Hemorrhage Volume Drives Early Brain Injury and Outcome in Poor-Grade Aneurysmal SAH.

BACKGROUND AND PURPOSE: Early brain injury is a major determinant of clinical outcome in poor-grade (World Federation of Neurosurgical Societies [WFNS] IV-V) aneurysmal SAH and is radiologically defined by global cerebral edema. Little is known, though, about the effect of global intracranial hemorrhage volume on early brain injury development and clinical outcome. MATERIALS AND METHODS: Data from the multicentric prospective Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) Registry of consecutive patients with poor-grade aneurysmal SAH admitted from January 1, 2015, to August 31, 2022, was retrospectively evaluated. Poor grade was defined according to the worst-pretreatment WFNS grade. Global intracranial hemorrhage volume as well as the volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH were calculated by means of analytic software in a semiautomated setting. Outcomes included severe global cerebral edema (defined by Subarachnoid Hemorrhage Early Brain Edema Score grades 3-4), in-hospital mortality (mRS 6), and functional independence (mRS 0-2) at follow-up. RESULTS: Among 400 patients (median global intracranial hemorrhage volume of 91 mL; interquartile range, 59-128), severe global cerebral edema was detected in 218/400 (54.5%) patients. One hundred twenty-three (30.8%) patients died during the acute phase of hospitalization. One hundred fifty-five (38.8%) patients achieved mRS 0-2 at a median of 13 (interquartile range, 3-26) months of follow-up. Multivariable analyses showed global intracranial hemorrhage volume as independently associated with severe global cerebral edema (adjusted OR, 1.009; 95% CI, 1.004-1.014; P < .001), mortality (adjusted OR, 1.006; 95% CI, 1.001-1.01; P = .018) and worse clinical outcome (adjusted OR, 0.992; 95% CI, 0.98-0.996; P < .010). The effect of global intracranial hemorrhage volume on clinical-radiologic outcomes changed significantly according to different age groups (younger than 50, 50-70, older than 70 year of age). Volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH affected the 3 predefined outcomes differently. Intracerebral hemorrhage volume independently predicted global cerebral edema and long-term outcome, intraventricular hemorrhage volume predicted mortality and long-term outcome, and SAH volume predicted long-term clinical outcome. CONCLUSIONS: Global intracranial hemorrhage volume plays a pivotal role in global cerebral edema development and emerged as an independent predictor of both mortality and long-term clinical outcome. Aging emerged as a reducing predictor in the relationship between global intracranial hemorrhage volume and global cerebral edema.

Clinical and angiographic characteristics of ruptured and unruptured distal cerebral aneurysms: a review of a large series of cases in a high-volume center.

OBJECTIVE: To evaluate clinical, angiographic features, and endovascular approach of ruptured and unruptured distal intracranial aneurysms (DIAs). METHODS: From January 2013 to February 2022, details of all consecutive intracranial aneurysms (IAs) treated endovascularly in our center were collected and retrospectively reviewed. IAs involving the anterior cerebral artery, middle cerebral artery, and posterior cerebral artery (distal to anterior communicating artery, limen insula, and P1 segment, respectively), and those distal to superior cerebellar artery, anterior-inferior cerebellar artery, and posterior inferior cerebellar artery's first segment were classified based on their etiology, location, size, and shape. Demographic, clinical, angiographic, and procedural variables, as well as follow-up outcomes were evaluated. RESULTS: Of 2542 IAs, 151 (5.9%) DIAs were counted (average size 5.4±2.9 mm), including 61 (40.4%) unruptured and 90 (59.6%) ruptured. No difference in the aneurysmal size was observed, but aneurysms smaller than 4 mm were observed more frequently in the ruptured group (36.7% vs 18%; P=0.01). In addition, ruptured DIAs were more often non-saccular (40% vs 18%; P=0.004) and irregular (93.3% vs 59%; P<0.001), They were treated mostly by coiling, glue, and parent artery sacrifice (P=0.02, P=0.006, and P=0.001), whereas unruptured DIAs were treated by stent-assisted coiling and flow-diverter stents (P=0.001 and P<0.001, respectively), without any differences in occlusion (81.6% vs 82.5%) and recanalization (21.1% vs 17.5%) rates. Procedure-related complications occurred in 20/151 (13.2%) patients, without any differences between subgroups. Ruptured DIAs were more often re-treated (18.4% vs 5.3%, P=0.02). In multivariate analyses, irregular shape appeared as an independent predictor of ruptured presentation (OR=8.1, 95% CI 3.0 to 21.7; P<0.001). CONCLUSIONS: Compared with unruptured DIAs, ruptured DIAs were more often non-saccular, irregular, and smaller than 4 mm. Despite different therapeutical approaches, ruptured and unruptured DIAs presented comparable occlusion and recanalization rates.

