Cerebral Midline Research Articles

Reversal of Middle Cerebral Artery Stenosis by Minimally Invasive Intracerebral Hematoma Evacuation

BACKGROUND AND IMPORTANCE: Acute intracerebral hematomas are known to induce significant mass effects within the brain, leading to critical complications such as cerebral midline shift, herniation, and increased intracranial pressure. The timing and efficacy of intracerebral hematoma evacuation remain subjects of ongoing debate in current literature. CLINICAL PRESENTATION: In our case report, we present a 74-year-old female patient diagnosed with basal ganglia hematoma. The resultant mass effect from the intracerebral hematoma led to middle cerebral artery (MCA) stenosis. Notably, early-stage minimally invasive hematoma evacuation was pivotal in facilitating successful revascularization of the MCA. CONCLUSION: Our case underscores the significance of prompt identification and management of MCA stenosis arising from intracerebral hematoma. Early intervention through minimally invasive hematoma evacuation proved instrumental in achieving successful MCA revascularization. These findings emphasize the critical role of timely interventions in mitigating potential complications associated with intracerebral hematoma.

NK1 tachykinin receptor antagonist treatment reduces cerebral edema and intracranial pressure in an ovine model of ischemic stroke

Following ischemic stroke, substance P (SP)-mediated neurogenic inflammation is associated with profound blood-brain barrier (BBB) dysfunction, cerebral edema, and elevated intracranial pressure (ICP). SP elicits its effects by binding the neurokinin 1 tachykinin receptor (NK1-R), with administration of an NK1-R antagonist shown to ameliorate BBB dysfunction and cerebral edema in rodent and permanent ovine stroke models. Given the importance of reperfusion in clinical stroke, this study examined the efficacy of NK1-R antagonist treatment in reducing cerebral edema and ICP in an ovine model of transient middle cerebral artery occlusion (tMCAo). Anesthetized sheep (n = 24) were subject to 2-hours tMCAo and randomized (n = 6/group) to receive early NK1-R treatment (days 1–3 post-stroke), delayed NK1-R treatment (day 5 post-stroke), or saline vehicle. At 6-days post-stroke animals were re-anaesthetized and ICP measured, followed by MRI to evaluate infarction, edema and BBB dysfunction. Following both early and delayed NK1-R antagonist administration, ICP was significantly reduced on day 6 compared to vehicle animals (p < 0.05), accompanied by a reduction in cerebral edema, midline shift and BBB dysfunction (p < 0.05). This study demonstrates that NK1-R antagonist treatment is an effective novel therapy for cerebral edema and elevated ICP following stroke in an ovine model, warranting future clinical evaluation.

Differences in vocal brain areas and astrocytes between the house wren and the rufous-tailed hummingbird.

The house wren shows complex song, and the rufous-tailed hummingbird has a simple song. The location of vocal brain areas supports the song's complexity; however, these still need to be studied. The astrocytic population in songbirds appears to be associated with change in vocal control nuclei; however, astrocytic distribution and morphology have not been described in these species. Consequently, we compared the distribution and volume of the vocal brain areas: HVC, RA, Area X, and LMAN, cell density, and the morphology of astrocytes in the house wren and the rufous-tailed hummingbird. Individuals of the two species were collected, and their brains were analyzed using serial Nissl- NeuN- and MAP2-stained tissue scanner imaging, followed by 3D reconstructions of the vocal areas; and GFAP and S100β astrocytes were analyzed in both species. We found that vocal areas were located close to the cerebral midline in the house wren and a more lateralized position in the rufous-tailed hummingbird. The LMAN occupied a larger volume in the rufous-tailed hummingbird, while the RA and HVC were larger in the house wren. While Area X showed higher cell density in the house wren than the rufous-tailed hummingbird, the LMAN showed a higher density in the rufous-tailed hummingbird. In the house wren, GFAP astrocytes in the same bregma where the vocal areas were located were observed at the laminar edge of the pallium (LEP) and in the vascular region, as well as in vocal motor relay regions in the pallidum and mesencephalon. In contrast, GFAP astrocytes were found in LEP, but not in the pallidum and mesencephalon in hummingbirds. Finally, when comparing GFAP astrocytes in the LEP region of both species, house wren astrocytes exhibited significantly more complex morphology than those of the rufous-tailed hummingbird. These findings suggest a difference in the location and cellular density of vocal circuits, as well as morphology of GFAP astrocytes between the house wren and the rufous-tailed hummingbird.

