Ninh Doan

Coincidence of an anterior cerebral artery aneurysm and a glioblastoma: case report and review of literature.

Background The association between glioblastoma and intracranial aneurysm is rare. Treatment guidelines do not exist, and operative mortality and morbidity are significantly high. To our knowledge, no prior cases have employed endovascular therapy for the treatment of these intra-tumor intracranial aneurysms followed by tumor resection. Case presentation A 74-year-old male, history of a left A2 aneurysm, presented after a motor vehicle accident at low speeds. Imaging was concerning for a possible traumatic brain contusion, an aneurysmal hemorrhage given history of left A2 aneurysm, or a hemorrhage from an underlying tumor given profound edema. The patient was discussed at the brain tumor board, where the plan was to address the aneurysm followed by resection of the mass versus close monitoring with subsequent imaging. The high risk of rehemorrhage, given the real possibility of an aneurysmal hemorrhage, motivated prompt treatment of the aneurysm. The patient was taken to the angiography suite; an anterosuperiorly projecting azygous A2 aneurysm, measuring 4.5 mm × 5.5 mm with a neck width at 3.5 mm and a small daughter sac, was completely obliterated with primary coiling. The following day, he underwent a left craniotomy along a forehead skin crease for mass excision. Final pathology revealed glioblastoma. The patient recovered well from both procedures, with a baseline neurological exam. The patient subsequently underwent hypofractionated radiation and temodar. Conclusion To our knowledge, no prior cases have employed endovascular therapy for the treatment of these intracranial aneurysms. We emphasize that efforts to introduce less invasive elements may improve the overall outcomes in this rare patient population.

Lumbar spine endplate fractures: Biomechanical evaluation and clinical considerations through experimental induction of injury.

Lumbar endplate fractures were investigated in different experimental scenarios, however the biomechanical effect of segmental alignment was not outlined. The objectives of this study were to quantify effects of spinal orientation on lumbar spine injuries during single‐cycle compressive loads and understand lumbar spine endplate injury tolerance. Twenty lumbar motion segments were compressed to failure. Two methods were used in the preparation of the lumbar motion segments. Group 1 (n = 7) preparation maintained pre‐test sagittal lordosis, whereas Group 2 (n = 13) specimens had a free‐rotational end condition for the cranial vertebra, allowing sagittal rotation of the cranial vertebra to create parallel endplates. Five Group 1 specimens experienced posterior vertebral body fracture prior to endplate fracture, whereas two sustained endplate fracture only. Group 2 specimens sustained isolated endplate fractures. Group 2 fractures occurred at approximately 41% of the axial force required for Group 1 fracture (p < 0.05). Imaging and specimen dissection indicate endplate injury consistently took place within the confines of the endplate boundaries, away from the vertebral periphery. These findings indicate that spinal alignment during compressive loading influences the resulting injury pattern. This investigation identified the specific mechanical conditions under which an endplate breach will take place. Development of endplate injuries has significant clinical implication as previous research identified internal disc disruption (IDD) and degenerative disc disease (DDD) as long‐term consequences of the axial load‐shift that occurs following a breach of the endplate.

Upright magnetic resonance imaging of the lumbar spine: Back pain and radiculopathy

Background: Lumbar back pain and radiculopathy are common diagnoses. Unfortunately, conventional magnetic resonance imaging (MRI) findings and clinical symptoms do not necessarily correlate in the lumbar spine. With upright imaging, disc pathologies or foraminal stenosis may become more salient, leading to improvements in diagnosis. Materials and Methods: Seventeen adults (10 asymptomatic and 7 symptomatic volunteers) provided their informed consent and participated in the study. A 0.6T upright MRI scan was performed on each adult in the seated position. Parameters were obtained from the L2/3 level to the L5/S1 level including those pertaining to the foramen [cross-sectional area (CSA), height, mid-disc width, width, thickness of ligamentum flavum], disc (bulge, height, width), vertebral body (height and width), and alignment (lordosis angle, wedge angle, lumbosacral angle). Each parameter was compared based on the spinal level and volunteer group using two-factor analysis of variance (ANOVA). Bonferroni post hoc analysis was used to assess the differences between individual spinal levels. Results: Mid-disc width accounted for 56% of maximum foramen width in symptomatic volunteers and over 63% in asymptomatic volunteers. Disc bulge was 48% greater in symptomatic volunteers compared to asymptomatic volunteers. CSA was generally smaller in symptomatic volunteers compared to asymptomatic volunteers, particularly at the L4-L5 and L5-S1 spinal levels. Thickness of ligamentum flavum (TLF) generally increased from the cranial to caudal spinal levels where the L4-L5 and L5-S1 spinal levels were significantly thicker than the L1-L2 spinal level. Conclusions: The data implied that upright MRI could be a useful diagnostic option, as it can delineate pertinent differences between symptomatic volunteers and asymptomatic volunteers, especially with respect to foraminal geometry.

