Supratentorial extra-ventricular ependymoma as a mass lesion in a child: report and literature review

Supratentorial extra-ventricular ependymoma (SEE) are extremely rare in pediatric population and have varied presentation based on size, location, epicentre and compression on neurovascular structure. The authors report a 7-year-old girl presenting with seizure, who had a lobar SEE on MRI scan, successfully treated by microsurgical resection and adjuvant therapy.

Diagnostic imaging strategies of acute intracerebral hemorrhage in European academic hospitals-a decision-making analysis

PURPOSE

To evaluate and compare which factors are relevant to the diagnostic decision-making and imaging workup of intracerebral hemorrhages in large, specialized European centers.

METHODS

Expert neuroradiologists from ten large, specialized centers (where endovascular stroke treatment is routinely performed) in nine European countries were selected in cooperation with the European Society of Neuroradiology (ESNR). The experts were asked to describe how and when they would investigate specific causes in a patient who presented with an acute, atraumatic, intracerebral hemorrhage for two given locations: (1) basal ganglia, thalamus, pons or cerebellum; (2) lobar hemorrhage. Answers were collected, and decision trees were compared.

RESULTS

Criteria that were considered relevant for decision-making reflect recommendations from current guidelines and were similar in all participating centers. CT Angiography or MR angiography was considered essential by the majority of centers regardless of other factors. Imaging in clinical practice tended to surpass guideline recommendations and was heterogeneous among different centers, e.g., in a scenario suggestive of typical hypertensive hemorrhage, recommendations ranged from no further follow-up imaging to CT angiography and MR angiography. In no case was a consensus above 60% achieved.

CONCLUSION

In European clinical practices, existing guidelines for diagnostic imaging strategies in ICH evaluation are followed as a basis but in most cases, additional imaging investigation is undertaken. Significant differences in imaging workup were observed among the centers. Results suggest a high level of awareness and caution regarding potentially underlying pathology other than hypertensive disease.

Transarterial Radioembolization to Impact Liver Volumetry: When and How

Inadequate volume of the future liver remnant (FLR) renders many patients with liver malignancies not amenable to surgical resection. Depending on the health of the liver and the patient in general, an FLR of 25-40% is required to avoid acute post-hepatectomy liver failure. Transarterial radioembolization (TARE) of a diseased liver lobe leads to atrophy of the embolized lobe and compensatory hypertrophy of the contralateral lobe. Although the absolute degree of FLR hypertrophy seems to be comparable to portal vein embolization, the kinetic of hypertrophy is much slower after radioembolization. However, TARE has the unique advantages of simultaneously offering local tumor control, possibly downstaging disease, and providing biological test of time. Progressions in technique and personalized dosimetry allow for more predictable ablative treatment of liver malignancies and preparation for major liver surgery. This article provides an overview of the existing literature, discusses the evidence, and considers possible criteria for patient selection.

How can we optimize the long-term outcome in children with intracranial cavernous malformations? A single-center experience of 61 cases

The objective is to provide a treatment algorithm for pediatric patients with intracranial cavernous malformations (CMs) based on our experience. Patients < 18 years of age who were treated either surgically or conservatively at the authors' institution between 1982 and 2019 were retrospectively evaluated. A total of 61 pediatric patients were treated at the authors' institution: 39 with lobar CMs; 18 with deep CMs, including 12 in the brainstem and 6 in the basal ganglia; and 4 with CMs in the cerebellar hemispheres. Forty-two patients underwent surgery, and 19 were treated conservatively. The median follow-up time was 65 months (1-356 months). In surgically treated patients, lesions were larger (2.4 cm vs 0.9 cm, p < 0.001). In patients with lobar CMs, seizures were more common (72% vs 21%, p = 0.003) in the surgery group than in conservatively managed patients. In deep CMs, modified Rankin scale (mRS) was higher (4 vs 1, p = 0.003) in the surgery group than in conservatively treated patients. At the time of last follow-up, no differences in Wieser outcome class I were seen (86% vs 67%) in lobar CMs, and mRS scores had aligned between the treatment groups in deep CMs (1 vs 0). We encountered no new permanent neurological deficit at time of last follow-up. We propose a treatment algorithm according to lesion location and size, burden of symptoms, epilepsy workup, and further clinical course during observation. A conservative management is safe in pediatric patients with asymptomatic CMs. Gross total resection should be the aim in patients with symptomatic lobar CMs. A less aggressive approach with subtotal resection, when required to prevent neurological compromise, sustainably improves neurological outcome in patients with deep CMs.

