Primary spontaneous intracerebral hemorrhage in COVID-19 patients: differences among presentation patterns - A systematic review.

OBJECTIVE: The objective of this study was to determine if there are differences between the presentation patterns of hemorrhagic stroke (HS) associated to COVID-19. METHODS: It was performed a systematic search based on PRISMA guidelines of the cases reported in PUBMED of HS associated to SARS-CoV-2 infection and we added to this sample cases from our own hospital cohort. Patients in the database were separated by groups according to presentation symptoms: if they debuted with neurological symptoms or debuted with pulmonary symptoms. RESULTS: Seventy cases were included in the study. Patients that debuted with pulmonary symptoms accounted for 68.6% of the cases with an interval between the development of symptoms and the presentation of HS of 15.6 days. We found that the use of anticoagulants during hospitalization, multifocal image pattern, and the elevation of D-dimer, Ferritin, and lactate dehydrogenase levels were significantly associated with the group of pulmonary presentation, whereas the presence of hypertension during hospitalization, and a lower hemoglobin level was associated with the group of neurologic symptoms. CONCLUSION: Although HS associated with COVID-19 is a clinical entity with increasing evidence, it is necessary to establish that there are two forms of presentation with their own characteristics.

OBJETIVO: determinar si existen diferencias entre los patrones de presentación de hemorragia intracraneal asociada a COVID-19. PACIENTES Y MÉTODOS: Se realizó una búsqueda sistemática basada en la guía PRISMA de los casos reportados en PUBMED de hemorragia intracraneal asociados a infección por SARS-CoV-2 y se agregaron a esta muestra casos de nuestra propia cohorte hospitalaria. RESULTADOS: se incluyeron 70 casos. Los pacientes que debutaron con síntomas pulmonares representaron el 68.6% de los casos con un intervalo entre el desarrollo de los síntomas y la presentación de la hemorragia intracraneal de 15.6 días. Encontramos que el uso de anticoagulantes durante la hospitalización, el patrón de imagen multifocal y la elevación de los niveles de dímero D, ferritina y deshidrogenasa láctica se asociaron significativamente con el grupo de presentación pulmonar, mientras que la presencia de hipertensión durante la hospitalización, y un nivel de hemoglobina más bajo se asoció con el grupo que debutó con síntomas neurológicos. CONCLUSIÓN: si bien la hemorragia intracraneal asociada a COVID-19 es una entidad clínica con evidencia creciente, es necesario establecer que existen dos formas de presentación con características propias.

Blood-brain Barrier Damage is Pivotal for SARS-CoV-2 Infection to the Central Nervous System.

Transsynaptic transport is the most accepted proposal to explain the SARS-CoV-2 infection of the CNS. Nevertheless, emerging evidence shows that neurons do not express the SARS-CoV-2 receptor ACE2, which highlights the importance of the blood-brain barrier (BBB) in preventing virus entry to the brain. In this study, we examine the presence of SARS-CoV-2 messenger ribonucleic acid (mRNA) and the cytokine profile in cerebrospinal fluids (CSF) from two patients with a brain tumor and COVID-19. To determine the BBB damage, we evaluate the Q- albumin index, which is an indirect parameter to assess the permeability of this structure. The Q-albumin index of the patient with an intraventricular brain tumor suggests that the BBB is undamaged, preventing the passage of SARS-CoV-2 and pro-inflammatory molecules. The development of brain tumors that disrupt the BBB (measured by the Q-albumin index), in this case, a petroclival meningioma (Case 1), allows the free passage of the SARS-CoV-2 virus and probably lets the free transit of pro-inflammatory molecules to the CNS, which leads to a possible activation of the microglia (astrogliosis) and an exacerbated immune response represented by IL-13, IFN-γ, and IL-2 trying to inhibit both the infection and the carcinogenic process.

Stereotactic biopsy for intracranial space occupying lesions: Experience in a referral hospital in Mexico.

