Radiological Improvement Research Articles

Paradoxical deterioration during treatment of tuberculous meningitis responded to infliximab but not to steroids

Paradoxical deterioration in patients with tuberculous meningitis is a significant diagnostic and treatment challenge. We present the case of a 55-year-old previously healthy male, human immunodeficiency virus (HIV)-negative, presenting with headache, fever, agitation and slurred speech, who was ultimately diagnosed with tuberculous meningoencephalitis confirmed by cerebrospinal fluid polymerase chain reaction positive for Mycobacterium tuberculosis complex. After initiation of a standard antitubercular therapy combined with glucocorticoids, the patient experienced an initial neurological improvement. However, after 3 months of therapy, he had a major stroke with neurological deterioration, clinically and radiologically attributable to a paradoxical deterioration or an immune reconstruction syndrome as described in HIV-positive patients. Due to the persistence of inflammatory symptoms and radiological evidence of worsening tuberculomas despite ongoing antituberculosis therapy, off-label use of the tumour necrosis factor (TNF) inhibitor infliximab was initiated. The patient received three doses of infliximab at 5 mg/kg at monthly intervals, which led to marked clinical and radiological improvement. Follow-up magnetic resonance imaging showed regression of lesions, and the patient was eventually discharged with a significant recovery of motor and speech functions. This case underscores the potential of TNF inhibitors in managing severe cases of paradoxical deterioration in patients with tuberculous meningitis, challenging existing treatment paradigms and suggesting a need for further research into the pathophysiology and treatment of this condition.

Treatment and Early Outcomes of Capitellar Osteochondritis Dissecans.

Treatment for osteochondritis dissecans (OCD) of the humeral capitellum has been predominantly guided by fragment stability and articular cartilage integrity. Nonoperative management is recommended for stable lesions, whereas surgical intervention is indicated for unstable lesions and those that fail nonoperative care. Several surgical options may be considered, although limited information is available regarding indications for specific surgical techniques and comparative postoperative results. To assess surgical outcomes of patients with capitellar OCD treated according to a decision-making approach focused on subchondral bone involvement. Cohort study; Level of evidence, 3. Patients diagnosed with capitellar OCD at a tertiary academic center were enrolled in a prospective longitudinal cohort study. Patient information was collected at the time of enrollment, and OCD lesions were classified according to the Nelson grade. Clinical and radiologic data were collected both pre- and postoperatively for those undergoing surgical treatment. Surgical procedures were performed based on an evolving treatment framework that included considerations specifically for lesion containment and depth of subchondral bone disease. Timmerman scores were obtained to assess patient functional outcomes. A total of 154 patients were prospectively enrolled, 19 of whom had bilateral disease. The mean age at presentation was 13.7 years; 39% were gymnasts and 28.5% were primary baseball or softball athletes. Surgery was performed on 145 elbows, including 43 drilling/microfracture procedures, 21 internal fixations, and 63 autologous osteochondral grafting (OG) procedures. Clinically, there were significant improvements in pain, elbow motion, and mechanical symptoms. Timmerman scores significantly improved after each type of surgical procedure. A total of 76% of patients returned to their primary sport. When stratified by the Nelson grade, patients with OG had lower revision surgery rates than those treated with drilling/microfracture and fixation. Furthermore, for Nelson grade 2 lesions, patients treated with OG had significantly better postoperative elbow motion and higher Timmerman scores compared with those treated with other procedures. Using a treatment framework incorporating lesion containment and depth of subchondral bone disease, surgery for capitellar OCD provides clinical, radiologic, and functional improvements. Patients treated with OG may have lower revision rates and better functional outcomes compared with those treated with other surgical techniques, with OG warranting consideration even for lower-grade OCD lesions.

