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Background Intracranial aneurysm (IA) is a debilitating cerebrovascular degeneration. Current clinical diagnosis relies mainly on conventional angiogram except for some peculiar aneurysms. Nonetheless, there is no documentation of aneurysm showing robust intracranial artifact on computed tomography or magnetic resonance imaging. Case Description Herein, we report a 45-year-old female with an IA showing a robust intracranial metal artifact. During surgery, the culprit lesion for the artifact was discovered to be hard plaque on the ventral part of the aneurysm. Craniotomy clipping and vessel reconstruction were successful, but minor vasospasm was observed postoperatively. Postoperative pathology and optical emission spectrometer analyses showed elevated iron and copper level in the plaque on the IA. After comparing with other aneurysm samples, we believe the overenriched local iron deposition contributed to the metal artifact on imaging. Conclusions Taken together, accidental findings of intracranial metal artifacts on computed tomography and magnetic resonance imaging can be indicative to iron deposition on intracranial aneurysm. Neuroimaging using magnetic field should be performed with caution. Local accumulation of lysed products from erythrocyte might contribute to the occurrence of this enriched iron deposition, but further evidence regarding the pathogenesis of copper deposition should be provided. Surgically, measures should be taken to avoid perioperative complications like vasospasm and delayed cerebral ischemia. Future report of similar cases would be helpful in optimizing the treatment modality for the aneurysm with metallic plaque.

To evaluate whether the postoperative neutrophil-to-lymphocyte ratio (NLR) is a prognostic marker for patients with intracerebral hemorrhage (ICH) undergoing surgical hematoma evacuation.This retrospective cohort study was conducted to identify patients with ICH who underwent hematoma evacuation between January 2013 and December 2018. Data on demographics, clinical features, laboratory tests (admission and postoperative), and imaging information were collected. The associations between variables and 30-day mortality were assessed by multivariable logistic regression analysis. The predictive power of independent predictors was evaluated by receiver operating characteristic (ROC) curve analysis.A total of 380 patients were included. Multivariable analysis identified admission Glasgow Coma Scale score (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.53-0.70; P0.001) and initial hematoma volume (OR, 1.01; 95% CI, 1.01-1.02; P = 0.022) were independently associated with 30-day mortality. With regard to laboratory biomarkers, postoperative NLR (OR, 1.04; 95% CI, 1.01-1.08; P = 0.014) was independently correlated with 30-day death, but admission NLR (OR, 1.00; 95% CI, 0.97-1.03; P = 0.944) was not. The best predictive cutoff point of 12.97 for postoperative NLR (area under the ROC curve, 0.606; P = 0.006) for predicting 30-day mortality was determined by ROC analysis.In patients with ICH undergoing hematoma evacuation, admission Glasgow Coma Scale score, initial hematoma volume, and postoperative NLR were independently associated with 30-day mortality. Postoperative NLR may be a prognostic marker in surgical ICH patients, and future studies are needed to confirm this finding.

Background Brainstem hemorrhage (BSH) is the most dangerous and devastating subtype of intracerebral hemorrhage and is associated with high morbidity and mortality. However, to date, no effective prevention methods or specific therapies have been available to improve its clinical outcomes. We preliminarily explored the efficacy of deferoxamine (DFO), a clinical chelator known for its iron-scavenging activities, in a rat model of BSH induced with collagenase infusion. Methods DFO or saline was administrated 6 hours after BSH induction and then every 12 hours for ≤7 days. The survival curve of the rats was created, and the neurological scores were examined on days 1, 3, and 7 after BSH. The rats were sacrificed after 1, 3, and 7 days of DFO treatment for histological examination and immunohistochemistry. Results The results showed that administration of DFO delayed erythrocytes lysis, reduced iron deposition, reduced reactive oxygen species generation, reduced heme oxygenase-1 expression, and alleviated brain injury such as neuron degeneration and myelin sheath injury. However, DFO did not improve the survival rate and neurobehavioral outcomes in this model. Conclusions Administration of DFO had limited therapeutic effects on collagenase-induced brainstem hemorrhage in rats. Some potential explanations were proposed, and more preclinical work is required to clarify the controversial curative effect of DFO in ICH.

We investigated the outcomes of patients with an unruptured intracranial aneurysm (UIA) and2 risk factors concerning complications, obliteration rate, and other factors after surgical or endovascular treatment.Coiling and clipping were compared in patients with UIAs treated in West China Hospital from January 2015 to May 2017. Patient survival, dependency, retreatment, complications, and other clinical outcome indexes were compared between the 2 groups.A total of 82 patients (92 aneurysms) had undergone treatment for UIAs with multiple risk factors. Of these 82 patients, 45 (54.9%) had undergone clipping and 37 (45.1%) had undergone coiling. No deaths were related to either treatment. Morbidity (modified Rankin scale score2) at 1 year had developed in 1 of 45 and 1 of 37 patients in the clipping and coiling groups, without a statistically significant difference. Hospitalization5 days (30 of 45 vs. 12 of 37; P0.05) was less frequent after coiling. The number of aneurysms with complete occlusion (48 of 51 vs. 33 of 41; P0.05) was greater in the surgical group. No differences in peritreatment complications were found in the surgical and endovascular groups (8 of 45 vs. 6 of 37; P0.05).In our study, clipping and coiling showed advantages for the treatment of UIAs with multiple risk factors. Surgical clipping of UIAs is achievable with a low rate of unfavorable outcomes and a high rate of complete obliteration for patients with multiple risk factors. However, endovascular treatment was also successful, with a shorter length of stay and low procedure-related morbidity. Additional randomized evidence are required to support the superior efficacy of clipping.

Objective Delayed cerebral ischemia (DCI) is significantly related to death and unfavorable functional outcome in patients with aneurysmal subarachnoid hemorrhage (SAH). The association between alpha-delta ratio (ADR) on quantitative electroencephalography (EEG) and DCI has been reported in several previous studies, but their results are conflicting. This meta-analysis was conducted to assess the accuracy of ADR for DCI prediction in patients with aneurysmal SAH. Methods PubMed and Embase were systematically searched for related records. Study selection and data collection were completed by 2 investigators. Sensitivity, specificity, and their 95% confidence intervals (CIs) were pooled. A summary receiver operating characteristic curve was plotted to show the pooled accuracy. Deeks funnel plot was used to evaluate publication bias. Results Five studies were included in this meta-analysis. The pooled sensitivity and specificity of worsening ADR for DCI prediction in patients with aneurysmal SAH were 0.83 (95% CI 0.44–0.97) and 0.74 (95% CI 0.50–0.89), respectively. In addition, the area under the summary receiver operating characteristic curve was 0.84 (95% CI 0.81–0.87). No obvious publication bias was found using Deeks funnel plot (P = 0.29). Conclusions Worsening ADR on quantitative EEG is a reliable predictor of DCI in patients with aneurysmal SAH. Further studies are still needed to confirm the role of quantitative EEG in DCI prediction.

Primary intraventricular hemorrhage (PIVH) is a rare condition in adult patients. PIVH occurs frequently in adult hemorrhagic Moyamoya disease (MMD). Idiopathic PIVH is defined as PIVH without cerebrovascular abnormalities. This study is aimed to compare the baseline characteristics and outcomes of acute MMD-related and idiopathic PIVH.Adult patients with acute MMD-related or idiopathic PIVH were retrospectively included. Baseline characteristics and outcomes at discharge were obtained and compared. Chi-square test, Student's t-test, or rank-sum test were used in statistical analyses.This study finally included 32 patients with acute MMD-related PIVH and 112 with acute idiopathic PIVH. Patients with acute MMD-related PIVH were significantly younger (53.3 ± 15.8 vs. 42.8 ± 12.2 years, P0.001). The admission systolic blood pressure in patients with acute idiopathic PIVH was significantly higher (161.7 ± 30.9 vs. 134.6 ± 24.6 mm Hg, P0.001). Patients with acute idiopathic PIVH had significantly higher admission serum urea (5.68 ± 2.66 vs. 4.34 ± 1.62 mmol/L, P = 0.008), cystatin C (0.97 ± 0.72 vs. 0.68 ± 0.16 mg/L, P = 0.023), and uric acid (309.01 ± 105.97 vs. 242.24 ± 77.65 μmol/L, P = 0.001). In patients with acute MMD-related PIVH, only one (3.1%) patient was dead at discharge. In contrast, a total of 22 (19.6%) patients with acute idiopathic patients died at discharge (P = 0.027).Compared with patients with acute idiopathic PIVH, patients with acute MMD-related PIVH have younger age, lower blood pressure, and better renal function. Moreover, patients with acute MMD-related PIVH have lower short-term mortality.

