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Elevated blood glucose is frequently detected early after aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether hyperglycemia at admission is associated with mortality in patients with aSAH.In a multicenter observational study of patients with aSAH, we defined normal glycemia, mild hyperglycemia, moderate hyperglycemia, and severe hyperglycemia as blood glucose of 4.00-6.09 mmol/L, 6.10-7.80 mmol/L, 7.81-10.00 mmol/L, and 10.00 mmol/L, respectively. We performed propensity score matching to obtain the adjusted odds ratios (OR) with 95 % confidence intervals (CI).Of 6771 patients with aSAH, 511(7.5 %) had died in hospital, and hyperglycemia at admission was observed in 4804 (70.9 %). Propensity scores matching analyses indicated that compared with normal glycemia, the odds of in-hospital mortality were slightly lower in patients with mild hyperglycemia (OR 0.89, 95 % CI 0.56-1.40), significantly higher in patients with moderate hyperglycemia (OR 1.90, 95 % CI 1.20-3.01), and in patients with severe hyperglycemia (OR 3.45, 95 % CI 2.15-5.53; P trend 0.001). Long-term survival was worse among patients with hyperglycemia and was proportional to its severity. Similar dose-response associations were evident for poor functional outcomes and major disability. Hyperglycemia was associated with an increased risk of hospital-acquired infections (OR 1.46, 95 % CI 1.29-1.66) and rebleeding (OR 1.58, 95 % CI 1.06-2.35).Among aSAH patients, hyperglycemia at admission was independently associated with increased mortality. Both moderate hyperglycemia and severe hyperglycemia were associated with an increased risk of mortality, but these associations were not seen in mild hyperglycemia (blood glucose 6.10-7.80 mmol/L).

Treating blood blister-like aneurysms (BBA) is a major neurosurgical challenge. Whether endovascular repair serves as a better strategy than microsurgery remains controversial. We aim to perform a propensity score-matched (PSM) retrospective study to analyze the short-term outcome in BBA patients who received microsurgery and endovascular treatment. One hundred fifty-five eligible patients with internal carotid artery BBA were retrospectively collected with demographic and angiographic baseline in a single center. Three-month outcome and adverse events were set as outcome endpoints. PSM was used to match the microsurgery and endovascular group. Matching effect was evaluated by distribution variation analysis and love plot. The outcome of neurosurgery and endovascular treatment was then compared before and after PSM. Better WFNS levels (p = .017) and modified Fisher grade (p = .027) were noted in endovascular group before matching. Other baseline including angiographic features were comparable between two groups. Before matching, the 3-month outcome of endovascular repair surgery was more favorable than microsurgery (p .0001). The occurrence of adverse events was also higher in the microsurgery group (p = .0079). In PSM-adjusted groups, the superior outcome effect of endovascular treatment still existed but with a reduced significance (p = .004). Similar trend was also observed in the adverse event rate (p = .038). Fatality rate was comparable between two adjusted groups regardless of PSM adjustment. Endovascular surgery of BBAs exhibits overall more favorable short-term outcome regardless of PSM matching. Microsurgery does not cause a higher fatality rate, hence it could be considered a salvage plan for those high-grade BBA patients.