RADT-33. GAMMA KNIFE RADIOSURGERY FOR ORBITAL CAVERNOUS HEMANGIOMA: A SYSTEMATIC REVIEW AND SINGLE-ARM META-ANALYSIS

Abstract Gamma knife radiosurgery (GKRS) for orbital cavernous hemangioma (OCH) has emerged as a promising method due to its significant clinical improvement and low incidence of complications. This study aimed to evaluate the safety and efficacy of GKRS for the treatment of OCH. Following the PRISMA framework, we searched PubMed, Cochrane Central, and Embase for studies reporting outcomes of GKRS for OCH, including complications, visual improvement, proptosis, tumor reduction rate, and tumor progression rate. From 1856 search results, six studies with 100 patients were included. Only five minor complications related to GKRS were reported, including three with orbital pain and two with periorbital chemosis, resulting in a complication rate of 13% (95% CI: 7% - 25%). Visual acuity and visual field improvement rates after GKRS were 80% (95% CI: 63% - 96%) and 71% (95% CI: 47% - 95%), respectively. Proptosis improved in 94% of cases (95% CI: 83% - 100%). The tumor reduction rate was 77% after GKRS (95% CI: 69% - 85%). In conclusion, GKRS for OCH appears to be a safe technique, as evidenced by the rate of clinical improvement and radiological improvement. However, studies are limited by the absence of a control group, and additional studies are needed to evaluate the relative efficacy of GKRS compared with alternative surgical modalities for OCH.

Comparative analysis of 333 proGAV® and proGAV 2.0® adjustable valves in pediatric hydrocephalus treatment: survival and complication rate assessment

ObjectiveProGAV and ProGAV2.0 adjustable valves are extensively used for treating hydrocephalus in pediatric patients. This study aims to conduct a comprehensive comparison between these two valves concerning their survival and complication rates.MethodsThis retrospective study included all pediatric patients who underwent ProGAV or ProGAV2.0 valve implantation at our neurosurgical clinic from August 2008 to August 2020. A comparative analysis was performed considering age, gender, follow-up duration, complication and survival rates, adjustments, spontaneous adjustments, and adjustment difficulty rates. All valves were followed up for a maximum of 3 years.ResultsInclusion involved 333 cases (mean age of 5.4 ± 5.1 years; 54.1% males), comprising 173 cases (52.0%) with ProGAV valve implantation and 160 cases (48.0%) with ProGAV 2.0. Early complications within the first month post-implantation were observed in 51 cases (15.3%). No significant differences were noted in valve implantation indications, age distribution, or survival duration (27.1 vs. 27.8 months, p = 0.629) between the two groups. Predominant indications for implantation were post-hemorrhagic hydrocephalus and aqueduct stenosis for both valve types. Notably, both valves showed non-significantly different explantation rates during the first three years after implantation (34.7% vs. 29.7%, p < 0.289). However, there was a significantly higher early post-implantation complication rate (22% vs. 9.4%, p = 0.002), and a significantly increased association with difficulties in valve adjustments and spontaneous adjustments (p = 0.041 and 0.011, respectively). ProGAV2.0 cases displayed notably enhanced clinical and radiological improvement within the initial 6 months after implantation (p = 0.001 and p = 0.038). Younger children (< 2 years of age) also experienced significantly more valve adjustment difficulties (p = 0.049) and had higher rates of valve explantation (p < 0.001).ConclusionThe findings of this study highlight the superior performance of the ProGAV2.0 valve in terms of complication rate and maladjustment rate when employed in the treatment of pediatric hydrocephalus. Both valves demonstrated an acceptable survival rate with 65.3% for ProGAV and 71.3% for ProGAV2.0 within three years of implantation.

A conservative management approach for spinal tuberculosis causing cauda equine syndrome in pregnancy

Background: Spinal tuberculosis in pregnancy leading to neurological sequelae is rare and a challenging condition to manage. The usual approach is to perform urgent decompression surgery, but patients with a more stable course of the disease may benefit from a conservative approach with anti-tuberculosis (ATT) therapy.Case presentation: A pregnant mother in her second trimester presented with a history of chronic backache exacerbated by right-sided foot drop, L5 root sensory loss and intermittent urinary retention. MRI revealed L5 vertebral collapse with para-vertebral collection causing cauda equine compression at the L5-S1 level. High ESR, strongly positive tuberculin test, and the clinical and radiological findings were compatible with a diagnosis of spinal tuberculosis. Based on the multi-disciplinary team’s decision, a conservative management approach with ATT and supportive therapy was initiated with close observation. The patient showed a remarkable response to ATT with clinical and radiological improvement. She underwent an elective caesarean section at 37 weeks and delivered a healthy baby. On the fourth week postpartum, she underwent decompressive surgery with complete neurological recovery,Discussion and conclusion: Spinal TB in pregnancy causing neurological impairment is usually managed with urgent surgical interventions. This is one of the few reported cases where a conservative approach was undertaken, with close observation and a positive outcome.Therefore, it is important to carefully select patients needing surgical interventions and those who would benefit better from a conservative approach. High suspicion, early diagnosis, prompt treatment initiation and close monitoring are vital components in achieving the best outcome.