Objective Among several novel predictors on noncontrast computed tomography (CT) for hematoma expansion in spontaneous intracerebral hemorrhage (sICH), shape irregularity grade, satellite sign, and island sign are all related to irregular shape of hematoma. This study is aimed to compare the accuracy of these imaging markers for predicting hematoma expansion in the same cohort of sICH patients. Methods This retrospective study enrolled sICH patients who underwent diagnostic computed tomography (CT) scans within 6 hours after onset and another follow-up CT scan within 24 hours after initial CT scan. Shape irregularity grade, satellite sign, and island sign were assessed according to the definitions in previous studies. The accuracy of these imaging indicators for predicting hematoma expansion was analyzed using receiver operator analysis. Results Finally, a total of 196 patients were included. Shape irregularity grade ≥3 was found in 87 (44.39%) patients, satellite sign was identified in 76 (38.78%) patients, and island sign was shown in only 41 (20.92%) patients. Only island sign remained an independent predictor for hematoma expansion in multivariate logistic regression. The sensitivity values of shape irregularity grade ≥3, satellite sign, and island sign were 0.52, 0.63, and 0.48, respectively. By contrast, the specificity values of these 3 predictors were 0.58, 0.69, and 0.85, respectively. Shape irregularity grade ≥3 had the smallest area under the curve (0.597), and island sign had the largest (0.676). Conclusions Island sign seems to be the optimal shape-related predictor for hematoma expansion in sICH patients and could be included in the future predictive model for hematoma expansion.

Background The island sign is a novel imaging predictor for early hematoma growth, implying multifocal active bleeding. The prognostic value of the island sign for long-term outcome in patients with intracranial hemorrhage (ICH) remains unrevealed. The aim of this study is to investigate associations between the island land and long-term prognosis in patients with ICH. Methods Both clinical characteristics and radiologic parameters were retrospectively obtained from electronic medical records. According to the initial and follow-up computed tomography scans of patients, hematoma expansion and the island sign were determined independently with 2 experienced physicians. Multivariate logistic regression analyses were used to explore the associations of hematoma expansion, 1-year poor outcome, and 1-year death on other clinical variables. Results A total of 322 patients were included, and 126 of them presented with early hematoma expansion, with 81 exhibiting the island sign. There were 116 patients who died, and 157 patients with ICH had poor outcome at the first year after onset. The multivariate logistic regression analyses revealed that initial Glasgow Coma Scale score, hematoma size, and presence of intraventricular hemorrhage and island sign were strongly associated with long-term poor outcomes. Conclusions The island sign is an easy-to-use and novel imaging marker which predicts both early hematoma expansion and long-term poor prognosis.

Intracranial aneurysms (IAs) are occasionally associated with moyamoya disease (MMD). The purpose of this study was to elucidate differences between patients with MMD with and without IAs and differences between patients with IAs at different locations.Between May 2012 and December 2017, consecutive patients with MMD were enrolled in a retrospective single-center study. IAs were classified as circle of Willis (CoW) or peripheral aneurysms according to the anatomic location. Clinical characteristics and hemodynamic parameters were collected and analyzed. A hemispheric analysis was performed for Suzuki stage and computed tomography perfusion parameters.The study included 31 patients with MMD with IAs and 279 patients with MMD without IAs. The patients with IAs had more severe neurological dysfunction, more advanced Suzuki stage, and less hemodynamic dysfunction than the patients without IAs (P0.05). Of patients with MMD with IAs, 17 had CoW aneurysms, and 13 had peripheral aneurysms. Patients with CoW aneurysms were older and had more advanced Suzuki stage than patients with peripheral aneurysms (P0.05).Patients with MMD with IAs had different clinical and hemodynamic features compared with patients with MMD without IAs. CoW aneurysms and peripheral aneurysms may occur at different stages of MMD, which may explain their differences in anatomical location, type of hemorrhage, and treatment strategy.

The inflammatory response plays a vital role in the pathologic mechanism of intracerebral hemorrhage. It recently has been reported that neutrophil to lymphocyte ratio (NLR) could represent a novel composite inflammatory marker for predicting the prognosis of intracranial hemorrhage (ICH). However, in considering the effects of surgical evacuation on the initiation of inflammatory responses, the relationship between NLR and functional outcome of patients with ICH after surgical treatment is still controversial. Here, we aimed to assess the predictive value of admission NLR and other available laboratory parameters for 90-day outcome of patients with ICH undergoing neurosurgical treatment.In total, 104 patients with acute ICH admitted to West China Hospital from October 2016 to January 2018 were retrospectively enrolled. Admission absolute neutrophil count, lymphocyte count, and white blood count were extracted from electronic medical records of patents with ICH. The associations between outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. The comparison of predictive power of independent predictors was evaluated by receiver operating characteristic curves.In total, 59 patients with ICH who underwent surgical treatment exhibited unfavorable outcomes, which was associated with greater admission NLR (odds ratio [OR] 0.692, 95% confidence interval [CI] 0.518-0.925, P = 0.01; OR 1.148, 95% CI 1.078-1.222, P0.01; OR 1.215, 95% CI 1.015-1.454, P = 0.03), lower Glasgow Coma Scale score, and larger hematoma. NLR showed the best predictive power by comparing with other laboratorial variables (area under the curve 0.668, 95% CI 0.569-0.757, P 0.01) and also was found to linearly correlate with Glasgow Coma Scale score at admission, hematoma volume, absolute neutrophil count, absolute lymphocyte count, and hydrocephalus. Meanwhile, the best predictive cutoff point of 6.46 for NLR also was identified.Other than the association of prognosis of patients with ICH, NLR exhibited potential independent predictive ability for 90-day functional outcomes of patients with ICH after surgery.

Objectives The prognostic value of admission serum glucose for early hematoma growth in patients with intracranial hemorrhage remains controversial. Island sign is a novel imaging predictor for early hematoma growth, implying multifocal active bleeding. The aim of this study is to investigate the potential associations between hyperglycemia and early hematoma expansion in patients with intracranial hemorrhage with or without island sign. Patients and Methods Clinical characteristics and radiologic parameters were retrospectively obtained from the electronic medical record. Admission blood glucose was measured within 24 hours from disease onset. Hematoma expansion and island sign were estimated by 2 experienced reviewers from initial and follow-up computed tomography scans. Multivariate logistic regression analyses were used to explore the associations of hematoma expansion and island sign on other clinical variables. Results In total, 187 patients were enrolled in current study; 61 patients were presented to have early hematoma expansion, whereas 32 exhibited island sign. The average blood glucose level was 7.64 mmol/L among all patients. The multivariate logistic regression analyses revealed that the time from ictus to initial computed tomography scan, Glasgow Coma Scale score on admission, hematoma volume, island sign, and hyperglycemia were associated with hematoma expansion, whereas only admission serum glucose and hematoma size were associated with island sign. Conclusions Admission serum glucose is associated with hematoma growth and prevalence of island sign, respectively. These results indicated that elevated blood glucose level plays a pathological role in active bleeding. Further studies concerning exact molecular signal pathway are urgently required.

