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Introduction Perianeurysmal edema and aneurysm wall enhancement are previously described phenomenon after coil embolization attributed to inflammatory reaction. We aimed to demonstrate the prevalence and natural course of these phenomena in unruptured aneurysms after endovascular treatment and to identify factors that contributed to their development. Methods We performed a retrospective analysis of consecutively treated unruptured aneurysms between January 2000 and December 2011. The presence and evolution of wall enhancement and perianeurysmal edema on MRI after endovascular treatment were analyzed. Variable factors were compared among aneurysms with and without edema. Results One hundred thirty-two unruptured aneurysms in 124 patients underwent endovascular treatment. Eighty-five (64.4 %) aneurysms had wall enhancement, and 9 (6.8 %) aneurysms had perianeurysmal brain edema. Wall enhancement tends to persist for years with two patterns identified. Larger aneurysms and brain-embedded aneurysms were significantly associated with wall enhancement. In all edema cases, the aneurysms were embedded within the brain and had wall enhancement. Progressive thickening of wall enhancement was significantly associated with edema. Edema can be symptomatic when in eloquent brain and stabilizes or resolves over the years. Conclusions Our study demonstrates the prevalence and some appreciation of the natural history of aneurysmal wall enhancement and perianeurysmal brain edema following endovascular treatment of unruptured aneurysms. Aneurysmal wall enhancement is a common phenomenon while perianeurysmal edema is rare. These phenomena are likely related to the presence of inflammatory reaction near the aneurysmal wall. Both phenomena are usually asymptomatic and self-limited, and prophylactic treatment is not recommended.

Background Cerebrospinal fluid shunts in the treatment of hydrocephalus, although associated with clinical benefit, have a high failure rate with repeat computed tomography (CT) imaging resulting in a substantial cumulative radiation dose. Therefore, we sought to develop a whole-body ultralow-dose (ULD) CT protocol for the investigation of shunt malfunction and compare it with the reference standard, plain radiographic shunt series (PRSS). Methods Following ethical approval, using an anthropomorphic phantom and a human cadaveric ventriculoperitoneal shunt model, a whole-body ULD-CT protocol incorporating two iterative reconstruction (IR) algorithms, pure IR and hybrid IR, including 60% filtered back projection and 40% IR was evaluated in 18 adult patients post new shunt implantation or where shunt malfunction was suspected. Effective dose (ED) and image quality were analysed. Results ULD-CT permitted a 36% radiation dose reduction (median ED 0.16 mSv, range 0.07–0.17, versus 0.25 mSv (0.06–1.69 mSv) for PRSS ( p = 0.002). Shunt visualisation in the thoracoabdominal cavities was improved with ULD-CT with pure IR ( p = 0.004 and p = 0.031, respectively) and, in contrast to PRSS, permitted visualisation of the entire shunt course ( p < 0.001), the distal shunt entry point and location of the shunt tip in all cases. For shunt complications, ULD-CT had a perfect specificity. False positives (3/22, 13.6%) were observed with PRSS. Conclusions At a significantly reduced radiation dose, whole body ULD-CT with pure IR demonstrated diagnostic superiority over PRSS in the evaluation of cerebrospinal fluid shunt malfunction.