Many blood blister aneurysms (BBAs) have been documented with a rapid progression history in repeated angiography. The underlying mechanism and clinical significance remained elusive. This current study aims to clarify the clinical and histopathological differences between short-term progressive BBA and non-progressive BBAs. Eighty-one patients with BBAs were consecutively included for this single-center retrospective analysis. Clinical and radiological data on these patients were retrieved from 2017 to 2019. BBAs were defined as either progressive or non-progressive based on observed growth based on repeated imaging. Histopathological examinations of a saccular aneurysm, a progressive BBA, and a non-progressive BBA were conducted using representative aneurysm samples. Among all enrolled patients, 26 of the them were identified with progressive BBAs, while the other 55 with non-progressive BBAs. Progressive BBAs were diagnosed significantly earlier in angiography (3.36 ± 0.61 vs. 6.53 ± 1.31 days, p < 0.05) and showed a higher presence rate of daughter sacs (61.5 vs. 38.2%, p < 0.05). Three different progression patterns were identified. BBAs that developed daughter sac enlargement are diagnosed significantly later than BBAs exhibiting other progression patterns. Patients with progressive and non-progressive BBAs exhibited similar overall clinical outcomes and incidence for complications. For patients with non-progressive BBAs, microsurgery appears to be inferior to endovascular treatment, while for patients with progressive BBAs, the short-term outcomes between microsurgery and endovascular treatment were identical. Histopathological analysis revealed that both subtypes shared a similar pseudoaneurysms structure, but non-progressive BBAs had more histologically destructed aneurysm wall with less remnant fibrillar collagen in adventitia. Progressive and non-progressive BBAs may not be distinct pathological lesions but represent different stages during the BBA development. Early intervention, regardless of treatment methods, is recommended for salvageable patients with progressive BBAs, but microsurgery should be performed with caution for non-progressive BBAs due to increased surgical risk.

The use of prophylactic anticonvulsants among patients with subarachnoid hemorrhage (SAH) is controversial. We sought to assess the effectiveness of different durations of prophylactic antiepileptic drug (AED) use among SAH patients. We searched the MEDLINE, Embase, Cochrane, and ClinicalTrials.gov databases until March 1, 2020. Randomized controlled trials or observational studies comparing different durations or different drugs were selected. The primary outcome was poor clinical outcomes. The secondary outcome was in-hospital seizure. Bayesian network meta-analysis was also performed to indirectly compare the effectiveness of different prophylaxes. A total of 5 papers were included. Three studies with a total of 959 patients were included in the analysis of the primary outcome; the results showed that long-term exposure to prophylactic AEDs (more than 3 days) led to poor clinical outcomes (OR 1.55; 95% CI 1.01–2.39; p = 0.045). Four studies with 1024 patients were included in the analysis of the secondary outcome; the results showed no association between the duration of prophylactic AED use and the occurrence of in-hospital seizures (OR 0.62; 95% CI 0.18–2.15; p = 0.447). In the network meta-analysis, no significant difference was found among the four different prophylaxes. Our findings suggested that, when compared with the short-term use, the long-term use of prophylactic AEDs in SAH patients has a similar effect on in-hospital seizure prevention but is associated with poor clinical outcomes. However, these findings were based on a small number of available studies with obvious heterogeneity in study design and different prescription regimens. Further well-designed studies are warranted to elucidate these questions.

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: Homologous recombination (HR) is a key pathway in DNA double-strand damage repair. HR deficiency (HRD) more commonly occurs in triple-negative breast cancers (TNBCs) than in other breast cancer subtypes. Several clinical trials have demonstrated the value of HRD in stratifying breast cancer patients into distinct response groups to poly ADP ribose polymerase (PARP) inhibitors and chemotherapy.Methods: We retrospectively collected TNBC samples to establish a multiomics cohort (n=343) to explore the biological and phenotypic mechanisms underlying the better prognosis of patients with high HRD scores. The HRD score was calculated using the sum of the telomeric allelic imbalance (TAI) score, loss of heterozygosity (LOH) score and large-scale state transition (LST) score. Gene set enrichment analysis (GSEA) were conducted to reveal underlying pathways of low HRD score patients. Radiomics model were established to predict HRD score in a noninvasive method.Results: Multivariable Cox analysis revealed the independent prognostic value of a low HRD score (hazard ratio, 2.20, 95% confidence interval, 1.05 to 4.59, p=0.04). Furthermore, amino acid and lipid metabolism pathways were highly enriched in tumors with low HRD scores, which was also demonstrated by differentially abundant metabolite analysis. A noninvasive radiomics method was developed to predict HRD status and performed well in the independent validation cohort (support vector machine model: area under the curve (AUC), 0.739, sensitivity, 0.571, and specificity, 0.824; logistic regression model: AUC, 0.695, sensitivity, 0.571, and specificity, 0.882).Conclusions: In conclusion, we revealed the prognostic value of the HRD score, predicted HRD status with noninvasive radiomics features and preliminarily explored druggable targets in TNBC patients with low HRD scores.

