Transient Morbidity Research Articles

P17.76 * LOW-DOSE RATE STEREOTACTIC IODINE-125 BRACHYTHERAPY FOR THE TREATMENT OF INOPERABLE PRIMARY AND RECURRENT GLIOBLASTOMA: SINGLE-CENTER EXPERIENCE WITH 201 CASES

BACKGROUND: Treatment options for inoperable glioblastoma are limited. Low-dose-rate stereotactic iodine-125 brachytherapy (SBT) has been reported as an effective and low-risk treatment option for circumscribed low-grade gliomas and brain metastases. The present study evaluates this treatment approach for patients with inoperable glioblastoma. METHODS: Between 1990 and 2012, 201 patients with histologically proven glioblastoma were treated with SBT (iodine-125 seeds; median cumulative surface dose, 60Gy; median dose-rate, 6cGy/h; median gross-tumor-volume, 17ml) either as primary treatment (n = 103) or at recurrence (n = 98). In addition to SBT, 90.3% of patients in the primary treatment group received external boost radiotherapy (median dose, 25.2Gy). Adjuvant chemotherapy was added for 30.8% of patients following SBT and consisted of temozolomide for the majority of cases (88.7%). Procedure-related complications, clinical outcome, progression-free and overall survival (PFS, OS) were evaluated. Median follow-up was 9.8 months. RESULTS: The procedure-related mortality was zero. During follow-up, transient and permanent procedure-related morbidity was observed in 7.5% and 2.0%, respectively. Calculated from the time of SBT, median OS and PFS rates were 10.5 and 6.2 months, with no significant differences among primary and recurrent tumors (11.1 vs.10.4 months for OS and 6.2 vs. 5.9 months for PFS). For OS, multivariate analysis revealed Karnofsky performance score, age, and adjuvant chemotherapy as independent prognostic factors (all p < 0.01). CONCLUSION: Low-dose-rate SBT is a safe and effective local treatment option for patients with circumscribed inoperable glioblastoma initially or at recurrence. It deserves prospective validation since it may potentially improve the outcome for a subset of patients with inoperable GBM.

Low-dose rate stereotactic iodine-125 brachytherapy for the treatment of inoperable primary and recurrent glioblastoma: single-center experience with 201 cases.

Treatment options for inoperable glioblastoma are limited. Low-dose-rate stereotactic iodine-125 brachytherapy (SBT) has been reported as an effective and low-risk treatment option for circumscribed low-grade gliomas and brain metastases. The present study evaluates this treatment approach for patients with inoperable glioblastoma. Between 1990 and 2012, 201 patients with histologically proven glioblastoma were treated with SBT (iodine-125 seeds; median cumulative surface dose, 60Gy; median dose-rate, 6cGy/h; median gross-tumor-volume, 17ml) either as primary treatment (n=103) or at recurrence (n=98). In addition to SBT, 90.3% of patients in the primary treatment group received external boost radiotherapy (median dose, 25.2Gy). Adjuvant chemotherapy was added for 30.8% of patients following SBT and consisted of temozolomide for the majority of cases (88.7%). Procedure-related complications, clinical outcome, progression-free and overall survival (PFS, OS) were evaluated. Median follow-up was 9.8months. The procedure-related mortality was zero. During follow-up, transient and permanent procedure-related morbidity was observed in 7.5 and 2.0%, respectively. Calculated from the time of SBT, median OS and PFS rates were 10.5 and 6.2months, with no significant differences among primary and recurrent tumors (11.1 vs.10.4months for OS and 6.2 vs. 5.9months for PFS). For OS, multivariate analysis revealed Karnofsky performance score, age, and adjuvant chemotherapy as independent prognostic factors (all p<0.01). Low-dose-rate SBT is a relatively safe and potentially effective local treatment option for patients with circumscribed inoperable glioblastoma initially or at recurrence. It deserves prospective validation since it may improve the outcome for a subset of patients with inoperable GBM.

