Brain Herniation Research Articles

Clinico-pathological features and molecular background of oligodendrogliomas

Background: Diffuse gliomas are the most frequent primary central nervous system (CNS) neoplasms, originating from the parenchyma itself, oligodendrogliomas accounting for approximately 10% of cerebral gliomas. For the past 20 years, the study of genetic/molecular mechanisms of glioma genesis and progression has gradually come into focus. However, the biological and clinical significance of these mutations are still to be completely characterized. The purpose of this article is to describe our clinical experience with oligodendrogliomas and to review the current literature, in order to better describe the characteristics of the molecular/genetic oligodendroglioma subgroups.
 Methods: We performed a single-institution retrospective study that included 66 patients with oligodendrogliomas operated in our department between January 2011 and December 2018.
 Results: Our study included 26 female patients (39%) and 40 male patients (59%). The mean age at presentation was 39.9year-old (range 26-59year-old). The tumours were located predominantly in the right hemisphere (53%), the majority being situated in the frontal lobe (59%). 64% of the patients had signs of mass effect on the imaging studies, 13% presented with brain herniation syndromes, and 16 % of the surgically treated patients had a relapse with regrowth and malignant transformation of the tumour. The most common complaint that the patients had at admission was a headache. Seizures were the second most common symptom that determined the patients to seek medical attention.
 Conclusion: The expanding knowledge regarding the genetic alterations of oligodendroglial tumours could lead to significant changes in treatment strategies. However, the utility of each particular marker in planning the treatment has yet to be established. Emerging data will, most likely, improve outcome prediction and adjuvant therapy strategies by identifying the patients most likely to benefit from a particular treatment.

MRI findings differentiating tonsillar herniation caused by idiopathic intracranial hypertension from Chiari I malformation.

Some patients with idiopathic intracranial hypertension (IIH) have cerebellar tonsillar herniation ≥ 5mm mimicking Chiari malformation I (CMI), which can result in misdiagnosis and unjustified treatment. Our purpose was to identify IIH patients with tonsillar herniation ≥ 5mm (IIHTH) and compare with CMI patients to assess imaging findings that could distinguish the two conditions. Ninety-eight patients with IIH, 81 patients with CMI, and 99 controls were retrospectively assessed. Two neuroradiologists blindly reviewed MR images. IIHTH patients were compared with CMI patients and controls regarding the extent of tonsillar herniation (ETH), bilateral transverse sinus stenosis (BTSS), hypophysis-sella ratio (HSR), and bilateral tortuosity of optic nerve (BTON). 13/98 (13.2%) IIH patients had tonsillar herniation ≥ 5mm (IIHTH) and were significantly younger and had higher BMI compared with CMI patients and controls. ETH was significantly less in the IIHTH than CMI (6.5 ± 2.4mm vs. 10.9 ± 4.4mm; p < 0.001). BTSS and HSR < 0.5 were more common in IIHTH than CMI (p < 0.001 and p = 0.003, respectively). No differences were seen between CMI and controls. BTON was significantly more common in IIHTH compared to control (p = 0.01) but not to the CMI (p = 0.36). Sensitivity and specificity to differentiate IIHTH from CMI were 69.2% and 96.1% for BTSS and 69.2% and 75.3% for HSR < 0.5. The presence of BTSS and/or HSR < 0.5 in patients with ETH ≥ 5mm should suggest further evaluation to exclude IIH before considering CMI surgery.

Staged radiosurgery of large brain metastasis with mass effect and brain dislocation: case report

Introduction. Currently, one of the effective methods of treatment of intracranial metastases is stereotactic radiosurgery. The main factors limiting its use are the size (volume) of the tumor or the location of the metastasis in critical proximity to radiosensitive brain structures, such as the optic pathways, thalamus, brain stem, due to the high risk of developing local radiation necrosis. To reduce the risk of adverse radiation effects, hypofractionated radiotherapy by linac or staged Gamma Knife radiosurgery is used. However, large brain metastases that cause dislocation of the brain midline structures are traditionally considered an object for surgical excision, the main purpose of which is to eliminate the mass effect caused by the tumor.The objective of the publication: to demonstrate a case of successful application of staged Gamma Knife radiosurgery of large brain metastases accompanied by brain compression and dislocation.Materials and methods. Patient, 38‑year-old, with right-sided hemiplegia (0 score) and large (Ø = 3 cm, V = 12.9 cm3) breast cancer metastasis in the deep site of the left hemisphere, accompanied by severe perifocal edema and braindislocation (midline shift up to 15 mm). The treatment was carried out by Gamma Knife in two stages with an interval of 1.5 months.Results. As a result, not only a complete regression both of the perifocal edema and midline shift were noted, but also a significant decrease of the tumor volume and dramatical improvement in the patient’s neurological status already in the interval between the stages of radiosurgery: restoration of active movements in the right limbs (up to 4 score).Conclusion. This case demonstrates the possibility of effective and safe non-invasive treatment of large brain metastases accompanied by brain compression and dislocation, which makes it possible to achieve regression of the mass effect and improve the neurological quality of life of cancer patients.

Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension: A United Kingdom and Ireland Survey on Practice Variation.

IntroductionDiversion of cerebrospinal fluid (CSF) in a traumatic brain injury (TBI) is an established means for achieving control of intracranial pressure (ICP), aimed at improving intracranial homeostasis. The literature and anecdotal reports suggest a variation in practice between neurosurgical centres internationally, with current guidelines advocating ventricular drainage over lumbar drainage. We sought to establish the current neurosurgical practice in the United Kingdom regarding the methods of ICP control in TBI.MethodsA 20-point survey was distributed electronically to British and Irish neurosurgeons after ratification by the Society of British Neurological Surgeons. Questions were directed at the clinician’s opinion and experience of lumbar drain usage in patients with TBI: frequency, rationale, and experience of complications. Questions on lumbar drain usage in neurovascular patients were asked for practice comparison.ResultsThirty-six responses from 21 neurosurgical centres were returned. Twenty-three per cent (23%) of responders reported using lumbar drains for refractory ICP in TBI patients: six units use lumbar drains and 15 do not. Three units showed partial usage, with mixed “yes/no” responses between consultants. Concerns of tonsillar herniation and familiarity with EVD were commonly given reasons against the usage of lumbar drains. Fifty-six per cent (56%) reported use in neurovascular patients.ConclusionThis contemporary practice survey demonstrates mixed practice across the UK and within some centres. Responses and survey feedback demonstrate that the use of lumbar drains in TBI is a polarising topic. The variety of practice between and within neurosurgical units supports consideration of the prospective study of CSF diversion methods for control of refractory ICP in patients with TBI.

LINC-20. Impact of the COVID-19 pandemic on 30-day mortality and unplanned reoperation rates for pediatric central nervous system tumors

INTRODUCTION: Unplanned reoperations and mortality within 30 days are important indicators when evaluating the quality of care provided by surgical systems. We reviewed these outcomes among children with primary central nervous system (CNS) tumors treated during the COVID-19 pandemic. METHODS: This is a retrospective study of all pediatric patients who underwent neurosurgery for primary CNS tumors at the Philippine General Hospital, the national university hospital, from January 1, 2020 until December 31, 2021. Their clinical presentation, perioperative course, and outcomes were analyzed. During this time, our hospital concurrently served as a COVID-19 referral center, thus, the workforce was restructured, and resources were reallocated to care for COVID-19 patients. RESULTS: A total of 92 pediatric patients with CNS tumors underwent 140 neurosurgical operations during the study period. Two-thirds of the patients were males, and mean age was 9.3 ± 5.0 years (range: 3 months to 18 years). Average preoperative length of stay was 3.9 ± 2.6 days. Tumor resection was performed in 73 patients (79%). Most common histologic diagnoses were medulloblastoma (20%) and low-grade glioma including pilocytic astrocytoma (20%). Overall, the 30-day mortality and unplanned reoperation rates were 12% and 22%, respectively. Eight patients died from brain herniation and/or tumor progression. Reasons for unplanned reoperations were postoperative hydrocephalus (20%), infection (9%), hematoma (7%), and tumor residual (3%). DISCUSSION: Worldwide, the COVID-19 pandemic has altered hospital protocols and shifted resources considerably. The observed high rates of death and reoperation are likely due to delays in seeking care leading to worse neurologic status at presentation, delays in performing essential surgery within the hospital, and shortage of health workers providing specialist care. It is important to periodically assess perioperative outcomes to improve the quality of surgical care given to children with CNS tumors, who remain a vulnerable population during the COVID-19 pandemic.