Blood blister aneurysms (BBAs) are intracranial arterial lesions appearing in nonbranching sites of the supraclinoid internal carotid artery as well as the basilar artery. Endovascular treatment of BBAs is still not well established because of the rarity of these lesions. We report incidences of BBAs with associated vasospasms. Treatment of the BBAs and associate vasospasms with single Pipeline Flex embolization device (PLED) assisted coiling resulted in seemly shorting of the PLEDs in 3 patients. A retrospective analysis of patients with BBAs who were treated with single PLED assisted coiling from July 2018 to October 2019 was conducted. Patients’ ethnic and medical records, aneurysmal characteristics, intraoperative-rupture, cerebral vasospasm (CVS), postprocedure contrast filling, follow-up imaging, and results were analyzed. Neurological examination at baseline and outcome based on modified Rankin scale (mRS) at discharge as well as follow-ups were also documented. Six patients consisting of 5 females and 1 male, with a mean age of 48.3 years (range from 34–67) were identified during our analysis. All the BBAs were located in nonbranching site of supra-clinoidal segment of internal carotid artery with a mean neck width of 4.5 mm and mean aneurysm size of 4.23 mm. PLED assisted coiling's were performed in all of them. CVS was observed in 3 patients while 1 patient had an intraoperative-rupture of the BBA. Postprocedure contrast filling was still present in 1 patient. All the patients had good outcomes with discharge and follow-up mRS scores ≤ 2 except 1 patient with mRS score = 3 with aphasia. PLED assisted endovascular coiling is very safe and efficient in treating patients with BBAs. Resolution of CVSs after treatment made the PLEDs seemly shorter. Furthermore, a combination of arterial lengthening after gaining their tensile strength back and radical expansion of the PLED could account for the shortening.

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.

Background: Treatment of hypertensive brainstem hemorrhage (HBSH) is still controversial, especially for severe cases (GCS ≤ 8). With the improvement in neuroimaging and microsurgical techniques, severe HBSH is no longer considered inoperable. We analyzed comatose patients in whom radiology revealed severe HBSH. We further analyzed the outcome of cases we successfully operated on and compared surgical intervention with conservative management. Methods: We retrospectively analyzed data obtained from patients with HBSH who represented at our facility from 2005 to 2015. We evaluated their demographics data, lesion characteristics, surgical approaches, as well as outcomes. We further assessed their outcomes with the Glasgow Outcome Scale (GOS). We also compared the outcome of surgical hematoma evacuation with conservative treatment. Results: A total of 286 adult patients with severe HBSH was included in the study. Forty-six (46) patients were treated via craniotomy and the evacuation of the hematoma within 3 h to 2 days on admission at the emergency department. Ultra-early surgery (within 6 h of ictus) was performed in twenty (20) cases (43.5%). 240 patients were managed conservatively. The mortality rate for surgical group was 14/46 (30.4%) while the conservative group was 169/240(70.4%). The timing of surgical intervention was one of the strongest factors affecting outcome GOS (p = 0.02). The volume of the hematoma, GCS score on admission and the presence of acute hydrocephalus also affected the outcome (p = 0.03 respectively). Conclusions: Our data suggest that early surgical intervention is very crucial in achieving successful outcomes in patients with severe HBSH. Keywords: Brainstem, cerebral hemorrhage, Hypertension, Microsurgery, Neuroimaging, Outcome

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.

