Does endovascular treatment with curative intention have benefits for treating High-grade AVM versus radiosurgery? Efficacy, safety, and cost-effectiveness analysis

BACKGROUND: The treatment of high-grade arteriovenous malformations (AVMs) remains challenging. Microsurgery provides a rapid and complete occlusion compared to other options, but is associated with undesirable morbidity and mortality. The aim of this study was to compare the occlusion rates, incidence of unfavorable outcomes, and cost-effectiveness of embolization and stereotactic radiosurgery (SRS) as a curative treatment for high-grade AVMs.METHODS: A retrospective series of 57 consecutive patients with high-grade AVM treated with embolization or SRS, with the aim of achieving complete occlusion, was analyzed. Demographic, clinical, and angio-architectonic variables were collected. Both treatments were compared for the occlusion rate and procedure-related complications. In addition, a cost-effectiveness analysis was performed.RESULTS: Thirty (52.6%) patients were men and 27 (47.4%) were women (mean age 39 years). AVMs were unruptured in 43 (75.4%) patients, and ruptured in 14 (24.6%) patients. The presence of deep venous drainage, nidus volume, perforated arterial supply, and eloquent localization were more frequent in the SRS group. Complications such as hemorrhage or worsening of previous seizures were more frequent in the embolization group. No significant differences were observed in the occlusion rates or in the time necessary to achieve occlusion between the groups. The incremental cost-effectiveness ratio for endovascular treatment vs. SRS was $ 53.279.CONCLUSION: Both techniques achieved similar occlusion rates, but SRS carried a lower risk of complications. Staged embolization may be associated with a greater risk of hemorrhage, while SRS was demonstrated to have a better cost-effectiveness ratio. These results support SRS as a better treatment option for high-grade AVMs

Neurosurgical emergency management during the lockdown period in health care regions in Spain with different COVID-19 impact: lessons learned to improve outcomes on the future waves

Background COVID-19 has overloaded health care systems, testing the capacity and response in every European region. Concerns were raised regarding the impact of resources’ reorganization on certain emergency pathology management. The aim of the present study was to assess the impact of the outbreak (in terms of reduction of neurosurgical emergencies) during lockdown in different regions of Spain. Methods We analyzed the impact of the outbreak in four different affected regions by descriptive statistics and univariate comparison with same period of two previous years. These regions differed in their incidence level (high/low) and in the time of excess mortality with respect to lockdown declaration. That allowed us to analyze their influence on the characteristics of neurosurgical emergencies registered for every region. Results 1185 patients from 18 neurosurgical centers were included. Neurosurgical emergencies that underwent surgery dropped 24.41% and 28.15% in 2020 when compared with 2019 and 2018, respectively. A higher reduction was reported for the most affected regions by COVID-19. Non-traumatic spine experienced the most significant decrease in number of cases. Life-threatening conditions did not suffer a reduction in any health care region. Conclusions COVID-19 affected dramatically the neurosurgical emergency management. The most significant reduction in neurosurgical emergencies occurred on those regions that were hit unexpectedly by the pandemic, as resources were focused on fighting the virus. As a consequence, life-threating and non-life-threatening conditions’ mortality raised. Results in regions who had time to prepare for the hit were congruent with an organized and sensible neurosurgical decision-making.Peer reviewe

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: A nationwide study in Spain

Objective To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain. Settings The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied. Participants This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020. Interventions An exploratory factorial analysis was performed to select the most relevant variables of the sample. Primary and secondary outcome measures Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection. Results Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/10 5 people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade =3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/10 5 people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated. Conclusions Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/10 5 people/week) was a statistically independent predictor of mortality. Trial registration number CEIM 20/217

Estudio comparativo de los resultados del tratamiento con intención curativa con embolización y radiocirugía en malformaciones arteriovenosas cerebrales de alto grado. Validación de escalas predictivas y pronósticas

