Intraluminal assessment of inflammatory factors in patients with intracranial aneurysms

BACKGROUND

The formation, growth, and rupture of intracranial aneurysms (IA) are due to several pathophysiological mechanisms, including focal hemodynamic injury and inflammation of the arterial wall. We investigated the differences between venous, parent artery, and intra-aneurysmal blood by measuring inflammatory factors and antibodies in patients with ruptured (rIA) or unruptured intracranial aneurysms (uIA).

METHOD

A prospective study was performed in patients who presented with IA and required endovascular treatment. Blood was drawn from the lumen of the aneurysm sac, the parent artery, and the peripheral veins, to determine the serum concentrations of complement factors C3, C4, IgG, IgM, IgA antibodies, and C-reactive protein (CRP).

RESULTS

Thirty-six patients (15 with uIA and 21 with rIA) were enrolled in the study. In both groups, C3, C4, IgM, IgG, and IgA showed a gradual decrease from venous to intra-aneurysmal samples, but only IgG in the parent artery and intra-aneurysmal samples reached a significant decrease in uIA compared with venous samples. Accordingly, C3 and IgG concentrations in the intra-aneurysmal samples showed a significant decrease in rIA compared with venous samples. A significant increase in CRP concentrations was observed in parent artery and intra-aneurysmal samples from patients with rIA compared with patients with uIA; a significant increase in C3 concentrations was observed in parent artery samples from patients with rIA compared with patients with uIA, and a significant decrease in IgM concentrations was observed in venous, parent artery, and intra-aneurysmal samples from patients with rIA compared with patients with uIA.

CONCLUSIONS

A decrease in C3 and IgG in the aneurysm sac indicates activation of the complement system in the arterial wall. CRP in the aneurysm sac and lumen of the parent artery was significantly increased in ruptured compared with unruptured aneurysms, whereas venous, parent artery, and intra-aneurysmal IgM were decreased in ruptured compared with unruptured aneurysms. These results argue for the role of an ongoing inflammatory process in aneurysms leading to their growth and rupture.

Child abuse experience, training, knowledge, and attitude of healthcare professionals in sixty hospitals in Greece

OBJECTIVE

This study aims to record the overall perception of healthcare professionals on child abuse and identify potential affecting factors in a nationwide scale in Greece as well as to provide information that might be useful for future educational actions.

MATERIALS AND METHODS

A total of 1,185 healthcare professionals in 60 hospitals with pediatric departments across Greece participated in this cross-sectional study. Participants included pediatricians, pediatric surgeons, residents, nurses, psychiatrists, psychologists, and social workers. Sections under investigation involved experience and training in child abuse, knowledge of formal and judicial issues, clinical knowledge, and self-assessment.

RESULTS

Although more than half of the participants had confronted child abuse (n=712, 60.08%), only 273 (38.34% of them) submitted reports. One third of participants reported that they had received some training (n=440, 37.13%), mainly of postgraduate nature and based on personal initiative. Of those who reported child abuse, 175 (64.10%) had been trained. Each professional category was aware of topics regarding its own interest, without adequate knowledge of other disciplines. One third of psychiatrists, psychologists, and social workers felt confident in discussing with children and parents. Relevant scores were lower in the other categories. The lower scores were recorded among nurses and residents. The training deficit and reluctance to engage with judicial issues were the main causes of avoidance to deal with child abuse.

CONCLUSIONS

Focused and organized training in child abuse is crucial to create reliable professionals in the field. The internet is a considerably helpful tool. Professionalism must characterize knowledge and practice in child abuse at the same level as in other medical topics. Motivation to engage should be early inspired and developed during the graduate years.

