E. Magro

Treatment of Brain AVMs (TOBAS): study protocol for a pragmatic randomized controlled trial

BackgroundThe management of unruptured brain arteriovenous malformation (AVM) patients remains controversial. Furthermore, curative attempts to treat ruptured AVM patients have not been questioned so far, and there is a lack of prospective data on clinical results according to treatment modality. Endovascular treatment is often used aiming to improve the safety or efficacy of surgery or radiation therapy, but benefits have never been documented in a trial. A care trial context is needed to evaluate interventions at the same time they are practised.Methods/Trial designTOBAS is a pragmatic, prospective, multicenter, randomized, controlled trial and registry which offers a care trial context for brain AVM patients, including surgical resection, radiosurgery or endovascular embolization, alone or combined. The study includes two RCTs and a multimodality prospective registry. The objectives of the proposed study are to assess whether preventive interventions (surgery, embolization, radiation therapy, alone or combined), selected by the local treatment team and performed as locally practiced, randomly allocated and compared with conservative management, in unruptured brain AVM patients eligible for active or conservative management, can improve the proportion of patients having an independent outcome (modified Rankin Scale (mRS)u2009<u20093, as assessed by a standardized questionnaire administered by non-masked care personnel) at 10xa0years. All patients judged ineligible for randomized allocation are to be entered in a multimodal registry. The objective of a nested trial in patients with ruptured or unruptured AVMs to be treated by surgery or radiation therapy, is to assess whether pre-surgical or pre-radiation embolization, randomly allocated and compared with no embolization, can improve the proportion of patients with complete eradication of the AVM, as locally adjudicated, combined with a good clinical outcome (mRSu2009<u20093). The study will require up to 2000 patients in approximately 30 centers or more, followed for 10xa0years. TOBAS is registered at clinicaltrials.gov: NCT02098252 as of 25 March 2014.

Management of ruptured posterior fossa arteriovenous malformations.

OBJECTIVEnPosterior fossa arteriovenous malformations (pAVMs) are rare and because of their location at or close to vital structures, their treatment remains challenging despite overall improvements in the management of cerebrovascular lesions. We reviewed our recent series of ruptured pfAVMs in search of guiding principles in the management of these complex lesions.nnnMETHODSnThis is a retrospective series of consecutive patients admitted for a ruptured pfAVM from 2002 to 2013. We analyzed clinical and radiological data, as well as initial and definitive management. Outcome was assessed using the modified Rankin Scale (mRS) at 6 months.nnnRESULTSnThe study included 34 patients (19 women and 15 men). Upon admission, 79% of patients presented with an intra-cerebellar hematoma, 42% of which required urgent drainage. Hydrocephaly was also present in 82% of patients, 56% of which required emergency ventriculostomy. There was an aneurysm associated with the AVM in 47% of cases. In 38% of the cases, the aneurysm was the source of the hemorrhage. Only 68% of patients were amenable to undergo treatment of the AVM: 24% exclusively by surgery, 9% by embolization, 3% by radiosurgery, and 32% using combined means. Five patients died within the first week: one as a direct result of the severity of the hemorrhage, and the other four due to re-bleeding before treatment. Outcome was favorable (mRS 0-2) in 71% of patients.nnnCONCLUSIONnPatients with a ruptured pfAVM are often comatose upon admission, requiring emergency live-saving surgical treatment. An associated aneurysm is often the source of bleeding which if dealt with immediately, offers time to plan the most appropriate strategies to eliminate the AVM. Nevertheless, early re-bleeding is frequent, and a cause of concern as it often leads to death. Despite the gravity of the clinical condition upon admission, outcome is favorable for those amenable to treatment.

Subdural Metastasis of Prostate Cancer

Dural metastasis from prostate cancer is rare and may mimic a subdural hematoma (SDH). Preoperatively diagnosis may be difficult and only reveal its presence during surgery. We present such a case and review the literature to identify common characteristics. A 65-year-old man presented with headache, confusion, and progressive right upper limb weakness. Past history included a prostate adenocarcinoma with bone metastasis 3 years earlier. Head computed tomography (CT) scan without contrast revealed a multinodular bilateral hyperdense extra-axial lesion interpreted as acute SDH. At surgery planned for SDH drainage no blood was found; instead there was an en plaque subdural yellowish tumor. Histopathologic examination was consistent with metastatic adenocarcinoma of the prostate. We found 11 cases reported as dural metastasis of prostate cancer mimicking SDH. Surgery was performed on nine cases with no suspicion of dural metastasis. On preoperative nonenhanced CT scan images, three types of image patterns can be described: a nodule in SDH, multinodular metastasis surrounded by SDH, and large en plaque subdural tumor. The latter group consists of those cases where no blood but rather an en plaque subdural tumor was found at surgery. Even though rare, dural metastasis should be considered among the differential diagnoses in a patient known for prostate cancer.

Le traitement des MAVS cérébrales (TOBAS) : une étude randomisée controlée avec registre

OBJECTIVEnThe management of unruptured and ruptured brain arteriovenous malformations (AVMs) remains controversial. The Treatment of Brain AVM Study (TOBAS) was designed to assess curative treatments in the management of AVMs. The purpose of our study is to provide a care trial context to brain AVM patients.nnnMETHODSnTOBAS is a pragmatic, prospective study including 2xa0randomized controlled trials and a registry. All AVM patients can be recruited. The preferred management modality will be predetermined prior to randomization by the team based on clinical judgment. Patients eligible for both conservative and interventional management will be randomly allocated conservative or curative treatment. Randomization will be stratified by a treatment modality (surgery, radiosurgery or embolization) and minimized according to a history of previous rupture and Spetzler-Martin grade. A second randomization will allocate eligible patients to embolization/no embolization prior to surgery or radiosurgery. The primary outcome of the study is death (any cause) or disabling stroke (mRS>2) at 10xa0years. All patients managed according to clinical judgment alone will be included in the registry. The study is registered under: wwwTrials.gov, ID: NCT02098252.nnnEXPECTED RESULTSnA minimum recruitment of 540xa0patients is required to show that treatment can reduce the primary outcome by 10xa0% (from 25xa0to 15xa0%); 440xa0patients will be needed to show a 10xa0% increase in angiographic occlusion for a good clinical outcome with pre-embolization.nnnCONCLUSIONnThe trial is designed to offer optimal and verifiable care to patients with brain AVMs in spite of the uncertainty. We are currently seeking the participation of multiple centers.