Claudin-5a is essential for the functional formation of both zebrafish blood-brain barrier and blood-cerebrospinal fluid barrier

BackgroundMammalian Claudin-5 is the main endothelial tight junction component maintaining blood-brain barrier (BBB) permeability, while Claudin-1 and -3 seal the paracellular space of choroid plexus (CP) epithelial cells contributing to the blood-cerebrospinal fluid barrier (BCSFB). In zebrafish, two paralogs of claudin-5a and -5b are expressed while their roles in the formation of BBB and BCSFB are unclear.MethodsThe expression patterns of Claudin-5a and -5b in zebrafish brains were systematically analyzed by immunofluorescence (IF) assay. The developmental functions of Claudin-5a and -5b were characterized by generating of claudin-5a and -5b mutants respectively. Meanwhile, the cerebral inflammation and cell apoptosis in claudin-5a-/- were assessed by live imaging of transgenic zebrafish, RT-qPCR, IF, and TUNEL assay. The integrity of BBB and BCSFB was evaluated by in vivo angiographic and dye permeation assay. Finally, RT-qPCR, whole-mount RNA in situ hybridization (WISH), and transmission electron microscopy (TEM) analyses were performed to investigate the development of cerebral vessels and choroid plexus.ResultsWe showed that Claudin-5a and -5b are both expressed in zebrafish cerebrovascular endothelial cells (ECs). In addition, Claudin-5a was strongly expressed in CP epithelial cells. Loss of Claudin-5b showed no effect on zebrafish vasculogenesis or BBB function. In contrast, the knockout of claudin-5a caused a lethal phenotype of severe whole-brain oedema, ventricular dilatation, and cerebral hernia in zebrafish larvae, although the cerebral vasculogenesis and the development of CP were not altered. In claudin-5a-/- , although ultrastructural analysis of CP and cerebral capillary showed intact integrity of epithelial and endothelial tight junctions, permeability assay indicated a disruption of both BBB and BCSFB functions. On the molecular level, it was found that ZO-1 was upregulated in the CP epithelium of claudin-5a-/-, while the notch and shh pathway responsible for CP development was not affected due to loss of Claudin-5a.ConclusionsOur findings verified a non-functional role of zebrafish Claudin-5b in the BBB and identified Claudin-5a as the ortholog of mammalian Claudin-5, contributing to the development and the functional maintenance of both BBB and BCSFB.

MEDB-57.GNAS inactivation as a driver for sonic hedgehog-activated medulloblastoma

INTRODUCTION: Sonic hedgehog (SHH)-activated medulloblastoma is one of the four consensus molecular subgroups of medulloblastoma and is typically associated with PTCH1, SUFU, and/or SMO mutations. GNAS inactivating mutations are a less commonly recognized tumorigenic driver for SHH pathway activation. CASE PRESENTATION: We report the case of an 11-month-old male who presented with a large posterior fossa mass, cerebellar tonsillar herniation, and obstructive hydrocephalus. Following a successful gross total resection, pathology was consistent with desmoplastic/nodular medulloblastoma. Tumor molecular profiling using a DNA-based, next-generation sequencing platform detected a pathogenic frameshift mutation in the GNAS gene (p.D189Mfs*14, NM_000516.4:c.565_568del) at a variant allele frequency of 81%, suggestive of biallelic GNAS inactivation. The same mutation was detected from a buccal swab sample, confirming germline GNAS inactivation. Whole genome methylation profiling was consistent with medulloblastoma subclass SHH B (infant). Concurrent with this brain tumor evaluation, a skin biopsy was performed of scattered subcutaneous, plate-like nodules distributed over the patient’s back and extremities. This revealed metaplastic-appearing cancellous bone within the dermis and subcutaneous tissue consistent with plate-like osteoma cutis. He was treated with high-dose chemotherapy followed by autologous stem cell rescue and remains disease-free 15 months from diagnosis. DISCUSSION: There have been scattered case reports describing germline loss-of-function GNAS mutations acting as tumorigenic drivers of SHH medulloblastoma. However, GNAS alterations are not covered by most standard diagnostic molecular sequencing panels for medulloblastoma. Other phenotypic manifestations of germline inactivating GNAS mutations include pseudohypoparathyroidism, pseudopseudohypoparathyroidism, progressive osseous heteroplasia, and osteoma cutis. CONCLUSION: Knowledge of the possible association between germline GNAS inactivating mutations and the development of childhood SHH-activated medulloblastoma is essential for prompt diagnosis and treatment initiation. As such, consideration should be given for inclusion of GNAS alterations in diagnostic medulloblastoma sequencing panels, especially in the setting of osteoma cutis or other endocrinopathies.

