Aneurysm Clipping and Outcome for Hunt &Hess Grade 4, 5 Subarachnoid Hemorrhage—A Literature Review

“Subarachnoid Hemorrhage is non-traumatic nasty bleeding into the subarachnoid area, the territory between the arachnoid and the piamater of the central nervous system showing prompt developing signs of neurological sequelae”. It is one among the neurological emergencies which is a very distressing cerebrovascular disease with complicated mechanisms that risks brain perfusion and its function, having higher morbidity and mortality rates. Its mortality rate is still ranged between 8.3% and 66.7%, with noticeable regional variations, beside recent advances in treatment approaches. The incidence of SAH among the population of 2 - 22.5/100,000 was reported with a minimum of 60% of aneurysm ruptures occurring amid ages of 40 and 60 years with 3:2 male:female ratio. The rupture risks for unruptured aneurysms are increased by the issues like present smokers, larger size of aneurysm, and amid young population. The surgical treatment decision should be contemplated upon factors such as aneurysm’s size, aneurysm’s location, patient’s illness history, and surgeon’s operative experiences. Latest technical progresses in imaging techniques, increased consideration of illness history, more awareness of incidences of aneurysms and use of micro neurosurgery, have raised the chance for detection of subarachnoid hemorrhage (SAH) and possible better outcomes with surgical management. Factors that may affect outcome include age, size and site of aneurysm, interval between ictus and surgery, CT Fisher Grade & Hunt and Hess Grading earlier to surgery, & Glasgow Coma Scale at the while of discharge. The studies here support the wide spread concept that surgical clipping of SAH for Hunt and Hess Grade 4, 5 SAH, which is also considered as poor Grade SAH stipulates an effective treatment if done earlier provides better outcome.

RGD-FasL Induces Apoptosis of Pituitary Adenoma Cells

This study was to investigate the cytotoxic effects on pituitary adenoma cell lines GH3/MMQ/AtT20 induced by RGD-FasL and the underlying mechanism. Fas/DcR3 mRNAs were detected by RT-PCR and their surface expressions were measured by flow cytometry. Cytotoxicity exerted by RGD-FasL on tumor cells was measured with MTT assay and the induced apoptosis was determined by agarose gel electrophoresis. The cell cycle and apoptosis was assessed by flow cytometry with PI staining. The expressions of caspase8/9/3, Bcl-2, RANKL and JNK2 were detected by Western blotting. Approximately 13.7% of GH3 cells, 25.5% of MMQ cells, 22.2% of AtT20 cells express Fas, while 23.9% of GH3 cells, 24.1% of MMQ cells, 4.6% of AtT20 cells express DcR3. The cytotoxic effects of FasL/RGD-FasL on tumor cells were all taken in a dose-dependent manner. Cell lines MMQ/AtT20 showed the same sensitivity to RGD-FasL as to FasL, while cell line GH3 was less sensitive to RGD-FasL. The cell cycle analysis indicated that RGD-FasL could inhibit cells in G0/G1 phase and G2/M phase. In MMQ and AtT20 cells treated with RGD-FasL, the AI was not significantly different from that treated with FasL, while in GH3 cells treated with RGD-FasL, the AI was lower than that treated with FasL. The expressions of caspase-8/9/3, RANKL and JNK2 were increased while that of Bcl-2 was decreased after treatment with RGD-FasL, suggesting that RGD-FasL induces apoptosis through caspase activation. We concluded that RGD-FasL could possibly be considered as a novel therapeutical candidate for the treatment of pituitary adenomas. Cellular ＆ Molecular Immunology.

The role of blood oxygenation level-dependent functional magnetic resonance imaging(BOLD-fMRI) combined with diffusion tensor imaging(DTI) in surgery for tumors involving motor pathways

Objective:Blood oxygenation level-dependent functional magnetic resonance imaging(BOLD-fMRI)in combination with diffusion tensor imaging(DTI)can clearly show the specific relationship between brain tumors and motor pathways.The purpose of this study was to investigate the role of this combination in surgery for brain tumors involving motor pathways.Methods:From September 2018 to March 2019,preoperative BOLD-fM RI and DTI examinations were performed in patients with brain tumors involving motor pathways who were being treated in a neurosurgery department.The patients were divided into two groups according to the combined examination results.In one group,the motor pathways were intact;in the other,motor pathways were infiltrated by tumors.The surgical plan was total resection of the tumor as far as possible and with no damage to the motor pathway.The preoperative and postoperative motor dysfunction and the rate of total resection in the two groups were compared.Results:Of the 20 patients with intact motor pathways,15 had normal preoperative motor function,and 5 had preoperative motor dysfunction;of those 5 patients,3 exhibited postoperative aggravation of motor dysfunction.Total excision was performed in 16 patients with intact motor pathways and incomplete excision in 4.Of the 22 patients with motor pathway infiltration,8 had normal preoperative motor function and 14 had preoperative motor dysfunction;of those14,10 exhibited a postoperative increase in motor dysfunction.Total excision was performed in 8 patients with infiltrated motor pathways and incomplete excision in 14.Statistical analysis showed that there were significant differences between the two groups in preoperative motor function,postoperative changes in motor function,and total surgical resection rate(all p<0.05).Conclusions:First,whether tumors invade the motor pathway is an important factor affecting the degree of preoperative motor dysfunction.Second,the risk for postoperative motor dysfunction was lower in patients with intact motor pathways than in patients with infiltrated motor pathways.Third,the rate of total tumor resection was higher in patients with intact motor pathways than in patients with infiltrated motor pathways.Last,the combination of BOLD-fM RI and DTI aided in the decision to perform total resection.

