Volume 04 · Issue 02 · 2018

To examine whether embolization of dural or pial blood supply branch is more efficient for symptom alleviation for unruptured mixed dural-pial arteriovenous malformations (DPAVMs).

We retrospectively reviewed 30 DPAVM patients from a database of 425 consecutive cerebral arteriovenous malformation (CAVM) patients who underwent endovascular embolization between January 2010 and December 2015 at our institution. Demographics, angioarchitectural characteristics, endovascular embolization details and patients clinical outcomes were recorded. The modified Rankin Scale (mRS), Engel's classification and Visual Analogue pain scale (VAS) were used to assess clinical outcomes.

The single center cohort data shows that the incidence of DPAVM is 7.1%. Among the 30 DPAVM patients, 9 (30.0%) are ruptured and 21 (70.0%) are unruptured. Four (19.0%) of the 21 unruptured DPAVM patients are failed to follow-up, leaving 17 to analysis the clinical outcomes. Clinical presentations of the 17 unruptured DPAVM patients are epilepsy (n = 10), headache (n = 5) and focal neurological dysfunction (n = 2). Six patients have DPAVMs occluded via pial blood supply branches, 4 via dural branches and 7 via both pial and dural branches. Unruptured DPAVM patients with nidus occluded via dural blood supply branches, or both pial and dural branches have higher symptom alleviation rate than patients with nidus occluded via pial branches (100%/85.7% vs 66.7%).

For DPAVM patients presented with epilepsy, headache and FND, embolization via dural blood supply branches may be more efficient for symptom alleviation. Large cohort study is needed to confirm the generalizability.

Inflammatory responses are implicated as crucial patho-mechanisms of vascular brain malformations. Inflammation is suggested to be a key contributor to aneurysm rupture; however it is unclear whether inflammation contributes similarly to bleeding of cerebral cavernous malformations (CCMs). Black blood MRI is a sequence which identifies inflammation in blood vessel walls and in the present study is used to detect inflammatory response in CCMs.

Fifteen patients with 17 CCMs treated in our department in 2017 were retrospectively analysed. All patients received black blood MRIs and the results were analysed in correlation with, size and bleeding of CCMs.

Size and bleeding status of CCMs did not correlate with contrast enhancement in the CCM wall. One of 3 patients with bleeding displayed contrast enhancement in black blood MRI, whereas the others had non enhancing lesions. Because of the small number of cases a statistical analysis was not performed.

In this limited cohort, inflammatory reactions in CCMs could not be detected by black blood MRI suggesting that the level of inflammation is minimal in these lesions and those different patho-mechanisms play a more important role in the rupture of CCMs.

The low-profile visualized intraluminal support (LVIS) stent has become a promising endovascular option for treating intracranial aneurysms. To achieve better treatment of aneurysms using LVIS, we developed a fast virtual stenting technique for use with LVIS (F-LVIS) to evaluate hemodynamic changes in the aneurysm and validate its reliability.

A patient-specific aneurysm was selected for making comparisons between the real LVIS (R-LVIS) and the F-LVIS. To perform R-LVIS stenting, a hollow phantom based on a patient-specific aneurysm was fabricated using a three-dimensional printer. An R-LVIS was released in the phantom according to standard procedure. F-LVIS was then applied successfully in this aneurysm model. The computational fluid dynamics (CFD) values were calculated for both the F-LVIS and R-LVIS models. Qualitative and quantitative comparisons of the two models focused on hemodynamic parameters.

The hemodynamic characteristics for R-LVIS and F-LVIS were well matched. Representative contours of velocities and wall shear stress (WSS) were consistently similar in both distribution and magnitude. The velocity vectors also showed high similarity, although the R-LVIS model showed faster and more fluid streams entering the aneurysm. Variation tendencies of the velocity in the aneurysm and the WSS on the aneurysm wall were also similar in the two models, with no statistically significant differences in either velocity or WSS.

The results of the computational hemodynamics indicate that F-LVIS is suitable for evaluating hemodynamic factors. This novel F-LVIS is considered efficient, practical, and effective.