Tubercular dactylitis/Spina ventosa-A rare skeletal form of extrapulmonary tuberculosis.

A 9-year-old girl presented with progressive, painful swelling over the left index finger, associated with local signs of inflammation and restriction of finger movements. After the swelling was punctured using a needle, chronic discharging sinus formed. Examination revealed firm swelling over the right parotid area, bilateral cervical and left axillary lymphadenopathy, and firm swelling over the left index finger with a chronic discharging sinus over the lateral aspect of proximal phalanx. Mantoux intradermal injection was reactive (22x24 mm induration). Blood and pus cultures were sterile. Hand radiograph revealed dactylitis (Figure 1A-C). Fine aspiration and cytology of the cervical lymph node showed degenerated inflammatory cells, epithelioid granuloma and acid-fast bacilli. She was initiated on 4-drug antitubercular therapy (ATT). At 2-months follow-up, she was asymptomatic and had the pain and swelling over the left finger have reduced with significant radiological improvement. Tubercular dactylitis or 'spina ventosa' (wind-filled sail) refers to cystic expansion of short, tubular bones. It is commonly seen in younger children (between 1 and 6 years of age) and adults (between 20 and 50 years of age). A common presentation in endemic areas is presence of a painless, fusiform swelling over a single digit, most commonly the proximal phalanx of index or middle finger as in the index case, or over the metacarpals of middle and ring fingers. Earliest radiological clues include periosteitis followed by gradual destruction of bone and cyst formation in the cavity giving a ballooned-out appearance.

Surgical Strategy and Decision Making in Recurrent Atlanto-Axial Dislocations: The Role of Traction

ObjectiveTo analyse patients with recurrent atlantoaxial dislocation and give a criterion of an ideal patient who can benefit from redo surgery. MethodsThis retrospective study was conducted in a tertiary care centre, which included 20 patients who failed atlantoaxial surgery from January 2013 to June December 2021. They were evaluated using X-ray, CT, and MRI examinations, and their clinical data were accessed from the hospital's medical records department and the picture archiving and communication system. They were given a trial of traction to look for clinical and/or radiological improvement. Those showing clinical and/or radiological improvement underwent redo fixation. The operative steps involved removing joint capsules, denuding articular cartilage and joint preparation followed by reduction of basilar invagination by the combination of spacer and/or bone graft and putting screws in C1/Occiput and C2. A strut graft was placed between Occiput/ C1 and C2. ResultsThe mean change in mJOAS and Nurick grade following the first surgery was statistically significant (1.00 ± 0.73, p-value 0.002 and -0.15 ± 0.27, p-value 0.046, respectively). On similar paths, the mean change in mJOAS and Nurick grade following the second surgery was also statistically significant (4.25 ± 0.32, p-value <0.001 and -1.2 ± 0.11, p-value <0.001, respectively). Improper usage of constructs (31.57%), inadequate/no joint preparation (42.10%/57.90%) and poor choice of graft (100%) were the leading causes of failure of index surgery. ConclusionsThe best candidates who can benefit after re-do surgery are the ones who exhibit either clinical and/or radiological improvement on the trial of traction, as the pathological C1-C2 joints are either not fused or have undergone pseudoarthrosis. Those patients who do not exhibit significant clinical or radiological improvement post-trial of traction should not be offered subsequent surgical intervention.

Non-Surgical Management of Methicillin-Sensitive Staphylococcus Aureus Bacteremia-Related Mediastinitis.

Acute mediastinitis is rarely caused by haematogenous spread of a remote infection. In this respect, since the only medical therapy is usually unsuccessful, treating acute mediastinitis with no source of infection detected is very challenging and management not standardized. In this case report, we describe non-surgical management experience of acute mediastinitis caused by methicillin-sensitive Staphylococcus aureus. In a 79-year-old man judged not eligible for cardiac surgery, we attempted the infection source control through vacuum-assisted closure therapy, together with antimicrobial therapy. We observed gradual clinical, laboratory and radiologic improvements: reduced swelling and normalization of the white blood cell count and C-reactive protein level were associated with reduction in size of a periaortic abscess. We managed a clinical condition with high mortality risk with chronic antimicrobial therapy alone, a strategy that is rarely considered. With this medical strategy we achieved an optimal response to a clinical picture that does not allow any other approach. Mediastinitis is a rare but severe infection with a high mortality rate.Chronic antimicrobial therapy can be an effective strategy in high surgical risk patients.The present case demonstrates good tolerability of lifelong antibiotic therapy.

