Complex intracranial aneurysms: a DELPHI study to define associated characteristics.

PURPOSE: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. METHODS: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. RESULTS: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. CONCLUSIONS: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.

Delayed intraventricular hemorrhage in moderate-to-severe traumatic brain injury: prevalence, associated risk factors, and prognosis.

BACKGROUND: The presence of traumatic intraventricular hemorrhage (tIVH) on an admission CT scan is related to a worse outcome and increased mortality in patients with moderate and severe TBI. Currently, there is no available data regarding the predictive value of the appearance of tIVH as a delayed finding on follow-up CT scan. The purpose of this study was to determine the prevalence, associated risk factors, and prognosis of delayed tIVH. METHODS: The study is based on 401 consecutive adult patients (age ≥ 18 years) with moderate-to-severe TBI admitted in our hospital for a 5-year period. At least one control CT was performed in 320 (79.8 %) patients. The prevalence of delayed tIVH was assessed and the potential risk factors and mortality were analyzed. RESULTS: Delayed tIVH appeared in 38 cases (11.9 % of the second CT scans and 9.5 % of all patients). The patients with delayed tIVH are significantly older (57.39 vs. 48.63 years, p = 0.009) and developed statistically significant more frequent enlargement of an existing lesion (47.4 vs. 20.2 %, p = 0.001) and appearance of a new lesion (100 vs. 33.7 %, p < 0.001). Delayed tIVH appeared significantly more frequent in surgically treated patients with ICH as a main surgical lesion (p = 0.010) and is associated with significantly higher mortality (p < 0.001). CONCLUSIONS: Delayed tIVH as a progression of injury in moderate-to-severe TBI has a relatively high occurrence and is associated with increased mortality. The only factor independently related to a new appearance of tIVH is the presence of ICH as a main surgical lesion on the control preoperative CT scans.

Prognostic value of matrix metalloproteinases in oral squamous cell carcinoma.

The aim of this study was to investigate whether there is a correlation between the expressions of four matrix metalloproteinases (MMPs): MMP-2, MMP-7, MMP-9 and MMP-13, and the TNM (tumour-node-metastasis) stages of oral squamous cell carcinoma (OSCC); and to explore the implication of these MMPs in OSCC dissemination. Samples from 61 patients diagnosed with oropharyngeal tumour were studied by immunohistochemistry against MMP-2, MMP-7, MMP-9 and MMP-13. The assessment of immunoreactivity was semi-quantitative. The results showed that MMP-2 and MMP-9 had similar expression patterns in the tumour cells with no changes in the immunoreactivity during tumour progression. MMP-9 always had the highest expression, whereas that of MMP-2 was moderate. MMP-7 showed a significant decrease in expression levels during tumour evolution. MMP-13 had constant expression levels within stage T2 and T3, but showed a remarkable decline in immunoreactivity in stage T4. No significant differences in the MMPs immunoreactivity between tumour cells and stroma were observed. Although strong evidence for the application of MMPs as reliable predictive markers for node metastasis was not acquired, we believe that combining patients' MMPs expression intensity and clinical features may improve the diagnosis and prognosis. Strong evidence for the application of MMPs as reliable predictive markers for node metastasis was not acquired. Application of MMPs as prognostic indicators for the malignancy potential of OSCC might be considered in every case of tumour examination. We believe that combining patients' MMPs expression intensity and clinical features may improve the process of making diagnosis and prognosis.

The Presence of Bilateral Dilated Pupils is Not a Death Sentence in a Stroke Patient: A Case Report.

