An integrative survival analysis and a systematic review of the cerebellopontine angle glioblastomas.

Glioblastomas presenting topographically at the cerebellopontine angle (CPA) are exceedingly rare. Given the specific anatomical considerations and their rarity, overall survival (OS) and management are not discussed in detail. The authors performed an integrative survival analysis of CPA glioblastomas. A literature search of PubMed, Scopus, and Web of Science databases was performed per PRISMA guidelines. Patient data including demographics, clinical features, neuroimaging, management, follow-up, and OS were extracted. The mean age was 39 ± 26.2 years. The mean OS was 8.9 months. Kaplan-Meier log-rank test and univariate Cox proportional-hazards model identified hydrocephalus (log-rank, p = 0.034; HR 0.34; 95% CI 0.12-0.94; p = 0.038), chemotherapy (log-rank, p < 0.005; HR 5.66; 95% CI 1.53-20.88; p = 0.009), and radiotherapy (log-rank, p < 0.0001; HR 12.01; 95% CI 3.44-41.89; p < 0.001) as factors influencing OS. Hydrocephalus (HR 3.57; 95% CI 1.07-11.1; p = 0.038) and no adjuvant radiotherapy (HR 0.12; 95% CI 0.02-0.59; p < 0.01) remained prognostic on multivariable analysis with fourfold and twofold higher risk for the time-related onset of death, respectively. This should be considered when assessing the risk-to-benefit ratio for patients undergoing surgery for CPA glioblastoma.

Venous thromboembolic and hemorrhagic events after meningioma surgery: A single-center retrospective cohort study of risk factors.

Microsurgical resection of meningiomas in a majority of cases leads to a favorable outcome. Therefore, severe postoperative adverse events are less acceptable. The main purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) and hemorrhagic complications in patients after operative treatment of intracranial meningiomas and to identify the risk factors in this patient subgroup. Of 106 patients undergoing elective craniotomy for meningioma overall incidence of symptomatic VTE was noted in 5.7% (six patients). For the risk-factor analysis older age (57.20 ± 11.60 vs. 71.00 ± 0.90 years, p < 0.001), higher body mass index (27.60 ± 4.80 vs. 33.16 ± 0.60 kg/m2, p < 0.001), WHO grade II (3.00% vs. 33.33%, p = 0.02), lower intraoperative blood loss (466.00 ± 383.70 vs. 216.70 ± 68.30 mL, p < 0.001), bedridden status and neurologic deficit (0.00% vs. 33.33%, p = 0.003 and 38.00% vs. 100.00%, p = 0.004) were associated with greater VTE risk. No risk factors for hemorrhagic complications were identified on univariate analysis. In conclusion, the incidence of VTE in meningioma patients is not negligible. Identified risk factors should be taken into account in the decision-making process for chemoprophylaxis when the risk of bleeding decreases.

Metabolomics as a potential tool for monitoring patients with aneurysmal subarachnoid hemorrhage.

Metabolomics has evolved into a particularly useful tool to study interactions between metabolites and serves as an aid in unraveling the complexity of entire metabolomes. Nonetheless, it is increasingly viewed as a methodology with practical applications in the clinical setting, where identifying and quantifying biomarkers of interest could prove useful for diagnostics. Starting from a concise overview of the most prominent analytical techniques employed in metabolomics, herein we present a review of its application in studies of brain metabolism and cerebrovascular diseases, paying most attention to its uses in researching aneurysmal subarachnoid hemorrhage. Both animal models and human studies are considered, and metabolites identified as potential biomarkers are highlighted.

Primary Intraparenchymal Meningiomas: A Case Report and a Systematic Review.

