Genetic pathways in cerebral palsy: a review of the implications for precision diagnosis and understanding disease mechanisms

ABSTRACT

Cerebral palsy is a diagnostic term utilized to describe a group of permanent disorders affecting movement and posture. Patients with cerebral palsy are often only capable of limited activity, resulting from non-progressive disturbances in the fetal or neonatal brain. These disturbances severely impact the child's daily life and impose a substantial economic burden on the family. Although cerebral palsy encompasses various brain injuries leading to similar clinical outcomes, the understanding of its etiological pathways remains incomplete owing to its complexity and heterogeneity. This review aims to summarize the current knowledge on the genetic factors influencing cerebral palsy development. It is now widely acknowledged that genetic mutations and alterations play a pivotal role in cerebral palsy development, which can be further influenced by environmental factors. Despite continuous research endeavors, the underlying factors contributing to cerebral palsy remain are still elusive. However, significant progress has been made in genetic research that has markedly enhanced our comprehension of the genetic factors underlying cerebral palsy development. Moreover, these genetic factors have been categorized based on the identified gene mutations in patients through clinical genotyping, including thrombosis, angiogenesis, mitochondrial and oxidative phosphorylation function, neuronal migration, and cellular autophagy. Furthermore, exploring targeted genotypes holds potential for precision treatment. In conclusion, advancements in genetic research have substantially improved our understanding of the genetic causes underlying cerebral palsy. These breakthroughs have the potential to pave the way for new treatments and therapies, consequently shaping the future of cerebral palsy research and its clinical management. The investigation of cerebral palsy genetics holds the potential to significantly advance treatments and management strategies. By elucidating the underlying cellular mechanisms, we can develop targeted interventions to optimize outcomes. A continued collaboration between researchers and clinicians is imperative to comprehensively unravel the intricate genetic etiology of cerebral palsy.

Posterior Inferior Cerebellar Artery Aneurysm Shaped Like a "Calabash Gourd" and Mimicking a Tumor

Posterior inferior cerebellar artery aneurysms are likely to be fusiform, yet they hardly enlarge to mimic a tumor in the posterior fossa on radiology. They constitute about 3%-4% of all cerebral aneurysms. A 65-year-old woman presented with tremor in her right upper limb for 1 year and intermittent dizziness for 8 months. Interestingly, magnetic resonance imaging revealed 2 unanimously enhanced masses like mother and daughter located in the right cerebellum hemisphere. The lesion was resected via surgery, and histopathology established the diagnosis of an aneurysm. Her tremor and dizziness subsided 3 months after the surgery, and at her 2-year follow-up she was well with no further neurologic deficits.

The pivotal role of irradiation-induced apoptosis in the pathogenesis and therapy of medulloblastoma

BACKGROUND

Medulloblastoma (MB) is a rare primitive neuroectodermal tumors originating from the cerebellum. MB is the most common malignant primary brain tumor of childhood. MB originates from neural precursor cells in distinctive regions of the rhombic lip, and their maturation occurs in the cerebellum or the brain stem during embryonal development. Also, apoptosis is a programmed cell death associated with numerous physiological as well as pathological regulations.

RECENT FINDINGS

Irradiation (IR)-induce apoptosis triggers cell death, with or without intervening mitosis within a few hours of IR and these share different morphologic alteration such as, loss of normal nuclear structure as well as degradation of DNA. Moreover, MB is strikingly sensitive to DNA-damaging therapies and the role of apoptosis a key treatment modality. Furthermore, in MB, the apoptotic pathways are made up of several triggers, modulators, as well as effectors. Notably, IR-induced apoptotic mechanisms in MB therapy are very complex and they either induce radiosensitivity or inhibit radioresistance leading to potential effective treatment strategies for MB.

CONCLUSION

This review explicitly explores the pivotal roles of IR-induced apoptosis in the pathogenesis and therapy of MB.

Localized Congenital Cutis Verticis Gyrate with Skull Erosion

Localized congenital cutis verticis gyrate (CVG) is rare and potentially risks skull involvement. A 23-year-old woman presented with a congenital scalp mass in the occipital region. Local thickening of her left occipital scalp with ridges and furrows was observed on examination. Head computed tomography scan showed a lytic area underneath the same area of the occipital calvarium. The mass was surgically removed due to the skull erosion and cosmetic reasons. Pathologic evaluation established CVG. Surgical excision is best for localized congenital CVG with skull erosion due to cosmetic reasons. Surgical excision was rewarding to the patient it allowed her to style her hair.

Aflatoxin B1 induces infertility, fetal deformities, and potential therapies

Aflatoxin B1 (AFB1) is a subsidiary poisonous metabolite, archetypally spawned by Aspergillus flavus and A. parasiticus, which are often isolated in warm or tropical countries across the world. AFB1 is capable of disrupting the functioning of several reproductive endocrine glands by interrupting the enzymes and their substrates that are liable for the synthesis of various hormones in both males and females. In men, AFB1 is capable of hindering testicular development, testicular degeneration, and reduces reproductive capabilities. In women, a direct antagonistic interaction of AFB1 with steroid hormone receptors influencing gonadal hormone production of estrogen and progesterone was responsible for AFB1-associated infertility. AFB1 is potentially teratogenic and is responsible for the development of malformation in humans and animals. Soft-tissue anomalies such as internal hydrocephalus, microphthalmia, cardiac defects, augmented liver lobes, reproductive changes, immune modifications, behavioral changes and predisposition of animals and humans to neoplasm development are AFB1-associated anomalies. Substances such as esculin, selenium, gynandra extract, vitamins C and E, oltipraz, and CDDO-Im are potential therapies for AFB1. Thus, this review elucidates the pivotal pathogenic roles of AFB1 in infertility, fetal deformities, and potential therapies because AFB1 toxicity is a key problem globally.

Lhermitte-Duclos disease with excessive calcification in a septuagenarian: A case report

RATIONALE

Lhermitte-Duclos disease (LDD), or dysplastic cerebellar gangliocytoma (DCG), is a rare tumor originating from the cerebellar cortex. LDD is a benign neuroglial tumor with uncertain prognosis. Over 200 cases have been reported in the literature mostly in the form of case reports. Thus, we present a spectacular case of LDD with excessive calcification in a female septuagenarian.

PATIENT CONCERNS

A 72-year-old female presented with progressive dizziness for 8 months and suffered a head and sacrococcygeal region injury 20 days prior to her admission in our neurosurgery department.

DIAGNOSIS

Computed tomography scan showed a right nonspecific cerebellar mass with striated calcification. Magnetic resonance imaging revealed a right "tiger-striped" alteration of the cerebellar cortex. H&E staining revealed a low grade glial neural tumor which was consistent with the diagnosis of LDD or DCG.

INTERVENTION

The lesion was total resected.

OUTCOMES

The patient recovered well and the cerebellar dysfunctional symptoms subsided 3 months after the operation and 2 years follow-up revealed no recurrence of the lesion and no neurological deficits.

LESION

We postulate that the calcification of LDD is age-related and the pathogenesis of disease often observed in young adulthood.

Giant Brain Arteriovenous Malformation Managed by Staged Embolizations and Surgical Resection with Satisfactory Outcome

Spetzler-Martin grade V (>6 cm) arteriovenous malformations (AVMs) are traditionally considered inoperable. A 35-year-old man presented with repeated seizures for 7 years, and computed tomography arteriography and magnetic resonance imaging revealed left deep hemispheric AVM. A combination of embolization and surgical resection successfully achieved a cure of the patient. Well-equipped neurosurgery facilities can best manage selective Spetzler-Martin grade V AVMs with no neurologic deficits contrary to their traditionally inoperable concept. Successful surgery offers the patient a better quality of life.

Rapid disappearance of acute subdural hematoma due to abrogated hyper-fibrinolytic activity by tranexamic acid: Case report

RATIONALE

Acute subdural hematoma (ASDH) occurs after tearing of bridging veins within the dura resulting in the accumulation of blood between the arachnoid and dura layers within 72 hours after traumatic head injury. Also, antigen fibrin D-dimer (DD) is the principal enzymatic degradation product of cross-linked fibrin by plasmin. We observed that early tranexamic acid (TXA) treatment resolved hyper-fibrinolysis and rapid disappearance ASDH.