Lateral-PLIF for spinal arthrodesis: concept, technique, results, complications, and outcomes.

BACKGROUND: Posterior lumbar interbody fusion (PLIF) surgery represents an effective option to treat degenerative conditions in the lumbar spine. To reduce the drawbacks of the classical technique, we developed a variant, so-called Lateral-PLIF, which we then evaluated through a prospective consecutive series of patients. METHODS: All adult patients treated at our institute with single or double level Lateral-PLIF for lumbar degenerative disease from January to December 2017 were prospectively collected. Exclusion criteria were patients < 18 years of age, traumatic patients, active infection, or malignancy, as well as unavailability of clinical and/or radiological follow-up data. The technique consists of insert the cages bilaterally through the transition zone between the central canal and the intervertebral foramen, just above the lateral recess. Pre- and postoperative (2 years) questionnaires and phone interviews (4 years) assessed pain and functional outcomes. Data related to the surgical procedure, postoperative complications, and radiological findings (1 year) were collected. RESULTS: One hundred four patients were selected for the final analysis. The median age was 58 years and primary symptoms were mechanical back pain (100, 96.1%) and/or radicular pain (73, 70.2%). We found a high fusion rate (95%). A statistically significant improvement in functional outcome was also noted (ODI p < 0.001, Roland-Morris score p < 0.001). Walking distance increased from 812 m ± 543 m to 3443 m ± 712 m (p < 0.001). Complications included dural tear (6.7%), infection/wound dehiscence (4.8%), and instrument failure (1.9%) but no neurological deterioration. CONCLUSIONS: Lateral-PLIF is a safe and effective technique for lumbar interbody fusion and may be considered for further comparative study validation with other techniques before extensive use to treat lumbar degenerative disease.

Ultra-Early "Fishmouth stenosis" and thrombosis of a Surpass Evolve flow diversion device following treatment of multiples right siphon aneurysms.

We present a case of ultra-early symptomatic fish-mouth type stenosis (FMTS) of a Surpass Evolve flow diverter stent (SE-FDS) occurring within 24 h after deployment for the treatment of multiple unruptured right siphon aneurysms in a 44-year-old patient. The patient developed left hemiplegia and hemineglect, and was treated with mechanical thrombectomy (MT) and Tirofiban infusion. This is the first report of an ultra-early FMTS with a SE-FDS and its mechanism is discussed in the light of available data in the literature.

Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry.

BACKGROUND: Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES: To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS: Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS: Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION: UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.

Prediction of Early Distant Recurrence in Upfront Resectable Pancreatic Adenocarcinoma: A Multidisciplinary, Machine Learning-Based Approach.

Despite careful selection, the recurrence rate after upfront surgery for pancreatic adenocarcinoma can be very high. We aimed to construct and validate a model for the prediction of early distant recurrence (<12 months from index surgery) after upfront pancreaticoduodenectomy. After exclusions, 147 patients were retrospectively enrolled. Preoperative clinical and radiological (CT-based) data were systematically evaluated; moreover, 182 radiomics features (RFs) were extracted. Most significant RFs were selected using minimum redundancy, robustness against delineation uncertainty and an original machine learning bootstrap-based method. Patients were split into training (n = 94) and validation cohort (n = 53). Multivariable Cox regression analysis was first applied on the training cohort; the resulting prognostic index was then tested in the validation cohort. Clinical (serum level of CA19.9), radiological (necrosis), and radiomic (SurfAreaToVolumeRatio) features were significantly associated with the early resurge of distant recurrence. The model combining these three variables performed well in the training cohort (p = 0.0015, HR = 3.58, 95%CI = 1.98-6.71) and was then confirmed in the validation cohort (p = 0.0178, HR = 5.06, 95%CI = 1.75-14.58). The comparison of survival curves between low and high-risk patients showed a p-value <0.0001. Our model may help to better define resectability status, thus providing an actual aid for pancreatic adenocarcinoma patients' management (upfront surgery vs. neoadjuvant chemotherapy). Independent validations are warranted.

Quantitative assessment of lung involvement on chest CT at admission: Impact on hypoxia and outcome in COVID-19 patients.