A 3-miRNA Signature Enables Risk Stratification in Glioblastoma Multiforme Patients with Different Clinical Outcomes

Malignant gliomas constitute a complex disease phenotype that demands optimum decision-making as they are highly heterogeneous. Such inter-individual variability also renders optimum patient stratification extremely difficult. microRNA (hsa-miR-20a, hsa-miR-21, hsa-miR-21) expression levels were determined by RT-qPCR, upon FFPE tissue sample collection of glioblastoma multiforme patients (n = 37). In silico validation was then performed through discriminant analysis. Immunohistochemistry images from biopsy material were utilized by a hybrid deep learning system to further cross validate the distinctive capability of patient risk groups. Our standard-of-care treated patient cohort demonstrates no age- or sex- dependence. The expression values of the 3-miRNA signature between the low- (OS > 12 months) and high-risk (OS < 12 months) groups yield a p-value of <0.0001, enabling risk stratification. Risk stratification is validated by a. our random forest model that efficiently classifies (AUC = 97%) patients into two risk groups (low- vs. high-risk) by learning their 3-miRNA expression values, and b. our deep learning scheme, which recognizes those patterns that differentiate the images in question. Molecular-clinical correlations were drawn to classify low- (OS > 12 months) vs. high-risk (OS < 12 months) glioblastoma multiforme patients. Our 3-microRNA signature (hsa-miR-20a, hsa-miR-21, hsa-miR-10a) may further empower glioblastoma multiforme prognostic evaluation in clinical practice and enrich drug repurposing pipelines.

Computed tomography angiography scoring systems and the role of skull defects in the confirmation of brain death

To assess and compare all current computed tomography angiography (CTA) scoring systems for the diagnostic workup of brain death (BD) to digital subtraction angiography (DSA) and clinical tests. Fifty-two patients with a clinical suspicion of BD underwent CTA and subsequently DSA. The diagnostic performance of all current CTA scoring systems was compared to that of DSA, in all patients with a suspicion of BD. A comparison to clinical tests was made only in DSA-positive for BD patients (n = 49), since in DSA-negative BD patients (n = 3) clinical tests were not performed. Further subgroup analysis was performed in relation to skull defects (SDs) stratification. Statistical analysis was conducted by applying statistics-contingency tables, Cochran's-Q test and McNemar's test. The CTA -10, and -7- and all 4-point scoring systems, showed overall sensitivities of 81,6%, 87.8% and 95.9% respectively and 100% specificity, when compared to DSA. In patients with a clinical verification of BD, the CTA -10 and -7-point scoring systems were significantly inferior to clinical tests (p = 0.004 and p = 0.031), while the 4-point scoring systems showed no such difference (p = 0.5). All 4-point scoring systems showed 100% sensitivity in patients with a minor SD or no SD. In patients with a major SD, all CTA scoring systems (- 10, - 7- and all 4-point) were less sensitive (62.5%, 62.5% and 75% respectively). The presence of a major SD was associated with an 8 × relative risk for false negative results in all 4-point scoring systems. CTA showed excellent diagnostic performance in patients with a suspicion of BD. The 4-point CTA scoring systems are the most sensitive for the diagnosis of BD, although in patients with a major SD patient, the role of CTA is ambiguous.

Demographic and anatomical comparison of ruptured and unruptured intracranial aneurysms: a case control study

BACKGROUND

Our understanding of the pathophysiology and management of intracranial aneurysms (IAs) continuously advances. This case-control study analyzed the demographics of patients with IAs and the morphological Digital Subtraction Angiography (DSA) characteristics of ruptured and unruptured IAs.

METHODS

Two patient groups with saccular ruptured and unruptured IAs eligible for coiling were prospectively analyzed during a 3-year period. Patient groups were compared regarding gender, age, arterial vasculature side, anatomical location, diameter, preoperative DSA appearance, aneurysmal and anatomical Circle of Willis variations (CWV) co-existence.

RESULTS

One hundred and three patients with ruptured and eighty-six patients with unruptured IAs were studied. Anterior communicating and internal carotid artery IAs were the dominant locations: 42.7 % and 23.3 % in ruptured and 29 % and 41.9 % in unruptured IAs, respectively. The female-to-male ratio was 1.78 in ruptured and 2.44 in unruptured IAs (p =0.317), while the rupture was more frequent in younger patients (p =0.034). Angiographically, smaller diameter (p =0.01), abnormal morphology (p =0.0001), and co-existence of CWV (p =0.016) were reported in ruptured IAs. Location at bifurcation/trifurcation (p =0.487) and the co-existence of additional or mirror IA did not differ significantly (p =0.879).

CONCLUSIONS

On DSA, ruptured and unruptured IAs differed in size, morphology, and co-existence of CWV; findings that may favor the treatment of specific unruptured IAs. However, a higher level of evidence is needed to include all these factors in the treatment decision process, provide patient-oriented treatment and reliably identify unruptured IAs at greater risk. HIPPOKRATIA 2021, 25 (3):100-107.

