Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial.

BACKGROUND: The optimum systolic blood pressure after endovascular thrombectomy for acute ischaemic stroke is uncertain. We aimed to compare the safety and efficacy of blood pressure lowering treatment according to more intensive versus less intensive treatment targets in patients with elevated blood pressure after reperfusion with endovascular treatment. METHODS: We conducted an open-label, blinded-endpoint, randomised controlled trial at 44 tertiary-level hospitals in China. Eligible patients (aged ≥18 years) had persistently elevated systolic blood pressure (≥140 mm Hg for >10 min) following successful reperfusion with endovascular thrombectomy for acute ischaemic stroke from any intracranial large-vessel occlusion. Patients were randomly assigned (1:1, by a central, web-based program with a minimisation algorithm) to more intensive treatment (systolic blood pressure target <120 mm Hg) or less intensive treatment (target 140-180 mm Hg) to be achieved within 1 h and sustained for 72 h. The primary efficacy outcome was functional recovery, assessed according to the distribution in scores on the modified Rankin scale (range 0 [no symptoms] to 6 [death]) at 90 days. Analyses were done according to the modified intention-to-treat principle. Efficacy analyses were performed with proportional odds logistic regression with adjustment for treatment allocation as a fixed effect, site as a random effect, and baseline prognostic factors, and included all randomly assigned patients who provided consent and had available data for the primary outcome. The safety analysis included all randomly assigned patients. The treatment effects were expressed as odds ratios (ORs). This trial is registered at ClinicalTrials.gov, NCT04140110, and the Chinese Clinical Trial Registry, 1900027785; recruitment has stopped at all participating centres. FINDINGS: Between July 20, 2020, and March 7, 2022, 821 patients were randomly assigned. The trial was stopped after review of the outcome data on June 22, 2022, due to persistent efficacy and safety concerns. 407 participants were assigned to the more intensive treatment group and 409 to the less intensive treatment group, of whom 404 patients in the more intensive treatment group and 406 patients in the less intensive treatment group had primary outcome data available. The likelihood of poor functional outcome was greater in the more intensive treatment group than the less intensive treatment group (common OR 1·37 [95% CI 1·07-1·76]). Compared with the less intensive treatment group, the more intensive treatment group had more early neurological deterioration (common OR 1·53 [95% 1·18-1·97]) and major disability at 90 days (OR 2·07 [95% CI 1·47-2·93]) but there were no significant differences in symptomatic intracerebral haemorrhage. There were no significant differences in serious adverse events or mortality between groups. INTERPRETATION: Intensive control of systolic blood pressure to lower than 120 mm Hg should be avoided to prevent compromising the functional recovery of patients who have received endovascular thrombectomy for acute ischaemic stroke due to intracranial large-vessel occlusion. FUNDING: The Shanghai Hospital Development Center; National Health and Medical Research Council of Australia; Medical Research Futures Fund of Australia; China Stroke Prevention; Shanghai Changhai Hospital, Science and Technology Commission of Shanghai Municipality; Takeda China; Hasten Biopharmaceutic; Genesis Medtech; Penumbra.

Outcome of Primary Central Nervous System Lymphoma Treated with Combined Surgical Resection and High- Dose Methotrexate Chemotherapy: A Single-Institution Retrospective Study.

AIM: To evaluate the feasibility and long-term clinical results of combined surgical resection and high-dose methotrexate (HD-MTX) chemotherapy for primary central nervous system lymphoma (PCNSL) of the brain. MATERIAL AND METHODS: Fifty-eight patients were diagnosed with PCNSL by histopathological examination of brain biopsy specimens at the Second Affiliated Hospital of Bengbu Medical College from March 2013 to December 2017. All patients received MTX at adose of 3.5 g/m2 every 2 weeks for 6 cycles. Clinical information, including ages, number of lesions, and tumor locations, were retrospectively collected from the medical records. RESULTS: The complete remission rates in patients treated with MTX plus craniotomy for surgical resection and those treated with MTX alone were 70.0% and 32.1%, respectively (p=0.021). Adding craniotomy to MTX chemotherapy did not increase the complication rate. The most common adverse events were hematological toxicity, liver toxicity, and gastrointestinal reaction were similar between groups. Multivariate analysis showed that surgical resection was associated with longer progression-free survival (PFS) (OR: p=0.002). CONCLUSION: Combining craniotomy for surgical resection and MTX-based chemotherapy may be safe and effective for treating PCNSL.

