Abstract
Background:
Although initially considered safe when covering bifurcation sites, flow-diverting stents may provoke thrombosis of side branches that are covered during aneurysm treatment.
...Objective:
To understand the occurrence and clinical expression of side-branch remodeling in distal intracranial arterial sites after flow diverter deployment by means of correlation of imaging and clinical data.
Methods:
We analyzed our prospectively collected data on a series of patients treated with flow diverters for intracranial aneurysms at bifurcation sites. From February 2011 to May 2013, 32 patients with 37 aneurysms (anterior communicating artery, 9 24.3%; anterior cerebral artery, 5 13.5%; middle cerebral artery, 19 (51.4%); terminal internal carotid artery, 4 10.8%) were treated. We divided aneurysms into 2 groups based on the side branches covered by the stent during treatment. Group A consisted of cases with side branches that supplied brain territories also receiving a direct collateral supply. Group B consisted of cases in which side branches supplied territories without direct collateral supply. The 2 groups were compared statistically.
Results:
Total exclusion occurred in 97.3% of aneurysms at follow-up. Initial modified Rankin Scale (mRS) score was 0 to 1 for 29 patients (90.6%) and 2 for 3 patients (9.4%). New permanent neurological deficit was reported in 3 patients (9.4%). At the 6-month follow-up, the mRS score was 0 to 1 for 31 patients (96.8%) and 3 for 1 patient (3.2%). Although 78.5% of side branches in group A underwent narrowing or occlusion after 6 months, no new stroke was found on magnetic resonance imaging.
Conclusion:
Symptomatic modifications of side branches after flow diverter treatment depend on the extent and type of collateral supply.
Fall of the elderly person is a public health problem. The objectives of our study were to evaluate the relevance of systematically performing in emergency a computed tomography (CT) scan for fall in ...the elderly person, to identify specific criteria predicting the appearance of lesions.
We performed a retrospective analysis of 500 consecutive patients aged 65 and over, who underwent an emergency head CT scan for fall from their height. Outcome at the end of the acute care, clinico-biological data and delays between trauma an d CT were collected, and crossed with a detection of head lesion on the CT scan.
Of 500 patients, 38 (7.6%) had traumatic lesions depicted on the CT scan and 267 (53.4%) were hospitalized after the CT scan. Three (0.6%) had been operated for urgent head surgery. Nine of the 38 (23.6%) patients with traumatic lesion returned home. Presence of a lesion depicted on the CT scan was not correlated with the orientation of the patient (P < 0.0001). Post-traumatic injury was significantly associated with male sex (RR = 2.19, P = 0.0217), consciousness impairment (RR = 1.56, P < 0.0001), focal neurological deficit (RR = 6.36, P = 0.0362) and past history of post-traumatic brain injury (RR = 7.17, P = 0.0027). Anticoagulant therapy was not associated with increased risk of traumatic lesions (P = 0.3315). ROC analysis determined that a 5-hours time-interval between head trauma and CT allowed optimal detection of lesions.
The systematic indication of an emergency head CT scan for fall in elderly patients presents a low diagnostic and therapeutic yield and is not relevant. Male sex, consciousness impairment, focal neurological deficit, past history of post-traumatic brain injury and time-interval between head trauma and CT are statistically related to the presence of lesions and should therefore be taken into account.
Background
The dorso-lateral part of the subthalamic nucleus (STN) is considered as the usual target of deep brain stimulation for Parkinson’s disease. Nevertheless, the exact anatomical location of ...the electrode contacts used for chronic stimulation is still a matter of debate. The aim of this study was to perform a systematic review of the existing literature on this issue.
Method
We searched for studies on the anatomical location of active contacts published until December 2012.
