BACKGROUND AND PURPOSE—Carotid webs have been increasingly recognized as a cause of recurrent stroke, but evidence remains scarce. We aim to report the clinical outcomes and first series of carotid ...stenting in a cohort of patients with strokes from symptomatic carotid webs.
METHODS—Prospective and consecutive data of patients <65 years old with cryptogenic stroke admitted within September 2014 to May 2017. Carotid web was defined by a shelf-like/linear filling defect in the posterior internal carotid artery bulb by computed tomographic angiography.
RESULTS—Twenty-four patients were identified (91.6% strokes/8.4% transient ischemic attacks TIAs). Median age was 46 (41–59) years, 61% were female, and 75% were black. Median National Institutes of Health Stroke Scale score was 10.5 (3.0–16.0) and ASPECTS (Alberta Stroke Program Early CT Score) was 8 (7–8). There were no parenchymal hemorrhages, and 96% of patients were independent at 3 months. All webs caused <50% stenosis. In patients with bilateral webs (58%), median ipsilateral web length was larger than contralateral (3.1 3.0–4.5 mm versus 2.6 1.85–2.9 mm; P=0.01), respectively. Twenty-nine percent of patients had thrombus superimposed on the symptomatic carotid web. A recurrent stroke/TIA involving the territory of the previously symptomatic web occurred in 7 (32%; 6 strokes/1 TIA) patients3 <1 week, 2 <first year, and 3 >1 year of follow-up. Two recurrences occurred on dual antiplatelet therapy, 3 on antiplatelet monotherapy, 1 within 24 hours of thrombolysis, and 1 off antithrombotics. Median follow-up was 12.2 (8.0–18.0) months. Sixteen (66%) patients were stented at a median 12.2 (7.0–18.7) days after stroke with no periprocedural complications. No recurrent strokes/TIAs occurred in stented individuals (median follow-up of 4 2.4–12.0 months).
CONCLUSIONS—Carotid web is associated with high recurrent stroke/TIA risk, despite antithrombotic use, and is amenable to carotid stenting.
Subarachnoid hemorrhage (SAH) can lead to devastating neurological outcomes, and there are few pharmacologic treatments available for treating this condition. Both animal and human studies provide ...evidence of inflammation being a driving force behind the pathology of SAH, leading to both direct brain injury and vasospasm, which in turn leads to ischemic brain injury. Several inflammatory mediators that are elevated after SAH have been studied in detail. While there is promising data indicating that blocking these factors might benefit patients after SAH, there has been little success in clinical trials. One of the key factors that complicates clinical trials of SAH is the variability of the initial injury and subsequent inflammatory response. It is likely that both genetic and environmental factors contribute to the variability of patients’ post-SAH inflammatory response and that this confounds trials of anti-inflammatory therapies. Additionally, systemic inflammation from other conditions that affect patients with SAH could contribute to brain injury and vasospasm after SAH. Continuing work on biomarkers of inflammation after SAH may lead to development of patient-specific anti-inflammatory therapies to improve outcome after SAH.
Summary Epidural abcessess can involve the intercranial or spinal compartments and can result in potentially devastating neurological injuries. Although rare, incidence of spinal epidural abscesses ...(SEAs) is increasing as predisposing factors such as injected-drug use, chronic immunosuppression, and spinal surgery become more common. Whereas symptoms of SEAs can include fever, back pain, and neurological dysfunction, the presentation of intracranial epidural abscesses (ICEAs) is less well defined. Neuroimaging narrows the potential diagnoses and enables prompt empirical therapy until specific microbiological diagnosis is made. Surgical intervention is an integral part of treatment for epidural abscesses in patients with neurological symptoms or who have not responded to medical management. Prognosis for both SEAs and ICEAs is typically poor because of delayed diagnosis and intervention and is dependent on the neurological status at the time of diagnosis. Increased clinical awareness can greatly improve outcomes by helping to diagnose patients earlier.
Abstract
Intracerebral hemorrhage (ICH) accounts for 10% to 20% of strokes worldwide and is associated with high morbidity and mortality rates. Neuroimaging is indispensable for rapid diagnosis of ...ICH and identification of the underlying etiology, thus facilitating triage and appropriate treatment of patients. The most common neuroimaging modalities include noncontrast computed tomography (CT), CT angiography (CTA), digital subtraction angiography, and magnetic resonance imaging (MRI). The strengths and disadvantages of each modality will be reviewed. Novel technologies such as dual-energy CT/CTA, rapid MRI techniques, near-infrared spectroscopy, and automated ICH detection hold promise for faster pre- and in-hospital ICH diagnosis that may impact patient management.
