Cavernous malformations of the central nervous system: An international consensus statement.

Introduction: Cavernous malformations (CM) of the central nervous system constitute rare vascular lesions. They are usually asymptomatic, which has allowed their management to become quite debatable. Even when they become symptomatic their optimal mode and timing of treatment remains controversial. Research question: A consensus may navigate neurosurgeons through the decision-making process of selecting the optimal treatment for asymptomatic and symptomatic CMs. Material and methods: A 17-item questionnaire was developed to address controversial issues in relation to aspects of the treatment, surgical planning, optimal surgical strategy for specific age groups, the role of stereotactic radiosurgery, as well as a follow-up pattern. Consequently, a three-stage Delphi process was ran through 19 invited experts with the goal of reaching a consensus. The agreement rate for reaching a consensus was set at 70%. Results: A consensus for surgical intervention was reached on the importance of the patient's age, symptomatology, and hemorrhagic recurrence; and the CM's location and size. The employment of advanced MRI techniques is considered of value for surgical planning. Observation for asymptomatic eloquent or deep-seated CMs represents the commonest practice among our panel. Surgical resection is considered when a deep-seated CM becomes symptomatic or after a second bleeding episode. Asymptomatic, image-proven hemorrhages constituted no indication for surgical resection for our panelists. Consensus was also reached on not resecting any developmental venous anomalies, and on resecting the associated hemosiderin rim only in epilepsy cases. Discussion and conclusion: Our Delphi consensus provides an expert common practice for specific controversial issues of CM patient management.

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.

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.

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.

Computed tomography angiography scoring systems and the role of skull defects in the confirmation of brain death.

To assess and compare all current computed tomography angiography (CTA) scoring systems for the diagnostic workup of brain death (BD) to digital subtraction angiography (DSA) and clinical tests. Fifty-two patients with a clinical suspicion of BD underwent CTA and subsequently DSA. The diagnostic performance of all current CTA scoring systems was compared to that of DSA, in all patients with a suspicion of BD. A comparison to clinical tests was made only in DSA-positive for BD patients (n = 49), since in DSA-negative BD patients (n = 3) clinical tests were not performed. Further subgroup analysis was performed in relation to skull defects (SDs) stratification. Statistical analysis was conducted by applying statistics-contingency tables, Cochran's-Q test and McNemar's test. The CTA -10, and -7- and all 4-point scoring systems, showed overall sensitivities of 81,6%, 87.8% and 95.9% respectively and 100% specificity, when compared to DSA. In patients with a clinical verification of BD, the CTA -10 and -7-point scoring systems were significantly inferior to clinical tests (p = 0.004 and p = 0.031), while the 4-point scoring systems showed no such difference (p = 0.5). All 4-point scoring systems showed 100% sensitivity in patients with a minor SD or no SD. In patients with a major SD, all CTA scoring systems (- 10, - 7- and all 4-point) were less sensitive (62.5%, 62.5% and 75% respectively). The presence of a major SD was associated with an 8 × relative risk for false negative results in all 4-point scoring systems. CTA showed excellent diagnostic performance in patients with a suspicion of BD. The 4-point CTA scoring systems are the most sensitive for the diagnosis of BD, although in patients with a major SD patient, the role of CTA is ambiguous.

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.

Multiple Exostoses Syndrome and Basilar Artery Aneurysm: A Case Report.

BACKGROUND: Hereditary multiple exostoses (HME) is an inherited genetic condition, characterized by the formation of multiple osteochondromas, developing throughout childhood and into puberty. Vascular complications associated with HME are uncommon. METHODS: A case of a patient with HME who was admitted to hospital with subarachnoid hemorrhage (SAH), as a result of acute rupture of a basilar tip aneurysm (BTA), will be presented. Relevant literature on this topic will be systematically reviewed. RESULTS: We describe a rare case of a 48-year-old male patient presenting multiple exostoses in both upper and lower limbs, with no familial history of such lesions. The patient experienced an episode of loss of consciousness, followed by tonal seizures, after a short (five-day) history of headache, proved finally to be secondary to SAH due to rupture of a BTA. There was no antecedent of trauma, neck manipulation, or previous infection. Aneurysm was successfully treated with the intravascular procedure (aneurysm occlusion with coil). Progressively, the patient recovered from dysphasia and tetraparesis, almost completely, following the appropriate treatment and rehabilitation program.In the systematic review, eight cases (including the one presented) of vertebrobasilar vascular system stroke secondary to solitary spinal osteochondroma or multiple osteochondromas were found, but only the present case was associated with basilar artery aneurysm. CONCLUSION: Despite the fact that the etiopathogenesis of basal artery aneurysm presentation in a patient with osteochondromas remains unknown, medical society needs to be aware of this rare condition, as SAH may be a severe complication.

Common and uncommon intracranial arterial anatomic variations in multi-detector computed tomography angiography (MDCTA). What radiologists should be aware of.

OBJECTIVES: The aim of this retrospective study was twofold: (1) to show the role of multi-detector computed tomography angiography (MDCTA) in the evaluation of intracranial arterial anatomic variations; (2) to highlight their clinical importance with illustrated example cases. MATERIALS AND METHODS: One thousand seven hundred thirty-nine patients who underwent carotid and/or cerebral CTA using a 16-row multi-detector CT over the last 9 years were retrospectively analysed with attention to the presence of persistent carotid-basilar anastomosis and other intracranial arterial variations. RESULTS: All kinds of persistent carotid-basilar anastomosis were present in our series. The most common was the presence of fetal pCom (23 %). From the other studied anatomic variants, the most common was the presence of a hypoplastic A1 segment. In all cases CTA was an excellent diagnostic tool, providing not only high-resolution angiographic images, but also details of the surrounding structures. CONCLUSIONS: The knowledge of intracranial anatomic variations could be very important for the treatment planning of patients who need neurointervention or to explain uncommon and unexpected clinical findings. CTA can reliably provide this kind of information by depicting intracranial anatomic variations. TEACHING POINTS: • Knowledge of intracranial anatomic variations is important. • Radiologist should be aware of the intracranial anatomic variations. • Computed tomography angiography can reliably depict intracranial anatomic variations.