Association between transient acute kidney injury and morbidity and mortality after lung transplantation: A retrospective cohort study

PurposeAcute kidney injury (AKI) is a common occurrence after lung transplantation (LTx). Whether transient AKI or early recovery is associated with improved outcome is uncertain. Our aim was to describe the incidence, factors, and outcomes associated with transient AKI after LTx. Materials and MethodsWe performed a retrospective cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. Our primary outcome transient AKI was defined as return of serum creatinine below Kidney Disease–Improving Global Outcome AKI stage I within 7days after LTx. Secondary outcomes included occurrence of postoperative complications, mortality, and long-term kidney function. ResultsOf 445 LTx patients enrolled, AKI occurred in 306 (68.8%) within the first week after LTx. Of these, transient AKI (or early recovery) occurred in 157 (51.3%). Transient AKI was associated with fewer complications including tracheostomy (17.2% vs 38.3%; P<.001), reintubation (16.4% vs 41.9%; P<.001), decreased duration of mechanical ventilation (median [interquartile range], 69 [41-142] vs 189 [63-403] hours; P<.001), and lower rates of chronic kidney disease at 3 months (28.5% vs 51.1%, P<.001) and 1 year (49.6% vs 66.7%, P=.01) compared with persistent AKI. Factors independently associated with persistent AKI were higher body mass index (per unit; odds ratio [OR], 0.91; 95% confidence interval, 0.85-0.98; P=.01), cyclosporine use (OR, 0.29; 0.12-0.67; P=.01), longer duration of mechanical ventilation (per hour [log transformed]; OR, 0.42; 0.21-0.81; P=.01), and AKI stages II to III (OR, 0.16; 0.08-0.29; P<.001). Persistent AKI was associated with higher adjusted hazard of death (hazard ratio, 1.77 [1.08-2.93]; P=.02) when compared with transient AKI (1.44 [0.93-2.19], P=.09) and no AKI (reference category), respectively. ConclusionsTransient AKI after LTx is associated with fewer complications and improved survival. Among survivors, persistent AKI portends an increased risk for long-term chronic kidney disease.

E-030 Endovascular Treatment with Flow Diverter of Recanalized and Multitreated Aneurysms Initially Treated by Endovascular Approach

Background and purposeTo evaluate the feasibility, safety, and efficacy of endovascular treatment with flow diverters (FD) in patients with recanalised and multitreated aneurysms, in a retrospective, multicenter, single-arm study.Materials and...

Molecular stereotactic biopsy technique improves diagnostic accuracy and enables personalized treatment strategies in glioma patients.

In gliomas molecular biomarkers are increasingly gaining diagnostic, prognostic and predictive significance. Determination of biomarker status after biopsy is important as not all patients are eligible for open tumor resection. We developed and validated prospectively (6/10-12/11) a protocol allowing for both reliable determination of multiple biomarkers and representative histological diagnoses from small-sized biopsies. All molecular stereotactic biopsies were performed according to a detailed workflow. The selection of specimens best suited for molecular analyses was intra-operatively guided by the attending neuropathologist. Postoperative screening was done by methylation specific PCR using two distinct cryopreserved specimens to test for reproducibility of the findings and to rule out contamination. The DNA of a single best-suited specimen (1 mm(3)) was subjected to detailed molecular analysis (MGMT promoter methylation, IDH1/2 mutational status, LOH 1p and/or 19q). 159 consecutively enrolled untreated gliomas were analyzed (94 glioblastomas, 2 gliosarcomas, 24 anaplastic astrocytomas, 10 oligo-tumors grade II/III, 20 grade II astrocytomas and 9 pilocytic astrocytomas). Transient morbidity was 2 %. Overall, the drop-out rate due to tissue contamination was 0.4 %. Median time from biopsy to histological and molecular genetic analyses was 3 and 5 days, respectively. Distributions of the respective biomarker status for tumor subgroups were consistent with the literature. The final histological diagnosis was changed/modified in 5/159 patients according to molecular findings. Treatment after molecular biopsy was highly personalized. Molecular stereotactic biopsy is feasible and safe, can be implemented in daily clinical practice, improves diagnostic precision and enables personalized treatment.

Endovascular treatment with flow diverters of recanalized and multitreated aneurysms initially treated by endovascular approach

PurposeTo evaluate the feasibility, safety and efficacy of endovascular treatment with flow diverters in patients with recanalized and multitreated aneurysms in a retrospective, multicenter, single-arm study.MethodsThe study included 29 patients...

Treatment of complex intracranial aneurysms using flow-diverting silk® stents. An analysis of 32 consecutive patients.