SURG-15. A Case Series of Pediatric Patients with Brain Tumors and Perioperative COVID-19 Infection

INTRODUCTION: Surgery in patients diagnosed with COVID-19 is associated with increased risk of morbidity and mortality, especially within 6 weeks of SARS-CoV-2 infection. Furthermore, most studies have focused on adults, and little is known about perioperative outcomes in children with COVID-19. METHODS: We reviewed the operative census of the Division of Neurosurgery of Philippine General Hospital from March 2020 until December 2021. We identified all pediatric patients with brain tumors and confirmed COVID-19 infection within two weeks of their neuro-oncologic surgery. Their clinical course and outcomes are described herein. RESULTS: Four patients were included in this case series: three had tumors in the cerebellum, one in the pineal region. All of them were boys, with ages ranging from 4 months to 13 years. All tumors were malignant, and two were confirmed to be medulloblastoma after tumor resection. COVID-19 infection was diagnosed by the presence of SARS-CoV-2 RNA through a nasopharyngeal swab. Three patients acquired the virus post-operatively, likely from nosocomial transmission. In the remaining patient, it was community-acquired. All the patients had chest radiographs consistent with pneumonia but none had marked elevation of serum inflammatory markers. No patient received remdesivir or tocilizumab. At the time of their presentation, either the COVID-19 vaccine was not yet available in the country, or the patient was not yet eligible for vaccination. One patient died because of brain herniation from tumor progression, two were discharged and eventually underwent adjuvant therapy, and one remained in-hospital as of this writing. DISCUSSION: COVID-19 infection resulted in delays in the management of patients with pediatric CNS tumors. Given the high risk of these patients for potential complications, consensus guidelines must be established to achieve good outcomes and prolong survival.

Case Report on the Management of Posterior Reversible Encephalopathy Syndrome (PRES) Postpartum

Advances in Medical, Dental and Health Sciences,2022,5,1,7-8.DOI:10.5530/amdhs.2022.1.2Published:May 2022Type:Case ReportAuthors:Benita Grace Babu Author(s) affiliations:Benita Grace Babu* Department of Pharmacy Practice, Bapuji Pharmacy College, Davangere, Karnataka, INDIA.Abstract:Posterior Reversible Encephalopathy Syndrome (PRES) is an underdiagnosed neurological disorder characterized by neurological symptoms which can develop acutely or sub acutely. It is usually more common among middle aged females. As specified by its name, it is a reversible condition, however timely detection and appropriate management is necessary in order to prevent complications like neurologic deficits and cerebellar herniation. Here is a case report of a 20 year old patient who presents with PRES syndrome in the early postpartum period. Keywords:Management, Neurology, Posterior reversible encephalopathy syndrome, Postpartum, PRES, Rare diseaseView:PDF (329.52 KB)

Evaluating Craniovertebral Stability in Chiari Malformation Coexisting with Type II Basilar Invagination: An Observational Study Based on Kinematic Computed Tomography and Its Clinical Application

Treatment of Chiari malformation (CM) is controversial, especially when it coexists with "stable" or Type II basilar invagination (CM+II-BI). Precise evaluation of craniovertebral junction (CVJ) stability is crucial in such patients; however, this has never been validated. This study aimed to dynamically evaluate atlanto-condyle and atlantoaxial stability by kinematic computed tomography (CT) and report its surgical treatment. The study recruited 101 patients (control, CM, and CM+II-BI groups: 48, 34, and 19 patients, respectively). During kinematic CT, the CVJ stability-related parameters were measured and compared between the 3 groups. The surgical strategy for treating CM+II-BI was based on these results. Preoperative and postoperative images were acquired, and functional scores were used to assess the outcome. Among the 3 groups, the length of the clivus and the height of the condyle were the shortest in the CM+II-BI group, which was accompanied by the greatest rotation of the atlas and atlanto-condyle facet movement on cervical flexion and extension. Moreover, in such patients, increased Chamberlain's baseline violation indicated the aggregate invagination of the odontoid in the flexed position, and asymmetric displacement of atlantoaxial facets was observed. Seventeen CM+II-BI patients underwent surgical treatment with atlantoaxial distraction and occipitocervical fusion. The syringomyelia width and tonsillar herniation decreased significantly, and functional scores indicated symptom relief and good outcomes. CVJ instability, especially the ultramovement of atlanto-condyle facets, commonly exists in II-BI as evaluated using kinematic CT. The surgical strategy of atlantoaxial distraction and occipitocervical fusion should be considered to treat such patients.

