Nicotine Replacement Therapy for Smokers with Acute Aneurysmal Subarachnoid Hemorrhage: An International Survey

INTRODUCTION Smoking prevalence is twice as high among patients admitted to hospital because of the acute condition of aneurysmal subarachnoid hemorrhage (aSAH) as in the general population. Smoking cessation may improve the prognosis of aSAH, but nicotine replacement therapy (NRT) administered at the time of aSAH remains controversial because of potential adverse effects such as cerebral vasospasm. We investigated the international practice of NRT use for aSAH among neurosurgeons. METHODS The online SurveyMonkey software was used to administer a 15-question, 5-min online questionnaire. An invitation link was sent to those 1425 of 1988 members of the European Association of Neurosurgical Societies (EANS) who agreed to participate in surveys to assess treatment strategies for withdrawal of tobacco smoking during aSAH. Factors contributing to physicians' posture towards NRT were assessed. RESULTS A total of 158 physicians from 50 nations participated in the survey (response rate 11.1%); 68.4% (108) were affiliated with university hospitals and 67.7% (107) practiced at high-volume neurovascular centers with at least 30 treated aSAH cases per year. Overall, 55.7% (88) of physicians offered NRT to smokers with aSAH, 22.1% (35) offered non-NRT support including non-nicotine medication and counselling, while the remaining 22.1% (35) did not actively support smoking cessation. When smoking was not possible, 42.4% (67) of physicians expected better clinical outcomes when prescribing NRT instead of nicotine deprivation, 36.1% (57) were uncertain, 13.9% (22) assumed unaffected outcomes, and 7.6% (12) assumed worse outcomes. Only 22.8% (36) physicians had access to a local smoking cessation team in their practice, of whom half expected better outcomes with NRT as compared to deprivation. CONCLUSIONS A small majority of the surveyed physicians of the EANS offered NRT to support smoking cessation in hospitalized patients with aSAH. However, less than half believed that NRT could positively impact clinical outcome as compared to deprivation. This survey demonstrated the lack of consensus regarding use of NRT for hospitalized smokers with aSAH

Aberrant Lck Signal via CD28 Costimulation Augments Antigen-Specific Functionality and Tumor Control by Redirected T Cells with PD-1 Blockade in Humanized Mice

Combination therapy of adoptively transferred redirected T cells and checkpoint inhibitors aims for higher response rates in tumors poorly responsive to immunotherapy like malignant pleural mesothelioma (MPM). Only most recently the issue of an optimally active chimeric antigen receptor (CAR) and the combination with checkpoint inhibitors is starting to be addressed. Fibroblast activation protein (FAP)-specific CARs with different costimulatory domains, including CD28, Δ-CD28 (lacking lck binding moiety), or 4-1BB were established. CAR-T cells were characterized and antitumor efficacy was tested in a humanized mouse model in combination with PD-1 blockade. Finally, the Δ-CD28 CAR was tested clinically in a patient with MPM. All the three CARs demonstrated FAP-specific functionality Gene expression data indicated a distinct activity profile for the Δ-CD28 CAR, including higher expression of genes involved in cell division, glycolysis, fatty acid oxidation, and oxidative phosphorylation. only T cells expressing the Δ-CD28 CAR in combination with PD-1 blockade controlled tumor growth. When injected into the pleural effusion of a patient with MPM, the Δ-CD28 CAR could be detected for up to 21 days and showed functionality. Overall, anti-FAP-Δ-CD28/CD3ζ CAR T cells revealed superior functionality, better tumor control in combination with PD-1 blockade in humanized mice, and persistence up to 21 days in a patient with MPM. Therefore, further clinical investigation of this optimized CAR is warranted

Haemorrhagic transformation of malignant middle cerebral artery infarction after thrombolysis