Background Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease. Emerging evidence has indicated that the apolipoprotein E (ApoE) genotype might be associated with the risk of aSAH as well as complications and outcomes after aSAH, although the results remain controversial. Methods We searched published literature on PubMed, Embase, China National Knowledge Infrastructure, and Wanfang database to identify studies involving the ApoE genotype and aSAH. A meta-analysis was performed to summarize the relationship between ApoE genotype and aSAH, including susceptibility, complications, and prognosis. Results Eighteen studies were considered eligible for inclusion. Generally, e4 carriers had increased risk of aSAH (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.01–1.49). White patients with the e2/e2 genotype had a greater risk of aSAH (OR 3.38, 95% CI 1.13–10.11). The patients with aSAH carrying the e4 allele had an increased risk of poor outcome (OR 2.21, 95% CI 1.21–4.05) compared with non-e4 carriers, especially in Asian patients (OR 4.99, 95% CI 1.73–14.40). ApoE e4 carriers have increased risk of delayed ischemic neurologic deficit compared with non-e4 carriers in the overall population. No significant difference was detected regarding the effect of certain ApoE genotypes on aSAH admission severity, rebleeding, or cerebral vasospasm after aSAH. Conclusions We found that the ApoE genotype was significantly associated with aSAH risk, whereas its effect on certain ethnic populations differs. Patient carrying the e4 allele might have a worse outcome, whereas current evidence was insufficient to prove the association between ApoE genotypes and post-SAH complications.

Objective Hematoma expansion (HE) is closely related to poor outcome in spontaneous intracerebral hemorrhage (sICH). Island sign (IS) is a novel HE predictor based on noncontrast computed tomography (NCCT). This study is aimed to confirm the accuracy of IS for predicting HE and compare it to the spot sign (SS) on computed tomography angiography (CTA). Methods Patients with sICH and initial CTA within 6 hours after onset and follow-up NCCT within 24 hours after initial CTA were included. IS and SS were screened by 2 independent readers. The sensitivity and specificity were evaluated for both signs. Receiver-operator analysis was conducted to assess the accuracy of both signs for predicting HE. Results This study included 165 patients. IS was found in 33 (20.0%) patients, and SS was identified in 42 (25.5%) patients. In the 41 patients with HE, 19 (46.3%) had IS and 26 (63.4%) had SS. The sensitivity and specificity of IS were 46.3% and 88.7%, respectively. In contrast, the sensitivity and specificity of SS were 63.4% and 87.1%, respectively. The areas under the curve of IS and SS were 0.675 and 0.753, respectively (P = 0.275). Conclusions IS is independently associated with HE. Although the accuracy of IS for predicting HE is lower than SS, it can be an alternative predictor if CTA cannot be performed.

Objective To summarize the characteristics of intracranial pseudoaneurysms (IPAs) in pediatric patients. Methods Pediatric IPAs treated at our center between January 2012 and April 2017 were analyzed retrospectively. Related literature was reviewed, and the results of those studies were compared with our present findings. Results A total of 15 pediatric IPAs from 64 pediatric intracranial aneurysms (23.4%) were included in our study. Eleven of the 15 patients (73.3%) were male, and 9 (60%) had a history of head trauma. Seven patients (46.6%) presented with seizures, 9 of 11 patients (81.8%) with ruptured aneurysms with presented intracerebral hematoma, and 9 IPAs (60%) were large or giant in size. The internal carotid artery (ICA) and middle cerebral artery (MCA) were the most common aneurysm sites (n = 6; 40.0%). Eight IPAs (53.3%) were distal arterial aneurysms. Seven patients (46.7%) underwent craniotomy surgery, and 8 (53.3%) underwent endovascular treatment. During a mean follow-up of 2.0 ± 1.3 years, 12 patients (80.0%) had favorable outcomes, with a modified Rankin Scale (mRS) score of 0–2. One patient in the endovascular group died due to postoperative rebleeding. Conclusions IPAs are prevalent among all pediatric intracranial aneurysms, and head trauma is the most important risk factor. IPAs present with more intracerebral hematomas, tend to be larger, and are commonly observed in the ICA, MCA, and distal arterial location; they also carry a high risk of seizures. Both surgical and endovascular treatment could achieve favorable clinical outcomes, but more studies are needed to reveal which treatment approaches are best suited for pediatric IPAs.

To reveal the characteristics of spontaneous intracerebral hemorrhage (sICH) in a plateau area based on the Tibetan population.Data of Tibetan and Han patients (control group) with sICH treated at our center from January 2013 to April 2017 were retrospectively reviewed.A total of 122 Tibetan and 927 Han patients were included. Compared with Han patients, Tibetan patients were older (54.7 ± 11.2 vs. 50.9 ± 18.3 years, P = 0.027), exhibited higher male-to-female ratios (73.8% vs. 55.0%, P0.001), were more overweight (22.1% vs. 13.1%, P = 0.007) had more smokers (36.9% vs. 20.5%, P 0.001), had a higher concentration of hemoglobin (163.7 ± 17.6 vs. 134.8 ± 20.2 g/L, P 0.001), and included a higher number of patients with hypertension (83.6% vs. 60.5%, P 0.001), diabetes mellitus (19.2% vs. 9.3%, P = 0.002), and prior hemorrhagic stroke (9.0% vs. 2.0%, P0.001). Tibetan patients also experienced more brainstem hemorrhage (11.5% vs. 5.1%, P = 0.039) in the infratentorial region and had a higher risk of in-hospital complications resulting from hematoma enlargement (20.5% vs. 10.4%, P = 0.002) and cerebral infarction (59.0% vs. 9.7%, P 0.001). During a 6-month follow-up period, they had higher rates of unfavorable outcomes and case mortality (P0.05). A multivariable analysis adjusted for confounding factors revealed that the Tibetan race was positively associated with unfavorable clinical outcomes in sICH patients (P0.05).Tibetan sICH patients from the plateau area presented unique characteristics in their baseline measurements, incidence of comorbidities, hematoma location, risk of in-hospital complications, and clinical outcomes compared with Han patients. The Tibetan race was positively associated with unfavorable 6-month outcomes in ICH patients.

Background It remains unknown if ultra-early (within 24 hours after onset) treatment can improve the prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate the effect of ultra-early treatment on functional outcomes and mortality in patients with poor-grade aSAH via a systematic review and meta-analysis. Methods We performed a literature search in the PubMed, MEDLINE, and Web of Science databases. Primary outcomes were death and functional outcome assessed at any time period. Secondary outcomes were the rebleeding rate before an aneurysm occlusion procedure and the incidence of intraoperative technique difficulty (ITD). The results are reported as odds ratio (OR) with 95% confidence interval (CI). Results A total of 14 articles containing 1111 patients met our inclusion criteria and were included in our analysis. The pooled incidence was 47% (95% CI, 40%–54%) for favorable outcome across 13 studies, 26% (95% CI, 19%–32%) for mortality in 11 studies, 10% (95% CI, 3%–16%) for rebleeding in 5 studies, and 20% (95% CI, 10%–31%) for ITD in 5 studies after ultra-early treatment of poor-grade aSAH. Compared with delayed treatment (>24 hours), the ultra-early treatment failed to improve outcomes (OR, 1.23; 95% CI, 0.75–2.01; P = 0.40) or reduce mortality (OR, 0.84; 95% CI, 0.58–1.22; P = 0.45), but tended to prevent preoperative rebleeding (OR, 0.59; 95% CI, 0.32 to 1.07; P = 0.08) in 6, 4, and 4 case-control studies, respectively. Conclusions Our findings show no significant change both in functional outcome and mortality between ultra-early and delayed treatment although ultra-early treatment may be associated with lower rebleeding rate.

