doses, peak skin doses and effective doses in patients undergoing anterior cervical discectomy and fusion utilising VirtualDose-IR software.

In this study, the effect of patient- and procedure-related parameters on organ doses (ODs), peak skin dose (PSD) and effective dose (E) during anterior cervical discectomy and fusion (ACDF) was evaluated. Patient- and procedure-related parameters, as well as fluoroscopy time, kerma-area product (KAP), cumulative air-kerma (Kair) and incident Kair, were analysed for 50 ACDF procedures performed with a mobile C-arm. These parameters were inserted in VirtualDose-IR software implementing sex-specific and body mass index (BMI)-adjustable anthropomorphic phantoms to calculate OD, PSD and E. The BMI, gender and type of implants did not significantly affect KAP, incident Kair, PSD and E. However, the type of fusion significantly affected the E. The single fusions in C5/C6 resulted in significantly higher KAP, incident Kair and E than C4/C5 levels, while those performed in C6/C7 resulted in significantly higher E and PSD than C4/C5 levels. The thyroid, oesophagus and salivary glands received the largest doses in all groups studied. The BMI did not significantly affect ODs. The salivary glands absorbed significantly higher doses in males than females, while the extrathoracic region's dose significantly increased for multi- than single-level fusions. The fusions in C6/C7 resulted in significantly higher oesophagus and thyroid doses than C3/C4 and C4/C5 levels, as well as fusions performed in C5/C6 compared with C4/C5 levels. The data presented here could be used by the neurosurgeons as a comparator for future studies in optimising radiation protection during ACDF procedures in the operating theatre by keeping the ODs, PSD and E as low as reasonably practicable.

Bioenergetic Profiling in Glioblastoma Multiforme Patients with Different Clinical Outcomes.

The accumulation of cell biomass is associated with dramatically increased bioenergetic and biosynthetic demand. Metabolic reprogramming, once thought as an epiphenomenon, currently relates to disease progression, also in response to extracellular fate-decisive signals. Glioblastoma multiforme patients often suffer misdiagnosis, short survival time, low quality of life, and poor disease management options. Today, tumor genetic testing and histological analysis guide diagnosis and treatment. We and others appreciate that metabolites complement translational biomarkers and molecular signatures in disease profiling and phenotyping. Herein, we coupled a mixed-methods content analysis to a mass spectrometry-based untargeted metabolomic analysis on plasma samples from glioblastoma multiforme patients to delineate the role of metabolic remodeling in biological plasticity and, hence, disease severity. Following data processing and analysis, we established a bioenergetic profile coordinated by the mitochondrial function and redox state, lipids, and energy substrates. Our findings show that epigenetic modulators are key players in glioblastoma multiforme cell metabolism, in particular when microRNAs are considered. We propose that biological plasticity in glioblastoma multiforme is a mechanism of adaptation and resistance to treatment which is eloquently revealed by bioenergetics.

Suction thrombectomy using a microcatheter as a salvage method for acute distal occlusion during cerebral aneurysm embolization: A case report.

The aneurysm coiling process presents a risk of thromboembolic complications, mostly in patients with ruptured aneurysms, given the fact that they cannot receive antiplatelet therapy. Management strategies include medical anticoagulation or antiplatelet therapy, intra-arterial thrombolysis, and mechanical thrombectomy using direct aspiration first-pass technique or stent retrievers. We report our own experience of using an Excelsior SL-10 Microcatheter (Stryker, Fremont, California, USA) with an internal diameter of 0.0165", originally designed for coil delivery, for contact aspiration of a thrombotic occlusion of a distal anterior cerebral artery during coiling of a broad-based trilobar anterior communicating artery aneurysm. The clot was removed under continuous manual aspiration, and complete recanalization has been accomplished. Mechanical thrombectomy through microcatheter aspiration may be a safe and feasible treatment option for acute distal artery occlusions, especially in the case of tortuous distal vessels during embolization of cerebral aneurysms.