Haemorrhagic transformation of malignant middle cerebral artery infarction (MCI) after thrombolysis is a devastating form of stroke. For this reason, decompressive craniectomy has been en vogue for select patients with results suggesting relevant improvement in mortality albeit largely a trade-off for unfavourable outcome particularly in the >60 years old group.A 49-years-old man was referred after developing generalized tonic-clonic seizures and left hemiparesis following thrombolysis for right MCI. Repeat CT brain scan showed haemorrhagic transformation of the right MCI. He underwent craniotomy, clot evacuation and insertion of an intracranial pressure monitor but warranted a second operation to remove the bone flap, subtemporal decompression due to failed medical management at controlling the intracranial pressure. And ICP bolt was positioned on the contralateral side.He was discharged eight weeks following admission with GCS 11/15.The increasing practice of thrombolysis has introduced new insights into the treatment of malignant MCI including the option of a prophylactic decompressive craniectomy. However, evidence for such practice is currently under investigation. Haemorrhagic transformation of MCI after thrombolysis should now be considered a surgical disease in this climate with dual indication for early decompression in select patients

Dorsal thoracic arachnoid web – Confounders of a rare entity in the developing setting

Dorsal thoracic arachnoid webs constitute a rare clinical entity due to a thickening in the arachnoid membrane at that level with resultant compression of the spinal cord and myelopathic features. Obstruction to cerebrospinal fluid flow can lead to syringomyelia, which may assume variable positions relative to the web. Dorsal arachnoid webs are more predominant in the thoracic spine and are diagnosed by the pathognomonic ‘scalpel sign’ on spinal magnetic resonance imaging. Early intervention prevents clinical deterioration. On the other hand, failure to recognize this rare entity can result in progressively compromised ambulatory capacity which translates into loss of income and economic burden with dire social consequences

sEVD-smartphone-navigated placement of external ventricular drains

BACKGROUND Currently, the trajectory for insertion of an external ventricular drain (EVD) is mainly determined using anatomical landmarks. However, non-assisted implantations frequently require multiple attempts and are associated with EVD malpositioning and complications. The authors evaluated the feasibility and accuracy of a novel smartphone-guided, angle-adjusted technique for assisted implantations of an EVD (sEVD) in both a human artificial head model and a cadaveric head. METHODS After computed tomography (CT), optimal insertion angles and lengths of intracranial trajectories of the EVDs were determined. A smartphone was calibrated to the mid-cranial sagittal line. Twenty EVDs were placed using both the premeasured data and smartphone-adjusted insertion angles, targeting the center of the ipsilateral ventricular frontal horn. The EVD positions were verified with post-interventional CT. RESULTS All 20 sEVDs (head model, 8/20; cadaveric head, 12/20) showed accurate placement in the ipsilateral ventricle. The sEVD tip locations showed a mean target deviation of 1.73° corresponding to 12 mm in the plastic head model, and 3.45° corresponding to 33 mm in the cadaveric head. The mean duration of preoperative measurements on CT data was 3 min, whereas sterile packing, smartphone calibration, drilling, and implantation required 9 min on average. CONCLUSIONS By implementation of an innovative navigation technique, a conventional smartphone was used as a protractor for the insertion of EVDs. Our ex vivo data suggest that smartphone-guided EVD placement offers a precise, rapidly applicable, and patient-individualized freehand technique based on a standard procedure with a simple, cheap, and widely available multifunctional device

Inclusion of the coronal insertion angle in the protocol for freehand frontal ventriculostomy

With great interest, we read the study published by Vigo et al. [1] The authors are to be commended for this relevant article, which was inspired by the idea of a more precise, faster and safer ventriculostomy technique. They elaborated a standardized protocol for freehand frontal ventriculostomy which includes information about three parameters: the length of the catheter to be inserted, the insertion point, and the trajectory to the target within the foramen of Monro. In their study they concluded that two of the three parameters, the catheter length and the entry point, are very consistent in the patients analysed and can be easily measured pre-interventionally on multiplanar reconstructed (MPR) imaging. The optimal catheter length between Kocher’s point and foramen of Monro showed only minor variations of 67.4 ± 1 mm in 125 patients.... Keywords: Hydrocephalus; Neuroanatomy; Neuronavigation; Ventriculostom

