Contralateral Progression Research Articles

Is initial unilateral revascularization acceptable in pediatric patients with bilateral moyamoya disease with mild contralateral hemodynamic disturbance?

Although asymmetrical vascular involvement between hemispheres is common in pediatric patients with bilateral moyamoya disease, whether hemispheres with mild vascular changes and hemodynamic impairment require immediate surgical revascularization or whether they can be observed until disease progression remains unclear. The authors evaluated the long-term outcomes of their strategy to initially perform unilateral surgery and withhold surgery to the contralateral hemispheres with mild vascular changes and hemodynamic impairment. The authors retrospectively evaluated Japanese pediatric patients (onset age ≤ 15 years) diagnosed with bilateral sporadic moyamoya disease who underwent unilateral revascularization. The authors investigated whether the patient underwent additional collateral surgery and the incidence of ischemic events during follow-up. They also compared visual assessments of arterial spin labeling (ASL) images obtained before initial surgery, before additional contralateral surgery, and at last follow-up. Overall, 30/47 patients (63.8%) experienced progression of hemodynamic impairment in the contralateral hemisphere and underwent additional surgery. The age at initial surgery of the patients who needed additional contralateral surgery was significantly younger than that of the patients who did not require contralateral surgery (mean [SD] 7.0 [3.0] years vs 9.8 [2.6] years, p = 0.002). One patient (age 4 years) developed ischemic stroke before admission for preoperative evaluation 2 months after novel symptom onset, and another patient (age 6 years) experienced ischemic stroke in the contralateral hemisphere while discontinuing antiplatelet agents before surgery; both patients fully recovered from the neurological deficits. In contralateral hemispheres that required additional surgery, the ASL visual assessment scores significantly decreased before the additional contralateral surgery compared to those obtained before the initial surgery (p = 0.008). In pediatric patients with bilateral moyamoya disease, withholding surgery for hemispheres with mild vascular changes and hemodynamic impairment is generally safe. Younger patients were more likely to experience contralateral progression and require additional surgery, so close follow-up is needed. ASL imaging is useful for detecting and following the progression of hemodynamic impairment in conservatively treated hemispheres.

Clinical and genetic factors associated with contralateral progression in unilateral moyamoya disease: Longitudinal and Cross-Sectional Study

ObjectiveThis study aimed to explore the long-term outcome of unilateral moyamoya disease and predict the clinical and genetic factors associated with contralateral progression in unilateral moyamoya disease. MethodsWe retrospectively recruited unilateral moyamoya disease patients with available genetic data who underwent encephaloduroarteriosynangiosis (EDAS) surgery at our institution from January 2009 to November 2017. Long-term follow-up data, including clinical outcomes, angiographic features, and genetic information, were analyzed. ResultsA total of 83 unilateral moyamoya disease patients with available genetic data were enrolled in our study. The mean duration of clinical follow-up was 7.9 ± 2.0 years. Among all patients, 19 patients demonstrated contralateral progression to bilateral disease. Heterozygous Ring Finger Protein 213 p.R4810K mutations occurred significantly more frequently in unilateral moyamoya disease patients with contralateral progression. Furthermore, patients with contralateral progression typically demonstrated an earlier age of onset than those with non-progressing unilateral moyamoya disease. In the contralateral progression group, posterior circulation involvement was observed in 11 (11/19, 57.9%) patients compared to 12 (12/64, 18.8%) in the non-contralateral progression group (P = 0.001). The time to peak of cerebral perfusion and neurological status showed significant postoperative improvement. ConclusionLong-term follow-up revealed that the EDAS procedure might provide benefits for unilateral moyamoya disease patients. Ring Finger Protein 213 p.R4810K mutations, younger age, and posterior circulation involvement might predict the contralateral progression of unilateral moyamoya disease.