Central nervous system crystal-storing histiocytosis: A case report and literature review.

Crystal-storing histiocytosis (CSH) is a rare form of histiocytosis with intralysosomal accumulations of immunoglobulins or paraproteins that aggregate as crystals. Central nervous system (CNS) involvement of CSH is uncommon but should be considered in cases of persistent parenchymal enhancement on neuroimaging. We describe one local case of CNS CSH and 10 additional cases identified by literature review. Among 11 CSH patients, lesions involved either the dura (2/11) or brain parenchyma (9/11). Two cases had leptomeningeal enhancement. One case had spinal cord involvement. Two cases were associated with marginal zone lymphoma; one case was associated with an immunoglobulin A-plasma cell dyscrasia. Eight of 11 cases had outcome data available: 7/8 cases had clinical and/or radiological improvement and 1/8 had radiological stability. Central nervous system involvement of CSH is rare. Potential cases should be comprehensively evaluated for lymphoma or myeloma with positron emission tomography/computed tomography (CT) of the body or alternatively, CT of the chest, abdomen, pelvis and nuclear bone scan, bone marrow biopsy, serum protein electrophoresis, and cerebrospinal fluid protein electrophoresis. Treatment is targeted toward the underlying malignancy.

Embolic Materials' Comparison in Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score-Matched Analysis of 1070 Cases.

Multiple preferences exist for embolic materials selection in middle meningeal artery embolization (MMAE) for chronic subdural hematoma with limited comparative literature data. Herein, we compare different embolic materials. Consecutive patients undergoing MMAE for chronic subdural hematoma at 14 North-American centers (2018-2023) were classified into 3 groups: (a) particles, (b) Onyx, (c) n-butyl cyanoacrylate (n-BCA). The end points were unplanned rescue surgery, radiographic success (≥50% reduction in hematoma thickness at last imaging "minimum of 2 weeks"), and major complications. Initial unmatched analysis compared the 3 groups; subsequent propensity score matching (PSM) compared particles vs liquid embolics (groups b and c combined). Additional subgroup PSM analyses compared particles vs Onyx, particles vs n-BCA, and Onyx vs n-BCA. All matched analyses controlled for age, sex, concurrent surgery, previous surgery, hematoma thickness, midline shift, pretreatment antithrombotics, and baseline modified Rankin Scale. Eight hundred and seventy-two patients (median age 73 years, 72.9% males) underwent 1070 MMAE procedures. Onyx was most used (41.4%), then particles (40.3%) and n-BCA (15.5%). Surgical rescue rates were comparable between particles, Onyx, and n-BCA (9.8% vs 7% vs 11.7%, respectively, P = .14). Similarly, radiographic success (78.8% vs 79.3% vs 77.4%; P = .91) and major complications (2.4% vs 2.3% vs 2.5%; P = .83) were comparable. The PSM comparing particles vs liquid generated 128 matched pairs; general anesthesia and bilateral procedures were significantly higher in particles (37.8% vs 21.3%; P = .004 and 39.8% vs 27.3%; P = .034, respectively). No differences in surgical rescue, radiographic improvement, or major complications were noted (P > .05). Concurrently, PSM comparing particles vs Onyx, particles vs n-BCA, and Onyx vs n-BCA, resulted in 112, 42, and 40 matched pairs, respectively, without differences in surgical rescue, radiographic success, or major complications (P > .05). We found no differences in radiological improvement, surgical rescue, or major complications between embolic materials in MMAE. Current randomized trials are exclusively using liquid embolics, and these data suggest that future trials involving particles are likely to produce similar outcomes.

Hypophysitis in COVID-19: a systematic review.