Bilateral dilated pupils are an ominous clinical sign of brainstem dysfunction, which uniformly leads to a bad prognosis for the patient. In some rare instances in adult patients, it could be reversible. We present a clinical case of an elderly stroke patient with bilateral dilated pupils with a surprisingly favorable clinical outcome. An 80-year-old female patient presented in the emergency department in a coma, areflexia, and bilaterally dilated non-reactive pupils. One and a half hours ago the patient suddenly lost consciousness and became unresponsive. A computed tomography (CT) scan showed a hyperdense basilar tip, and CT angiography confirmed the presence of a defect in the filling of the basilar tip and the bilateral P1 segments of the posterior cerebral arteries (PCA). The patient was ineligible for intravenous thrombolysis. Endovascular treatment was performed with partial recanalization of the basilar artery thrombolysis in cerebral ischemia (TICI) 2a. The diameter and light reactivity of patients' pupils are important parts of the neurological exam. A dilated pupil is an ominous sign associated with a severe prognosis and even worse if both pupils are dilated. Bilateral fixed dilated pupils could be present in basilar artery occlusion (BAO), i.e., basilar tip occlusion. This is explained by ischemia in the mesencephalon, where the nucleus of the oculomotor nerve lies. This ischemic stroke has the highest mortality rate, greater than 85%. The only proven treatment for BAO patients is recanalization with intravenous r-tPA (recombinant tissue plasminogen activator), intra-arterial r-tPA, or endovascular treatment. With adequate treatment, a good outcome can be obtained in up to 35%, and the mortality can be dropped to 40%. Patients with posterior circulation stroke, especially BAO, are still one of the hardest to diagnose on time. They require timely and coordinated efforts by an interdisciplinary team of neurologists, neuroradiologists and neurosurgeons. Timely recanalization within 12 hours and potentially up to 24 hours is the goal. This could lead to a favorable outcome. Loss of consciousness and bilateral fixed dilated pupils could be present in patients with BAO and shouldn't be accepted as a sign of a definite bad outcome. This definitely should not discourage treating physicians. All efforts should be focused on finding the right diagnosis in a timely manner. The differential diagnosis is crucial and may be the difference between life and death, especially in the context of BAO.

Development and assessment of case-specific physical and augmented reality simulators for intracranial aneurysm clipping.

BACKGROUND: Microsurgical clipping is a delicate neurosurgical procedure used to treat complex Unruptured Intracranial Aneurysms (UIAs) whose outcome is dependent on surgeon's experience. Simulations are emerging as excellent complements to standard training, but their adoption is limited by the realism they provide. The aim of this study was to develop and validate a microsurgical clipping simulator platform. METHODS: Physical and holographic simulators of UIA clipping have been developed. The physical phantom consisted of a 3D printed hard skull and five (n = 5) rapidly interchangeable, perfused and fluorescence compatible 3D printed aneurysm silicone phantoms. The holographic clipping simulation included a real-time finite-element-model of the aneurysm sac, allowing interaction with a virtual clip and its occlusion. Validity, usability, usefulness and applications of the simulators have been assessed through clinical scores for aneurysm occlusion and a questionnaire study involving 14 neurosurgical residents (R) and specialists (S) for both the physical (p) and holographic (h) simulators by scores going from 1 (very poor) to 5 (excellent). RESULTS: The physical simulator allowed to replicate successfully and accurately the patient-specific anatomy. UIA phantoms were manufactured with an average dimensional deviation from design of 0.096 mm and a dome thickness of 0.41 ± 0.11 mm. The holographic simulation executed at 25-50 fps allowing to gain unique insights on the anatomy and testing of the application of several clips without manufacturing costs. Aneurysm closure in the physical model evaluated by fluorescence simulation and post-operative CT revealed Raymond 1 (full) occlusion respectively in 68.89% and 73.33% of the cases. For both the simulators content validity, construct validity, usability and usefulness have been observed, with the highest scores observed in clip selection usefulness Rp=4.78, Sp=5.00 and Rh=4.00, Sh=5.00 for the printed and holographic simulators. CONCLUSIONS: Both the physical and the holographic simulators were validated and resulted usable and useful in selecting valid clips and discarding unsuitable ones. Thus, they represent ideal platforms for realistic patient-specific simulation-based training of neurosurgical residents and hold the potential for further applications in preoperative planning.

Outcomes Associated With Intracranial Aneurysm Treatments Reported as Safe, Effective, or Durable: A Systematic Review and Meta-Analysis.