PATIENTS CONCERNS

A 48-year-old female presented with unconsciousness for 2 hours after head trauma. Her Glasgow Coma Scale score was >8 points.

DIAGNOSIS

Computed tomography scan established ASDH with midline shift and brainstem compression and surgery was scheduled. Also, laboratory results indicated high DD spike of 34,820 μg/L and a reduction in plasma fibrinogen 1 hour after the injury.

INTERVENTION

She was treated with intravenous TXA immediately after admission.

OUTCOMES

Her DD spike decreased remarkably in 48 hours with associated rapid disappearance of ASDH thereby averting surgical intervention. She recovered fully with no long-term complications.

LESSONS

Historically, hyper-fibrinolysis is associated with poor outcome in head trauma. However, early initiation of TXA which is noninvasive treatment modality for ASDH could avert surgery and reduce cost, anesthesia, and other complications associated with surgery.

Elucidating the Focal Immunomodulatory Clues Influencing Mesenchymal Stem Cells in the Milieu of Intervertebral Disc Degeneration

The intervertebral discs (IVDs) are a relatively mobile joint that interconnects vertebrae of the spine. Intervertebral disc degeneration (IVDD) is one of the leading causes of low back pain, which is most often related to patient morbidity as well as high medical costs. Patients with chronic IVDD often need surgery that may sometimes lead to biomechanical complications as well as augmented degeneration of the adjacent segments. Moreover, treatment modalities like rigid intervertebral fusion, dynamic instrumentation, as well as other surgical interventions are still controversial. Mesenchymal stem cells (MSCs) have exhibited to have immunomodulatory functions and the ability to differentiate into cartilage, making these cells possibly an epitome for IVD regeneration. Transplanted MSCs were able to repair IVDD back to the normal disc milieu via the activation of the generation of extracellular matrix (ECM) proteins such as aggrecan, proteoglycans and collagen types I and II. IVD milieu clues like, periostin, cluster of differentiation, tumor necrosis factor alpha, interleukins, chemokines, transforming growth factor beta, reactive oxygen species, toll-like receptors, tyrosine protein kinase receptor and disialoganglioside, exosomes are capable of influencing the MSCs during treatment of IVDD. ECM microenvironment clues above have potentials as biomarkers as well as accurate molecular targets for therapeutic intervention in IVDD.

Genome-wide Association Studies of REST Gene Associated Neurological Diseases/traits with Related Single Nucleotide Polymorphisms

BACKGROUND

Genome-wide association studies (GWAS) have been used to explore the connections between genotypes and phenotypes by comparing the genotype frequencies of genetic changes in individuals with similar origins but distinct traits.

OBJECTIVES

The aim is to employ the GWAS catalog to identify and investigate the various correlations between genotypes and phenotypes of the REST gene.

METHODS

In this study, we utilized a large dataset of GWAS comprising 62,218,976 individuals in 112 studies and 122 associations with 122 traits (www.ebi.ac.uk/gwas/genes/REST) from European, Asian, Hispanic, African ancestry up to 28 February 2023. Protein-association network evaluation and gene ontology enrichment study was utilized to evaluate the biological function of the discovered gene modules.

RESULTS

We identified several associations for both neurodevelopmental and neurodegenerative disorders linked to REST, as well as its mapped gene modules and their functional relationship networks.

CONCLUSION

This work offers fresh insights into identifying risk loci of neurological disorders caused by REST.

Mechanical thrombectomy for vertebral and basilar artery occlusions: An institutional experience with 17 patients

Acute ischemic stroke of the posterior circulation as a result of vertebrobasilar artery occlusions is often associated with severe morbidity and mortality rates. Vertebrobasilar artery occlusion retrieval via mechanical thrombectomy (MT) is a novel treatment modality for occlusive strokes. Nevertheless, factors associated with positive outcomes have not yet been adequately investigated. Thus, the present study focused on factors associated with good prognosis following this type of treatment. The present study retrospectively analyzed a series of 17 patients with acute vertebral artery occlusions (VAOs) and basilar artery occlusions (BAOs) treated with MT. In all patients, information such as sex and age, time from admission to the onset of femoral artery access, the number of thrombi removed, the time of femoral artery access to recanalization, pre- and post-operative National Institutes of Health Stroke Scale (NIHSS) scores, pre- and post-operative thrombolysis in cerebral infarction, as well as modified Rankin scale scores were documented and analyzed. The analysis comprised of 11 patients with BAOs and 6 patients with VAOs. A recanalization rate of 70.6% was achieved with an overall good functional outcome of 58.8% at 90 days. Observationally, there was a notable improvement in outcomes when comparing the NIHSS prior to surgery with NIHSS at 1 week after the surgery. A lower NIHSS score prior to MT may be a good prognostic factor. An average time of ~5.5 h from patient admittance to recanalization with a 70.6% recanalization rate with an overall good functional outcome of 58.8% at 90 days suggested that, patients for whom the surgeries were performed within 5 h of admittance may still have hope for recanalization compared to an initial 1.5-h average time for recanalization.

The impact of residual hematoma after evacuation on the outcomes of patients with ruptured intracranial aneurysms with intracerebral hematoma: A longitudinal single-center observational study

Intracerebral hematoma (ICH) as a result of ruptured of intracranial aneurysms often arises in patients with subarachnoid hemorrhage. Few studies focused on risk factors for ICH and not the impact of residual hematoma after evacuation on the outcomes of the patients. Therefore, 2 questions need to be answered: does residual hematoma after evacuation have impact on the outcome of patients who present with ICH as a result of ruptured intracranial aneurysms? Is radical pursuit of the hematoma necessary? The study was a single-center longitudinal observational type. Data of 2044 consecutive patients with subarachnoid hemorrhage from January 2009 to December 2019 were reviewed. ICHs were established and the locations of aneurysms as well as hematoma volumes were measured by computed tomographic scan before aneurysm occlusion. Only patients who received aneurysm clipping were included. Patients were stratified into hematoma evacuation without residuals versus residual hematoma after evaluation groups, and outcome was assessed according to the modified Rankin Scale (mRS) at 6 months. Out of the 1365 patients who received clipping, 476 patients presented in poor grade, whereas 889 patients' good grade. Our mRS scores revealed that patients who attained hematoma evacuation without residuals in the good-grade category attained better functional outcome than those with residual hematoma after evacuation. Contrarily, our mRS scores did not establish any significant difference in outcome between the poor-grade patients with hematoma evacuation without residuals and patients with residual hematoma after evacuation. Furthermore, our logistic regression model showed that advance age, poor Hunt-Hess grade, and vascular injury due to surgery were contributing factors for poor outcome of patients with ICH. Our data suggested that aggressive hematoma evacuation may not benefit the poor-grade patients. Majority of poor outcomes were due to surgical complications which were vascular related as a result of excessive pursuit of ICH.

Localized Giant Cell Tumor of the Tendon Sheath of the Upper Cervical Spine: A Case Report

INTRODUCTION

Giant cell tumor of the tendon sheath (GCTTS) is commonly seen in the appendicular skeleton, and rarely arises from the axial skeleton. We describe a rare case of GCTTS in an adolescent in the upper cervical spine.

CASE PRESENTATION

A previously healthy 16-year-old boy presented with a 6-month history of numbness of right upper extremity, and had experienced a neck pain 4 months ago. Spinal MRI demonstrated a small syrinx at C2 level and a well-circumscribed extradural mass with contrast enhancement extending from the posterior arch of C1 to C2. The extradural mass was totally resected, and the syrinx underwent clinical and imaging surveillance.

DISCUSSION

GCTTS should be considered in the differential diagnosis of the axial skeletal lesion although very rare. Gross-total resection is advocated in GCTTS of the upper cervical spine, and subtotal resection with meticulous lesion monitoring should be performed in unresectable cases.

