Brain tumor grading diagnosis using transfer learning based on optical coherence tomography

In neurosurgery, accurately identifying brain tumor tissue is vital for reducing recurrence. Current imaging techniques have limitations, prompting the exploration of alternative methods. This study validated a binary hierarchical classification of brain tissues: normal tissue, primary central nervous system lymphoma (PCNSL), high-grade glioma (HGG), and low-grade glioma (LGG) using transfer learning. Tumor specimens were measured with optical coherence tomography (OCT), and a MobileNetV2 pre-trained model was employed for classification. Surgeons could optimize predictions based on experience. The model showed robust classification and promising clinical value. A dynamic t-SNE visualized its performance, offering a new approach to neurosurgical decision-making regarding brain tumors.

RAPID-ED: A predictive model for risk assessment of patient's early in-hospital deterioration from emergency department

Introduction

The objective of this multi-center retrospective cohort study was to devise a predictive tool known as RAPID-ED. This model identifies non-traumatic adult patients at significant risk for cardiac arrest within 48 hours post-admission from the emergency department.

Methods

Data from 224,413 patients admitted through the emergency department (2016-2020) was analyzed, incorporating vital signs, lab tests, and administered therapies. A multivariable regression model was devised to anticipate early cardiac arrest. The efficacy of the RAPID-ED model was evaluated against traditional scoring systems like National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) and its predictive ability was gauged via the area under the receiver operating characteristic curve (AUC) in both hold-out validation set and external validation set.

Results

RAPID-ED outperformed traditional models in predicting cardiac arrest with an AUC of 0.819 in the hold-out validation set and 0.807 in the external validation set. In this critical care update, RAPID-ED offers an innovative approach to assessing patient risk, aiding emergency physicians in post-discharge care decisions from the emergency department. High-risk score patients (≥13) may benefit from early ICU admission for intensive monitoring.

Conclusion

As we progress with advancements in critical care, tools like RAPID-ED will prove instrumental in refining care strategies for critically ill patients, fostering an improved prognosis and potentially mitigating mortality rates.

Frame-based versus robot-assisted stereo-electro-encephalography for drug-resistant epilepsy

BACKGROUND

Stereoelectroencephalography (SEEG) is an effective presurgical invasive evaluation for drug-resistant epilepsies. The introduction of robotic devices provides a simplified, accurate, and safe alternative to the conventional SEEG technique. We report our institutional experience with robot-assisted SEEG and compare its in vivo accuracy, operation efficiency, and safety with the more traditional SEEG workflow.

METHODS

All patients with medically refractory focal epilepsy who underwent SEEG depth electrode implantation between 2014 and 2022 were included in this study. Technical advancements of the robot-assisted technique are described. Analyses of patient demographics, electrode implantation accuracy, operation time, and procedure-related complications were performed.

RESULTS

One hundred and sixty-six patients underwent 167 SEEG procedures. The first 141 procedures were performed using a conventional approach involving a Leksell stereotactic system, and the last 26 procedures were robot-assisted. Among the 1726 depth electrodes that were inserted, the median entry point localization error was as follows: conventional (1.0 mm; range, 0.1-33.5 mm) and robot-assisted (1.1 mm; range, 0-4.8 mm) (P = 0.17). The median target point localization error was as follows: conventional (2.8 mm; range, 0.1-49 mm) and robot-assisted (1.8 mm; range, 0-30.3 mm) (P < 0.001). The median operation time was significantly reduced with the robot-assisted workflow (90 min vs. 77.5 min; P < 0.01). Total complication rates were as follows: conventional (17.7%) and robot-assisted (11.5%) (P = 0.57). Major complication rates were 3.5% and 7.7% (P = 0.77), respectively.

CONCLUSIONS

SEEG is a safe and highly accurate method that provides essential guidance for epilepsy surgery. Implementing SEEG in conjunction with multimodal planning systems and robotic devices can further increase safety margin, surgical efficiency, and accuracy.

Natural History and Histopathology of Expanding Cysts and Hematomas After Stereotactic Radiosurgery for Arteriovenous Malformations of the Brain: A Case Series

BACKGROUND

We reviewed the clinical course and histopathologic findings for cases involving the formation of expanding cysts and/or hematomas after gamma knife surgery (GKS) for arteriovenous malformations (AVMs).

METHODS

We report a single-center retrospective review of 18 patients who presented with cyst and/or hematoma expansion after GKS for AVMs between 1993 and 2023. Expanding cysts and hematomas were defined as well-demarcated cavities filled with fluid or well-marginated heterogenous hematomas presenting with expansion proximal to or in the location of the original AVM, respectively. Patient demographics, AVM characteristics, history of interventions and surgeries, and imaging and histopathologic features of expanding cysts and hematomas were collected for analysis.

RESULTS

Among 1072 AVM patients treated using GKS, 18 presented with expanding cysts or hematomas during a total follow-up period of 16,757 patient-years (0.11 case/100 persons/patient-year). The time to cyst or hematoma identification was 4-13 years after initial GKS, with a mean duration of 8.6 years. Among the patients examined, 7 (38.9%) presented mainly with hematoma, 10 (55.6%) presented mainly with cysts, and 1 presented with approximately equal components of both. Among the 18 patients, 13 (72.2%) underwent craniotomy to treat cyst or hematoma expansion. All the specimens had similar histopathologic characteristics, including organizing hematoma with fresh and old hemorrhage, fibrinoid necrosis of the vessels, gliosis of normal brain tissue, infiltration of hemosiderin-laden histiocytes, and extravascular protein leakage.

CONCLUSIONS

Our findings suggest that the formation of these 2 complications can be attributed to a common mechanism involving radiation-induced vascular damage in brain tissue adjacent to the AVM and subsequent chronic inflammation and capillary dilatation.

The learning curve for cavernous sinus surgery illustrated by symptomatic intracavernous aneurysm clipping through a pretemporal transcavernous approach

OBJECTIVE

The anatomy of the cavernous sinus (CS) has been well studied in the laboratory for decades; however, performing surgery in and around the CS is still a challenge. To reveal the learning curve for CS surgery via the pretemporal transcavernous approach (PTTC), surgical procedures were examined. The authors proposed 4 levels of surgical difficulty in opening the walls of the CS through this approach. Details of the approach were illustrated by surgical videos of symptomatic intracavernous aneurysm clipping.

METHODS

Four levels of surgical difficulty were proposed. The higher the level, the more the CS walls were opened. Pathologies corresponding to each level of difficulty in and around the CS were categorized in each level together with explanations. From 2015 to 2021, 5 patients with symptomatic intracavernous aneurysms (diplopia due to compressive cranial neuropathy) underwent the PTTC at the authors' institute and served as representative cases in opening the walls of the CS. All CS cases from 2009 to 2021 were reviewed and categorized to demonstrate the learning curve.

RESULTS

Four levels of surgical difficulty are as follows: level 1, a basic Dolenc extradural approach, which involves opening the anterior third of the superior and lateral walls of the CS; level 2, mobilizing the internal carotid artery (ICA) and opening the proximal dural ring to enter the roof of the CS and treat lesions around the clinoid and upper cavernous ICA; level 3, opening the entire aspect of the superior and lateral walls of the CS, which involves opening the oculomotor triangle and peeling the lateral wall of the CS to the tentorial incisura; and level 4, mobilizing cranial nerves III, IV, and V1 to gain access to the supra-/infratrochlear triangles to have proximal ICA control and opening the posterior wall as the last step to enter the posterior fossa. Surgical steps were described and illustrated with surgical videos of symptomatic intracavernous aneurysm clipping.

CONCLUSIONS

The learning curve for CS surgery is long. The authors use 4 levels of surgical difficulty to describe applications of the PTTC in CS surgery. This approach serves as an effective workhorse in treating CS pathologies with low morbidity and high success rates when performed by experienced neurosurgeons.

Automated identification and quantification of metastatic brain tumors and perilesional edema based on a deep learning neural network

PURPOSE

This paper presents a deep learning model for use in the automated segmentation of metastatic brain tumors and associated perilesional edema.

METHODS

The model was trained using Gamma Knife surgical data (90 MRI sets from 46 patients), including the initial treatment plan and follow-up images (T1-weighted contrast-enhanced (T1cWI) and T2-weighted images (T2WI)) manually annotated by neurosurgeons to indicate the target tumor and edema regions. A mask region-based convolutional neural network was used to extract brain parenchyma, after which the DeepMedic 3D convolutional neural network was in the segmentation of tumors and edemas.