Granulomatous amebic encephalitis following hematopoietic stem cell transplantation.

Background: Granulomatous amebic encephalitis (GAE) is rare, but often fatal. The infection has been documented predominantly among the immunocompromised population or among those with chronic disease. To date, however, there have only been eight cases regarding the infection following hematopoietic stem cell transplantation (HSCT). Case Description: A 62-year-old female with a history of relapsed diffuse large B-cell lymphoma, recently underwent peripheral blood autologous stem cell transplant after BEAM conditioning (day 0). On day +15, she began to exhibit worsening fatigue, generalized weakness, and fever. Symptoms progressed to nausea, emesis, somnolence, confusion, and frontal headaches over the next few days. Imaging demonstrated multifocal ill-defined vasogenic edema with patchy enhancement. The patient was started on broad antibiotics, antifungals, and seizure prophylaxis. Evaluation for bacterial, fungal, mycobacterial, and viral etiologies was fruitless. Her mental status progressively deteriorated. On day +22, she exhibited severe lethargy and went into pulseless electrical activity arrest, requiring chest compressions. The episode lasted <2 min and her pulse was restored. She was taken to the operating room for a brain biopsy. Postoperatively, her right pupil began to dilate compared to the left; she demonstrated extensor posturing in her upper extremities and withdrawal in her lower extremities. Repeat computed tomography demonstrated progressive edema. Given poor prognosis and poor neurological examination, the family opted for withdrawal of care. Final pathology was consistent with Acanthamoeba GAE. Conclusion: The authors report the third case of GAE after autologous stem cell transplant, and the ninth case overall after HSCT. This case is unusual due to its rapid clinical presentation after HSCT compared to prior literature. The case highlights the need for high suspicion of Acanthamoeba infection in this patient population.

Surgical decompression coupled with diagnostic dynamic intraoperative angiography for bow hunter's syndrome.

Background: Bow hunters syndrome, also known as rotational vertebrobasilar insufficiency, arises from mechanical compression of the vertebral artery during the neck rotation. Surgical options have been the mainstay treatment of choice. Postoperative imaging is typically used to assess adequate decompression. On the other hand, intraoperative assessment of decompression has been rarely reported. Case Description: A 52-year-old male began to see “black spots,” and experienced presyncope whenever he rotated his head toward the right. The patient ultimately underwent a dynamic diagnostic cerebral angiogram, which revealed a dominant right vertebral artery and complete proximal occlusion of the right vertebral artery with the head rotated toward the right. Subsequently, the patient underwent an anterior transcervical approach to the right C6/C7 transverse process. The bone removal occurred along with the anterior wall of the C6 foramen transversarium, followed by the upper portion of the anterior C6 body medially, and the transverse process of C6 laterally. An oblique osseofibrous band was noted to extend across the vertebral artery; it was dissected and severed. An intraoperative cerebral angiogram confirmed no existing compression of the vertebral artery with the head rotated toward the right. The patient recovered from surgery without issues; he denied recurrence of preoperative symptoms at follow-up. Conclusions: The authors report the third instance where intraoperative dynamic angiography was employed with good outcomes. Although intraoperative cerebral angiography is an invasive procedure, which prompts additional risks, the authors believe the modality affords better, real-time visualization of the vertebral artery, allowing for assessment of the adequacy of the decompression. This advantage may reduce the probability for a second procedure, which has its own set of risks, and may counteract the risks involved with intraoperative dynamic angiography.

Acid ceramidase is a novel drug target for pediatric brain tumors

Pediatric brain tumors are the most common solid tumors in children and are also a leading culprit of cancer-related fatalities in children. Pediatric brain tumors remain hard to treat. In this study, we demonstrated that medulloblastoma, pediatric glioblastoma, and atypical teratoid rhabdoid tumors express significant levels of acid ceramidase, where levels are highest in the radioresistant tumors, suggesting that acid ceramidase may confer radioresistance. More importantly, we also showed that acid ceramidase inhibitors are highly effective at targeting these pediatric brain tumors with low IC50 values (4.6–50 μM). This data suggests acid ceramidase as a novel drug target for adjuvant pediatric brain tumor therapies. Of these acid ceramidase inhibitors, carmofur has seen clinical use in Japan since 1981 for colorectal cancers and is a promising drug to undergo further animal studies and subsequently a clinical trial as a treatment for pediatric patients with brain tumors.

