Growth and rupture of an intracranial aneurysm: the role of wall aneurysmal enhancement and CD68.

Introduction: Intracranial aneurysms occur in 3%-5% of the general population. While the precise biological mechanisms underlying the formation, growth, and sudden rupture of intracranial aneurysms remain partially unknown, recent research has shed light on the potential role of inflammation in aneurysm development and rupture. In addition, there are ongoing investigations exploring the feasibility of employing new drug therapies for controlling the risk factors associated with aneurysms. CD68, a glycosylated glycoprotein and the human homolog of macrosialin, is prominently expressed in monocyte/macrophages within inflamed tissues and has shown potential application in oncology. An observational study was conducted with the aim of comparing the histological characteristics of aneurysm walls with preoperative MRI scans, specifically focusing on CD68 activity. Method: An observational pilot study was conducted to investigate the histological characteristics of the aneurysm wall that could be potentially associated with aneurysm growth and rupture. A total of 22 patients diagnosed with ruptured and unruptured intracranial aneurysms who had undergone conventional clipping between January 2017 and December 2022 were included in the study. Results: A histopathological analysis of the aneurysm wall was performed in all patients, particularly focusing on the presence of CD68. A preoperative MRI with gadolinium was conducted in 10 patients with unruptured aneurysms and six patients with ruptured aneurysms. An emergency clipping was performed in the remaining six patients. The results showed that CD68 positivity and wall enhancement were significantly associated with intracranial aneurysm wall degeneration, growth, and rupture. Conclusion: The histological and radiological inflammatory findings observed in the wall of cerebral aneurysms, as well as the CD68 positivity, are significantly associated with the risk of intracranial aneurysm growth and rupture. This study highlights the crucial importance of considering clinical and medical data when making treatment decisions for intracranial aneurysms. Furthermore, it emphasizes the relevance of evaluating wall enhancement in MRI scans as part of the diagnostic and prognostic process.

Multimodal Intraoperative Neurophysiological Monitoring in Intramedullary Spinal Cord Tumors: A 10-Year Single Center Experience.

OBJECTIVE: The study aimed at evaluating the efficacy and the ability of D-wave monitoring combined with somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to predict functional outcomes in intramedullary spinal cord tumor (IMSCT) surgery. METHODS: Between December 2011 and December 2020, all patients harboring IMSCT who underwent surgery at our institution were prospectively collected in a surgical spinal registry and retrospectively analyzed. Patient charts and surgical and histological reports were analyzed. The multimodal IONM included SSEPs, MEPs, and-whenever possible-D-waves. All patients were evaluated using the modified McCormick and Frankel grade at admission and 3, 6, and 12 months of follow-up. RESULTS: Sixty-four patients were enrolled in the study. SSEP and MEP monitoring was performed in all patients. The D-wave was not recordable in seven patients (11%). Significant IONM changes (at least one evoked potential modality) were registered in 26 (41%) of the 64 patients. In five cases (8%) where the SSEPs and MEPs lost and the D-wave permanently dropped by about 50%, patients experienced a permanent deterioration of their neurological status. Multimodal IONM (SSEP, MEP, and D-wave neuromonitoring) significantly predicted postoperative deficits (p = 0.0001), with a sensitivity of 100.00% and a specificity of 95.65%. However, D-waves demonstrated significantly higher sensitivity (100%) than MEPs (62.5%) and SSEPs (71.42%) alone. These tests' specificities were 85.10%, 13.89%, and 17.39%, respectively. Comparing the area under ROC curves (AUCs) of these evoked potentials in 53 patients (where all three modalities of IONM were registered) using the pairwise t-test, D-wave monitoring appeared to have higher accuracy and ability to predict postoperative deficits with strong statistical significance compared with MEP and SSEP alone (0.992 vs. 0.798 vs. 0.542; p = 0.018 and p < 0.001). CONCLUSION: The use of multimodal IONM showed a statistically significant greater ability to predict postoperative deficits compared with SSEP, MEP, and D-wave monitoring alone. D-wave recording significantly increased the accuracy and clinical value of neurophysiological monitoring in IMSCT tumor resection.

Role of 11C Methionine Positron Emission Tomography (11CMETPET) for Surgery and Radiation Therapy Planning in Newly Diagnosed Glioblastoma Patients Enrolled into a Phase II Clinical Study.