This systematic review aims to collect and examine recent research findings regarding hypophysitis in COVID-19 patients. We conducted a comprehensive literature review in English on the topic "Hypophysitis in COVID-19," using the MEDLINE (PubMed) database in July 2024. The selected articles were systematically tabulated and we have assessed in this review patient demographics, symptom presentation, imaging results, diagnosis, clinical management, and outcomes. Seven reported cases of post-COVID-19 hypophysitis were identified, comprising 4 (57%) females and 3 (43%)males, with a median age of 37 years. The interval between COVID-19 infection symptoms and the onset of hypophysitis ranged from 2 to 3 weeks. Initial symptoms included frontal headache in 4 (57%) cases and polyuria and polydipsia in 3 (43%)cases. Anterior or posterior hypopituitarism was observed in 6 (85%)patients. Radiological findings varied: 2 (28.5%) cases showed panhypophysitis, 3 (43%) cases exhibited gland enlargement with homogeneous contrast enhancement on magnetic resonance imaging (MRI), 1 case involved the loss of the posterior pituitary bright spot, and 1 case involved pituitary apoplexy/enlargement of the gland and infundibulum. No pituitary biopsies were performed. Four (57%) patients received glucocorticoid (GC) treatment. Long-term follow-up was documented in only one case, a 16-year-old female followed for 2 years reporting complete clinical and radiological resolution. Although rare, hypophysitis related to COVID-19 is documented in the literature exhibiting distinct characteristics such as a homogeneous gender prevalence, an average age of onset around 35 years, and primary symptoms of headache, polyuria, and polydipsia which are indicative of angiotensin-vasopressin deficiency. This is in contrast with primary autoimmune hypophysitis characterized by a female prevalence and typical symptoms with headache and visual impairment. Longer-term follow-up of these patients is needed to better understand the potential lasting impact on pituitary function and radiological improvement. Future research should also explore the presence of anti-pituitary antibodies and the other possible pathophysiological mechanisms potentially involved in these cases.

Clonal Bronchopulmonary B-Cell Proliferations of Indeterminate Malignant Potential in Patients with Common Variable Immune Deficiency (CVID) associated Granulomatous Lymphocytic Interstitial Lung Disease (GLILD)

Abstract Introduction/Objective Pulmonary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) is often challenging to distinguish from reactive nodular lymphoid hyperplasia, and assessing B-cell clonality in such cases is crucial in making the distinction. However, patients with common variable immune deficiency (CVID) can harbor clonal or oligoclonal lymphoid populations in their tissues, particularly in association with granulomatous lymphocytic interstitial lung disease (GLILD), making the distinction from MALT lymphoma extremely challenging. We report six cases of GLILD with clonal or oligoclonal B cell infiltrates in lung wedge resection specimens and describe their clinicopathologic characteristics, management, and outcomes. Methods/Case Report A retrospective review was performed to collect lung wedge resection specimens from patients with CVID showing atypical B-cell infiltrates associated with GLILD between 01/2015 and 08/2023. The clinicopathologic findings, management, and response to treatment were studied. Results (if a Case Study enter NA) A total of six GLILD cases were identified with variable degrees of architectural and cytologic lymphoid atypia. Clonality of the lymphoid infiltrate was assessed by kappa/lambda in situ hybridization staining in all six, flow cytometry in 3/6, and IGH gene rearrangement in 4/6 cases. The infiltrate showed frank lambda restriction in 1/6, lambda predominance in 1/6, polytypic expression in 1/6, and no significant plasmacytic component in 3/6 cases. Flow cytometry detected atypical light chain skewed B-cell populations in 3/3 of cases. IGH was positive for clonality in 3/4 and oligoclonal in 1/4 cases. Four patients received therapeutic intervention for GLILD, including one with Rituximab monotherapy, two with Rituximab+Azathioprine, and one with Rituximab+Mycophenolate leading to marked symptomatic and radiologic improvement in all four patients. The remaining two patients were observed to have stable disease. Conclusion Patients with CVID can harbor clonal B-cell populations due to their underlying immune dysfunction. Studies have shown that these can be transient and may not always progress to overt lymphoma. In the setting of GLILD, detecting these populations makes the distinction from MALT lymphoma very challenging. Given that the first- line therapy for both GLILD and MALT is anti-CD20 therapy, the malignant potential of these clones remains uncertain and can only be determined with long-term clinical follow-up.