Surveillance duplex ultrasound prompted interventions after carotid endarterectomy

ObjectiveCurrent societal guidelines recommend duplex ultrasound (DUS) surveillance beyond 30 days after carotid endarterectomy (CEA) for patients with risk factors for restenosis or who underwent primary closure. However, the appropriate duration of this surveillance has not yet been identified, and the rate at which DUS surveillance prompts intervention is unknown. Multiple calls for decreasing health care spending that does not provide value, including unnecessary testing, have been made. The purpose of this study was to examine the rate of intervention prompted by surveillance DUS on the ipsilateral or contralateral carotid artery after CEA and determine the value of continued surveillance by determining the rate of DUS-prompted intervention. MethodsA single-center, retrospective chart review of all patients older than 18 years who had undergone CEA from August 2009 to July 2022 was performed. Patients with at least one postoperative duplex in our Intersocietal Accreditation Council-accredited ultrasound lab were included. Exclusion criteria were patients with incomplete medical charts or patients who underwent a concomitant procedure. The primary end point was return to the operating room for subsequent intervention based on abnormal surveillance DUS findings. Secondary end points were the number of postoperative surveillance duplexes, duration of surveillance, and incidence of perioperative stroke. The study participant data were queried for patients who had a diagnosis of stroke that occurred following their procedure. ResultsA total 767 patients, accounting for 771 procedures, were included in this study, which resulted in 2145 ultrasound scans. A total of 40 (5.2%) patients required 44 subsequent interventions that were prompted by DUS surveillance scans. The average number of ultrasound scans per patient was 2.8 (range: 0-14), and the average duration of surveillance was 26.4 months (range: 0-155 months). Of the 767 patients, 669 (87.2%) had a unilateral CEA. A total of 62 of 767 (8.1%) patients had planned endarterectomies on the contralateral side based on initial imaging, not prompted by interval DUS surveillance scans. Of 767 patients, 28 (3.7%) patients who underwent CEA had a subsequent procedure for progression of contralateral disease, which was prompted by duplex surveillance scans. The average duration between index CEA and intervention on contralateral carotid was 29.57 months (range: 3-81 months). A total of 11 patients, accounting for 12 procedures, underwent a subsequent procedure for restenosis of their ipsilateral carotid, prompted by duplex surveillance scans. The average duration between index CEA and reintervention on the ipsilateral carotid was 17.9 months (range: 4-70 months). Three of 767 (0.4%) patients in total were identified as having a perioperative stroke. ConclusionsThe overall rate of ipsilateral reintervention after CEA is low. A small percentage of patients will progress their contralateral disease, ultimately requiring surgical intervention. These data suggest that regular duplex surveillance after CEA is warranted for patients with at least moderate contralateral disease; however, the yield is low for ipsilateral restenosis after 36 months based on this single institution study. Further study is needed to better delineate which patients need follow-up to decrease unnecessary testing while still targeting patients most at risk of restenosis or contralateral progression of disease.

Progression of initially unilateral Moyamoya angiopathy in Caucasian Europeans.

Moyamoya angiopathy (MMA) is a rare cause of stroke in Caucasians, but it is much more frequent in East Asia. Since 2021, diagnostic criteria not only comprise bilateral, but also unilateral MMA. Hitherto, progression of unilateral MMA has predominantly been described in East Asians. Our study aimed to analyze the occurrence and characteristics of progression of initially unilateral MMA in Caucasian Europeans. By retrospective analysis of medical records of 200 European Caucasians with MMA, admitted to our German center between 2010 and 2022, cases of unilateral MMA and its progression, i.e. progressive ipsi- or novel contralateral arterial stenosis, during follow-up were identified. Kruskal Wallis Test and Fisher's Exact Test were used to identify statistically significant differences between progressive and stable patients concerning demographic, clinical, laboratory, and radiographic features. Our cohort comprised 63 patients with initially unilateral MMA. Fourteen (22.2%) had an ipsi- (n = 3, 21.4%) or contralateral (n = 11, 78.6%) progression. Mean age of patients with progressive MMA at symptom onset was 32 ± 14.1years. The ratio of women to men in this subgroup was 2.5:1. Mean follow-up period was 5.4 ± 3.7years, mean age at progression was 39.9 ± 12.7years. Mean time interval between penultimate follow-up and progression was 4.8 ± 4.5years. Patients with progression showed affection of the posterior cerebral artery (p = 0.009) and suffered from vertigo (p = 0.009) significantly more often. Unilateral MMA progresses in a substantial proportion in European Caucasians. Long-term follow-up is required due to potential late progression with consecutive symptoms and the need for bypass surgery.