Importance: Testing new medical devices or procedures in terms of safety, effectiveness, and durability should follow the strictest methodological rigor before implementation. Objectives: To review and analyze studies investigating devices and procedures used in intracranial aneurysm (IA) treatment for methods and completeness of reporting and to compare the results of studies with positive, uncertain, and negative conclusions. Data Sources: Embase, MEDLINE, Web of Science, and The Cochrane Central Register of Clinical Trials were searched for studies on IA treatment published between January 1, 1995, and the October 1, 2022. Grey literature was retrieved from Google Scholar. Study Selection: All studies making any kind of claims of safety, effectiveness, or durability in the field of IA treatment were included. Data Extraction and Synthesis: Using a predefined data dictionary and analysis plan, variables ranging from patient and aneurysm characteristics to the results of treatment were extracted, as were details pertaining to study methods and completeness of reporting. Extraction was performed by 10 independent reviewers. A blinded academic neuro-linguist without involvement in IA research evaluated the conclusion of each study as either positive, uncertain, or negative. The study followed Preferring Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Main Outcomes and Measures: The incidence of domain-specific outcomes between studies with positive, uncertain, or negative conclusions regarding safety, effectiveness, or durability were compared. The number of studies that provided a definition of safety, effectiveness, or durability and the incidence of incomplete reporting of domain-specific outcomes were evaluated. Results: Overall, 12 954 studies were screened, and 1356 studies were included, comprising a total of 410 993 treated patients. There was no difference in the proportion of patients with poor outcome or in-hospital mortality between studies claiming a technique was safe, uncertain, or not safe. Similarly, there was no difference in the proportion of IAs completely occluded at last follow-up between studies claiming a technique was effective, uncertain, or noneffective. Less than 2% of studies provided any definition of safety, effectiveness, or durability, and only 1 of the 1356 studies provided a threshold under which the technique would be considered unsafe. Incomplete reporting was found in 546 reports (40%). Conclusions and Relevance: In this systematic review and meta-analysis of IA treatment literature, studies claiming safety, effectiveness, or durability of IA treatment had methodological flaws and incomplete reporting of relevant outcomes supporting these claims.

Novel Nanosized Spinel MnCoFeO4 for Low-Temperature Hydrocarbon Oxidation.

The present paper reports on MnCoFeO4 spinels with peculiar composition and their catalytic behavior in the reactions of complete oxidation of hydrocarbons. The samples were synthesized by solution combustion method with sucrose and citric acid as fuels. All samples were characterized by powder X-ray diffraction, N2-physisorption, scanning electron microscopy, thermal analysis, X-ray photoelectron spectroscopy, and Mössbauer spectroscopy. The catalytic properties of the spinels with Mn:Co:Fe = 1:1:1 composition were studied in reactions of complete oxidation of methane, propane, butane, and propane in the presence of water as model pollutants. Both prepared catalysts are nanosized materials. The slight difference in the compositions, structure, and morphology is due to the type of fuel used in the synthesis reaction. The spinel, prepared with sucrose, shows a higher specific surface area, pore volume, higher amount of small particles fraction, higher thermal stability, and as a result, more exposed active sites on the sample surface that lead to higher catalytic activity in the studied oxidation reactions. After the catalytic tests, both samples do not undergo any substantial phase and morphological changes; thus, they could be applied in low-temperature hydrocarbon oxidation reactions.

Properties of CuFeS2/TiO2 Nanocomposite Prepared by Mechanochemical Synthesis.

CuFeS2/TiO2 nanocomposite has been prepared by a simple, low-cost mechanochemical route to assess its visible-light-driven photocatalytic efficiency in Methyl Orange azo dye decolorization. The structural and microstructural characterization was studied using X-ray diffraction and high-resolution transmission electron microscopy. The presence of both components in the composite and a partial anatase-to-rutile phase transformation was proven by X-ray diffraction. Both components exhibit crystallite size below 10 nm. The crystallite size of both phases in the range of 10-20 nm was found and confirmed by TEM. Surface and morphological properties were characterized by scanning electron microscopy and nitrogen adsorption measurement. Scanning electron microscopy has shown that the nanoparticles are agglomerated into larger grains. The specific surface area of the nanocomposite was determined to be 21.2 m2·g-1. Optical properties using UV-Vis and photoluminescence spectroscopy were also investigated. CuFeS2/TiO2 nanocomposite exhibits strong absorption with the determined optical band gap 2.75 eV. Electron paramagnetic resonance analysis has found two types of paramagnetic ions in the nanocomposite. Mössbauer spectra showed the existence of antiferromagnetic and paramagnetic spin structure in the nanocomposite. The CuFeS2/TiO2 nanocomposite showed the highest discoloration activity with a MO conversion of ~ 74% after 120 min irradiation. This study has shown the possibility to prepare nanocomposite material with enhanced photocatalytic activity of decoloration of MO in the visible range by an environmentally friendly manner.

Nickel-Decorated Mesoporous Iron-Cerium Mixed Oxides: Microstructure and Catalytic Activity in Methanol Decomposition.