A case of dorsolateral pontine infarct: Description of a new vascular alternating syndrome

INTRODUCTIONnInferolateral pontine infarcts are well-described lesions of the anterior inferior cerebellar artery territory with a wide variety of clinical presentations. We report the case of isolated unilateral hearing loss and contralateral sensation of coldness due to a dorsolateral lower pontine infarct.nnnCASE DESCRIPTIONnWe describe the case of a 48-year-old female patient who developed isolated selective high-frequency hearing loss on the left side, and contralateral hemibody sensation of coldness. MRI showed a left-sided dorsolateral lower pontine ischemic lesion. A subsequent angiogram revealed the lesion to result from the spontaneous dissection of a long circumferential branch of the basilar artery.nnnCONCLUSIONnTo our knowledge, this is the first reported case of a vascular alternating syndrome consisting of isolated ipsilateral hearing loss and contralateral thermal dysesthesia from a dorsolateral lower pontine infarct. Occlusion of a long perforating branch of the basilar artery and consequent posterolateral lower pontine infarct may result in an alternating syndrome with subtle clinical symptoms. Knowledge of this type of syndrome may direct physicians towards the diagnosis of a dorsolateral lower pontine infarct, despite vague clinical complaints.

Pyogenic Ventriculitis as Clinical Presentation of Diverticulitis

A 51-year-old male was brought to the emergency room with fever and depressed consciousness. The family reported a 3-day history of asthenia, myalgia, stiffness of the neck, chills, and confusion. His medical history was relevant for chronic alcohol abuse and gout. On physical examination, the patient was febrile (39.2°C), hypertensive, and tachypneic. He was unconscious with no focal neurological deficits. Urgent noncontrast computed tomography (CT) scan showed hydrocephalus with trans-ependymal edema with sparing of the fourth ventricle. The patient was intubated and an external ventricular drain was urgently inserted, which drained obviously purulent cerebrospinal fluid (CSF). The patient was started on a broad-spectrum antimicrobial therapy, which was later readjusted because CSF and blood cultures grew Streptococcus intermedius.The brain magnetic resonance imaging (Figure 1) scan revealed severe ventriculitis evidenced by intraventricular debris, intense enhancement of the ependymal lining of the ventricles associated with periventricular cerebritis, and multiple bilateral brain microabscesses. A chest and abdomen CT scan performed to search for a primary infection revealed a perforated diverticulitis complicated by multiple liver abscesses that were subsequently drained percutaneously. During hospitalization, the patient eventually developed multiloculated hydrocephalus that required multiple drains and finally a ventriculopleural shunt after endoscopic fenestration of the ventricular septations. The patient improved remarkably and was awaiting rehabilitation when he suddenly died of a respiratory complication.

Diffusion des abcès multiples à Listeria monocytogenes par les faisceaux de fibres du système nerveux central

Introduction La listeriose se manifeste couramment chez l’adulte par une septicemie et conduit a une atteinte du systeme nerveux central (SNC), classiquement une meningite ou une rhombencephalite, plus rarement un abces cerebral. Les etudes animales ont demontre que les infections a L.xa0monocytogenes peuvent envahir le systeme nerveux central par une voie intra-neurale peripherique. Si cela a ete suggere chez l’Homme, la voie de dissemination dans le SNC n’a pas encore ete elucidee. La dissemination de cette bacterie pourrait se faire par les faisceaux de fibres blanches. Nous faisons l’hypothese que les abces multiples suivent ces faisceaux et que le diagnostic peut etre envisage sur l’imagerie. Materiels et methode Nous avons fait une revue de la litterature a la recherche d’abces cerebraux multiples a laquelle nous avons ajoute un cas supplementaire afin d’analyser la distribution de ces abces en imagerie. Nous avons considere un nombre d’abces de 3 ou plus, ou les imageries etaient disponibles en excluant les localisations uniques dans le tronc cerebral. Resultats Nous avons trouve 77xa0abces encephaliques dans la litterature, 17 etaient multiples (>xa03). Six cas ne presentaient pas d’imagerie. Sur les 11 restants, 3 n’interessaient que le tronc cerebral. Sur les 8xa0cas analyses, auquel nous avons ajoute notre patient pour un total de 9xa0cas, un cas presentait des abces bilateraux qui ne suivaient pas des faisceaux de fibres blanches et un cas presentait des abces bilateraux qui se distribuait le long des faisceaux de fibres blanches d’un seul cote. Pour les sept autres cas, les multiples abces etaient strictement unilateraux et suivaient les faisceaux de fibres blanches. Conclusion L’aspect en imagerie des abces a L.xa0monocytogenes appuie l’hypothese d’une dissemination intra-axonale de cette bacterie le long des faisceaux de fibres de la substance blanche. A notre connaissance, il s’agit de la premiere description en imagerie d’une dissemination intra-axonale de L.xa0monocytogenes chez l’Homme. Ceci donne un aspect caracteristique a l’imagerie qui permet de faire un diagnostic precoce et d’instaurer plus rapidement un traitement.