The relationship between the level of vitamin D and ruptured intracranial aneurysms among patients with high sun exposure.

Non-traumatic subarachnoid hemorrhage (SAH) accounts for 3-5% of acute strokes. Intracranial aneurysm is the most common cause of non-traumatic SAH. Vitamin D influences the cardiovascular system, including the formation and rupture of cerebral aneurysms. To evaluate the serum vitamin D level in patients living in the tropical zone who suffered aneurysmal subarachnoid hemorrhage and its correlation with demographic and neurological characteristics. This is an analytical cross-sectional study to assess the serum level of vitamin D in a study population of 99 patients treated and diagnosed with aSAH in a public hospital in Recife-PE over a period of 12 months. In the study sample, composed of individuals with high sun exposure due to the lifestyle they lead in a tropical region, we observed hypovitaminosis D (85.9%), with a median of 19.9 ng/ml, although the majority of individuals are skin with high concentration of melanin (Fitzpatrick skin type IV and V). In addition, rates of sun exposure are high to all patients (Solar Index 9.03 P50). Most individuals were female (79.8%); there was no statistical difference in solar exposure/solar index between genders. As for the neurological repercussions, there was no statistical relevance in the clinical prognostic scales evaluated. As the sample was composed mainly of individuals whose economic activity is agriculture, the values of solar index found are vastly higher than those of other studies conducted in high latitude regions. In line with the literature review, some aspects were raised with the objective of justifying such findings that go from the base of the poor diet of these individuals, the increase of melanin in the skin and genetic alterations that directs us to possible mechanisms of natural photoprotection to high sun exposure. Thus, we had a vast majority (85%) of hypovitaminosis D, which in fact makes us wonder if there is any influence of calcitriol on vitamin D receptors in vascular walls and in the cardiovascular system as a whole, which influence bleeding events of this nature. As for the neurological repercussions, measured using assessment scales (Glasgow coma scale, WFNS scale, Hunt-Hess and Fisher's tomographic scale) there was no significant difference in the results. As it is only a descriptive study, the causal relationship of the facts cannot be established. However, in a population exposed to high sun exposure and affected by aneurysmal SAH, there is a significant rate of hypovitaminosis D, which supports the hypothesis that vitamin D plays a role in vascular pathologies, such as cerebral aneurysms and SAH.

Subarachnoid hemorrhage and COVID-19: Association or coincidence?

ABSTRACT: Some evidences suggest the involvement of the central nervous system in patients infected with SARS-CoV-2. We aim to analyze possible associations between coronavirus disease 2019 (COVID-19) pandemic and spontaneous subarachnoid hemorrhage (SAH), in a comprehensive neurological center.We conducted a retrospective case series of 4 patients infected by COVID-19, who developed spontaneous SAH. Clinical data were extracted from electronic medical records.Between March 24, 2020, and May 22, 2020, 4 cases (3 females; 1 male) of SAH were identified in patients infected with SARS-CoV-2, in a comprehensive neurological center in Brazil. The median age was 55.25 years (range 36 -71). COVID-19-related pneumonia was severe in 3 out of 4 cases, and all patients required critical care support during hospitalization. The patients developed Fisher grade III and IV SAH. Digital subtraction angiography (DSA) was performed in 3 of the 4 patients. However, in only 1 case, an aneurysm was identified. Inflammatory blood tests were elevated in all cases, with an average D-dimer of 2336 µg/L and mean C-reactive protein (CRP) of 3835 mg/dl The outcome was poor in the majority of the patients, with 1 death (25%); 2 (50%) remained severely neurologically affected (mRS:4); and 1 (25%) had slight disability (mRS:2).This study shows a series of 4 rare cases of SHA associated with COVID-19. The possible mechanisms underlying the involvement of SARSCoV-2 and SHA is yet to be fully understood. Therefore, SHA should be included in severe neurological manifestations in patients infected by this virus.

Safety and Effectiveness of the Pipeline Flex Embolization Device With Shield Technology for the Treatment of Intracranial Aneurysms: Midterm Results From a Multicenter Study.

BACKGROUND: The safety and efficacy of the first generation of the Pipeline Embolization Device (PED; Medtronic Inc) have been proven in large case series. Ischemic events are one of the most common complications following treatment of aneurysms with flow diverters. The new PED Flex with Shield technology (PED Shield; Medtronic Inc) was introduced to minimize the rate of complications. OBJECTIVE: To evaluate the outcomes of patients harboring aneurysms treated with the PED Shield. METHODS: This was an observational, prospective, single-arm multicenter study of patients treated with the PED Shield. The primary safety endpoint was the absence of major neurological complications and death. The secondary effectiveness endpoint was angiographic occlusion at 6 and 12 mo. Technical complications were also reported. RESULTS: Between November 2017 and December 2018, 151 patients from 7 centers with 182 aneurysms were enrolled. The mean aneurysm size was 7.0 mm; 27 (14.8%) aneurysms were large, and 7 (3.8%) were giant. In 141 of 151 patients (93.4%), the primary endpoint was reached. The overall rate of periprocedural complications was 7.3%. Of the aneurysms, 79.7% met the study's secondary endpoint of complete occlusion at 6 mo and 85.3% at 12 mo. CONCLUSION: The PED Shield is a safe and effective treatment for intracranial aneurysms. The results regarding total occlusion and ischemic complications did not differ from those obtained in case series using previous versions of the PED. Long-term follow-up and comparative studies are required to provide stronger conclusions regarding the reduced thrombogenicity of this device.