Hybrid operation for arteriovenous malformations with associated multiple intracranial aneurysms and subarachnoid hemorrhage: Case report

RATIONALE

The hybrid surgical concept for the treatment of brain arteriovenous malformations (AVMs) with associated intracranial aneurysms (IAs) is still not widely practiced. Concomitant occurrence of AVMs with IAs is common. Subarachnoid hemorrhage (SAH) as a result of AVM or IA rupture is often associated with these dual pathological phenomena. We present a case of concomitant occurrence of AVMs and IAs that was successfully treated using the hybrid operation concept.

PATIENT CONCERNS

A 62-year-old man presented with sudden onset of severe headache, dizziness, nausea, and vomiting for 4 hours.

DIAGNOSIS

Computed tomography revealed SAH and a hematoma in the right frontal lobe. A computed tomographic angiogram also revealed a right frontal AVM with 3 IAs.

INTERVENTIONS

We used a hybrid operating room to successfully treat both AVMs and IAs.

OUTCOMES

Two years of follow-up showed that the patients were well and performed their daily duties.

LESSONS

The hybrid operating room is an innovative, safe, and effective method for the treatment of AVMs with associated IAs, particularly high-grade AVMs and IAs with hemorrhage or SAH. Patients with concomitant AVMs and IAs have the highest chance of hemorrhage compared with those with AVM or IAs alone.

Hemangioblastoma masquerading as a ring enhancing lesion in the cerebellum: A case report

RATIONALE

Hemangioblastomas (HGBMs) are very rare, and the cerebellum is usually the most common site of occurrence. HGBMs with ring-enhanced walls are often misdiagnosed as metastases, abscesses, glioblastomas, tuberculomas, and demyelinating diseases. Thus, we present a rare case of HGBM masquerading as a ring-enhancing lesion in the cerebellum.

PATIENT CONCERNS

We present a 33-year-old female who was admitted to our department because of headaches, unstable walking, and visual loss in both eyes. Cranial nerve examination revealed deficits in cranial nerve II.

DIAGNOSIS

Magnetic resonance imaging revealed 2 cystic lesions in the cerebellum, with irregular ring-enhanced cyst walls composed of smaller nodular parts. Immunohistochemical staining of resected specimens established HGBM.

INTERVENTIONS

The lesions were completely resected using a right retrosigmoid approach.

OUTCOMES

Two years of follow-up revealed no recurrence of her symptoms or tumor. She is currently well and performs her daily duties.

LESSONS

HGBMs with enhanced cysts are often misdiagnosed by radiology because of their ring-enhanced nature. Computed tomography angiography may be the best modality for differentiating cerebellar HGBM from other ring-enhancing lesions. Surgery is the gold standard of treatment for these lesions.

A petroclival glioma mimicking trigeminal schwannoma: A case report

RATIONALE

Glioma in the petroclival region is very rare. Also, very few cases of primary gliomas have been reported to have radiographic as well as intraoperative features of extra-axial lesions resulting in diagnostic dilemma in the literature. We present a rare case of petroclival glioma mimicking trigeminal schwannoma in a young female.

PATIENT CONCERNS

We present a 21-years old female with a 3-month history of pain in the right eye with no visual impairment. Cranial nerves examination revealed mild deficits in the trigeminal nerve, facial nerve, auditory nerve, oculomotor as well as the trochlear nerve.

DIAGNOSES

Magnetic resonance imaging detected an extra-axial mass with mixed signal intensities in the right petroclivus area. Immunohistochemical established glioma with world health organization (WHO) grade II.

INTERVENTIONS

The lesion was resected via 2 successive operations in 6 months interval. The patient was further treated with radiotherapy and post-radiotherapy temozolamide.

OUTCOMES

Two years follow-up revealed no recurrence of the lesions and she is well. Nevertheless, he is still being followed diligently to uncover any recurrence.

LESSONS

The extra-axial nature as well as petroclival location of the glioma makes our case very unique and very rare. The imaging characteristics were very extraordinary for a glioma which resulted in diagnostic dilemma. Thus, the definitive diagnosis was based on the histopathological evaluation of the excised tumor.

The Appearance of Middle Meningeal Artery Fistulae After Willis Covered Stent for Traumatic Carotid-cavernous Fistulae: Two Case Reports

INTRODUCTION

Carotid cavernous fistulae (CCF) are rare, and they occur when there is a communication between the internal carotid artery (ICA) and cavernous sinus. These lesions are associated with blunt or penetrating traumatic injuries of the carotid arteries. We present the first cases of cavernous dural arteriovenous fistulae (cDAVF) in the middle meningeal artery (MMA) after the treatment of direct CCF in the ICA with Willis-covered stents (WCSs).

CASE PRESENTATION

Our patients comprised 22 and 50-year-old males with histories of head injuries months before admission at our facility. In both patients above, cerebral angiography revealed fistulae in the right ICA and left ICA, respectively. They were treated with WCSs via the trans-artery endovascular route. In both cases, the treatments were not in the way attempted via the MMA. Subsequently, they developed cDAVF in the middle meningeal artery (MMA), which were treated with Onyx Liquid Embolic System (Onyx HD-500) (Covidien / ev3 Neurovascular) and conservatively, respectively.

CONCLUSION

These are the first cases in whom WCSs for the management of direct CCF resulted in cDAVF at the MMA. The WCSs inside the ICA could have resulted in the cDAVF via unknown mechanisms but not iatrogenic.

Delayed Multiple Non-ischemic Cerebral Enhanced Lesions After Endovascular Therapy For Left Internal Carotid Aneurysm: A Case Report

INTRODUCTION

Endovascular therapy (EVT) for intracranial arterial aneurysms is depicted with several complications. Very recently, delayed non-ischemic cerebral enhanced (NICE) lesions have been identified as a rare complication associated with EVT. This complication always stands a higher chance of being missed in asymptomatic patients. We report a case of multiple NICE lesions in a known chronic hepatitis B infection and chronic gastritis patient with left internal carotid aneurysm (ICA) treated with detachable coils.

CASE PRESENTATION

A 52 years old female with left ICA was treated with detachable coils via the endovascular route. Three weeks after the operation, she presented with numbness of her right limbs which was persistent and waked her up from sleep each night. She admitted skin allergies after wearing metals except for gold and silver since childhood. MRI revealed multiple abnormal lesions in the left temporal lobe, hippocampus, insula, and parietal lobe and some perifocal edema which were consistent with the diagnosis of delayed NICE lesions.

CONCLUSION

It is very important to report the occurrences of these lesions in literature because of their allergic origin. We advocate that allergy to metals especially those used in coating endovascular equipment should be evaluated before every EVT for intracranial aneurysms.

Cerebral vasospasm resulted in "stent shortening" after pipeline assisted coil embolization for blood blister aneurysms

Blood blister aneurysms (BBAs) are intracranial arterial lesions appearing in nonbranching sites of the supraclinoid internal carotid artery as well as the basilar artery. Endovascular treatment of BBAs is still not well established because of the rarity of these lesions. We report incidences of BBAs with associated vasospasms. Treatment of the BBAs and associate vasospasms with single Pipeline Flex embolization device (PLED) assisted coiling resulted in seemly shorting of the PLEDs in 3 patients.A retrospective analysis of patients with BBAs who were treated with single PLED assisted coiling from July 2018 to October 2019 was conducted. Patients' ethnic and medical records, aneurysmal characteristics, intraoperative-rupture, cerebral vasospasm (CVS), postprocedure contrast filling, follow-up imaging, and results were analyzed. Neurological examination at baseline and outcome based on modified Rankin scale (mRS) at discharge as well as follow-ups were also documented.Six patients consisting of 5 females and 1 male, with a mean age of 48.3 years (range from 34-67) were identified during our analysis. All the BBAs were located in nonbranching site of supra-clinoidal segment of internal carotid artery with a mean neck width of 4.5 mm and mean aneurysm size of 4.23 mm. PLED assisted coiling's were performed in all of them. CVS was observed in 3 patients while 1 patient had an intraoperative-rupture of the BBA. Postprocedure contrast filling was still present in 1 patient. All the patients had good outcomes with discharge and follow-up mRS scores ≤ 2 except 1 patient with mRS score = 3 with aphasia.PLED assisted endovascular coiling is very safe and efficient in treating patients with BBAs. Resolution of CVSs after treatment made the PLEDs seemly shorter. Furthermore, a combination of arterial lengthening after gaining their tensile strength back and radical expansion of the PLED could account for the shortening.