This study describes the peri-procedural and late complications and angiographic follow-up results of 32 patients with 34 complex aneurysms treated with flow diverter Silk stents in a single centre. In this retrospective study, 40 Silk stents (SS) were implanted in 34 complex intracranial aneurysms in 32 patients. In our series, 20 (58.8%) carotid-ophthalmic internal carotid artery (ICA), six (17.6%) cavernous ICA, two (5.9%) supraclinoid ICA, two (5.9%) petrosal ICA (the same patient- bilateral) and four (11.8%) posterior circulation aneurysms were treated. One of the posterior circulation lesions was a fenestrated-type aneurysm. Twenty wide-necked, saccular; eight neck remnant; four fusiform and two blister-like aneurysms were included in our series. SS were successfully implanted in all patients (100%). Misdeployment occurred in 17.6% of patients. In two of these patients adequate stent openness was achieved via Hyperglide balloon dilatation. Coil embolization in addition to SS placement was utilized in four aneurysms. One patient (3%) experienced transient morbidity due to a thromboembolic event and there was one mortality (3%) due to remote intraparenchymal haemorrhage. Complete occlusion of 27/33 (81.8 %) and 29/33 (87.9 %) aneurysms was achieved six and 12 months after the procedure, respectively. In-stent intimal hyperplasia was detected in 6.1 % patients. Flow-diverter Silk stent implantation is an effective method of treating complex aneurysms with acceptable mortality and morbidity rates. Complete occlusion is achieved in most of the complex aneurysms.

Outcomes for a case series of unruptured anterior communicating artery aneurysm surgery

Surgical outcomes following repair of unruptured anterior communicating artery (AcomA) aneurysms have not been adequately addressed in the literature. We present our operative experiences in a consecutive series of 103 patients with 115 unruptured AcomA aneurysms. Clinical results, operative complications, angiographic outcomes and prognostic factors associated with surgery are presented. Of the 115 aneurysm repairs attempted, 114 were treated by clipping or excision and suture. One aneurysm, less than 2mm, was wrapped. Six patients (5.8%; 95% confidence interval [CI], 2.5–12.4) experienced a new permanent neurological deficit. There was no postoperative mortality. Transient morbidity occurred in 11 patients (10.7%; 95% CI, 5.9–18.3), including transient anosmia (four patients), acute postoperative confusion and memory disturbances (four patients), extradural haematoma requiring surgery (two patients) and cerebrospinal fluid rhinorrhea (one patient). Of the 84 aneurysms (73.0%) that had documented postoperative angiography, 82 (97.6%) had complete obliteration of the aneurysm and two (2.4%) had neck remnants (mean angiographic follow-up 28.0months; range, 1.6–146.4months). Retreatment was performed in one patient (1.0%). Logistic regression analysis of risk factors revealed that aneurysm size (p<0.01) was a significant predictor of outcome. There was no incidence of subarachnoid haemorrhage in the 272 person years of follow-up. In the current study, surgical treatment of unruptured AcomA aneurysms resulted in 5.8% morbidity and no mortality. The robustness of aneurysm repair achieved by open microsurgery is an important consideration when considering the option between endovascular and microsurgical treatment for unruptured AcomA aneurysms.

Effect of vacuum spine board immobilization on incidence of pressure ulcers during evacuation of military casualties from theater

Background contextIn the summer of 2009, the vacuum spine board (VSB) was designated by the US Air Force as the preferred method of external spinal immobilization during aeromedical transport of patients with suspected unstable thoracolumbar spine fractures. One purported advantage of the VSB is that, by distributing weight over a larger surface area, it decreases the risk of skin pressure ulceration. PurposeTo examine whether the rate of pressure ulcers has changed since the introduction of the VSB. Study designRetrospective cohorts. Patient sampleInjured US service members undergoing spinal immobilization during evacuation from the Iraq and Afghanistan theaters to Landstuhl, Germany. Outcome measuresPresence and stage of pressure ulceration, and deterioration in neurologic status. MethodsRecords of the initial 60 patients medically evacuated on the VSB to Landstuhl Regional Medical Center were retrospectively analyzed for patient demographics, injury characteristics, and incidence of pressure injury. The incidence of pressure ulcers after the use of VSB was compared with that in a historical control consisting of 30 patients with unstable spinal injuries evacuated before the introduction of the VSB. No sources of external funding were used for this investigation. ResultsThe combined cohort had a mean age of 28.8 years and mean Injury Severity Score (ISS) of 20.63 and comprised 96% men. Most injury mechanisms were blunt (58%). The rate of neurological injury was 19%. There were no cases of progressive neurological deficit or deformity in either cohort. In the VSB group, using a broad definition of pressure ulcer, incidence was 13 of 60 patients (22%). Using a strict definition, incidence was eight of 60 (13%): five Stage I and three Stage II. In the non-VSB group, incidence of pressure ulcers was three of 30 (10%), using either definition, all Stage II. Difference in incidence between the groups was not statistically significant. Intubated patients had a significantly higher incidence of pressure ulcers. ConclusionBoth the VSB and historic means (non-VSB) of spinal immobilization appear to be safe and produce only transient morbidity despite an average of 9 to 10 hours of transport. Intubated status was identified as the most important risk factor for the development of a pressure ulcer.

