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The GCS-Pupils (GCS-P) score is a recently described scoring system to aid outcome prediction in patients with traumatic brain injury (TBI). The aim of this study was to provide the first external validation of the GCS-P score by identifying independent predictors of outcome in TBI patients.Review of prospective adult (≥ 16 years) TBI database at a tertiary neurosurgical center with a catchment population of 1.5 million over a 12-month period commencing October 2016. Multivariate logistic regression was used to identify predictors of discharge destination and 30-day mortality.Three hundred and fifty-eight patients were included. The median age was 60 years with a male predominance of 64%. The median GCS-P was 14 (interquartile range 12-15) and the commonest GCS-P category was mild (13-15; 238/358, 66%). Discharge destination was home in 69% of patients and rehab services or equivalent in 31%. Multivariate analysis identified age (p = 0.01), CT findings of an acute subdural hematoma (p = 0.01) or diffuse axonal injury (p = 0.02), and a neurosurgical operation (p = 0.02) as independent predictors of discharge destination. The 30-day mortality rate was 11%. Within the category of severe TBI (GCS-P ≤ 8), GCS-P was able to identify patients with a very high likelihood of 30-day mortality (GCS-P ≤ 4; 16/31, 52%). Multivariate analysis revealed the Charlson comorbidity score (p = 0.01), GCS-P (p = 0.02), and traumatic subarachnoid hemorrhage (p = 0.05) as independent predictors of mortality.The GCS-P is a useful predictor of 30-day mortality, although its usefulness for other clinical outcomes remains to be proven.

Medically refractory idiopathic intracranial hypertension (IIH) is frequently treated with venous sinus stenosis stenting with high success rates. Patient selection has been driven almost exclusively by identification of supraphysiological venous pressure gradients across stenotic regions based on theoretical assessment of likelihood of response.To explore the possibility of benefit in low venous pressure gradient patients.Using a single-center, prospectively maintained registry of patients with IIH undergoing venous stenting, we defined treatment groups by gradient pressures of ≤4, 5 to 8, and8 mmHg based on the most frequently previously published thresholds for stenting. Baseline demographics, clinical, and neuro-ophthalmological outcomes (including optical coherence tomography and Humphrey visual fields) were compared.Among 53 patients, the mean age was 32 years and 70% female with a mean body mass index was 36 kg/m 2 . Baseline characteristics were similar between groups. The mean change in lumbar puncture opening pressure at 6 months poststenting was similar between the 3 groups (≤4, 5-8, and8 mmHg; 13.4, 12.9, and 12.4 cmH 2 O, P = .47). Papilledema improvement was observed across groups at 6 months (100, 93, and 86, P = .7) as were all clinical symptoms. The mean changes in optical coherence tomography retinal nerve fiber layer (-30, -54, and -104, P = .5) and mean deviation in Humphrey visual fields (60, 64, and 67, P = .5) at 6 weeks were not significantly different.Patients with IH with low venous pressure gradient venous sinus stenosis seem to benefit equally from venous stenting compared with their higher gradient counterparts. Re-evaluation of our restrictive criteria for this potentially vision sparing intervention is warranted. Future prospective confirmatory studies are needed.

Background Venous sinus stenosis (VSS) stenting has emerged as an effective treatment for patients with Idiopathic Intracranial Hypertension (IIH). However, stenting carries risk of in-stent stenosis/thrombosis and cumulative bleeding risk from long-term dual antiplatelet (DAPT) use. Thus, we investigated the potential safety and efficacy of primary balloon angioplasty as an alternative to stenting in IIH. Methods A prospectively maintained single-center registry of IIH patients undergoing endovascular procedures was queried. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012- 2021. Patients were dichotomized into primary balloon angioplasty (Group A) and primary stenting (Group S), comparing clinical outcomes using bivariate analyses. Results 62 patients were included with median age of 33 [IQR 26-37], 74% females. Group A (9/62) and Group S (53/62) had similar baseline characteristics. Papilledema improvement was higher in Group S at 6 weeks and 6 months (44 vs. 93, p = 0.002 and 44 vs. 92%, p = 0.004), with similar improvements across all symptoms. Group S had higher mean post-procedure venous pressure gradient change (8 vs. 3 mmHg, p = 0.02) and a lower CSF opening pressure at 6 months (23 vs. 36 cmH2O, p Conclusions Primary VSS balloon angioplasty provides a marginal and short-lived improvement of IIH symptoms compared to stenting. These findings suggest a cautious and limited role for short-term rescue angioplasty in poor shunting and stenting candidates with refractory IIH.