RESULTS

Five-fold cross-validation demonstrated the efficacy of the brain parenchyma extraction model, achieving a Dice similarity coefficient of 96.4%. The segmentation models used for metastatic tumors and brain edema achieved Dice similarity coefficients of 71.6% and 85.1%, respectively. This study also presents an intuitive graphical user interface to facilitate the use of these models in clinical analysis.

CONCLUSION

This paper introduces a deep learning model for the automated segmentation and quantification of brain metastatic tumors and perilesional edema trained using only T1cWI and T2WI. This technique could facilitate further research on metastatic tumors and perilesional edema as well as other intracranial lesions.

The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.

Quantified flow and angioarchitecture show similar associations with hemorrhagic presentation of brain arteriovenous malformations

INTRODUCTION

The purpose of our study was to elucidate the impact of brain arteriovenous malformation (BAVM) flow and wall shear stress (WSS) on angioarchitecture and to evaluate their association with hemorrhagic presentations.

MATERIALS AND METHODS

Forty-one patients with BAVMs were evaluated by phase-contrast MR angiography. Volume flow rate and WSS were quantified. Angioarchitectural features such as location, angiogenesis, venous stenosis, venous ectasia, venous phlebitis, venous rerouting, exclusive deep vein and venous sac were evaluated by two neuroradiologists. The correlation between BAVM flow and size was evaluated with Spearman correlation coefficients. Differences of size, flow, and WSS between the hemorrhagic and non-hemorrhagic groups, the seizure and non-seizure groups, and between the different groups based on angioarchitecture were evaluated with Mann-Whitney U tests. Accuracy in predicting hemorrhage was evaluated with receiver operating characteristic curves.

RESULT

BAVM flow was highly correlated with volume (ρ = 0.77). Higher flow was more commonly associated with angiogenesis, venous ectasia, venous rerouting, and venous phlebitis. Flow and angioarchitecture showed similar efficacy in differentiating hemorrhagic from non-hemorrhagic BAVMs. WSS did not demonstrate differences across any clinical groups.

CONCLUSION

Flow quantification and angioarchitecture analysis of BAVMs showed similar efficacy as evaluated by associations with hemorrhagic presentation. High flow affects both arterial and venous angioarchitecture, reflecting the nature of low vascular resistance in BAVMs.

Stereo-EEG for Epileptogenic Focus Localization in Schizencephaly: A Single-center Experience in Four Patients

OBJECTIVE

Schizencephaly is a congenital cerebral malformation characterized by clefts in the hemispheres of the brain, where variations in semiology often make it difficult to localize epileptogenic focus. Here, we report on a series of patients who underwent stereo-encephalography (SEEG) for epileptogenic focus localization and subsequent SEEG-guided surgical intervention.

METHODS

Four patients (ages 27, 33, 27, 25 years) with a mean seizure history of 16 years (range 8-22 years) were analyzed. Data pertaining to semiology, video encephalography (EEG), magnetic resonance imaging, positron emission tomography, and invasive EEG studies, surgical intervention and post-surgery outcome were collected and analyzed.

RESULTS

All seizure onset zones were within the extent of schizencephaly; however, the limbic system (including the hippocampus, amygdala, cingulate gyrus, or insula) was involved in early spreading. Two patients underwent SEEG-guided radiofrequency thermo-ablation (RFTA) in the seizure onset zone, 1 patient underwent lesionectomy via craniotomy, and 1 underwent neither RFTA nor lesionectomy. At 2 years post-surgery, the outcomes were as follows: Engel grade Ia (n = 2), Ib (n = 1), and III (n = 1).

CONCLUSIONS

This article reports on a precise approach to treating patients with schizencephaly dependent of seizure onset zone and functional cortex mapping. Subsequent SEEG-guided surgical interventions (radiofrequency thermo-ablation and lesionectomy) were shown to reduce seizure frequency, while preserving the neurologic functions in drug-resistant epilepsy patients with schizencephaly.

Imaging markers of cerebral amyloid angiopathy and hypertensive arteriopathy differentiate Alzheimer disease subtypes synergistically

Background

Both cerebral amyloid angiopathy (CAA) and hypertensive arteriopathy (HA) are related to cognitive impairment and dementia. This study aimed to clarify CAA- and HA-related small vessel disease (SVD) imaging marker associations with cognitive dysfunction and Alzheimer disease (AD) subtypes.

Methods

A sample of 137 subjects with clinically diagnosed late-onset AD identified from the dementia registry of a single center from January 2017 to October 2021 were enrolled. Semi-quantitative imaging changes (visual rating scale grading) suggestive of SVD were analyzed singularly and compositely, and their correlations with cognitive domains and AD subtypes were examined.

Results

Patients with typical and limbic-predominant AD subtypes had worse cognitive performance and higher dementia severity than minimal-atrophy subtype patients. Deep white matter hyperintensity (WMH) presence correlated inversely with short-term memory (STM) performance. The three composite SVD scores correlated with different cognitive domains and had distinct associations with AD subtypes. After adjusting for relevant demographic factors, multivariate logistic regression (using minimal-atrophy subtype as the reference condition) revealed the following: associations of the typical subtype with periventricular WMH [odds ratio (OR) 2.62; 95% confidence interval (CI), 1.23–5.57, p = 0.012], global SVD score (OR 1.67; 95%CI, 1.11–2.52, p = 0.009), and HA-SVD score (OR 1.93; 95%CI, 1.10–3.52, p = 0.034); associations of limbic-predominant subtype with HA-SVD score (OR 2.57; 95%CI, 1.23–5.37, p = 0.012) and most global and domain-specific cognitive scores; and an association of hippocampal-sparing subtype with HA-SVD score (OR 3.30; 95%CI, 1.58–6.85, p = 0.001).

Conclusion

Composite SVD imaging markers reflect overall CAA and/or HA severity and may have differential associations with cognitive domains and AD subtypes. Our finding supports the possibility that the clinical AD subtypes may reflect differing burdens of underlying CAA and HA microangiopathologies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-022-01083-8.

Environment is associated with chytrid infection and skin microbiome richness on an amphibian rich island (Taiwan)

Growing evidence suggests that the origins of the panzootic amphibian pathogens Batrachochytrium dendrobatidis (Bd) and Batrachochytrium salamandrivorans (Bsal) are in Asia. In Taiwan, an island hotspot of high amphibian diversity, no amphibian mass mortality events linked to Bd or Bsal have been reported. We conducted a multi-year study across this subtropical island, sampling 2517 individuals from 30 species at 34 field sites, between 2010 and 2017, and including 171 museum samples collected between 1981 and 2009. We analyzed the skin microbiome of 153 samples (6 species) from 2017 in order to assess any association between the amphibian skin microbiome and the probability of infection amongst different host species. We did not detect Bsal in our samples, but found widespread infection by Bd across central and northern Taiwan, both taxonomically and spatially. Museum samples show that Bd has been present in Taiwan since at least 1990. Host species, geography (elevation), climatic conditions and microbial richness were all associated with the prevalence of infection. Host life-history traits, skin microbiome composition and phylogeny were associated with lower prevalence of infection for high altitude species. Overall, we observed low prevalence and burden of infection in host populations, suggesting that Bd is enzootic in Taiwan where it causes subclinical infections. While amphibian species in Taiwan are currently threatened by habitat loss, our study indicates that Bd is in an endemic equilibrium with the populations and species we investigated. However, ongoing surveillance of the infection is warranted, as changing environmental conditions may disturb the currently stable equilibrium.

Validation of the Taiwanese version of the Epilepsy Surgery Satisfaction Questionnaire (Tw-ESSQ-19)

OBJECTIVE

Satisfaction with epilepsy surgery in Mandarin-speaking countries remains unknown. We aimed to validate in our Taiwanese patients an existing instrument to measure patient satisfaction with epilepsy surgery, the 19-item Epilepsy Surgery Satisfaction Questionnaire (ESSQ-19).