Nickel-decorated mesoporous cerium-iron oxide composites were synthesized by a combination of incipient wetness impregnation and template-assisted hydrothermal techniques. The effects of the Fe/Ce ratio and the calcination temperature of cerium-iron oxides on the phase composition, texture, structure, and redox properties of the composites were studied by a combination of N2 physisorption, XRD, high-resolution transmission electron microscopy, SEM, Mössbauer, Raman, XPS, ultraviolet-visible and FTIR spectroscopies, H2-temperature-programmed reduction, and total oxidation of ethyl acetate as a catalytic test. The combined physicochemical characterization and in situ FTIR investigation of methanol decomposition was used for a proper understanding of the microstructure of the Ni/FeCe oxide composites and the mechanism of the reaction occurring on them. The complex role of the FeCe support in the stabilization of highly dispersed Ni particles, the generation of surface intermediates, and the impact of the support phase transformation under the reaction medium are discussed.

Formation of Catalytic Active Sites in Hydrothermally Obtained Binary Ceria-Iron Oxides: Composition and Preparation Effects.

A series of mesoporous cerium-iron binary oxides was prepared by a hydrothermal technique using CTAB as a template. The influence of the Fe/Ce ratio and the variations in the preparation techniques such as the type of solvent and the precipitation agent, the approach of the template release, and the temperature of calcination on the phase composition, textural, structural, surface, and redox properties of the obtained materials was studied in details by XRD, nitrogen physisorption, TPR, FTIR, UV-vis, XPS, Raman, and Moessbauer spectroscopies. The materials were tested as catalysts in methanol decomposition and total oxidation of ethyl acetate. It was assumed that the binary materials represented a complex mixture of differently substituted ceria- and hematite-like phases. Critical assessment of their formation on the base of a common mechanism scheme was proposed. This scheme declares the key role of the formation of shared Ce-O-Fe structures by insertion of Fe3+ in the ceria lattice and further competitive compensation of the lattice charge balance by the existing in the system ions, which could be controlled by the Fe/Ce ratio and the hydrothermal synthesis procedure used. This mechanism provides proper understanding and regulation of the catalytic behavior of cerium-iron oxide composites in methanol decomposition with a potential for hydrogen production and total oxidation of ethyl acetate as a model of VOCs.

Impact of surgical treatment on the performance status of patients with high-grade gliomas.

OBJECTIVES: The objective of our study is to evaluate the impact of neurosurgical operative treatment on the performance status assessed by the Karnofsky Performance Scale (KPS) in patients with HGG for the first, for the second intervention and for the different age groups. METHODS: A group of 425 patients operated consecutively for high-grade gliomas were included in this study. The performance status was evaluated preoperatively and 15 days postoperatively with the KPS. Analyses for the different histological grade, tumor locations and age groups divided by decades have been made. RESULTS: The initial, preoperative KPS score for patients with grade III tumor was 77.65 and for grade IV - 71.35. Following the first operation mean KPS has a statistically significant increase and reaches 82.24 and 78.41, respectively. The improvement of the performance status after the first operation was significant for all relevant age groups, including the sixth, seventh and eighth decades. Although the obtained mean KPS scores after the second operation did not show improvement there was also no clear evidence for worsening in this group of patients (n = 100) and the negative results obtained were not statistically significant. CONCLUSION: According to our study, the first operation has a beneficial effect on the performance status in patients with HGG. The results for the second operation are more ambiguous, but there is no clear evidence for worsening of the KPS score after the second intervention. These results were relevant for all age groups, so we may expect amelioration in the performance status even in older patients.

IDH1/IDH2 but not TP53 mutations predict prognosis in Bulgarian glioblastoma patients.

Mutations in genes encoding isocitrate dehydrogenase isoforms 1 (IDH1) and 2 (IDH2) have been associated with good prognosis for patients with brain neoplasias and have been commonly found together with mutated TP53 gene. To determine the prevalence of IDH1, IDH2, and TP53 mutations and their impact on overall survival 106 glioblastoma patients were analysed. IDH1 mutations were detected in 13 and IDH2 mutation in one patient. Two homozygous samples with R132H mutation in IDH1 gene and a novel aberration K129R in IDH2 gene were found. Sixty-four percent of IDH1/IDH2 mutated tumours harboured also a mutation in TP53 gene. Genetic aberrations in TP53 were present in 37 patients. Statistical analysis of the impact of the studied factors on the overall survival showed that the mutations in IDH1/IDH2, but not the ones in TP53, were associated with longer survival. Also, the impact of age on prognosis was confirmed. This is the first comprehensive study on glioblastomas in Bulgaria. Our results suggest that IDH1/IDH2 but not TP53 mutations together with other prognostic factors such as age might be applied in clinical practice for prediction of outcome in patients with glioblastomas.