Objective To investigate the relationship between single nucleotide polymorphisms or haplotypes of COL4A1 gene and the outcome of intracerebral hemorrhage (ICH). Methods In our study, 181 patients with hypertensive ICH were enrolled and followed up at 3 and 6 months. Outcome data included any cause of death and disability. Genomic DNA was extracted by DNA extraction kit, and the 6 single nucleotide polymorphism genotyping of the COL4A1 gene was detected through MassARRAY Analyzer. Unphased 3.1.4 and SPSS 19.0 were used to analyze the association between alleles, genotypes, and haplotypes of the COL4A1 gene and the outcomes of ICH. Results Of the 181 patients with hypertensive ICH, 12 were lost in follow-up, which accounted for 6.6%. Our association analysis showed that the rs532625 AA genotype of the COL4A1 gene may increase risk of disability at 3 months; the rs532625 A allele and AA genotype were association factors of the risk of disability at 6 months; the rs532625 AA genotype was an association factor of the risk of death/disability at 6 months. After adjusting for gender, age, coma, and severe neurologic deficits, only the rs532625 AA genotype was independently associated with the risk of disability at 3 and 6 months and the risk of death/disability at 6 months. Conclusions Our study found that the rs532625 AA genotype in the COL4A1 gene was independently associated with the risk of disability at 3 and 6 months and death/disability at 6 months in a Chinese Han population. These conclusions need to be verified in future studies with larger samples.

Objective To investigate the association between single nucleotide polymorphisms or haplotypes of the COL4A1 gene and the risk of intracerebral hemorrhage (ICH). Methods We conducted a case-control study that included 181 patients from the Chinese Han population with hypertensive ICH and 197 hypertension patients without ICH. Genomic DNA was extracted by DNA extraction kit, and the 6 single nucleotide polymorphism genotypes of the COL4A1 gene were detected with a MassARRAY Analyzer. Unphased 3.1.4 and SPSS 19.0 were used to analyze the association between alleles, genotypes, and haplotypes of the COL4A1 gene and the risk of ICH. Results Compared with the control group, patients in the ICH group were significantly younger. There were no differences in gender, diabetes, hyperlipidemia, current smoking, and alcohol consumption between the 2 groups. Our association analysis showed that the rs3742207 A, rs11069830 A, and rs679505 A alleles were association factors of the risks of ICH; rs11069830 AA, rs544012 AC, and rs679505 AA genotypes were association factors of the risk of ICH; AA haplotype (rs3742207–rs11069830) was an association factor of the risk of ICH. After adjusting age and gender by multivariate logistic regression, the rs544012 AC and rs679505 AA genotypes were independently associated with the risk of ICH. Conclusions Our study showed that the rs544012 AC and rs679505 AA genotypes were independently associated with the risk of ICH in the Chinese Han population and that the AA haplotype (rs3742207–rs11069830) in the COL4A1 gene may be related to the risk of ICH in the Chinese Han population; these conclusions need further confirmation in future studies with larger samples.

Background Spontaneous intracerebral hemorrhage (sICH) is a devastating disease with high mortality and morbidity, and the application of decompressive craniectomy (DC) in sICH is controversial. We conducted a systematic review to verify the effects of DC on improving outcome in sICH. Methods Through searching several electronic databases, we screened eligible publications. Respective risk ratio (RR) and its 95% confidence interval (CI) were calculated, data were synthesized with a fixed-effect model, and sensitivity analyses and subgroup analyses were performed. Publication bias was measured with Begg and Egger tests. Results Overall effect showed that DC significantly reduced the poor outcome compared with the control group (RR, 0.91; 95% CI, 0.84–0.99; P = 0.03). But in the subgroup analyses, only studies published after 2010, studies using hematoma evacuation as control, and studies measuring outcome with Glasgow outcome score showed better outcomes in the DC group than in the control group. The other subgroup analyses and sensitivity analyses achieved inconsistent results. Compared with the control group, DC effectively decreased mortality (RR, 0.67; 95% CI, 0.53–0.85; P = 0.0008). The sensitivity analyses and subgroup analyses achieved consistent results. Conclusions The application of DC effectively reduced mortality in patients with sICH. DC might improve functional outcomes in certain populations and needs further verification. DC is not associated with increased incidences of postoperative rebleeding and hydrocephalus.

Background Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) are challenging lesions with high morbidity and mortality. Both surgical and endovascular approaches have been used to treat BBAs; however, little is known about their safety and efficacy. Objective To review our experience with the treatment of BBAs and explore the optimal treatment strategy. Methods A total of 83 patients with BBAs were reviewed retrospectively. The characteristics of the patients and the aneurysms, treatment results, and follow-up outcomes were analyzed. Results The cohort comprised 52 females and 31 males with a mean age of 46.6 years; 33 patients were assigned to the microsurgical therapy. Subsequently, 27/33 patients underwent surgical clipping, 4/33 underwent trapping without bypass, 2/33 underwent wrapping, and 50 patients underwent endovascular therapy, including stent-assisted coiling (49 patients) and coiling (1 patient). Intraoperative rupture occurred in 14 and 4 patients in the microsurgical and endovascular groups, respectively. Ischemic events occurred in 16 and 8 patients in the microsurgical and endovascular groups, respectively. At 1-year follow-up, a favorable clinical outcome was achieved in 18 (54.5%) and 38 (76.0%) patients in the microsurgical and endovascular groups, respectively. The multivariate regression model showed that the treatment strategies, Fisher grade, and vasospasm contributed significantly to the prediction of outcome for 1 year. Conclusions BBAs are challenging vascular lesions with poor prognosis. Endovascular treatment may be more effective and safer with better outcomes than surgical approaches.

Objective This systematic review and meta-analysis was aimed to evaluate the predictive values of shape irregularity and density heterogeneity of hematoma on noncontrast computed tomography (NCCT) for hematoma expansion (HE). Methods A literature search was performed in PubMed, Embase, Scopus, Web of Science, and Cochrane Library. Studies about predictive values of shape regularity or density heterogeneity of hematoma on NCCT for HE in spontaneous intracerebral hemorrhage were included. Meta-analysis was performed to pool the data. Publication bias assessment, subgroup analysis, and univariate meta-regression were conducted. Results A total of 7 studies with 2294 patients were included. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of shape irregularity were 67%, 47%, 1.30, and 0.71, respectively. In contrast, the pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of density irregularity were 52%, 69%, 1.70, and 0.69, respectively. Conclusions Considering the relatively low sensitivity and specificity, the predictive values of shape irregularity and density heterogeneity of hematoma for HE are limited. Further studies are still needed to find optimal NCCT predictors for HE in spontaneous intracerebral hemorrhage patients.

Background Cavernous malformations (CMs) involving the midbrain are more challenging for surgical treatment than are CMs at other sites because of the surrounding critical structures and deep location. However, specific features and treatment strategies have not been well illustrated. Objective To evaluate the long-term durability of surgical treatment of midbrain CMs (MBCMs) as well as surgical outcomes and complications. Methods A retrospective study was conducted in 34 patients who underwent microsurgical resection of MBCMs between 1995 and 2015. Demographics, lesion characteristics, surgical approaches, surgical outcomes, and complications were analyzed. Results A total of 34 adult patients with a mean age of 38.6 years were assessed. All patients presented with a history of hemorrhage. Lesion locations included the midbrain ( n = 27), midbrain and thalamus ( n = 2), and pontomesencephalic junction ( n = 5). Mean lesion size was 1.7 cm; average clinical follow-up was 5.6 years. Mean modified Rankin Scale (mRS) scores on admission, at discharge, and at last follow-up were 2.0, 2.7, and 1.7, respectively. Postoperatively, 19 patients (55.9%) showed new or worsened neurologic deficits. Multivariate analysis showed that admission mRS score (≥3) was an independent predictor of poor functional outcome (odds ratio, 50.832; 95% confidence interval, 2.967–901.283; P = 0.007). No rehemorrhage or recurrence case was found during the follow-up period. Conclusions Although surgery for MBCMs is associated with significant perioperative morbidity and mortality, most patients show favorable outcomes. Higher preoperative mRS score is an independent predictor of poor functional outcome.

