Follow-up of intra-arterial delivery of bevacizumab for treatment of butterfly glioblastoma in patient with first-in-human, real-time MRI-guided intra-arterial neurointervention.

This case report shows that real-time MRI may aid in the precision of intra-arterial delivery of bevacizumab to butterfly glioblastoma. Fast clinical improvement, decrease of contrast enhancing status, and no serious adverse effects were observed at discharge from hospital. The patient regained pre-recurrent neurological status for 2 months with a subsequent fast clinical decline and an increase in tumor volume. The patient underwent a second procedure of intra-arterial delivery of bevacizumab to the brain, with substantial clinical and radiological improvement, but not the level of improvement observed after the first procedure. Another clinical decline occurred with an increase in tumor size and the patient was treated 2 months later with a third intra-arterial infusion of bevacizumab. While another positive effect was achieved, it was less pronounced than before, and the patient died 1.5 months later. There were no technical, ischemic or other complications during the procedures. The patient survived 218 days from the first symptoms of tumor recurrence, 190 days from the first MRI, and 175 days from the first intra-arterial treatment of bevacizumab.

Acute platelet response to aneurysmal subarachnoid hemorrhage depends on severity and distribution of bleeding: an observational cohort study.

Microthrombosis after aneurysmal subarachnoid hemorrhage (aSAH) is considered to initiate neuroinflammation, vessel remodeling, and blood-brain barrier leakage. We aimed to verify the hypothesis that the intensity of thrombogenicity immediately after aSAH depends on the amount and distribution of extravasated blood. This observational cohort study included 37 consecutive aSAH patients admitted no longer than 24 h after ictus. Volumes of subarachnoid and intraventricular hemorrhages as well as the Subarachnoid Hemorrhage Early Brain Edema Scale (SEBES) score were calculated in each case. Platelet system status was described by platelet count (PLT), mean platelet volume (MPV), MPV to PLT ratio, and platelet-large cell ratio (P-LCR). Median hemorrhage volume amounted to 11.4 ml (interquartile range 2.8-26.8 ml). Patients with more severe hemorrhage had lower PLT and higher MPV to PLT ratio (ρ = - 0.49, p < .002; ρ = 0.50, p < .002, respectively). PLT decreased by 2.80 G/l per 1 ml of hemorrhage volume (95% CL 1.30-4.30, p < .001). Further analysis revealed that intraventricular hemorrhage volume was associated with P-LCR and MPV (ρ = 0.34, p < .039; ρ = 0.33, p < .048, respectively), whereas SAH volume with PLT and MPV:PLT ratio (ρ = - 0.40, p < .013; ρ = 0.41, p < .013, respectively). The odds of unfavorable neurological outcome increased 3.95 times per 1 fl of MPV (95% CI 1.19-13.12, p < .025). MPV was independently correlated with SEBES (ρ = 0.44, p < .006). This study demonstrated that the extent and distribution of aneurysmal subarachnoid hemorrhage are related to different types of acute platelet response, which may be interpreted as local and systemic thrombogenicity. Increased mean platelet volume measured in the acute phase of aSAH may identify patients at risk for unfavorable neurological outcomes and may serve as a marker of early brain injury.

Clipping of a ruptured middle cerebral artery aneurysm in a patient with coronavirus disease 2019 (COVID-19): A case report.

AIM OF THE STUDY: The aim of this study is to present our suggestions for organization, personal protective equipment (PPE) use, work flow of the operating theater, and the treatment of patients with COVID-19 and co-existing neurological disease. MATERIALS AND METHODS: We present the case of a 70-year-old male who was transferred to our Department because of subarachnoid hemorrhage with ruptured right middle cerebral artery aneurysm and SARS CoV-2 infection. The emergency clipping of the aneurysm and hematoma evacuation was performed. According to the therapeutic committee guidelines, chloroquine was started for COVID-19 treatment. RESULTS: Postoperatively, the patient is in good condition, with the Glasgow Coma Scale (GCS) score of 15, with mild, left hemiparesis, 4+/5 points on the Lovett scale, without symptoms of acute respiratory distress syndrome (ARDS). No one from the stuff was infected during the treatment. CONCLUSIONS: Managing patients with infectious diseases such as COVID-19 presents many challenges and risks for healthcare personnel. Our experience suggests that by following strict safety protocols of PPE use, donning and doffing, and reducing operation time, the surgery may be safe for both the healthcare personnel and the patient.