BACKGROUND: Primary intraparenchymal meningiomas are exceedingly rare and often challenging to diagnose, given their misleading radiologic features. It is hypothesized that they arise from the cap cells of the pia mater that enter the brain via penetrating blood vessels during brain development. We systematically reviewed and analyzed previously reported features of primary intraparenchymal meningiomas in terms of radiography, presenting symptoms, and histopathology. METHODS: A literature search of the Web of Science and PubMed databases and crossed references was performed in March 2021, per PRISMA guidelines, with no restrictions regarding publication date. Data regarding demographic features, clinical, radiographic, and histopathologic characteristics were extracted. RESULTS: A total of 52 patients (including the reported case) were included in this review. The mean age was 21.1 years (range, 0.3-66 years) with a male/female ratio of 1.9:1. The most common localizations of intraparenchymal meningiomas were in the frontal (30.8%) and temporal (21.2%) lobes. Cyst formation was more readily observed and was noted in 51.4% of patients. Histopathology showed a higher incidence of World Health Organization grade II (14/52, 26.9%) and World Health Organization grade III (7/52, 13.5%) of primary intraparenchymal meningiomas. CONCLUSIONS: We present a comprehensive analysis of every reported primary intraparenchymal meningioma. Because of their rarity and capacity to mimic other more common intra-axial tumors, they represent a diagnostic challenge. This systematic review highlights the importance of paying attention to atypical intra-axial lesions, with a particular reflection on the discrepancy between clinical characteristics and imaging features.

Comparison of radiological versus clinical cerebral vasospasm after aneurysmal subarachnoid hemorrhage: is vasospasm always present?

OBJECTIVES: Radiological and clinical cerebral vasospasm (CV) is defined either as a delayed narrowing of cerebral arteries after aneurysmal subarachnoid hemorrhage (aSAH) or/and occurrence of new neurological deficit/worsening of Modified Glasgow coma score for 2 or more points. The objective of this study is to determine the presence and correlation between clinical and radiological presence of vasospasm in patients with aSAH. METHODS: This study was designed as a clinical, prospective single center study at the Clinic of Neurosurgery, Clinical Center of Vojvodina, Novi Sad, Serbia. A total of 50 patients was included in the study after having radiologically confirmed aSAH. Intensity and region of CV was determined by CT and CTA performed both on admission and on day 9 of hospitalization, except for cases where clinical protocol required earlier imaging due to occurrence of clinical signs and symptoms of CV. In all patients, values of arterial blood pressure (PABP), headache (HA), body temperature (PBT), nonspecific behaviors (NSB), deterioration of consciousness (DC), new neurological deficit (NND), deterioration of two points or more per modified Glasgow Coma Scale (DmGCS ≥ 2) were monitored. RESULTS: CTA showed angiographic vasospasm detected in 100% patients with aSAH. Statistically significant positive correlation was found between the intensity of radiological CV and appearance of NND and DmGCS ≥ 2. CONCLUSIONS: This study confirms that CV always follows aSAH. Future research into pathophysiology of CV is needed in order to determine exact treatment strategies and targets so treatment towards zero mortality can be achieved.

FACTORS ASSOCIATED WITH DEPRESSION IN PATIENTS WITH SCHIZOPHRENIA.

The aim of this study was to analyze risk factors present in schizophrenic patients with depressive symptomatology. The sample comprised of 76 respondents diagnosed with schizophrenia. In the study, we used the Positive and Negative Syndrome Scale (PANSS) and Calgary Depression Scale for Schizophrenia. The prevalence of depression was estimated to be 30%. The mean scores on the negative subscale of the PANSS were significantly higher in patients with schizophrenia and depression compared to control group (U=3.64, p=0.00), and so were those on the General Psychopathology Scale (U=4.91, p=0.00). Socio-demographic factors were identified as important factors (p<0.05). Personal and environmental factors such as loneliness, immediate social environment, social support and isolation were statistically significantly different between the groups (p<0.05). There was a correlation of poor compliance with psycho-pharmacotherapy, increased number of hospitalizations and shorter remission period with the severity of clinical presentation (p<0.05). Since the presence of these factors is associated with depression in schizophrenia, their early detection in clinical practice is vital to ensure timely prevention of the development of depressive symptomatology.

Post-Concussion Symptoms in Complicated vs. Uncomplicated Mild Traumatic Brain Injury Patients at Three and Six Months Post-Injury: Results from the CENTER-TBI Study.