A fenestrated persistent primitive hypoglossal artery harboring a ruptured aneurysm: A case report

RATIONALE

Persistent primitive hypoglossal artery (PPHA) is a rare and permanent carotid-vertebrobasilar anastomoses. Patients with PPHA usually have higher changes of developing intracranial aneurysms due the high intracranial hemodynamics. Although cases of PPHA alone and PPHA with aneurysms have been reported in literature, cases of fenestrated PPHA harboring a ruptured aneurysm have seldomly be reported in literature. We present a rare occurrence of a fenestrated PPHA harboring a reputed aneurysm.

PATIENTS CONCERNS

A 43-year-old woman was presented with a sudden-onset severe headache and nausea.

DIAGNOSIS

Computerized tomography scan showed third, fourth, and bilateral ventricular hemorrhages. Computed tomographic angiogram showed a PPHA with fenestration malformation and a cystic protrusion consistent with an aneurysm.

INTERVENTION

The patient underwent a successful stent-assisted coil embolization via the trans-arterial route under general anesthesia.

OUTCOMES

Two years follow-up revealed no recurrence of her symptomatology and she is currently well and go about her normal daily life.

CONCLUSION

Fenestrated PPHAs harboring aneurysms may be more prone to rupture because of the fenestration and connective tissue weakness of the artery as well as changes in hemodynamics of the already malformed and weak artery.

Intracranial Cerebrospinal Fluid Volume Evaluation in Healthy People and Hydrocephalus Patients using SPACE Sequence

Introduction

Cerebrospinal Fluid (CSF) is produced mainly by the choroid plexus but with a substantial influence by the ependymal lining of the ventricles in the brain. Hydrocephalus occurs as a result of discrepancy in the production as well as circulation of CSF as a result of congenital and acquired conditions. Nevertheless, studies on the differences between CSF dynamics according to age and gender are still insufficient. Thus, this study evaluated the volume of intracranial CSF in healthy people and hydrocephalus patients taking into account the differences between CSF dynamics according to age and gender using Sampling Perfection with Application optimised Contrast using different flip-angle Evolution (SPACE) sequence.

Methods

120 healthy volunteers and 60 patients with hydrocephalus were included in this study. SPACE sequence was used to evaluate intracranial CSF with a 3.0T magnetic resonance machine. The total volume of intracranial CSF and the amount of CSF in the ventricle were obtained using a software, and the volume ratio of CSF in the subarachnoid space, the ventricle and the subarachnoid space were calculated.

Results

The mean volume of intracranial CSF, ventricular CSF, and subarachnoid CSF of male volunteers were (206.9±47.7) cm3, (33.0±10.7) cm3, (173.9±37.9) cm3 respectively. The average volume of intracranial CSF, ventricular CSF, and subarachnoid CSF of female volunteers were (199.7±44.9) cm3, (30.8±9.4) cm3, and (168.9±37.0) cm3, respectively. Thus, no significant statistically (P>0.05) difference between males and females was found. (3) The mean values ​​of intracranial CSF, ventricle CSF and subarachnoid CSF, ventricle and subarachnoid CSF volume ratio in patients with hydrocephalus were significantly greater than health volunteers. Thus, the difference between the two groups was statistically significant (P<0.05).

Conclusion

SPACE sequence can quantitatively determine the content of CSF. The change of CSF volume has nothing to do with gender but with age. It is feasible to use SPACE sequence to evaluate the spatial distribution and volume of intracranial CSF.

Elucidating the Pivotal Neuroimmunomodulation of Stem Cells in Spinal Cord Injury Repair

Spinal cord injury (SCI) is a distressing incident with abrupt onset of the motor as well as sensory dysfunction, and most often, the injury occurs as result of high-energy or velocity accidents as well as contact sports and falls in the elderly. The key challenges associated with nerve repair are the lack of self-repair as well as neurotrophic factors and primary and secondary neuronal apoptosis, as well as factors that prevent the regeneration of axons locally. Neurons that survive the initial traumatic damage may be lost due to pathogenic activities like neuroinflammation and apoptosis. Implanted stem cells are capable of differentiating into neural cells that replace injured cells as well as offer local neurotrophic factors that aid neuroprotection, immunomodulation, axonal sprouting, axonal regeneration, and remyelination. At the microenvironment of SCI, stem cells are capable of producing growth factors like brain-derived neurotrophic factor and nerve growth factor which triggers neuronal survival as well as axonal regrowth. Although stem cells have proven to be of therapeutic value in SCI, the major disadvantage of some of the cell types is the risk for tumorigenicity due to the contamination of undifferentiated cells prior to transplantation. Local administration of stem cells via either direct cellular injection into the spinal cord parenchyma or intrathecal administration into the subarachnoid space is currently the best transplantation modality for stem cells during SCI.

Obstructive ureteric calculus with superimposed infections causing reversible posterior leukoencephalopathy syndrome: A case report

RATIONALE

Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinicoradiological phenomenon first observed 2 decades ago. Reversibility is the hallmark of this rare clinical phenomenon once the triggering pathology is aptly and adequately treated. Tinnitus preceding bilateral hearing loss as a symptomatology of RPLS has not been reported in the literature. Furthermore, chronic obstructive ureteric calculus with superimposed infections as a cause of RPLS has not been reported in the literature.

PATIENT CONCERNS

A 57-year-old female was admitted at our facility because of 2 days history of hearing loss in both ears. She experienced tinnitus in both ears 2 weeks prior to the hearing loss. She is a known hypertensive. She has also undergone multiple surgical treatments for urinary calculi.

DIAGNOSIS

Computed tomography (CT) scan of the urinary system revealed a calculus at the right ureter. Magnetic resonance imaging (MRI) showed abnormal signals at both temporo-parieto-occipital (TPO) cortices, the subcortical area, as well as the left hippocampus which was consistent with the diagnosis of RPLS.

INTERVENTIONS

While on antibiotics for treatment of infections, the patient went into hypertensive encephalopathy and pneumonia was also established necessitating intensive care.

OUTCOMES

We observed a resolution of the patient's temperature and hypertension when the right ureteric stone finally descended into the bladder. Also, we observed disappearance of the abnormal signals at both TPO cortices, the subcortical area, as well as the left hippocampus. Two years follow-up revealed no recurrence of her symptomatology.

LESIONS

Patients who present with hypertensive encephalopathy maybe more prone to developing RPLS. Renal insufficiency alone or hypertension alone may not be single predisposing entities to RPLS but rather multiple predisposing factors.

Radiation induced glioma in a sexagenarian: A case report

INTRODUCTION

Radiation induced gliomas often occurs after radiation therapy for other brain tumors. Medulloblastoma often occurs in children and its associated radiation-induced glioblastoma multiforme's (GBM) after radiotherapy often has a long latency period. Our case is very unique because the medulloblastoma was detected at an advance age and the latency period of radiation-induced GBM was relatively shorter.

PATIENTS CONCERNS

A 64-year-old male was first admitted at our hospital in March 2018 with dizziness, vomiting, and blurred vision.

DIAGNOSIS

Magnetic resonance imaging of brain revealed a lesion with local mixed density and mass enhancement in left cerebellar region. Histopathology established medulloblastoma (World Health Organization) grade 4 and a classic histological subtype after surgery.

INTERVENTION

Surgical resection followed by radiation therapy were the initial therapeutic modalities.

OUTCOMES

In April 2019, the patient was readmitted with dizziness and blurred vision. Magnetic resonance imaging showed the left cerebellar hemisphere bulky enhancement lesion. Again, a multimodal therapy comprising surgical resection, radiation therapy as well as chemotherapy was adapted after histopathology established GBM.

LESION

Radiotherapy for medulloblastoma patients at advance ages is a critical predisposing factor for the development of radiation-induced GBM in a very short period of time. We suggest that, radiotherapy as adjuvant therapy for medulloblastoma patients at advance ages should be chosen with extreme caution.