Results
We identified 13 studies, published between 2002 and 2010, including 260 patients and 466 electrodes. One hundred and sixty-four active contacts (35 %) were identified within the STN, 117 (25 %) at the interface between STN and the surrounding structures, 184 (40 %) above the STN and one within the substantia nigra. We observed great discrepancies between the different series. The contra-lateral improvement was between 37 and 78.5 % for contacts located within the STN, between 48.6 and 73 % outside the STN, between 65.3 and 66 % at the interface. The authors report no clear correlation between anatomical location and stimulation parameters.
Conclusions
Post-operative analysis of the anatomical location of active contacts is difficult, and all the methods used are debatable. The relationship between the anatomical location of active contacts and the clinical effectiveness of stimulation is unclear. It would be necessary to take into account the volume of the electrode contacts and the diffusion of the stimulation. We can nevertheless assume that the interface between dorso-lateral STN, zona incerta and Forel’s fields could be directly involved in the effects of stimulation.
Background
The effects of surgical site infections (SSI) after glioblastoma surgery on patient outcomes are understudied. The aim of this retrospective multicenter study was to evaluate the impact of ...SSI on the survival of glioblastoma patients.
Methods
Data from SSI cases after glioblastoma surgeries between 2009 and 2016 were collected from 14 French neurosurgical centers. Collected data included patient demographics, previous medical history, risk factors, details of the surgical procedure, radiotherapy/chemotherapy, infection characteristics, and infection management. Similar data were collected from gender- and age-paired control individuals.
Results
We used the medical records of 77 SSI patients and 58 control individuals. 13 were excluded. Our analyses included data from 64 SSI cases and 58 non-infected glioblastoma patients. Infections occurred after surgery for primary tumors in 38 cases (group I) and after surgery for a recurrent tumor in 26 cases (group II). Median survival was 381, 633, and 547 days in patients of group I, group II, and the control group, respectively. Patients in group I had significantly shorter survival compared to the other two groups (
p
< 0.05). The one-year survival rate of patients who developed infections after surgery for primary tumors was 50%. Additionally, we found that SSIs led to postoperative treatment discontinuation in 30% of the patients.
Discussion
Our findings highlighted the severity of SSIs after glioblastoma surgery, as they significantly affect patient survival. The establishment of preventive measures, as well as guidelines for the management of SSIs, is of high clinical importance.
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Pre-surgical embolization of large intracranial meningioma has been demonstrated to decrease blood loss and to improve the resectability of the tumor. Few reports have evaluated the ...risk and benefits of using Onyx in this indication. The objective of our study was to assess the efficiency and safety of pre-surgical embolization in a consecutive series of intracranial meningioma using Onyx.
We conducted a retrospective study of consecutive patients treated from 2010 to 2018 with pre-surgical embolization with Onyx for intracranial histologically-proven meningioma. Safety was evaluated by a report of the complications related to the procedure while efficacy was assessed on angiographic and histopathologic criteria.
Forty-four meningioma in 44 patients treated with pre-surgical embolization were included in this study. Proximal artery occlusion was obtained in 97.6% (41/42) of the cases and good intra-tumoral penetration was achieved in 75.6% (31/41). Embolic agent inside blood vessels was identified in 63.5% (28/44) of cases. Embolization-induced necrosis was present in 79.6% (35/44) of cases. Six complications have been encountered (13.6%); 3 were stated as minor complications (6.8%) and 3 as major occurring in case of trans-ophthalmic route (6.8%).
The present work is to date the largest study to evaluate intracranial meningioma embolization using Onyx. Onyx's allowed good intra-tumoral penetration and proximal artery occlusion in most cases but carries a higher risk of complication in case of ophthalmic supply.
Abstract Introduction Neurosurgery and Maxillofacial Surgery Departments of Limoges University Hospital Centre have developed a new concept of a custom made ceramic implant in hydroxyapatite (HA) for ...the reconstruction of large and complex craniofacial bone defects (more than 25 cm2 ). Materials and methods The manufacturing process of the implants used a stereolithography technique that produces implants with three-dimensional shapes derived directly from the scan file of the patient's skull without moulding or machining. Eight patients received 8 implants between 2005 and 2008. Results The surgical procedure is simple and fast. The post-operative follow-up was 12 months. No major complications (infection or fracture of the implant) were observed. The cosmetic result was considered satisfactory by both patients and surgeons. Conclusions These new implants are well suited for reconstruction of large craniofacial bone defects (greater than 25 cm2 ) in adults and children over 8 years.