Neuroimaging Findings in Fetal Hemimegalencephaly: Case Study and Review.

Limited information exists in the prenatal literature regarding the neuroimaging features of fetal hemimegalencephaly. This report describes ultrasound and magnetic resonance imaging (MRI) findings in a second-trimester fetus with an isolated, severe form of hemimegalencephaly. The most prominent imaging findings included unilateral enlarged cerebral hemisphere and ipsilateral ventriculomegaly causing cerebral asymmetry, midline shift, and macrocephaly. Abnormal cortical development imaging signs were also evident. A literature review encompassing 23 reports describing 36 cases, including ours, is presented. Characteristic ultrasound findings for the diagnosis of hemimegalencephaly are not always apparent prenatally. Asymmetric ventriculomegaly emerges as the most common but nonspecific presenting feature during routine second- or third-trimester ultrasound scans. Subsequent high-resolution prenatal neurosonography and fetal MRI facilitate definitive prenatal diagnosis, showcasting associated features primarily related to cortical migration, differentiation, and maturation. Postnatally, the prognosis is poor due to intractable seizures, hemiplegia, and progressive neurodevelopmental delay.

The Development of Psychosis in Patients with Substance Use Disorder and Its Association with Cavum Septum Pellucidum and Adhesio Interthalamica.

It is known that there is a relationship between psychotic disorders and the presence of cerebral midline defects, such as the cavum septum pellucidum and the absence of adhesio interthalamica. This study aims to investigate whether these defects in people with alcohol/substance use disorders are associated with the occurrence and persistence of psychotic symptoms. The files of the patients who were hospitalized in an addiction inpatient unit were retrospectively scanned. The presence of cavum septum pellucidum and the absence of adhesio interthalamica were determined by evaluation of the magnetic resonance imaging findings. The presence of psychotic symptoms at admission and the persistence of psychotic symptoms after 2 weeks of detoxification treatment were used as dependent variables in different logistic regression models. The presence of cavum septum pellucidum and the absence of adhesio interthalamica were included in 2 separate models as independent variables. The results of the regression analyses showed no significant relationship with respect to cavum septum pellucidum. However, the analyses revealed that the absence of adhesio interthalamica increases the risk of the persistence of psychotic symptoms. Our findings suggest that the absence of adhesio interthalamica can be considered a structural risk factor for the development of psychosis in people receiving treatment for substance use.

Supraorbital vs pterional keyhole for anterior circulation aneurysms: A systematic review and meta-analysis

BackgroundThe supraorbital approach is a modification of the traditional pterional approach, and it offers the benefits of a shorter skin incision and a smaller craniotomy than the pterional approach. The purpose of this systemic review study was to compare the two surgical approaches for raptured and unruptured anterior cerebral circulation aneurysms. MethodsWe searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to August 2021, for published studies on the supraorbital vs pterional keyhole approach for anterior cerebral circulation aneurysms, and reviewers performed a brief qualitative descriptive analysis of both approaches. ResultsFourteen eligible studies were included in this systemic review. Results indicated that the supraorbital approach for anterior cerebral circulation aneurysms had fewer ischemic events compared to pterional approach. However, no significant difference between both groups in terms of complications such as intraoperative aneurysm rupture, brain hematoma, and postoperative infections for ruptured aneurysms. ConclusionThe meta-analysis suggests that the supraorbital method for clipping anterior cerebral circulation aneurysms might be a viable alternative to the traditional pterional method as the supraorbital group had decreased ischemic events compared to the pterional group, however, the associated difficulties in utilizing this approach among ruptured aneurysms with cerebral oedema and midline shifts further needs to be understood.