Republished: Real-time MRI guidance for intra-arterial drug delivery in a patient with a brain tumor: technical note.

Patients suffering from malignant brain tumors are burdened with a grim prognosis. The blood brain barrier is considered a primary obstacle in therapeutic drug delivery to the brain. Intra-arterial (IA) delivery of therapeutic agents following osmotic BBB opening has been attempted for years, but high variability has limited its widespread implementation. It has been recently shown in animal studies that MRI is superior to X-ray for guiding IA infusions, as it allows direct visualization of the brain parenchyma perfused and facilitates predictable drug targeting. Moreover, PET imaging has revealed that IA, not intravenous, delivery of bevacizumab results in brain accumulation, providing strong rationale for utilizing the IA route. Here, we present our experience in a patient with recurrent butterfly glioblastoma enrolled in first-in-man MRI-guided neurointervention for targeted IA drug delivery.

Real-time MRI guidance for intra-arterial drug delivery in a patient with a brain tumor: technical note.

Patients with malignant brain tumors have a poor prognosis. The blood-brain barrier (BBB) is considered a primary obstacle in therapeutic drug delivery to the brain. Intra-arterial (IA) delivery of therapeutic agents following osmotic BBB opening has been attempted for years, but high variability has limited its widespread implementation. It has recently been shown in animal studies that MRI is superior to X-ray for guiding IA infusions, as it allows direct visualization of the brain parenchyma supplied by the catheter and facilitates predictable drug targeting. Moreover, PET imaging has shown that IA rather than intravenous delivery of bevacizumab results in accumulation in the brain, providing a strong rationale for using the IA route. We present a patient with recurrent butterfly glioblastoma enrolled in a first-in-man MRI-guided neurointervention for targeted IA drug delivery.

Langerhans cell histiocytosis of the orbit and frontal sinus of the adult woman: A first case report in Poland.

BACKGROUND: Langerhans cell histiocytosis (LCH) is a term describing a clonal proliferation of pathologic Langerhans cells (histiocytes), which may manifest as unisystem (unifocal or multifocal) or multisystem disease. LCH is a rare cause of the orbital tumor with the predilection to its lateral wall which is particularly common in children. CASE DESCRIPTION: We report an unusual case of a 33-year-old woman, 6 months after childbirth, who presented with the edema of the right orbit and upper eyelid with headaches. On physical examination, the patient had a right superior and lateral swelling of the eyelid and the orbit and right enophthalmos, without blurred vision. Magnetic resonance imaging showed well-defined, expansile, intensely homogeneously enhancing mass lesion in the right superolateral orbital rim with the destruction of the upper wall of the orbit, growing into the frontal sinus and frontal part of the cranium with the bold of the dura mater in this region. Radical excision of the tumor was achieved through a right fronto-temporo-orbito-zygomatic craniotomy. Histopathological examination had confirmed the diagnosis of the LCH. The patient was discharged home with a modified Rankin Scale score of 0. CONCLUSION: The main purpose of this case report is that LCH should be considered as one of the possible causes of quickly appearing tumor of the orbit in adults.

Analysis of the serum components in acute period after subarachnoid hemorrhage.