METHODS

Consecutive patients with epilepsy who received epilepsy surgery one year earlier in Taipei Veterans General Hospital were recruited and provided clinical and demographic data. The Mandarin version of the ESSQ-19 for the Taiwanese population and eight other questionnaires were completed to assess construct validity. To evaluate the validity and reliability of the tool, the data were analyzed by confirmatory factor analysis, Spearman's rank correlation, and internal consistency analysis.

RESULTS

The study involved 120 patients (70 F/50 M, median age 35 years [IQR = 28-41]). The mean summary score (±SD) of the Tw-ESSQ-19 was 82.5 ± 14.5. The mean scores of the four domains were 90.3 ± 15.4 (surgical complications), 83.2 ± 16.7 (seizure control), 80.1 ± 17.3 (recovery from surgery), and 76.6 ± 18.3 (psychosocial functioning). The questionnaire was shown to have good construct validity with satisfactory goodness-of-fit of the data (standardized root mean square residual = 0.0492; comparative fit index = 0.946). It also demonstrated good discriminant validity (being seizure free [AUC 0.78; 95% CI 0.68-0.89], endorsing depression [AUC 0.84; 95% CI 0.76-0.91], self-rating epilepsy as disabling [AUC 0.71; 95% CI 0.58-0.84], and self-rating epilepsy as severe [AUC 0.78; 95% CI 0.64-0.93]), high internal consistency in four domains (Cronbach's alpha = 0.83-0.96), and no significant floor/ceiling effects of the summary score.

SIGNIFICANCE

The Mandarin version of the ESSQ-19 adapted for the Taiwanese population is a reliable and valid self-reported questionnaire for assessing patient satisfaction with epilepsy surgery.

Plasma Matrix Metalloproeteinase-9 Is Associated with Seizure and Angioarchitecture Changes in Brain Arteriovenous Malformations

Both angiogenesis and inflammation contribute to activation of matrix metalloproeteinase-9 (MMP-9), which dissolves the extracellular matrix, disrupts the blood-brain barrier, and plays an important role in the pathogenesis of brain arteriovenous malformations (BAVMs). The key common cytokine in both angiogenesis and inflammation is interleukin 6 (IL-6). Previous studies have shown elevated systemic MMP-9 and decreased systemic vascular endothelial growth factor (VEGF) in BAVM patients. However, the clinical utility of plasma cytokines is unclear. The purpose of this study is to explore the relationship between plasma cytokines and the clinical presentations of BAVMs. Prospectively, we recruited naive BAVM patients without hemorrhage as the experimental group and unruptured intracranial aneurysm (UIA) patients as the control group. All patients received digital subtraction angiography, and plasma cytokines were collected from the lesional common carotid artery. Plasma cytokine levels were determined using a commercially available, monoclonal antibody-based enzyme-linked immunosorbent assay. Subgroup analysis based on hemorrhagic presentation and angiograchitecture was done for the BAVM group. Pearson correlations were calculated for the covariates. Means and differences for continuous and categorical variables were compared using Student's t and χ² tests respectively. Plasma MMP-9 levels were significantly higher in the BAVM group (42,945 ± 29,991 pg/mL) than in the UIA group (28,270 ± 17,119 pg/mL) (p < 0.001). Plasma MMP-9 levels in epileptic BAVMs (57,065 ± 35,732; n = 9) were higher than in non-epileptic BAVMs (35,032 ± 28,301; n = 19) (p = 0.049). Lower plasma MMP-9 levels were found in cases of BAVM with angiogenesis and with peudophlebitis. Plasma MMP-9 is a good biomarker reflecting ongoing vascular remodeling in BAVMs. Angiogenesis and pseudophlebitis are two angioarchitectural signs that reflect MMP-9 activities and can potentially serve as imaging biomarkers for epileptic BAVMs.

Clinical characteristics and long-term outcome of cerebral cavernous malformations-related epilepsy

OBJECTIVE

Cerebral cavernous malformations (CCMs) present variably and epileptic seizures are the most common symptom. The factors contributing to cavernoma-related epilepsy (CRE) and drug resistance remain inconclusive. The outcomes of CRE after different treatment modalities have not yet been fully addressed. This study aimed to characterize the clinical features of patients with CRE and the long-term seizure outcomes of medical and surgical treatment strategies.

METHODS

This was a retrospective cohort of 135 patients with CCM who were diagnosed in 2007~2011 and followed up for 93.6 months on average. The patients were divided into drug-resistant epilepsy (DRE) (n = 29), non-DRE (NDRE) (n = 45), and no epilepsy (NE) (n = 61).

RESULTS

Temporal CCM was the factor most strongly associated with the development of both CRE and DRE. The majority of patients with single temporal CCMs had CRE (86.8%, n = 33) and 50% had DRE, whereas only 14.7% (n = 5) with a non-temporal supratentorial CCM had DRE (P < 0.05). The most common lesion site in the DRE group was the mesiotemporal lobe (50%). Multiple CCMs were more frequently observed in the CRE (29.2%) than the NE (11.5%) group (P < 0.05). In patients with CRE, multiple lesions were associated with a higher rebleeding rate (odds ratio: 11.1), particularly in those with DRE (odds ratio: 15.4). The majority of patients who underwent resective surgery for DRE (76.5%, n = 13) achieved ILAE class I and II seizure outcomes even after a long disease course.

SIGNIFICANCE

Temporal CCM not only predisposes to CRE but is also a major risk factor for drug resistance. The mesiotemporal lobe is the most epileptogenic zone. Multiple CCMs are another risk factor for CRE and increase the rebleeding risk in these patients. Surgical resection could provide beneficial long-term seizure outcomes in patients with DRE.

Range map datasets for terrestrial vertebrates across Taiwan

Accurate data describing the geographic distribution of specific species form the basis for effective conservation management policies. However, for most species the freely available distributional information is usually confined to either expert maps or purely theoretical maps constructed by using a variety of modeling frameworks. These maps usually do not provide enough resolution for conservation applications or do not accurately describe the current distribution status. In this study, we constructed a novel workflow designed to integrate data from various species distribution models and expert knowledge into a single unified modeling process. Under this workflow, we systematically constructed current distribution maps for a selection of terrestrial vertebrates found across Taiwan.

We used species distribution modeling as the base and then aggregated multiple open datasets describing species occurrence and environmental factors as data sources. Thereafter, we estimated the primary broad-scale and high spatial resolution species range maps using the MaxEnt modeling algorithm, and then consulted experts on each taxa to refine these maps.

This dataset provides up-to-date species distribution maps for 379 terrestrial vertebrates in Taiwan, with members from across four taxa (27 amphibians, 52 reptiles, 264 birds, and 36 mammals). This dataset helps to fill the spatial knowledge gaps for conservation concerns and improves our understanding of the geographic distribution of more than half (61%) of the vertebrate species of Taiwan. Furthermore, by stacking the range maps of multiple species, we can identify vertebrate diversity hotspots and identify priority areas for conservation.

Bifocal lesions have a poorer treatment outcome than a single lesion in adult patients with intracranial germinoma

Intracranial germinoma (IG) rarely occurs in adults. Its optimal treatment strategy is unclear. We evaluated the outcomes of radiotherapy in adults with intracranial germinoma. Data of 29 adult patients (age, 18–52 years; median age, 24.3 years) with IG treated with radiotherapy at Taipei Veterans General Hospital were retrospectively reviewed. They were followed up for a median time of 5.9 years (range, 1.0–12.8 years). We used the Kaplan–Meier method to estimate the progression-free survival (PFS) and overall survival (OS), and univariate and multivariate Cox proportional hazards regression models to identify the factors affecting PFS. PFS and OS were compared between adult and pediatric patients with IG. The 1-, 3-, and 5-year PFS rates were 96.6%, 85.8%, and 77.8%, respectively, in the adult patients, and the OS rate were all 100%. Seven patients (24.1%) experienced recurrence, and in six of them, salvage therapy successfully controlled the disease. Two patients (6.9%) died after 5 years of follow-up due to disease progression and central pontine myelinolysis. In the univariate and multivariate Cox analysis, bifocal lesions had a significantly lower PFS than those with single lesions (p = 0.008). Kaplan–Meier survival analysis showed that adult patients had a poorer PFS (p = 0.06) and OS (p = 0.025) than pediatric patients. Our study showed bifocal lesions were associated with lower PFS than a single lesion among adult IG patients, and adult IG patients tended to have poorer PFS and OS compared to pediatric IG patients. For adult patients with bifocal IG, we recommend treatment with craniospinal irradiation, whole ventricle irradiation (WVI) with chemotherapy, or frequent spine images follow-up for patients who received only WVI.