Cerebral Toxoplasmosis in an Immunocompetent Patient With Confirmed Covid-19 Positive

A case of a 30 years-old male patient, diagnosed with cerebral toxoplasmosis, confirmed HIV, with positive COVID-19. Once he came to the emergency department with a chief complaint of left upper and lower limbs weakness progressing for two days. The patient appeared malnourished and was afebrile and assessed to be well hydrated. He was alert but drowsy and had speech difficulty. A focused neurologic examination was performed and revealed a loss of nasolabial fold indicating facial nerve palsy. Neck stiffness was present and there was reduced motoric power in the left upper and lower limb of 2/5, with positive Babinski sign and Chaddock sign. According to brain CT, showed vasogenic cerebral edema and midline shift. Further laboratory exams showed positive IgG antibodies for Toxoplasma, with a titer exceeding 300 IU/ml, positive serum HIV, with CD4 cell count below 200cell/mm3. Complete blood count study highlighted low haemoglobin and elevated white cell count. He tested positive for COVID-19 by nasopharyngeal swab RT-PCR. Chest CT were done and revealed features of viral pneumonia with ground glass opacity appearance. In summary, we present a patient with cerebral involvement of toxoplasmosis possibly facilitated by pre-existing immunodeficiency as an opportunistic infections of HIV, and with COVID-19 complicated as acute infections. This case report reinforces a potential role for other comorbidities, rather than HIV infection as regards SARS-CoV-2 infection outcomes. For better assessment we need to do MRI.

Abstract Number ‐ 233: Vaccine‐Induced Thrombotic Thrombocytopenia presenting as Massive Stroke: Case Report and Literature Review

Introduction Vaccines have been pivotal for the COVID‐19 pandemic. Rare adverse effects of the vaccines such as thrombosis have been observed. Here we report a case of an acute malignant ischemic stroke in a young healthy patient caused by thrombosis due to Vaccine‐Induced Thrombotic Thrombocytopenia (VITT). Methods Electronic chart review for a case report. Results A 43‐year‐old Caucasian female with a medical history of hypertension was found unresponsive on the morning of presentation. Her Last known normal was the night before. On arrival in the emergency department, she was globally aphasic, with left eye deviation, right‐sided neglect, right facial droop, and right‐side hemiplegia. Pupils were equal and reactive to light. NIHSS was 23. Head CT showed large left middle cerebral artery and anterior cerebral artery strokes with significant cerebral edema and midline shift. Head and neck CTA showed left ICA and left MCA occlusions. She was taken for decompressive craniectomy immediately. Ten days prior to the stroke, she received her first COVID vaccination. She smoked but did not take oral contraceptives. She did not have a family history of hypercoagulability. Stroke workup showed LDL 141, A1C 4.8%, and a negative COVID test. She had normal white and red blood cell counts but low platelet counts at 73,000, which was 233,000 one month prior. 2D echocardiogram showed an ejection fraction of 54% and no patent foramen ovale or thrombus. Lower extremity doppler showed deep vein thrombosis. Because of arterial and venous thrombosis with new thrombocytopenia, hematology was consulted. She was found to have positive anti–PF4–heparin antibody, leading to a VITT diagnosis. She received IVIG, rituximab, and steroid treatments, and her platelets gradually returned to the baseline. She was later transferred to a rehabilitation facility. Conclusions VITT is characterized by thrombosis and thrombocytopenia with positive PF4 antibodies after a median of 14 days post‐vaccination. It was reported in COVID vaccines from all manufacturers. The mechanism remains unclear. The current hypothesis describes a two‐hit process through which the vaccine triggers neoantigen formation (the first hit) followed by a systemic inflammatory response (the second hit). Incidence of VITT from COVID vaccinations is unknown but the reported cases were rare. VITT‐caused acute stroke, especially malignant strokes, is even rarer.Although the COVID vaccines can cause rare life‐threatening adverse events, they are essential for controlling the pandemic. When encountering an ischemic stroke patient with thrombocytopenia, we should consider VITT. Further study with post‐vaccination registration and monitoring is warranted.