The aim of this study was to assess the occurrence of post-concussion symptoms and post-concussion syndrome (PCS) in a large cohort of patients after complicated and uncomplicated mild traumatic brain injury (mTBI) at three and six months post-injury. Patients were included through the prospective cohort study: Collaborative European NeuroTrauma Effectiveness Research (CENTER-TBI). Patients enrolled with mTBI (Glasgow Coma Scale 13-15) were further differentiated into complicated and uncomplicated mTBI based on the presence or absence of computed tomography abnormalities, respectively. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) assessed post-concussion symptoms and PCS according to the mapped ICD-10 classification method. The occurrence of post-concussion symptoms and syndrome at both time points was calculated. Chi square tests were used to test for differences between and within groups. Logistic regression was performed to analyse the association between complicated versus uncomplicated mTBI and the prevalence of PCS. Patients after complicated mTBI reported slightly more post-concussion symptoms compared to those after uncomplicated mTBI. A higher percentage of patients after complicated mTBI were classified as having PCS at three (complicated: 46% vs. uncomplicated: 35%) and six months (complicated: 43% vs. uncomplicated 34%). After adjusting for baseline covariates, the effect of complicated versus uncomplicated mTBI at three months appeared minimal: odds ratio 1.25 (95% confidence interval: 0.95-1.66). Although patients after complicated mTBI report slightly more post-concussion symptoms and show higher PCS rates compared to those after uncomplicated mTBI at three and six months, complicated mTBI was only found a weak indicator for these problems.

Nocardial brain abscess mimicking lung cancer metastasis in immunocompetent patient with pulmonary nocardiasis: a case report.

Nocardia is a ubiquitous microorganism which can be the cause of local and disseminated infection in humans. Immunocompetent and immunocompromised patients both can be affected and Nocardia cyriacigeorgica was reported as a pathogen isolated in patients worldwide. In most cases, nocardiosis is present as pulmonary infection because inhalation is the primary way of bacterial exposure. Nocardial brain abscess occurs usually secondary to a septic focus elsewhere in the body. Considering the facts that the elderly population is growing, such as the number of immunocompromised patients together with high mortality rate in patients with nocardial infection of the central nervous system, we have to raise awareness of the possibility for this rare but potentially fatal condition. We present a case where nocardial abscesses of lung and brain were initially suspected as lung cancer with brain metastases. The patient was treated with a combination of surgical resection and antimicrobial therapy with good outcome.

Benefit and outcome of using temozolomide-based chemoradiotherapy followed by temozolomide alone for glioblastoma in clinical practice.

PURPOSE: Temozolomide (TEM), an oral alkylating agent, has shown promising activity in the last 10 years in the treatment of glioblastoma multiforme (GBM). Our goal was to show the benefit of concomitant therapy involving 3D conformal radiotherapy and temozolomide in clinical practice. METHODS: This was a retrospective/prospective study and included a total of 113 patients with GBM diagnosis. Forty- seven patients received postoperative radiotherapy and 66 received concomitant temozolomide plus 3D conformal radiotherapy. RESULTS: The mean overall survival of patients who received postoperative radiotherapy alone was 9.93±6.475 months, compared to statistically longer overall survival in the group of patients who received radiotherapy plus temozolomide (13.89±8.049 months) (p=0.006). The latter group was divided into two subgroups, one consisting of patients who received 6 complete cycles of temozolomide, and a second with patients who received incomplete treatment. Statistically significant longer overall survival was registered in the first subgroup compared to the second (p=0.006). CONCLUSION: The concomitant usage of temozolomide and radiotherapy was beneficial, and statistically significant difference among groups and subgroups was observed regarding overall survival.

Endoscopic repair of cerebrospinal fluid rhinorrhea.

INTRODUCTION: Nasal liquorrhea indicates a cerebrospinal fluid fistula, an open communication between the intracranial cerebrospinal fluid and the nasal cavity. It can be traumatic and spontaneous. OBJECTIVE: The aim of this study was to assess the outcome of endoscopic repair of cerebrospinal fluid fistula using fluorescein. METHODS: This retrospective study included 30 patients of both sexes, with a mean age of 48.7 years, treated in the period from 2007 to 2015. All patients underwent lumbar administration of 5% sodium fluorescein solution preoperatively. Fistula was closed using three-layer graft and fibrin glue. RESULTS: Cerebrospinal fluid fistulas were commonly located in the ethmoid (37%) and sphenoid sinus (33%). Most patients presented with traumatic cerebrospinal fluid fistulas (2/3 of patients). The reported success rate for the first repair attempt was 97%. Complications occurred in three patients: one patient presented with acute hydrocephalus, one with reversible encephalopathy syndrome on the fifth postoperative day with bilateral loss of vision, and one patient was diagnosed with hydrocephalus two years after the repair of cerebrospinal fluid fistula. CONCLUSION: Endoscopic diagnosis and repair of cerebrospinal fluid fistulas using fluorescein intrathecally has high success rate and low complication rate.