Therapeutic potential role of exosomes for ischemic stroke

Exosomes are extracellular vesicles with a diameter of 30–100 nm,which are released into the extracellular space by fusion of multivesicular and plasma membranes.These vesicles actually play a distinct role in cell communication,although they were considered as membrane debris in the past.The endosomal sorting complex required for transport(ESCRT)-dependent and ESCRT-independent mechanisms are currently considered to be involved in the sorting of exosomes,and the release of exosomes is related to the members of Rab protein family and SNARE family.In recent years,the therapeutic potential of exosomes has become apparent.For example,via the direct transplantation of exosomes,the ischemic area after stroke is reduced,and the neurological function is improved significantly.Furthermore,they can be used as effective drug delivery vehicles due to their unique characteristics such as low immunogenicity and nanometer size.In conclusion,exosomes provide a cell-free treatment for ischemic stroke.

Neurological diseases caused by coronavirus infection of the respiratory airways

Infections of the central nervous system(CNS)infections are critical problems for public health.They are caused by several different organisms,including the respiratory coronaviruses(Co Vs).Co Vs usually infect the upper respiratory tract causing the common cold.However,in infants,and in elderly and immunocompromised persons,they can also affect the lower respiratory tract causing pneumonia and various syndromes of respiratory distress.Co Vs also have neuroinvasive capabilities because they can spread from the respiratory tract to the CNS.Once infection begins in the CNS cells,it can cause various CNS problems such as status epilepticus,encephalitis,and long-term neurological disease.This neuroinvasive properties of Co Vs may damage the CNS as a result of misdirected host immune response,which could be associated with autoimmunity in susceptible individuals(virus-induced neuro-immunopathology)or associated with viral replication directly causing damage to the CNS cells(virus-induced neuropathology).In December 2019,a new disease named COVID-19 emerged which is caused by Co Vs.The significant clinical symptoms of COVID-19 are related to the respiratory system,but they can also affect the CNS,causing acute cerebrovascular and intracranial infections.We describe the possible invasion routes of coronavirus in this review article,and look for the most recent findings associated with the neurological complications in the recently published literature.

Mechanisms and major sites of distal catheter migration in ventriculoperitoneal shunting maneuvers: A review article

A ventriculoperitoneal shunt(VPS) is a medical device used to deflect cerebrospinal fluid from cerebral ventricles to the peritoneal cavity. Since 1908, ventriculoperitoneal shunts have been considered the best option in hydrocephalus management. Manifestation related to VPS may arise anywhere whilst tunneling the VPS from the ventricle to the peritoneal cavity, but complications associated with the distal catheter are especially common and a leading cause of revision surgeries. Among the many complications associated with peritoneal shunts, migration of the catheter into other parts of the body is still common. Scrotal migration mainly takes place in children aged 4 days to 5 years. Patent processus vaginalis, formation of an inguinal hernia, and increased intraabdominal pressure are leading risk factors associated with migration of the peritoneal catheter into the scrotum. Thoracic migration of peritoneal catheters predominantly occurs in adult patients. Important mechanisms in thoracic migration include(1) iatrogenic perforation of the external or internal jugular veins by the surgeon during tunneling and(2) gradual destruction of the venous structures by the catheter due to routine extension and flexion of the neck. After entering the vessel, negative intrathoracic pressure combined with positive intraabdominal pressure aids migration into the thoracic cavity. Sharp tips or shunt types contribute to intraabdominal migration and perforation.