661: ROLE OF DECOMPRESSIVE HEMICRANIECTOMY IN PEDIATRIC MALIGNANT MIDDLE CEREBRAL ARTERY INFARCTION

Introduction: Malignant conversion of cerebral infarct leading to cerebral herniation is well described in adults. There is a lack of sufficient literature on malignant infarction in children. We report a rare case of middle cerebral artery infarct (MCAI) in a teenage girl with initial improvement (honeymoon period), followed by progression to malignant MCAI (MMCAI), requiring an urgent decompressive hemicraniectomy (DHC). Additionally, we report improvement at discharge and at 4-month follow-up. Description: A 14-year-old previously healthy female presented with loss of consciousness for 45 minutes followed by right side weakness. Her MRI of the brain showed acute infarct without hemorrhage involving the territory of the left MCA requiring PICU management. The initial diagnostic workup was suggestive of idiopathic MCAI. She had right-sided hemiplegia, and National Institute of Health Stroke Scale (NIHSS) score of 19. On hospital day 3, she showed improvement with NIHSS changing from 19 to 15. On the evening of hospital day 5, she developed progressively worsening headaches, emesis, and loss of consciousness. CT head demonstrated malignant cerebral edema, midline shift and uncal and sub-falcine herniation. She was intubated and taken emergently to the operating room for a left-sided DHC. She was then managed in the PICU with neuroprotective strategies, aggressive management of her elevated intracranial pressure, and goal-directed management of her cerebral perfusion pressure. She subsequently improved with successful extubation on hospital day 21 and discharge on hospital day 66. At a 4-month follow-up in the neurosurgery clinic, she was alert, interactive, verbal with slow speech, able to identify simple objects, lift right shoulder, and extend the right lower extremity. Discussion: Our case described above is a unique report of DHC in a pediatric patient who had rare MMCAI with a positive outcome. The additional feature of our case worth reporting was the initial honeymoon period before malignant conversion. This rare presentation highlights the importance of monitoring the neurological status in a patient with an MCAI for progression to life-threatening malignant MCAI. This case report also highlights the importance of consideration of DHC for a favorable outcome of MMCAI.

Extent of Tumor Resection and Survival in Pediatric Patients With High-Grade Gliomas

Pediatric patients with high-grade gliomas have a poor prognosis. The association among the extent of resection, tumor location, and survival in these patients remains unclear. To ascertain whether gross total resection (GTR) in hemispheric, midline, or infratentorial pediatric high-grade gliomas (pHGGs) is independently associated with survival differences compared with subtotal resection (STR) and biopsy at 1 year and 2 years after tumor resection. PubMed, EBMR, Embase, and MEDLINE were systematically reviewed from inception to June 3, 2022, using the keywords high-grade glioma, pediatric, and surgery. No period or language restrictions were applied. Randomized clinical trials and cohort studies of pHGGs that stratified patients by extent of resection and reported postoperative survival were included for study-level and individual patient data meta-analyses. Study characteristics and mortality rates were extracted from each article. Relative risk ratios (RRs) were pooled using random-effects models. Individual patient data were evaluated using multivariate mixed-effects Cox proportional hazards regression modeling. The PRISMA reporting guideline was followed, and the study was registered a priori. Hazard ratios (HRs) and RRs were extracted to indicate associations among extent of resection, 1-year and 2-year postoperative mortality, and overall survival. A total of 37 studies with 1387 unique patients with pHGGs were included. In study-level meta-analysis, GTR had a lower mortality risk than STR at 1 year (RR, 0.69; 95% CI, 0.56-0.83; P < .001) and 2 years (RR, 0.74; 95% CI, 0.67-0.83; P < .001) after tumor resection. Subtotal resection was not associated with differential survival compared with biopsy at 1 year (RR, 0.82; 95% CI, 0.66-1.01; P = .07) but had decreased mortality risk at 2 years (RR, 0.89; 95% CI, 0.82-0.97; P = .01). The individual patient data meta-analysis of 27 articles included 427 patients (mean [SD] age at diagnosis, 9.3 [5.9] years), most of whom were boys (169 of 317 [53.3%]), had grade IV tumors (246 of 427 [57.7%]), and/or had tumors that were localized to either the cerebral hemispheres (133 of 349 [38.1%]) or midline structures (132 of 349 [37.8%]). In the multivariate Cox proportional hazards regression model, STR (HR, 1.91; 95% CI, 1.34-2.74; P < .001) and biopsy (HR, 2.10; 95% CI, 1.43-3.07; P < .001) had shortened overall survival compared with GTR but no survival differences between them (HR, 0.91; 95% CI, 0.67-1.24; P = .56). Gross total resection was associated with prolonged survival compared with STR for hemispheric (HR, 0.29; 95% CI, 0.15-0.54; P < .001) and infratentorial (HR, 0.44; 95% CI, 0.24-0.83; P = .01) tumors but not midline tumors (HR, 0.63; 95% CI, 0.34-1.19; P = .16). Results of this study show that, among patients with pHGG, GTR is independently associated with better overall survival compared with STR and biopsy, especially among patients with hemispheric and infratentorial tumors, and support the pursuit of maximal safe resection in the treatment of pHGGs.

