Successful use of inhaled nitric oxide to decrease intracranial pressure in a patient with severe traumatic brain injury complicated by acute respiratory distress syndrome: a role for an anti-inflammatory mechanism?

Use of inhaled nitric oxide in humans with traumatic brain injury and acute respiratory distress syndrome has twice previously been reported to be beneficial. Here we report a third case. We propose that INO may decrease the inflammatory response in patients with increased intracranial pressure caused by traumatic brain injury accompanied by acute respiratory distress syndrome thereby contributing to improved outcomes

Pediatric primary intramedullary spinal cord glioblastoma

Spinal cord tumors in pediatric patients are rare, representing less than 1% of all central nervous system tumors. Two cases of pediatric primary intramedullary spinal cord glioblastoma at ages 14 and 8 years are reported. Both patients presented with rapid onset paraparesis and quadraparesis. Magnetic resonance imaging in both showed heterogeneously enhancing solitary mass lesions localized to lower cervical and upper thoracic spinal cord parenchyma. Histopathologic diagnosis was glioblastoma. Case #1 had a small cell component (primitive neuroectodermal tumor-like areas), higher Ki67, and p53 labeling indices, and a relatively stable karyotype with only minimal single copy losses involving regions: Chr8;pter-30480019, Chr16;pter-29754532, Chr16;56160245–88668979, and Chr19;32848902-qter on retrospective comparative genomic hybridization using formalin-fixed, paraffin-embedded samples. Case #2 had relatively bland histomorphology and negligible p53 immunoreactivity. Both underwent multimodal therapy including gross total resection, postoperative radiation and chemotherapy. However, there was no significant improvement in neurological deficits, and overall survival in both cases was 14 months.This report highlights the broad histological spectrum and poor overall survival despite multi modality therapy. The finding of relatively unique genotypic abnormalities resembling pediatric embryonal tumors in one case may highlight the value of genome-wide profiling in development of effective therapy. The differences in management with intracranial and low-grade spinal cord gliomas and current management issues are discussed

Usefulness and Impact of Intraoperative Imaging for Glioma Resection on Patient Outcome and Extent of Resection: A Systematic Review and Meta-Analysis

BACKGROUND: Diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and intraoperative magnetic resonance imaging (iMRI) permit greater visualization and more accurate presurgical planning. Meta-analysis of these techniques for maximizing resection, postoperative functionality, and survival may further validate purported strengths of these techniques compared with standard neuronavigation. METHODS: A systematic search of the PubMed database was conducted in line with the PRISMA guidelines for meta-analysis with the following keywords: Diffusion tensor imaging OR intraoperative MRI OR functional MRI AND glioma surgery resection outcome. Articles found to meet inclusion criteria were segregated and analyzed and resulting data were compared with standard neuronavigation (control cohort).RESULTS: A total of 435 articles were identified, with 29 distinct studies meeting inclusion criteria, including DTI (n = 3), fMRI (n = 5), and iMRI (n = 21). Nine studies directly compared results with standard navigation. Mean gross total resection (GTR) rates were not different among cases using DTI, fMRI, iMRI, or traditional neuronavigation (P = 0.136). On controlling for covariates, more patients received GTR in the advanced imaging cohort, although statistically insignificant (46.5% [95% confidence interval, 38.0%-55.0%] vs. 30.4% [95% confidence interval, 11.6%-49.1%]; P = 0.127; partial eta(2) = 0.217). Patients undergoing advanced imaging showed attenuated incidence of postsurgical permanent neurologic deficits, although also statistically insignificant (11.3% vs. 13.8%; P = 0.838). CONCLUSIONS: Current data are overall insufficient to support the notion that advanced imaging techniques are superior, either as a combined cohort or individually, in achieving GTR, improved symptom resolution, or survival compared with traditional neuronavigation

M2 segment thrombectomy is not associated with increased complication risk compared to M1 segment: A meta-analysis of recent literature