Successful treatment of pan-drug resistant Acinetobacter baumannii nosocomial meningitis/ventriculitis by combined intravenous and intrathecal colistin-tigecycline administration: a case series.

Background: This study aims to evaluate the efficacy of combined intraventricular and intravenous co-administration of colistin and tigecycline in the management of pan-drug resistant Acinetobacter baumannii meningitis/ventriculitis. Methods: In this case series we report 3 patients with healthcare-associated ventriculitis/meningitis caused by pan-drug resistant Acinetobacter baumannii that were treated with combined colistin and tigecycline administration through both intraventricular and intravenous routes. Results: All patients were administered colistin intraventricularly at a dose of 250.000 IU q.d. and intravenously at 9 million IU loading dose, followed after 12 hours by maintenance dose of 4.5 million IU every 12 hours and tigecycline intraventricularly at a dose of 10 mg b.i.d. and intravenously at 200 mg loading dose followed after 12 hours by 100 mg every 12 hours. In patients with a calculated creatinine clearance of less than 60 ml/min, according to the Cockcroft-Gault formula, the maintenance dose of colistin was reduced based on a modified formula. All patients had a favourable clinical and microbiological response with evidence of CSF sterilization. Conclusions: Taking advantage of the synergistic action of combined colistin and tigecycline through administration both intraventricularly and intravenously may be a promising salvage option for critically ill patients with pan-drug resistant A. baumannii CNS infection.

A 3-miRNA Signature Enables Risk Stratification in Glioblastoma Multiforme Patients with Different Clinical Outcomes.

Malignant gliomas constitute a complex disease phenotype that demands optimum decision-making as they are highly heterogeneous. Such inter-individual variability also renders optimum patient stratification extremely difficult. microRNA (hsa-miR-20a, hsa-miR-21, hsa-miR-21) expression levels were determined by RT-qPCR, upon FFPE tissue sample collection of glioblastoma multiforme patients (n = 37). In silico validation was then performed through discriminant analysis. Immunohistochemistry images from biopsy material were utilized by a hybrid deep learning system to further cross validate the distinctive capability of patient risk groups. Our standard-of-care treated patient cohort demonstrates no age- or sex- dependence. The expression values of the 3-miRNA signature between the low- (OS > 12 months) and high-risk (OS < 12 months) groups yield a p-value of <0.0001, enabling risk stratification. Risk stratification is validated by a. our random forest model that efficiently classifies (AUC = 97%) patients into two risk groups (low- vs. high-risk) by learning their 3-miRNA expression values, and b. our deep learning scheme, which recognizes those patterns that differentiate the images in question. Molecular-clinical correlations were drawn to classify low- (OS > 12 months) vs. high-risk (OS < 12 months) glioblastoma multiforme patients. Our 3-microRNA signature (hsa-miR-20a, hsa-miR-21, hsa-miR-10a) may further empower glioblastoma multiforme prognostic evaluation in clinical practice and enrich drug repurposing pipelines.

Hemorrhage of a Cavernous Hemangioma of the Brainstem Presenting with Fever of Unknown Origin: A Case Report.

BACKGROUND Cavernous malformations (CMs) or hemangiomas are benign vascular hamartomas of the central nervous system (CNS) that constitute 5-15% of all CNS vascular malformations. Most patients with brainstem CMs present with a sudden onset of seizures, intracranial hemorrhage, cranial nerve deficits, headache, or ataxia. Up to 20% to 50% of patients are asymptomatic, and their CMs are diagnosed incidentally on brain magnetic resonance imaging. CASE REPORT We present a case of a 42-year-old man with a brainstem cavernous hemangioma presenting with fever of unknown origin and mild headache without meningismus. The patient underwent a midline suboccipital craniectomy and removal of a ruptured brainstem cavernous hemangioma and the surrounding thrombus. Postoperatively, the patient developed left facial nerve palsy, left abducens nerve palsy, and xerostomia. Abducens palsy and xerostomia resolved spontaneously days after the operation. At the 6-month follow-up, the patient showed stable improvement with resolution of his neurological deficits. CONCLUSIONS To our knowledge, there is no reported case of a patient with a ruptured brainstem cavernoma presenting with fever of unknown origin as the main symptom. We assume that the minimal intraventricular hemorrhage triggered the hypothalamic thermoregulating mechanism. Thus, it would be useful for physicians to raise the suspicion of a ruptured brainstem cavernous malformation with further imaging evaluation when investigating fever of unknown origin.