Long Term Results of Elective Nodal Salvage Radiotherapy in Oligometastatic Prostate Cancer : A Mono-Institutional Series

Background The development of new metabolic diagnostic imaging PET is changing the history of metastatic prostate cancer (pCa), identifying situations of progression with a low disease burden; radiation treatment of metabolically active oligometastatic sites has been shown to be effective to prolong patient survival. In the scenario of oligometastatic disease to pelvic lymph nodes there is no uniform consensus on treatment volumes and radiotherapy doses to use. Methods We retrospectively assessed a series of 50 patients treated from 2015 to 2021 at our center who presented with recurrent pelvic lymph node pCa disease with 1-3 lymph-nodes lateralized to one side of the pelvis. Patients were treated with intensity modulated Rapid Arc radiotherapy (IMRT), limiting the treatment volume to the chain of the affected side only. During the follow-up, the patients who presented a biochemical recurrence of the disease were evaluated by PET. Results The biochemical progression-free survival and the metastatic progression-free survival were respectively 36% and 49% at 5 years. 22/50 patients presented a documented recurrence on PET. Only one patient presented a relapse within the irradiated volume and no patient presented a relapse on the contralateral pelvic lymph node chain. No patient had gastrointestinal toxicity > grade 1 RTOG. Conclusion Treatment of patients with oligorecurrent (1-3 lesions) pelvic pCa, limiting the volume of irradiation to only one side of the affected lymph node chain, results in good biochemical disease control and presents a low risk of neoplastic contralateral progression.

RNF213 R4810K Variant in Suspected Unilateral Moyamoya Disease Predicts Contralateral Progression.

BackgroundEarly‐stage unilateral moyamoya disease (MMD) is difficult to discriminate from isolated intracranial atherosclerotic stenosis, and identification of contralateral progression may aid in the diagnosis of MMD. The RNF213 (ring finger protein 213) R4810K variant is a strong genetic susceptibility factor for MMD; however, the role of contralateral progression in unilateral MMD is unknown.Methods and ResultsPatients who had undergone RNF213 R4810K genotyping with suspected unilateral MMD between January 2017 and August 2021 from 2 tertiary university hospitals were retrospectively reviewed. We compared the clinical features and radiographic outcomes of patients with and without this variant. The risk factors of contralateral progression in patients with suspected unilateral MMD were evaluated. The RNF213 R4810K variant was observed in 72 of 123 patients with suspected unilateral MMD, all of which were heterozygous. The allele frequency of the R4810K variant was significantly higher in the suspected unilateral MMD group compared with the historical control group (29.3% versus 1.2%; P<0.0001). Family history of MMD was significantly more common in patients with the variant than in those without (17% versus 4%; P=0.003). Eleven of 72 patients with the variant developed contralateral progression, whereas only 1 of 51 patients without the variant developed contralateral progression during a median follow‐up period of 28 months (log‐rank test; P=0.03). The presence of the RNF213 R4810K variant significantly correlated with contralateral progression (adjusted odds ratio, 6.39 [95% CI, 1.11–36.63]; P=0.04).ConclusionsContralateral progression is more likely to occur in patients with suspected unilateral MMD with the RNF213 R4810K variant than in those without the variant. However, because our study used a small sample size, this finding should be carefully interpreted and requires further studies with more patients and longer follow‐up periods.

Abstract 6216: Intratumoral B0112 in combination with radiotherapy synergizes to achieve CD8 T cell mediated local tumor control

Abstract Background: Radioimmunotherapy combines irradiation of tumor lesions with immunotherapy to achieve local and abscopal control of cancer. Most immunotherapy agents are given systemically, but strategies for delivering immunotherapy locally are under clinical scrutiny to maximize efficacy and avoid toxicity. Local immunotherapy by injecting various patterns of molecules shows efficacy both preclinical and clinically. BO112 is a viral mimetic based on nanoplexed double stranded RNA (poly IC) which exerts immune-mediated antitumor effects in mice and humans upon intratumoral delivery. BO112 and external beam irradiation were used to make the proof-of-concept local immunotherapy plus radiation therapy combinations. Methods: Murine transplantable tumor cells lines (TSA, MC38 and B16 ova) were used to show increased immunogenic features under irradiation as well as bilateral tumor models in which only one of the lesions could be irradiated. Flow cytometry on cell suspensions from tumor draining lymph nodes and multiplex tissue immunofluorescence were used to determine mechanims of antitumor immunity. Depletions of immune cell populations and knock out mice for IFNAAR and BAFT3 genes were used to delineate the immune system requirements for efficacy. Results: In cultures of TSA breast cancer cells the combination of irradiation and BO112 showed more prominent features of immunogenic tumor-cell death including type I interferon reléase. Injection of BO112 in the tumor lesions under radiation achieved excellent control of the treated tumors whilst modest delays in contralateral tumor progression were observed. Local effects were associated with more prominent presence of antitumor CTLs and cDC1 dendritic cells in the tumor and regional lymph nodes. Importantly, local irradiation plus BO112 in a tumor lesion enhanced the therapeutic effect of radiotherapy on distant uninjected tumor lesion. Conclusions: This study demonstrates that local BO112 immunotherapy and external beam radiation therapy can exert synergies to achieve local tumor control. This beneficial effect can be extended to non-injected lesions as long as they are also irradiated, suggesting strategies to treat oligometastatic patients with lesions susceptible to radiotherapy and at least one of them accessible for BO112 repeated intratumoral injections. Citation Format: Maria.E. Rodriguez-Ruiz, Irantzu serrano, Eneko Garate, Inmaculada Rodriguez, maite alvarez, Carmen Molina, Miguel Fernandez de Sanmamed, Leire Arbea, Marta Moreno, Marisol Quintero, Ignacio Melero. Intratumoral B0112 in combination with radiotherapy synergizes to achieve CD8 T cell mediated local tumor control [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6216.