Risk factors and treatments for brain metastasis (BM) in patients with adenocarcinoma have not been fully profiled in previous studies because of the enrolment of patients with tumours of mixed histology. Thus, we specifically addressed the issue in patients with adenocarcinoma.

Clinical data for 373 patients with pathologically confirmed adenocarcinoma were studied retrospectively. Factors including age (≤60 vs. > 60), gender (male vs. female), stage at diagnosis, T status (T1-2 vs. T3-4), N status (N0-1 vs. N2-3), epidermal growth factor receptor (EGFR) mutation status (wild-type vs. mutant) and smoking status (never vs. current) were analyzed.

In multivariate analysis, age (P= 0.006) and N status (P= 0.041) were independent risk factors for BM. In patients with BM, adding systemic therapy to local therapy improved median post-brain-metastasis survival (mPBMS) (P = 0.02). However, if stratification was conducted according to the recursive partitioning analysis (RPA) classification or graded prognostic assessment (GPA) scoring, only patients in RPA class II (P = 0.020) or with GPA score 1.5-2.5 (P = 0.032) could benefit from local plus systemic therapy. Those who received both pemetrexed and tyrosine kinase inhibitors (TKIs) as systemic therapies had a longer mPBMS than those who received TKIs alone, regardless of whether local therapy was applied. In patients with EGFR-sensitive mutations, TKIs therapy led to a longer mPBMS than conventional chemotherapy (P= 0.002).

Adenocarcinoma patients who were younger than 60 years of age and those with N2-3 disease have a significantly higher risk of BM. The addition of systemic therapy to local therapy can significantly prolong mPBMS, but the survival benefit confined in certain populations. Patients with opportunity to receive both pemetrexed and TKIs had the longest mPBMS.

Shunt infection (SI) is a dreaded and major complication in the management of hydrocephalus after cerebral fluid shunts. We reviewed retrospectively shunted for hydrocephalus during the last 2 years to evaluate the incidence of SI, including the risk factors and types of infection.

Patients who had undergone a shunt operation from January 2013 to December 2014 in our hospital were observed, study clinical data and a 6-24 months follow-up. Patients with infection complications were found and investigated.

Among 343 cases of shunt surgery performed in our hospital, 6-24 months follow-up was done. 13 patients (10 men and 3 women) were found shunt infections, 11 (3.7%) were post-operation of ventriculo-peritoneal shunt and 2 (4.2%) of lumbo-peritoneal shunt.92.3% cases of shunt infections were present within 2 months after shunt surgery, gram positive cocci accounted for 90% of the bacteria. After different surgery and antibiotic treatment, 8 patients became better and 5 worse.

The data in our single institution shows no significant differences between sex and shunt surgery. Infections more likely to present within the first 2 months after shunt placement, and gram-positive cocci account for a great proportion in detected bacteria.

There are controversies concerning the natural history of arteriovenous malformations (AVMs) in literature and it is not clear which AVMs should be treated and which should be just observed. Objective criteria beyond growth in serial MRIs or angiographies are needed. The use of black blood MRI is currently under investigation for evaluating the rupture risk of cerebral aneurysms, however its use for assessment of AVMs has yet to be evaluated. We therefore conducted a feasibility study on the application of black blood MRI (bbMRI) in AVMs to assess rupture risk.

Retrospective study of 10 patients with intracranial AVMs and 4 patients with arteriovenous fistulas who received a black blood MRI before treatment.

AVM niduses (9/10) show contrast enhancement irrespective of rupture or size. All arteriovenous fistulas (4/4) were contrast enhancing irrespective of rupture.

High flow malformations are in a permanent stage of inflammation which does not seem to allow conclusions on their rupture risk at the current stage. BbMRI is a feasible method of identifying inflammation in AVMs and arteriovenous fistulas. However, future prospective studies are needed to evaluate whether bbMRI contrast enhancement correlates with rupture risk.