Objective Carotid blister aneurysms remain a formidable surgical challenge with varied surgical options. There have been significant advancements in the endovascular management of these aneurysms with the introduction of flow diverters. The comparative risk profiles for different endovascular options compared to surgical management of these lesions is not completely understood. Methods The study is a comprehensive systematic review and meta-analysis on the treatment of carotid blood blister aneurysms. Pubmed searches were used to identify relevant articles and patient level data was extracted. Two and three group analyses were conducted comparing surgical and endovascular strategies and surgical, stent coil and flow diversion techniques respectively. Patient outcomes were graded on the modified Rankin Scale with a score of 2 or less defined as favorable. Results In total, 83 studies (41 and 42 studies on surgical and endovascular interventions, respectively) with 1119 patients met our inclusion criteria. A statistically significant difference (at the 5% level of significance) in the effect among three different interventions was not found (Q = 3.41, p = 0.1815) under the random-effect model. Our results did show summary proportions of favorable outcomes were higher in the stent coil (0.87, 95% CI: 0.79 – 0.94) and flow diversion (0.87, 95% CI: 0.75 – 0.96) than that of surgery (0.76, 95% CI: 0.71 – 0.83). Conclusions Our results suggest a trend towards improved patient outcomes with endovascular techniques compared to surgical strategies but statistical significance was not achieved. We also found that endovascular techniques compare favorably. Increasing retreatments were found to negatively affect patient outcomes.

INTRODUCTION: Prior retrospective and case-control studies have shown that the use of general anesthesia (GA) during endovascular therapy (EVT) for acute ischemic stroke with large vessel occlusion (AIS-LVO) was independently associated with poor clinical outcomes compared with cases performed under conscious sedation (CS). Conversely, recent small randomized clinical trials (RCT) demonstrated a trend toward better outcome in cases performed under GA. METHODS: We submitted an online survey to 193 Society of Vascular Interventional Neurology and 78 American Association of Neurological Surgeons and Congress of Neurological Surgeons – Cerebrovascular Section neuroendovascular practitioners. Questions were aimed at understanding the current state of anesthesia practice during EVT, and to determine if there is clinical equipoise for a large multicenter RCT comparing GA versus CS during EVT. RESULTS: Between March and May of 2017, we received 116 (43%) responses. Anesthesiologists were responsible for managing 96% of the GA cases as compared to only 51% of the CS cases (P < 0.0001). Notable 56% of providers reported performing less than a quarter of their cases under GA. Only 7% performed all cases under GA compared with 17% who used solely CS (P = 0.048). More than half of respondents thought a new RCT was necessary, of whom 61% were interested in participating. Among interested responders, 59% were located in centers with 3 or more neurointerventionalists. CONCLUSION: The significant variation among neuroendovascular providers, added with the lack of consensus among recent trials and meta-analyses, demonstrate clinical equipoise for further studies to explore the effects of anesthesia during EVT in AIS-LVO.