BACKGROUND: The aim of this study was to quantify COVID-19 pneumonia features using CT performed at time of admission to emergency department in order to predict patients' hypoxia during the hospitalization and outcome. METHODS: Consecutive chest CT performed in the emergency department between March 1st and April 7th 2020 for COVID-19 pneumonia were analyzed. The three features of pneumonia (GGO, semi-consolidation and consolidation) and the percentage of well-aerated lung were quantified using a HU threshold based software. ROC curves identified the optimal cut-off values of CT parameters to predict hypoxia worsening and hospital discharge. Multiple Cox proportional hazards regression was used to analyze the capability of CT quantitative features, demographic and clinical variables to predict the time to hospital discharge. RESULTS: Seventy-seven patients (median age 56-years-old, 51 men) with COVID-19 pneumonia at CT were enrolled. The quantitative features of COVID-19 pneumonia were not associated to age, sex and time-from-symptoms onset, whereas higher number of comorbidities was correlated to lower well-aerated parenchyma ratio (rho = -0.234, p = 0.04) and increased semi-consolidation ratio (rho = -0.303, p = 0.008). Well-aerated lung (≤57%), semi-consolidation (≥17%) and consolidation (≥9%) predicted worst hypoxemia during hospitalization, with moderate areas under curves (AUC 0.76, 0.75, 0.77, respectively). Multiple Cox regression identified younger age (p < 0.01), female sex (p < 0.001), longer time-from-symptoms onset (p = 0.049), semi-consolidation ≤17% (p < 0.01) and consolidation ≤13% (p = 0.03) as independent predictors of shorter time to hospital discharge. CONCLUSION: Quantification of pneumonia features on admitting chest CT predicted hypoxia worsening during hospitalization and time to hospital discharge in COVID-19 patients.

Before sentinel bleeding: early prediction of postpancreatectomy hemorrhage (PPH) with a CT-based scoring system.

OBJECTIVES: Clinically significant pancreatic fistula (POPF) has been established as a well-known risk factor for late and severe postpancreatectomy hemorrhage after pancreaticoduodenectomy (PD) (postpancreatectomy pancreatic fistula-associated hemorrhage [PPFH]). Our aim was to assess whether contrast-enhanced CT scan after PD is an effective tool for early prediction of PPFH. METHODS: From a prospectively acquired database, all consecutive patients who underwent PD between January 2013 and May 2019 were identified; within this database, all patients who were evaluated, for clinical suspicion of POPF, with at least one contrast-enhanced CT scan examination, were enrolled in this retrospective study. The selected CT findings included perianastomotic fluid collections and air bubbles; pancreaticojejunostomy (PJ) was analyzed in terms of dehiscence and defect. RESULTS: One hundred seventy-eight out of 953 PD patients (18.7%) suffered from clinically significant POPF; after exclusions, 166 patients were enrolled. Among this subset, 33 patients (19.9%) had at least one PPFH episode. In multivariable analysis, PPFH was associated with postoperative CT evidence of fluid collections (p = 0.046), air bubbles (p = 0.046), and posterior PJ defect (p < 0.001). Based on these findings, a practical 4-point prediction score was developed (AUC: 0.904, Se: 76%, Sp: 93.8%): patients with a score ≥ 3 demonstrated a significantly higher risk of PPFH development (OR = 45.6, 95% CI: 13.0-159.3). CONCLUSIONS: Postoperative CT scan permits early stratification of PPFH risk, thus providing an actual aid for patients' management. KEY POINTS: • Postpancreatectomy hemorrhage (PPH) is a dramatic, clinically unpredictable occurrence. • After pancreaticoduodenectomy (PD), early identification of posterior pancreaticojejunostomy defect, perianastomotic air bubbles, and retroperitoneal fluid collections enables effective PPH risk stratification by means of a practical CT-based 4-point scoring system. • CT scan after PD allows a paradigm shift in the management PPH, from a conventional "wait and see" approach, to a more proactive one that relies on early anticipation and timely prevention.

Percutaneous Microwave Ablation Versus Cryoablation in the Treatment of T1a Renal Tumors.