Multiple Exostoses Syndrome and Basilar Artery Aneurysm: A Case Report

BACKGROUND

Hereditary multiple exostoses (HME) is an inherited genetic condition, characterized by the formation of multiple osteochondromas, developing throughout childhood and into puberty. Vascular complications associated with HME are uncommon.

METHODS

A case of a patient with HME who was admitted to hospital with subarachnoid hemorrhage (SAH), as a result of acute rupture of a basilar tip aneurysm (BTA), will be presented. Relevant literature on this topic will be systematically reviewed.

RESULTS

We describe a rare case of a 48-year-old male patient presenting multiple exostoses in both upper and lower limbs, with no familial history of such lesions. The patient experienced an episode of loss of consciousness, followed by tonal seizures, after a short (five-day) history of headache, proved finally to be secondary to SAH due to rupture of a BTA. There was no antecedent of trauma, neck manipulation, or previous infection. Aneurysm was successfully treated with the intravascular procedure (aneurysm occlusion with coil). Progressively, the patient recovered from dysphasia and tetraparesis, almost completely, following the appropriate treatment and rehabilitation program.In the systematic review, eight cases (including the one presented) of vertebrobasilar vascular system stroke secondary to solitary spinal osteochondroma or multiple osteochondromas were found, but only the present case was associated with basilar artery aneurysm.

CONCLUSION

Despite the fact that the etiopathogenesis of basal artery aneurysm presentation in a patient with osteochondromas remains unknown, medical society needs to be aware of this rare condition, as SAH may be a severe complication.

Cerebellar hemorrhage after supratentorial burr hole drainage of a chronic subdural hematoma

Cerebellar hemorrhage is an unusual, but increasingly recognized complication after supratentorial surgery. Even rarer are the cases of cerebellar hemorrhage after supratentorial burr-hole drainage of a chronic subdural hematoma (CSDH). The pathophysiology of this rare complication still remains unclear. Hypertension and overdrainage of cerebrospinal fluid seem to be causative factors of postoperative cerebellar hemorrhage. The most important key to minimize this hazardous sequel is to be aware of this potential complication and its pathogenetic mechanisms. We report our case of a 43-year old man who developed cerebellar hemorrhage after burr hole trephination for supratentorial CSDH.

Recovery of ophthalmoplegia after endovascular treatment of intracranial aneurysms

BACKGROUND AND PURPOSE

Recovery of aneurysm induced CNP after endosaccular coiling has been reported in the literature. The aim of this study was to assess in detail the parameters that affect the outcome after endovascular treatment of ophthalmoplegic aneurysms due CNP.

MATERIALS AND METHODS

Between November 1999 and March 2008, 30 consecutive patients (8 men, 22 women; mean age, 54.9 years) presenting with CNP underwent endosaccular coiling with or without additional use of stents in the parent artery. Subarachnoid hemorrhage was present in 10 patients, whereas 20 patients had unruptured aneurysms. The mean size of the aneurysms was 10 mm. Initial CNP was complete in 11 patients and partial in 19. Mean follow-up after coiling was 19 months.

RESULTS

The mean interval between the onset of CNP and aneurysm embolization was 48 days. Fifteen patients (50%) had complete recovery of oculomotor function, 12 had incomplete recovery (40%), and 3 (10%) remained unchanged after treatment. In 4 aneurysms (13.3%), 1 additional embolization was performed, whereas in 4 other aneurysms, 2 additional embolization procedures were necessary. Procedure-related permanent morbidity occurred in 2 patients (6.6%).

CONCLUSIONS

Endosaccular coiling is an effective and safe method for the treatment of ophthalmoplegic aneurysms. Age, neck size, and time of treatment do not seem to constitute prognostic factors with respect to CNP recovery, though patients with small aneurysms, unruptured status, and/or location in the posterior circulation showed a tendency for better outcome. The degree of initial CNP was the only statistically significant prognostic factor concerning the final outcome, resulting in better recovery, in case of incomplete initial CNP.