Endovascular treatment of traumatic carotid cavernous fistula with balloon-assisted sinus coiling. A technical description and initial results.

This study aimed to propose an alternative treatment for carotid cavernous fistula (CCF) using the balloon-assisted sinus coiling (BASC) technique and to describe this procedure in detail. Under general anesthesia, we performed the BASC procedure to treat five patients with traumatic CCF. Percutaneous access was obtained via the right femoral artery, and a 7F sheath was inserted, or alternatively, a bifemoral 6F approach was accomplished. A microcatheter was inserted into the cavernous sinus over a 0.014-inch microwire through the fistulous point; the microcatheter was placed distal from the fistula point, and a "U-turn" maneuver was performed. Through the same carotid access, a compliant balloon was advanced to cross the point of the fistula and cover the whole carotid tear. Large coils were inserted using the microcatheter in the cavernous sinus. Coils filled the adjacent cavernous sinus, respecting the balloon. Immediate complete angiographic resolution was achieved, and an early angiographic control (mean = 2.6 months) indicated complete stability without recanalization. The clinical follow-up has been uneventful without any recurrence (mean = 15.2 months). An endovascular approach is optimal for direct CCF. Because the detachable balloon has been withdrawn from the market, covered stenting requires antiplatelet therapy and its patency is unconfirmed, but cavernous sinus coiling remains an excellent treatment option. Currently, there is no detailed description of the BASC procedure. We provide detailed angiograms with suitable descriptions of the exact fistula point, and venous drainage pathways. Familiarity with these devices makes this technique effective, easy and safe.

[Multivoxel spectroscopy with short echo time: choline/N-acetyl-aspartate ratio and the grading of cerebral astrocytomas]. / Espectroscopia multivoxel com tempo de eco curto: a razão colina/N-acetil-aspartato e a graduação dos astrocitomas cerebrais.

The choline/N-acetyl-aspartate (Cho/NAA) ratio, obtained by the multivoxel spectroscopy with short echo time (TE), was evaluated, in the histological grading of the brain astrocytomas (grades I, II and III-IV) in comparison with the normal cerebral parenchyma. A significant increase (p<0.05) in the average ratios of Cho/NAA was observed in the three astrocytoma groups studied in relation to normal tissue, having a tendency to increase with the increase in grading, without any statistic significance, which corresponded to: 0.53+/-0.24 in the control group, 1.19+/-0.49 in grade I, 1.58+/-0.65 in grade II and 5.13+/-8.12 in the high grade group (grades III-IV), with variation in the values encountered. There was an increase in the Cho/NAA ratio in 4/5 (80%) in grade I, 5/6 (83%) in grade II and 10/20 (50%) in grades III and IV. We conclude that multivoxel spectroscopy with short TE can be used in discriminating between normal parenchyma and neoplasm tissue. However, not all neoplasm tissue studied presented an increase in Cho/NAA, especially in the group with higher grade of malignancy.

Espectroscopia multivoxel com tempo de eco curto: a razão colina/N-acetil-aspartato e a graduação dos astrocitomas cerebrais / Multivoxel spectroscopy with short echo time: choline/N-acetyl-aspartate ratio and the grading of cerebral astrocytomas

Avaliou-se a relação colina/N-acetil-aspartato (Co/NAA), obtida pela espectroscopia multivoxel com tempo de eco (TE) curto, na graduação histológica dos astrocitomas encefálicos (graus I, II e III-IV), comparando com o parênquima cerebral normal. Observou-se aumento significativo (p<0,05) das relações médias de Co/NAA nos três grupos de astrocitomas estudados em relação ao tecido normal, havendo tendência de elevação com o aumento da graduação, sem significância estatística, que correspondeu a: 0,53±0,24 no grupo controle, 1,19±0,49 no grau I, 1,58±0,65 no grau II e 5,13±8,12 no grupo de alto grau (graus III-IV). Houve aumento da relação Co/NAA em 4/5 (80 por cento) dos pacientes com grau I, 5/6 (83 por cento) com grau II e 10/20 (50 por cento) com graus III e IV. Concluiu-se que a espectroscopia multivoxel com TE curto pode ser usada na discriminação entre o parênquima normal e o tecido neoplásico. Entretanto, nem todo tecido neoplásico estudado apresentou aumento da relação Co/NAA, principalmente o grupo com maior malignidade.

The choline/N-acetyl-aspartate (Cho/NAA) ratio, obtained by the multivoxel spectroscopy with short echo time (TE), was evaluated, in the histological grading of the brain astrocytomas (grades I, II and III-IV) in comparison with the normal cerebral parenchyma. A significant increase (p<0.05) in the average ratios of Cho/NAA was observed in the three astrocytoma groups studied in relation to normal tissue, having a tendency to increase with the increase in grading, without any statistic significance, which corresponded to: 0.53±0.24 in the control group, 1.19±0.49 in grade I, 1.58±0.65 in grade II and 5.13±8.12 in the high grade group (grades III-IV), with variation in the values encountered. There was an increase in the Cho/NAA ratio in 4/5 (80 percent) in grade I, 5/6 (83 percent) in grade II and 10/20 (50 percent) in grades III and IV. We conclude that multivoxel spectroscopy with short TE can be used in discriminating between normal parenchyma and neoplasm tissue. However, not all neoplasm tissue studied presented an increase in Cho/NAA, especially in the group with higher grade of malignancy.