Coagulation Differences Detectable in Deep and Lobar Primary Intracerebral Hemorrhage Using Thromboelastography

BACKGROUND

There are radiographic and clinical outcome differences between patients with deep and lobar intracerebral hemorrhage (ICH) locations. Pilot studies suggest that there may be functional coagulation differences between these locations detectable using whole blood coagulation testing.

OBJECTIVE

To confirm the presence of interlocation functional coagulation differences using a larger cohort of deep and lobar ICH patients receiving whole blood coagulation testing: thromboelastography (TEG; Haemonetics).

METHODS

Clinical and laboratory data were prospectively collected between 2009 and 2018 for primary ICH patients admitted to a tertiary referral medical center. Deep and lobar ICH patients receiving admission TEG were analyzed. Patients with preceding anticoagulant use and/or admission coagulopathy (using prothrombin time/partial thromboplastin time/platelet count) were excluded. Linear regression models assessed the association of ICH location (independent variable) with TEG and traditional plasma coagulation test results (dependent variable) after adjusting for baseline hematoma size, age, sex, and stroke severity.

RESULTS

We identified 154 deep and 53 lobar ICH patients who received TEG. Deep ICH patients were younger and had smaller admission hematoma volumes (median: 16 vs 29 mL). Adjusted multivariable linear regression analysis revealed longer TEG R times (0.57 min; 95% CI: 0.02-1.11; P = .04), indicating longer clot formation times, in deep compared to lobar ICH. No other TEG parameter or plasma-based coagulation differences were seen.

CONCLUSION

We identified longer clot formation times, suggesting relative coagulopathy in deep compared to lobar ICH confirming results from prior work. Further work is required to elucidate mechanisms for these differences and whether ICH location should be considered in future coagulopathy treatment paradigms for ICH.

Does lobar or size-reduced lung transplantation offer satisfactory early and late outcomes?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether size-reduced or lobar lung transplantation (LLTx) offers the same benefit as classic lung transplantation (LTx). Of the 147 papers found using the reported search, 9 were selected to provide the best evidence. Details of the studies regarding authors, date, journal, country of publication, study type, group studied, relevant outcomes and results are given. All studies reported survival rates of LLTx and most compared it with classical LTx. No statistical differences were reported in medium term and long term. Two of the studies reported a higher incidence of postoperative complications, such as the need for cardiopulmonary bypass, reperfusion oedema or primary graft dysfunction, and longer intubation or intensive care unit stay times. Although the largest study showed a significantly worse 1-year survival in LLTx, a sub-analysis considering patients successfully discharged showed similar outcomes at 1, 3 and 5 years when compared with classic LTx patients. We conclude that LLTx is a valid therapeutic option for recipients with significant donor size mismatch, offering similar outcomes as classical LTx in the medium term and long term.

Management of congenital lobar overinflation in an adult

Congenital lobar overinflation is characterized by disruption of bronchopulmonary development which produces lobar or segmental bronchial abnormalities and overinflation of normal lung tissue. This is a 44-year old man, never smoker, who presents dyspnea every time he arrived in highlands, marked decreased breathing sounds and hyperresonance in the left hemithorax. Imaging studies suggested left upper lobe overinflation. The affected area was resected resulting in symptoms improvement. Accepted treatment is resection, however conservative management has been proposed for asymptomatic patients because cases of spontaneous improvement have been described. We recommend close monitoring and resection if symptoms or overinflation progress.

Functional Coagulation Differences Between Lobar and Deep Intracerebral Hemorrhage Detected by Rotational Thromboelastometry: A Pilot Study

BACKGROUND

Lobar intracerebral hemorrhage (ICH) is known to have better clinical outcomes and preliminary evidence of less hematoma expansion compared to deep ICH. No functional coagulation differences between lobar and deep ICH have been identified using traditional plasma-based coagulation tests. We investigated for coagulation differences between lobar and deep ICH using whole-blood coagulation testing (Rotational Thromboelastometry: [ROTEM]).

METHODS

Clinical, radiographic, and laboratory data were prospectively collected for primary ICH patients enrolled in a single-center ICH study. Patients with preceding anticoagulant use or admission coagulopathy on traditional laboratory testing were excluded. Lobar and deep ICH patients receiving admission ROTEM were analyzed. Linear regression was used to assess the association of ICH location with coagulation test results after adjusting for potential confounders.

RESULTS

There were 12 lobar and 19 deep ICH patients meeting inclusion criteria. Lobar ICH patients were significantly older and predominantly female. Lobar ICH had faster intrinsic pathway coagulation times (139.8 vs 203.2 s; 95% CI - 179.91 to - 45.96; p = 0.002) on ROTEM testing compared to deep ICH after adjusting for age, sex, and hematoma volume. This revealed functional coagulation differences, specifically quicker clot formation in lobar compared to deep ICH. No differences were noted using traditional coagulation testing (prothrombin time/partial thromboplastin time/platelet count).