Pilot study of focused ultrasound for drug-resistant epilepsy

Objective

The neuromodulatory effects of focused ultrasound (FUS) have been demonstrated in animal epilepsy models; however, the safety and efficacy of FUS in humans with epilepsy have not been well established. Patients with drug‐resistant epilepsy (DRE) undergoing stereo‐electroencephalography (SEEG) provide an opportunity to investigate the neuromodulatory effects of FUS in humans.

Methods

Patients with DRE undergoing SEEG for localization of the seizure onset zone (SOZ) were prospectively enrolled. FUS was delivered to the SOZ using a neuronavigation‐guided FUS system (ceiling spatial‐peak temporal‐average intensity level = 2.8 W/cm², duty cycle = 30%, modulating duration = 10 min). Simultaneous SEEG recordings were obtained during sonication and for 3 days after treatment. Seizures, interictal epileptiform discharges, and adverse events after FUS were monitored.

Results

Six patients met the eligibility criteria and completed FUS treatment. A decrease in seizure frequency was observed in two patients within the 3‐day follow‐up; however, one patient presented an increase in the frequency of subclinical seizures. Posttreatment magnetic resonance imaging revealed neither lesion nor brain edema. Significant changes in spectral power of SEEG were noted at the targeted electrodes during FUS treatment. One patient reported subjective scalp heating during FUS, and one patient developed transient naming and memory impairment that resolved within 3 weeks after FUS.

Significance

FUS can be safely delivered to the SOZ of patients with DRE, resulting in significant changes in spectral power of SEEG. A larger sample cohort and pursuing optimal sonication parameters will be required to elucidate the neuromodulatory effects of FUS when used for seizure control.

Utilization of Amplitude-Integrated Electroencephalography to Predict Neurologic Function after Resuscitation in Adults with Cardiogenic Cardiac Arrest

BACKGROUND

Amplitude-integrated electroencephalography (aEEG) has been used as a tool to recognize brain activity in children with hypoxic encephalopathy.

OBJECTIVES

To assess the prognostic value of aEEG during the post-resuscitation period of adult cardiogenic cardiac arrest, comatose survivors were monitored within 24 h of a return of spontaneous circulation using aEEG.

METHODS

Forty-two consecutive patients experiencing cardiac arrest were retrospectively enrolled, and a return of spontaneous circulation was achieved in all cases. These patients were admitted to the Coronary Intensive Care Unit due to cardiogenic cardiac arrest. The primary outcome was the best neurologic outcome within 6 months after resuscitation, and the registered patients were divided into two groups based on the Cerebral Performance Category (CPC) scale (CPC 1-2, good neurologic function group; CPC 3-5, poor neurologic function group). All patients received an aEEG examination within 24 h after a return of spontaneous circulation, and the parameters and patterns of aEEG recordings were compared.

RESULTS

Nineteen patients were in the good neurologic function group, and 23 were in the poor group. The four voltage parameters (minimum, maximum, span, average) of the aEEG recordings in the good neurologic function groups were significantly higher than in the poor group. Moreover, the continuous pattern, but not the status epilepticus or burst suppression patterns, could predict mid-term good neurologic function.

CONCLUSIONS

aEEG can be used to predict neurologic outcomes based on the recordings' parameters and patterns in unconscious adults who have experienced a cardiac collapse, resuscitation, and return of spontaneous circulation.

Correlation between intraoperative mapping and monitoring and functional outcomes following supratentorial glioma surgery

OBJECTIVES

Intraoperative neurophysiological monitoring (IONM) has long been regarded as the "gold standard" when resecting a supratentorial glioma, as it facilitates the goals of maximal tumor resection and preservation of sensorimotor function. The purpose of the present study was to evaluate the ability of motor evoked potentials (MEPs) monitoring or subcortical mapping (SCM), alone or in combination, to predict postoperative functional outcomes in glioma surgery.

MATERIALS AND METHODS

We retrospectively reviewed patients with supratentorial glioma that underwent craniotomy for tumor removal with IONM. Statistical analyses were used to evaluate whether the following criteria correlated with postoperative functional outcomes: Reduced amplitude (>50% reduction) or disappearance of MEPs (criterion 1), SCM with a stimulation intensity threshold less than 3 mA (criterion 2), the presence of both two phenomena (criterion 3), or either one of the two phenomena (criterion 4).

RESULTS

Ninety-two patients were included in this study, of whom 15 sustained new postoperative deficits, 4 experienced improved functional status, and 73 were unchanged. Postoperative functional status correlated significantly with all four criteria, and especially with criterion 3 (r = 0.647, P = 0.000). Sensitivity of IONM was better if using criteria 2 and 4, but specificity was better if using criteria 1 and 3. Criterion 3 had the most favorable overall results.

CONCLUSION

Using statistical methodology, our study indicates that concomitant interpretation of MEPs and SCM is the most accurate predictor of functional outcomes following supratentorial glioma surgery. However, accurate interpretations of the monitoring results by experienced neurophysiologists are essential.

An Easy Adjustable Sling Technique of Ectatic Vertebral Artery Transposition for Microvascular Decompression

Hemifacial spasm caused by an elongated, tortuous, or enlarged vertebral artery (VA) can be difficult to treat. Greater rates of incomplete cure also have been noted.^1-6 In this video, we demonstrate the key steps of a simple and effective adjustable sling technique of an ectatic VA transposition for microvascular decompression. In this patient, an ectatic VA was stacked on the posterior inferior cerebellar artery, and together they compressed the root exit zone (REZ) of the facial nerve. We cut a suturable and unabsorbable artificial dural graft into a sling. The rougher side of the sling was used to wrap around the VA to obtain more friction and avoid sliding. Suitable width of the sling was determined to prevent prominent indentation on the VA. We wrapped the VA at a perforator-free zone and lifted the VA away from the REZ by pulling the sling in a lateral direction. At the same time, the anchor point for the aneurysm clip to hold the sling at the lateral skull base also was determined. We made a small dural incision at the anchor point, where an aneurysm clip was applied to hold the sling securely under tension but not to cause kinking of the VA/posterior inferior cerebellar artery. The patient had no hemifacial spasm immediately after the operation and thereafter. This adjustable sling technique provides an easy and strong hold to maintain an ectatic VA away from the REZ of the facial nerve (Video 1).

Delta Shock Index During Emergency Department Stay Is Associated With in Hospital Mortality in Critically Ill Patients

Background: Delta shock index (SI; i.e., change in SI over time) has been shown to predict mortality and need for surgical intervention among trauma patients at the emergency department (ED). However, the usefulness of delta SI for prognosis assessment in non-traumatic critically ill patients at the ED remains unknown. The aim of this study was to analyze the association between delta SI during ED management and in-hospital outcomes in patients admitted to the intensive care unit (ICU).

Method: This was a retrospective study conducted in two tertiary medical centers in Taiwan from January 1, 2016, to December 31, 2017. All adult non-traumatic patients who visited the ED and who were subsequently admitted to the ICU were included. We calculated delta SI by subtracting SI at ICU admission from SI at ED triage, and we analyzed its association with in-hospital outcomes. SI was defined as the ratio of heart rate to systolic blood pressure (SBP). The primary outcome was in-hospital mortality, and the secondary outcomes were hospital length of stay (HLOS) and early mortality. Early mortality was defined as mortality within 48 h of ICU admission.

Result: During the study period, 11,268 patients met the criteria and were included. Their mean age was 64.5 ± 15.9 years old. Overall, 5,830 (51.6%) patients had positive delta SI. Factors associated with a positive delta SI were multiple comorbidities (51.2% vs. 46.3%, p < 0.001) and high Simplified Acute Physiology Score [39 (29–51) vs. 37 (28–47), p < 0.001). Patients with positive delta SI were more likely to have tachycardia, hypotension, and higher SI at ICU admission. In the regression analysis, high delta SI was associated with in-hospital mortality [aOR (95% CI): 1.21 (1.03–1.42)] and early mortality [aOR (95% CI): 1.26 (1.07–1.48)], but not for HLOS [difference (95% CI): 0.34 (−0.48 to 1.17)]. In the subgroup analysis, high delta SI had higher odds ratios for both mortality and early mortality in elderly [aOR (95% CI): 1.59 (1.11–2.29)] and septic patients [aOR (95% CI): 1.54 (1.13–2.11)]. It also showed a higher odds ratio for early mortality in patients with triage SBP <100 mmHg [aOR (95% CI): 2.14 (1.21–3.77)] and patients with triage SI ≥ 0.9 [aOR (95% CI): 1.62 (1.01–2.60)].