Background Venous stenting (VS) for venous sinus stenosis in the setting of idiopathic intracranial hypertension has been increasing in acceptance by neurointerventionalists. Stent-adjacent stenosis (SAS) and in-stent stenosis leading to symptom recurrence and the need for retreatment are known delayed complications. However, the effect of the dual antiplatelet therapy (DAPT) duration on these complications has remained poorly characterized. Methods An extensive literature search was performed to identify reports of VS for patients with idiopathic intracranial hypertension from 2000 to 2020. The primary outcome was the occurrence of SAS. The secondary outcomes included the occurrence of composite stenosis (in-stent stenosis and SAS) and stent survival, defined as the need for retreatment or other surgical management. Generalized linear mixed models were used to explore the effects of DAPT duration (3 vs ≥6 months) on the primary and secondary outcomes. Results A total of 325 patients met the inclusion criteria and were included in our analysis. SAS occurred in 9% (95% confidence interval, 6%-15%) of the patients, and stent survival was 90% (95% confidence interval, 84%-93%) in the cohort. With every 1-mm Hg increase in the venous pressure gradient, an 8% decrease was found in the odds of stent survival (P = 0.043). The meta-regression revealed no association between the DAPT duration and the primary outcome or the odds of composite stenosis and stent survival. Conclusions We found no differences between 3 and ≥6 months of DAPT in terms of the risk of stent stenosis or stent survival. However, patients with a higher venous pressure gradient before VS had a greater risk of stent failure.

Background Ischemic stroke is increasingly being realized to be an inflammatory disease. Post stroke peripheral leukocyte recruitment to the brain has been well studied in preclinical models of ischemic stroke. Limited studies have examined the intravascular inflammatory milieu in the brain during ischemia. Thrombi collected from ischemic stroke thrombectomy patients can be valuable resources for these studies. There are a handful of studies focusing on the role of inflammation in clot pathology. Small studies have demonstrated that higher thrombus leukocyte fraction and neutrophil to lymphocyte ratios are associated with technically challenging procedures and a trend to worse long term outcomes. Methods We prospectively collected 44 thrombi obtained during mechanical thrombectomy in patients with LVO ischemic strokes. Data on demographics, clinical, procedural and clot composition were collected. These thrombi were paraffin embedded, sliced and stained with Hematoxylin and Eosin. Images were taken using a light microscope,20 and 40x magnification. Image J was used to quantify the leukocytes using previously described methods. The median and maximum leukocyte count of the 5 analyzed images for each patient was used for analysis. Outcome was defined as location at discharge with discharge to home or rehab considered favorable. Fisher’s exact and Mann-Whitney U tests were used for comparison of categorical and continuous variables, respectively. Multivariate logistic regression was then performed. Pearson’s correlation coefficient was used to assess the relationship of leukocytes to NIHSS and time from symptom onset to groin puncture. Results Among 44 patients with large vessel occlusion, median age was 65.5 years [59–73 years], 15 (35%) were women, 84% had hypertension, 43% had atrial fibrillation, and 24% had hyperlipidemia. Median NIHSS was 18 [14–22] and median leukocyte count in the thrombi was 537 [397–794.5]. NIHSS on admission had a negative correlation with favorable discharge outcome as defined by discharge to home or rehab (OR=0.44, p=0.021). Total leukocyte count did not correlate with NIHSS at arrival (r=-0.0086; P=0.9560), number of passes, TICI score nor with time from last seen well to groin puncture (r=0.1937; P=0.2134). On multivariate analysis, there was a negative correlation between maximum thrombus leukocyte count and discharge outcome (OR=0.066, p=0.048) after accounting for age and NIHSS on admission. Conclusion Leukocyte count in thrombi retrieved post mechanical thrombectomy shows a significant negative correlation with discharge outcome in patients with ischemic stroke. Our study focused on total leukocyte count and corroborates with previous studies which focused on leukocyte fraction. Further studies using flow cytometry and concomitant peripheral blood analysis along with long term outcome measures are necessary to better define this relationship and understand role of inflammation in LVO stroke. Disclosures P. Chen: None. F. Sheriff: None. M. Inam: None. V. Lopez-Rivera: None. E. Lekka: None. A. Oni-Orisan: None. C. Finger: None. J. Hudobenko: None. D. Morales: None. S. Seth: None. B. Manwani: None.