Genetic and nongenetic factors for contralateral progression of unilateral moyamoya disease: the first report from the SUPRA Japan Study Group.

Although many studies have analyzed risk factors for contralateral progression in unilateral moyamoya disease, they have not been fully elucidated. The aim of this study was to examine whether genetic factors as well as nongenetic factors are involved in the contralateral progression. The authors performed a multicenter cohort study in which 93 cases with unilateral moyamoya disease were retrospectively reviewed. The demographic features, RNF213 R4810K mutation, lifestyle factors such as smoking and drinking, past medical history, and angiographic findings were analyzed. A Cox proportional hazards model was used to find risk factors for contralateral progression. Contralateral progression was observed in 24.7% of cases during a mean follow-up period of 72.2 months. Clinical characteristics were not significantly different between 67 patients with the R4810K mutation and those without it. Cox regression analysis showed that the R4810K mutation (hazard ratio [HR] 4.64, p = 0.044), childhood onset (HR 7.21, p < 0.001), male sex (HR 2.85, p = 0.023), and daily alcohol drinking (HR 4.25, p = 0.034) were independent risk factors for contralateral progression. These results indicate that both genetic and nongenetic factors are associated with contralateral progression of unilateral moyamoya disease. The findings would serve to help us better understand the pathophysiology of moyamoya disease and to manage patients more appropriately.

Erratum. Genetic and nongenetic factors for contralateral progression of unilateral moyamoya disease: the first report from the SUPRA Japan Study Group.

"Erratum. Genetic and nongenetic factors for contralateral progression of unilateral moyamoya disease: the first report from the SUPRA Japan Study Group" published on 29 Oct 2021 by American Association of Neurological Surgeons.

The contralateral progression in a cohort of Chinese adult patients with unilateral moyamoya disease after revascularization: a single-center long-term retrospective study

BackgroundMoyamoya disease (MMD) is a chronic progressive cerebrovascular disease mainly existing in the Asian population, which can be divided into unilateral and bilateral types. Contralateral progression has been reported in pediatric patients with unilateral MMD, while large series about contralateral progression in Chinese adult patients were rare. The goal of this study is to elucidate the clinical features and incidence of contralateral progression in Chinese MMD adult patients.MethodsOne hundred one Chinese adult patients with unilateral MMD who received surgery treatments between January 2015 and January 2017 in our hospital were enrolled in this study. This study contained 89 patients. Digital subtraction angiography was performed in all patients for initial diagnosis, and magnetic resonance angiography was repeated 6 months from the initial operation and then annually. Clinical characteristics, contralateral progression, and risk factors were studied. Previous related studies were also reviewed and meta-analyzed.ResultsOf these 89 patients, contralateral progression was identified in 8 patients (9.0%) within a median follow-up period of 63 months, which was lower than that in previous studies (25.9%). Single-factor analysis and multivariate analysis did not reveal significant risk factors related to the contralateral progression.ConclusionThe progress rate in this cohort of Chinese adult patients with unilateral MMD after revascularization was 9.0%, which indicates that some of the unilateral MMD were an early form of bilateral MMD rather than a separate condition.Trial registration.This work was approved by the Medical Ethics Committee of Zhongnan Hospital of Wuhan University (approval number: Kelun-2017005).