Introduction The aim of this was to analyze the effect of different treatment options on radial neck fractures in children and to explore the factors affecting the prognosis of fractures. Methods The clinical data of 131 children with radial neck fractures admitted to our hospital from 2010 to 2018 were retrospectively analyzed, and the patients were divided into 6 groups according to treatment methods [manual reduction with Kirschner wires (K-wires) for internal fixation (group A); manual reduction with elastic stable intramedullary nails (ESINs) for internal fixation (group B); leverage reduction with K-wires for internal fixation (group C); leverage reduction with ESINs for internal fixation (group D); manual and leverage reduction with K-wires/ESINs for internal fixation (group E); and open reduction with K-wires/ESINs for internal fixation (group F)]. Postoperative elbow function and complications were analyzed. Results Among the 131 patients with fractures, the median age was 8 years, the median preoperative angulation was 52°, the follow-up rate was 86.3% (113/131), the average follow-up time was 58.3 months, and the postoperative complication rate was 17.7% (20/113). The comparison among the different treatment groups showed that group B had the best recovery of elbow function, postoperatively, and the lowest postoperative complication rate. Age, duration of hospitalization, and preoperative angulation were independent factors affecting postoperative complications. Older age, longer duration of hospitalization, and higher angulation increase the postoperative complications. Conclusion Different treatment options have different efficacies for radial neck fractures in children, of which manipulative reduction with internal fixation using ESINs can achieve good efficacy and a low postoperative complication rate. Age, duration of hospitalization, and preoperative angulation are independent factors for postoperative complications.

BACKGROUND: To determine the histopathological and MRI features of BRCA1/2 mutation-associated familial breast cancers compared with those of BRCA1/2 mutation-negative and sporadic breast cancers and to further compare the imaging features of cancers from BRCA1 and BRCA2 mutation carriers according to lesion type on MRI. METHODS: A retrospective review of medical records was conducted to determine tumour clinicopathologic features and MRI characteristics between June 2011 and July 2017, and 93 lesions with BRCA mutations, 93 lesions without BRCA mutations from familial breast cancers and 93 lesions from sporadic breast cancers were included. Histopathologic data, including immunohistochemistry findings and MRI data according to the BI-RADS lexicon, were reviewed. The association between MRI or histopathologic findings and BRCA mutations was analysed. RESULTS: BRCA-positive familial breast cancers had a higher number of IDCs with high nuclear grade and lymph node metastasis (all P

OBJECTIVE D-dimer is a marker for hypercoagulability and thrombotic events. The authors sought to investigate whether D-dimer levels predicted long-term mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS This was a retrospective study of patients with aSAH in West China Hospital, Sichuan University, between December 2013 and June 2019. D-dimer levels were measured within 24 hours after admission and were grouped by quartiles. The primary outcome was long-term mortality. Patient deaths were determined through the Household Registration Administration System in China, with a median of 4.4 years of follow-up. RESULTS This study included 2056 patients. Compared with patients with the lowest quartile (0.00–0.97 mg/L) of D-dimer levels, the odds of long-term mortality were significantly higher in all other patients, including those with D-dimer levels between 0.97 mg/L and 1.94 mg/L (adjusted hazard ratio [aHR] 1.85, 95% CI 1.32–2.60), those with D-dimer levels between 1.94 mg/L and 4.18 mg/L (aHR 1.94, 95% CI 1.40–2.70), and those patients with the highest quartile (> 4.18 mg/L) of D-dimer levels (aHR 2.35, 95% CI 1.70–3.24; p < 0.001). Similar results were observed for the endpoints of 1-year mortality and long-term mortality in 1-year survivors. CONCLUSIONS Elevated D-dimer levels at admission were associated with short-term and long-term mortality. This biomarker could be considered in future risk nomograms for long-term outcomes and might support future management decisions.

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.