Background Postcraniotomy meningitis is a severe complication in neurosurgery, and can result in high morbidity and mortality. Closed continuous lumbar drainage (CCLD) as an adjuvant method for treating postcraniotomy meningitis in adults is rarely assessed. This study aimed to evaluate the efficacy of CCLD in the treatment of postcraniotomy meningitis. Methods A total of 1062 patients older than 16 years with postcraniotomy meningitis were included, between January 2000 and December 2015. Of these, 474 received intravenous antibiotic therapy, steroid administration and adjuvant CCLD (experimental Group). The remaining 588 patients only received intravenous antibiotic and steroid therapies (control Group). Data were extracted from medical records. Results In the experimental group, meningitis-related mortality was 2.7%, and 77.4% individuals achieved a Glasgow Outcome Scale of 4–5. In the control group, meningitis-related mortality reached 11.6%, with only 61.1% of patients achieving a GOS of 4–5. The time to negative cerebrospinal fluid laboratory test and the duration of meningitis-related symptoms were significantly shorter in the experimental group compared with controls ( P Conclusions Intravenous antibiotic and steroid therapies, assisted by CCLD, can lead to lower mortality and improved Glasgow Outcome Scale score in patients with meningitis after craniotomy. Laboratory results negative for cerebrospinal fluid leak and meningitis-related symptom relief occurred faster in the experimental group. Intravenous antibiotic and steroid therapies combined with CCLD appear to be an effective and safe treatment for postcraniotomy meningitis.

Purpose To summarize the clinical and radiologic features of pediatric basal ganglia region tumors (PBGRT) in correlation with their histopathologic findings to reduce inappropriate surgery and identify tumors that can benefit from maximal safe resection. Methods The records of 35 children with PBGRT treated in our hospital from December 2011 to December 2015 were analyzed retrospectively. The clinical and radiologic features of these tumors were summarized and correlated with their histopathologic diagnosis. Results Our series included 15 astrocytomas and 11 germ cell tumors (GCTs). Basal ganglia astrocytomas were characterized by various clinical presentations and an ill-circumscribed mass with the involvement of surrounding structures on neuroimaging and mostly occurred in the first decade of life ( n = 10; 66.7%). Basal ganglia GCT mostly occurred in the second decade of life ( n = 8; 72.7%) with hemiparesis as the most common symptom ( n = 9; 81.8%). The tumors were located predominantly in the caput of caudate nucleus ( n = 8; 72.7%) with hemiatrophy as the typical sign ( n = 8; 72.7%). Occasionally, other tumors also could occur in this region, including primitive neuroectodermal tumor ( n = 1), atypical teratoid/rhabdoid tumor ( n = 1), anaplastic ependymoma ( n = 1), lymphoma ( n = 1), extraventricular neurocytoma ( n = 1), gangliogliomas ( n = 2), oligodendroglioma ( n = 1), and dysembryoplastic neuroepithelial tumor ( n = 1). Conclusions Astrocytoma and GCT are the most common PBGRTs. Low-grade astrocytomas could benefit from maximal surgical resection, whereas GCTs merit neoadjuvant chemoradiation therapy followed by second-look surgery. We advocate routine testing of tumor markers and analysis of their clinical and radiologic features to optimize the therapeutic strategy.

Although there have been many studies on primary hemorrhagic neurovascular diseases (PHNVDs) in different populations, a study focusing on PHNVDs in Tibetan people was lacking. This study aimed to explore the notable characteristics of Tibetan PHNVDs by comparing the 3 most common PHNVDs (aneurysmal subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and arteriovenous malformation) in our institution between Tibetan and Han patients.In this retrospective observational study, the hospital information system was used to access the records of patients with PHNVDs. A total of 249 Tibetan patients and 2093 corresponding contemporary Han patients were recruited from January 2012 to January 2016. Sociodemographic information and clinical data on each PHNVD subtype were collected and compared between the 2 races.For Tibetan patients, a significantly higher incidence (P0.05) of rebleeding and cerebral infarction was observed in all 3 PHNVD subtypes. In the aneurysmal subarachnoid hemorrhage group, Tibetan patients had significantly higher incidence of blood blisterlike aneurysms (BLAs) (19.6% [19/97] vs. 3.2% [34/1071]; P0.001). In the spontaneous intracerebral hemorrhage group, Tibetan patients had a significantly higher incidence of brainstem hemorrhage in the subtentorial area (10.8% vs. 5.1%; P = 0.035).For Tibetan PHNVDs, a high incidence of BLAs in aneurysmal subarachnoid hemorrhage, a tendency toward brainstem hemorrhage in subtentorial spontaneous intracerebral hemorrhage, and a high rate of infarction and rebleeding in all 3 subtypes were all recognized.

In the present study, we sought to evaluate the timing and outcomes in patients with hemorrhagic stroke who received tracheostomy.A retrospective database search was undertaken to identify patients with hemorrhagic stroke between January 2010 and December 2018. Clinical data on basic demographics, clinical features, and outcomes were extracted. The primary outcome was in-hospital mortality and secondary outcomes were hospital stays and hospital costs. Univariate and multivariate analyses were used to compare the characteristics and outcomes between patients with hemorrhagic stroke who underwent tracheostomy early (days 1-6) and late (days 7 or later).A total of 425 patients were identified, 74.4% (n = 316) received an early tracheostomy during the hospitalization. Patients with hemorrhagic stroke who received early tracheostomy had a higher rate of neurosurgical operation (odds ratio, 2.77; 95% confidence interval, 1.54-4.99; P = 0.001) and different types of hemorrhagic stroke (P = 0.001) in comparison with the late tracheostomy patients. In addition, early tracheostomy was associated with shorter hospital stays (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P = 0.003) and reduced hospital costs (P0.001) than with late tracheostomy. However, no significant difference was observed with regard to in-hospital mortality between early and late tracheostomy groups (P = 0.744).In our cohort, early tracheostomy in patients with hemorrhagic stroke may help reduce hospital stays and hospital costs, but not in-hospital mortality. Future prospective multicenter studies are warranted to validate these findings.

Background Spinal dural arteriovenous fistula (DAVF) occurs at any spinal level; however, a sacral location of fistula is extremely rare, and the clinical characteristics of sacral DAVF have not been well described. This study aimed to document the clinical features of sacral DAVF and review the existing literature. Case Description The first patient was a 55-year-old man who had progressive weakness and numbness in his lower extremities, along with mild urinary incontinence. The second case was a 32-year-old man who had a 1-year history of progressively worsening bilateral lower extremity weakness associated with diminished sensation. The third patient was a 43-year-old woman with 6-month history of progressive motor weakness of her lower limbs. On spinal angiography, a sacral DAVF with perimedullary vein drainage in all cases was observed. The sacral fistulas were completely obliterated with surgical intervention, and the symptoms of these patients have been gradually resolved. Follow-up magnetic resonance imaging showed complete or partial resolution of the edema within the spinal cord and disappearance of the abnormal vascular flow voids. Conclusions Sacral DAVFs are extremely rare and are easily missed by spinal angiography. Clinicians should be aware of the possibility of the occurrence of sacral DAVFs, and spinal angiography for the complete assessment of spinal vasculature should be carried out.

Objective Delayed cerebral ischemia (DCI) happens in about 30% of patients with aneurysmal subarachnoid hemorrhage (SAH) and is related to higher mortality and disability. Some studies have shown cerebral autoregulation impairment can be a predictor of DCI in aneurysmal SAH. We conducted this meta-analysis to evaluate the predictive value of cerebral autoregulation impairment for DCI based on the current literature. Methods A systematic literature search was performed in PubMed and Embase. According to inclusion and exclusion criteria, 2 authors screened the records and extracted data from the included studies. Pooled sensitivity, specificity, and their 95% confidence intervals (CIs) were obtained. To investigate the overall accuracy, a summary receiver operating characteristic (SROC) curve was built and the area under SROC curve was calculated. Deeks' linear regression was used to assess the publication bias. All statistical analyses were performed with Stata 14.0. Results A total of 7 studies were finally included in this meta-analysis. The pooled sensitivity and specificity values of impaired cerebral autoregulation for DCI prediction were 0.79 (95% CI, 0.65–0.88) and 0.85 (95% CI, 0.615–0.96). Moreover, the area under the SROC curve of cerebral autoregulation impairment for DCI prediction was 0.87 (95% CI, 0.835–0.89). No obvious publication bias was found in Deeks' linear regression (P = 0.99). Conclusions Cerebral autoregulation impairment can be a helpful predictor of DCI in aneurysmal SAH. Its accuracy for DCI prediction should be verified by more studies in the future.