Abstract
BACKGROUND: Cranioplasty after decompressive craniectomy (DC) is routinely performed for reconstructive purposes and has been recently linked to improved cerebral blood flow (CBF) and ...neurological function.
OBJECTIVE: To systematically review all available literature to evaluate the effect of cranioplasty on CBF and neurocognitive recovery.
METHODS: A PubMed, Google Scholar, and MEDLINE search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines included studies reporting patients who underwent DC and subsequent cranioplasty in whom cerebral hemodynamics were measured before and after cranioplasty.
RESULTS: The search yielded 21 articles with a total of 205 patients (range 3–76 years) who underwent DC and subsequent cranioplasty. Two studies enrolled 29 control subjects for a total of 234 subjects. Studies used different imaging modalities, including CT perfusion (n = 10), Xenon-CT (n = 3), single-photon emission CT (n = 2), transcranial Doppler (n = 6), MR perfusion (n = 1), and positron emission tomography (n = 2). Precranioplasty CBF evaluation ranged from 2 days to 6 months; postcranioplasty CBF evaluation ranged from 7 days to 6 months. All studies demonstrated an increase in CBF ipsilateral to the side of the cranioplasty. Nine of 21 studies also reported an increase in CBF on the contralateral side. Neurological function improved in an overwhelming majority of patients after cranioplasty.
CONCLUSION: This systematic review suggests that cranioplasty improves CBF following DC with a concurrent improvement in neurological function. The causative impact of CBF on neurological function, however, requires further study.
Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults, and radiation is one of the main treatment modalities. However, cure rates remain low despite best available therapies. ...Immunotherapy is a promising modality that could work synergistically with radiation, which has been shown to increase antigen presentation and promote a proinflammatory tumor microenvironment. Programmed-death-1 (PD-1) is a surface receptor expressed on activated and exhausted T cells, which mediate T cell inhibition upon binding with its ligand PD-L1, expressed on many tumor types including human GBMs. We tested the combination of anti-PD-1 immunotherapy with stereotactic radiosurgery in a mouse orthotopic GBM model.
We performed intracranial implantation of mouse glioma cell line GL261 transfected with luciferase into C57BL/6 mice. Mice were stratified into 4 treatment groups: (1) control; (2) radiation only; (3) anti-PD-1 antibody only; and (4) radiation plus anti-PD-1 antibody. Overall survival was quantified. The mice were killed on day 21 after implantation to assess immunologic parameters in the brain/tumor, cervical lymph nodes, and spleen.
Improved survival was demonstrated with combination anti-PD-1 therapy plus radiation compared with either modality alone: median survival was 25 days in the control arm, 27 days in the anti-PD-1 antibody arm, 28 days in the radiation arm, and 53 days in the radiation plus anti-PD-1 therapy arm (P<.05 by log-rank Mantle-Cox). Long-term survival was seen only in the combined treatment arm, with a fraction (15%-40%) of animals alive at day 180+ after treatment. Immunologic data on day 21 after implantation showed increased tumor infiltration by cytotoxic T cells (CD8+/interferon-γ+/tumor necrosis factor-α+) and decreased regulatory T cells (CD4+/FOXP3) in the combined treatment group compared with the single modality arms.
The combination of PD-1 blockade and localized radiation therapy results in long-term survival in mice with orthotopic brain tumors. These studies provide strong preclinical evidence to support combination trials in patients with GBM.
Highlights • The timing of delayed cranioplasty and complications were cataloged among published studies. • Early cranioplasty (<3 months) is associated with increased odds of hydrocephalus. • Early ...cranioplasty after trauma is associated with reduced odds of extra-axial fluid collections. • There was no significant difference among any other complication, including infection.