Intraventricular cystic papillary meningioma: A case report and literature review.

INTRODUCTION: Papillary meningioma is an extremely rare malignant lesion with high degree of invasiveness, high recurrence rate, and perivascular pseudopapillary structure. The incidence of cystic degeneration in papillary meningiomas is relatively low, and cystic papillary meningiomas growing in the ventricle are even rarer. Here, we present a case of cystic meningioma and review the literature to propose the diagnosis, treatment, immunohistochemical features, and prognosis of the same. PATIENT CONCERNS: In July 2013, a 35-year-old male Chinese patient presented with dizziness that lasted for a week, without relief. Magnetic resonance imaging (MRI) revealed a 2.0 cm × 1.5 cm × 3.0 cm-sized mass located in the left lateral ventricle trigone. The tumor was small and likely non-malignant. Therefore, the patient received conservative treatment and regular follow-ups. In June 2017, the patient experienced sudden severe headache, dizziness, and vomiting. DIAGNOSIS AND INTERVENTION: MRI revealed that the mass in the left lateral ventricle trigone had increased to 5.0 cm × 7.0 cm × 8.0 cm over 4 years. The patient underwent surgical resection via the left parietal-occipital approach. Two months postoperatively, the patient received 60 Gy local radiotherapy. The postoperative histopathology suggested that the mass was a cystic papillary meningioma. OUTCOMES: Two years after the operation, the patient was asymptomatic, and no recurrence of the lesion was noted on MRI. CONCLUSION: The diagnosis of intraventricular cystic papillary meningioma depends mainly on its histology and imaging features. Total resection and adjuvant radiotherapy can result in a relatively good prognosis of patients with intraventricular cystic papillary meningiomas.

MiR-424-5p Inhibits Proliferation, Invasion and Promotes Apoptosis and Predicts Good Prognosis in Glioma by Directly Targeting BFAR.

The biological function of miRNA (miR)-424-5p in glioma has not been clarified. This study was to explore the roles of miR-424-5p/Bifunctional apoptosis regulator (BFAR) axis in glioma. Ninety-six pairs of human glioma tissues and their adjacent non-cancer tissues were collected. The levels of BFAR and miR-424-5p were detected by quantitative polymerase chain reaction (qPCR) in glioma tissues and cell lines. Moreover, the biological roles of miR-424-5p and BFAR in glioma cells were assessed. We found a miR-424-5p binding site in the 3'UTR of BFAR by using TargetScan 7.2 online database. The miR-424-5p level was dramatically decreased in glioma tissues and cell lines, and the BFAR expression was significantly increased. The BFAR expression was negatively related to the miR-424-5p level in glioma tissues. Compared to patients with high miR-424-5p levels in glioma tissues, patients with low miR-424-5p levels had significantly lower survival rate (χ2 = 13.728 and P < 0.001). Compared to patients with high BFAR levels in glioma tissues, patients with low BFAR levels had significantly higher survival rate (χ2 = 5.516 and P = 0.027). Furthermore, up-regulation of miR-424-5p obviously restrained glioma cells proliferation and invasion, and promoted apoptosis. Besides, knockdown of BFAR also could markedly inhibit the proliferation and invasion, and promote apoptosis. Finally, overexpression of BFAR in glioma cells partially reversed the inhibited effects of miR-424-5p mimic. Knockdown of miR-424-5p restrained glioma cell apoptosis and promoted invasion and proliferation via regulation of BFAR.

Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke.