Objectives To investigate the risk factors in the development of pneumonia and its impact on outcome after primary intraventricular hemorrhage (PIVH). Methods This is a single-center retrospective study including consecutive patients with PIVH admitted to West China Hospital from 2010 to 2016. Pneumonia was defined according to the modified Centers for Disease Control and Prevention criteria within 7 days after PIVH onset. Poor outcome (modified Rankin score ≥3) and mortality at discharge and at 90 days were analyzed. Results Among the included 174 patients, pneumonia occurred in 13 (7.5%) patients. Patients with pneumonia had lower Glasgow Coma Scale (GCS) score (P = 0.001) and greater Graeb score (P = 0.001) at admission, presented more often with acute hydrocephalus (P = 0.04) and greater rates with stroke history (P = 0.002), and harbored greater admission blood glucose (P = 0.01) and absolute neutrophil counts (P = 0.02). In a multivariable analysis, only GCS score and stroke history were independent predictors of pneumonia after PIVH. The patients with pneumonia had longer duration of hospital stay (P = 0.002) and poorer outcome (P = 0.02) at 90 days. However, after adjustment for confounders, pneumonia after PIVH was not an independent predictor of poor outcome at 90 days. Conclusions GCS score and stroke history were independent predictors of pneumonia development after PIVH. Pneumonia after PIVH was associated with longer duration of hospital stay and poorer outcome at 90 days.

Objectives The neutrophil-to-lymphocyte ratio (NLR) reflects the balance between innate and adaptive inflammatory responses. This study intended to evaluate parameters associated with admission high NLR and its impact on clinical outcome in patients with primary intraventricular hemorrhage (PIVH). Methods This study retrospectively analyzed consecutive patients with PIVH without a history of head trauma or parenchymal/subarachnoid hemorrhage on computed tomography scan between 2010 and 2016 in a single center. Clinical outcomes at discharge and 90 days were assessed with the modified Rankin Score (mRS) and dichotomized as good (mRS 0–2) and poor (mRS 3–6) outcomes. Associations were estimated using multivariable logistic regression. Results We had 171 patients with PIVH included in the present study. There were 94 male (55.0%) and 77 female (45.0%) patients, with an average age of 46.1 ± 17.2 years. Multivariable logistic analyses revealed independent associations of high NLR (≥8.25) with higher Graeb score, Moyamoya disease, higher admission blood glucose level, and lower platelet count. The patients with high NLR had poorer outcome at discharge and 90 days. After adjustment, the patients with high NLR tended to be associated with poor outcome both at discharge and 90 days. In addition, NLR exhibited a superior predictive power of pneumonia in PIVH than absolute neutrophil count and white blood cell count. Conclusions NLR tended to be associated with 90-day clinical outcomes of patients with PIVH and exhibited independent predictive power for pneumonia in PIVH.

Background and Objective Recurrence is a major problem in craniopharyngioma (CP) management. Recent study shows that high FABP5/CRABPII may be related to tumor growth and that all- trans retinoic acid (ATRA) may suppress primary CP growth. We studied the expression profile of FABP5 and CRABPII in recurrent CP tissue and the effect of ATRA on recurrent CP cells. Methods Fifty cases of patients with CP were enrolled in the retrospective study. Among them, 15 were recurrent. Fresh specimens were collected for immunohistochemistry, reverse transcription polymerase chain reaction, and western blotting analysis of FABP5 and CRABPII. Fresh specimens from 6 primary and recurrent CPs were collected and subjected to cell culture using an explants method. ATRA at various concentrations was applied to recurrent CP cell culture, and cell growth was recorded and analyzed. Results Immunohistochemistry, reverse transcription polymerase chain reaction, and western blot study showed that FABP5 was expressed significantly higher in recurrent tumors, whereas CRABPII was expressed significantly higher in primary tumors. The FABP5/CRABPII ratio was significantly higher in recurrent rather than primary tumors. Recurrent CP cells grew faster than primary cells, and ATRA induced cellular apoptosis and inhibited CP cell growth in a dose-dependent manner. Conclusions A high expression ratio between FABP5 and CRABPII may be related to CP tumor recurrence and ATRA could be a potential therapeutic agent for CP chemotherapy.

Objective The BAT score is a novel prediction score of hematoma expansion based on noncontrast computed tomography (CT) and consists of the blend sign, hypodensities, and time interval from onset to CT. This study aimed to compare the BAT score and the spot sign on CT angiography in a cohort of patients with spontaneous intracerebral hemorrhage. Methods Eligible patients with spontaneous intracerebral hemorrhage were analyzed retrospectively. The BAT score and the spot sign were assessed according to the criteria described in previous studies. Receiver operating curve analysis was used to assess the performance of the BAT score and the spot sign in hematoma expansion prediction. Results In 225 included patients, 34 (15.1%) had a BAT score ≥3. The spot sign was shown in 68 (30.2%) patients. Hematoma expansion was identified in 56 (24.9%) patients. In multivariate analysis, both BAT score ≥3 and presence of spot sign were independently correlated with hematoma expansion. BAT score ≥3 had 0.41 sensitivity and 0.93 specificity, and spot sign had 0.64 sensitivity and 0.81 specificity. The area under the curve of BAT score ≥3 and area under the curve of spot sign were 0.673 and 0.727, respectively (P = 0.386). Conclusions The BAT score based on noncontrast CT is a good predictor of hematoma expansion. When CT angiography spot sign is unobtainable, the BAT score can be used to predict hematoma expansion.

Objective Primary intraventricular hemorrhage (PIVH) is rare in the aging population and remains a challenge for cerebrovascular surgeons. In the present study, the authors reviewed the patient characteristics, angiographic results, and treatments and determined clinical outcomes in 34 patients older than 60 years of age who were treated at West China Hospital between 2010 and 2014. Methods The medical records of elderly patients were queried. The parameters regarding patient demographics, presenting symptoms, treatment modalities, angiographic results, and clinical outcomes were assessed and analyzed. Results There were 19 male (55.9%) and 15 female (44.1%) patients, with an average age (±SD) of 67.9 ± 7.7 years in our study. The most common symptoms on presentation were headache (50%), followed by disturbance of consciousness (26.5%). Only 5 patients (14.3%) were diagnosed with underlying cerebrovascular etiologies including Moyamoya disease (5.9%), arteriovenous malformations (2.9%), and aneurysms (5.9%). Idiopathic PIVH was diagnosed in 29 patients (85.7%). Thirteen patients (38.2%) underwent surgical intervention, while 21 patients (61.8%) received conservative treatment. Twelve patients (35.3%) had an unfavorable outcome at discharge, and an unfavorable outcome was observed in 14 patients (41.2%) at the 3-month follow-up. Patients with higher Graeb score might be associated with an unfavorable outcome both in short-term and long-term follow-up. Conclusions Most PIVH patients were diagnosed with idiopathic PIVH in the elderly. Surgical treatment of aging patients should be optimized to improve clinical outcomes. The admission Graeb scores were considered to be the independent prognostic factors for both short-term and long-term outcomes.