BACKGROUND: Stereotactic brain biopsy (SBB) is used for establishing the histological diagnosis of intracranial lesions that are not amenable for a direct surgical approach. OBJECTIVE: The objective of the study was to describe our experience having an evaluation of the biopsy sample by a neuropathologist during SBB. MATERIALS AND METHODS: Retrospective analysis of 140 consecutive patients who underwent SBB between 2014 and 2018 in whom trans-operatory analysis of the sample was performed. RESULTS: There were 56% men. The mean age was 45 years. Histological diagnosis was performed in 131 of 140 patients (94% overall diagnostic yield). The presurgical radiological diagnosis was correct in 39%. Neoplastic lesions were reported in 108 cases, and 32 were non-neoplastic. We performed craniotomy and resection after biopsy in 14%. We found complications in 6% of patients. CONCLUSIONS: SBB continues to be a safe, useful, and inexpensive procedure. The diagnostic performance of SBB increases when intraoperative cytological evaluation by a neuropathologist is included in the study.

ANTECEDENTES: la biopsia cerebral por estereotaxia (SBB) se utiliza para establecer el diagnóstico histológico de lesiones intracraneales que no son susceptibles de un abordaje quirúrgico directo. OBJETIVO: describir nuestra experiencia de tener una evaluación de la muestra de biopsia por un neuropatólogo durante el procedimiento. MATERIAL Y MÉTODOS: análisis retrospectivo de 140 pacientes consecutivos sometidos a SBB entre 2014-2018 en los que se realizó análisis transoperatorio de la muestra. RESULTADOS: El 56% fueron hombres. La edad promedio fue de 45 años. El diagnóstico histológico se realizó en 131 de 140 pacientes (rendimiento diagnóstico global del 94%). El diagnóstico radiológico prequirúrgico fue correcto solo en el 39%. Se identificaron lesiones neoplásicas en 108 casos, y en 32 se documentaron lesiones no neoplásicas. En el 14% de los casos se realizó posterior a la biospia craneotomía y resección de la lesión. Encontramos complicaciones en el 6% de los pacientes. CONCLUSIONES: SBB sigue siendo un procedimiento seguro, útil y económico. El rendimiento diagnóstico de SBB aumenta cuando se incluye la evaluación citológica intraoperatoria por un neuropatólogo.

Resection of meningiomas in a different location (sphenoid wing and tuberculum sellae) through a single craniotomy report of a case and review of the literature.

Meningiomas are the most frequent extra-axial tumors of the nervous system. Multiple meningiomas are defined as the presence of two or more lesions that appear simultaneously or not, in different intracranial location, without association to neurofibromatosis. Each lesion must be evaluated individually for treatment, which consists in microsurgical resection in most cases. A 59-year-old woman presented with neurological symptoms from different anatomical site. Two extra-axial tumors of different location, at right sphenoid wing and the other in the tuberculum sellae were identified. Microsurgical resection was decided in one-step surgery, using the same craniotomy for both lesions with complete resection.

Los meningiomas son los tumores extraaxiales más frecuentes del sistema nervioso. Los meningiomas múltiples o meningiomatosis (MM) se definen como la presencia de 2 o más lesiones que aparecen simultáneamente o no, en diferente localización intracraneal, sin asociación con neurofibromatosis. Cada lesión debe ser evaluada de manera individual para su tratamiento. Presentamos una paciente con meningiomatosis. La sintomatología era muy variada de localizaciones anatómicas diferentes. En los estudios de imagen, se identificaron tumores extra axiales de diferente localización, una lesión alar y otra del tubérculo sellar. Se decidió la resección microquirúrgica en un solo tiempo, mediante la misma craneotomía.

Hemorrhagic stroke associated to COVID-19 infection in Mexico General Hospital.