Las malformaciones arteriovenosas, a pesar de su rareza, cuya incidencia se estima en un 1,1 por 100.000 habitantes, son la segunda causa de infarto hemorrágico en pacientes jóvenes. Existe controversia respecto a si el tratamiento de las lesiones que no se presentan con hemorragia puede empeorar la historia natural de la enfermedad. En la actualidad, existen cuatro opciones de tratamiento. Estosson, la resección microquirúrgica, el tratamiento endovascular, la radiocirugía y el tratamiento conservador. Respecto a las lesiones de bajo grado existe cierto consenso de cual de los métodos terapéuticos utilizar. Esto no es así cuando se habla de malformaciones de alto grado. El tratamiento a través de la resección microquirúrgica sigue siendo el gold estándar, ya que es el tratamiento que ha demostrado lograr la mayor tasa de obliteración, y por tanto de curación de las malformaciones de alto grado, sin embargo, conlleva una alta tasa de complicaciones y de resultados desfavorables en cuanto a morbimortalidad. Es por esto que la embolización y la radiocirugía despiertan gran interés. Estas opciones terapéuticas han sido comparadas con el gold estándar y con la historia natural de la enfermedad, sin embargo, no existen estudios clínicos que comparen estas dos herramientas terapéuticas en el manejo de las malformaciones de alto grado. Por otro lado, no todas las modalidades de tratamiento disponen de escalas validadas que puedan estratificar el riesgo de complicaciones, ni la tasa de oclusión del mismo..

State of the Art and Future Direction in Diagnosis, Molecular Biology, Genetics, and Treatment of Brain Arteriovenous Malformations

Brain arteriovenous malformations (bAVMs) are uncommon and represent a heterogeneous group of lesions. Although these 2 facts have delayed research on this topic, knowledge about the pathophysiology, diagnosis, and treatment of bAVMs has evolved in recent years.We conducted a review of the literature to update the knowledge about diagnosis, molecular biology, genetic, pathology, and treatment by searching for the following terms: "Epidemiology AND Natural History," "risk of hemorrhage," "intracranial hemorrhage," "diagnosis," "angiogenesis," "molecular genetics," "VEGF," "KRAS," "radiosurgery," "endovascular," "microsurgery," or "surgical resection."Our understanding of bAVMs has significantly evolved in recent years. The latest investigations have helped in defining some molecular pathways involved in the pathology of bAVM. Although there is still more to learn and discover, describing these pathways will allow the creation of targeted treatments that could improve the prognosis of patients with bAVMs

Detection of IDH1 Mutations in Plasma Using BEAMing Technology in Patients with Gliomas

Molecular testing using blood-based liquid biopsy approaches has not been widely investigated in patients with glioma. A prospective single-center study enrolled patients with gliomas ranging from grade II to IV. Peripheral blood (PB) was drawn at different timepoints for circulating tumour DNA (ctDNA) monitoring. Next-generation sequencing (NGS) was used for the study of isocitrate dehydrogenase 1 (IDH1) mutations in the primary tumor. Beads, Emulsion, Amplification and Magnetics (BEAMing) was used for the study of IDH1 mutations in plasma and correlated with the NGS results in the tumor. Between February 2017 and July 2018, ten patients were enrolled, six with IDH1-mutant and four with IDH1 wild-type gliomas. Among the six IDH-mutant gliomas, three had the same IDH1 mutation detected in plasma (50%), and the IDH1-positive ctDNA result was obtained in patients either at diagnosis (no treatment) or during progressive disease. While the false-negative rate reached 86% (18/21), 15 out of the 18 (83%) plasma-negative results were from PB collected from the six IDH-mutant patients at times at which there was no accompanying evidence of tumor progression, as assessed by MRI. There were no false-positive cases in plasma collected from patients with IDH1 wild-type tumors. BEAMing detected IDH1 mutations in the plasma of patients with gliomas, with a modest clinical sensitivity (true positivity rate) but with 100% clinical specificity, with complete agreement between the mutant loci detected in tumor and plasma. Larger prospective studies should be conducted to expand on these findings, and further explore the clearance of mutations in PB from IDH1-positive patients in response to therapy

Article White Light Emission by Simultaneous One Pot Encapsulation of Dyes into One-Dimensional Channelled Aluminophosphate