Background Conventional approaches to deep-seated cerebral lesions range from biopsy to transcortical or transcallosal resection. Although the former does not reduce tumor burden, the latter are more ...invasive and associated with greater potential for irreparable injury to normal brain. Disconnection syndrome, hemiparesis, hemianesthesia, or aphasia is not uncommon after such surgery, especially when lesion is large. By contrast, the transsulcal parafascicular approach uses naturally existing corridors and a tubular retractor to minimize brain injury. Methods A retrospective review of patients undergoing minimally invasive transsulcal parafascicular resection of ventricular and periventricular lesions, across 5 independent centers, was conducted. Results Twenty patients with lesions located in the lateral ventricle ( n = 9), the third ventricle ( n = 6) and periventricular region ( n = 4) are described in this report. Average age was 64 years (8 male/12 female). The average depth from cortical surface was 4.37 cm. A 13.5-mm-diameter tubular retractor (BrainPath NICO Corporation, Indianapolis, Indiana, USA) of differing lengths was used, aided by neuronavigation. Gross total resection was obtained in 17 patients. Pathologies included colloid cyst, subependymoma, glioma, meningioma, central neurocytoma, lymphoma, and metastasis. Three patients experienced transient morbidity: memory loss (2), hemiparesis (1). One patient died 3 months postoperatively as a result of unrelated pulmonary illness. Follow-up ranged from 6 to 27 months (average, 12 months). Conclusions This technique is safe and effective for the treatment of intraventricular and periventricular lesions. Surgery-related morbidity is minimal and often transient. Lesions are satisfactorily resected and residuum occurs only when the neoplasm involves vital structures. The tubular retractor minimizes trauma to brain incident in the surgeon's path.
Abstract Background Delayed vasospasm is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). This phenomenon was first described more than 50 years ago, but ...only recently has the role of inflammation in this condition become better understood. Methods The literature was reviewed for studies on delayed vasospasm and inflammation. Results There is increasing evidence that inflammation and, more specifically, leukocyte-endothelial cell interactions play a critical role in the pathogenesis of vasospasm after aSAH, as well as in other conditions including meningitis and traumatic brain injury. Although earlier clinical observations and indirect experimental evidence suggested an association between inflammation and chronic vasospasm, recently direct molecular evidence demonstrates the central role of leukocyte-endothelial cell interactions in the development of chronic vasospasm. This evidence shows in both clinical and experimental studies that cell adhesion molecules (CAMs) are up-regulated in the perivasospasm period. Moreover, the use of monoclonal antibodies against these CAMs, as well as drugs that decrease the expression of CAMs, decreases vasospasm in experimental studies. It also appears that certain individuals are genetically predisposed to a severe inflammatory response after aSAH based on their haptoglobin genotype, which in turn predisposes them to develop clinically symptomatic vasospasm. Conclusion Based on this evidence, leukocyte-endothelial cell interactions appear to be the root cause of chronic vasospasm. This hypothesis predicts many surprising features of vasospasm and explains apparently unrelated phenomena observed in aSAH patients. Therapies aimed at preventing inflammation may prevent and/or reverse arterial narrowing in patients with aSAH and result in improved outcomes.
Purpose
Genetic analyses of gliomas have identified key molecular features that impact treatment paradigms beyond conventional histomorphology. Despite at-times lower grade histopathologic ...appearances,
IDH
-wildtype infiltrating gliomas expressing certain molecular markers behave like higher-grade tumors. For
IDH
-wildtype infiltrating gliomas lacking traditional features of glioblastoma, these markers form the basis for the novel diagnosis of
diffuse astrocytic glioma, IDH-wildtype
(wt)
, with molecular features of glioblastoma
(GBM)
, WHO grade-IV
(DAG-G). However, given the novelty of this approach to diagnosis, literature detailing the exact clinical, radiographic, and histopathologic findings associated with these tumors remain in development.
Methods
Data for 25 patients matching the DAG-G diagnosis were obtained from our institution’s retrospective database. Information regarding patient demographics, treatment regimens, radiographic imaging, and genetic pathology were analyzed to determine association with clinical outcomes.
Results
The initial radiographic findings, histopathology, and symptomatology of patients with DAG-G were similar to lower-grade astrocytomas (WHO grade 2/3). Overall survival (OS) and progression free survival (PFS) associated with our cohort, however, were similar to that of
IDH
-wt GBM, indicating a more severe clinical course than expected from other associated features (15.1 and 5.39 months respectively).
Conclusion
Despite multiple features similar to lower-grade gliomas, patients with DAG-G experience clinical courses similar to GBM. Such findings reinforce the need for biopsy and subsequent analysis of molecular features associated with any astrocytoma regardless of presenting characteristics.
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