The overall safety of the HydroCoil, an expansile hybrid hydrogel-platinum coil, is unknown. We report a prospective observational study of our first 100 cerebral aneurysms treated with HydroCoils, focusing on safety and initial efficacy. Indications, procedural complications, clinical and angiographic outcomes were recorded. Packing density, number of coils deployed and angiographic results were compared with those in a matched control group of 100 aneurysms treated solely with bare platinum coils. HydroCoil complication rates were compared to bare platinum coil rates at our institution and in published series. Adjuvant HydroCoil treatment led to increased mean percentage aneurysm filling compared to controls (50 +/- 21% versus 27 +/- 13%, P < 0.001). Immediate posttreatment angiographic results showed significantly (P < 0.001) more complete occlusions and fewer incomplete (<95%) occlusions compared to controls. Intermediate follow-up angiograms (median 7.5 months) in 63 aneurysms showed a trend towards fewer incomplete occlusions with HydroCoil treatment. There were significantly fewer major recurrences with HydroCoil treatment compared to the control treatment (9.5% versus 22.6%, P = 0.046). In the adjuvant HydroCoil group, major recurrent aneurysms had significantly less percentage volume packing with HydroCoils than non-recurrent aneurysms (50.3 +/- 5.0% versus 65.3 +/- 18.0%, P = 0.04). There was a 12% procedural complication rate, 6% procedural morbidity and 1% mortality rate, similar to institutional and reported bare platinum coil complication rates. HydroCoils can be safely deployed with a similar complication rate to bare platinum coils. They result in improved aneurysm filling. Intermediate follow-up angiography showed significantly fewer major recurrences. Long-term follow-up is required to confirm initial improved stability.

Viral and bacterial tests, including TB stains and culture, were negative. MR scan of brain showed extensive leptomeningeal enhancement; as well as patchy white matter signal abnormality and curvilinear enhancement mainly affecting the pons and cerebellum but also in the right frontal lobe (figure 1). MR scan of brain at 2 months since last imaging showed a new, different pattern of widespread T2/FLAIR (fluid-attenuated inversion recovery) hyperintensity, without enhancement, through much of the brainstem and periventricular cerebral hemispheres (figure 4). Discussion HLH is a life-threatening syndrome of excessive immune activation that can mimic sepsis. The HLH 2004 diagnostic criteria require five of eight criteria, including fever, splenomegaly, cytopenias, hypertriglyceridaemia or hypofibrinogenaemia, evidence of haemophagocytosis (in bone marrow, spleen or lymph nodes), low or absent NK cell activity, hyperferritinaemia and elevated sIL-2r.2 A genetic diagnosis does not require the same level of clinical evidence. A genetic study of 12 patients with CLIPPERS identified primary HLH biallelic variants in one-third of them; none met the criteria for systemic HLH.1 HLH-directed therapy, such as the HLH 2004 treatment protocol followed by HSCT, can improve survival and outcomes in systemic HLH.

BackgroundResearch into the potential utility of plasma-derived circulating cell-free nucleic acids as non-invasive adjuncts to radiological imaging have been occasioned by the invasive nature of brain tumour biopsy. The objective of this study was to determine whether significant differences exist in the plasma transcriptomic profile of glioma patients relative to differences in their tumour characteristics, and also whether any observed differences were representative of synchronously obtained glioma samples and TCGA glioma-derived RNA.MethodsBlood samples were collected from twenty glioma patients prior to tumour resection. Plasma ccfmRNAs and glioma-derived RNA were extracted and profiled.ResultsBCL2L1, GZMB, HLA-A, IRF1, MYD88, TLR2, and TP53 genes were significantly over-expressed in glioma patients (p < 0.001, versus control). GZMB and HLA-A genes were significantly over-expressed in high-grade glioma patients (p < 0.001, versus low-grade glioma patients). Moreover, the fold change of the BCL2L1 gene was observed to be higher in patients with high-grade glioma (p = 0.022, versus low-grade glioma patients). There was positive correlation between the magnitude of fold change of differentially expressed genes in plasma- and glioma-derived RNA (Spearman r = 0.6344, n = 14, p = 0.017), and with the mean FPKM in TCGA glioma-derived RNA samples (Spearman r = 0.4614, n = 19, p < 0.05). There was positive correlation between glioma radiographic tumour burden and the magnitude of fold change of the CSF3 gene (r = 0.9813, n = 20, p < 0.001).ConclusionWe identified significant differential expression of genes involved in cancer inflammation and immunity crosstalk among patients with different glioma grades, and there was positive correlation between their transcriptomic profile in plasma and tumour samples, and with TCGA glioma-derived RNA.