FROM VEIN TO BRAIN: ENHANCING TRAffiCKING OF CAR T-CELLS IN DIFFUSE MIDLINE GLIOMA

Abstract AIMS H3K27M-altered diffuse midline glioma (DMG) is the deadliest childhood brain tumour, with treatment limited by anatomical location and chemoresistance; palliative radiotherapy remains the mainstay of treatment. Chimeric antigen receptor (CAR) T-cell therapy produces promising pre-clinical results in treating these tumours whilst leaving interspersed normal brain cells intact. Early clinical outcomes of GD2-CAR T-cell therapy for H3K27M-altered DMG demonstrate short-lived neurological and radiological improvement. Enhancing trafficking to and infiltration into the tumour core may enhance CAR T-cell efficacy. Here, advanced T-cell engineering modules are tested for their ability to improve CAR T-cell trafficking. METHOD A library of T-cell engineering modules was created each with a unique DNA barcode to allow identification of CAR T-cells expressing a given module. The library includes chemokine receptors (CCR) to improve tumour homing by chemotaxis towards tumour-secreted chemokines, adhesion molecules to increase extravasation across the blood-brain-barrier, and molecules to degrade upregulated tumour extracellular matrix (ECM) components to improve CAR T-cell motility through the tumour. Murine T-cells were co-transduced with a CAR and barcoded advanced T-cell engineering modules and administrated intravenously in syngeneic models of high-grade glioma (HGG)/DMG. Tumour, normal brain, bone marrow, spleen and liver tissue were collected at several time points post CAR T-cell administration to assess presence of CAR T-cells using genetic barcodes. RESULTS Co-expression of advanced T-cell engineering modules did not impair CAR T-cell function in vitro. CARs co-expressing selected CCRs were preferentially detected in tumour tissue in mice with GL261-EGFRvIII or H3.3K27Mp53LOFPDGFRAWT-engrafted tumours. Findings were further validated by flow cytometry detection of selected CCR-expressing CAR T-cells as compared to CAR T-cells without additional engineering components. Similar experiments for adhesion molecules and ECM modifiers are planned. CONCLUSION Results to date indicate that CAR T-cells co-expressing selected CCRs enhance their homing to HGG/DMG tumours, encouraging further in vivo research to assess impact on CAR T-cell efficacy.

Amikacin Liposomal Inhalation Suspension for Non-Tuberculous Mycobacteria Lung Infection: A Greek Observational Study.

Background and Objectives: Intravenous amikacin, recommended for severe or recurrent M. avium complex (MAC) infections and as initial treatment for M. abscessus lung disease, is often limited by serious adverse effects such as renal and auditory toxicities. Inhaled Amikacin Liposome Inhalation Suspension (ALIS) enhances pulmonary drug deposition while minimizing systemic adverse effects, and it has recently been introduced as an add-on therapy for refractory MAC infections or when other standard treatments are inadequate. This study aims to retrospectively describe the outcomes of Greek patients with difficult-to-treat non-tuberculous mycobacterial (NTM) lung disease following the addition of ALIS to guideline-based therapy. Materials and Methods: Seventeen consecutive patients (median age: 66 years) treated with ALIS as an add-on therapy to a standard regimen at "Sotiria" General Hospital of Chest Diseases (Athens, Greece) from 2020 to 2023 were enrolled in this study. These patients had recurrent or refractory NTM lung disease and/or limited treatment options due to prior treatment-related adverse effects. Clinical, radiological, and microbiological data on treatment response and overall outcomes after ALIS initiation were recorded for each patient. Results: By the end of 2023, 14 out of 17 patients had either successfully completed or were continuing their ALIS therapy. At 6 months, 85.7% (12/14) showed clinical, microbiological, and radiological improvement. However, 25% (3/12) of treated patients, primarily those with monomicrobial or combined M. abscessus lung disease, experienced disease relapse after therapy completion. The most frequent adverse effects related to ALIS were mild and localized to the respiratory tract, with only one patient discontinuing therapy due to hypersensitivity pneumonitis. Conclusions: Adding ALIS to standard regimens was effective and safe in a small group of Greek patients with refractory or recurrent NTM lung disease, particularly those who had discontinued intravenous aminoglycosides due to significant adverse effects, with notable responses observed in MAC lung disease. Further research is needed to validate these findings in clinical practice and to investigate ALIS's role in NTM lung disease caused by other species.