Bypass surgery for ischemic stroke caused by intracranial artery stenosis or occlusion

Surgical revascularization may be beneficial in patients with ischemic stroke caused by intracranial stenosis or occlusion who are ineligible for thrombolysis. Objective: To evaluate the outcome of superficial temporal artery to middle cerebral artery(STA-MCA) bypass in ischemic stroke caused by intracranial artery stenosis or occlusion. Methods: We retrospectively studied successive case series of 19 patients who underwent surgical treatment between 2013–2017 of STA-MCA bypass. Surgical procedure was performed for the patients with acute ischemic stroke who were ineligible for thrombolysis. Results: Of the 19 patients enrolled, symptom aggravation occurred during medical treatment, the patients were ineligible for thrombolysis despite being within 8 hours of symptom onset. Bypass significantly improved National Institutes of Health Stroke Scale scores, mean patient age was 78.05 years(range, 39-78 y). However, male 11(57.95%)out of nineteen patients were presented with left-sided-lesions while female 8(42%) had right-sided lesions with significant infarction growth by diffusion weighted imaging achieved, after surgical maneuver. No major complications occurred intraoperatively, in contrast to 2(10.5%) minor manifestation were suffering minor complications probably they included the remote infarction(posterior cerebral artery territory). Pooled analysis with our patients showed a significant neurological improvement and a good outcome in 13(68.4%) patients without hemorrhage or any other complication, 6(31.6%) patients with unfavorable outcome(severe disability 2; vegetative state 4, non of them are died 0;). Conclusion: STA-MCA bypass may be beneficial to patients with acute stroke or stenosis in progress who are ineligible for medical therapy. Furthermore, it appears safe when the infarction is small. These findings indicate that STA-MCA bypass could be considered as a treatment option in selected patients with ischemic stroke caused by intracranial stenosis or occlusion.

Management of post-stroke neuropsychiatric disorders

Post-stroke neuropsychiatric(NP) disorders are common and have complex etiologies.Multiple factors such as lesion location, personality characteristics, socioeconomic status, pre-stroke psychiatric history, and family support are the determining factors in most cases. Although depression and anxiety are more common, emotional incontinence and catastrophic reactions are also frequently observed. Post-stroke depression(PSD)has been associated with an increased risk of stroke recurrence. Despite its serious consequences and high prevalence, PSD remains undetected and untreated. Treatment options of NP disorders depend on severity, presentation at the time of diagnosis, and patient cooperation, and include antidepressants, mood stabilizers, exercise therapy, psychotherapy, and even revascularization. The efficient management of NP disorders improves outcomes, quality of life, and survival rates in post-stroke patients. However,very few studies have identified definitive treatment for these patients; therefore, further research is required.

Effect of hemorrhagic cerebrospinal fluid drainage on cognitive function after intracranial aneurysm clipping

Objective:The effects of repeated lumbar puncture and continuous lumbar cistern drainage on the cognitive function of patients with aneurysmal subarachnoid hemorrhage were compared and analyzed.Methods:Retrospective analysis was performed on 59 patients with aneurysmal subarachnoid hemorrhage treated at our Neurosurgery Department between October 2017 and October 2018.According to the hemorrhagic cerebrospinal fluid drainage mode after aneurysm clipping,the patients were divided into the following two groups:the repeated lumbar puncture drainage(Group A,n=28)and continuous lumbar cistern drainage(Group B,n=31).Before and 1 month after surgery,the cognitive function of the patients was scored using the Montreal Cognitive Assessment Scale.Scores of 27~30 were defined as normal,and scores of<27 as cognitive impairment.Results:The incidences of cognitive impairment were 46%(13/28)and 32%(10/31)for Groups A and B,respectively,before surgery,but the difference was not significant(P>0.05).The incidences of cognitive impairment were 35%(10/28)and 12%(4/31)for Groups A and B,respectively,at 1 month after surgery,with significant difference(P<0.05).Conclusion:Compared with repeated lumbar puncture,continuous lumbar cistern drainage for aneurysmal subarachnoid hemorrhage significantly reduced the incidence of cognitive impairment after aneurysm clipping.

Resection of intramedullary spinal cord tumor under awake anesthesia: A novel approach to minimize postoperative motor deficits

Objective: To observe advantages and disadvantages of the resection of intramedullary spinal cord tumor under awake anesthesia. Methods: Two patients with intramedullary spinal cord tumor underwent resection under awake anesthesia and followed up post-operatibely for any motor deficits. Results: Patients who underwent tumor resection under awake(AAA) anesthesia combined with intraoperative NPM had no motor deficits postoperatively. More accurate and nondelayed responses were observed in the awake cycle of anesthesia and helped guide surgery, thus avoiding injuries to the spinal cord. Conclusion: Intramedullary spinal cord tumors are not common, but only gross total resection(GTR) can provide complete remission of symptoms and progression-free survival. However, GTR sometimes results in motor function deficits postoperatively,particularly when the cervical cord is involved, and especially if surgery is done under general anesthesia with intraoperative neurophysiological monitoring(NPM) alone,because of delayed sensory evoked potential and motor evoked potential responses. We present two cases that underwent GTR of cervical intramedullary spinal cord tumors under an asleep-awake-asleep(AAA) cycle of anesthesia, combined with intraoperative NPM in which no post-operative motor deficits were observed on 6-months follow up.