BACKGROUND: In acute ischemic stroke, there is uncertainty regarding the benefit and risk of administering intravenous alteplase before endovascular thrombectomy. METHODS: We conducted a trial at 41 academic tertiary care centers in China to evaluate endovascular thrombectomy with or without intravenous alteplase in patients with acute ischemic stroke. Patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation were randomly assigned in a 1:1 ratio to undergo endovascular thrombectomy alone (thrombectomy-alone group) or endovascular thrombectomy preceded by intravenous alteplase, at a dose of 0.9 mg per kilogram of body weight, administered within 4.5 hours after symptom onset (combination-therapy group). The primary analysis for noninferiority assessed the between-group difference in the distribution of the modified Rankin scale scores (range, 0 [no symptoms] to 6 [death]) at 90 days on the basis of a lower boundary of the 95% confidence interval of the adjusted common odds ratio equal to or larger than 0.8. We assessed various secondary outcomes, including death and reperfusion of the ischemic area. RESULTS: Of 1586 patients screened, 656 were enrolled, with 327 patients assigned to the thrombectomy-alone group and 329 assigned to the combination-therapy group. Endovascular thrombectomy alone was noninferior to combined intravenous alteplase and endovascular thrombectomy with regard to the primary outcome (adjusted common odds ratio, 1.07; 95% confidence interval, 0.81 to 1.40; P = 0.04 for noninferiority) but was associated with lower percentages of patients with successful reperfusion before thrombectomy (2.4% vs. 7.0%) and overall successful reperfusion (79.4% vs. 84.5%). Mortality at 90 days was 17.7% in the thrombectomy-alone group and 18.8% in the combination-therapy group. CONCLUSIONS: In Chinese patients with acute ischemic stroke from large-vessel occlusion, endovascular thrombectomy alone was noninferior with regard to functional outcome, within a 20% margin of confidence, to endovascular thrombectomy preceded by intravenous alteplase administered within 4.5 hours after symptom onset. (Funded by the Stroke Prevention Project of the National Health Commission of the People's Republic of China and the Wu Jieping Medical Foundation; DIRECT-MT ClinicalTrials.gov number, NCT03469206.).

Factors Promoting Futile Recanalization After Stent Retriever Thrombectomy for Stroke Affecting the Anterior Circulation: A Retrospective Analysis.

OBJECTIVE: To investigate the factors associated with futile recanalization after stent retriever thrombectomy in patients with acute ischemic stroke due to large vessel occlusion. METHODS: We retrospectively analyzed the medical records of 56 patients with an acute anterior circulation macrovascular occlusion who underwent successful stent retriever thrombectomy. Patients were classified as successful recanalization or futile recanalization at the follow-up. Univariate analysis and binary logic regression analysis were used to explore the association between patients' demographic and clinical characteristics and futile recanalization. RESULTS: The rate of futile recanalization was significantly higher after stent retrieval thrombectomy in patients with an Alberta Stroke Program Early CT (ASPECT) score ≤7 points versus >7 points (P < 0.001), ≥5 passes with the stent retriever versus <5 passes with the stent retriever (P = 0.036), or a longer recanalization time (P = 0.008). The influence of number of stent retriever pass is foremost, followed by ASPECT and occurrence to recanalization. CONCLUSIONS: Improving technical expertise with mechanical thrombectomy and shortening the therapeutic time window may improve the prognosis of patients with acute ischemic stroke due to large vessel occlusion.

A metastatic skull tumor from intrahepatic cholangiocarcinoma: A case report and literature review.