Introduction: Recent clinical comparisons of M1 and M2 segment endovascular thrombectomy have reached incongruous results in rates of complication and functional outcomes. This study aims to clarify the controversy surrounding this rapidly advancing technique through literature review and meta-analysis. Methods: A Pubmed search was performed (January 2015-September 2019) using the following keywords: “M2 AND (“stroke” OR “occlusion”) AND (“thrombectomy” OR “endovascular”)”. Safety and clinical outcomes were compared between segments via weighted Student\u27s t-test, Chi-square and odds ratio while study heterogeneity was analyzed using Cochran Q and I2 tests. Results: Pubmed identified 208 articles and eleven studies were included after full-text analysis, comprising 2,548 M1 and 758 M2 mechanical thrombectomy segment cases. Baseline National Institutes of Health Stroke Scale scores were comparatively lower in patients experiencing an M2 occlusion (16 ± 1.25 vs 13.6 ± 0.96, p \u3c 0.01). Patients who underwent M2 mechanical thrombectomy were more likely to experience both good clinical outcomes (modified Rankin Scale 0–2) (48.6% vs 43.5% respectively, OR 1.24; CI 1.05–1.47, p = 0.01) and excellent clinical outcomes (modified Rankin Scale 0–1) (34.7% vs. 26.5%%, OR 1.6; CI 1.28–1.99, p \u3c 0.01) at 90 days compared to M1 mechanical thrombectomy. Neither recanalization rates (75.3% vs 72.8%, OR 0.92, CI 0.75–1.13, p = 0.44) nor symptomatic intracranial hemorrhage rates (5.6% vs 4.9%, OR 0.92; CI 0.61–1.39, p= 0.7) were significantly different between M1 and M2 cohorts. Mortality was less frequent in the M2 cohort compared to M1 (16.3% vs 20.7%, OR 0.73; CI 0.57–0.94, p = 0.01). M1 and M2 cohorts did not differ in symptom onset-to-puncture (238.1 ± 46.7 vs 239.8 ± 43.9 min respectively, p=0.488) nor symptom onset-to recanalization times (318.7 ± 46.6 vs 317.7 ± 71.1 min respectively, p = 0.772), though mean operative duration was shorter in the M2 cohort (61.8 ± 25.5 vs 54.6 ± 24 min, p \u3c 0.01). Conclusions: Patients who underwent M2 mechanical thrombectomy had a higher prevalence of good and excellent clinical outcomes compared to the M1 mechanical thrombectomy cohorts. Additionally, our data suggest lower mortality rates in the M2 cohort and symptomatic intracranial hemorrhage rates that are similar to the M1 cohort. Therefore, M2 segment thrombectomy likely does not pose a significantly elevated operative risk and may have a positive impact on patient outcomes

Usefulness and Impact of Intraoperative Imaging for Glioma Resection on Patient Outcome and Extent of Resection: A Systematic Review and Meta-Analysis

BACKGROUND: Diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and intraoperative magnetic resonance imaging (iMRI) permit greater visualization and more accurate presurgical planning. Meta-analysis of these techniques for maximizing resection, postoperative functionality, and survival may further validate purported strengths of these techniques compared with standard neuronavigation. METHODS: A systematic search of the PubMed database was conducted in line with the PRISMA guidelines for meta-analysis with the following keywords: Diffusion tensor imaging OR intraoperative MRI OR functional MRI AND glioma surgery resection outcome. Articles found to meet inclusion criteria were segregated and analyzed and resulting data were compared with standard neuronavigation (control cohort). RESULTS: A total of 435 articles were identified with 29 distinct studies meeting inclusion criteria including: DTI (n = 3), fMRI (n = 5), iMRI (n = 21). Nine studies directly compared results to standard navigation. Mean GTR rates were not different among cases using DTI, fMRI, iMRI or traditional neuronavigation (p = 0.136). Upon controlling for covariates, more patients received GTR in the advanced imaging cohort, though statistically insignificant (46.5% [95% CI 38.0-55.0%] vs. 30.4% [11.6-49.1%], p = 0.127; Partial eta(2) = 0.217). Patients undergoing advanced imaging demonstrated attenuated incidence of post-surgical permanent neurological deficits, although also statistically insignificant (11.3% vs. 13.8%, p = 0.838). CONCLUSIONS: Current data are overall insufficient to support the notion that advanced imaging techniques are superior, either as a combined cohort or individually, in achieving GTR, improved symptom resolution, or survival compared with traditional neuronavigation

Posterior Reversible Encephalopathy Syndrome Secondary to CSF Leak and Intracranial Hypotension: A Case Report and Literature Review

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical neuroradiological condition characterized by insidious onset of neurological symptoms associated with radiological findings indicating posterior leukoencephalopathy. PRES secondary to cerebrospinal fluid (CSF) leak leading to intracranial hypotension is not well recognized etiology of this condition. Herein, we report a case of PRES that occurred in the setting of CSF leak due to inadvertent dural puncture. Patient underwent suturing of the dural defect. Subsequently, his symptoms resolved and a repeated brain MRI showed resolution of brain lesions. The pathophysiology and mechanistic model for developing PRES in the setting of intracranial hypotension were discussed. We further highlighted the importance of tight blood pressure control in patients with CSF leak and suspected intracranial hypotension because they are more vulnerable to develop PRES with normal or slightly elevated bleed pressure values

EXTREMELY HALOPHILIC ARCHAEA FROM ALGERIAN SALT LAKES: ISOLATION, PHYLOGENETIC IDENTIFICATION AND BIOPROSPECTION OF HYDROLYTIC ENZYMES

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