Clinical Course of Unilateral Moyamoya Disease.

The natural history of unilateral moyamoya disease (MMD) progressing to bilateral MMD remains an enigma in modern vascular neurosurgery. Few, small series with limited follow-up have reported relatively high rates of contralateral stenosis progression. To review our large series of unilateral MMD patients and evaluate radiographic and surgical progression rates, and identify any factors associated with progression. We included all unilateral MMD cases treated from 1991 to 2017 in an observational study. We examined time to contralateral radiographic progression and contralateral progression requiring surgery. Using Cox regression analysis, we evaluated factors potentially associated with contralateral progression. There were 217 patients treated for unilateral MMD. About 71% were female, and the average age at first surgery was 33.8 yr. Average follow-up was 5.8 yr (range 1-22 yr). A total of 18 patients (8.3%) developed contralateral progression. And 8 of these (3.7%) developed progression requiring bypass surgery. Baseline stenosis and hyperlipidemia (HLD) were significantly associated with radiographic progression (hazard ratio [HR] = 9.7, P=.006; HR=4.0, P=.024). Baseline stenosis was associated with surgical progression (HR=44.2, P=.002). Results were similar when controlling for possible confounders using multivariate regression. Previous series showed relatively high rates of progression in unilateral MMD (15%-30%), but these studies were small and long-term follow-up was rarely available. Our large series indicates that the rate of progression is lower than previously reported but still warrants yearly noninvasive screening. These data may provide indirect support for statin therapy in MMD.

Matching Selection of Donor-Recipient Vessels in Revascularization Surgery Effectively Reduce the Incidence of Postoperative Hyperperfusion Syndrome in Adult Moyamoya Disease: A Retrospective Comparison Study

Introduction: Cerebral hyperperfusion syndrome (CHS) is one of the most serious complications after revascularization surgery in patients with moyamoya disease (MMD). However, there are few effective measures to prevent the occurrence of CHS. Objective: The present study aims to examine the effect of the method about matching selection of donor-recipient vessels during revascularization surgery on the incidence of postoperative CHS in adult MMD patients. Methods: 216 Chinese adult patients with MMD received surgery treatment between January 2018 and December 2019 in our hospital were enrolled in this study. 191 out of 216 patients were included in this study. Matching selection method was defined as follows: (1) blood flow: the direction of blood flow and speed of the donor artery and potential receptor arteries were measured by flow 800 indocyanine green video angiography; (2) vascular diameter: the diameters of the donor artery and potential receptor arteries by a miniature ruler. Only the artery with antegrade flow and with smallest difference in flow speed and diameter with the donor artery will be selected as the receptor artery to perform anastomosis. Matching selection was performed from January 2019. Digital subtraction angiography was performed in all patients for initial MMD diagnosis. Perioperative cerebral perfusion and related clinical symptoms were monitored. Clinical characteristics, contralateral progression, and risk factors were reviewed. The incidence of CHS and the correlation of CHS with baseline characteristics or clinical conditions were analyzed. Results: Of these 191 patients, 82 patients received matching selection of donor-recipient vessels during revascularization surgery and 109 patients without. The postoperative CHS incidence in the matching group was 3.66%, which was much lower than that in the nonmatching group (15.60%). Multivariate analysis did not reveal a significant risk factor between the progression group and the nonprogression group. Correlation analysis revealed only the matching selection method was significantly associated with the reduced postoperative CHS incidence in MMD patients. Conclusions: The matching selection of donor-recipient vessels during revascularization surgery effectively reduces the incidence of postoperative CHS in adult patients with MMD.

Posterior sloping angle of the capital femoral physis in slipped capital femoral epiphysis has poor clinical utility and should not guide treatment on prophylactic fixation

