Opinion article: Neurosurgical treatment for neuro-ophthalmologic conditions

A significant role of the neuro-ophthalmologist is to counsel patients on appropriate management and anticipated visual prognosis for conditions affecting the afferent and efferent visual systems, including those requiring neurosurgical treatment. However, the literature regarding anticipated neuro- ophthalmologic prognosis after neurosurgical intervention for cerebral aneurysms, sellar lesions, optic pathway tumors, and elevated intracranial pressure is limited with many key questions unanswered. For example, if a cerebral aneurysm is equally amenable to clipping or endovascular coiling, is there a preferred approach in terms of visual prognosis based on aneurysm location? Is dural venous sinus stenting (VSS) for idiopathic intracranial hypertension (IIH) superior, equivalent or inferior to shunting in terms of visual recovery and safety profile? Landmark studies on pituitary tumors using pre-operative optical coherence tomography (OCT) imaging of the optic nerve head to predict visual recovery after surgical decompression of the optic chiasm have changed neuro-ophthalmologic practice and enabled patients to be better informed regarding expected visual outcomes. 1,2 In order to optimize an interdisciplinary team approach to patient care, further studies of visual outcomes for neuro- ophthalmologic conditions requiring neurosurgical intervention are needed

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Angiogenesis in the brain during development: the effects of vascular endothelial growth factor and angiopoietin-2 in an animal model

OBJECT: The goal of this study was to examine the roles of vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2) in the formation of blood vessels in the brain in a developmental animal model not routinely used for such a study. METHODS: Either VEGF, Ang-2, or a combination of the two factors were injected into the optic tectum of 4-day-old quail embryos. Immunohistochemical analysis and laser confocal microscopy were used to observe the effects on endothelial cells in the brain. Vascular endothelial growth factor and Ang-2 had very different effects on the development of blood vessels; the former caused expansion and the latter retraction of these vessels. Treatment with a combination of VEGF and Ang-2 caused retroorbital or intraventricular hemorrhage, and brain blood vessels appeared enlarged and dysmorphic, with dramatically extended filopodia. CONCLUSIONS: Some of these observations may provide insight into how one may develop a better model of brain arteriovenous malformations

Cushing-type ectopic pituitary adenoma with unusual pathologic features

AbstractEctopic pituitary adenomas comprise, by varying reports, approximately 1-2% of all pituitary adenomas. They are often located in the nasopharyngeal region associated with the pharyngeal pituitary. The location and pathologic features of these masses make them atypical when compared with intrasellar pituitary adenomas. A 54-year-old man presented with vertebral compression fracture and physical stigmata of Cushing’s disease. Biochemical testing confirmed hypercortisolemia responsive to high dose dexamethasone suppression. MRI of the head demonstrated an enhancing mass in the posterior aspect of the sphenoid sinus not involving the sella turcica. Endoscopic biopsy followed by resection confirmed this mass to be a pituitary adenoma with unusual pathologic features. Most notably, the tumor cells demonstrated large, eosinophilic, vacuolated cytoplasm. Immunohistochemical profile of the tumor was typical of an ACTH secreting tumor, notably with positivity for ACTH. The patient did well from his surgery. Post-operatively his serum cortisol level normalized and he remains in chemical remission one year after surgery. Ectopic pituitary adenomas are an unusual manifestation of hormonally active pituitary neoplastic disease. Their atypical clinical presentations, location, and pathologic features can make them a diagnostic challenge. Clinicians should be aware of these entities, especially when considering differential diagnosis for a mass in the sphenoid sinus and nasopharyngeal region

Conus perimedullary arteriovenous fistula with intracranial drainage: Case report

OBJECTIVE AND IMPORTANCE: Perimedullary arteriovenous fistulae (AVFs) do not commonly present with subarachnoid hemorrhage or intracranial venous drainage causing neurological symptoms. We present a case with both of these features. The patient was inadvertently treated for an unruptured intracranial aneurysm before his true problem was recognized. CLINICAL PRESENTATION: A 65-year-old man presented with sudden-onset lower-extremity weakness, diplopia, nausea, and dysarthria on the day of admission. A lumbar puncture documented subarachnoid hemorrhage, and imaging studies revealed a left middle cerebral artery aneurysm. It was noted during surgery that this aneurysm was unruptured, and the patient did not exhibit improvement after surgery. INTERVENTION: Spinal angiography demonstrated a spinal perimedullary AVF feeding from the left T12 radicular artery; venous drainage extended rostrally into the posterior fossa venous system. The AVF was surgically occluded via a posterior laminectomy at the level of the AVF. After surgery, the patient\u27s symptoms began to abate. CONCLUSION: Conus perimedullary AVFs can have venous drainage that extends as far as intracranial veins, which can lead to confusing clinical findings because the symptoms may suggest an intracranial process, although the lesion is in the spine. Surgeons must be aware of this confusing presentation

Bow hunter stroke caused by cervical disc herniation. Case report

Bow hunter stroke, which is characterized by transient vertebrobasilar ischemia brought on by head turning, is an unusual condition usually caused by structural abnormalities at the craniocervical junction. The authors present a case in which compression of the left vertebral artery (VA) at the C4-5 level was caused by a laterally herniated intervertebral disc. A 56-year-old man presented with a 6-month history of dizziness and syncope when he turned his head 45 degrees or more to the left. Transcranial Doppler (TCD) ultrasonography demonstrated decreased blood flow through the left VA, and angiography revealed an occlusion of the left VA at the C4-5 level, both when the patient turned his head to the left. Via an anterior cervical approach, the VA canal was unroofed through the transverse foramina to decompress the left VA at C4-5; intraoperatively, the left VA was found to be compressed by a laterally herniated cervical disc fragment. To the best of the authors\u27 knowledge this is the first report of a laterally herniated cervical disc causing bow hunter stroke. The use of TCD may be of value in the diagnosis and management of the disorder, and herniated cervical disc must be included in the roster of potential causes for this rare disease

Cushing-type ectopic pituitary adenoma with unusual pathologic features

Ectopic pituitary adenomas comprise, by varying reports, approximately 1-2% of all pituitary adenomas. They are often located in the nasopharyngeal region associated with the pharyngeal pituitary. The location and pathologic features of these masses make them atypical when compared with intrasellar pituitary adenomas. A 54-year-old man presented with vertebral compression fracture and physical stigmata of Cushing’s disease. Biochemical testing confirmed hypercortisolemia responsive to high dose dexamethasone suppression. MRI of the head demonstrated an enhancing mass in the posterior aspect of the sphenoid sinus not involving the sella turcica. Endoscopic biopsy followed by resection confirmed this mass to be a pituitary adenoma with unusual pathologic features. Most notably, the tumor cells demonstrated large, eosinophilic, vacuolated cytoplasm. Immunohistochemical profile of the tumor was typical of an ACTH secreting tumor, notably with positivity for ACTH. The patient did well from his surgery. Post-operatively his serum cortisol level normalized and he remains in chemical remission one year after surgery. Ectopic pituitary adenomas are an unusual manifestation of hormonally active pituitary neoplastic disease. Their atypical clinical presentations, location, and pathologic features can make them a diagnostic challenge. Clinicians should be aware of these entities, especially when considering differential diagnosis for a mass in the sphenoid sinus and nasopharyngeal region