Percutaneous embolization of carotid paragangliomas using solely Onyx

BACKGROUND AND PURPOSE

Paragangliomas are highly vascularized usually benign neoplasms arising from nerve tissue. Endovascular preoperative embolization is used to facilitate surgery but is often not complete, due to tiny feeding arteries not feasible for selective catheterization. Our purpose was to evaluate angiographic and clinical outcome using Onyx for percutaneous glomus tumor embolization.

MATERIALS AND METHODS

A consecutive series of 4 patients with 6 paragangliomas located at the bifurcation of the common carotid artery were treated with percutaneous embolization using Onyx as the sole embolic material.

RESULTS

Complete devascularization of the 6 paragangliomas was achieved using a percutaneous embolization technique with Onyx as a sole agent, combined with an endovascular microballoon that offered protection of the internal carotid artery.

CONCLUSIONS

Further documentation is necessary to prove the higher grade of devascularization of paragangliomas with Onyx compared with other embolic material and the associated potential to facilitate surgery. Nevertheless, Onyx seems to be safe when used percutaneously due to its lavalike pattern flow and its controllable properties, allowing slow tumor bed penetration.

Endovascular treatment resolves non-hemorrhagic brainstem dysfunction due to tentorial dural AV fistula

Tentorial dural arteriovenous fistulas (tDAVF) clinically present usually with subarachnoid and/or intraparenchymal hemorrhage. Reported rates range from 58% to 92% and neurological deficits occur in 79% to 92% of patients. This is due to venous congestion resulting from retrograde leptomeningeal venous drainage, which rarely, can be clinically silent. A 69-year-old woman presented with vertigo, double vision and gait instability. Cerebral digital subtraction angiography revealed a tDAVF with retrograde cerebellar venous drainage directed through the vein of Galen into the straight sinus. MRI showed extensive cerebellar edema due to venous congestion. Clinical manifestations of cerebellar and brainstem dysfunction resolved completely after transarterial embolization with N-butylcyanoacrylate.

Embolization of intracranial arteriovenous malformations with ethylene-vinyl alcohol copolymer (Onyx)

BACKGROUND AND PURPOSE

Endovascular therapy of intracranial arteriovenous malformations (AVMs) is increasingly used. However, it is still under discussion which embolic material is optimal. We report our experience in the treatment of AVMs with ethylene-vinyl alcohol copolymer (Onyx).

MATERIALS AND METHODS

Between July 2002 and January 2008, brain AVMs were embolized with Onyx in 82 consecutive patients in our department. There were 41 females and 41 males with a mean age of 44.2 years (range, 15-85 years). Clinical presentation included symptoms due to intracerebral hemorrhage (n = 37), seizures (n = 18), nonhemorrhagic neurologic deficits (n = 8), headaches (n = 9), or incidental symptoms (n = 10). According to the Spetzler-Martin scale, 59 AVMs were grades I-II, 16 were grade III, and 7 were grades IV-V.

RESULTS

Complete obliteration at the end of all endovascular procedures was achieved in 20/82 patients (24.4%), with an average of 75% (range, 30%-100%) volume reduction. A mean of 2.9 (range, 1-10) feeding pedicles was embolized per patient, whereas an average of 2.6-mL Onyx was used per patient. Procedure-related permanent disabling morbidity was 3.8%, whereas mortality was 2.4%.

CONCLUSIONS

The overall initial complete obliteration rate of intracranial AVMs with Onyx embolization is relatively high, compared with other embolic agents, with evidence of stability with time. Morbidomortality rates due to AVM embolization as a single treatment method or as a part of a multimodality treatment should be further assessed regarding the natural course of the disease.

The effect of nifedipine on the patency of microvascular anastomosis in rats

Despite advances in microsurgical technique and experience in clinical microvascular surgery, there remains the possibility of vessel thrombosis. Factors that may contribute to vascular pedicle thrombosis include operative trauma, pedicle malposition, kinking, hypercoagulability and arterial vasoconstriction. The purpose of this study was to evaluate the effect of intravenous administration of nifedipine on the patency of the microvascular anastomosis of the femoral artery in rats. A total of 60 rats were used and divided into three groups. The first group (A) was used as a control group with no medical agent, the second group (B) was medicated with heparin, and the third group (C) was medicated with nifedipine. Patency was assessed with the distal empty refill test, one hour (1) and forty-eight hours (48) after completion of the anastomosis. The nifedipine and heparin treated groups (B & C) did not show higher patency rate compared to the control group (A). There was no statistically significant difference of patency percent after 1 hour and 48 hours among the three groups (p = 0.231/p = 0.480). Intravenous administration of nifedipine does not improve the patency of microvascular anastomosis. Surgical technique remains the most important factor for successful microvascular anastomosis.