Accurate assessment of treatment response in children with intracranial pus collections is vital to guide appropriate therapy and reduce morbidity and mortality. To correlate serial MR-measurable changes in diffusion-weighted imaging (DWI) with clinical response to treatment. We retrospectively reviewed clinical notes, conventional MR sequences and DWI in eight children with intracranial pus collections. Trace DWI signal intensity and apparent diffusion coefficient (ADC) values were compared at three time points: at initial diagnosis (eight children, 13 collections), at follow-up during continued clinical infection (three children, sp collections), and at follow-up when clinical infection had resolved (seven children, 12 collections). At initial diagnosis all patients were septic and collections showed restricted diffusion (mean ADC 0.61+/-0.15 x 10(-3) mm(2)/s). Patients with persistent clinical sepsis at follow-up DWI had collections with persistent low ADC values (0.66+/-0.21 x 10(-3) mm(2)/s), significantly (P<0.001) below normal cortical gray matter values. Successful resolution of the infection was associated with a significant rise in ADC values (1.57+/-0.57 x 10(-3) mm(2)/s, P<0.01) compared both to patients with signs of continued sepsis and to normal gray matter values. Persistent restricted diffusion in pus collections correlates with continued sepsis. Treatment response is associated with clinical resolution of sepsis and ADC value elevation significantly above normal gray matter values.

Correspondence to Dr Geoffrey Ronan, Neurology, Cork University Hospital Group, 1 Hollymount House, Lee Road, Cork, Ireland, T23KPK3; 111314731@umail.ucc.ie   A 53-year-old woman presented with acute onset of bifrontal headache with fever and vomiting, and a 6-week history of unilateral, left-sided, clear, salty rhinorrhoea. CSF PCR was negative for Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli, Streptococcus agalactiae, Haemophilus influenzae, Listeria monocytogenes, cytomegalovirus, enterovirus, herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2), human herpesvirus 6, varicella zoster virus, human parechovirus and Cryptococcus neoformans. Investigative work-up for granulomatous disease showed serum ACE of 38 IU (8–65), adjusted serum calcium of 2.36 mmol/L (2.25–2.59), erythrocyte sedimentation rate of 11 mm/hour (1–20), negative anti-neutrophil cytoplasmic antibody and normal serum immunoglobulins.

ObjectivesThere is potential for high radiation exposure during neurointerventional procedures. Increasing regulatory requirements mandate dose monitoring of patients and staff, and justification of high levels of radiation exposure. This paper demonstrates the potential to use radiation dose-tracking software to establish local diagnostic reference levels.MethodsConsecutive neurointerventional procedures, performed in a single institution within a one-year period, were retrospectively studied. Dose area product (DAP) data were collected using dose-tracking software and clinical data obtained from a prospectively generated patient treatment database.ResultsTwo hundred and sixty-four procedures met the selection criteria. Median DAP was 100 Gy.cm2 for aneurysm coiling procedures, 259 Gy.cm2 for arteriovenous malformation (AVM) embolisation procedures, 87 Gy.cm2 for stroke thrombolysis/thrombectomy, and 74 Gy.cm2 for four-vessel angiography. One hundred and nine aneurysm coiling procedures were further studied. Six significant variables were assessed using stepwise regression analysis to determine effect on DAP. Aneurysm location (anterior vs posterior circulation) had the single biggest effect (p = 0.004).ConclusionsThis paper confirms variable radiation exposures during neurointerventional procedures. The 75th percentile (used to define diagnostic reference levels) of DAP measurements represents a reasonable guidance metric for monitoring purposes. Results indicate that aneurysm location has the greatest impact on dose during coiling procedures and that anterior and posterior circulation coiling procedures should have separate diagnostic reference levels.Key Points• Dose-tracking software is useful for monitoring patient radiation dose during neurointerventional procedures• This paper provides a template for methodology applicable to any interventional suite• Local diagnostic reference levels were defined by using the 75th percentile of DAP as per International Commission on Radiological Protection recommendations• Aneurysm location is the biggest determinant of radiation dose during coiling procedures.• Anterior and posterior circulation coiling procedures should have separate diagnostic reference levels.