Construction and Evaluation of Prognosis Prediction Model for Patients with Brain Contusion and Laceration Based on Machine Learning

Objective Finding valuable risk factors for the prognosis of brain contusion and laceration can help patients understand the condition and improve the prognosis. This study is aimed at analyzing the risk factors of poor prognosis in patients with brain contusion after the operation. Methods A total of 136 patients with cerebral contusion and laceration combined with cerebral hernia treated by neurosurgical craniotomy in our hospital were retrospectively selected and divided into a training set (n = 95) and a test set (n = 41) by the 10-fold crossover method. Logistic regression and back-propagation neural network prediction models were established to predict poor prognosis factors. The receiver operating characteristic curve (ROC) and the calibration curve were used to verify the differentiation and consistency of the prediction model. Results Based on logistic regression and back-propagation neural network prediction models, GCS score ≤ 8 on admission, blood loss ≥ 30 ml, mannitol ≥ 2 weeks, anticoagulants before admission, and surgical treatment are the risk factors that affect the poor prognosis of patients with a cerebral contusion after the operation. The area under the ROC was 0.816 (95% CI 0.705~0.926) and 0.819 (95% CI 0.708~0.931), respectively. Conclusion The prediction model based on the risk factors that affect the poor prognosis of patients with brain contusion and laceration has good discrimination and accuracy.

Evaluation of cervical sagittal parameters on supine magnetic resonance imaging in patients with Chiari I malformation without syringomyelia

ObjectiveThe current study aimed to assess the effects of tonsillar herniation on cervical alignment in Chiari I patients without syringomyelia using new cervical sagittal alignment parameters, such as C0–2 Cobb angle, C2–7 cobb angle, T1 slope, and C2–7 sagittal vertical axis (SVA). MethodsTwo spinal surgeons independently evaluated midline T2-weighted sagittal magnetic resonance imaging findings of 28 Chiari I patients without syringomyelia and 40 patients without tonsillar herniation but with similar complaints. Thereafter, the measured C0–2 Cobb angle, C2–7 Cobb angle T1 slope, and C2–7 SVA were compared using the t-test. ResultsDifferences in the mean values for C2–7 Cobb angle, T1 slope, and C2–7 SVA were found between Chiari I patients and those without tonsillar herniation. ConclusionThe current study showed that Chiari I patients were less lordotic (kyphotic) compared to subjects without tonsillar herniation.

Sinking Skin Flap Syndrome Presenting as Paradoxical Herniation Syndrome (P8-7.002)

Sinking Skin Flap Syndrome Presenting as Paradoxical Herniation Syndrome (P8-7.002)

Left ‐ Right Asymmetry of the Jugular Foramen in Multisuture Syndromic Craniosynostosis

IntroductionApert and Crouzon syndromes are among the most common craniosynostosis syndromes found in children. Mutations have been found in the fibroblast growth factor receptor 2 (FGFR2) gene in both syndromes. Although different mutations, the common mutated receptor raises suspicion for its involvement in the cranial morphogenesis found in these syndromic craniosynostosis patients.The shapes of these children’s skulls have long been thought to be the result of early fusion of the synchondroses. The syndromic morphology of the skulls in these patients, in particular Apert, results from a combination of abnormal development of the skull base, neural tissue, and calvaria. Investigations of these effects has led multiple studies to find decreased volumes of the posterior fossa in craniosynostosis patients and effects on the basicranial foramina of the skull, in particular the jugular foramen.Craniosynostotic children develop elevated intracranial pressure (ICP), as well as, other complications such as hydrocephalus and tonsillar herniation related to this increased pressure and skull dysmorphology. Narrowing of the jugular foramen is a potential cause of venous hypertension and may contribute to the ICP.This study analyzes the size of the jugular foramina in an effort to relate the severity of the foraminal stenosis to timing of synchondroses fusion, seen earlier in Crouzon patients. Additionally, as right jugular foramina have been found to be larger than left in the general population, our study analyzes the right and left jugular foramen sizes in relationship to each other in each Apert and Crouzon patient.MethodsTwelve preoperative CT scans of individuals diagnosed with either Apert or Crouzon syndrome were individually segmented and volume of the right and left jugular foramina estimated in Avizo. Volumes were analyzed using Wilcoxon Rank Sum and Kruskal‐Wallis one‐way ANOVA tests in SPSS. Scatter plots of the ratio of right to left foraminal volumes were created using Excel. This study was conducted under LSUHSC IRB #920.Results and DiscussionInitial results found no significant differences between right and left jugular foramina, however, absolute measurement of volumes most often recorded larger volumes on the left, contrary to that seen in the normal population. Scatter plots revealed two distinct clusters based on ratio of left‐right asymmetry which may reflect a difference in diagnosis.