Pituitary Abscess with Unusual Clinical Course

The aim is to present unusual clinical course and magnetic resonance imaging (MRI) features of pituitary abscess. A 59-year-old man presented with fever, polyuria, polydipsia and marked weight loss within the last two months. Basic endocrinology tests revealed the presence of anterior pituitary dysfunction, associated with central diabetes insipidus and increased levels of inflammatory markers. The presence of expansile sellar lesion, showing restricted diffusion signal pattern compatible with acute pituitary pyogenic abscess was found on MRI. Regression of pituitary abscess was obvious during the next few weeks of parenteral antibiotic treatment. Adequate substitution treatment with L thyroxine, hydrocortisone, testosterone and desmopressin was achieved. Seventeen months later, clinical deterioration associated with recurrent pituitary abscess was confirmed on MRI. Abscess regression was obvious again after conservative treatment. However, control MRI study performed three years after initial scanning revealed the presence of pituitary tumor, most consistent with macroadenoma. Surgical intervention was ordered. Histologic evaluation indicated the presence of fibrotic changes, associated with granulation tissue and rare cellular elements, compatible with chronic inflammation. To the best of our knowledge, there are no studies in the literature describing such a pattern of chronic evolution of pyogenic pituitary abscess with consequent chronic inflammatory changes with granulation tissue proliferation, mimicking macroadenoma.

SEMIOLOGY OF PATHOLOGICAL CONDITIONS IN PATIENTS INDICATED FOR STEREOTACTIC BIOPSY.

INTRODUCTION: Brain tumors produce symptoms and signs which are often non-specific, and therefore they may occur for more than a few months prior to diagnosis. The aim of this study was to determine the frequency of referent signs and symptoms among patients referred for stereotactic brain biopsy. MATERIAL AND METHODS: In this study, we retrospectively analyzed medical history of 65 patients (67.7% males and 32.3% females) between the ages of 16 and 81 years. The following symptoms and signs were included in the analysis: organic brain syndrome, lateralization of crossed pyramidal tract, cranial nerve dysfunction, speech disorders, cerebellar-vestibular syndrome, nausea, vomiting, headache, the occurrence of at least one epileptic seizure and respondents' physical weakness. RESULTS: Physical weakness was the most frequent symptom to be recogized (76.9%), whereas pyramidal neurological lateralization was the most commonly recognized sign (58.5%). There was a significant correlation between the course of disease and physical weakness (rho = -0.34, p = 0.005), as well as the course of disease and lateralization of the pyramidal tract (rho =0.65, p = 0.00). No significant correlation was found between other clinical signs and symptoms. CONCLUSION: An accurate diagniosis and early recognition of signs and symptoms may be useful in determining indications for stereotactic brain biopsy.

ANAESTHESIA FOR AWAKE BRAIN TUMOUR SURGERY: CASE REPORT.

INTRODUCTION: There is an increasing trend towards performing awake craniotomy procedures. The method is indicated for surgical treatment of brain changes located in functional regions. This technique poses a unique challenge for the anaesthesiologist in view of providing adequate sedation, analgesia, hemodynamic and respiratory stability yet to keep the patient awake and cooperative during the procedure' Case Report. After the adequate preoperative preparation of the patient, the surgical procedure on tumorous change in the left frontoparietal area (Broca's area) was performed. Due to the tumour localization, the surgical treatment was performed in awake condition under intraoperative neurophysiological monitoring of the patient. Analgosedation (Ramsay score 2-3) was provided via continuous infusion. of propofol and reminfentanil. Local infiltration anaesthesia (scalp block) was preformed with levobupivacaine. The surgical procedure proceeded without any major incidents and complications. CONCLUSION: A propofol/remiWentanil combination provided safe and effective analgosedation of the patient.

The Fisher Grade in predicting a degree of cerebral vasospasm in patients after intracranial aneurysm rupture.