Conclusion: High delta SI during ED stay is correlated with in-hospital mortality and early mortality in patients admitted to the ICU via ED. Prompt resuscitation should be performed, especially for those with old age, sepsis, triage SBP <100 mmHg, or triage SI ≥ 0.9.

In-Hospital Outcomes in Patients Admitted to the Intensive Care Unit after a Return Visit to the Emergency Department

Background: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. Method: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. Results: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: −1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: −303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. Conclusion: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice.

New Era of Immunotherapy in Pediatric Brain Tumors: Chimeric Antigen Receptor T-Cell Therapy

Immunotherapy, including chimeric antigen receptor (CAR) T-cell therapy, immune checkpoint inhibitors, cancer vaccines, and dendritic cell therapy, has been incorporated as a fifth modality of modern cancer care, along with surgery, radiation, chemotherapy, and target therapy. Among them, CAR T-cell therapy emerges as one of the most promising treatments. In 2017, the first two CAR T-cell drugs, tisagenlecleucel and axicabtagene ciloleucel for B-cell acute lymphoblastic leukemia (ALL) and diffuse large B-cell lymphoma (DLBCL), respectively, were approved by the Food and Drug Administration (FDA). In addition to the successful applications to hematological malignancies, CAR T-cell therapy has been investigated to potentially treat solid tumors, including pediatric brain tumor, which serves as the leading cause of cancer-associated death for children and adolescents. However, the employment of CAR T-cell therapy in pediatric brain tumors still faces multiple challenges, such as CAR T-cell transportation and expansion through the blood–brain barrier, and identification of the specific target antigen on the tumor surface and immunosuppressive tumor microenvironment. Nevertheless, encouraging outcomes in both clinical and preclinical trials are coming to light. In this article, we outline the current propitious progress and discuss the obstacles needed to be overcome in order to unveil a new era of treatment in pediatric brain tumors.

Cingulate gyrus epilepsy: semiology, invasive EEG, and surgical approaches

OBJECTIVE

The semiology of cingulate gyrus epilepsy is varied and may involve the paracentral area, the adjacent limbic system, and/or the orbitofrontal gyrus. Invasive electroencephalography (iEEG) recording is usually required for patients with deeply located epileptogenic foci. This paper reports on the authors' experiences in the diagnosis and surgical treatment of patients with focal epilepsy originating in the cingulate gyrus.

METHODS

Eighteen patients (median age 24 years, range 5-53 years) with a mean seizure history of 23 years (range 2-32 years) were analyzed retrospectively. The results of presurgical evaluation, surgical strategy, and postoperative pathology are reported, as well as follow-up concerning functional morbidity and seizures (median follow-up 7 years, range 2-12 years).

RESULTS

Patients with cingulate gyrus epilepsy presented with a variety of semiologies and scalp EEG patterns. Prior to ictal onset, 11 (61%) of the patients presented with aura. Initial ictal symptoms included limb posturing in 12 (67%), vocalization in 5, and hypermotor movement in 4. In most patients (n = 16, 89%), ictal EEG presented as widespread patterns with bilateral hemispheric origin, as well as muscle artifacts obscuring the onset of EEG during the ictal period in 11 patients. Among the 18 patients who underwent resection, the pathology revealed mild malformation of cortical development in 2, focal cortical dysplasia (FCD) Ib in 4, FCD IIa in 4, FCD IIb in 4, astrocytoma in 1, ganglioglioma in 1, and gliosis in 2. The seizure outcome after surgery was satisfactory: Engel class IA in 12 patients, IIB in 3, IIIA in 1, IIIB in 1, and IVB in 1 at the 2-year follow-up.

CONCLUSIONS

In this study, the authors exploited the improved access to the cingulate epileptogenic network made possible by the use of 3D electrodes implanted using stereoelectroencephalography methodology. Under iEEG recording and intraoperative neuromonitoring, epilepsy surgery on lesions in the cingulate gyrus can result in good outcomes in terms of seizure recurrence and the incidence of postoperative permanent deficits.

Outcomes of hippocampus-sparing lesionectomy for temporal lobe epilepsy and the significance of intraoperative hippocampography

OBJECTIVES

We investigated hippocampal-sparing lesionectomy (HSL) outcomes in temporal lobe epilepsy (TLE) and the significance of high-frequency oscillations (HFOs) detected by hippocampography in HSL.

METHODS

We retrospectively reviewed data from patients who underwent HSL for lesional TLE. Patients were included when MRI confirmed (i) a lesion limited to the temporal lobe with normal hippocampi preoperatively and (ii) hippocampal integrity postoperatively. Factors possibly related to outcomes were collected. Intraoperative hippocampography was reviewed, and spikes, ripples, and fast ripples were marked. Seizure outcomes were tracked ≥ 2 years. Postoperative neuropsychological tests were performed and analyzed.

RESULTS

We included 67 patients (35 males/32 females, median age at surgery 28 years, 57 seizure-free). Complete resection was significantly associated with being seizure-free without aura, an outcome achieved by 32 (69.6%) patients with complete resection vs 1 (12.5%) with incomplete resection (p = 0.004). Spikes/ripples/fast ripples appeared frequently in the hippocampus, occurring in 86.4%/82.4%/75.0% of cases before resection and 76.7%/78.1%/63.0% after resection. The presence and rate were unconnected to seizure outcome. Postoperative neuropsychological outcomes in intelligence and visual memory improved overall.

CONCLUSIONS

HSL in lesional TLE can produce satisfactory seizure and cognitive outcomes. Intraoperative hippocampography-guided resection of apparently normal hippocampi should be performed cautiously and might not be necessary.

SIGNIFICANCE

This study provided evidence in decision making for patients with lesional TLE with a radiologically normal hippocampus.

Gene Modified CAR-T Cellular Therapy for Hematologic Malignancies

With advances in the understanding of characteristics of molecules, specific antigens on the surface of hematological malignant cells were identified and multiple therapies targeting these antigens as neoplasm treatments were developed. Among them, chimeric antigen receptor (CAR) T-cell therapy, which got United States Food and Drug Administration (FDA) approval for relapsed/refractory (r/r) diffuse large B-cell lymphoma (DLBCL) as well as for recurrent acute lymphoblastic leukemia (ALL) within the past five years, and for r/r mantle cell lymphoma (MCL) this year, represents one of the most rapidly evolving immunotherapies. Nevertheless, its applicability to other hematological malignancies, as well as its efficacy and persistence are fraught with clinical challenges. Currently, more than one thousand clinical trials in CAR T-cell therapy are ongoing and its development is changing rapidly. This review introduces the current status of CAR T-cell therapy in terms of the basic molecular aspects of CAR T-cell therapy, its application in hematological malignancies, adverse reactions during clinical use, remaining challenges, and future utilization.

Emerging trends in gene-modified-based chimeric antigen receptor-engineered T-cellular therapy for malignant tumors: The lesson from leukemia to pediatric brain tumors

In 2017 and 2018, Food and Drug Administration has approved YESCARTA (axicabtagene ciloleucel) and KYMRIAH (tisagenlecleucel), two chimeric antigen receptor (CAR)-engineered T-cell products, for B-cell malignancies. It also marked a watershed moment in the development of immunotherapies for cancer. Despite the successes in adults, it remains clinically applicable only in B-cell acute lymphoblastic leukemia in pediatrics. Notably, multiple clinical trials and recent case reports about childhood central nervous system (CNS) tumors, the leading cause of deaths in children, have emerged and granted promising results. With the growing consideration of the biological responses in the interaction of human immunity, the major technical obstacles such as on-target off-tumor toxicity in widespread solid tumors, antigenic heterogeneity, adaptive resistance, difficult T-cell (CD4/CD8) trafficking, and immunosuppressive environments in CNS are gradually approached and ameliorated. The new spotlights of this review are focusing on current development, and emerging treatments for pediatric CNS tumors integrating molecular research with the mainstream of CAR-T therapeutic strategies to sketch a main axis and pathway forward in the improvement of novel gene-modified-based cellular platform.