Das Risiko intrazerebraler Gefäßmissbildungen

In general, intracranial vascular malformations are divided into pial AVM, dural AV fistula, cavernoma and capillary telangiectasias. Developmental venous anomalies are sometimes thought to be vascular malformations. In fact, they are just a variant of venous drainage. In general, pial AVMs have a high risk of intracerebral bleeding. In dural AV fistulas, the individual bleeding risk can be effectively estimated by analyzing the venous drainage. Cavernomas have a low bleeding risk and the bleeding is rarely life-threatening. DVAs do not have any bleeding risk but 30 % are associated with cavernomas. Capillary telangiectasias also have no bleeding risk. Therefore, a radiological finding of an intracranial vascular malformation should not automatically elicit the reaction "time bomb in your head with a bleeding risk" but should be subjected to an analysis of the bleeding risk for the individual patient.

Radiculopathy after lumbar discectomy due to intraspinal retained Surgicel: clinical and magnetic resonance imaging evaluation

BACKGROUND CONTEXT

Lumbar radiculopathy after lumbar spine surgery is an alerting sign usually caused by either a recurrent disc herniation or epidural hematoma. However, pressure on a spinal nerve root may also be exerted by a retained piece of Surgicel used to achieve hemostasis during lumbar spine surgical procedures.

PURPOSE

To describe a case of lumbar radiculopathy that was caused by a piece of Surgicel left in the spinal canal after operation for lumbar disc herniation.

STUDY SETTING

A case report of a retained piece of Surgicel being the cause of S1 radiculopathy.

METHODS

Patient interview, medical records, imaging studies, and literature review.

RESULTS

A 29-year-old man developed acute left S1 radiculopathy after a successful hemilaminectomy and discectomy operation for a L5-S1 disc herniation. In the magnetic resonance imaging studies that were performed, a postoperative hematoma could not be excluded and a reoperation revealed compression from Surgicel that was used for hemostasis. The patient was free of symptoms after reoperation.

CONCLUSIONS

This case depicts the difficulty in distinguishing-by means of magnetic resonance imaging-nerve root compression caused by a postoperative hematoma and a recurrent disc herniation, from that caused by a retained Surgicel. Therefore, hemostatic agents should be meticulously used in spine surgery.

Giant osteoma of the frontoethmoidal sinus associated with two cerebral abscesses

A 36-year-old woman presented with severe frontal headache, fever, left palpebral swelling, and proptosis. Radiographic studies showed a giant frontoethmoidal osteoma, that extended intracranially into the frontal lobe and was associated with two abscesses, one within the lesion and the other in the right frontal lobe. The tumour was excised and the abscesses drained. The patient made a full recovery.

Dorsal Extradural Thoracic Disc Fragment

Dorsal epidural migration of an extruded disc fragment is an infrequent event, especially in the thoracic spine. An uncommon case involving a 55-year-old man is presented, with a 1-month history of paraparesis and thoracolumbar pain. Magnetic resonance imaging demonstrated a dorsally located, extramedullary mass at the T10-T11 intervertebral level. The lesion was suspected to be a tumor. The patient underwent a T10-T11 laminectomy. Intraoperatively, an encapsulated mass of soft tissue adherent to the dural sac was found. The pathologic diagnosis was inflammatory tissue and disc material. Six months after the operation, the patient remained asymptomatic, and radiologic control showed no residual mass. Although rare, a sequestered disc fragment should be included in the differential diagnosis of an enhancing posterior extramedullary thoracic mass. Preoperative diagnosis of such pathology is difficult because the clinical signs and radiologic images may not entirely exclude other more common thoracic spinal lesions, especially tumors.