Background/Aim: Intracranial aneurysms are pathological enlargement of the wall of cerebral arteries. Intracranial aneurysms rupture is a dramatic event with a significant morbidity and mortality. The Fisher Grade is widely accepted in assessment of the extensiveness of aneurysmal subarachnoid hemorrhage (aSAH) and the presence of other intracranial hemorrhage on the computed tomography (CT) scan. Significant early complication of a aSAH may be a cerebral vasospasm. The aim of this study was to determine the relationship between the extensiveness of aSAH, assessed by the Fisher Grade on admission, with the intensity of cerebral vasospasm in patients with ruptured intracranial aneurysm. Methods: This prospective clinical study included 50 patients with aSAH hospitalized at the Clinic of Neurosurgery, Clinical Center of Vojvodina, Novi Sad, Serbia. All the patients underwent 256-layer cranial CT and CT angiography on admission and on the day 9. Based on native CT scans, they were classified according to the Fisher Grade. On CT angiography images, intensity of cerebral vasospasm was determined. Results: On the basis of admission CT images, 24% of patients were classified into the Fisher Grade group 2, while 34% and 42% were in the groups 3 and 4, respectively. A positive correlation of the Fischer Grade on admission with the intensity of cerebral vasospasm was established, but with no statistical significance (ρ = 0.273, p = 0.160). Conclusion: This study showed that the Fisher Grade is not significant in predicting the intensity of cerebral vasospasm in patients hospitalized with intracranial aneurysm rupture.

The evaluation of malignant astrocytoma score (MAS).

BACKGROUND/AIM: At the moment there are few scoring systems for malignant astrocytoma but they are not widely accepted. The aim of this study was to evaluate malignant astrocytoma score (MAS) on a new group of patients with malignant astrocytoma, to compare MAS with other prognostic tools and to describe the use of MAS in everyday practice in neurooncology. METHODS: The study was performed on 124 patients with supratentorial malignant astrocytoma grade III or IV. They were operated on and subsequently irradiated with 50-60 Gy. RESULTS: The mean age of the patients was 57.3 years. The mean Karnofski performance status (KPS) of the functional inpairment was 54. The removal of the tumor > 90% was done in 59.7% of patients. The mean survival was 9.1 months, and 27.4% of patients had a 12-month survival. The area under receiver operating characteristic (ROC) curve (AUC) of the MAS for predicting 6-, 12- and 18-month survival was 0.754, 0.783 and 0.882, respectively. We compared the MAS with the two mostly cited scoring systems. The AUC for the same prediction for medical research council (MRC) was 0.601, 0.693, 0.772 respectively. For the Radiation Therapy Oncology Group (RTOG) the AUC was 0.732, 0.765, 0.827, respectively. CONCLUSION: MAS represents a useful scoring system for determining illness severity and prognosis in patients with malignant supratentorial astrocytoma. It can be helpful in comparing single patients or groups of patients, as well as results of different treatments and in controlling the quality of hospital treatment and so on.

Treatment of pediatric patient with ruptured intracranial aneurysm--case report.

INTRODUCTION: Despite the contemporary diagnostics of intracranial aneurysms their treatment is still a great challenge. The decision when and if to apply a surgical or endovascular treatment of intracranial aneurysms should be made by a team of medical specialists which consists of a cerebrovascular neurosurgeon, neuro-radiologist and neuro-anesthesiologist. CASE REPORT: We report a case of a patient aged 16 who was admitted because of a sudden intensive headache followed by sickness, vomiting, and loss of consciousness. On admission the patient was conscious but sleepy. Glasgow Coma Scale score was 14 and the World Federation of Neurological Surgeons Scale grade was I. The computed tomography scan showed a massive subarachnoid haemorrhage. The computed tomography angiography and digital subtraction angiography revealed a ruptured saccular aneurysm in the left vertebral artery. An early treatment with the coiling of the lumen of the aneurysm was performed under general anaesthesia. On the tenth day the boy was discharged in good condition and without any neurological deficits. Six months after the intervention the patient was without symptoms and the control digital subtraction angiography showed the complete occlusion of the aneurysm. CONCLUSION: Intracranial aneurysms in children are more common in males and are predominantly localized in the posterior circulation. In addition, they are frequently of greater size and more complex architecture and they are associated with a lower incidence of clinically manifest vasospasm. According to previous experience, endovascular treatment of intracranial aneurysms in paediatric patients has proven to be a safe and efficient method with a small number of complications.