Prophylactic pinning of the uninvolved side after unilateral slipped capital femoral epiphysis (SCFE) is controversial as it balances increased surgical risks against the possibility of protecting a normal hip from initial slip and deformity. A posterior sloping angle (PSA) of greater than 12-14.5° has been proposed by various authors as a treatment threshold to predict for contralateral hip progression and prophylactic pinning. A retrospective review of a 10-year series of patients with the diagnosis of SCFE and follow-up of 18 months was conducted. Patients were divided into two groups, those with Isolated Unilateral Slips and those who subsequently underwent Subsequent Contralateral Progression. PSA measurements were performed by two clinicians and assessed for inter-observer reliability. Data collected included age, sex, ethnicity, Loder class, endocrinopathy, renal impairment, radiation exposure, and PSA. There were no significant differences between the distribution of gender, site of slip, age of onset, Loder class, and presence of medical comorbidities between the Isolated Unilateral Slip and Subsequent Contralateral Progression groups (p > 0.05). The mean PSA value was not significantly higher in the Subsequent Contralateral Progression group (17.9 ± 4.32 (10.5-23.5)) compared to the Isolated Unilateral Slip group (15.8 ± 5.31 (6-26)) (p = 0.32). The receiver operator coefficient-derived ideal treatment threshold of 16.5° gave a sensitivity of 0.71, specificity of 0.64, and number needed to treat of 3. PSA differences between the Subsequent Contralateral Progression and Isolated Unilateral Slip groups were not statistically significant in this series. All proposed treatment thresholds had poor specificity. Prophylactic pinning should not be based on isolated PSA values. III.

Impact of Endothelial Shear Stress on the Bilateral Progression of Unilateral Moyamoya Disease.

Background and Purpose- In unilateral moyamoya disease, altered endothelial shear stress on the intact-side terminal internal carotid artery might trigger the progression to bilateral disease. We analyzed the endothelial shear stress parameters of the normally appearing terminal internal carotid artery in unilateral moyamoya disease and its association with the progression to bilateral disease. Methods- This retrospective cohort study included patients diagnosed with unilateral moyamoya disease by cerebral angiography and followed-up with regular magnetic resonance imaging/magnetic resonance angiography evaluations for >1 year. Endothelial shear stress parameters acquired were mean and maximum signal intensity gradients (SIG) and SIG SD at the vessel boundary in time-of-flight sequences in initial brain magnetic resonance imaging/magnetic resonance angiography. Contralateral disease progression defined as the detection of newly developed vessel steno-occlusion with an magnetic resonance angiography steno-occlusive stage of ≥2, in the previously intact side of the brain on follow-up magnetic resonance imaging/magnetic resonance angiography evaluation. Results- Among 146 patients (66 males [45.2%] and 80 females [54.8%]; 76 pediatric [52.1%]), contralateral disease progression was detected in 43 patients (29.5%) after a mean follow-up of 4.3±2.4 years. Multivariate analysis showed that SIG SD was significantly associated with this progression (odds ratio, 13.001 [95% CI, 1.764-95.794], P=0.012). In receiver operating characteristic curve analysis, SIG SD predicted the contralateral progression with area under the curve values of 0.803 (95% CI, 0.726-0.880, P<0.001). The regression model was reproduced in the external cohort of 31 patients. Conclusions- Increased spatial variability of the endothelial shear stress around the normally appearing terminal internal carotid artery, as measured by SIG SD in time-of-flight sequences, may predict the contralateral progression of unilateral moyamoya disease.

Alpha Angle as a Predictor of Impending Contralateral Slipped Capital Femoral Epiphysis in an Asian Population.

BackgroundProphylactic pinning of the uninvolved side after unilateral slipped capital femoral epiphysis (SCFE) is controversial. The alpha angle, a measurement of femoral head-neck aspherity, was proposed as a predictor of progression of contralateral SCFE with a treatment threshold of greater than 50.5°. The aim of this study was to evaluate its validity in our cohort of patients.MethodsA retrospective review of a 10-year series of patients who presented with unilateral SCFE was conducted. Minimum follow-up duration to identify contralateral progression was 18 months. Age, sex, ethnicity, and endocrinopathies were noted. Alpha angle measurements of the unaffected hip were performed by two independent observers. The average values of measurements were used for analysis. Univariate and multivariate logistic regression analyses were performed to identify predictors of contralateral progression. A receiver operating characteristic (ROC) curve was generated.ResultsThere were 43 patients with unilateral SCFE. Seven patients (16.3%) developed contralateral SCFE. There were 31 males (72.1%) and 12 females (27.9%). The mean duration from index surgery to contralateral fixation was 43.9 weeks (range, 16.2 to 77 weeks). The mean alpha angle was significantly higher in the patients with contralateral progression (mean, 50.7°; standard deviation [SD], 5.4°; range, 43.8° to 58.5°) than in the patients without progression (mean, 43.0°; SD, 4.2°; range, 33.0° to 52.5°; p < 0.001). The alpha angle was also identified as a statistically significant predictor of contralateral progression on multivariate analysis (p = 0.02). The intraclass correlation coefficient for interobserver reliability was moderately strong at 0.76 (95% confidence interval, 0.55 to 0.87). The area under the ROC curve was 0.88. The treatment threshold of 50.5° had a sensitivity of 0.43, specificity of 0.94, and number needed to treat (NNT) of 2.7. The ideal treatment threshold derived from the ROC curve was 49.0°, which had a sensitivity of 0.71, specificity of 0.89, and an NNT of 1.7.ConclusionsAlpha angle is a potential predictor of contralateral hip involvement in children with SCFE who may benefit from prophylactic hip fixation. Results from our series suggest a treatment threshold be 49.0°. However, given the limited sample size and moderately strong interobserver reliability, larger studies are needed to validate our findings.