The update of chimeric antigen receptor-T cells therapy in glioblastoma

Glioblastoma (GBM) is the most malignant central nervous system neoplasm and the outcome is difficult to break through for decades. Ninety percent of patients who suffered from treatment failed. Since 2010, the chimeric antigen receptor (CAR)-T cell therapy has achieved a durable effect in the treatment of B-cell hematologic malignancies. Although several preclinical and clinical trials have emerged as a potential option in solid tumor including high-grade gliomas, the results are limited at present. The challenges of CAR-T cells in GBM are including identification of tumor-specific antigens, preservation activity of T cell, trafficking of enough CAR-T cells to the tumor site, and reversed unique immune suppressive environment of the central nervous system. The success of targeting brain tumors with CAR-T cells has more consideration. In this review article, we will summarize the current key clinical trials of CAR-T therapies in this field. And will outline the obstacles of application of CAR-T cells for the treatment of GBM as well. This review is intended to help guide the future direction of CAR-T therapy in GBM that will move the outcome forward in the future.

Procedure-Related Temporal Infarct After Retractorless Transsylvian Selective Amygdalohippocampectomy and Impact on 2-Year Epilepsy Outcome

BACKGROUND

Selective amygdalohippocampectomy (SAH) is designed to treat patients with mesial temporal lobe epilepsy (MTLE).

OBJECTIVE

To determine the volume and impact of temporal lobe infarction after retractorless transsylvian SAH (en bloc resection of the hippocampus) that have not been reported.

METHODS

A retrospective analysis of patients treated with retractorless transsylvian SAH. Infarctions were detected by magnetic resonance imaging (MRI) within the first week after the operation. Neuropsychological testing was performed preoperatively and 6 mo later. Seizure outcome was evaluated 2 yr after epilepsy surgery.

RESULTS

Between 2010 and 2014, a total of 30 patients were included in this study. Analysis of postoperative MRI showed the following: (1) mean removal volume of the hippocampus-parahippocampus was 5.72 cm3, and (2) mean volumes of temporal and insular infarctions were 1.71 and 0.25 cm3, respectively. Twenty-five patients (83.3%) were free of disabling seizures (Engel class I) at 2 yr of outcome. Neuropsychological testing revealed improvement in Perceptual Organization Index (P = .036) and verbal paired associates II (P = .014) after the operation. Neither infarction volume nor removal volume was related to epilepsy outcome in linear regression model.

CONCLUSION

Transsylvian SAH has comparable seizure outcomes but bears inherent risks of vasospasm/vascular injury. Immediate postoperative small infarction volume around resection cavity or along surgical corridor was noticed after retractorless transsylvian SAH, which did not cause neuropsychological deteriorations, in contrast to previous study with the use of self-sustaining rigid retraction system. Further study should be performed to compare procedure-related infarctions and their impacts on neuropsychological outcomes in different selective approaches.

Social functioning and health-related quality of life trajectories in people with epilepsy after epilepsy surgery

OBJECTIVE

An improvement in quality of life (QoL) over time after epilepsy surgery has been demonstrated in people with epilepsy; however, social functioning has been less investigated. We conducted this study to examine whether postsurgical improvement is parallel between QoL and social functioning in patients with epilepsy.

METHODS

We retrospectively reviewed patients who underwent epilepsy surgery. All participants completed a comprehensive neuropsychological assessment, the Quality of Life in Epilepsy Inventory (QOLIE-89) questionnaire, and the Social and Occupational Functioning Scale for Epilepsy (SOFSE) before surgery and at 3 months, 6 months, and 1 year after surgery. Demographic and epilepsy-related information was also collected. Generalized estimating equations with identity links were used to model the QOLIE-89 and SOFSE over time and possible associated factors. A p < 0.05 was considered statistically significant.

RESULTS

A total of 76 patients, including 36 males and 43 females aged 18 to 62 years were collected. Both total QOLIE-89 and overall SOFSE improved over time after epilepsy surgery (adjusted p value < 0.001 and 0.002, respectively, with Bonferroni's correction). Total QOLIE-89 improved 3 months after surgery, while overall SOFSE showed no significant improvement until 6 months after surgery. The presurgical Full-Scale Intelligence Quotient (FSIQ) of the Wechsler Adult Intelligence Scale-III and years of education were significantly associated with time-dependent improvement for both total QOLIE-89 and overall SOFSE (p value < 0.001). At one year after surgery, overall SOFSE and total QOLIE-89 scores were significantly higher in the seizure-free group than in the nonseizure-free group (p value = 0.040 and 0.032, respectively).

CONCLUSION

Social functioning significantly improved in people with epilepsy after surgery as QoL, but it took more time to exhibit improvement. People with better FSIQ and more years of education had better improvement in social functioning over time. The early intervention of rehabilitation programs after epilepsy surgery might be necessary to facilitate the improvement in social functioning.

Disseminated cutaneous herpes zoster and multiple cerebral infarcts in an adult with diabetes mellitus

Ischemic stroke is a rare complication of varicella-zoster virus (VZV) infection. We present the case of a patient with a medical history of type 2 diabetes mellitus (DM) who experienced disseminated cutaneous VZV infection followed by multiple cerebral infarcts associated with VZV vasculopathy. Brain magnetic resonance imaging revealed multiple hyperintense lesions over the bilateral deep white matter and basal ganglia. A skin biopsy revealed small-vessel leukocytoclastic vasculitis with neutrophilic, lymphocytic, and eosinophilic infiltration. This case report describes the rare finding of cutaneous leukocytoclastic vasculitis in VZV infection and highlights that VZV infection is an uncommon but critical etiology of cryptogenic stroke in patients with DM.

Pretemporal trans-Meckel's cave transtentorial approach for large petroclival meningiomas

OBJECTIVE Despite the advances in skull base techniques, large petroclival meningiomas (PCMs) still pose a challenge to neurosurgeons. The authors' objective of this study was to describe a pretemporal trans-Meckel's cave transtentorial approach for large PCMs and to report the surgical outcomes. METHODS From 2014 to 2017, patients harboring large PCMs (> 3 cm) and undergoing their first resection via this procedure at the authors' institute were included. In combination with pretemporal transcavernous and anterior transpetrosal approaches, the trans-Meckel's cave transtentorial route was created. Surgical details are described and a video demonstrating the procedure is included. Retrospective review of the medical records and imaging studies was performed. RESULTS A total of 18 patients (6 men and 12 women) were included in this study, with mean age of 53 years. The mean sizes of the preoperative and postoperative PCMs were 4.36 cm × 4.09 cm × 4.13 cm (length × width × height) and 0.83 cm × 1.08 cm × 0.75 cm, respectively. Gross-total removal was performed in 7 patients, near-total removal (> 95%) in 7 patients, and subtotal removal in 4 patients (> 90% in 3 patients and > 85% in 1 patient). There were no surgical deaths or patients with postoperative hemiplegia. Surgical complications included transient cranial nerve (CN) III palsy (all patients, resolved in 3 months), transient CN VI palsy (2 patients), CN IV palsy (3 patients, partial recovery), hydrocephalus (3 patients), and CSF otorrhea (1 patient). Temporal lobe retraction-related neurological deficits were not observed. CONCLUSIONS A pretemporal trans-Meckel's cave transtentorial approach offers large surgical exposure and multiple trajectories to the suprasellar, interpeduncular, prepontine, and upper-half clival regions without overt traction, which is mandatory to remove large PCMs. To unlock Meckel's cave where a large PCM lies abutting the cave, pretemporal transcavernous and anterior transpetrosal approaches are prerequisites to create adequate exposure for the final trans-Meckel's cave step.

Pretemporal transcavernous transtentorial approach for left pontine glioma

A 39-year-old man, who had a history of spinal myxopapillary ependymoma with cerebrospinal seeding status post twice operations and radiation therapy, presented with aggravating headaches, diplopia, dysphagia, and unsteady gait for 2 weeks. The brain MRI revealed a parenchymal lesion at the left aspect of the pons, about 2.8 × 2.3 × 3.2 cm³. The patient underwent a pretemporal transcavernous transtentorial approach for tumor removal. The pathological report showed an anaplastic astrocytoma. In this approach, a wider surgical corridor was obtained by opening the Meckel’s cave and cutting the tentorium, via which a safe entry point into the pons could be determined with neuromonitoring. In the authors’ opinion, this approach is safe and effective in selected ventrolateral pontine gliomas.