RATIONALE: Intrahepatic cholangiocarcinoma (ICC) originates from the epithelial cells of the secondary branches that are distant from the intrahepatic bile duct. ICC is a rare pathological type of primary liver cancer, with a high malignancy rate and poor prognosis. However, patients with ICC metastasis to the skull are extremely rarely encountered. Herein, we present a case of a metastatic skull tumor from ICC, along with a literature review. PATIENT CONCERNS: A 50-year-old right-handed man who did not smoke was diagnosed with a poorly differentiated ICC (T2aN0M0) in segment VI of the liver in February 2017. Hepatectomy was performed. The patient then presented with a painful mass in the posterior occipital region with dizziness experienced since 1 month, for which he underwent posterior occipital craniotomy. Postoperative specimens were sent for pathological examination. DIAGNOSES: We diagnosed the patient with a metastatic skull tumor from ICC. INTERVENTIONS: The patient underwent posterior occipital craniotomy and total resection of the tumor. OUTCOMES: The patient received chemotherapy 1 month after surgery, and after 6 months of follow-up, the patient was alive. LESSONS: ICC often shows metastases to the vertebrae. Therefore, physicians should consider the possibility of metastasis in patients with ICC, especially in those who show a painful skull mass of unknown origin; moreover, among patients with vertebral metastasis, physicians should be very vigilant about an occipital mass. We believe that the craniospinal venous system may be the pathway for occipital metastasis in patients with ICC.

Brain metastasis of choriocarcinoma presenting as multiple intracranial hematomas: A case report.

RATIONALE: Choriocarcinoma is the most malignant type of gestational trophoblastic neoplasia. Brain metastasis is the main cause of death and disability in choriocarc- inoma patients. Brain metastasis of choriocarcinoma easily invades the vessel wall to form microaneurysms, so we have reason to believe that multiple intracerebral hemorrhage is related to neoplastic intracranial microaneurysms. PATIENT CONCERNS: We report a rare case of brain metastasis of choriocarcinoma that caused six hemorrhages in four lesions within 50 days and anterior cerebral artery aneurysm. DIAGNOSES: We diagnosed multiple intracerebral hematoma, choriocarcinoma and intracranial aneurysms. INTERVENTIONS: Evacuation of hematoma by craniotomy. OUTCOMES: The patient finally asked to terminate the treatment and was discharged. One month later, the patient died of upper gastrointestinal bleeding. LESSONS: more than 20 cases of oncotic aneurysm from choriocarcinoma have been reported in the English literature, but few had multiple hematomas. Therefore, this case is unique. Brain metastasis of choriocarcinoma should be considered when patients experience unexplained cerebral hemorrhage, especially repeated intracranial hemorrhage in women of childbearing age. Early and intensive treatment can help achieve a better prognosis and avoid a fatal outcome. Multiple intracranial hematomas are related to neoplastic intracranial microaneurysms.

Chondromyxoid fibroma of the frontal bone mimicking meningioma.

Chondromyxoid fibroma (CMF) is a rare benign cartilaginous tumor that usually arises from lower-extremity long-bone metaphyses, with approximately 5.4% of all CMFs presenting in the craniofacial bones. Chondromyxoid fibroma of the frontal bone is exceedingly rare, with only a few cases reported. Herein, we report another case of CMF arising from the frontal bone mimicking meningioma. We suggest that histopathologic examination is of vital importance for the diagnosis of CMF; complete surgical resection is the best treatment option for frontal CMF.

Intracranial hemorrhage due to rupture of an anterior communicating artery aneurysm in a patient with pituitary adenoma.

The coexistence of pituitary adenoma (PA) and anterior communicating artery aneurysm is extremely rare, making the diagnosis difficult and the treatment challenging. Herein, we present a PA patient with intracranial hemorrhage due to rupture of an anterior communicating artery aneurysm. For the best diagnosis of intracranial aneurysm among PA patients, cranial magnetic resonance together with three-dimensional time-of-flight magnetic resonance angiography are strongly recommended. Previous treatment of the intracranial aneurysm is advisable and essential to avoid possible catastrophic bleeding during the transsphenoidal or microsurgical removal of PA.

Nonaneurysmal subarachnoid hemorrhage secondary to transsphenoidal surgery for pituitary adenomas.

Nonaneurysmal subarachnoid hemorrhage (SAH) is a rare and severe complication of transsphenoidal surgery for pituitary adenoma(PA). To improve recognition of this complication, we reviewed and examined 4 patients with nonaneurysmal SAH secondary to transsphenoidal surgery for PAs. Furthermore, possible causes contributed to the SAH, and the attention on preventing the occurrence of SAH is reviewed and stressed.