Effect of Dupilumab on Radiological Remission in Patients with Chronic Rhinosinusitis with Nasal Polyp: A One Step Forward Toward Clinical Remission.

While achieving complete radiological improvement in patients with nasal polyps is often observed following surgical resection, the impact of biologic therapy, specifically dupilumab, on polyp size is an area of great interest. The objective of this study was to assess the effect of dupilumab in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) by assessing nasal polyps using the computed tomography (CT) staging system, Lund-Mackay score (LMS). A two-year prospective cohort study was conducted on 29 patients diagnosed with CRSwNP and asthma and eligible for dupilumab as an add-on therapy. The study involved comprehensive assessments of patients before biologic initiation and after the study. These assessments included clinical, laboratory, and radiological evaluations. Dupilumab treatment reduces LMS across sinuses (p<0.001) and improves nasal obstruction (p=0.001). Blood eosinophil count (BEC) predicts persistent sinus obstruction, doubling the likelihood per unit increase (odds ratio: 1.67, p=0.02). BEC levels identify persistent nasal obstruction (AUC: 76%, p=0.04), with a cutoff point above 255.5 cells per microliter, revealing a sensitivity of 100% and a specificity of 42%. The probability of persistent nasal obstruction at the 20th month is 55%, regardless of prior nasal polyp surgery (p=0.41). Dupilumab led to significant radiological improvements in patients with CRSwNP, demonstrating a potential role of radiological remission, irrespective of prior nasal polyp surgery. Additionally, BEC levels may guide the likelihood of persistent nasal obstruction.

Non-Invasive Bracing of Acromioclavicular Joint Dislocations is not Superior to Early Functional Rehabilitation and not Inferior to Surgical Stabilization in Rockwood type III and V Injuries

BackgroundTreatment of acromioclavicular joint (ACJ) separations remains controversial. Yet, conservative treatment has become more common even for high-grade injuries. Available conservative treatment does to date however not address the loss of anatomical joint integrity in Rockwood (RW) III and V injuries. In a recent case report, we outlined the concept of restoring ACJ integrity by non-invasively bracing a RW V injury. AimThe purpose of this study was to prospectively evaluate the clinical and radiological efficacy of a modern Kenny-Howard splint like brace and compare it to early functional rehabilitation or surgery for RW III and V injuries after a minimum of 12 months. MethodsPatients with acute RW III injuries (n=18) and patients with RW V injuries who refused surgery (n=7) were prospectively enrolled and treated with an ACJ brace and followed up clinically and radiologically for 12 months. Endpoint results were compared to injury grade-, sex-, age-, and follow-up-period-matched patients treated with early functional rehabilitation (n=23) and surgical TightRope stabilization (n=23). Clinical outcomes included Constant Score (CS), Subjective Shoulder Value (SSV), Taft Score (TS), and modified Acromioclavicular Joint Instability Score (mAJIS) and radiological outcome included coracoclavicular (CC) index. ResultsCS, SSV, TS, and mAJIS improved in RW III and CS and SSV in RW V patients treated with the ACJ brace. Significance was only reached in RW III patients (p < 0.001). Radiological indices did not improve over time in RW III and V patients. No differences were found when comparing functional and cosmetic outcomes (CS, SSV, TS, mAJIS) after a minimum of 12 months between bracing, surgery, and early functional rehabilitation in RW III and V patients. The CC index was most improved in patients treated by surgery compared to bracing after a minimum of 12 months (p=0.0011 for RW III). ConclusionBrace treatment led to comparable clinical and cosmetic outcomes as early functional rehabilitation or surgery in patients with high grade ACJ injuries after a minimum of 12 months. However, no sustainably improved reduction of the ACJ resulted from bracing, when compared to early functional rehabilitation, thus questioning its utility. While surgery ensured radiological improvement compared to bracing, no benefit was seen over early functional rehabilitation.

Infliximab for parenchymal neuro-Behçet's syndrome: case series and meta-analysis.