Troponin and non-traumatic subarachnoid haemorrhage

Introduction: Subarachnoid haemorrhage (SAH) is a devastating event, with a mortality of up to 50%. Acute cardiac dysfunction is common after such an event, and it is known to have a negative impact on the outcome of these patients. Cardiac troponin release occurs frequently after SAH and represents an early biomarker for neurogenic cardiac dysfunction.&#x0D; Objective: The present study aimed to evaluate the impact of a raised troponin value on the outcome of SAH patients.&#x0D; Methods: This is a prospective observational study held between 2014-2017 at the University Emergency Hospital, Bucharest. Data on clinical admission status, high-sensitivity troponin I, ECG and echocardiographic evaluation results, ICU length of stay and in-hospital mortality rate. Statistical analysis was performed using non-parametrical Mann-Whitney and chi-square tests. The results were considered significant at p&lt;0.05.&#x0D; Results: A total of 335 consecutive patients with non-traumatic SAH were admitted during the study period. 92 of them were excluded and 243 were analyzed, 203 with aneurysmal SAH and 40 with non-aneurysmal, non-traumatic SAH. High-sensitivity troponin I reached its peak level 48 to 72 hours after SAH and was higher in patients with aneurysmal SAH. For all SAH patients, its median and peak values on days 1 and 2 were correlated with the ICU length of stay and inversely correlated with in-hospital length of stay. For the first 3 days, the median and maximum troponin values are higher in patients who died compared with those who survived and were discharged home (p-value &lt; 0.001). Predictors of an elevated troponin on day 1 are loss of consciousness at ictus, a high Hunt and Hess and Fisher Scale grade, intraventricular haemorrhage and cerebral midline shift.&#x0D; Conclusions: The release of cardiac troponin is a valuable marker of neurogenic cardiac dysfunction in the first 3 days after SAH. The study replicates other data in the literature and highlights the association between SAH severity, early troponin elevation and in-hospital death.

OTHR-05. Visual impairment in children with a newly diagnosed brain tumor: a Dutch prospective nationwide cohort study

Abstract PURPOSE: Visual impairment is a serious adverse effect in children with a brain tumor. To date, visual impairment is often underestimated and unrecognized, while early detection of visual impairment is important to potentially preserve the visual function. Our aim was to assess the prevalence and type of abnormal ophthalmological findings in an unselected cohort of children with a newly diagnosed brain tumor and to identify potential oncological and clinical risk factors. PATIENTS AND METHODS: In this prospective nationwide cohort study, we included children, aged 0-18 years, with a newly diagnosed brain tumor in the Netherlands between May 2019 and August 2021. A comprehensive ophthalmological examination (including orthoptic evaluation, visual acuity, visual fields and funduscopy) was performed at diagnosis. Multivariable logistic regression analyses were performed to estimate the odds ratio (OR) and 95% confidence interval (CI) of the risk factors. RESULTS: In total, 170 children were included (43.5% female; median age [interquartile range], 8.3 [3.9 – 13.0] years; 48.2% infratentorial tumors, 31.2% midline tumors and 20.6% cerebral hemispheres tumors). Overall, 101 children (59.4%) presented with visual symptoms at diagnosis. The most common findings on ophthalmological examination were papilledema (52.4%), gaze deficits (33.5%), visual field defects (28.1%), nystagmus (24.8%), strabismus (19.9%) and decreased visual acuity (8.6%). The risk of papilledema was associated with older age in years (OR 1.2, 95% CI 1.1 – 1.3) and hydrocephalus (OR 14.8, 95% CI 5.4 – 40.0). Visual field defects were detected more frequently in children with a tumor located in the cerebral hemisphere (OR 4.5, 95% CI 1.3 – 15.3) or midline (OR 7.0, 95% CI 2.2 – 21.9). CONCLUSIONS: More than 50% of the children had abnormal ophthalmological findings at brain tumor diagnosis. These findings emphasize the necessity of standardized ophthalmological surveillance and the importance of awareness of health care providers of ophthalmological abnormalities in this patient group.