Morphometric analysis of the tentorial notch by magnetic resonance

IntroductionThe tentorial notch is the aperture between the free edges of the tentorium cerebelli. This complex space varies greatly in dimensions; its study could improve the understanding of the mechanism of brain injuries. The morphometric analysis of the tentorial notch has been analyzed mainly in cadaveric studies. However, the postmortem effect could have an impact in such measures, varying amongst themselves. The aim of this study was to evaluate the morphometry of tentorial notch by Magnetic Resonance Imaging (MRI) in a Hispanic population.MethodsA descriptive cross‐sectional study was performed. We analyzed retrospectively 45 MRI in the tentorial notch from asymptomatic patients, age ranging from 18 to 60 years. The images were evaluated intraobservatory by an expert radiologist. We measured: maximum notch width (MNW), the maximum width of the notch in the axial plane; notch length (NL), the length of the tentorial notch from the superoposterior edge of the dorsum sellae to the apex of the notch; interpedunculoclival distance, the distance from the interpeduncular fossa to the superoposterior edge of the dorsum sellae; apicotectal distance, the distance from the tectum in the median plane to a perpendicular line dropped from the apex of the tentorial notch to the cerebellum; cisternal third nerve distance, the distance covered by the cisternal portion of the third cranial nerve; inter‐third nerve angle, the angle between the two third cranial nerves.ResultsAccording to the quartile of the MNW, we divided the patients into narrow, midrange and wide groups. Also, quartile groups determined by NL were classified as short, midrange and long. The mean and standard deviation of MNW was of 31.42 ± 2.75 mm; NL, 55 ± 4.91 mm. apicotectal distance, 18.85 ± 3.83; interpedunculoclival distance, 21.03 ± 3.24; inter‐third nerve angle, 54.53 ± 7.25; right and left cisternal third nerve distance, 22.75 ± 4.55 and 21.78 ± 4.36 respectively. Statistical differences was identified only between sexes in the MNW.ConclusionMorphometric changes in cadaveric models in the tentorial notch and its neurovascular relations may have implications for a better understanding of the mechanisms of brain herniation and traumatic lesions. In addition, this data could improve the anatomical knowledge for neurosurgeons for cranial base surgical approaches. Although this data does not replace the image guidance, it improves the orientation for neurosurgeons.Significance/implicationDifferences in the clinical presentation of some neurological injuries could be related to variations in the space of the tentorial notch and the position of the brainstem. A transtentorial herniation is the movement of the temporal lobe through the tentorial notch. This pathology occurs in vascular disease, tumors, and brain edema. Furthermore, the location of the pressure and the pathological process, the dimensions of the notch could be a factor for the pattern of herniation.

Analysis of the Therapeutic Effect and Prognostic Factors of 126 Patients With Hypertensive Cerebral Hemorrhage Treated by Soft-Channel Minimally Invasive Puncture and Drainage.

BackgroundSurgery is the main method for the clinical treatment of hypertensive cerebral hemorrhage. Traditional craniotomy faces the disadvantages of the long operation time, easy to cause secondary injury to patients during the operation, and prone to infection after the operation, which is not conducive to the rehabilitation of patients. At present, it is urgent to find a surgical scheme, which can clear hematoma in time, protect brain tissue, and effectively reduce surgical trauma in the clinic.Materials and MethodsThe case database of our hospital was consulted, and the clinical data of patients with hypertensive intracerebral hemorrhage (HICH) treated with soft channel minimally invasive puncture and drainage from February 2018 to October 2021 were retrospectively analyzed. Patients were evaluated for efficacy, and the changes in serum C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), homocysteine (Hcy), endothelin (ET), and vasopressin (AVP) levels before surgery, 3 days after surgery, and 7 days after surgery were analyzed. Clinical data were collected and Logistic regression was used to analyze the prognostic factors.ResultsFinally, according to the inclusion and exclusion criteria, 126 patients were selected as the research object. Among them, there were 24 cases (19.05%) of recovery, 47 cases (37.30%) of markedly effective, 34 cases (26.98%) of effective, 11 cases (8.73%) of ineffective, and 10 cases (7.94%) of death. The total effective rate was 83.33%. The hematoma was basically removed in 116 cases (92.06%). The average evacuation time of hematoma was (7.82 ± 1.63) days. Post-operative intracranial infection occurred in 2 cases (1.59%) and post-operative rebleeding occurred in 5 cases (3.97%). The average hospital stay was (34.16 ± 16.59) days. Serum CRP, TNF-α, IL-6, Hcy, ET, and AVP levels of all patients on the third and seventh days after surgery were lower than those before surgery, and those on the seventh day after surgery were lower than those on the third day after surgery (p < 0.05). The differences in pre-operative Glasgow Coma Scale (GCS) score, bleeding volume, ventricular rupture, complicated cerebral hernia, and attack time to surgery between the good prognosis group and the bad prognosis group were statistically significant (p < 0.05). Pre-operative GCS score, bleeding volume, ventricular rupture, complicated cerebral hernia, and onset time to surgery were all independent factors that affect the prognosis of patients (p < 0.05).ConclusionSoft-channel minimally invasive puncture and drainage treatment of HICH has a significant effect, which is conducive to the complete removal of hematoma, reducing hospitalization time, while adjusting the balance and stability of various cytokines, and improving patient prognosis. Pre-operative GCS score, bleeding volume, rupture into the ventricle, complicated cerebral hernia, and time from onset to operation are all independent factors that affect the prognosis of patients.