INTRODUCCIÓN: en la actual pandemia de COVID-19, existe evidencia creciente que ha identificado el neurotropismo del virus SARS-CoV-2 y sus complicaciones neurológicas, incluida la enfermedad cerebrovascular isquémica y escasamente hemorragia cerebral (HC). OBJETIVO: describir las características clínicas, radiológicas, de laboratorio y pronósticas de los pacientes con HC asociada al SARS-CoV-2. MÉTODOS: se incluyeron pacientes consecutivos con prueba de PCR confirmatoria para infección por SARS-CoV-2 y HC. RESULTADOS: en un período de 90 días, en un centro de referencia COVID-19 en México, de 1108 pacientes con infección por SARS-CoV-2, se encontraron 4 pacientes (0.36%) con HC. Tenían una edad de 71(±12.2) años, 2 eran mujeres. Se encontró que dos tenían factores de riesgo cardiovascular previos. En dos casos se encontró el origen en el núcleo dentado mientras que los otros dos correspondieron al tálamo. Tres de los cuatro pacientes murieron. Postulamos que el descontrol hipertensivo, coagulopatía, trombocitopenia y la respuesta inmune inducida por el virus SARS-CoV-2 podrían desencadenar HC en un paciente con riesgo previo. CONCLUSIONES: la HC se asocia a la infección por SARS-CoV-2 con mal pronóstico cuando se presenta. Los equipos de neurocirugía deben estar preparados para el tratamiento oportuno de estos pacientes. INTRODUCTION: In the current COVID-19 pandemic, there is a growing body of evidence that has identified the neurotropism of the SARS-CoV-2 virus and its neurological complications, including cerebrovascular disease, focusing mainly in ischemic and scarcely about hemorrhagic stroke (HS). OBJECTIVE: The objective of the study was to describe clinical, radiological, laboratory tests, and prognostic characteristics of patients with SARS-CoV-2 associated HS. METHODS: Consecutive patients with a confirmatory PCR test for SARS-CoV-2 infection and a HS demonstrated by head CT were included in the study. RESULTS: Over a period of 90 days, in a COVID-19 reference center in Mexico, out of a total of 1108 patients with SARS-CoV-2 infection, it found 4 patients (0.36%) who meet criteria. They had an age of 71 (±12.2) years, 2 were women. It was found that two had prior cardiovascular risk factors. Two of the HS originated in the dentate nucleus while the other two corresponded to the thalamus. Three of the four patients died. We suggest that catastrophic uncontrolled blood pressure, coagulopathy, thrombocytopenia, and immune response induced by SARS-CoV-2 could in a specific patient trigger HS. CONCLUSIONS: HS is associated to SARS-CoV-2 infection with poor prognosis when it presented. Neurosurgery teams should prepare for the timely and appropriate treatment of this patients.

High Levels of IL-8 and MCP-1 in Cerebrospinal Fluid of COVID-19 Patients with Cerebrovascular Disease.

The coronavirus family has tropism for the Central Nervous System (CNS), however, there is no solid evidence demonstrating that the neurological effects of COVID-19 result from direct viral infection or systemic inflammation. The goals of this study were to examine the cytokine profile and the presence of SARS-CoV-2 messenger ribonucleic acid (mRNA) in cerebrospinal fluids (CSF) from two patients with cerebrovascular disease and COVID-19. Although the SARS-CoV-2 mRNA was not detected in CSF of both patients, we found abnormally high levels of numerous proinflammatory cytokines and chemokines, especially IL-8 and MCP-1. Since these chemokines mediate activation and recruitment of neutrophils, monocytes, and macrophages, it is feasible that cerebrovascular disease related-neuroinflammation found in both patients results from an exacerbated inflammatory response instead of SARS-CoV-2 direct invasion to CNS. These results suggest that neuroinflammation plays a key role in cerebrovascular disease and COVID-19.

A High-Fidelity Hybrid Virtual Reality Simulator of Aneurysm Clipping Repair With Brain Sylvian Fissure Exploration for Vascular Neurosurgery Training.

INTRODUCTION: Microsurgery clipping is one of the most challenging surgical interventions in neurosurgery. The opportunities to train residents are scarce, but the need for accumulating practice is mandatory. New simulating tools are needed for skill learning. METHODS: The design, implementation, and assessment of a new hybrid aneurysm clipping simulator are presented. It consists of an ergonomic workstation with a patient head mannequin and a physics-based virtual reality simulation with bimanual haptic feedback. The simulator recreates scenarios of microsurgery from the patient fixation and the exploration of the brain lobes through Sylvian fissure and vascular structures to the aneurysm clipping. Skill metrics were introduced, including monitoring of gestures movements, exerted forces, tissue displacements, and precision in clipping. RESULTS: Two experimental conditions were tested: (1) simple clipping without brain tissue exploration and (2) clipping the aneurysm with brain Sylvian fissure exploration. Differences in the bimanual gestures were observed between both conditions. The quantitative measurements of tissue displacement of the brain lobes exhibited more tissue retrieval for the surgical gestures of neurosurgeons. Appraisal with questionnaires showed positive scores by neurosurgeons in all items evaluating the usability and realism of the simulator. CONCLUSIONS: The simulator was well accepted and feasible for training purposes. The analysis of the interactions with virtual tissues offers information to establish differential and common patterns between tested groups and thus useful metrics for skill evaluation of practitioners. Future work can lead to other tasks during the intervention and the inclusion of more clinical cases.