Radiculopathy after lumbar discectomy due to intraspinal retained Surgicel: clinical and magnetic resonance imaging evaluation.

BACKGROUND CONTEXT: Lumbar radiculopathy after lumbar spine surgery is an alerting sign usually caused by either a recurrent disc herniation or epidural hematoma. However, pressure on a spinal nerve root may also be exerted by a retained piece of Surgicel used to achieve hemostasis during lumbar spine surgical procedures. PURPOSE: To describe a case of lumbar radiculopathy that was caused by a piece of Surgicel left in the spinal canal after operation for lumbar disc herniation. STUDY SETTING: A case report of a retained piece of Surgicel being the cause of S1 radiculopathy. METHODS: Patient interview, medical records, imaging studies, and literature review. RESULTS: A 29-year-old man developed acute left S1 radiculopathy after a successful hemilaminectomy and discectomy operation for a L5-S1 disc herniation. In the magnetic resonance imaging studies that were performed, a postoperative hematoma could not be excluded and a reoperation revealed compression from Surgicel that was used for hemostasis. The patient was free of symptoms after reoperation. CONCLUSIONS: This case depicts the difficulty in distinguishing-by means of magnetic resonance imaging-nerve root compression caused by a postoperative hematoma and a recurrent disc herniation, from that caused by a retained Surgicel. Therefore, hemostatic agents should be meticulously used in spine surgery.

Dorsal extradural thoracic disc fragment: a diagnostic challenge.

Dorsal epidural migration of an extruded disc fragment is an infrequent event, especially in the thoracic spine. An uncommon case involving a 55-year-old man is presented, with a 1-month history of paraparesis and thoracolumbar pain. Magnetic resonance imaging demonstrated a dorsally located, extramedullary mass at the T10-T11 intervertebral level. The lesion was suspected to be a tumor. The patient underwent a T10-T11 laminectomy. Intraoperatively, an encapsulated mass of soft tissue adherent to the dural sac was found. The pathologic diagnosis was inflammatory tissue and disc material. Six months after the operation, the patient remained asymptomatic, and radiologic control showed no residual mass. Although rare, a sequestered disc fragment should be included in the differential diagnosis of an enhancing posterior extramedullary thoracic mass. Preoperative diagnosis of such pathology is difficult because the clinical signs and radiologic images may not entirely exclude other more common thoracic spinal lesions, especially tumors.

Neurilemoma of the popliteal fossa: report of two cases with long subclinical course and misleading presentation.

The authors report two cases of neurilemoma localised in the popliteal fossa. Both patients experienced non-specific symptoms, such as painful numbness and burning dysaesthesia, involving the lower extremity. Tinel's sign was positive over the popliteal fossa. The patients sought medical advice and underwent conservative treatment without any relief, for a long time before the right diagnosis was made. Magnetic resonance imaging revealed in both patients a well- circumscribed mass posterior to the sciatic nerve, occupying the popliteal fossa. Following surgical excision of the neurilemoma, the patients experienced immediate relief of their chronic symptoms. In similar situations, ultrasound or magnetic resonance imaging of the whole sciatic nerve should be performed if this is indicated by detailed physical examination. Once the diagnosis is made, neurilemomas should be surgically removed, in order to exclude malignancy, prevent neurologic deficits and provide relief of symptoms.

Giant osteoma of the frontoethmoidal sinus associated with two cerebral abscesses.

A 36-year-old woman presented with severe frontal headache, fever, left palpebral swelling, and proptosis. Radiographic studies showed a giant frontoethmoidal osteoma, that extended intracranially into the frontal lobe and was associated with two abscesses, one within the lesion and the other in the right frontal lobe. The tumour was excised and the abscesses drained. The patient made a full recovery.

Extended cervicolumbar spinal epidural abscess associated with paraparesis successfully decompressed using a minimally invasive technique.

STUDY DESIGN: A case of a multisegmental, cervicothoracolumbar epidural abscess, in an 80-year-old man, successfully decompressed by using a minimally invasive technique, is presented. OBJECTIVE: To review risk factors, diagnosis, treatment, decompression techniques, and morbidity and mortality regarding spinal epidural abscess. SUMMARY OF BACKGROUND DATA: Extended spinal epidural abscess is a rate entity. To our knowledge, this is the first report of a multilevel spinal epidural abscess, completely decompressed by limited laminectomies in combination with the use of a silicon catheter, epidurally. METHODS: The clinical and radiographic features associated with spinal epidural abscess, as well as decompression technique, are presented. The 80-year-old man, with a one week history of urinary tract infection, presented with fever and low back pain, mild weakness in his legs and jaundice. He underwent bilateral limited laminectomies at T2-T3 and a right hemilaminectomy at L1-L2 and the pus was drained, under mild continuous suction, using a 2.7 mm outer and 1.3 mm inner diameter silicon catheter, inserted caudally and cranially into the epidural space, at both the laminectomy sites. RESULTS: The patient experienced immediate relief of the low back pain, gradual fever subsidence and full neurological recovery during the next 3 weeks. CONCLUSION: In cases of suspected acute epidural abscess, especially in elderly debilitating patients: the whole spine should be scanned by MRI to exclude the possibility of multilevel involvement and adequate pus drainage, when indicated, could be performed with the above described minimally invasive technique.