Tubular laminectomy and percutaneous vertebroplasty for aggressive vertebral hemangioma.

BACKGROUND: Vertebral hemangiomas (VH) are the most common benign vascular neoplasms of the spine. Aggressive VH (AVH) may become symptomatic due to soft-tissue expansion/extraosseous extension into the paraspinal and/or epidural spaces. There are several options for treating painful AVH, including radiotherapy and/or open surgery. CASE DESCRIPTION: A 59-year-old male presented with a 2-year history of intermittent back pain and progressive thoracic myelopathy in the past 2 months. MRI revealed a T9 level lesion, with high-intensity signal on both T1 and T2 images and an extraosseous component with significant cord compression. We performed minimally invasive tubular unilateral laminotomy for bilateral decompression of the thoracic spine at the T9 level, followed by bilateral percutaneous vertebroplasty with biopsy. Postoperatively, the pain was immediately relieved, and the myelopathy improved. The biopsy confirmed the diagnosis of a VH. CONCLUSION: Combining minimally invasive techniques consisting of tubular laminectomy and percutaneous vertebroplasty are safe and effective ways for treating AVHs.

Ruptured infectious ICA pseudoaneurysm into the sphenoid sinus after maxillofacial infection, successfully treated by selective embolization.

BACKGROUND: Intracranial infectious aneurysms are cerebral aneurysms caused by pathogen-induced inflammation undermining the arterial wall. We present a rare case of inflammatory pseudoaneurysm of cavernous internal carotid artery (ICA). CASE DESCRIPTION: A 51-year-old female with a recent diagnosis of acute lymphoblastic leukemia developed maxillofacial infection with Pseudomonas and Acinetobacter after chemotherapy onset. Initial plain computed tomography (CT) revealed bony dehiscence of the left ICA canal, as well as bilateral protrusion of the vessel within the sphenoid sinus. Following infection spread into the left sphenoid sinus, she presented with episodes of intermittent epistaxis, without any profound vascular abnormalities on postcontrast CT. CT angiography that was performed 15 days later, due to refractory epistaxis, illustrated a large narrow necked irregular shape pseudoaneurysm of the left paraophthalmic ICA, extending into the ipsilateral sphenoid sinus. The aneurysm was completely occluded by selective embolization without parent or adjacent vessel sacrifice, documented on both intraoperative and follow-up angiogram, with no recurrence of epistaxis. CONCLUSION: Conclusively, ruptured internal carotid infectious aneurysms are rare but potentially fatal causes of epistaxis when extended into the sphenoid sinus. Selective coiling is feasible and can provide definitive treatment of these lesions.

Spontaneous thoracolumbar epidural hematoma in an apixaban anticoagulated patient.

BACKGROUND: Spontaneous spinal epidural hematomas (SSEHs) are often attributed to anticoagulation. Although they are rare, they may contribute to significant morbidity and mortality. CASE DESCRIPTION: An 83-year-old female with a history of atrial fibrillation on apixaban, presented with 4 days of back pain, progressive lower extremity weakness and urinary retention. When the patient's MRI showed a dorsal thoracolumbar SSEH, the patient underwent a T10-L3 laminectomy for hematoma evacuation. Within 2 postoperative months, her neurological deficits fully resolved. CONCLUSION: Apixaban is associated with SSEH resulting in severe neurological morbidity and even mortality. Prompt MRI imaging followed by emergency surgical decompressive surgery may result in full resolution of neurological deficits.