A temporal pattern in the occurrence of aneurysmal subarachnoid hemorrhage in the Province of Vojvodina, Serbia.

BACKGROUND: Numerous studies with conflicting results have tried to prove the influence of seasonal variations or different meteorological factors on the occurrence of aneurysmal subarachnoidal hemorrhage (SAH). The aim of this study was to establish a mathematical model of a series of aneurysmal rupture dates in different patients and verify a temporal pattern in the occurrence of SAH. METHODS: We analyzed a group of 563 patients with the exact aneurysm rupture dates, hospitalized at the Clinic of Neurosurgery, Clinical Center of Vojvodina, Novi Sad, Serbia, between January 1, 1998 and December 31, 2009. After the monthly distributions, we evaluated the period between two subsequent rupture dates. RESULTS: The absolute number of SAH per month varied between 0 and 10. The monthly seasonal indices show a fluctuation of the time series (with the peak in March and nadir in September), but the median values of the number of aneurysm ruptures in a particular month did not differ significantly. The time scale of the aneurysm rupture dates shows that the most frequent interval between subsequent ruptures was 1 day (in 75 cases or 13.34%). Following this period, the number of days between ruptures showed a gradually decreasing pattern that could be approximated by exponential distribution. CONCLUSIONS: The results are a clear confirmation that SAH patients do indeed present in clusters in a restricted population area. This exact clustering in our series is not particularly connected to month or season, yet strongly supports the existence of a temporal pattern in SAH occurrence.

Spontaneous thrombosis of basilar artery aneurysm after subarachnoidal hemorrhage in a patient with thrombophilia and recurrent deep venous thrombosis.

We report a patient with combined thrombophilia--protein C deficiency and mild hyperhomocysteinemia with total spontaneous thrombosis of a basilar tip aneurysm after subarachnoid hemorrhage, without neurological deficit. At admission, the patient had headache, drowsiness, and nausea, with no neurological deficit. Computed tomography (CT) did not show the presence of subarachnoid blood, and magnetic resonance examination revealed discrete remains of a subarachnoid hemorrhage in projections of temporal, frontal and occipital lobes, with no vascular abnormalities. Initial angiography showed a small basilar tip aneurysm and the patient was scheduled for endovascular treatment. A second angiography, performed before the planned endovascular treatment, did not show the aneurysm and complete thrombosis was suspected. A follow-up angiogram, 6 months after this event, showed preserved posterior cerebral circulation with no aneurysm present. The patient was discharged in good condition, without neurological deterioration. We did not find any previous reports of similar conditions.

[Morphological characteristics of meningiomas].

INTRODUCTION: Meningiomas are common intracranial neoplasms which originate from the soft meninges, precisely from meningeal arachnoidal cells. The aim of this investigation was to establish the age and sex distribution of the examinees, localization, frequency and histological types of meningiomas. MATERIAL AND METHODS: The investigation was carried out in the period from January 2001 to June 2006. It included 490 consecutive patients of both sexes with diagnosed intracranial tumors and undergoing surgical treatment at the Neurosurgery Clinic of the Clinical Center of Vojvodina. The surgery samples were analyzed in the Laboratory of the Institute of Pathology and Histology of the Clinical Center of Vojvodina. Out of 490 patients with diagnosed intracranial tumors, 137 (27.96%) were diagnosed to have meningiomas. RESULTS: Meningiomas were more frequent in females (63%) than in males (37%) and they were most common in the 50-59 year age group (37.2%). The most common localization of meningiomas was the frontal region (36.5%). Meningiomas were more common on the left side (44.5%). In regard to other histological types of intracranial tumors, meningiomas were more frequent in females (36.3%). The most common histological type of meningiomas was transitional meningiomas (59.1%). The commonest histological types of meningiomas were benign meningiomas (93.4%). Malignant histological types of meningiomas were more common in males (83.3%), whereas benign histological types were more common in females (64.1%). CONCLUSION: A typical patient with meningiomas is a woman 50-59 years old. The tumor is located in the left frontal region. On histology it is benign, transitional type of meningiomas.