Objective Intracerebral hemorrhage (ICH) is a type of stroke that leads to high mortality. Hematoma growth (HG) happens in about one third of all patients with ICH and is independently related to poor outcome. Previous studies have shown that an indicator on noncontrast computed tomography, called hypodensities, can predict HG in patients with ICH. Thus, this study was done to assess the predictive validity of this marker. Methods Bibliographic databases were searched, without language restriction, for original investigation on hypodensities and HG in ICH. Data were extracted, and study quality was assessed by 2 reviewers independently. Pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio, and their 95% confidence intervals (CIs) were obtained. A summary receiver operating characteristic curve was depicted. Results Five cohorts with 2157 patients in 4 studies were included in the present meta-analysis. The pooled sensitivity was 0.58 (95% CI 0.46–0.68) and the pooled specificity was 0.71 (95% CI 0.62–0.79). In addition, the pooled positive LR was 2.0 (95% CI 1.6–2.5) and the pooled negative LR was 0.60 (95% CI 0.49–0.73). The pooled diagnostic odds ratio was 3 (95% CI 2–5) and the area under summary receiver operating characteristic curve was 0.69 (95% CI 0.65–0.73). Conclusions This study suggests that hypodensities on noncontrast computed tomography can be helpful in HG prediction, although its pooled predictive values are not very satisfying in the current study. The role of hypodensities in predicting HG should be confirmed by further studies.

Objective To evaluate the parameters related to the high risk of preoperative seizures in infants (1 year or younger) with ruptured intracranial aneurysms. Methods Infants with ruptured intracranial aneurysms treated at our institution from January 2012 to January 2018 were retrospectively analyzed. Seventeen similar cases of infant patients with seizures reported in published studies were reviewed. Results The mean age of the 7 infant patients treated at our institution was 4.1 ± 3.3 months (range, 28 days to 11 months), with 2 male and 5 female subjects. One patient (14.3%) had an internal carotid artery aneurysm with subarachnoid hemorrhage, and the remaining 6 patients (85.7%) had middle cerebral artery (MCA) aneurysms in the distal arterial region with lobe hemorrhage. Five of the 7 infants (71.4%) had seizures, 4 of whom (4/5, 80.0%) had MCA distal arterial aneurysms with lobe hemorrhage. Management was successful for all patients with aneurysm clipping or resection surgery, and one patient experienced postoperative seizures. Of the 17 reviewed cases of infant patients with seizures, 10 patients (58.8%) exhibited the typical distal arterial aneurysm with lobe hemorrhaging, and 6 (60%) of them had aneurysms in MCA. Conclusions Infant patients with ruptured intracranial aneurysms have a high risk of preoperative seizures. The typical radiologic finding of distal arterial aneurysm with lobe hemorrhage was frequently observed in the MCA, and it might be related to the high risk of preoperative seizures in this population. Microsurgical techniques effectively control postoperative seizures in infants with ruptured intracranial aneurysms.

Background A successful animal brainstem hemorrhage model can be used to study pathophysiology and molecular mechanisms of neurologic deterioration or recovery and therapeutic interventions after the brainstem hemorrhage. Herein, we provide a reproducible and reliable model for rat brainstem hemorrhage and summarize our key points to success in modeling. Methods Twenty-four adult male Sprague-Dawley rats were divided into 3 groups and were injected with 30, 40, and 60 μL autologous blood into the right pontine basal tegmentum after being sedated. The initial model was evaluated with neurobehavior testing, autopsy, and histopathology. The modeling conditions were modified in Group IV rats, and 20 more rats were used to check the reproducibility and reliability of the modified model. Finally, magnetic resonance imaging (MRI) was used to confirm the brainstem hemorrhage. Results Only 6 rats had significant pontine hemorrhage in initial 3 groups on autopsy. Whereas after the modification, all Group IV rats had serious pontine hemorrhage, and modified conditions model had a 90% success rate. MRI confirmed a stable hematoma in the right basal tegmental pons with oval shape 24 hours after of blood injection. Histopathologically, there was significant perihematomal swelling, migration of inflammatory cells and structural changes in neuronal shape and contents. Conclusions An ideal and repeatable rat brainstem hemorrhage model by injecting autologous blood stereotactically was created, and it mimics the natural onset of brainstem hemorrhage. This brainstem hemorrhage model shows promise that providing a better way for neurology researchers to investigate pathophysiologic procedure of brainstem intracranial hemorrhage and further explore the treatment.

Objective Hematoma expansion is related to unfavorable prognosis in intracerebral hemorrhage (ICH). The black hole sign is a novel marker on non–contrast computed tomography for predicting hematoma expansion. However, its predictive values are different in previous studies. Thus, this meta-analysis was conducted to evaluate the predictive significance of the black hole sign for hematoma expansion in ICH. Methods A systematic literature search was performed. Original researches on the association between the black hole sign and hematoma expansion in ICH were included. Sensitivity and specificity were pooled to assess the predictive accuracy. Summary receiver operating characteristics curve (SROC) was developed. Deeks' funnel plot asymmetry test was used to assess the publication bias. Results Five studies with a total of 1495 patients were included in this study. The pooled sensitivity and specificity of the black hole sign for predicting hematoma expansion were 0.30 and 0.91, respectively. The area under the curve was 0.78 in SROC curve. There was no significant publication bias. Conclusions This meta-analysis shows that the black hole sign is a helpful imaging marker for predicting hematoma expansion in ICH. Although the black hole sign has a relatively low sensitivity, its specificity is relatively high.

Objective Giant wide-neck paraclinoid aneurysms remain a formidable challenge for neurosurgeons due to the brisk retrograde blood flow during surgical clipping. Theoretically, Entire orifice blockade (EOB) by placing a longitudinal intracarotid balloon catheter across the aneurysm neck could achieve a good vascular control in treating cerebral aneurysms, but related studies have been scarce. The aim of this study was to evaluate the safety and efficiency of the EOB-assisted microsurgical technique for treating giant wide-neck paraclinoid aneurysms. Methods Clinical data and treatment summaries of patients with giant wide-neck paraclinoid aneurysms who underwent EOB-assisted microsurgical clipping were retrospectively reviewed. Results A total of 26 patients were analyzed. All but 3 patients harbored unruptured aneurysms. The mean largest diameter of the aneurysms was 26.8±2.0 mm, and the mean neck size was 12.5±2.4 mm. All lesions were successfully clipped without residual aneurysms. Post-operative images revealed no major branch occlusion due to thromboembolic complications. Four patients presented neurologic deficits caused by vasospasm, 3 of which were completely resolved by postoperative treatment. At a mean follow-up time of 1.86 ± 0.95 years (range, 0.5–3.5 years), none of the patients died, and 96.2% (n = 25) of the patients had favorable clinical outcomes with modified Rankin Scale values of 0–2. Conclusions For patients with giant wide-neck paraclinoid aneurysms, EOB-assisted microsurgical clipping is a safe and useful procedure for obtaining vascular control, for softening and shrinking the aneurysm sac and for providing a wide and clean operative field that allows the clip to be effectively placed.

Objective To quantitatively study the degree of posterior fossa crowdedness (PFC) in patients with hemifacial spasm (HFS) and to further investigate whether overcrowding in posterior fossa affects the efficacy and safety of microvascular decompression. Methods We conducted a prospective case-control study of patients diagnosed with HFS and sex- and age-matched healthy control patients. All subjects underwent high-resolution, 3-dimensional magnetic resonance imaging, and posterior fossa crowdedness index (PFCI) and cerebrospinal fluid volume (CSFV) were measured. Patients with HFS underwent primary microvascular decompression and long-term follow-up. Associations of PFCI and other factors with operative outcomes and complications were analyzed. Results The study enrolled 153 subjects: 102 patients and 51 control subjects. Compared with control subjects, patients had a more PFC (PFCI: 83.2% vs. 80.2%; P = 0.005) and smaller posterior fossa CSFV (16,248.0 mm 3 vs. 20,054.0 mm 3 ; P = 0.001). The mean effective space of posterior fossa cerebrospinal fluid in patients with HFS was 11.8% smaller than in control subjects ( P = 0.004). Compared with men, women showed larger PFCI (83.6% vs. 82.2%; P = 0.012) and smaller PF CSFV (16,027.5 mm 3 vs. 17,299.5 mm 3 ; P = 0.009). Sixty-one patients (59.8%) were spasm-free immediately postoperatively, and 95 (93.1%) were spasm-free at follow-up. Complication rates were 9.8% in the short term, and 2.9% at follow-up. Lower PFCI (odds ratio [OR] 0.63; P = 0.019) and severe indention (OR 1.41; P = 0.027) were significantly associated with better short-term outcomes. Greater PFCI (OR 2.05, P = 0.008) was associated with greater early complication incidence. Conclusion Patients with HFS had more PFC. PFC potentially leads to cranial nerve and vascular structure crowding, which may increase HFS risk. PFC was significantly associated with poor short-term outcomes and greater incidence of early complications but not long-term outcomes and complications.