This study aims to evaluate the efficacy and safety of infliximab (IFX) in patients with parenchymal neuro-Behçet's syndrome (p-NBS). We retrospectively analysed eleven p-NBS patients treated with IFX at our institution and combined them with studies from database searches for a meta-analysis. Pooled estimates of clinical response (complete and partial remission) and MRI improvement at months 3, 6, and 12 were calculated. One patient achieved CR and the other ten patients achieved PR at our institution. 8 studies (77 patients) were included in the meta-analysis. At 3, 6, and 12 months, 97% (95%CI 61.9-100%), 89.6% (95%CI 45.9-100%), 100% (95%CI 96.0-100%) of patients showed clinical response and 100% (95%CI 89.7-100%), 89.1% (95% CI 26.3-100%), 99.5% (95% CI 96.0-100%) of patients showed radiological improvement, respectively. Severe adverse events were observed in 7 patients. IFX was effective and relatively safe for p-NBS. Patients should be re-evaluated after 3 months of IFX to determine further therapy.

Neurosarcoidosis presenting as transient ischemic attacks: A Case Report

Sarcoidosis is a multi-organ granulomatous disease of unknown etiology characterized by the presence of non-caseating granulomas. It has the potential to affect multiple organs including the nervous system. Neurosarcoidosis is present in around 5% of sarcoidosis patients. The clinical manifestations of neurosarcoidosis are heterogeneous, as granulomas can affect the brain, spinal cord and peripheral nervous system, separately or in different combinations. We report a case of neurosarcoidosis with pulmonary involvement in a young female patient presented with multiple episodes of transient ischemic attacks (TIAs). She was treated with boluses of cyclophosphamide followed by azathioprine which led to marked clinical and radiological improvement.

ASYMMETRICAL CORTICAL VEIN SIGN (ACVS) PREDICT NEUROLOGICAL AND RADIOLOGICAL IMPROVEMENT IN LARGE AND DISTAL VESSEL OCCLUSION POST REPERFUSION THERAPY

ABSTRACT Purpose To investigate the dynamic changes in ACVS on SWIs in patients who underwent reperfusion therapy and evaluate their association with neurological and radiological improvement Materials and Methods All patients treated for acute ischemic stroke between June 2020 and June 2022, in a single tertiary centre (Hospital Sultan Abdul Aziz Shah) who underwent reperfusion therapy and MRI imaging were retrospectively identified based on clinical and radiology reports. Expected Results This study hypothesizes an improvement in ACVS is expected to correlate with favourable neurological outcomes (MRS at 3 months and NIHSS score) and radiological outcome (DWI / ASPECT scores and Modified Mori score). Conversely, a worsening of ACVS is anticipated to be associated with unfavourable neurological and radiological outcomes. Conclusion Asymmetrical Cortical Vein Signs (ACVS) can serve as a valuable predictor of neurological and radiological outcomes in patients with large and distal vessel occlusion after reperfusion therapy Keywords: ACVS (The Asymmetrical cortical vein sign), Ischemic penumbra , Large vessel occlusion (LVO), Distal vessel occlusion (DVO)

Scaffolds for Osteochondral Lesions of the Talus: Systematic Review and Meta-Analysis of the Last Ten Years Literature.

Scaffolds are widely used devices for the treatment of osteochondral lesions of the talus (OCLT), aimed at enhancing mechanical stability and fostering chondrogenic differentiation. A systematic review and meta-analysis were performed to evaluate the safety, and clinical and radiological results of scaffolds for OCLT management. On 2 January 2024, a search was performed in four databases (PubMed, Embase, Web of Science, and Scopus), according to PRISMA guidelines. The risk of bias in the included studies was also evaluated. Thirty clinical studies were included in the qualitative analysis: 12 retrospective case series, 3 retrospective comparative studies, 9 prospective case series, 1 prospective comparative study, and 1 Randomized Controlled Trial (RCT). Natural scaffolds, such as bilayer collagen (COLL)I/III and hyaluronic scaffolds, were the most employed. Only minor adverse events were observed, even if more serious complications were shown, especially after medial malleolar osteotomy. An overall clinical and radiological improvement was observed after a mean of 36.3 months of follow-up. Patient age and Body Mass Index (BMI), lesion size, and location were correlated with the clinical outcomes, while meta-analysis revealed significant improvement in clinical scores with hyaluronic scaffolds compared to microfracture alone. This study highlights the safety and positive clinical outcomes associated with the use of scaffolds for OCLT. In the few available comparative studies, scaffolds have also demonstrated superior clinical outcomes compared to microfractures alone. Nevertheless, the analysis has shown the limitations of the current literature, characterized by an overall low quality and scarcity of RCTs.