Outcomes for unruptured ophthalmic segment aneurysm surgery

Ophthalmic segment aneurysms present unique technical challenges because of their proximity to the optic nerve and the anterior clinoid process. The current study was performed to examine whether surgery for unruptured ophthalmic segment aneurysms is an effective treatment modality with acceptable complication rates. A consecutive case series (prospectively collected data) was retrospective reviewed for the period between April 1992 and August 2012. Clinical results, operative complications, angiographic outcomes and prognostic factors associated with surgery are presented. Of the 169 patients with 182 unruptured ophthalmic segment aneurysms that were surgically repaired, 11 (6.4%) experienced new permanent neurological deficits, including six instances of complete visual loss. There was one postoperative death (0.6%) related to a middle cerebral artery infarction. Transient morbidity occurred in 18 patients (10.4%), including cerebrospinal fluid rhinorhea (10 patients), oculomotor nerve palsy (four patients) and transient dysphasia (four patients). A total of 142 aneurysms (78.0%) had documented postoperative angiography. Surgical treatment resulted in 135 (95.1%) complete obliterations and seven (4.9%) neck remnants. Retreatment was performed in three patients (1.7%). Logistic regression analysis of risk factors revealed that age (p<0.02), aneurysm size (p<0.01) and the use of temporary clipping (p<0.01) were significant negative predictors of outcome. The risk associated with surgical repairs for unruptured ophthalmic segment aneurysms is no greater than aneurysms in other locations (6.4% morbidity; 0.6% mortality) and no more hazardous than outcomes achieved by alternative therapies. The robustness of aneurysm repair achieved by open microsurgery is an important consideration.

The Significance of Cyst Remnants After Endoscopic Colloid Cyst Resection

Controversy surrounds the fate of cyst remnants after endoscopic colloid cyst resection. Our study evaluated recurrence rates in patients with total endoscopic resection of colloid cysts vs those with coagulated cyst remnants. Sixty-five consecutive patients and 67 procedures for endoscopic resection of colloid cysts from 1995 to 2011 were reviewed. Degree of resection was based on intraoperative assessment and postoperative magnetic resonance imaging (MRI). Recurrence rates were compared between patients with complete resection those with coagulated cyst remnants. Data analysis was performed of 56 patients and 58 procedures, with no follow-up in 9 patients. All patients had MRI-defined complete resection. On intraoperative assessment, 9 procedures had coagulated remnants and 45 procedures had complete resection (4 data unknown). The overall recurrence rate was 6.89% (4/58), 33.3% (3/9) with cyst remnants, and 2.2% (1/45) with total resection (P = .0124). Maximum follow-up was 144 months (mean, 40.4 months). Mean follow-up was 66.0 months for cyst remnant cases, and 33.5 months for totally resected cases. There was no mortality or permanent morbidity. Transient morbidity included memory deficit (n = 2), aseptic meningitis (n = 1), and local wound infection (n = 1). Endoscopic colloid cyst resection results in a low overall recurrence rate. Immediate postoperative MRI was insufficient for assessing degree of resection and was a poor predictor of recurrence. Ablation of cyst remnants rather than total removal is associated with a significantly higher rate of recurrence. The primary goal of endoscopic surgery should, therefore, be removal of all cyst contents and wall remnants.