The video can be found here: https://youtu.be/sUt-9QFGgCI.

Pretemporal transcavernous transtentorial approach for right pontine cavernous malformation

A 57-year-old man presented with acute changes in mental status. Brain CT showed a high-density lesion at the pons. Brain MRA revealed a very slow-flow vascular lesion at the right aspect of the pons, about 3.9 ⋅ 3.0 ⋅ 3.0 cm3, compatible with a pontine cavernous malformation (CM). Gross-total removal was achieved. In this approach, a wider surgical corridor was obtained by opening the Meckel’s cave and cutting the tentorium. For a midline attack point on the pons, additional removal of the posterior clinoid process can meet the goal. In the authors’ opinion, this approach is safe and effective in selected ventrolateral pontine CMs.

The video can be found here: https://youtu.be/moHqEkp5eCA.

Blink synkinesis monitoring during microvascular decompression for hemifacial spasm

BACKGROUND

In the present study, we investigated whether blink synkinesis monitoring during microvascular decompression (MVD) is effective for predicting long-term outcomes in patients with hemifacial spasm (HFS).

METHODS

This retrospective study included 69 patients who had undergone MVD for HFS at a tertiary hospital. All patients underwent intraoperative monitoring of blink synkinesis, lateral spread responses (LSRs), and facial nerve motor-evoked potentials (FNMEPs). Baseline signals were compared to those obtained following decompression with Teflon, and postoperative outcomes were recorded.

RESULTS

A total of 65 patients were observed with complete relief of symptoms after 1 year after MVD, while 61 patients were observed with initial disappearance of blink synkinesis, 57 patients were observed with initial elimination of the LSR, and 45 patients with initial decreases in FNMEP amplitude (>50%). The highest sensitivity and accuracy values were observed for blink synkinesis. Chi-square tests comparing the sensitivity of the three methods revealed that FNMEP monitoring was associated with significantly lower sensitivity values than the remaining methods. Combined use of blink synkinesis and LSRs did not significantly increase sensitivity (61/65 vs 62/65) or accuracy (62/69 vs 63/69).

CONCLUSION

Our results demonstrate that blink synkinesis monitoring is safe during MVD for HFS. Furthermore, blink synkinesis was associated with the highest sensitivity and predictive values among the three methods evaluated. These findings suggest that blink synkinesis can be regarded as the first choice for intraoperative monitoring during MVD. Concurrent use of blink synkinesis and LSR monitoring may maximize the ability to predict patient prognosis and determine the extent of decompression.

Ictal networks of temporal lobe epilepsy: views from high-frequency oscillations in stereoelectroencephalography

OBJECTIVEIn this study, the authors investigated high-frequency oscillation (HFO) networks during seizures in order to determine how HFOs spread from the focal cerebral cortex and become synchronized across various areas of the brain.METHODSAll data were obtained from stereoelectroencephalography (SEEG) signals in patients with drug-resistant temporal lobe epilepsy (TLE). The authors calculated intercontact cross-coefficients between all pairs of contacts to construct HFO networks in 20 seizures that occurred in 5 patients. They then calculated HFO network topology metrics (i.e., network density and component size) after normalizing seizure duration data by dividing each seizure into 10 intervals of equal length (labeled I1-I10).RESULTSFrom the perspective of the dynamic topologies of cortical and subcortical HFO networks, the authors observed a significant increase in network density during intervals I5-I10. A significant increase was also observed in overall energy during intervals I3-I8. The results of subnetwork analysis revealed that the number of components continuously decreased following the onset of seizures, and those results were statistically significant during intervals I3-I10. Furthermore, the majority of nodes were connected to a single dominant component during the propagation of seizures, and the percentage of nodes within the largest component grew significantly until seizure termination.CONCLUSIONSThe consistent topological changes that the authors observed suggest that TLE is affected by common epileptogenic patterns. Indeed, the findings help to elucidate the epileptogenic network that characterizes TLE, which may be of interest to researchers and physicians working to improve treatment modalities for epilepsy, including resection, cortical stimulation, and neuromodulation treatments that are responsive to network topologies.

Recent Asian origin of chytrid fungi causing global amphibian declines

Globalized infectious diseases are causing species declines worldwide, but their source often remains elusive. We used whole-genome sequencing to solve the spatiotemporal origins of the most devastating panzootic to date, caused by the fungus Batrachochytrium dendrobatidis, a proximate driver of global amphibian declines. We traced the source of B. dendrobatidis to the Korean peninsula, where one lineage, BdASIA-1, exhibits the genetic hallmarks of an ancestral population that seeded the panzootic. We date the emergence of this pathogen to the early 20th century, coinciding with the global expansion of commercial trade in amphibians, and we show that intercontinental transmission is ongoing. Our findings point to East Asia as a geographic hotspot for B. dendrobatidis biodiversity and the original source of these lineages that now parasitize amphibians worldwide.

Development and worldwide use of non-lethal, and minimal population-level impact, protocols for the isolation of amphibian chytrid fungi

Parasitic chytrid fungi have emerged as a significant threat to amphibian species worldwide, necessitating the development of techniques to isolate these pathogens into culture for research purposes. However, early methods of isolating chytrids from their hosts relied on killing amphibians. We modified a pre-existing protocol for isolating chytrids from infected animals to use toe clips and biopsies from toe webbing rather than euthanizing hosts, and distributed the protocol to researchers as part of the BiodivERsA project RACE; here called the RML protocol. In tandem, we developed a lethal procedure for isolating chytrids from tadpole mouthparts. Reviewing a database of use a decade after their inception, we find that these methods have been applied across 5 continents, 23 countries and in 62 amphibian species. Isolation of chytrids by the non-lethal RML protocol occured in 18% of attempts with 207 fungal isolates and three species of chytrid being recovered. Isolation of chytrids from tadpoles occured in 43% of attempts with 334 fungal isolates of one species (Batrachochytrium dendrobatidis) being recovered. Together, these methods have resulted in a significant reduction and refinement of our use of threatened amphibian species and have improved our ability to work with this group of emerging pathogens.

MicroRNA-142-3p is involved in regulation of MGMT expression in glioblastoma cells

Background

Glioblastoma multiforme (GBM) is the most malignant brain tumor, and there is no effective treatment strategy. Patients with GBM have a median overall survival of only 14.6 months. Current treatment consists of safe and maximal surgical excision, followed by concurrent chemoradiotherapy and maintenance chemotherapy. There are several obstacles that hinder the effectiveness of this aggressive treatment. Temozolomide (TMZ) is an oral alkylating drug that acts through alkylating the O⁶ position of guanine in DNA that leads to cell death. However, the expression and enzymatic activity of the DNA repair protein MGMT limits the therapeutic benefit from treatment with TMZ. MGMT reduces the efficacy of alkylating drugs by removing the methyl or alkyl group from damaged O⁶-methylguanine. Expression levels of MGMT play an important role in the outcome of GBM patients. miRNAs are a group of small regulatory RNAs that control target gene expression by binding to mRNAs. miR-142-3p has been found to be an important factor in the development and maintenance of the oncogenic state.

Results

In this study, we sought to investigate whether miR-142-3p can regulate MGMT gene expression in GBM cells. Here, we show that miR-142-3p downregulates MGMT expression through binding to the 3′-UTR of MGMT mRNA, thus affecting protein translation. Responsiveness to TMZ was significantly enhanced after transfection with miR-142-3p. Overexpression of miR-142-3p also sensitized GBM cells to alkylating drugs.

Conclusion

Above all, our findings demonstrate that miR-142-3p plays a critical role in regulating MGMT expression, has great potential for future clinical applications, and acts as a new diagnostic marker for this intractable disease.

Comparison of the effectiveness of using the optic strut and tuberculum sellae as radiological landmarks in diagnosing paraclinoid aneurysms with CT angiography

OBJECTIVE

The treatment of paraclinoid aneurysms remains challenging. It is important to determine the exact location of the paraclinoid aneurysm when considering treatment options. The authors herein evaluated the effectiveness of using the optic strut (OS) and tuberculum sellae (TS) as radiographic landmarks for distinguishing between intradural and extradural paraclinoid aneurysms on source images from CT angiography (CTA).