Objective: To explore the effects of microsurgical vascular decompression (MVD) and gamma knife respectively on the treatment of pain, anxiety and depression in patients with primary trigeminal neuralgia. Methods: From February 2011 to June 2017, we treated 108 patients with primary trigeminal neuralgia. According to the treatment plan of the patients, they were divided into an observation group and a control group, 54 cases each. The observation group underwent microsurgical vascular decompression (MVD) for the treatment of primary trigeminal neuralgia, while the control group received gamma knife treatment. The effects of pain, improvement of anxiety and depression were compared between two groups at 1 week, 3 months, and 6 months after treatment. Results: The pain, anxiety and depression scores of the observation group was significantly lower than that of the control group (P

Vasa vasorum is associated with the pathogenesis of various cerebrovascular diseases, but its presence in intracranial aneurysms (IA) and its ability to act as a predicting factor of IA rupture remain unrevealed.Histological investigation was performed for 3 middle meningeal arteries and 25 human IAs that were sequentially collected from 2017 to 2019. Relevant medical information was collected from the hospital information and imaging system. Fisher's exact tests and Student's t tests were performed to identify the histological and clinical differences between aneurysms with and without vasa vasorum.Vasa vasorum were present in 14/25 (56%) aneurysm samples. They were detected at a similar frequency in male patients (4/9, 44.4%) and (10/16, 62.5%) female patients. Patients with vasa vasorum present aneurysms (47.07 ± 3.668 years, n = 14) or vasa vasorum absent aneurysms (50.27 ± 2.289 years, n = 11) did not differ in age (p = 0.49). True aneurysms and pseudoaneurysms also shared a similar rate of vasa vasorum presence (10/16, 62.5% in true aneurysms vs 4/9, 44.4% in pseudoaneurysms). The average size of aneurysms with vasa vasorum varied from 21.70 to 3.00 mm, and no statistical difference in size was detected when comparing aneurysms with and without vasa vasorum (p = 0.71). The vasa vasorum in almost all IAs had uniform vascular trajectory with occasional exceptions. The presence of vasa vasorum appears to be tightly associated with important histopathological changes of myointimal hyperplasia and increased immune cell infiltration in IAs (both p value 0.05), though it does not appear to be indicative of IA rupture or other rupture-related histological degenerations (all p values 0.05).The presence of vasa vasorum is common in IAs. While it is associated with aneurysm wall remodeling and robust inflammatory cell infiltration, our results indicate that it is not a single specific marker of rupture-prone aneurysms.

Whether intermittent pneumatic compression (IPC) is a more effective form of thromboprophylaxis than anticoagulants in individuals undergoing neurosurgery remains controversial. Relevant studies are sparse and inconsistent. Therefore, direct comparisons are difficult to perform and impractical. Hence, we summarized and compared the efficacy and safety of IPC and anticoagulants for the prevention of venous thromboembolism (VTE) in adults undergoing cranial or spinal procedures. Several electronic databases were searched for randomized controlled trials on the use of IPC and anticoagulants for thromboembolism prevention in neurosurgical patients, from inception to August 6, 2019. Studies reporting the selected endpoints were included in direct and Bayesian network meta-analyses to estimate the relative effects of the interventions. Overall, our analysis included 18 trials comprising 2474 patients. Both IPC (RR, 0.41; 95% CrI, 0.26-0.60) and chemical prophylaxis (RR, 0.48; 95% CrI, 0.28-0.68) were found to be more efficacious than the placebo in reducing the risk of deep vein thrombosis (DVT). In addition, our analysis also demonstrated that both IPC (RR, 0.10; 95% CrI, 0.01-0.60) and chemical prophylaxis (RR, 0.31; 95% CrI, 0.05-1.00) reduced the risk of pulmonary embolism (PE) significantly more than the placebo. Based on the available evidence of moderate-to-good quality, IPC is equivalent to anticoagulants for thromboprophylaxis in terms of efficacy. Evidence to support or negate the use of pharmacological prophylaxis in terms of safety is lacking. The results of ongoing and future large randomized clinical trials are needed.