Purely subcortical tumors in eloquent areas: Awake surgery and cortical and subcortical electrical stimulation (CSES) ensure safe and effective surgery

ObjectiveTo analyze the efficacy and safety of cortical and subcortical electrical stimulation CSES and awake surgery to approach purely subcortical tumors in highly functional locations, particularly in guiding the choice of the best transcortical path. Patients and methodsProspective analysis of the surgical, neurological, and radiological outcome of patients harboring supratentorial, subcortically located brain tumors or vascular malformations who are operated on through awake surgery and CSES. Functional magnetic resonance (fMRI; either sensory-motor or language, based on the location) was performed in order to confirm the proximity to functional cortical areas. Major white matter tracts were investigated by MRI diffusion tensor fiber tracking (DTI-ft). The Rankin modified score was chosen to express the pre and postoperative functional neurological status. Immediate postoperative MRI was used to evaluate the extent of resection. ResultsSeventeen patients were selected. The main distance of the tumors from the cortical surface was 18.2mm (range 9–48mm). Neuronavigation was used to show the most direct route to the tumor (transsulcal or transgyral), but CSES was fundamental to adapt the surgical corridor to the functional topography both cortically and subcortically. If the transgyral route was chosen, CSES helped to detect a non-eloquent area. When a transsulcal route was preferred, CSES documented the presence or absence of function in the deep sulcus. The transient postoperative morbidity was 76.4%, but at last follow-up (range 4–20 months), all the patients regained preoperative status and 2 improved. Postoperative MRI demonstrated complete resection in all cases. ConclusionsApproaching purely subcortical tumors requires microsurgical skills, but in eloquent areas, functional topography monitoring is mandatory to allow safe surgery. CSES in an awake patient is a method that produces very good results in terms of resection and neurological outcome.

Peri-Procedural Morbidity and Mortality Associated with Stent-Assisted Coiling for Intracranial Aneurysms

Despite experience and technological improvements, stent-assisted coiling for intracranial aneurysms still has inherent risks. We evaluated peri-procedural morbidity and mortality associated with stent-assisted coiling for intracranial aneurysms. Patients with cerebral aneurysms that were broad-based (>4 mm) or had unfavorable dome/neck ratios (<1.5) were enrolled in this study between February and November 2011 at our center. Aneurysms were treated with the self-expanding neurovascular stents with adjunctive coil embolization. Seventy-two consecutive patients (27 men and 45 women; 22-78 years of age; mean age, 52.8 years) underwent 13 procedures for 13 ruptured aneurysms and 64 procedures for 73 unruptured aneurysms. Nine [11.7%, 95%CI(4.5%-18.9%)] procedure-related complications occurred: one and eight with initial embolization of ruptured and unruptured aneurysms, respectively. Complications included six acute in-stent thromboses, one spontaneous stent migration, one post-procedural aneurysm rupture, and one perforator occlusion. Three complications had no neurologic consequences. Two caused transient neurologic morbidity, two persistent neurologic morbidity, and two death. Procedure-related neurologic morbidity and mortality rates, respectively, were as follows: overall, 5.2% (95%CI, 0.2%-10.2%) and 2.6% (95%CI, 0%-6.2%); ruptured aneurysms, 7.7% (95%CI, 0%-36%) and 0%(95%CI, 0%-25%); unruptured aneurysms, 4.7% (95%CI, 0%-9.9%) and 3.1% (95%CI, 0%-7.3%). Combined procedure-related morbidity and mortality rates for ruptured and unruptured aneurysms were 7.7% (95%CI, 1.7%-13.7%) and 7.8% (95%CI, 1.8%-13.8%), respectively. Stent-assisted coiling is an attractive option for intracranial aneurysms. However, stent-assisted coiling for unruptured aneurysms is controversial for its comparable risk to natural history.

Total resection in a giant left frontal arteriovenous malformation, grade V Spetzler-Martin - Case report

Abstract Background: Giant arteriovenous malformations (AVMs) are congenital lesions, with nidus sizing more than 6 cm. According to Spetzler-Martin scale, grade V AVMs have a nidus larger than 6 cm in diameter, profound venous drainage and are located in eloquent areas. Method: We report a case of a 39 years old woman, with giant left frontal AVM, grade V Spetzler-Martin, who was admitted for generalized seizures, with onset 32 years ago, refractory to full dose antiepileptic polytherapy, which severely impaired the patient’s quality of life. Results: The patient underwent surgery and we performed total resection of the AVM. We emphasize on surgical technique, intraoperative difficulties and outcome. Conclusions: Surgery is the therapy of choice in AVMs, because it provides cure of the lesion, and is the only treatment capable of preventing hemorrhage and controlling seizures. Management in grade V AVMs is challenging, because of their large size, multiple dilated arterial feeders from anterior and posterior circulation and external carotid arteries, high blood flow, vascular steel from the surrounding brain, enlarged draining veins, profound venous drainage and location in eloquent area. Giant AVMs with high flow nidus, causing a great degree of vascular steel in the surrounding brain, with hypoperfusion of normal parenchyma may develop early normal perfusion pressure breakthrough. Total resection in grade V AVMs can be performed with minimal transient morbidity and favorable outcome. Total resection permits control of intractable seizures with reduced dose of antiepileptic therapy.