Диагностические возможности пренатальной эхографии в диагностике аномалий разви- тия срединных структур головного мозга во втором триместре беременности

Introduction. Тhe application of the volume ultrasound expands opportunities of prenatal diagnosis and increases the detection of brain abnormalities.Objective: to assess diagnostic capabilities of ultrasound in prenatal diagnosis of the cerebral midline structures abnormalities in the second trimester of pregnancy.Materials and methods. 39 women, who had fetuses with cerebral midline structures abnormalities, were included into the study.Results. Abnormal image or absence of the septum pellucidum are informative signs of the cerebral midline structures abnormalities. Agenesis of the corpus callosum always has indirect ultrasound signs.Conclusion. The volume ultrasound improves the multiplane fetal brain assessment, prenatal diagnosis of brain abnormalities.

Risk factors for poor outcomes of spontaneous supratentorial cerebral hemorrhage after surgery

ObjectiveThis study aimed to explore the factors affecting the outcomes of spontaneous supratentorial cerebral hemorrhage 90 days after surgery.MethodsA total of 256 patients with spontaneous supratentorial intracerebral hemorrhage underwent craniotomy evacuation of hematoma. The control group included 120 patients who received conservative treatment. The patients were divided into two subgroups based on a bifurcation of the modified Rankin Scale (mRS) 90 days after clinical therapeutics: good outcome (mRS score 0–3) and poor outcome (mRS score 4–6). The differences in clinical and imaging data between the two subgroups were analyzed. Based on difference analysis results, a binary logistic regression model was constructed to analyze the influencing factors related to poor outcomes.ResultsThe difference analysis results in the surgery group showed statistically significant differences in age, sex, Glasgow Coma Score (GCS) on admission, coronary atherosclerosis, smoking, stroke history, blood glucose, D-dimer, hematoma size, deep cerebral hemorrhage, midline shift, hematoma burst into the ventricle, vortex sign, island sign, and black hole sign. Binary logistic regression analysis showed that deep cerebral hemorrhage, midline shift, and age > 58 years independently correlated with the poor outcomes of patients after surgery. The binary logistic regression results of the control group showed that age > 58 years and GCS ≤ 8 independently correlated with the poor outcomes of patients.ConclusionsDeep cerebral hemorrhage, midline shift, and age > 58 years significantly increased the risk of adverse prognosis in patients after surgery. The findings might help select the clinical treatment plan and evaluate the postoperative prognosis of patients.

Decompressive craniectomy in traumatic brain injury: the intensivist's point of view.

To perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC. Observational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014-2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer-Lemeshow and a bootstrapping analysis with 1,000 re-samples respectively. 37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78-0.91) and Hosmer-Lemeshow p=0.71. The developed score detected well those patients who were going to need an early DC (first 24hours) after a TBI (2.5±0.5) but not those who would need it in a later stage of their disease (1.7±0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24hours vs do not require DC, 1.7±0.8 vs 1±0.7; p=0.002). We have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.

Atypical involvement of central nervous system in classic Hodgkin lymphoma: a case report

BackgroundHodgkin lymphoma is a systemic disease that commonly involves the cervical, supraclavicular, and mediastinal lymph nodes. The involvement of central nervous system in Hodgkin lymphoma is extremely rare, and diagnosis is usually established using distinct morphological and immunohistochemical staining on the tissue biopsied. Extranodal presentation of HL is a rare occurrence. It has been evident that prognosis is encouraging in patients with disease that is limited to just central nervous system initially or as relapse, compared with involvement of multiple sites of relapse.Case presentationWe herein report a case of a 35-year-old South-East Asian male with relapsed Hodgkin lymphoma. The patient developed a parotid gland lesion, cervical lymphadenopathy with significant weight loss, and intermittent night sweats. Along with spread to the central nervous system, there was a high suspicion of tuberculosis. Upon biopsy of his cervical lymph node, the patient was confirmed to have Hodgkin lymphoma. Immediate treatment began with six cycles of chemotherapy consisting of adriamycin, bleomycin, vinblastine, and dacarbazine. The patient received three cycles of chemotherapy consisting of ifosfamide, carboplatin, and etoposide but then was lost to follow-up. Five years later, the patient suffered a road traffic accident. Upon work-up, a right parietal space-occupying lesion with moderate cerebral edema and midline shift was found on computed tomography of the brain. The patient underwent resection of the space-occupying lesion of brain, with features consistent with classical Hodgkin lymphoma on histopathology examination. It is crucial for such lesions to be investigated meticulously to rule out any secondary disease process.ConclusionRelapsed Hodgkin lymphoma with central nervous system involvement is relatively rare with just over two dozen cases reported to date and is observed infrequently in developing nations. Therefore, space-occupying lesion should always be investigated, and biopsy of such lesions is gold standard to establish diagnosis. With timely appropriate therapy, complete remission can be achieved. However, large-scale studies would be prudent to explore the presentation, survival, and treatment options for patients with Hodgkin lymphoma involving the central nervous system.