(1) Background: We investigated the role of [11C]-methionine PET in a cohort of newly diagnosed glioblastoma multiforme (GBM) patients to evaluate whether it could modify the extent of surgical resection and improve radiation therapy volume delineation. (2) Methods: Newly diagnosed GBM patients, ages 18-70, with a Karnofsky performance scale (KPS) ≥ 70 with available MRI and [11C]-methionine PET were included. Patients were treated with different amounts of surgical resection followed by radio-chemotherapy. The role of [11C]-methionine PET in surgical and RT planning was analyzed. A threshold of SUVmax was searched. (3) Results: From August 2013 to April 2016, 93 patients were treated and included in this analysis. Residual tumor volume was detected in 63 cases on MRI and in 78 on [11C]-methionine PET, including 15 receiving gross total resection. The location of uptake was mainly observed in FLAIR abnormalities. [11C]-methionine uptake changed RT volume in 11% of patients. The presence of [11C]-methionine uptake in patients receiving GTR proved to influence survival (p = 0.029). The threshold of the SUVmax conditioning outcome was five. (4) Conclusions: [11C]-methionine PET allowed to detect areas at higher risk of recurrence located in FLAIR abnormalities in patients affected by GBM. A challenging issue is represented by integrating morphological and functional imaging to better define the extent of surgical resection to perform.

Gamma Knife Radiosurgery for the Treatment of Trigeminal Neuralgia in Patients with Multiple Sclerosis: A Single-Center Retrospective Study and Literature Review.

OBJECTIVE: Trigeminal neuralgia (TN) in patients with multiple sclerosis (MS) is a challenging condition to manage that is treated with Gamma Knife radiosurgery (GKRS). The aim of this report is to assess the safety, efficacy, and durability of GKRS for the treatment of TN in patients with MS. Our findings are compared with those of the existing literature and discussed. METHODS: We retrospectively reviewed all patients at our institution who underwent GKRS for the treatment of TN secondary to MS and had 1 or more years of follow-up. Preoperative and postoperative pain intensities and facial numbness were evaluated with the Barrow Neurological Institute scores. Durability of successful pain relief was statistically evaluated with Kaplan-Meier analysis. The prognostic role of perioperative factors was investigated and analyzed using Cox proportional hazards regression. RESULTS: There were 29 patients with MS-TN who underwent GKRS at our institution. Two patients underwent bilateral treatment. Four patients underwent repeat GKRS for pain recurrence. The median period of follow-up assessment was 33 months. Rates of reasonable pain reduction at 1, 3, and 5 years were 70%, 57%, and 57% respectively. All patients who underwent repeat GKRS had durable pain reduction. No prognostic factor for successful pain reduction was found. CONCLUSIONS: Our study shows that GKRS for the treatment of TN secondary to MS is a safe and effective procedure in controlling pain in the short term but often fails to provide long-term pain control. GKRS can be safely repeated to prolong the time of pain reduction.

Do antiplatelet and anticoagulant drugs modify outcome of patients treated for chronic subdural hematoma? Still a controversial issue.

BACKGROUND: Anticoagulants (ACs) and antiplatelet aggregation agents (AAAs) seem to be correlated to a higher incidence of chronic subdural hematoma (CSDH) but whether or not they contribute to its recurrence is debated. Few data are available on clinical outcomes and indications for the management of this therapy are not so well defined. We investigated the role of ACs and AAAs in modifying patients' clinical outcomes treated for CSDH, especially for re-bleedings. METHODS: This retrospective study, enrolled patients treated for CSDH. Patients characteristics were recorded including drugs used (antiplatelet/anticoagulant) and clinical conditions (Modified Rankin Scale [mRS]) upon admission. Patients underwent surgery (burrhole vs. minicraniectomy) with subdural drainage positioning. Clinical/radiological follow-ups were performed at one and six months. Chi-square/Fisher's Exact test were used to compare variables and stepwise backward logistic regression analysis was used for defining their impact on complications, risk of re-bleeding and reoperation. RESULTS: Overall, 230 patients (45 on ACs, 76 on AAAs and nine on both) were enrolled. Higher mRS scores were significantly associated with a higher risk of general complications (OR=3.78, 95% CI: 1.66-8.62, P=0.002), higher risk of rebleeding (OR =15.82, 95% CI: 4.33-57.90, P<0.001) and re-operation (OR=11.39, 95% CI: 3.35-37.56, P<0.0001). No statistically significant association was found between AAAs or ACs and complications or re-bleedings or risk of reoperation. CONCLUSIONS: AAAs and ACs alone do not seem to worsen the clinical outcome or increase re-bleedings. mRS may be a predicting factor, since patients with higher scores showed a worse outcome and an increased risk of re-bleeding, general complications and reoperation.