Implantation of a Berlin Heart EXCOR

A previously healthy two-month-old infant born at thirty-six weeks presented with increasing fussiness, a respiratory rate of sixty breaths per minute and an oxygen saturation of 85 percent. A chest X-ray revealed significant cardiomegaly. A transthoracic echocardiogram demonstrated a severely dilated left ventricle with an ejection fraction of 26 percent. The patient’s hemodynamic stability was supported by milrinone at 0.5 mcg/kg/min and epinephrine at 0.04 mcg/kg/min. Because of her diagnosis of cardiomyopathy and critical status, the surgical team decided to proceed with operative implantation of the Berlin Heart EXCOR.The SurgeryFirst, a midline sternotomy was performed. Aortic cannulation was conducted high on the patient's left lateral aortic arch to ensure enough space for future placement of the inflow cannula. The team commenced cardiopulmonary bypass, and the patient remained warm throughout the procedure. Next, the cardiac mass was elevated out of the pericardial well, and a single 5-0 polypropylene stitch was placed in the right ventricle to facilitate exposure. A pen was used to mark the site for the proposed cannula in the cardiac apex followed by identification of the left obtuse marginal and left anterior descending coronary arteries. A 2-0 silk suture was placed in the cardiac apex to serve as a retraction suture for ventriculotomy. An 11-blade scalpel was then used to make a ventriculotomy and all obstructing muscle below was excised. The inflow cannula was anchored with two pledgets at the nine o’clock and three o’clock positions. The remainder of the graft was sewn counterclockwise with 4-0 polypropylene in a running fashion between the pledgets. The inflow tunnel site was created superior to the rectus muscle, and the inflow cannula was brought through the tunnel.Attention was then turned to the outflow cannula anastomosis. An 8-French Hemashield (collagen impregnated polyester) graft was connected to the Berlin cannula and tied with 2-0 silk ligature twice. An angled c-clamp was positioned on the right lateral anterior wall of the ascending aorta. An aortotomy was then created. The anastomosis of the graft to the aorta was performed using 5-0 polypropylene in a running continuous fashion. Similar tunneling was carried out to externalize the outflow cannula.The cannulae were then deaired and connected to the pneumatic pump. A needle was inserted into the pump to withdraw remaining air. The pump chamber and valves were inspected for air bubbles, and none were found. The team then began to step up the pneumatic flow to thirty beats per minute. As the LVAD rate was increased, flow rates on the cardiopulmonary bypass machine were decreased. Deairing was continued through the needle in the pump until no air was present on the transesophageal echo. The patient successfully came off cardiopulmonary bypass with stable hemodynamics. Evaluation of the Berlin Ikus showed a well-functioning ventricular assist device. The total pump time was 59 minutes. Intraoperative TEE demonstrated a well-positioned apical inflow cannula in the LV apex with adequate decompression of the LV. There was no aortic insufficiency and good RV function.Bivalirudin was started forty-eight hours postoperatively. Institutional protocol aims for a goal PTT of seventy to ninety seconds and to titrate the dose of bivalirudin accordingly. The patient’s dose ranged from 0.48-0.77 mg/kg/hr. The patient was extubated on postoperative day fourteen. She remains in the CVICU and is currently listed as status 1A for a heart transplant.</p

Antithrombotic therapy of Cerebral cavernous malformations /

Cavernous malformations are recognized as the most common vascular anomalies in the brain, that often lead to hemorrhage with neurological symptoms. Usually the treatment is surgical removal or stereotactic radiotherapy. We present a case of a slow-flow vascular anomaly located in the cavernous sinus with recurrent partial thrombotic areas. Inspired by treatment of peripheral venous anomalies antithrombotic therapy was initiated instead of surgery or stereotactic radiotherapy. This led to complete spontaneous resolution of the lesion and normalization of symptoms within nine months. The patient never showed any symptoms over a period of eight years while continuing antithrombotic therapy. Based on this case this therapy may be a reasonable approach to treat intracerebral venous anomalies