Distal Ulna Hook Plate Fixation for Unstable Distal Ulna Fracture Associated With Distal Radius Fracture

The significance of distal ulna fractures is often undermined, which can result in inadequate treatment compared with fractures of the radius, the ulna's larger counterpart. However, little guidance exists in the current literature on how to manage distal ulna head or neck fractures and intra-articular ulna head fractures. Therefore, the purpose of this retrospective study was to evaluate the outcomes of distal ulna hook plate fixation for the treatment of an unstable distal ulna fracture associated with a distal radius fracture. Twenty-five patients with unstable distal ulna fractures who underwent stable fixation for an associated distal radius fracture were included in the study. All patients achieved satisfactory reduction and bony union. Average final motion was as follows: wrist flexion, 72° (range, 60°-85°); extension, 69° (range, 65°-80°); pronation, 77° (range, 55°-95°); supination, 82° (range, 65°-90°); ulnar deviation, 35° (range, 15°-50°); and radial deviation, 24° (range, 10°-40°). Average postoperative grip strength was 28 kg (range, 22-30 kg) and was 91% (range, 71%-100%) in the cases in which the dominant hand was injured and 80% (range, 65%-100%) in the cases in which the nondominant hand was injured. Average postoperative modified Mayo wrist score and Disabilities of the Arm, Shoulder and Hand score was 87 points (range, 65-100 points) and 14 points (range, 0-54 points), respectively. Chronic instability of the distal radioulnar joint was not encountered in any patient. Thus, the study demonstrated that distal ulna hook plate fixation for the treatment of unstable distal ulna fractures can achieve healing with good alignment, satisfactory function, and minimal transient morbidity.

Single-center experience with balloon-assisted coil embolization of intracranial aneurysms: Safety, efficacy and indications

ObjectiveBalloon-assisted coil embolization (BACE) has been widely used for the treatment of intracranial aneurysms. The routine use of this technique remains, however, controversial. In this study, we review our experience with BACE with respect to the indications, complications and effectiveness of the technique. Materials and methodsA retrospective review was conducted on 76 BACE procedures performed at a single institution between June 2009 and June 2011. ResultsOf 76 aneurysms (40 ruptured and 36 unruptured) treated with BACE, 64 were located in the anterior circulation and 12 in the posterior circulation. The mean aneurysm size was 6.8mm. A balloon was used for parent vessel protection in 56, side-branch protection in 12 and balloon-in-stent coiling in 8 patients. 75 aneurysms (98.6%) were successfully coiled with a mean packing density of 28.3%. Thromboembolic complications developed after the treatment of 5 aneurysms (6.6%) causing transient morbidity in 4 patients (5.2%). One balloon-unrelated rupture occurred with no significant extravasation due to temporary balloon occlusion. There were no procedure-related permanent morbidity or deaths. 47 patients had imaging follow-up (angiogram in 28, MRA in 19) at a mean timepoint of 7.8 months. 45 patients (95.7%) had complete or near-complete occlusion while 2 patients (4.3%) had major recurrences, one underwent surgical clipping and the other had stent-assisted coiling. One patient had a rehemorrhage (1.3%). ConclusionIn our experience, BACE has low complication and recurrence rates in the treatment of complex and wide-necked intracranial aneurysms. High packing densities were achieved with BACE technique.

Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions

Despite the increased risk of hemorrhage and deteriorating neurological function of once-bled cerebral cavernous malformations (CM), the management of eloquently located CMs remains controversial. All eloquently located CMs (n = 45) surgically treated between 03/2006 and 04/2011 in our department were consecutively evaluated. Eloquence was characterized according to Spetzler and Martin's definition. The following locations were approached: brainstem, n = 16; sensorimotor, n = 8; visual pathway, n = 7; cerebellum (deep nuclei and peduncles), n = 7; basal ganglia, n = 4, and language, n = 3. Follow-up data was available for 41 patients (91%) with a median interval of 14months. Outcomes were evaluated according to the Glasgow outcome and the modified Rankin scale. Immediately after surgery, 47% (n = 21) had a new deficit. At follow-up, 80% (n = 36) recovered to at least preoperative status or were better than before surgery, 9% (n = 4) exhibited a slight, and 7% (n = 3) had a moderate neurological impairment. Only two cases (4%) with a new permanent severe deficit were observed, both related to dorsal brainstem surgery. The outcome after the surgery of otherwise located brainstem CMs was as beneficial as that for non-brainstem CMs. Patients with initially poor neurological performance fared worse than oligosymptomatic patients. Despite the high postoperative transient morbidity, the majority improved profoundly during follow-ups. Compared with natural history, surgical treatment should be considered for all eloquent symptomatic CMs. Dorsal brainstem location and poor preoperative neurological status are associated with an increased postoperative morbidity.

Coiling for Paraclinoid Aneurysms: Time to Make Way for Flow Diverters?

Paraclinoid aneurysms represent challenging lesions for which endovascular techniques have gained widespread application in their treatment. A new endovascular strategy, flow diversion, is gaining importance in the treatment of these aneurysms. Before embracing flow diversion in larger numbers of patients with paraclinoid aneurysms, it is important to know the safety and efficacy of "traditional" endovascular methods for these aneurysms. We review complications and outcomes of patients with unruptured paraclinoid aneurysms treated with coils, with or without balloon and stent assistance, over the past 12 years at our institution. A retrospective review of 118 patients with 126 unruptured paraclinoid aneurysms, treated between 1999 and 2010, was performed. Clinical records, endovascular reports, angiographic results, and clinical outcomes were reviewed and analyzed. Fifty-nine percent of aneurysms were carotid-ophthalmic, 27% were hypophyseal, 9% were posterior carotid wall, 3% were carotid cave, and 2% were transitional. Twenty-one percent of aneurysms were symptomatic, and 3% were recurrent aneurysms after previous treatment. Fifty (40%) were treated with balloon assistance and 18 (14%) with stent assistance. Technical complications causing permanent morbidity occurred in 1 patient (0.8%), while early clinical complications causing transient morbidity occurred in 5 (4%) patients. Complete occlusion was achieved in 40% of aneurysms immediately after treatment and in 66 (62%) aneurysms during follow-up (mean 31.9 ± 28.4 months). Recurrences occurred in 18 patients (17%) and 10 (9%) patients were retreated. Clinical outcome was good in 95% and poor in 5% of the 107 patients with follow-up (mean 37.0 ± 33.7 months). Only in 1 patient was poor outcome related to the endovascular procedure. Transient ischemic attacks occurred in 4% of patients. No cases of rebleeding were observed during follow-up. Modern endovascular coil treatment of unruptured paraclinoid aneurysms appears safe, with satisfactory, although not ideal, rates of complete occlusion. The introduction of flow diverters will probably increase the rate of complete angiographic occlusion, but this must be achieved with low complication rates.

Carnoy′s solution in the mangement of odontogenic keratocyst

Carnoy's solution is a substance used as a complementary treatment after the conservative excision of odontogenic keratocyst. The application of Carnoy's solution promotes a superficial chemical necrosis and is intended to reduce recurrence rates. However, the inferior alveolar vascular–nervous plexus can occasionally be exposed after the removal of a lesion. The safety of the application of Carnoy's solution over this plexus has been reported, but to date, no clinical report has been made. The authors present a case that was given Carnoy's solution over the inferior alveolar vascular–nervous plexus as a complementary treatment for the keratocystic odontogenic tumor. Effective control of recurrence with low and transient neural morbidity was suggested with this technique.

Antibody responses and cross protection against lethal influenza A viruses differ between the sexes in C57BL/6 mice

A mouse model was used to determine if protective immunity to influenza A virus infection differs between the sexes. The median lethal dose of H1N1 or H3N2 was lower for naïve females than males. After a sublethal, primary infection with H1N1 or H3N2, females and males showed a similar transient morbidity, but females generated more neutralizing and total anti-influenza A virus antibodies. Immunized males and females showed similar protection against secondary challenge with a homologous virus, but males experienced greater morbidity and had higher lung viral titers after infection with a lethal dose of heterologous virus. Females develop stronger humoral immune responses and greater cross protection against heterosubtypic virus challenge.