AIM: Multi-profile monitoring of various blood serum factors during acute subarachnoid haemorrhage (SAH) is crucial for successful treatment. The aim of the study is to evaluate the serum concentration of different blood factors in the acute period of SAH. MATERIAL AND METHODS: 31 patients with confirmed aneurysmal SAH were enrolled in a prospective study. The concentrations of the following serum compounds were assessed on the day of admission and reassessed after 5 days: lipids profile, cardiac functionality enzymes and markers, electrolytes, osmolality, CRP (C-reactive protein), glucose, creatinine, urine. RESULTS: The mean level of high-density lipoprotein (HDL) changed significantly from 43.9±23.9 mg/dL to 27.5±19,8 mg/dL, p=0,013 (mean dif. 16.5±14,1 mg/dL; 37,3%). Concentration of low-density lipoprotein (LDL) decreased by 28.6% (mean dif. 26.78±61.32; p=0.047). Values of triglicerydes and total cholesterol did not differ significantly between the initial evaluations and these repeated after 5 days. The overall serum ions (Na < sup > + < /sup > , K < sup > + < /sup > , Mg < sup > 2+ < /sup > , Ca < sup > 2+ < /sup > ) concentrations and osmolality did not differ significantly between the initial measurements and after 5 days from SAH. The only mean value that appeared to be substantially increased at initial measurement was NT-proBNP and reached 1928.8±4952 pg/ ml, this value dropped down to 392.87±1147.9 mg/ml after 5 days (mean dif. 1535.96±4808.76 pg/ml; 79,6%; p = 0.247). CRP increased over 2 fold after 5 days up to 29.267±28.614 mg/L (mean dif. 16.06±34.05 pg/L; 121.6%; p=0.028). At 5-day follow up hematocrit dropped to 33.38 ± 3.81% from the initial value of 39.63 ± 2,56% (p=0.02). CONCLUSION: This study showed a significant decrease in the serum level of LDL and HDL, while triglycerides were moderately heightened. Routine monitoring of lipid profile and statin administration at the early stage of SAH is recommended.

Four-year trends in the treatment of cerebral aneurysms in Poland in 2009-2012.

BACKGROUND: The dilemma concerning the appropriate treatment of the intracranial aneurysms (IAs) has not yet been resolved and still remains under fierce debate. This study refers to the recent trends in the use of and outcomes related to coiling compared with clipping for unruptured and ruptured IAs in Poland over a 4-year period. METHODS: The analysis refers to treatment of IAs performed in Poland between 2009-2012. Patients' records were cross-matched by ICD-9 codes for ruptured SAH (430) or unruptured cerebral aneurysm (437.3) along with codes for clipping (39.51) and coiling (39.79, 39.72, or 39.52). Multivariable logistic regression was used to compare in-hospital deaths, hospital length of stay (LOS), therapy allocation and aneurysm locations in unruptured vs. ruptured and clipped vs. coiled groups. Differences in the number of procedures between 16 administrative regions were standardized per 100,000 people. RESULTS: In 2009-2012, 11,051 procedures were identified, including 5,968 ruptured and 5,083 unruptured aneurysms. Overall increase was 2.3 % in clipping and 13.1 % in coiling; a significant trend was found in endovascular procedures (p = 0.044). Ruptured aneurysms were clipped more frequently (OR = 1.66;); in unruptured IAs, endovascular procedure was preferred 3.5 times more than clipping. The annual in-hospital mortality was 7.6 % in clipping and 6.7 % in endovascular treatment. LOS was two times longer after clipping in unruptured aneurysms (OR = 2.013). After the procedures were standardized per 100,000 people, the average for Poland was established as 9.09 in 2009, 10.86 in 2010, 10.55 in 2011, and 11.49 in 2012. This index had the highest values in Mazovia (12.9, 2009; 15.4, 2010; 17.4, 2011; 18.6, 2012. CONCLUSIONS: Data analysis revealed an increase in overall number of IAs treated in Poland between 2009-2012. A significant upward trend of endovascular procedures was found, whereas the number of clipped aneurysms remained relatively steady over the study period.

Limitations of the of the oscillometric method for blood pressure measurements in dialyzed patients.