Contrast-enhanced encephalopathy and massive cerebral edema after endovascular coiling of cerebral aneurysm. A case report

Contrast-induced encephalopathy (CIEP) is a rare complication after endovascular therapy. The etiology of CIEP is still a matter of debate. We present a rare occurrence of CIEP in a known hypertensive and type 2 diabetic patient after endovascular coiling of cerebral aneurysm with oculomotor nerve palsy. A 68-year old female presented with seven days history of headache and left ptosis or blepharoptosis with mild mydriasis. The headaches were localized mainly at the left side of the nose, orbit, and upper forehead while the left ptosis was associated with blurred vision. Computed tomography angiography revealed an aneurysm in between the C4 segment of the left internal carotid artery (ICA) and the bifurcation of the left posterior communicating artery. Digital subtraction angiography further confirmed the aneurysm. We used the transarterial approach to assess the aneurysm and subsequent coiling. Iohexol (Omnipaque) contrast agent was used during the endovascular procedure. The patient’s condition deteriorated into acute confusion state with cardinal symptomology of CIEP immediately after the operation. Computed tomography scan revealed cortical contrast enhancement in the vascular territory of the ICA as well as edema. Her symptomatology resolved 48 hours after treated with anticonvulsants, intracranial pressure reduction and hydration. Chronic hypertension as well as type 2 diabetics may be critical predisposing factors to CIEP. CIEP should be suspected in patients presenting with acute confusion state after endovascular therapy. Massive edema with ischemic brain changes in white matter of the brain before endovascular procedure should rise suspicion of CIEP.

Institutional experience of in-stent stenosis after pipeline flow diverter implantation: A retrospective analysis of 6 isolated cases out of 118 patients

Pipeline embolization devices (PLEDs) are flow diverting stents that have exhibited be safe and efficient in the treatment of complex aneurysms. Nevertheless, in-stent stenosis (ISS) has been reported as one of the cardinal complications associated with PLED. The association of wall malapposition and ISS in patient treated with PLED has not been reported.A retrospective study was conducted to identify patients with ISS after implantation of PLED as treatment for intracranial aneurysms from April 25, 2018 to April 24, 2019. Incidence of ISS and its associated causes such as sharp change of the PLED, distal wall malapposition, inconsistent compliance between parent artery as well as the PLED occlusion due to intimal hyperplasia and vessel tortuosity. Assessment of conservative treatment and retreatment outcomes of ISS were documented.In all, 6 ISS cases were identified by 2 independent neurointerventionalists out of 118 aneurysm patients treated with PLED. Thus, the incidence rate of ISS in patients treated with PLED was as low as 5% at our institution compared to other studies. The follow-up time for detection of ISS ranged from 6 to 12 months after implantation. Several combinations of reasons such as sharp change of the PLED, distal wall malapposition, inconsistent compliance between parent arteries as well as PLED occlusion due to intimal hyperplasia and vessel tortuosity accounted for the causes of ISS during our analysis. Conservative treatment with a combination of antiplatelet during follow-ups did not resolve the ISS in our study probably due to associated underlying factors above.

Elucidating the Pivotal Role of Immune Players in the Management of COVID-19: Focus on Mesenchymal Stem Cells and Inflammation

The world is currently engulfed with a viral disease with no cure. Thus, far, millions of people are infected with the virus across the length and breadth of the world, with thousands losing their lives each passing day. The WHO in February 2020 classified the virus as a coronavirus and the name Coronavirus-19 (CoV-19) was offered to the virus. The disease caused by the virus was termed coronavirus disease-19 (COVID-19). The pathogenesis of COVID-19 is associated with elevation of several immune players as well as inflammatory factors which contribute to cytokine storms. Currently, the detection of CoV-19 RNA is through reverse transcriptase-polymerase chain reaction (RTPCR). Mesenchymal stem cells (MSCs) are capable of suppressing several kinds of cytokines via the paracrine secretion system. Therefore, MSCs therapy could be game changer in the treatment of the current COVID-19 pandemic. Moreover, intravenous IG may be capable of suppressing the high expression of IL-6 by the CoV-19 resulting in lessen disease burden. Anti-inflammatory medications like, corticosteroids, tocilizumab, glycyrrhetinic acid, as well as etoposide may be very advantageous in decreasing the COVID-19 burden because their mode of action targets the cytokine storms initiated by the CoV-19. It is important to indicate that, these medications do not target the virus itself. Therefore, potent CoV-19 anti-viral medications are needed to completely cure patients with COVID-19. Furthermore, a vaccine is urgently needed to stop the spread of the virus. This review, therefore, elucidates the immune players in the management of COVID-19; focusing principally on MSCs and inflammatory mediators.

The occurrence of aflatoxins and human health risk estimations in randomly obtained maize from some markets in Ghana

Maize and its products are most often prone to fungal contamination especially during cultivation and storage by toxigenic fungi. Aflatoxicosis still persist in Ghana despite the numerous education on several ways of its prevention at the farm as well as its adverse health implications which are food safety concerns. A random assessment and human risk analysis was conducted on 90 maize (72 white and 18 colored) samples from markets across all the regions of Ghana. Total aflatoxins (AFtotal) and the constitutive aflatoxins (AFB₁, AFB₂, AFG₁, and AFG₂) were analyzed by High-Performance Liquid Chromatography (HPLC). Out of a total of ninety (90) samples investigated, 72 (80%) tested positive for AFB₁ and the contamination levels ranged from 0.78 ± 0.04 to 339.3 ± 8.6 µg kg⁻¹. Similarly, AFG2 was detected in only 14 (15.5%) samples, and their values ranged between 1.09 ± 0.03 and 5.51 ± 0.26 µg kg⁻¹ while AF total ranged between 0.78 ± 0.04 and 445.01 ± 8.9 µg kg⁻¹ constituting approximately 72 (80%). Limits of AFB₁ and total aflatoxins (AFtotal) for the Ghana Standards Authority (GSA) (5 and 10 µg kg⁻¹) and the European Food Safety Authority (EFSA) (2 and 4 µg kg⁻¹), were used as checks. A total of 33 (41.25%) samples were above the limits for both. Risk assessments recorded for Estimated Daily Intake (EDI), Hazard Quotient (H.Q), Hazard Index (H.I), Margin of Exposure (MOE), av. Potency, and population risks ranged 0.087–0.38 μg kg⁻¹ bw day⁻¹, 1.5–6.9, 0.0087–0.38, 3.64–12.09, 0–0.0396 ng Aflatoxins kg⁻¹ bw day⁻¹ and, 3.5 × 10^–1–0.015 respectively for total aflatoxins. While ranges for aflatoxins B1 (AFB1) recorded were 0.068–0.3 μg Kg bw⁻¹ day⁻¹, 2.43–10.64, 0.0068–0.030, 4.73–20.51, 0–0.0396 ng Aflatoxins kg⁻¹ bw day⁻¹ and, 2.69 × 10^–3–0.012 for Estimated Daily Intake (EDI), Hazard Quotient (H.Q), Hazard Index (H.I), Margin of Exposure (MOE), Av. potency, and population risks respectively. It was deduced that although there was some observed contamination of maize across the different ecological zones, the consumption of maize (white and colored) posed no adverse health effects on the population of Ghana since computed H.I was less than 1 (< 1).

Foramen magnum meningioma with excessive calcification and no dura tail sign: A case report

RATIONALE

Foramen magnum meningiomas are very rare lesions. They frequently originate from the arachnoid cells at the dura matter of the craniocervical junction. Foramen magnum meningiomas are challenging for neurosurgeons because of the complex anatomy of foramen magnum. We present a rare case of FMM with excessive calcification and without the dura tail sign which made the lesion mimic a teratoma.

PATIENTS CONCERNS

A 63 years old woman presented with progressive numbness and hyperesthesia of the shoulders and upper limbs for 2 and half years. She also experienced occasional headaches and dizziness with no nausea, vomiting or fever.

DIAGNOSES

Computed tomography scan, and magnetic resonance imaging revealed a calcified mass at occipital cistern. The lesion did not show the usual "dura tail sign" which made it mimic a teratoma on magnetic resonance imaging. Histopathology established meningioma.