Contralateral progression after unilateral evacuation of bilateral chronic subdural hematomas: the volume relation ratio as prognostic factor?

Unilateral evacuation of bilateral chronic subdural hematomas (bcSDHs) is associated with higher retreatment rates than an initial bilateral intervention. One reason for that is a possible progression in the size of the contralateral side after unilateral treatment. Thus, the authors focused their study on finding predictors of the need for contralateral retreatment. All patients who had undergone unilateral or bilateral evacuation of bcSDHs in the Department of Neurosurgery at the University Hospital of St. Poelten during a 5-year period (7/2012 to 6/2017) were retrospectively identified. The preoperative hematoma volume was calculated using the XYZ/2 method. Of a total of 103 patients with bcSDHs, 61 patients underwent bilateral evacuation and 42 patients underwent unilateral evacuation. The retreatment rate after bilateral evacuation was significantly lower than that after unilateral evacuation (14.8% vs 31%, respectively; p = 0.049). Contralateral retreatment after unilateral evacuation was necessary in 9 patients (21.4%). The preoperative contralateral hematoma volume was significantly higher in those patients who needed contralateral retreatment after initial unilateral evacuation (68.4 cm3 vs 27.4 cm3, respectively; p < 0.001). Furthermore, the so-called volume relation ratio created by dividing the smaller by the larger hematoma volume was significantly higher when contralateral retreatment became necessary (0.56 vs 0.21, respectively; p < 0.001). Patients needing evacuation of bcSDHs should be considered for primary bilateral evacuation if the hematoma volume on the smaller side is greater than 40 cm3 and the subsequent volume relation ratio is greater than 0.4.

Valacyclovir Maintenance Therapy for a Case of Unilateral Acute Retinal Necrosis during Chemotherapy

Acute retinal necrosis (ARN) is an infectious retinitis caused by varicella zoster virus (VZV), herpes simplex or cytomegalovirus. Without systemic therapy, ARN may progress bilaterally in seventy percent of unilateral patients. A 38-year-old-man was admitted to our hospital with Hodgkin's lymphoma and hemophagocytic lymphohistiocytosis. During the chemotherapy, left facial herpes zoster developed. He received valacyclovir for 14 days. After improvement of the blisters, he continued acyclovir as secondary prophylaxis. Three weeks after the facial zoster, sudden visual loss in the left eye occurred. ARN induced by VZV was diagnosed with ophthalmoscopy and the polymerase chain reaction test of the anterior chamber. Because continuous chemotherapy for Hodgkin's lymphoma was needed, he continued valacyclovir as secondary prophylaxis for 6 months and he accomplished the chemotherapy without contralateral progression. Our case suggested the utility of valacyclovir for secondary prophylaxis. Further experiments would be required to establish secondary prophylaxis in immunocompromised patients.