CONCLUSIONS

Our pilot data may suggest that there are functional coagulation differences between lobar and deep ICH identified using ROTEM. Whole-blood coagulation testing may be useful in assessing coagulopathy in ICH patients and in determining reversal treatment paradigms, though further work is needed.

Hematoma Expansion Differences in Lobar and Deep Primary Intracerebral Hemorrhage

BACKGROUND

Hematoma expansion (HE) after intracerebral hemorrhage (ICH) is associated with worse outcome. Lobar ICHs are known to have better outcomes compared to deep ICH; however, it is unclear whether there are HE differences between these locations. We sought to investigate the hypothesis that lobar ICH has less HE compared to deep ICH.

METHODS

Primary ICH patients admitted between 2009 and 2016 were included in a prospective single-center ICH cohort study. Patients with preceding anticoagulant use, coagulopathy on admission labs, or presenting after 24 h from symptom onset were excluded. Lobar and deep ICH patients with baseline and follow-up computed tomography (CT) (within 24 h of admission CT) were evaluated. HE was defined primarily as relative growth > 33% given expected baseline hematoma volume differences between locations. Other commonly utilized definitions of HE: > 6 mL, and > 33% or > 6 mL, were additionally assessed. Multivariable logistic regression was used to assess the association of ICH location with HE while adjusting for previously identified covariates of HE.

RESULTS

There were 59 lobar and 143 deep ICH patients analyzed. Lobar ICH patients had significantly larger baseline hematoma volumes, lower admission systolic blood pressure, and longer times to admission CT compared to deep ICH. Multivariable logistic regression revealed an association of lobar ICH with lower odds of HE (> 33%) [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.11-0.93; p = 0.04] compared to deep ICH after adjusting for baseline ICH volume, blood pressure, and time to CT. Secondary analysis did not identify an association of lobar ICH with HE defined as > 6 mL (adjusted OR 1.44; 95% CI 0.59-3.50; p = 0.41) or > 33% or > 6 mL (adjusted OR 0.71; 95% CI 0.29-1.70; p = 0.44).

CONCLUSION

We identified less HE in lobar compared to deep ICH. The use of absolute growth thresholds in defining HE may be limited when assessing groups with largely different baseline hematoma sizes. Further study is required to replicate our findings and investigate mechanisms for HE differences between lobar and deep ICH locations.

Predictors of localization, outcome, and etiology of spontaneous intracerebral hemorrhages: focus on cerebral amyloid angiopathy

Despite its clinical relevance, cerebral amyloid angiopathy (CAA) is underdiagnosed worldwide. This retrospective study aimed to assess the incidence, etiology, predictors, and outcome of intracerebral hemorrhages (ICHs) in this region, with special focus on possible underlying CAA. Database screening of acute cares with intracranial hemorrhage diagnosis within 01/07/2014–01/07/2018 were conducted analyzing medical records and imaging. Spontaneous ICHs were classified as deep (basal ganglionic/thalamic/brainstem) and lobar/cerebellar (i.e., CAA-compatible) ICHs. Probable/definite CAA was established using the modified Boston criteria in a subgroup with ‘complete’ radiological/neuropathological work-up. The ability of several factors to discriminate between deep and lobar/cerebellar ICHs, between probable/definite CAA and non-probable CAA cases, and to predict 1-month case fatality was assessed. Of the 213 ICHs identified, 121 were in deep and 92 in lobar/cerebellar localization. Sub-analysis of 47 lobar/cerebellar ICHs with ‘complete’ work-up identified 16 probable/definite CAA patients, yielding an estimated 14.7% prevalence of CAA-related ICHs. Chronic hypertension was the most prevalent risk factor for all types of ICHs (including CAA-related), with hypertensive excess and younger age being independent predictors of deep whereas antiplatelet use of lobar/cerebellar localization. The 1-month case fatality was 33.8%, driven predominantly by age and INR > 1.4. Probable/definite CAA diagnosis was independently predicted by age, prior intracranial hemorrhage, and antiplatelet use. First in this region and among the few in the literature, this study reports a remarkable prevalence of CAA-related ICHs, emphasizing the need for an increased awareness of CAA and its therapeutic implications, especially regarding antiplatelets among the elderly.

Relationship between adherence to the Mediterranean Diet, intracerebral hemorrhage, and its location

INTRODUCTION

Although some authors evaluated the relationship between adherence to the Mediterranean Diet (MeDi) and both ischemic and hemorrhagic stroke, hemorrhagic stroke alone is not yet examined.