INTERVENTION

The tumor was completely resected via suboccipital approach.

OUTCOMES

Two years follow-up revealed no recurrence of the lesion and no neurological deficits.

LESSONS

We advocate the use of electromyographic and auditory brainstem responses to monitor the inferior cranial nerves because the tumor often adheres to these nerves.

Aflatoxins in randomly selected groundnuts (Arachis hypogaea) and its products from some local markets across Ghana: Human risk assessment and monitoring

A random assessment and human risk analysis were conducted on 80 groundnut pastes and raw groundnuts from some local markets across the different agroecological zones of Ghana. Total aflatoxins (AFtotal) and aflatoxins (AFB₁, AFB₂, AFG₁, and AFG₂) were analyzed using the High-Performance Liquid Chromatography (HPLC) method. Out of 80 samples investigated, 49 (61.25 %) tested positive for AFB₁ and ranged from 0.38 ± 0.04-230.21 ± 22.14 μg/kg. The same proportion was recorded for total aflatoxins (AF_total) and ranged between 0.38 ± 0.02-270.51 ± 23.14 μg/kg. Limits of AFB₁ and total aflatoxins (AFtotal) for the Ghana Standards Authority (GSA) (5 and 10 μg/kg) and the European Food Safety Authority (EFSA) (2 and 4 μg/kg), were used as checks. A total of 33 (41.25 %) samples were above the limits for both. Risk assessments recorded for Estimated Daily Intake (EDI), Margin of Exposure (MOE), potency, cancer risk, and population risks ranged 0.087-0.380 μg/Kg.bw/day, 1052.630-4597.700, 0-0.00396 ng Aflatoxins kg^-1bwday^-1 and, 1.5 × 10^-3 - 7.9 × 10^-4 respectively for total aflatoxins. While for aflatoxins B₁ (AFB₁), ranges of values of 0.068-0.300 μg/Kg.bw/day, 1333.33-5882.35, 0-0.00396 ng aflatoxins kg/bw/day and, 1.19 × 10^-3 - 6.34 × 10^-4 corresponded for Estimated Daily Intake (EDI), Margin of Exposure (MOE), potency, cancer risk, and population risk respectively. There were risks of adverse health effects involved in the consumption of groundnuts for all age groups investigated since MOE values were all below 10,000.

Awake endovascular coiling of a dissected intracranial aneurysm in a third-trimester twin pregnancy: A case report

RATIONALE

Subarachnoid hemorrhages (SAHs) from ruptured intracranial aneurysms are very rare during pregnancy. Management of ruptured intracranial aneurysms with SAH in pregnancy is often challenging because of the risks to the fetus and the mother. We present the first successful awake endovascular coiling of a dissected intracranial aneurysm in a third trimester twin pregnancy.

PATIENT CONCERNS

A 28 years' old pregnant woman was admitted at the obstetric department of our hospital on account of very severe headaches associated with nausea and vomiting.

DIAGNOSIS

Emergency obstetric ultrasound scan done confirmed 32 weeks' twin gestation, whereas magnetic resonance imaging established hemorrhage in the suprasellar cistern and the subarachnoid space. Magnetic resonance angiography revealed a dissected aneurysm in the ophthalmic segment of the left internal carotid artery.

INTERVENTIONS

Awake cerebral angiography as well as embolization of the aneurysm with coils was done via the transarterial route and the twins were delivered via caesarean section at 37 weeks' gestation.

OUTCOMES

Two years' follow-up indicated no complications and children as well as their mother are healthy.

LESIONS

Awake endovascular coiling was very beneficial in our case because we avoided general anesthesia and the use of osmotic diuretics which are potentially hazardous during pregnancy.

Exploring the Pivotal Immunomodulatory and Anti-Inflammatory Potentials of Glycyrrhizic and Glycyrrhetinic Acids

Licorice extract is a Chinese herbal medication most often used as a demulcent or elixir. The extract usually consists of many components but the key ingredients are glycyrrhizic (GL) and glycyrrhetinic acid (GA). GL and GA function as potent antioxidants, anti-inflammatory, antiviral, antitumor agents, and immuneregulators. GL and GA have potent activities against hepatitis A, B, and C viruses, human immunodeficiency virus type 1, vesicular stomatitis virus, herpes simplex virus, influenza A, severe acute respiratory syndrome-related coronavirus, respiratory syncytial virus, vaccinia virus, and arboviruses. Also, GA was observed to be of therapeutic valve in human enterovirus 71, which was recognized as the utmost regular virus responsible for hand, foot, and mouth disease. The anti-inflammatory mechanism of GL and GA is realized via cytokines like interferon-γ, tumor necrotizing factor-α, interleukin- (IL-) 1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, and IL-17. They also modulate anti-inflammatory mechanisms like intercellular cell adhesion molecule 1 and P-selectin, enzymes like inducible nitric oxide synthase (iNOS), and transcription factors such as nuclear factor-kappa B, signal transducer and activator of transcription- (STAT-) 3, and STAT-6. Furthermore, DCs treated with GL were capable of influencing T-cell differentiation toward Th1 subset. Moreover, GA is capable of blocking prostaglandin-E2 synthesis via blockade of cyclooxygenase- (COX-) 2 resulting in concurrent augmentation nitric oxide production through the enhancement of iNOS2 mRNA secretion in Leishmania-infected macrophages. GA is capable of inhibiting toll-like receptors as well as high-mobility group box 1.

Elucidating the pivotal role of convalescent plasma therapy in critically ill COVID-19 patients: A review

World Health Organization (WHO) declared coronavirus disease (COVID-19) a pandemic in March 2020. Currently almost every country in the world has reported cases with moderate to high mortality rates. The European Union (EU), the United States of America (USA) and the United Kingdom (UK) are the severely affected countries. Nevertheless, the WHO is very much concern about countries with weak health systems. The clinical characteristics of COVID-19 varies extensively, ranging from asymptomatic infections to severe as well as critical pneumonia with high mortality rates in the elderly and patients with co-morbid medical illness. Convalescent Plasma Therapy (CPT) has been successfully used in treating various viral disease outbreaks such as 1918 influenza pneumonia pandemic, poliomyelitis, measles, mumps, Machupo virus, Junin virus, Lassa virus, Ebola etc. High-titer specific antibodies maybe capable of binding to Coronavirus- 19 (CoV-19) and neutralize the viral particles, inhibit entry to uninfected cells, and trigger potent effector mechanisms such as complement activation as well as phagocytosis. Therefore, in most countries with very weak health systems with no Intensive Care Units (ICUs) or trained ICU physicians, early initiation of CPT for severely COVID- 19 patients may be rewarding. Therefore, solidarity control trials on CPT for COVID- 19 patients involving large number of patients are urgently needed.

The Pivotal Potentials of Scorpion Buthus Martensii Karsch-Analgesic-Antitumor Peptide in Pain Management and Cancer

Scorpion Buthus martensii Karsch -analgesic-antitumor peptide (BmK AGAP) has been used to treat diseases like tetanus, tuberculosis, apoplexy, epilepsy, spasm, migraine headaches, rheumatic pain, and cancer in China. AGAP is a distinctive long-chain scorpion toxin with a molecular mass of 7142 Da and composed of 66 amino acids cross-linked by four disulfide bridges. Voltage-gated sodium channels (VGSCs) are present in excitable membranes and partakes in essential roles in action potentials generation as compared to the significant function of voltage-gated calcium channels (VGCCs). A total of nine genes (Nav1.1-Nav1.9) have been recognized to encode practical sodium channel isoforms. Nav1.3, Nav1.7, Nav1.8, and Nav1.9 have been recognized as potential targets for analgesics. Nav1.8 and Nav1.9 are associated with nociception initiated by inflammation signals in the neuronal pain pathway, while Nav1.8 is fundamental for neuropathic pain at low temperatures. AGAP has a sturdy inhibitory influence on both viscera and soma pain. AGAP potentiates the effects of MAPK inhibitors on neuropathic as well as inflammation-associated pain. AGAP downregulates the secretion of phosphorylated p38, phosphorylated JNK, and phosphorylated ERK 1/2 in vitro. AGAP has an analgesic activity which may be an effective therapeutic agent for pain management because of its downregulation of PTX3 via NF-κB and Wnt/beta-catenin signaling pathway. In cancers like colon cancer, breast cancer, lymphoma, and glioma, rAGAP was capable of blocking the proliferation. Thus, AGAP is a promising therapy for these tumors. Nevertheless, research is needed with other tumors.

