Subarachnoid Haemorrhage in Malta : Are outcomes adversely affected due to lack of a local neurovascular service?

Objective: This study was performed to assess the incidence, treatment and outcome of non-traumatic Subarachnoid Haemorrhage (SAH) in an island which does not offer a neurovascular service and to determine whether such limitation is associated with a poor outcome. Method: Data of adult patients with a diagnosis of non-traumatic SAH was analysed retrospectively over a two-year period from January 01, 2009 to December 31, 2010. Results: The incidence of SAH in Malta is 3.16 cases per 100 000 population per year. An underlying aneurysm was found in 50% of all cases investigated with angiography. These patients were transported to the United Kingdom for definitve management and the outcome of all these patients at 6 months was excellent. (modified Rankin Scale of 0 or 1). Conclusions: With the incidence of non-traumatic SAH being in the low range, setting up an interventional neuroradiology service in our country to treat aneurysmal SAH would not have the required numbers to maintain expertise and would probably translate into worse clinical outcomes. Despite having geographical and logistic limitations, our standards of care and survival rates are not below those of other international centres. Outcomes for patients with low initial Hunt and Hess scores have not been adversely.peer-reviewe

TIA-like presentations of cerebral amyloid angiopathy

Transient focal neurological episodes (TFNEs ) are transient ischemic attack (TIA)-like episodes that may occur in patients with cerebral amyloid angiopathy (CAA). The duration of TFNEs is typically similar to TIAs with most symptoms resolving in minutes. Symptoms, similar to those of TIAs include sensory or visual disturbances, motor weakness and language impairment and there may be limb jerking or associated headache. TFNEs have a more gradual onset and tend to spread slowly to contiguous body parts like a migraine aura. TFNEs may occur repeatedly throughout the day and attacks may continue over several months. TFNEs are typically associated with focal cortical subarachnoid hemorrhage or with focal cortical superficial siderosis. They may also be seen in patients with CAA-related lobar hemorrhage, microhemorrhage or leukoencephalopathy. Migraine prophylactic agents such as verapamil and topiramate may be useful in stopping frequent recurrent TFNEs. TFNEs are an under-recognized cause of apparent TIAs. It is important to keep TFNEs in the differential diagnosis when a patient presents with a presumed TIA as thrombolysis or anticoagulation is relatively contraindicated in CAA. Gradient echo MRI should be performed to exclude microhemorrhages when TFNEs are suspected. Clinicians most frequently associate cerebral amyloid angiopathy (CAA) with intracerebral hemorrhage or with a clinical picture of vascular cognitive impairment.1 There have however, been increasing clinical reports documenting that CAA may cause a variety of acute clinical neurological manifestations.2 Although these phenomena are superficially similar to TIAs and may be mistaken for them, they have clinical time profiles and progressions that can distinguish them from TIAs clinically. They appear to be caused by different manifestations of the complications of CAA and are now known as transient focal neurological episodes (TFNE).2,3 CAA frequency increases with age with approximately 50 % of individuals over the age of 75 being affected. The exact cause of CAA remains uncertain however increased production and/or decreased breakdown of amyloid proteins may have a role. CAA predominantly affects occipital regions of the brain followed by frontal and temporal areas. Cerebellar vessels are less commonly affected.3The Boston criteria is the current standard criteria for diagnosis of CAA. In this review, we attempt to classify and describe the different causes of TFNE’s in CAA.peer-reviewe

A 5-year study on the epidemiology and outcome of patients with non-traumatic subarachnoid hemorrhage in Malta

Objective: The aim of this study was to measure the incidence, treatment and outcome of non-traumatic Subarachnoid Haemorrhage (SAH) cases occurring in Malta during the five-year period between January 2011 and December 2015, in order to determine whether the lack of a local neurovascular service is associated with a poor outcome. Method: A retrospective analysis of adult patients (above the age of 16) diagnosed with non-traumatic SAH was carried out. The data collected included a five-year period from January 1st 2011 till December 31st 2015. Results: The incidence of SAH was estimated at 4.04 cases per 100,000 population per year. An underlying aneurysm was found to be the cause of the SAH in 69.1 % of cases investigated with CT angiography or Cerebral Angiography. In these patients, definitive management in the form of coiling or clipping of the aneurysm was carried out in the United Kingdom as part of an agreement between countries, within days. The outcome of these patients measured at 6 months using the Modified Rankin Scale (MRS) was found to be excellent. Conclusion: Despite our geographical and logistical limitations, outcomes of those patients with initial low Hunt and Hess (H+H) scores have not been affected by the lack of a local neurovascular service. Results are comparable to those of other international centres. Further studies looking into feasibility of expanding our local services are being carried out.peer-reviewe

Neurogenic disturbances of cardiac rhythm

Arrhythmias are disturbances of electrical activation of the heart and are commonly encountered clinical conditions. Although typically associated with cardiac pathology, they have also been described in stroke and epilepsy. Two closely related structures, the insula and the temporal lobe, particularly the mesial region, have been implicated. Derangement of central autonomic control appears to be a key driver in neurogenic arrhythmogenesis and both these structures appear to play some role in influencing autonomic activity. Our understanding of this phenomenon is only in its infancy, and more research will be necessary to further it.peer-reviewe

