Altano-axial subluxation with torticollis secondary to Langerhans cell histocytosis

Langerhans Cell Histiocytosis is a rare disease featuring aberrant proliferation of dendritic cells that can infiltrate the bony skeleton. The authors report a case of six-year-old female presenting with torticollis. She was found to have extensive lytic LCH lesions in the cranio-cervical junction, causing atlanto-axial rotatory subluxation. Decision was made for a non-surgical approach to treat the patient. She was placed in a Halo brace, and given concomitant chemotherapy. Post-treatment imaging demonstrated near-complete reconstitution of the skeleton affected by LCH. This case highlights the feasibility of non-surgical treatment in selected LCH patients at high-risk of spinal instability. Keywords: Atlanto-axial subluxation, Langerhans cell histocytosis, Torticolli

Extending thrombolysis to 4·5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data

Background: Stroke thrombolysis with alteplase is currently recommended 0–4·5 h after stroke onset. We aimed to determine whether perfusion imaging can identify patients with salvageable brain tissue with symptoms 4·5 h or more from stroke onset or with symptoms on waking who might benefit from thrombolysis. Methods: In this systematic review and meta-analysis of individual patient data, we searched PubMed for randomised trials published in English between Jan 1, 2006, and March 1, 2019. We also reviewed the reference list of a previous systematic review of thrombolysis and searched ClinicalTrials.gov for interventional studies of ischaemic stroke. Studies of alteplase versus placebo in patients (aged ≥18 years) with ischaemic stroke treated more than 4·5 h after onset, or with wake-up stroke, who were imaged with perfusion-diffusion MRI or CT perfusion were eligible for inclusion. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] score 0–1) at 3 months, adjusted for baseline age and clinical severity. Safety outcomes were death and symptomatic intracerebral haemorrhage. We calculated odds ratios, adjusted for baseline age and National Institutes of Health Stroke Scale score, using mixed-effects logistic regression models. This study is registered with PROSPERO, number CRD42019128036. Findings: We identified three trials that met eligibility criteria: EXTEND, ECASS4-EXTEND, and EPITHET. Of the 414 patients included in the three trials, 213 (51%) were assigned to receive alteplase and 201 (49%) were assigned to receive placebo. Overall, 211 patients in the alteplase group and 199 patients in the placebo group had mRS assessment data at 3 months and thus were included in the analysis of the primary outcome. 76 (36%) of 211 patients in the alteplase group and 58 (29%) of 199 patients in the placebo group had achieved excellent functional outcome at 3 months (adjusted odds ratio [OR] 1·86, 95% CI 1·15–2·99, p=0·011). Symptomatic intracerebral haemorrhage was more common in the alteplase group than the placebo group (ten [5%] of 213 patients vs one [<1%] of 201 patients in the placebo group; adjusted OR 9·7, 95% CI 1·23–76·55, p=0·031). 29 (14%) of 213 patients in the alteplase group and 18 (9%) of 201 patients in the placebo group died (adjusted OR 1·55, 0·81–2·96, p=0·66). Interpretation: Patients with ischaemic stroke 4·5–9 h from stroke onset or wake-up stroke with salvageable brain tissue who were treated with alteplase achieved better functional outcomes than did patients given placebo. The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis

Search for new resonances in Wγ and Zγ final states in pp collisions at √s = 8 TeV with the ATLAS detector

This Letter presents a search for new resonances decaying to final states with a vector boson produced in association with a high transverse momentum photon, Vγ , with V=W(→ℓν)V=W(→ℓν) or Z(→ℓ+ℓ−)Z(→ℓ+ℓ−), where ℓ=eℓ=e or μ. The measurements use 20.3 fb−1 of proton–proton collision data at a center-of-mass energy of View the MathML sources=8 TeV recorded with the ATLAS detector. No deviations from the Standard Model expectations are found, and production cross section limits are set at 95% confidence level. Masses of the hypothetical aTaT and ωTωT states of a benchmark Low Scale Technicolor model are excluded in the ranges [275,960] GeV[275,960] GeV and [200,700]∪[750,890] GeV[200,700]∪[750,890] GeV, respectively. Limits at 95% confidence level on the production cross section of a singlet scalar resonance decaying to Zγ final states have also been obtained for masses below 1180 GeV