BACKGROUND: Despite more frequent use of the oscillometric method (OSC) for arterial blood pressure (BP) measurement, little is known about OSC's accuracy when used with hemodialysed patients. This study was undertaken to determine if hemodialysis (HD) and individual features in examined patients can affect the accuracy of OSC for BP measurement. MATERIAL/METHODS: In 54 hemodialysed patients (57 ± 15 years), during 2 sessions (before and after HD), 3 pairs of BP measurements each were performed on arms, alternately employing OSC and auscultatory method, with mercury manometers by 2 observers (REF). RESULTS: No difference was found in systolic BP measured before and after HD (SBP before HD: REF -147.3 ± 27.3, OSC -147.5 ± 25.0 mmHg, p>0.05, SBP after HD: REF-141.1 ± 33.9, OSC-141.2 ± 31.5 mmHg, p>0.05, respectively), but diastolic BP (DBP) was significantly higher both before and after HD during REF measurement in comparison with OSC (DBP before HD: REF -79.0 ± 17.0, OSC -76.7 ± 15.0 mmHg, DBP after HD: REF -78.6 ± 18.8, OSC -76.7 ± 16.7 mmHg, p<0.001, respectively). No significant correlation between loss of body weight caused by HD and differences in BP measured by REF and OSC after HD was indicated (Pearson's correlation coefficients: for SBP -0.041, for DBP 0.030). However, a significant correlation between differences in BP measured by REF and OSC before HD and differences in BP measured by REF and OSC after HD was observed (Spearman's rank correlation coefficients: for SBP 0.502 and for DBP 0.557, p<0.000001). CONCLUSIONS: Our study found that individual features, not HD, determine the accuracy of OSC for BP measurement in hemodialysed patients.

Determining the accuracy of blood pressure measurement by the Omron HEM-907 before and after hemodialysis.

BACKGROUND: The accuracy of oscillometric blood pressure (BP) measuring devices determined in resting conditions may be distorted in those under hemodialysis (HD). METHODS: The evaluation of accuracy of the Omron HEM-907 was performed in accordance with the International Protocol for validation of BP measuring devices (IP). Out of a group of 49 patients with end-stage renal disease (ESRD) (56.7 +/- 15.6 years), four groups of 33 patients each were selected to ascertain their BP before and after HD. RESULTS: The Omron HEM-907 fulfilled the IP accuracy requirements for systolic BP measurements before and after HD. In the case of diastolic BP before HD, the Omron HEM-907 did not fulfill both requirements for phase 2.2 IP. In only 21 out of 33 patients, the difference between the mean of two observers and the Omron HEM-907 device (Diff) was not more than 5 mmHg, while the requirement was 22 patients. In seven patients, all three Diff were over 5 mmHg, while the accepted limit is three. After HD, the Omron HEM-907 did not fulfill one out of two criteria of phase 2.2 IP - in five people, all three Diff were over 5 mmHg. CONCLUSION: The Omron HEM-907 oscillometric method of BP measurement should not be used to measure BP before and after HD in ESRD patients. In ESRD patients, an alternative method of BP measurement, in the event of a lack of a mercury sphygmomanometer, could be a classical auscultatory method together with the Omron HEM-907, which allows for this type of BP measurement.

[Assessment of the susceptibility of the gram-negative rods isolated from hospitalized patients to cefoperazone/sulbactam]. / Ocena wrazliwosci na cefoperazon/sulbaktam szczepów paleczek gram-ujemnych izolowanych od chorych hospitalizowanych.

The susceptibility to cefoperazone/sulbactam of 197 strains of Gram-negative rods demonstrating an ESBL-positive phenotype was determined. The assortment of the investigated strains was as follows (numbers of strains are given in the brackets): E. cloacae (63), S. marcescens (46), K. pneumoniae (21), P. mirabilis (17), E. coli (9), P. vulgaris (8), P. aeruginosa (20) and A. baumanni (13). 83 strains from 197 were susceptible (42.1%). The MIC values were determined and the disc-diffusion method was performed. The susceptibilities among particular species were as follows (the order of data in the brackets is: % of the susceptible strains/MIC50/MIC90): E. cloacae (54.0/16/64), S. marcescens (23.9/64/> or = 128), K. pneumoniae (38.1/32/64), P. mirabilis (41.2/32/64), E. coli (44.4/32/32), P. vulgaris (75.0/8/32), P. aeruginosa (35.0/32/64), A. baumannii (46.2/32/64). Using disc-diffusion method, for 184 strains the difference between diameter of the inhibition zone around the disc with cefoperazone and the disc with cefoperazone/sulbactam was calculated. This difference amounted 5 mm or more in the case of 76.6% of the investigated strains. The results indicate that the comparison of the inhibition zones around cefoperazone and cefoperazone/sulbactam discs may be an additional method useful for phenotypic detection of ESBL producing organisms. These results highly correlated with results obtained by using analogous test with cefpirome and cefpirome/clavulanic acid (85.6% of concordance).