Intracranial Meningioma in a Dog - Treatment with Radiotherapy

Background: The most common primary brain neoplasm is meningioma. Dolichocephalic breeds are predisposed and there is no sexual predilection. Clinical signs depend on the location and size of the tumor and have a progressive course. Primary treatement includes surgery, radiotherapy or both. This study aimed to describe the treatment of a dog with suspected intracranial meningioma with definitive radiotherapy, which resulted in significant clinical improvement and prolonged survival. Case: A 9-year-old Shetland Shepherd bitch was diagnosed with a head tilt to the left side that progressed over a few weeks. She previously received corticosteroid therapy, which resulted a clinical improvement that worsened after treatment was discontinued. Computed tomography revealed an extra-axial brain mass in the caudal fossa, lateralized to the right, well-delimited, and measuring approximately 1.5 × 1.4 × 1.7 cm, suggestive of intracranial meningioma. The patient was treated with radiotherapy using Cobalt-60 equipment, with 18 daily fractions of 2.5 Gy at a total dose of 45 Gy using parallel and opposite technique fields. A new tomography performed 30 days after treatment showed a remission of 85% of the initial brain mass measuring approximately 0.9 × 1.0 × 0.5 cm, as well as complete resolution of the clinical signs initially presented. After 14 months, the patient presented with signs of lethargy and ataxia and was medicated with hydroxyurea at a dose of 50 mg/kg 3 times a week and corticosteroid therapy. However, the patient’s neurological condition deteriorated, and she was subjected to reirradiation using the same protocol used previously, which resulted in clinical improvement and a 54% reduction in tumor volume on magnetic resonance. As a late side effect, only permanent alopecia in the irradiated region was observed. The patient died of disease 330 days after the second course of radiotherapy, with a total survival time of 1087 days. Discussion: Meningiomas are extra-axial neoplasms of the central nervous system that grow inside the dura mater. The literature shows that meningiomas are more common in dolichocephalic races with a mean age of 9 years, which supports our findings. Meningiomas most commonly affect the cortical thalamus and cerebellopontine region in dogs, which are normally associated with vestibular symptoms, as seen in this case. Diencephalic damage can result in vestibular signals since the thalamus functions as a relay station for vestibular afferent stimuli that are relayed to the cerebral cortex. In addition to the vestibular syndrome, common clinical signs associated with meningiomas in dogs include seizures, behavioral changes, and walking in circles, which are frequently misinterpreted due to tumor-induced side effects, such as cerebral edema, obstructive hydrocephalus, and cerebral hernia. Advanced imaging techniques should be used to diagnose intracranial neoplasms. In this case, computed tomography was critical for diagnosis and treatment planning. Meningioma treatment may comprise palliative measures, surgery, and radiotherapy. Radiotherapy as a single treatment can improve the quality of life with a decrease in clinical signs and a median survival time of approximately 250-536 days, as reported in the literature. Hydroxyurea can be a therapeutic option in inoperable cases and for patients with clinical limitations to undergo successive anesthesia during radiotherapy. Its most serious side effect is progressive myelosuppression. It can cause temporary partial tumor remission and improvement in clinical signs. As previously stated, radiotherapy can be an effective primary treatment option for treating intracranial meningiomas in dogs, with significant improvement in neurological clinical signs and mild side effects. Keywords: dogs, central nervous system, radiotherapy, reirradiation, oncology. Título: Meningioma intracraniano em cão - tratamento com radioterapia Descritores: cães, sistema nervoso central, radioterapia, reirradiação, oncologia.

An Optimal Animal Model of Ischemic Stroke Established by Digital Subtraction Angiography-Guided Autologous Thrombi in Cynomolgus Monkeys.