Spontaneous intracerebral hemorrhage remains a major cause of death and dependence. Endoscopic surgery (ES) is potential to improve outcomes, but a consensus on the superiority of ES has not been achieved. We conducted a systematic review to clarify the effect of ES in spontaneous intracerebral hemorrhage and compare it with other treatment options (craniotomy, conservation, and stereotactic aspiration [SA]).We performed this review based on the Preferred Reporting Items for Systematic review and Meta-Analysis. The subgroup analyses were stratified by study type, location, hematoma volume, interval to treatment, follow-up time, and stereotactic frame assistance.A total of 18 studies were included containing 1213 patients, most of whom harbored a hematoma greater than 50 mL. Compared with craniotomy and conservation, ES significantly reduced the mortality (P0.0001), poor outcomes (P0.00001), rebleeding (P = 0.0009), and pneumonia (P0.00001). In the subgroup analyses, late surgery (48 hours) benefited more from ES than early surgery (24 hours). The study location, hematoma volume, and stereotactic frame assistance insignificantly influenced the therapeutic effect of ES. Comparing ES and SA, we found that differences in mortality, poor outcomes, and rebleeding were insignificant, but ES had a greater evacuation rate and SA had shorter operative times.ES achieves a better performance than craniotomy and conservation in terms of reducing mortality, dependence, and specific complications. Despite being similarly effective in improving functional outcomes, ES and SA have respective advantages. ES is a feasible alternation to craniotomy and conservation, and the comparison between ES and SA warrants further study.

Objective To investigate the association between ultraearly hematoma growth (uHG) and clinical outcome in patients with spontaneous intracerebral hemorrhage (sICH) receiving hematoma evacuation. Methods Supratentorial sICH patients receiving hematoma evacuation within 24 hours after ictus were enrolled in this study. uHG was defined as baseline hematoma volume/onset-to-computed tomography (CT) time (mL/h). The outcome was assessed by the modified Rankin Scale (mRS) score at 3 months. Unfavorable outcome was defined as mRS >2. Results A total of 93 patients were enrolled in this study. The mean uHG was 10.3 ± 5.5 mL/h. In 69 (74.2%) of patients, the outcome was unfavorable at 3 months. The uHG in patients with unfavorable outcome were significantly higher than in those with favorable outcome (11.0 ± 6.1 mL/h vs. 8.3 ± 2.5 mL/h, P = 0.003). The optimal cutoff of uHG for predicting unfavorable outcome was 8.7 mL/h. The sensitivity, specificity, positive predictive value, and negative predictive value of uHG >8.7 mL/h for predicting unfavorable outcome were 56.5%, 75.0%, 86.7%, and 37.5%, respectively. Conclusions uHG is a helpful predictor of unfavorable outcome in sICH patients treated with hematoma evacuation. The optimal cutoff of uHG to assist in predicting unfavorable outcome in sICH patients receiving hematoma evacuation is 8.7mL/h.

Background Supraclinoid blister aneurysms (BAs) of the internal carotid artery are uncommon and deadly, and appropriate treatment is controversial. Endovascular reconstruction may allow treatment through aneurysm isolation. We report a single-institution experience in the use of Enterprise stent-assisted coiling (ESAC) for treating BAs to appraise the safety and efficacy of this technique. Methods Patients treated with ESAC for a BA at our institution between 2013 and 2016 were retrospectively included in this study. Patients' aneurysm characteristics, progression status, aneurysm occlusion on follow-up angiography, and modified Rankin Scale (mRS) score were recorded and analyzed. Occlusion rates and neurologic outcomes were compared between patients treated with a single stent and those treated with multiple telescoping stents. Results Forty-four patients were included (17 males; average age, 47.3 years), and ESAC was successfully performed in all patients. Immediate postprocedure angiography revealed complete occlusion in 23 patients (52.3%), residual neck in 15 (34.1%), and residual aneurysm in 6 (13.6%). Twenty patients (45.5%) suffered perioperative cerebral vasospasm, and 3 (6.8%) died of secondary ischemic stroke. The duration of follow-up ranged from 2.5 to 27 months (mean, 11.59 ± 5.76 months). One patient with recurrence was treated with additional coiling, and another patient was treated with a covered stent. The use of telescoping stents was associated with a better complete aneurysm occlusion rate compared with the use of single stents (84.4% [27 of 34] vs. 44.4% [4 of 9]; P = 0.04). Follow-up mRS score was ≤1 for 32 of 41 patients (78.4%). Conclusions ESAC to treat BAs is safe, effective, and provides good clinical outcomes. ESAC with telescoping stents has a higher follow-up complete occlusion rate compared with ESAC with single stents.

Background Spinal artery aneurysms (SAAs) are extremely rare lesions that can occur in isolation or associated with vascular malformations. Herein, we present 3 unusual cases of SAAs and discuss imaging, diagnosis, and surgical management strategies. Case Description The first patient was a 57-year-old woman who presented with sudden onset of severe headache. Spinal angiography demonstrated an isolated anterior spinal artery (ASA) aneurysm at the level of the craniocervical junction. The second patient was a 27-year-old woman who presented with progressive bilateral pain of her lower limbs. The result of spinal angiography was consistent with an aneurysm at the level of L1. The third patient was a 26-year-old man who presented with bilateral weakness and numbness of the lower limbs. Spinal angiography revealed a conus medullaris aneurysm associated with an arteriovenous malformation (AVM). All these lesions were successfully managed with clipping or resection, and good outcomes were achieved. Conclusion Spinal artery aneurysms are rare lesions. Herein, we report 3 such cases and emphasize the importance of surgical management.

Background Intracranial aneurysm in patients with sickle cell disease is rare, but with an increased incidence in the recent years. This type of intracranial aneurysm possesses distinctive characteristics, and it has been the subject of case reports and series. Material and Methods We systematically searched relevant publications through PubMed, EMBASE, Web of Science, and Google Scholar up to December 21, 2016. We extracted data about clinical features and outcomes and then conducted a descriptive analysis. Results We identified 46 related publications, comprising 111 patients and 218 aneurysms. The mean age was 27 years (range, 5–54 years), and the male:female ratio was 0.96 (52:54). A male predominance existed in children, whereas a female predominance in adults. Age distribution approximated normal distribution, with peak phase between 21 and 30 years. In the child cohort, 13 of 31 (41.9%) aneurysms ruptured, whereas 62 of 79 (78.5%) aneurysms rupturing in the adult cohort. Aneurysms tended to be multiple (45.0%), small (85.6%), and saccular type (90.8%) and they exhibited a preference for posterior circulation (31.7%). Conservation and clipping became the main treatment in children and adults, respectively, but children had more good outcomes (80%) than adults did (67.1%). Conclusions Intracranial aneurysms related to sickle cell disease mainly affected patients in their 20s, with a contradictory sex ratio in children and adults. Aneurysms manifested predisposition for multiplicity and posterior circulation. There was no difference between children and adults regarding shape and location of aneurysms. However, children with lower aneurysm rupturing rates had better outcomes than their adult counterparts did.