Case Report and Review of Literature of Delayed Acute Subdural Hematoma

BACKGROUND The authors present a case of delayed acute subdural hematoma and review all reported cases in the literature. The focus of this paper is to identify the subset of the population who are at risk, and determine whether they should be admitted for observation in the setting of mild traumatic brain injury. CASE DESCRIPTION A 75-year-old woman taking daily aspirin (81 mg) had a fall with loss of consciousness. Her Glasgow Coma Scale (GCS) score was 15 at the time of presentation to the emergency department. However, because of her postconcussive symptoms, computed tomography (CT) of the head was obtained, and the results were negative for any intracranial hemorrhage or fractures. She was admitted for workup. The next day, she neurologically deteriorated to a GCS score of 6. CT of the head was reobtained and showed acute, left-sided subdural hematoma with shift and herniation. She was taken to operating room for emergent decompressive craniotomy. Postoperatively, she developed left-sided temporal and occipital intraparenchymal hemorrhage. She died after being placed on comfort care. CONCLUSION Delayed acute subdural hematoma occurs mainly in the middle-aged or older population who are taking anticoagulation or antiplatelet therapy. Most patients have a GCS score of 15 with no loss of consciousness. Neurological deterioration occurs within the first 24 hours for 70% of the patients. Therefore, we recommend admission and observation of these selected group of patients. Due to small reported population of patients, we could not determine whether the patients taking anticoagulant, antiplatelet, or both anticoagulant and antiplatelet medication are at higher risk. In addition, the role of delayed CT of the head without change in the examination result needs to be explored further.

A completely thrombosed, nongiant middle cerebral artery aneurysm mimicking an intra-axial neoplasm.

Background: Few reports exist regarding thrombosed aneurysms where the initial work up was concerning for a neoplasm. To date, no published reports exist regarding a nongiant thrombosed middle cerebral artery aneurysm, where the primary workup and treatment plan was directed toward a preliminary diagnosis of intra-axial neoplasm. Case Description: We report a 43-year-old female who presented with a generalized tonic-clonic seizure attributed to a lesion along the right superior temporal gyrus. The lesion enhanced on initial magnetic resonance imaging (MRI) of the brain, as well as on follow-up MRI. Subsequent vascular studies and metastatic work up were negative. A craniotomy with image guidance was performed and an intraoperative diagnosis was made of a thrombosed aneurysm along a branch of the middle cerebral artery. The aneurysm was trapped and resected as there was no significant flow from the branch as seen on the prior cerebral angiogram. The patient had an uneventful postoperative course. Conclusion: Completely thrombosed, nongiant aneurysms can mimic an intra-axial neoplasm. Typical imaging features for thrombosed aneurysms may be missed, especially if the aneurysms are small, where imaging characteristics of the intraluminal contents is more difficult to appreciate. Although imaging may be consistent with a neoplastic lesion, there should be suspicion for a potential underlying aneurysm.

Acid ceramidase confers radioresistance to glioblastoma cells

Glioblastoma multiforme (GBM) is the most common primary, intracranial malignancy of the central nervous system. The standard treatment protocol, which involves surgical resection, and concurrent radiation with adjuvant temozolomide (TMZ), still imparts a grim prognosis. Ultimately, all GBMs exhibit recurrence or progression, developing resistance to standard treatment. This study demonstrates that GBMs acquire resistance to radiation via upregulation of acid ceramidase (ASAH1) and sphingosine-1-phosphate (Sph-1P). Moreover, inhibition of ASAH1 and Sph-1P, either with humanized monoclonal antibodies, small molecule drugs (i.e. carmofur), or a combination of both, led to suppression of GBM cell growth. These results suggest that ASAH1 and Sph-1P may be excellent targets for the treatment of new GBMs and recurrent GBMs, especially since the latter overexpresses ASAH1.

Management of Adult Traumatic Brain Injury: A Review

Traumatic brain injury (TBI) is a significant source of morbidity and mortality in the adult population. The management of traumatic brain injury depends on its severity. It must be recognized that almost all forms of treatment for TBI are geared towards the minimization of secondary injury, as it is assumed that primary injury is irreversible. The discussion here represents much of what is known up-to-date concerning TBI management, but its treatment continues to evolve once new mechanisms of injury are discovered and those that we know of now are refined. The treating staffs are encouraged to keep up with the current state of the literature to stay informed.