AIMS

We conducted a retrospective study to evaluate the relationship between adherence to MeDi and intracerebral hemorrhage (ICH) and different locations of ICH (ganglionic/internal capsule, brainstem/cerebellum, or lobar).

METHODS

We analyzed charts and collected data of all consecutive patients with ICH admitted to our Internal Medicine Ward from 2005 to 2014. A scale indicating the degree of adherence to the traditional MeDi Score was constructed.

RESULTS

When compared with 100 subjects without ICH, 103 subjects with ICH had significantly higher mean values of LDL (91.1 ± 38.7 mg/dl vs. 79.2 ± 34.4 mg/dl; p = 0.031), triglycerides (118.9 ± 62.9 mg/dl vs. 101.6 ± 47.6 mg/dl; p = 0.026), and proteinuria (32.6 ± 50.0 mg/dl vs. 18.1 ± 39.6 mg/dl; p=0.024) and a significantly lower mean MeDi Score (3.9 ± 1.0 vs. 7.0 ± 1.4; p < 0.0001). In a multiple regression analysis, smoking, diastolic blood pressure (DBP), and the MeDi Score remained significantly associated with ICH. We also observed a significantly lower mean MeDi Score in the lobar location group when compared with the ganglionic/internal capsule group (4.3 ± 1.0 vs. 3.5 ± 0.9; p < 0.0005).

DISCUSSION

Our findings regarding the higher prevalence of ICH in patients with lower adherence to MeDi may be related to the fact that patients with lower MeDi Score exhibit a worse cardiovascular risk profile with increased risk factors such as hypertension and dyslipidemia.

Frontotemporal dementia

Recent research reveals an overlap between frontotemporal dementia (FTD) and a variety of primary psychiatric disorders, challenging the artificial divisions between psychiatry and neurology. This chapter offers an overview of the clinical syndromes associated with FTD while describing links between these syndromes and neuroimaging. This is followed by a review of the neuropathology and genetic changes in the brain. We will illustrate the syndromic overlap that exists between FTD and several primary psychiatric disorders including bipolar affective disorder and schizophrenia. Emphasis will be placed on the behavioral variant of FTD (bvFTD), which is the common clinical syndrome seen with degeneration of the frontal lobes and is the most likely to be encountered in psychiatric settings.

Measurement of preoperative lobar lung function with computed tomography ventilation imaging: progress towards rapid stratification of lung cancer lobectomy patients with abnormal lung function

OBJECTIVES

In lung cancer preoperative evaluation, functional lung imaging is commonly used to assess lobar function. Computed tomography ventilation (CT-V) imaging is an emerging lung function imaging modality. We compared CT-V imaging assessment of lobar function and its prediction of postoperative lung function to that achieved by (i) positron emission tomography ventilation (PET-V) imaging and (ii) the standard anatomical segment counting (ASC) method. We hypothesized (i) that CT-V and PET-V have similar relative lobar function and (ii) that functional imaging and anatomic assessment (ASC) yield different predicted postoperative (ppo) lung function and therefore could change clinical management.

METHODS

In this proof-of-concept study, 11 patients were subjected to pulmonary function tests, CT-V and PET-V imaging. The Bland-Altman plot, Pearson's correlation and linear regression analysis were used to assess the agreement between the CT-V-, PET-V- and ASC-based quantification of lobar function and in the ppo lung function.

RESULTS

CT-V and PET-V imaging demonstrated strong correlations in quantifying relative lobar function (r = 0.96; P < 0.001). A Wilcoxon-signed rank test showed no significant difference in the lobar function estimates between the two imaging modalities (P = 0.83). The Bland-Altman plot also showed no significant differences. The correlation between ASC-based lobar function estimates with ventilation imaging was low, r < 0.45; however, the predictions of postoperative lung function correlated strongly between all three methods.

CONCLUSIONS

The assessment of lobar function from CT-V imaging correlated strongly with PET-V imaging, but had low correlations with ASC. CT-V imaging may be a useful alternative method in preoperative evaluation for lung cancer patients.

Approach to a child with recurrent pneumonia

Pneumonia, or inflammation of the lungs parenchyma associated with consolidation of alveolar spaces, is a substantial cause of morbidity and mortality in childhood particularly among children below 5 years of age. It is one of the common causes of admission to the paediatric ward. The aim of this article is to provide a guide to a systemic approach for diagnosis and treatment of children with recurrent pneumonia while not over investigating those with common but usually unrecognised conditions such as asthma or recurrent simple viral infections.