The concept of a Hybrid Angio-Surgical Suite (HASS) has emerged as a solution to the complexity of cerebrovascular surgery and the need for immediate intraoperative feedback. When to use it, what cases are suitable for its use, who can use it and how to use it remain debatable.

Provide the information regarding the application of the HASS for hospital, neurosurgeon and interventionalist.

We review the literatures of case reports and studies on the use of the hybrid angio-sugical suite along with application of HASS in our own practice.

Indications for using HASS on different types of cerebral vascular disease, including cerebral aneurysm, AVM, DAVF, carotid and vertebral stenosis/occlusion, are addressed. The application of HASS for other non-cerebral vascular diseases, such as trauma, spine and skullbase cases, is reviewed and discussed.

HASS has made many surgical procedures safer and many difficult or previously untreatable conditions much more tractable and cost-effective. Other than used in cerebral vascular disease, HASS has much more applications, such as trauma, spine and other neurosurgical diseases.

Pituitary carcinoma is very rare and hard to diagnose. However, some atypical pituitary adenomas present with a high rate of proliferation and extensive invasion, suggesting a tumor with a high degree of malignancy.

Here, we present a case study of this type of tumor. A 46 years old women was admitted for headaches and impaired vision, and MRI and CT revealed a sellar lesion. She underwent a transsphenoidal surgery followed by radiotherapy, but the tumor recurred only one month later. She decided to undergo a second and third operation. The final pathology showed a non-functioning adenoma that was approximately 80% ki-67-positive and extensively p53-positive. No metastasis was found. The tumor progressed extremely quickly, and the patient died 7 months after the initial diagnosis.

A pituitary adenoma like this should be treated like a carcinoma, and early treatment may increase the likelihood of survival. A traditional diagnosis standard is unfit for this type of tumor.

The orbit is susceptible to traumatic injuries, and surgical management of transorbital penetrating injury with foreign body retention is challenging due to the associated risks of nervous and vascular injury. Application of multiple imaging modalities is helpful for the preoperative surgical planning, and technical advances in percutaneous endoscopy would render the surgical approach even less invasive.

We present a 60-year-old female patient with a transorbital penetrating injury (TPI) caused by a bamboo stick in her right eye. The bamboo stick was initially pulled out at the emergency room but, 1 month later, massive bleeding from her nose and mouth occurred. CT and CTA revealed a foreign body in the right orbito-cranial region and a traumatic aneurysm at the right internal carotid artery. Endovascular embolization was first delivered to treat the aneurysm, and the remains of the bamboo stick were completely removed with a percutaneous endoscope. The patient was discharged 1 week later.

A careful preoperative examination by multiple imaging modalities, e.g., CT, MRI, and DSA are essential for the correct diagnosis and surgical planning for the patient with a TPI. We minimised the associated risks of vascular and nervous injuries during foreign body removal by sequential application of the endovascular intervention and percutaneous endoscopic technique.

Primary central nervous system lymphoma(PCNSL) is a rare kind of non-Hodgkin lymphoma. Rituximab combined with high-dose methotrexate, cytarabine and dexamethasone (R-MAD regimen) were reported effective for PCNSL patients. Rituximab can cause several side effects, including fever, chills and rigors.

In this case report, we demonstrate rituximab-induced interstitial pneumonitis in a PCNSL patient who has been treated with R-MAD regimen. The patient recovered after treatment and she remains complete remission after following consolidation chemotherapy.

Here is no report of potential fatal complications of Rituximab like interstitial pneumonitis nowadays in PCNSL patients. As Rituximab is widely used, physicians should raise their awareness of this rare complication and detect RTX-ILD in early stage.

Intracranial hemorrhage is the most common emergency in the neurology department, and patients with a medical history of hemophilia have a risk of severe bleeding.

A 56-year-old man was admitted to the emergency department in our hospital. He was diagnosed with hemophilia A and subdural hematoma. We administered an infusion of factor VIII to decrease the risk of bleeding and improve the prognosis. Factor VIII infusion is the most important factor in treating hemophilia A patients.

We recommend carefully checking coagulation function and the medical history once these patients are admitted, especially in the emergency department.