Current treatment strategies for advanced melanoma require serial assessment of disease status in affected patients. In this study, we sought to examine the relationship between radiographic tumour burden and blood borne biomarkers including plasma cfDNA, serum LDH, plasma VEGF, PD-L1 and IFN-γ in advanced melanoma patients receiving immunotherapy. We hypothesized that a combination of these explanatory variables in a suitable regression analysis model may predict changes in tumour burden during patient treatment. We extracted and quantified circulating cfDNA, LDH, VEGF, PD-L1, and IFN-γ from thirty patients with stage IV melanoma at baseline and at six months. All participating patients were evaluated with paired blood sample collection and CT scan assessments during treatment. Changes in radiographic tumour burden correlated with changes in levels of cfDNA (p≤0.001), LDH (p≤0.001), VEGF (p≤0.001), and PD-L1 (p<0.05) during treatment. Multiple regression analysis consisting of the follow-up to baseline assessment ratios of cfDNA, LDH, VEGF and PD-L1 explained changes in tumour burden (F (4, 23)=32.05, p<0.001); with an R of 0.8479 (Y=β0+β1*B+β2*C+β3*D+β4*E). A quantitative measure of cfDNA, LDH, VEGF and PD-L1 may complement current methods of assessing tumour burden in advanced melanoma patients.

IntroductionChildhood arterial ischaemic stroke (AIS) is uncommon with a reported incidence between 1.2 and 7.91 per 100,000 per year.1,2,3 Previously it was thought that children with AIS had a good outcome due to brain plasticity; however, mortality has been reported in up to 28%, and morbidity in up to 70% of survivors.4,5 There are no randomised trials of mechanical thrombectomy in children. The 2017 published RCPCH stroke guidelines draw on the excellent outcomes for mechanical thrombectomy in adult trials and recommend referral for intra-arterial clot extraction in patients with NIHSS score of 6 or more and up to 12 hours post onset if there is salvageable brain tissue on imaging.6 There are only 29 paediatric cases published in the literature that have undergone mechanical thrombectomy, 12 of which were for posterior circulation AIS.We describe a case of a 3-year-old girl with bilateral pontine and cerebellar infarction due to basilar artery thrombosis, related to a diagnosis of exclusion of severe iron deficiency anaemia who was successfully treated by mechanical thrombectomy.Case ReportOur patient presented with a one-day history of vomiting, and headache, on a background history of a viral prodrome the preceding week, and varicella infection three months earlier. Her haemoglobin was 4.6 g/dL, with a profoundly microcytic, hypochromic blood film. She received a blood transfusion with clinical improvement. At 36 hours after admission, she became irritable and developed a left divergent squint (NIHSS score 4). Neuroimaging demonstrated acute infarction of the pons, cerebellum and punctate lesions in both occipital lobes. MRA showed complete occlusion of right vertebral artery and basilar artery. Enoxaparin was commenced, but 12 hours later she developed left CNVII palsy and a dense left hemiparesis with hypertension. CT Brain showed worsening ischaemia. Given her ongoing clinical deterioration with major risk of significant morbidity and indeed mortality she underwent mechanical thrombectomy. Successful recannalisation of the basilar artery occurred with a distal left parieto-occipital thrombus remaining. At 9 months follow-up she has a mild left hemiparesis, left CN VII, III and IV palsies and right CNVI palsy, but mobilises independently and is on a normal diet (mRs 2); imaging shows established pontine infarction with gliosis.ConclusionThis case adds to the limited reports of mechanical thrombectomy in children in posterior circulation AIS, as a safe and effective treatment. It also highlights the importance of recognising severe iron-deficiency anaemia as a cause for AIS in children.