Hypopituitarism following traumatic brain injury

Traumatic brain injury (TBI) is a worldwide public health problem and an important cause of hypopituitarism. The incidence of hypopituitarism following moderate to severe TBI varies in different studies and may occur as multiple or isolated hormonal deficiencies, with gonadotrophin and growth hormone insufficiencies predominating, particularly in the acute setting. Adrenocorticotropic hormone deficiency is also common during the recovery phase. Pituitary function assessment in the acute phase post TBI is subject to multiple caveats and pitfalls due to hormonal alterations which occur as normal physiological responses to critical illness and the effects of drugs that are used in the intensive care unit. Nonetheless, assessment of the hypothalamo-pituitary-adrenal axis is of paramount importance during this period. Predictors of hypopituitarism during the acute phase of TBI remain unclear - further research is warranted.peer-reviewe

Case Fatality Rates of Subarachnoid Hemorrhage Are Decreasing with Substantial between-Country Variation : A Systematic Review of Population-Based Studies between 1980 and 2020

Background: The declining prevalence of smoking and hypertension has been associated with the decrease of subarachnoid hemorrhage (SAH) incidence in the 21st century. Since these same risk factors are linked to SAH mortality, the case fatality rate (CFR) of SAH has potentially also decreased during recent decades. Thus, we conducted a systematic review to address SAH CFR changes over the last 40 years. Methods: We performed a systematic literature search in OVID Medline, Scopus, and Cochrane Library databases. We focused on population-based studies published between 1980 and 2020 that had included both hospitalized and nonhospitalized SAH cases, and reported 1-month CFRs for at least two individual study periods for the same population. Finally, we used a linear regression analysis to estimate the annual CFR changes in each identified population and pooled the regional changes for larger geographical and sex-specific analyses. Results: Of the 4,562 initial publications, we included 22 studies (three of which reached a high-quality classification) consisting of 17,593 SAH patients from 16 different populations and 10 countries. Between 1980 and 2020, SAH CFR declined in all but two populations by an average of -1.5%/year. In the continent-based pooled geographical analyses, CFR decline was the most noticeable in North America (-2.4%/year) and Oceania (-2.2%/year). The decline was more moderate in Northern Europe (-0.8%/year) and Southern Europe (-0.7%/year). Overall, CFRs declined both in women (-1.9%/year) and in men (-1.2%/year). When comparing the first and second half of the study period, CFRs declined from 41% to 31%. Conclusion: Short-term SAH CFRs seem to have declined since 1980. Time trends of SAH CFRs can still be identified for only a few populations, and high-quality data are scarce. Whether the observed decline relates to changes in risk factors, treatment outcomes or diagnostics remains to be studied. (C) 2022 S. Karger AG, BaselPeer reviewe

Intelligent Word Embeddings of Free-Text Radiology Reports

Radiology reports are a rich resource for advancing deep learning applications in medicine by leveraging the large volume of data continuously being updated, integrated, and shared. However, there are significant challenges as well, largely due to the ambiguity and subtlety of natural language. We propose a hybrid strategy that combines semantic-dictionary mapping and word2vec modeling for creating dense vector embeddings of free-text radiology reports. Our method leverages the benefits of both semantic-dictionary mapping as well as unsupervised learning. Using the vector representation, we automatically classify the radiology reports into three classes denoting confidence in the diagnosis of intracranial hemorrhage by the interpreting radiologist. We performed experiments with varying hyperparameter settings of the word embeddings and a range of different classifiers. Best performance achieved was a weighted precision of 88% and weighted recall of 90%. Our work offers the potential to leverage unstructured electronic health record data by allowing direct analysis of narrative clinical notes.Comment: AMIA Annual Symposium 201

BRAF V600E, TERT promoter mutations and CDKN2A/B homozygous deletions are frequent in epithelioid glioblastomas: a histological and molecular analysis focusing on intratumoral heterogeneity

学位記番号:医博甲173

Clinicopathological characteristics of circumscribed high-grade astrocytomas with an unusual combination of BRAF V600E, ATRX, and CDKN2A/B alternations.

学位記番号：医博甲175

Acidente vascular cerebral induzido por cocaína em paciente jovem

O relato de caso apresentado neste trabalho, aborda a relação do uso da cocaína e o acidente vascular cerebral após um paciente adulto jovem chegar a uma unidade especializada com déficits neurológicos e histórico de uso de drogas ilícitas de forma aguda e de longa data, sem outras comorbidades constatadas. Além disso, apresentou exames laboratoriais e sorológicos sem alterações significativas. O único fator de risco identificado no caso em tela para o acidente vascular foi, portanto, o uso de cocaína. Assim, neste trabalho, enfatiza-se eventual relação entre o uso da cocaína com o caso em tela.  The case report presented here addresses the relationship between cocaine use and stroke. A young adult patient arrived at a specialized unit with neurological deficits and a history of acute and long-term illicit drug use and presented no other comorbidities. In addition, he presented laboratory and serological tests without alterations. The only risk factor identified for stroke was, therefore, cocaine use. Thus, this work points to an eventual relationship between cocaine use and the case in question.