Outcomes of patients undergoing craniotomy and decompressive craniectomy for severe traumatic brain injury with brain herniation: A retrospective study

The treatment of severe traumatic brain injury (TBI) with brain herniation is challenging because outcomes are often associated with high mortality and morbidity. Our aim was to identity factors contributing to decompressive craniectomy (DC) and evaluate treatment outcomes in patients with severe TBI with brain herniation.In this retrospective study, we analyzed medical records of severe TBI with brain herniation from May 2009 to December 2013. We reviewed their demographic data, mechanism of injury, Glasgow Coma Scale (GCS) score, pupil status, computed tomography findings, surgical treatment methods, time interval between brain herniation and surgery, as well as outcomes. GCS and pupil status are clinical parameters for detecting increase intracranial pressure while brain parenchyma bulged above the inner plate of the skull during operation indicated brain swelling as well as increased intracranial pressure on which basis the decision to perform DC or craniotomy was determined intraoperatively.One hundred ninety-four patients were included in the study. We performed DC in 143 of the patients while 51 of them we performed craniotomy. There were no statistically significant differences in the age, gender, or injury mechanism between the 2 groups. GCS, pupillary dilation, midline shift, hematoma type and timing of surgery were associated with DC. Nevertheless, logistic regression analysis revealed that hematoma type and timing of surgery were significantly associated with favorable DC outcomes (P < .001 and P = .023). Subdural hematoma and timing of surgery >1 hour were both identified as risk factors for DC. Six months after TBI, 34.0% of patients exhibited favorable outcomes. Overall mortality rate was 30.4%. Age, GCS, pupil dilation, hematoma type, and timing of surgery were all associated with patient outcomes. Further logistic regression analysis revealed that, lower GCS, bilateral pupil dilation, timing of surgery >1 hour, and advanced age were independent risk factors for poor outcomes (P = .001, P = .037, P = .028, and P = .001, respectively).Our study revealed that, DC is not mandatory for all TBI patients with brain herniation. Nevertheless, DC decreases mortality rate in severe TBI patients with brain herniation. Subdural hematoma and timing of surgery >1 hour are key indicators for DC. Lower GCS, bilateral pupil dilation, delayed timing of surgery and advance age are indicators of poor outcomes.

Low-profile visible intraluminal support stent-assisted embolization therapy for intracranial dissecting aneurysms: A retrospective analysis of six cases

Endovascular Embolization (EVE) of aneurysms is a very effective and efficient treatment modality. Nevertheless, a few complications have been reported after EVE of aneurysms. Our study therefore evaluated the safety and efficacy of Low-profile Visible Intraluminal Support (LVIS) stentassisted EVE for intracranial Dissecting Aneurysms (DAs). We conducted a retrospective study to identify patients with DAs who were treated with LVIS stent from July 2015 to September 2018. The DAs were categoried into ruptured and unruptured. The arteries harbouring the aneurysm were identified in all cases. LVIS device stent assisted coil EVE treatment modality was utilized to treat all the patients. Surgical safety, immediate surgery outcome, recurrence rate and imaging follow-up results of all patients were analysed. The Glasgow Outcome Scale (GOS) score of all patients where assessed during discharge. Cerebral angiography of all patients were reevaluated on scheduled visits from three months up to one year after their operations. A total of Six DA patients were identified during our analysis. Four of the cases were ruptured DAs while two cases were unruptured. The DAs originated from the Internal Carotid Artery (ICA) in two cases, while in the remaining four cases, the DAs originated from vertebral artery (VA). Stents and coils were successfully implanted in all six patients. The DAs were embolized satisfactorily and the parent arteries were patent immediately after the operations. We obsereved 5 points GOS score in four cases and 4 points in two cases. No aneurysmal recurrece, no stent collapse or displacement was obsereved in all cases during follow-ups. Our study suggests that, LVIS stent-assisted EVE is simple, safe and effective in the treatment of DAs.

Bilateral pediatric pial arteriovenous fistulas accompanying a giant arachnoid cyst with torticollis: A case report

RATIONALE

Pial arteriovenous fistula (PAVF) occurs when intracranial arteries communicate directly with veins. PAVFs are very rare congenital vascular lesions that are commonly seen in infants and children. Arachnoid cysts are congenital cavitation often filled with cerebrospinal fluid. We present a very rare associated occurrence of bilateral pediatric PAVF and a giant arachnoid cyst presenting as torticollis in a child. So far, this is the first case.

PATIENT CONCERNS

A 6-year-old male child was referred to our facility from a local hospital due to severe torticollis.

DIAGNOSES

An enhanced computed tomography scan revealed 2 slightly high-density masses at the anterior pontine cistern, right circumferential cistern, as well as left posterior occipital region. The same computed tomography scan revealed a giant arachnoid cyst in the left occipital as well as the temporal region with a thin cerebral cortex adjacent to the cyst.

INTERVENTIONS

Digital subtraction angiography confirmed that the 2 high-flow lesions were PAVFs. The patient was treated with a combination of detachable coils and Onyx Liquid Embolic System (Onyx HD-500) (Covidien/ev3 Neurovascular) via the transarterial endovascular route while the giant arachnoid cyst was managed conservatively.

OUTCOMES

The torticollis resolved 2 days after the procedure. He is currently well with no neurologic deficit.

LESSONS

We advocate that in cases of PAVF with accompanying cyst, the cyst should be managed conservatively if it is not associated with intracranial hemorrhage or focal neurologic deficit.

Elucidating the pathogenic and biomarker potentials of FOXG1 in glioblastoma

Glioblastoma (GB) is an extremely pugnacious brain cancer originating from neural stem (NS) cell-like cells. Forkhead box G1 (FOXG1; previously recognized as BF-1, qin, Chicken Brain Factor 1, or XBF-1 and renamed FOXG1 for mouse and human, and FoxG1 for other chordates) is an evolutionary preserved transcription factor driven from the forkhead box group of proteins FOXG1 modulates the speed of neurogenesis by maintaining progenitor cells in a proliferative mode as well as obstructing their differentiation into neurons during the initial periods of cortical formation. FOXG1 has been implicated in the formation of central nervous system (CNS) tumors and precisely GBs. Pathophysiologically, joint actions of FOXG1 and phosphatidylinositol- 3-kinases (PI3K) intermediate in intrinsic resistance of human GB cells to transforming growth factor-beta (TGF-β) stimulation of cyclin-dependent kinase inhibitor 1(p21Cip1) as well as growth inhibition. FOXG1 and NOTCH signaling pathways may functionally interrelate at different stages to facilitate gliomagenesis. Furthermore, FoxG1 actively contributed to the formation of transcription suppression complexes with corepressors of the Groucho/transducin-like Enhancer of split (Gro/TLEs). Also, FOXG1 was stimulated by Gro/TLE1 and abridged by Grg6. FOXG1 silencing in brain tumor-initiating cells (BTICs) also resulted in diminished secretion of markers characteristic undifferentiated natural neural stem/progenitor cells (NSPC) states, such as Oligodendrocyte transcription factor (OLIG2), (sex determining region Y)-box 2. (SOX2) and B lymphoma Mo-MLV insertion region 1 homolog (BMI1). This review therefore focuses on the pathogenic and biomarker potentials of FOXG1 in GB.