BACKGROUND: Tumour treating fields are a novel anticancer treatment that uses alternate electrical fields to disrupt cell division. It has been shown in a randomized controlled trial to significantly improve survival in patients with Glioblastoma. Use of the device is intensive for patients, with almost constant electrode application and battery use. The acceptability and tolerability for this new treatment is not known in a UK setting. The treatment currently costs €21,000 per month. METHODS: Three UK centres were offered support for trialling the treatment. Patients with proven MGMT unmethylated glioblastoma, had completed Stupp, had a performance score >70, and had social support (for placing the electrodes), where approached. Monthly assessments of compliance and quality of life (QOL) (ECOG BT 30), and quarterly MRIs and tolerability questionnaires were completed. RESULTS: Oncologists in one centre refused to support any use of the device, so no patients were approached in that centre. 8 patients were approached in the other two centres, 5 accepted, and 1 further patient had treatment started elsewhere. All patients tolerated the treatment, with no reduction in QOL outcomes. Patients approached were grateful to have been offered the treatment. The main reason for refusal was monthly travelling for compliance checks. The main adverse comments related to the weight of the mobile battery. One patient had skin irritation, and two patients found that the only aspect of life affected was showering. Two patients have progressed on treatment, with one having second line surgery, and both second line chemotherapy. CONCLUSIONS: Tumour treating fields is a well tolerated but intensive treatment, and acceptable to a UK population. A significant reduction in cost is required to allow routine UK use on the NHS.

BACKGROUND: Tumour treating fields (TTF) are a novel anticancer treatment that uses alternate electrical fields to disrupt cell division. In a randomized controlled trial, TTF significantly improved survival in patients with Glioblastoma. Use of the device is intensive for patients, with almost constant electrode application and battery use. Treatment currently costs €21,000 per month. Methods were explored to reduce cost and to examine acceptance and tolerability in a social health care setting. MATERIAL AND METHODS: Three UK centres were offered support for trialing the treatment. Patients with proven MGMT unmethylated glioblastoma, had completed radical chemoradiotherapy, had a performance score >70, and had social support (for placing the electrodes), where approached. Monthly assessments of compliance and quality of life (QOL) (EORTC BT 20), and quarterly MRIs and tolerability questionnaires were completed. Reductions in company support were explored to reduce device costs. RESULTS: Oncologists in one centre declined to support any use of the device, so no patients were approached in that centre. 8 patients were approached in the other two centres, 5 accepted, and 1 further patient had treatment started elsewhere. Company home visits were not offered and clinicians were trained in the use and interface with the equipment. All patients tolerated the treatment. The main reason for patient refusal was monthly travelling for compliance checks. The main adverse comments related to the weight of the mobile battery. Two patients had skin irritation, and two patients found that the only aspect of life affected was showering. Four patients have progressed, but maintained stable QOL scores. Two patients have since died. CONCLUSION: Tumour treating fields is a well tolerated but intensive treatment, and acceptable to a UK population. At present monthly company support on site is still required, but future improvements in software may allow further reductions in on site support leading to cost reduction. A significant reduction in cost is required to allow routine UK use in a social care setting.