The predictive value of external continuous lumbar drainage, with cerebrospinal fluid outflow controlled by medium pressure valve, in normal pressure hydrocephalus

BACKGROUND

Although sporadic studies have described temporary external cerebrospinal fluid (CSF) lumbar drainage as a highly accurate test for predicting the outcome after ventricular shunting in normal pressure hydrocephalus (NPH) patients, a more recent study reports that the positive predictive value of external lumbar drainage (ELD) is high but the negative predictive value is deceptively low. Therefore, we conducted a prospective study in order to evaluate the predictive value of a continuous ELD, with CSF outflow controlled by medium pressure valve, in NPH patients.

METHOD

Twenty-seven patients with presumed NPH were admitted to our department and CSF drainage was carried out by a temporary (ELD) with CSF outflow controlled by a medium pressure valve for five days. All patients received a ventriculoperitoneal shunt using a medium pressure valve based upon preoperative clinical and radiographic criteria of NPH, regardless of ELD outcome. Clinical evaluation of gait disturbances, urinary incontinence and mental status, and radiological evaluation with brain CT was performed prior to and after ELD test, as well as three months after shunting.

FINDINGS

Twenty-two patients were finally shunted and included in this study. In a three-month follow-up, using a previously validated score system, overall improvement after permanent shunting correlated well to improvement after ELD test (Spearman's rho = 0.462, p = 0.03). When considering any degree of improvement as a positive response, ELD test yielded high positive predictive values for all individual parameters (gait disturbances 94%, 95% CI 71%-100%, urinary incontinence 100%, 95% CI 66%-100%, and mental status 100%, 95% CI 66%-100%) but negative predictive values were low (< 50%) except for cognitive impairment (85%, 95% CI 55%-98%).

CONCLUSION

This study suggests that a positive ELD-valve system test should be considered a reliable criterion for preoperative selection of shunt-responsive NPH patients. In case of a negative ELD-valve system test, further investigation of the presumed NPH patients with additional tests should be performed.

Neurilemoma of the popliteal fossa: report of two cases with long subclinical course and misleading presentation

The authors report two cases of neurilemoma localised in the popliteal fossa. Both patients experienced non-specific symptoms, such as painful numbness and burning dysaesthesia, involving the lower extremity. Tinel's sign was positive over the popliteal fossa. The patients sought medical advice and underwent conservative treatment without any relief, for a long time before the right diagnosis was made. Magnetic resonance imaging revealed in both patients a well- circumscribed mass posterior to the sciatic nerve, occupying the popliteal fossa. Following surgical excision of the neurilemoma, the patients experienced immediate relief of their chronic symptoms. In similar situations, ultrasound or magnetic resonance imaging of the whole sciatic nerve should be performed if this is indicated by detailed physical examination. Once the diagnosis is made, neurilemomas should be surgically removed, in order to exclude malignancy, prevent neurologic deficits and provide relief of symptoms.

Extended cervicolumbar spinal epidural abscess associated with paraparesis successfully decompressed using a minimally invasive technique

STUDY DESIGN

A case of a multisegmental, cervicothoracolumbar epidural abscess, in an 80-year-old man, successfully decompressed by using a minimally invasive technique, is presented.

OBJECTIVE

To review risk factors, diagnosis, treatment, decompression techniques, and morbidity and mortality regarding spinal epidural abscess.

SUMMARY OF BACKGROUND DATA

Extended spinal epidural abscess is a rate entity. To our knowledge, this is the first report of a multilevel spinal epidural abscess, completely decompressed by limited laminectomies in combination with the use of a silicon catheter, epidurally.

METHODS

The clinical and radiographic features associated with spinal epidural abscess, as well as decompression technique, are presented. The 80-year-old man, with a one week history of urinary tract infection, presented with fever and low back pain, mild weakness in his legs and jaundice. He underwent bilateral limited laminectomies at T2-T3 and a right hemilaminectomy at L1-L2 and the pus was drained, under mild continuous suction, using a 2.7 mm outer and 1.3 mm inner diameter silicon catheter, inserted caudally and cranially into the epidural space, at both the laminectomy sites.

RESULTS

The patient experienced immediate relief of the low back pain, gradual fever subsidence and full neurological recovery during the next 3 weeks.

CONCLUSION

In cases of suspected acute epidural abscess, especially in elderly debilitating patients: the whole spine should be scanned by MRI to exclude the possibility of multilevel involvement and adequate pus drainage, when indicated, could be performed with the above described minimally invasive technique.