[EN] By simultaneous occlusion of rationally chosen dyes, emitting in the blue, green and red region of the electromagnetic spectrum, into the one-dimensional channels of a magnesium-aluminophosphate with AEL-zeolitic type structure, MgAPO-11, a solid-state system with e cient white light emission under UV excitation, was achieved. The dyes herein selected—acridine (AC), pyronin Y (PY), and hemicyanine LDS722—ensure overall a good match between their molecular sizes and the MgAPO-11 channel dimensions. The occlusion was carried out via the crystallization inclusion method, in a suitable proportion of the three dyes to render e cient white fluorescence systems by means of fine-tuned FRET (fluorescence resonance energy transfer) energy transfer processes. The FRET processes are thoroughly examined by the analysis of fluorescence decay traces using the femtosecond fluorescence up-conversion technique.This research was funded by Gobierno Vasco (IT912-16), Ministerio de Economía y Competitividad (MINECO), the Spanish Agencia Estatal de Investigación, and the EU’s Fondo Europeo de Desarrollo Regional under projects MAT2017-83856-C3-3-P and MAT2016-77496-R, and C1/C2 KU Leuven, FuEPoNa (3E190382).Peer reviewe

Formation of a Nonlinear Optical Host–Guest Hybrid Material by Tight Confinement of LDS 722 into Aluminophosphate 1D Nanochannels

In this work, hemicyanine dye LDS 722 is encapsulated into the 1D elliptical nanochannels of MgAPO‐11 aluminophosphate by a crystallization inclusion method. The synthesis of the hybrid material has been optimized through a systematic variation of the crystallization conditions in order to obtain pure and large crystals (around 20 μm×30 μm) suitable for optical applications. The tight fitting between the molecular size of the guest dye and the pore dimensions of the host has favored a rigid planar conformation of the dye, restricting its inherent flexibility, which is confirmed by molecular simulations. Consequently, the encapsulation of LDS 722 into MgAPO‐11 has led to an astonishing enhancement of the fluorescence with respect to the dye into MgAPO‐5, with slightly larger cylindrical channels, and with respect to the dye in solution. Moreover, the perfect alignment of LDS 722 (dye with intrinsic nonlinear‐optical properties) along the channels of MgAPO‐11 has revealed attractive second‐order nonlinear properties, such as second harmonic generation, proven through microscopy measurements in single crystals.The authors thank the Spanish Ministry of Economy and Innovation MINECO (MAT 2014‐51937‐C3‐3 and MAT2012‐31127) and Basque Government (IT339‐10 and IT912‐16) for funding this research. V.M.M. and L.G.H. acknowledge Ministerio de Economía y Competitividad MINECO for “Ramón y Cajal” (RYC‐2011‐09505 and RYC‐2012‐11794, respectively) contracts and R.S.L. acknowledges Universidad del País Vasco (UPV‐EHU) for a predoctoral contract.Peer reviewe

White Light Emission by Simultaneous One Pot Encapsulation of Dyes into One-Dimensional Channelled Aluminophosphate

By simultaneous occlusion of rationally chosen dyes, emitting in the blue, green and red region of the electromagnetic spectrum, into the one-dimensional channels of a magnesium-aluminophosphate with AEL-zeolitic type structure, MgAPO-11, a solid-state system with efficient white light emission under UV excitation, was achieved. The dyes herein selected—acridine (AC), pyronin Y (PY), and hemicyanine LDS722—ensure overall a good match between their molecular sizes and the MgAPO-11 channel dimensions. The occlusion was carried out via the crystallization inclusion method, in a suitable proportion of the three dyes to render efficient white fluorescence systems by means of fine-tuned FRET (fluorescence resonance energy transfer) energy transfer processes. The FRET processes are thoroughly examined by the analysis of fluorescence decay traces using the femtosecond fluorescence up-conversion techniqueThis research was funded by Gobierno Vasco (IT912-16), Ministerio de Economía y Competitividad (MINECO), the Spanish Agencia Estatal de Investigación, and the EU’s Fondo Europeo de Desarrollo Regional under projects MAT2017-83856-C3-3-P and MAT2016-77496-R, and C1/C2 KU Leuven, FuEPoNa (3E190382)