Summary Sinonasal intestinal-type adenocarcinomas (ITACs) are uncommon tumors of poor prognosis defined by their similarities to colorectal adenocarcinomas. The involvement of the epidermal growth ...factor receptor (EGFR) pathway in colorectal adenocarcinoma oncogenesis is well established, and the same is expected to apply to ITACs. In a series of 39 ITACs, we investigated EGFR amplification and chromosome 7 polysomy by fluorescence in situ hybridization; EGFR , KRAS , and BRAF mutational status by polymerase chain reaction sequencing; EGFR variant messenger RNA expression by quantitative reverse transcriptase polymerase chain reaction; and EGFR protein expression by immunohistochemistry with antibodies targeting the extracellular domain, the intracellular domain, and the phosphorylated isoform. The findings were analyzed with respect to clinical data, histologic typing, and patient outcome. EGFR amplification was observed in 3 cases with a focal distribution. EGFR proteins were overexpressed in all these foci with both extracellular domain and intracellular domain antibodies, suggesting involvement of the whole receptor. Chromosome 7 polysomy was observed in 15 cases and was not associated with EGFR protein expression. EGFR , KRAS , or BRAF mutations were observed in 5 different cases. The EGFRvIII mutant was not detected. In all cases, EGFR variants were expressed. There was no association between these molecular features and patient survival. In conclusion, (1) our study revealed various EGFR expression patterns in ITACs, indicating tumor heterogeneity; (2) EGFR amplification should be distinguished from chromosome 7 polysomy; (3) fluorescence in situ hybridization analysis could be guided by immunohistochemistry; and (4) ITACs share common alterations of the EGFR pathway with colorectal adenocarcinomas, except for a lower frequency of KRAS and BRAF mutations.
The standard of care for newly diagnosed glioblastoma is maximal safe surgical resection, followed by chemoradiation therapy. We assessed carmustine wafer implantation efficacy and safety when used ...in combination with standard care.
Included were adult patients with (n = 354, implantation group) and without (n = 433, standard group) carmustine wafer implantation during first surgical resection followed by chemoradiation standard protocol. Multivariate and case-matched analyses (controlled propensity-matched cohort, 262 pairs of patients) were conducted.
The median progression-free survival was 12.0 months (95% CI: 10.7-12.6) in the implantation group and 10.0 months (9.0-10.0) in the standard group and the median overall survival was 20.4 months (19.0-22.7) and 18.0 months (17.0-19.0), respectively. Carmustine wafer implantation was independently associated with longer progression-free survival in patients with subtotal/total surgical resection in the whole series (adjusted hazard ratio HR, 0.76 95% CI: 0.63-0.92, P = .005) and after propensity matching (HR, 0.74 95% CI: 0.60-0.92, P = .008), whereas no significant difference was found for overall survival (HR, 0.95 0.80-1.13, P = .574; HR, 1.06 0.87-1.29, P = .561, respectively). Surgical resection at progression whether alone or combined with carmustine wafer implantation was independently associated with longer overall survival in the whole series (HR, 0.58 0.44-0.76, P < .0001; HR, 0.54 0.41-0.70, P < .0001, respectively) and after propensity matching (HR, 0.56 95% CI: 0.40-0.78, P < .0001; HR, 0.46 95% CI: 0.33-0.64, P < .0001, respectively). The higher postoperative infection rate in the implantation group did not affect survival.
Carmustine wafer implantation during surgical resection followed by the standard chemoradiation protocol for newly diagnosed glioblastoma in adults resulted in a significant progression-free survival benefit.
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