Intracranial germinomas are uncommon and constitute less than 1% of all intracranial tumors. They usually arise in the midline of the brain, most commonly in the pineal region. Pineal germinomas tend to spread through the cerebrospinal fluid (CSF). However, pineal germinomas with fast-developing diffuse subarachnoid/leptomeningeal dissemination are extremely rare, especially in young children.The case of a 4-year-old boy with a pineal germinoma who died of diffuse subarachnoid/leptomeningeal dissemination 1 month after radiotherapy is reported. A PubMed search with specific key terms was used to review cases of pineal germinomas with metastasis.The patient presented with a two-week history of worsening headache, visual disturbances and nonprojectile vomiting. Parinaud's sign was positive on physical examination. Head computed tomography (CT)/magnetic resonance imaging (MRI) revealed a lesion in the pineal region with eccentric calcification and obvious supratentorial hydrocephalus. Pineal germinoma was suspected. A ventriculoperitoneal (VP) shunt followed by focal radiotherapy ameliorated the headaches and visual disturbances. The patient was discharged home without further treatment due to financial difficulties. One month after discharge, he was readmitted due to worsening headache, vomiting and lethargy. MRI showed a decrease in the size of the pineal lesion but revealed a diffuse leptomeningeal enhancement including the sulcus, basal cistern, prepontine cistern, and supravermian cistern. The patient's condition deteriorated rapidly, and he died 26 hours after readmission. The characteristics of pineal germinomas with metastasis are reported based on a review of the literature.Metastases in pineal germinomas predominately occur in adolescents or young adults, most commonly as spinal "drop metastases." Dissemination usually develops several years after the initial tumor diagnosis and has a relatively good clinical prognosis. However, fast widespread subarachnoid/leptomeningeal dissemination and sudden death may occur in a young child before salvage treatment, as in the presented case.

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.

This paper describes 2 unique cases of catheter removal-induced intracranial hemorrhage (CRIH). Acute intracranial hematoma including extradural, subdural, and ventricular hemorrhage is a rare but dangerous complication during catheter removal. Its occurrence is usually iatrogenic. The clinical data of two patients of CRIH were retrospectively collected with a brief review of the phenomenon. A huge subdural hematoma was confirmed in the first case and severe ventricular hematoma in the second case immediately after removing intracranial drains. Emergent craniotomy identified the parietal branch of superficial temporal artery and choroid plexus as the separate source of bleeding. According to the literature review, only 4 cases in 2 reports were diagnosed with CRIH. CRIH should be borne in mind during the procedure of removing a catheter for drainage. The chance of CRIH may be lowered by vigilant manipulation in the processes of both catheter insertion and removal. Early detection and timely evacuation is essential for good recovery. The first case is another example of CRIH in subdural cavity. However, CRIH in ventricles may also occur as demonstrated in the second patient, which was never reported to our knowledge.

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.

Patients surviving initial decompressive craniectomy are needed to undergo cranioplasty, which is potentially complicated by postoperative seizures. The definite incidence of post-cranioplasty seizures and application of prophylactic antiepileptic drugs remain controversial.We performed systematic review to clarify these issues. Searching through PubMed, Ovid, Web of Science and Cochrane library databases, we included publications recording the incidence of seizures after cranioplasty and prophylactic treatment. We pooled the respective incidence of seizures and 95% confidence interval (CI). The overall effect was expressed with events per 1,000 person-years calculated by the mean follow-up time. Trim and fill method was used to adjust for publication bias. Subgroup analyses were conducted to examine the differences in incidences of seizures.Two randomized and 14 observational studies were extracted. The pooled incidence of post-cranioplasty seizures was 0.092 (95%CI 0.063, 0.121), which decreased to 0.043 (95%CI 0.010, 0.076) after adjustment. The summarized incidences of early seizures and late seizures were 0.074 (95%CI 0.029, 0.119) and 0.053 (0.027, 0.079) respectively. In the subgroup analyses, randomized studies reported a higher incidence than observational studies, and early cranioplasty (6 months) resulted in an increased incidence compared with late cranioplasty (6 months). The overall effect from two randomized studies showed prophylactic antiepileptic drugs reduced nearly 80% of seizures.The estimated incidence of post-cranioplasty seizures is 43 per 1,000 person-years after adjustment. The incidence of early seizures is obviously higher than that of late seizures. Moreover, early cranioplasty leads to more post-cranioplasty seizures than late cranioplasty does. Based on the present evidences, the application of prophylactic antiepileptic drugs effectively reduces seizures.