PURPOSE: Radiofrequency and cryoablation (Cryo) are the most widely used techniques for the treatment of T1a renal tumors in non-surgical candidates, yet microwave ablation (MWA) has been gaining popularity. In this study, we tested the hypothesis that MWA has comparable safety and efficacy to Cryo in the treatment of selected T1a renal masses. MATERIALS AND METHODS: A retrospective comparative analysis of two patient cohorts was carried out on 83 nodules in 72 consecutive patients treated using image-guided percutaneous ablation with either Cryo or MWA. Patient demographics, tumor histology and characteristics, technical success, procedure time, adverse events and complications, nephrometry score (mRENAL) and renal function were evaluated. Local recurrence was evaluated at 1, 6, 12 and 18-24 months. RESULTS: Fifty-one nodules were treated with Cryo and 32 with MWA (44 and 28 patients, respectively). No statistical differences were observed following Cryo or MWA in median tumor size (p = 0.6), mRENAL (p = 0.1) or technical success (p = 0.8). Median procedure time was significantly lower using microwave ablation (p = 0.003). Median follow-up time was similar in the two groups (22 and 20 months, respectively). Occurrence of complications did not differ (Cryo 5/51, MWA 2/32; p = 0.57), and probability of complications or technical success adjusted for mRENAL did not reach statistical significance (p = 0.6). Renal function was preserved in all patients regardless of techniques. Disease recurrence was observed in 3/47 and in 1/30 treated nodules in the Cryo and MWA groups, respectively, without reaching statistical significance (p = 0.06). CONCLUSION: In the patient population studied, MWA showed comparable safety and efficacy relative to Cryo. LEVEL OF EVIDENCE: Level 3, Non-randomized cohort study.

Detection of Crohn's disease with diffusion images versus contrast-enhanced images in pediatric using MR enterography with histopathological correlation.

The purpose of this study was to determine whether MRE performed with diffusion-weighted imaging (DWI) sequences is comparable to contrast-enhanced MRE in the detection of active small-bowel inflammation in pediatric patients with Crohn's disease (CD). We included in our study 68 patients with diagnosis of CD between April 2015 and June 2018 that underwent MRE examination. Examination protocol includes coronal and axial FISP, T2-w half-Fourier RARE and DWI sequences, a baseline coronal T1-w fat-saturated ultrafast (GRE) sequence followed by contrast 3D T1-w GRE. All images were assessed by two radiologists who graded each of bowel segments for the presence of inflammation on a four-point confidence scale on the basis of wall thickening and wall signal on DWI and ADC maps and comparing their results with post-contrast images. When considering all bowel segments, we found 41 true positive and 25 true negative on DWI. One false positive case corresponded to the absence of inflammatory histopathology changes at the level of the terminal ileum in a 15-year-old male, and one false negative case was in a 10-year-old female with only jejunal lesion. The corresponding sensitivity, specificity, PPV, NPV and accuracy were 97.6% (95% CI 67.7-99.7), 96.1% (95% CI 66.7-98.5), 97.6% (95% CI 70.8-98.4), 96.1% (95% CI 64.2-90.6) and 97% (95% CI 84.2-97.5), respectively. Analyzing the gadolinium-enhanced set, 35 true positive and 25 true negative results were found. One false positive case was found, and it was the same as with DWI. The corresponding sensitivity, specificity, PPV, NPV and accuracy were 83.3% (95% CI 65.9-86.7), 96.1% (95% CI 68.7-88.9), 97.2% (95% CI 84.3-98.7), 78.1% (95% CI 27.9-72.1) and 88.2% (95% CI 41.2-85.6), respectively. Sensitivity for the detection of active IBD lesion was significantly better with DWI than with CE-T1-w imaging (p = 0.002), whereas the specificity was similar (p = 0.743). Our study has shown that DWI sequences have a high accuracy in detecting the bowel segment affected by CD. These results emphasize the utility to include the DWI/ADC in standard MR enterography protocols and suggest that DWI could replace T1-weighted post-contrast sequences.

The Relationships Between Vitamin K and Cognition: A Review of Current Evidence.

Vitamin K is a fat-soluble nutrient discovered in 1935 and its role in blood coagulation has been thoroughly explored. In recent years, studies conducted in vitro and on animals highlighted vitamin K involvement in brain cells development and survival. In particular, vitamin K seems to have an antiapoptotic and anti-inflammatory effect mediated by the activation of Growth Arrest Specific Gene 6 and Protein S. Moreover, this vitamin is involved in sphingolipids metabolism, a class of lipids that participate in the proliferation, differentiation, and survival of brain cells. An altered expression in sphingolipids profile has been related to neuroinflammation and neurodegeneration. This review stems from a growing interest in the role of vitamin K in brain functions, especially in cognition, also in view of an expected increase of prevalence of Alzheimer's disease and other forms of dementia. It collects recent researches that show interesting, even though not definitive, evidence of a direct correlation between vitamin K levels and cognitive performance. Moreover, vitamin K antagonists, used worldwide as oral anticoagulants, according to recent studies may have a negative influence on cognitive domains such as visual memory, verbal fluency and brain volume. The aim of this review is to analyze the evidence of clinical studies carried out up to date on the relationship between vitamin K intake and cognitive performances. The involvement of vitamin K antagonists (VKAs) in declining cognitive performances is also addressed separately.