Clinical Features and Long-Term Outcomes of Unilateral Moyamoya Disease

To elucidate the clinical features, risk factors for contralateral progression, and long-term outcomes of patients with unilateral moyamoya disease (MMD). We retrospectively reviewed 109 patients with unilateral MMD treated at Beijing Tiantan Hospital. Clinical features, radiologic findings, and outcomes were analyzed. The mean age at diagnosis was 30.8 ± 14.2 years with a one-peak distribution in the thirties. The ratio of women to men was 1.1:1. Familial occurrence was 5.5%. The primary symptoms at initial presentation were transient ischemic attack (39.4%), infarction (22%), and hemorrhage (26.6%). The distribution of the initial Suzuki stage was as follows: stage 2, n= 33; stage 3, n= 35; stage 4, n= 27; stage 5, n= 11, and stage 6, n= 3. Contralateral abnormality on initial angiography occurred in 19 adult patients (17.4%). Posterior cerebral artery involvement was observed in 28 (25.7%) patients. During the average follow-up of 43.8 ± 21.3 months, contralateral progression was observed in 18 patients (16.5%). Contralateral abnormalities (P= 0.033) on initial angiography and infarction at initial presentation (P= 0.041) were significantly associated with contralateral progression in adults and children, respectively. Approximately 91.7% of patients had a modified Rankin Scale score of 0-2 during follow-up. A one-peak pattern in age distribution, lower grade of Suzuki stage, fewer familial cases, and posterior cerebral artery involvement were observed in patients with unilateral MMD. Contralateral abnormalities on initial angiography and infarction at onset were risk factors for contralateral progression in adult and pediatric patients, respectively. Good functional outcomes can be anticipated in the vast majority of surgically treated patients.

Renal Sarcoidosis Mimicking Xanthogranulomatous Pyelonephritis

A 70-year-old male patient underwent left-sided nephrectomy for signs and symptoms that were suggestive of xanthogranulomatous pyelonephritis (recurrent fever, swollen malfunctioning kidney, granulomatous inflammation in renal biopsy). Contralateral progression and workup for further symptoms finally established the diagnosis of extrapulmonary sarcoidosis. With corticosteroid and azathioprine treatment, renal function was preserved in the long term. Awareness of similarities in computed tomography imaging and histopathological findings of xanthogranulomatous pyelonephritis and renal sarcoidosis may prevent delayed diagnosis and inappropriate treatment of the latter.

Carotid artery disease progression and related neurologic events after carotid endarterectomy

During the last decade, there has been a dramatic improvement in best medical treatment for patients with vascular disease. Yet, there is a paucity of contemporary long-term data for restenosis and contralateral internal carotid artery (ICA) progression. This study assessed ipsilateral and contralateral disease progression and cerebrovascular events after carotid endarterectomy (CEA). A consecutive cohort of CEAs between January 1, 2000, and December 31, 2010, was retrospectively analyzed. End points were restenosis ≥50% and ≥70%, contralateral carotid disease progression (50%-69%, 70%-99%, or occlusion) and stroke. Survival analysis and Cox regression models were used to assess the effect of baseline predictors. During the 11-year study period, 1639 patients underwent 1782 CEAs (50.0% patch closure, 23.9% primary closure, 26.1% eversion, and 2.5% combined with coronary artery bypass grafting). The combined stroke/death rate was 2.6% overall and 1.8% in the asymptomatic cohort. The rate of restenosis ≥50% at 2, 5, and 10years was 8.5%, 15.6%, 27.2%, and the rate for restenosis ≥70% was 3.4%, 6.5%, 10.2%, respectively. Restenosis ≥50% was predicted by hypertension (hazard ratio [HR], 2.09; P= .027), female gender (HR, 1.43; P= .042), and younger age (≤65years; HR, 1.56; P= .016), but not by statins, surgical technique, symptoms, or other baseline risk factors. Restenoses remained asymptomatic in 125 of 148 (84.5%). Progression of contralateral ICA disease at 2, 5, and 10years was estimated at 5.4%, 15.5%, and 46.8%, respectively. Contralateral progression was only predicted by smoking (HR, 1.74; P=.008). The stroke rate in patients with disease progression of the contralateral ICA was not different compared with those without progression (7.0% vs 3.3%; P= .063). Any-stroke rates at 2, 5, and 10years were 4.6%, 7.3%, and 15.7%, respectively. Predictors were symptomatic lesion (HR, 1.48; P= .039), renal insufficiency, defined as a glomerular filtration rate (GFR) of 30 to 59 vs<30mL/min/1.73m2 (HR, 0.34; P= .009) or GFR ≥60 vs GFR<30mL/min/1.73m2 (HR, 0.55; P= .109), and statin use (HR, 0.59; P= .006). Restenosis or contralateral disease progression after CEA, to a level that might warrant consideration for treatment, is very low. The potentially associated stroke rates are also very low and not clearly related to disease progression. With the exception of the postoperative duplex, surveillance within short intervals of<1 or 2years cannot be justified.