METHODS

Between January 2010 and September 2013, a total of 49 surgical patients with the preoperative diagnoses of paraclinoid aneurysm and 1 symptomatic cavernous-clinoid aneurysm were retrospectively identified. With the source images from CTA, the OS and the TS were used as landmarks to predict the location of the paraclinoid aneurysm and its relation to the distal dural ring (DDR). The operative findings were examined to confirm the definitive location of the paraclinoid aneurysm. Statistical analysis was performed to determine the diagnostic effectiveness of the landmarks.

RESULTS

Nineteen patients without preoperative CTA were excluded. The remaining 30 patients comprised the current study. The intraoperative findings confirmed 12 intradural, 12 transitional, and 6 extradural paraclinoid aneurysms, the diagnoses of which were significantly related to the type of aneurysm (p < 0.05) but not factors like sex, age, laterality of aneurysm, or relation of the aneurysm to the ophthalmic artery on digital subtraction angiography. To measure agreement with the correct diagnosis, the OS as a reference point was far superior to the TS (Cohen's kappa coefficients 0.462 and 0.138 for the OS and the TS, respectively). For paraclinoid aneurysms of the medial or posterior type, using the base of the OS as a reference point tended to overestimate intradural paraclinoid aneurysms. The receiver operating characteristic curve indicated that if the aneurysmal neck traverses the axial plane 2 mm above the base of the OS, the aneurysm is most likely to grow across the DDR and present as a transitional aneurysm (sensitivity 0.806; specificity 0.792).

CONCLUSIONS

High-resolution thin-cut CTA is a fast and crucial tool for diagnosing paraclinoid aneurysms. The OS serves as an effective landmark in CTA source images for distinguishing between intradural and extradural paraclinoid aneurysms. The DDR is supposed to be located 2 mm above the base of the OS in axial planes.

Microsurgical technique of symptomatic intracavernous aneurysm

Symptomatic intracavernous aneurysm is rare. Cranial nerves in the cavernous sinus are subjected to the mass effect of an expanding aneurysm. Microsurgical clipping is the treatment of choice to relieve compressive cranial neuropathy. In this video, the authors present a case of intracavernous aneurysm causing diplopia, ptosis, and facial numbness. The patient was operated on via a pretemporal transclinoid-transcavernous approach. The aneurysm was completely obliterated through direct clipping. There were no new-onset neurologic deficits and complications after the operation. Complete recovery of the diplopia, ptosis, and facial numbness was observed at the 6-month postoperative follow up. The video can be found here: http://youtu.be/4w5QUoNIAQM.

Differentiation of blood T cells: Reprogramming human induced pluripotent stem cells into neuronal cells

BACKGROUND

Human induced pluripotent stem cells (iPSCs) morphologically and functionally resemble human embryonic stem cells, which presents the opportunity to use patient-specific somatic cells for disease modeling and drug screening. In order to take one step closer to clinical applications, it is important to generate iPSCs through a less invasive approach and from any accessible tissue, including peripheral blood. Meanwhile, how to differentiate blood cell-derived iPSCs into neuron-like cells is still unclear.

METHODS

We utilized Epstein-Barr nuclear antigen-1-based episomal vectors, a nonviral system that can reprogram somatic cells into iPSCs in both feeder-dependent and feeder-free conditions, to generate iPSCs from T cells via electroporation and then induce them into neuronal cells.

RESULTS

We successfully isolated sufficient T cells from 20 mL peripheral blood of the donors and reprogrammed these T cells into iPSCs within 4 weeks. These iPSCs could be stably passaged to at least 50 passages, and exhibited the abilities of pluripotency and multiple-lineage differentiation. Notably, under the medium induction for 21 days, these T-cell-derived iPSCs could be differentiated into Nestin (neural progenitor marker)-, GFAP (glial cell marker)-, and MAP2 (neuron cell marker)-positive cells detected by immunofluorescence methods.

CONCLUSION

We have developed a safer method to generate integration-free and nonviral human iPSCs from adult somatic cells. This induction method will be useful for the derivation of human integration-free iPSCs and will also be applicable to the generation of iPSCs-derived neuronal cells for drug screening or therapeutics in the near future.

Endoscopic hematoma evacuation in patients with spontaneous supratentorial intracerebral hemorrhage

BACKGROUND

Surgical evacuation of spontaneous supratentorial intracerebral hemorrhage (ICH) is controversial because the traditional surgical approach sometimes causes further brain injury. The introduction of the neuroendoscope has brought with it the new idea of minimal invasiveness, which may improve the surgical results of ICH.

METHODS

Twenty-one patients with spontaneous supratentorial ICH underwent endoscopic hematoma evacuation between December 2010 and January 2012. Safe entry points could be Kocher's, Keen's, or Frazier's point, depending on the locations of the hemorrhages. The surgical steps were as follows: (1) cortical incision and dilation of the channel; (2) introduction of the transparent sheath; (3) gushing out of the hematoma under high intracranial pressure; (4) changing the angle of the transparent sheath, endoscope, and suction tip to remove residual hematoma; and (5) paving a layer of hemostatic agents after hematoma removal.

RESULTS

The median operative time was 120 minutes (range: 90-190 minutes), and the median blood loss was 160 mL (range: 50-300 mL). The median duration of intensive care unit stay was 6 days (range: 2-18 days). The median hematoma evacuation ratio was 90% (range: 60-99%). Two patients had rebleeding events, and the mortality rate was 9.5% (n = 2/21). The median Glasgow Coma Scale score improved from 8 to 11 within 1 week after surgery, and the median Glasgow Outcome Scale score was 3 after 6 months and 12 months follow-up.

CONCLUSION

With the introduction of the minimally invasive techniques and the evolution of the neuroendoscope and hemostatic agents, the median operative time and blood loss have been significantly decreased. Although the hematoma evacuation rates were similar between the endoscope (90%) and craniotomy (85%) groups, the median intensive care unit stay was decreased from 11 days to 6 days due to reduced surgical invasiveness. This represents an important advancement in treating spontaneous supratentorial ICH, and provides a measured preview of the promising results that can be expected in the future.

The right amygdalar tumor presenting with symptoms of separation anxiety disorder (SAD): a case report

A patient with an astrocytoma of the right-sided amygdala developed symptoms of separation anxiety disorders (SADs). These symptoms significantly subsided after tumor resection. The temporal relationship suggested that the amygdalar tumor could result in the specific symptoms. To our knowledge, this is the first report of SAD as one manifestation of the amygdalar tumor. The tumorigenesis of amygdala resulted in impaired regulation and abnormal activity associated with anticipating anxiety and conditioning. It deserves clinical attention to early detection and intervention.

Induction of dental pulp-derived induced pluripotent stem cells in the absence of c-Myc for differentiation into neuron-like cells

BACKGROUND

A recent research breakthrough has demonstrated that the ectopic expression of four genes is sufficient to reprogram human fibroblasts into inducible pluripotent stem cells (iPSCs). However, whether human dental pulp cells (DPCs) could be reprogrammed into iPSCs remains an open question. In this study, we demonstrated that DPCs from deciduous and permanent teeth can be reprogrammed into iPSCs without c-Myc and had the capacity to differentiate into neuron-like cells.

METHODS

DPCs were obtained from donors and reprogrammed into iPSCs using retroviral transduction with SOX2, OCT4, and KLF4. Then, these iPSCs were differentiated into neuron-like cells. Microarray and bioinformatics were used to compare the gene expression profile among these iPSCs and iPSC-derived neuron-like cells.

RESULTS

The DPCs displayed a high vitality and capability to quickly restart proliferation and expressed elevated pluripotency similar to mesenchymal stem cells. According to our results, DPC-derived iPSC colonies that could be subcultured and propagated were established as early as 10 days after transduction, in comparison with the skin fibroblast (DPC-derived iPSCs) without c-Myc presented embryonic stem cell-like properties and the pluripotent potential to differentiate into neuron-like cells, which resemble neurons both morphologically and functionally.

CONCLUSION

The human DPCs from deciduous and permanent teeth can undergo reprogramming to establish pluripotent stem cell lines without c-Myc. These surgical residues, usually regarded as medical waste, can be used as an alternative source of pluripotent stem cells for personalized medicine.