EPAC2: A new and promising protein for glioma pathogenesis and therapy

Gliomas are prime brain cancers which are initiated by malignant modification of neural stem cells, progenitor cells and differentiated glial cells such as astrocyte, oligodendrocyte as well as ependymal cells. Exchange proteins directly activated by cAMP (EPACs) are crucial cyclic adenosine 3’,5’-monophosphate (cAMP)-determined signaling pathways. Cyclic AMP-intermediated signaling events were utilized to transduce protein kinase A (PKA) leading to the detection of EPACs or cAMP-guanine exchange factors (cAMP-GEFs). EPACs have been detected as crucial proteins associated with the pathogenesis of neurological disorders as well as numerous human diseases. EPAC proteins have two isoforms. These isoforms are EPAC1 and EPAC2. EPAC2 also known as Rap guanine nucleotide exchange factor 4 (RAPGEF4) is generally expression in all neurites. Higher EAPC2 levels was detected in the cortex, hippocampus as well as striatum of adult mouse brain. Activation as well as over-secretion of EPAC2 triggers apoptosis in neurons and EPAC-triggered apoptosis was intermediated via the modulation of Bcl-2 interacting member protein (BIM). EPAC2 secretory levels has proven to be more in low-grade clinical glioma than high-grade clinical glioma. This review therefore explores the effects of EPAC2/RAPGEF4 on the pathogenesis of glioma instead of EPAC1 because EPAC2 and not EPAC1 is predominately expressed in the brain. Therefore, EPAC2 is most likely to modulate glioma pathogenesis rather than EPAC1.

Retraction Note to: Bio‑HMGB1 from breast cancer contributes to M‑MDSC differentiation from bone marrow progenitor cells and facilitates conversion of monocytes into MDSC‑like cells

The Editor-in-Chief has retracted this article.

Cystic-solid hemangioblastoma at the cerebellopontine angle: A case report

RATIONALE

Hemangioblastomas (HMGs) originating from the cerebellopontine angle (CPA) are extremely uncommon. Nevertheless, the cystic-solid form of this lesion at the above location is even rarer.

PATIENT CONCERNS

We present a 31-years old male with a right ear hearing loss of 3 months duration. He did not experience earache or discharge before the hearing loss. He; however, experienced visual acuity and dizziness. General physical examination did not yield much.

DIAGNOSES

Computed tomography and magnetic resonance imaging revealed a cystic-solid mass at right CPA. We initial misdiagnosed the lesion as an acoustic neuroma with cystic changes. Immunohistochemistry studies revealed HMG.

INTERVENTIONS

The lesion was total surgical resection via the retro-sigmoid approach.

OUTCOMES

The patient's symptomatology resolved after the surgery. Two years follow-up show no recurrence of the lesion and the patient is well.

LESIONS

Identification of feeding arteries and electro-coagulating them during the operation minimized intraoperative bleeding. The tumor should usually be dissected out whole and not piece meal fashion. Pre-operative CTA is very useful in outlining the vasculature of the tumor.

Elucidating the novel biomarker and therapeutic potentials of High-mobility group box 1 in Subarachnoid hemorrhage: A review

Subarachnoid hemorrhage (SAH) frequently arises after an aneurysm in a cerebral artery ruptures, resulting into bleeding as well as clot formation. High-mobility group box 1 (HMGB1) is an extremely preserved, universal protein secreted in the nuclei of all cell varieties. This review explores the biomarker as well as therapeutic potentials of HMBG1 in SAH especially during the occurrence of cerebral vasospasms. Plasma HMGB1 levels have proven to be very useful prognosticators of effective outcome as well as death after SAH. Correspondingly, higher HMGB1 levels in the cerebrospinal fluid (CSF) of SAH patients correlated well with poor outcome; signifying that, CSF level of HMGB1 is a novel predictor of outcome following SAH. Nonetheless, the degree of angiographic vasospasm does not always correlate with the degree of neurological deficits in SAH patients. HMGB1 stimulated cerebral vasospasm, augmented gene as well as protein secretory levels of receptor for advance glycation end product (RAGE) in neurons following SAH; which means that, silencing HMGB1 during SAH could be of therapeutic value. Compounds like resveratrol, glycyrrhizin, rhinacanthin, purpurogallin, 4′-O-β-D-Glucosyl-5-O-Methylvisamminol (4OGOMV) as well as receptor-interacting serine/threonine-protein kinase 3 (RIPK3) gene are capable of interacting with HMGB1 resulting in therapeutic benefits following SAH.

Delayed spontaneous rupture of cavernous segment of the internal carotid artery following dual ophthalmic segment aneurysms treatment with pipeline embolization device: A case report

RATIONALE

The incidence of double aneurysms on the ophthalmic segment of the internal carotid artery (ICA) is very rare. Nevertheless, delayed rupture of a parent artery instead of the aneurysmal sac following pipeline embolization device (PLED) is unusual.

PATIENT CONCERNS

We present a 72-year-old female who was admitted at our facility with gradual onset of nonspecific visual changes.

DIAGNOSIS

Conventional angiography revealed 2 aneurysms located at the ophthalmic segment of the left ICA.

INTERVENTIONS

Both aneurysms were successfully treated with PLED.

OUTCOMES

Two months after discharge, the patient was rushed into the emergency with bilateral conjunctival congestion. Computed tomography revealed intracranial hemorrhage at left temporal lobe while digital subtraction angiography established a left direct carotid cavernous fistula. We utilized stent (Solitaire 6*30) assisted coils to occlude the fistula. The patient is well and go about her normal duties.

LESSIONS

Manipulation of the tortuous parent artery resulted in a focal traumatic weakness in the artery and subsequently a delay tear. We are of the view that, endovascular surgeons should be on the lookout for this complication following flow deviation treatment modalities.

Reactive in-stent stenosis of a pipeline embolization device in a child: A case report

RATIONALE

Pipeline embolization device pipeline embolization device (PLED) is one of the most preferred flow-diverting devices used in treating giant and complex intercranial aneurysms. The occurrence of in-stent stenosis (ISS), which is a partially reversible complication, has been associated with PLED. Trauma around the neck of the aneurysm during our attempts to implant the PLED across the aneurysm resulted into inflammatory reactions, endotheliazation, granular tissue formation, and subsequent ISS.

PATIENT CONCERNS

We present an 11-year-old girl with dizziness of 6 days duration on account of which she was admitted at our institution. Physical as well as neurological examinations did not yield much.

DIAGNOSES

Cerebral angiography revealed a right cavernous segment giant aneurysm.

INTERVENTIONS

We initially implanted Pipeline embolization devices (PLEDs) (ev3, Irvine, California, USA) across the neck of the aneurysm which resulted into ISS 6 months after the operation.

OUTCOMES

We also attempted balloon angioplasty which failed during our second operation. She was finally treated with Neuroform stent (Stryker Neurovascular, USA) with no further complication and two years follow-up revealed no ISS.

LESSONS SUBSECTIONS AS PER STYLE

A combination of multiple kinds of flow diverting devices could reduce the incidence of ISS in selected patients with complex aneurysms. Minimal trauma caused by PLED at aneurysm site could also reduce incidence of ISS.

Concomitant occurrence of clinoid and cavernous segment aneurysms complicated with carotid cavernous fistula: A case report

RATIONALE

Dual aneurysms arising from the internal cerotic artery (ICA) is a very rare occurrence. Clinoid segment aneurysms (CSAs) are often seen at the carotid dural rings while cavernous carotid aneurysms (CCAs) are often a direct communication between the ICA and the cavernous sinus (CS). We present a case of complex concomitant occurrence of a CSA and a CCA complicated with delay aneurysmal rupture (DAR) resulting in carotid cavernous fistula (CCF) after our initial treatment of the patient with pipeline embolization devices (PLEDs) PATIENT CONCERNS:: We present a 64-year old female who we admitted at our institution due to one-year history of double vision. Neurological examinations were unremarkable.

DIAGNOSIS

Magnetic resonance imaging (MRI) and computer tomography (CT)-scan revealed dual aneurysms on the ICA. Digital subtracting angiogram (DSA) confirmed a small CSA and a large CCA on the right ICA.

INTERVENTIONS

We treated both aneurysms with PLED and subsequently observed DAR of CCA as a complication.

OUTCOMES

We successfully occluded the fistula with ONYX (ev3, Irvine, CA) via the trans-venous approach.

LESIONS

PLED was the best endovascular treatment option though DAR was inevitable. Although the trans-arterial approach may be the gold standard for the managing of CCF, the complex nature of our case made us opt for trans-venous approach. The trans-venous route is very appropriate for fistulas with complex parent arteries.