ObjectiveIschemic stroke seriously threatens human health, characterized by the high rates of incidence, disability, and death. Developing a reliable animal model that mimics most of the features of stroke is critical for pathological studies and clinical research. In this study, we aimed to establish and examine a model of middle cerebral artery occlusion (MCAO) guided by digital subtraction angiography (DSA) in cynomolgus monkeys.Materials and MethodsIn this study, 15 adult male cynomolgus monkeys were enrolled. Under the guidance of DSA, a MCAO model was established by injecting an autologous venous clot into the middle cerebral artery (MCA) via femoral artery catheter. Thrombolytic therapy with alteplase (rt-PA) was given to eight of these monkeys at 3 h after the occlusion. Blood test and imaging examination, such as computed tomography angiography (CTA), CT perfusion (CTP), brain magnetic resonance imaging (MRI), and brain magnetic resonance angiography (MRA), were performed after the operation to identify the post-infarction changes. The behavioral performance of cynomolgus monkeys was continuously observed for 7 days after operation. The animals were eunthanized on the 8th day after operation, and then the brain tissues of monkeys were taken for triphenyltetrazolium chloride (TTC) staining.ResultsAmong the 15 cynomolgus monkeys, 12 of them were successfully modeled, as confirmed by the imaging findings and staining assessment. One monkey died of brain hernia resulted from intracranial hemorrhage confirmed by necropsy. DSA, CTA, and MRA indicated the presence of an arterial occlusion. CTP and MRI showed acute focal cerebral ischemia. TTC staining revealed infarct lesions formed in the brain tissues.ConclusionOur study may provide an optimal non-human primate model for an in-depth study of the pathogenesis and treatment of focal cerebral ischemia.

Statistical shape models of the posterior cranial fossa and hindbrain volumes may provide a more robust clinical metric for Chiari malformation

Chiari malformation is characterised by the herniation of the cerebellar tonsils through the foramen magnum. However, tonsillar herniation and other 2D morphometric measurements of the posterior cranial fossa (PCF) have a weak association with patients’ symptoms and clinical outcomes. This study aimed to contrast current 2D metrics with a novel 3D shape analysis of the PCF and the hindbrain, to determine if 3D measurements provides further insight into the pathophysiology of Chiari. The cranium of 12 controls and 21 Chiari malformation patients with (N = 9) and without (N = 12) a syrinx were scanned. The morphology of the PCF was quantified with typical 2D measurements. Additionally, a correspondence-based shape model that normalised the PCF volume, was used to find 3D differences in the shape of the PCF, and the distance of the hindbrain from the inner surfaces of the PCF. Shape analysis showed that, compared to controls, the caudal (p = 0.007; 2.3 mm, IQR: 1.6–3.3 mm) and anterior (p = 0.027; 1.3 mm,IQR: 1.1–1.6 mm) surfaces of the hindbrain were closer to the PCF in patients with and without a syrinx, respectively. However, there were negligible differences in the shape of the PCF between patient groups (p > 0.39). Current morphometric measures should be normalised for variation in PCF volume, so that shape measures are not biased. The reduced CSF space between the hindbrain and PCF will alter CSF dynamics, which may compress cerebellar vasculature and contribute to patient symptomatology.

Cervical cerebrospinal fluid venous fistula with syringomyelia treated with suboccipital decompression: illustrative case.

BACKGROUNDCerebrospinal fluid (CSF) venous fistulas are a recently discovered and underdiagnosed cause of spontaneous spinal CSF leak, which may lead to spontaneous intracranial hypotension. Most cases occur in the thoracic spine, and only 2 cases were reported in the cervical spine. Treatments include the epidural blood patch, fibrin glue injection, and surgical ligation of the fistula.OBSERVATIONSThe authors report the treatment of a C6–7 CSF venous fistula, for which direct ligation was not feasible, with suboccipital decompression, leading to the complete resolution of the symptoms. Based on the clinical course and outcome in our patient, the authors summarize the previous theory and propose a hypothesis for the pathophysiology of headache and other symptoms in patients with CSF venous fistulas.LESSONSThe symptoms of CSF venous fistulas may be linked not only to intracranial hypotension but also to the altered CSF dynamics induced by tonsillar herniation. Suboccipital decompression should be considered as a potential treatment option, especially in patients with Valsalva-induced headache who show a poor response to surgical ligation, patients in whom surgical ligation is not feasible, and patients with foramen magnum obstruction. Further investigation of the pathophysiology of CSF venous fistulas is warranted and should be performed in the future.