Neuroradiological findings in Alagille syndrome.

Alagille syndrome (ALGS) is a multisystemic disease caused by mutations in genes of Notch pathway, which regulates embryonic cell differentiation and angiogenesis. Clinically, ALGS is characterized by cholestasis, cardiac defects, characteristic facial features, skeletal and ophthalmologic abnormalities. The aim of this review is to illustrate neuroradiological findings in ALGS, which are less well-known and prevalent, including cerebrovascular anomalies (such as aneurysms, dolichoectasia, Moyamoya syndrome and venous peculiarities), Chiari 1 malformation, craniosynostosis, intracranial hypertension, and vertebral anomalies (namely butterfly vertebra, hemivertebra, and craniocervical junction anomalies). Rarer cerebral midline malformations and temporal bone anomalies have also been described.

ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 2: performance of targeted neurosonography.

ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 2: performance of targeted neurosonography.

Decompressive craniectomy in traumatic brain injury: The intensivist's point of view

ObjetiveTo perform a score with early clinical and radiological findings after a TBI that identifies the patients who in their subsequent evolution are going to undergo DC. MethodObservational study of a retrospective cohort of patients who, after a TBI, enter the Neurocritical Section of the Intensive Care Unit of our hospital for a period of 5 years (2014–2018). Detection of clinical and radiological criteria and generation of all possible models with significant, clinically relevant and easy to detect early variables. Selection of the one with the lowest Bayesian Information Criterion and Akaike Information Criterion values for the creation of the score. Calibration and internal validation of the score using the Hosmer–Lemeshow and a bootstrapping analysis with 1000 re-samples respectively. Results37 DC were performed in 153 patients who were admitted after a TBI. The resulting final model included Cerebral Midline Deviation, GCS and Ventricular Collapse with an Area under ROC Curve: 0.84 (95% IC 0.78–0.91) and Hosmer–Lemeshow p=0.71. The developed score detected well those patients who were going to need an early DC (first 24h) after a TBI (2.5±0.5) but not those who would need it in a later stage of their disease (1.7±0.8). However, it seems to advice us about the patients who, although not requiring an early DC are likely to need it later in their evolution (DC after 24h vs. do not require DC, 1.7±0.8 vs. 1±0.7; p=0.002). ConclusionWe have developed a prognostic score using early clinical-radiological criteria that, in our environment, detects with good sensitivity and specificity those patients who, after a TBI, will require a DC.

The diagnostic value of intravenous contrast computed tomography in addition to plain computed tomography in dogs with head trauma

BackgroundThe aim of this study is to evaluate additional findings which can be detected by post-contrast computed tomography (CCT) in relation to plain CT (PCT) findings in patients presented with head trauma. Medical records of canine patients with the history of head trauma from three institutions were reviewed. PCT- and CCT-anonymized images were evaluated by a veterinary radiologist separately. From the categorized findings the following conclusions were drawn as: abnormalities were identified on (A) PCT but missed on CCT, (B) CCT but missed on PCT, (C) both PCT and CCT.ResultsThirty-two patients were included. The results showed that findings identified on CCT or PCT (category A and B) but missed on the other series were limited to mild soft tissue and sinus changes. Overall, 61 different fracture areas, 6 injuries of the temporomandibular joint (TMJ), 4 orbital injuries, 14 nasal cavities with soft tissue density filling, 13 areas of emphysema, 4 symphysis separations, 12 intracranial hemorrhages, 6 cerebral edema, 5 cerebral midline shifts, 3 intracranial aeroceles, 3 brain herniations and 6 intraparenchymal foreign bodies (defined as an abnormal structure located within the brain: e.g. bony fragments, bullet, teeth,..) were identified on both PCT and CCT separately (category C). Severity grading was different in 50% (3/6) of the reported cerebral edema using PCT and CCT images.ConclusionThe results showed that PCT is valuable to identify the presence of intracranial traumatic injuries and CCT is not always essential to evaluate vital traumatic changes.