Intracranial Meningiomas in the Elderly: Clinical, Surgical and Economic Evaluation. A Multicentric Experience.

Meningioma is one of the most common intracranial tumors. It is benign and slow growing in the majority of cases. Given the increase in life expectancy and the number of radiological tests performed, the incidence in the elderly population (≥65 years) is continuously increasing. The surgical outcomes and prognostic factors in this age group are unclear. A retrospective analysis of all the patients treated for intracranial meningiomas in two different Italian institutions was performed. The clinical, radiological, surgical and follow-up data were retrospectively reviewed. Statistical analyses were performed to identify relationships between factors and outcomes. We also carried out an economic analysis. We analyzed 321 patients with intracranial meningioma. The mean age was 72.6 years (range, 65-90), with a female predominance (F/M, 1.41). Pre-operative deficits, cognitive impairment and seizures (p < 0.001) were associated with a worse post-operative Karnofsky performance scale (KPS) score (<80). A high pre-operative KPS score was associated with a good clinical and neurological outcome (p < 0.001). Being aged between 65 and 74 years, low surgical timing and Simpson removal grades of I and II were associated with a good outcome (p < 0.001). The length of hospitalization was significantly related to the outcome (p < 0.001). The complication rate was 14.3%. At 6-month follow-up, the mortality rate was 2.5%. The average cost was higher in patients with a pre-operative KPS score lower than 80. The outcome of intracranial-meningioma resection in elderly individuals is favorable when the pre-operative KPS score is >80. Treatment should be patient-specific, and additional factors should be considered. Patients with poor pre-operative clinical conditions might benefit from a combined strategy with partial resection and radiosurgery in order to reduce surgical timing and the complication rate.

Functional Outcome After Odontoid Fractures in the Elderly.

While several papers on mortality and the fusion rate in elderly patients treated surgically or non-surgically for odontoid fractures exist, little information is available on quality of life after treatment. The aim of treatment in these patients should not be fracture healing alone but also quality of life improvement.A literature search using PubMed identified seven papers including information on functional evaluation of 402 patients.Patients treated with anterior screw fixation had a good functional outcome in 92.6% of cases. This percentage seemed to decrease in octogenarians. Less information was available for patients treated with posterior approaches; it would seem that up to a half of such patients experienced pain and limitations in activities of daily living after surgery. Patients treated with a halo device had a functional outcome that was worse (or at least no better) than that of patients treated with surgery, with absence of limitations in activities of daily living in 77.3% of patients. Patients treated with a collar had a good functional outcome in the majority of cases, with absence of limitations in activities of daily living in 89% of patients.More studies are needed for evaluation of functional outcome, especially in patients treated with a collar, a halo device or a posterior approach.

Chronic subdural hematoma in patients aged 80 years and older: A two-centre study.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a common condition in the elderly, and the ageing of population will increase the number of "superaged" patients presenting this pathology for the years to come. Few studies investigating the outcome of superaged patients surgically treated for CSDH are available, and study populations are generally small. The outcome of surgically treated patients and risk factors are not completely clear. Aim of the work is to identify the risk factors which may influence the outcome of patients aged 80 years and older surgically treated for CSDH. PATIENTS AND METHODS: This is a retrospective two-centre study including 151 surgically treated patients. A univariate (Fisher exact test) and multivariate (logistic regression) analysis of possible risk factors influencing outcome was performed. Outcome was expressed as: 6-month clinical outcome, 6-month mortality, complications and length of hospital stay. RESULTS: Univariate analysis showed an association between Charlson Comorbidity Index (CCI) and 6-month clinical outcome (p = 0,048), complications (p = 0,034) and 6-month mortality (p = 0,007). Antithrombotic drugs were associated with longer hospital stay (p < 0,001). Logistic regression analysis showed an association between CCI and complications (p = 0,016, HR = 3,18) and 6-month mortality (p = 0,034, HR = 11,71), and between antithrombotic drugs and longer hospital stay (p = 0,002, HR = 3,07). CONCLUSIONS: Age alone is not a predictor of bad outcome for patients aged 80 years and older surgically treated for CSDH. Charlson Comorbidity Index (CCI) may prove a valuable outcome predicting tool in these patients, and a longer hospital stay may be anticipated for patients under antithrombotic agents.