Objectives To determine the potential costs and health benefits of a serum-based spectroscopic triage tool for brain tumours, which could be developed to reduce diagnostic delays in the current clinical pathway. Design A model-based health pre-trial economic assessment. Decision tree models were constructed based on simplified diagnostic pathways. Models were populated with parameters identified from rapid reviews of the literature and clinical expert opinion. Setting Explored as a test in both primary and secondary care (neuroimaging) in the UK health service, as well as application to the USA. Participants Calculations based on an initial cohort of 10 000 patients. In primary care, it is estimated that the volume of tests would approach 75 000 per annum. The volume of tests in secondary care is estimated at 53 000 per annum. Main outcome measures The primary outcome measure was quality-adjusted life-years (QALY), which were employed to derive incremental cost-effectiveness ratios (ICER) in a cost-effectiveness analysis. Results Results indicate that using a blood-based spectroscopic test in both scenarios has the potential to be highly cost-effective in a health technology assessment agency decision-making process, as ICERs were well below standard threshold values of £20 000–£30 000 per QALY. This test may be cost-effective in both scenarios with test sensitivities and specificities as low as 80%; however, the price of the test would need to be lower (less than approximately £40). Conclusion Use of this test as triage tool in primary care has the potential to be both more effective and cost saving for the health service. In secondary care, this test would also be deemed more effective than the current diagnostic pathway.

BACKGROUND: Tumour treating fields (TTFields) are an innovative anticancer treatment that uses alternating electrical fields to disrupt cell division. In a randomized controlled trial, TTFields significantly improved newly diagnosed Glioblastoma patient survival. The device may be thought to be taxing for patients, with almost constant electrode application and battery use. Methods were explored to reduce cost and examine acceptance. METHODS: Three United Kingdom (UK) centres were offered support for trialing the treatment. Patients with proven MGMT unmethylated glioblastoma, had completed radical chemoradiotherapy, had a performance score > 70, and had social support (for placing the electrodes), where approached. Monthly assessments of compliance and quality of life (QOL) (EORTC BN 20), and quarterly MRIs and tolerability questionnaires were completed. RESULTS: Oncologists in one centre declined to support any use of the device. 8 patients were approached in the other two centres, 5 accepted, and 1 further patient had treatment started elsewhere. A UK politician developed glioblastoma, used the device, and this was followed by positive press reports. Clinicians were trained in the use and interface with the equipment. All patients tolerated the treatment and used for 85% or more. The reason for patient refusal was monthly travelling for compliance checks. Adverse comments related to the mobile battery weight. Two patients had skin irritation, and two found that showering was affected. Four patients have progressed, but maintained stable QOL scores. Two patients have died. CONCLUSIONS: TTFields is well tolerated but requires patient dedication to use the device for at least 18 hours per day and in our pilot access study was acceptable to a UK population. Recent positive press support aided recruitment. A significant reduction in cost is required to allow routine UK use.

OBJECTIVE: Review the incidence of seizures and the value of prophylactic antiepileptic drug (AED) treatment following surgery for Low Grade Gliomas (LGGs). DESIGN: Retrospective study. SUBJECTS: All patients who underwent surgery for LGG between 2010-15 at our centre. METHODS: Retrospective review. RESULTS: 91 out of 137 patients received AEDs preoperatively;70 due to initial presentation and 21 prophylactically.20/137 patients (14.6%) had seizures in the immediate postoperative period (14 days).Incidence of seizures in the immediate postoperative period was significantly lower in patients established on AEDs compared to the ones who received AEDs as prophylaxis or did not receive AED at all (10.0 vs 28.57 vs 15.22%, p = 0.10), but this difference became insignificant in the follow up period of 1 year (p = 0.69). 35 craniotomies were performed awake; seizures in the immediate postoperative period were more frequent in awake surgery but this was not significant (20 vs 12.75%, p = 0.29). The extent of resection, demonstrated an inverse trend on seizures at 1 year; only 3.3% of the patients who underwent total resection suffering seizures vs 12.5% of near total and 19.51% subtotal debulking or biopsy (p = 0.09). CONCLUSIONS: Patients established on regular AEDs tend to have fewer seizures in the immediate post operative period, but this difference becomes insignificant at 1 year. Awake craniotomy has no significant impact in the immediate and long term seizure activity. The extent of resection is a valid prognostic predictor of seizure activity.

Molecular biomarkers are commonly used for the management of several types of malignant tumours in routine clinical practice. However, this is not the case for malignant gliomas. Cytokines and Angiogenesis factors are potential candidates due to their intrinsic role in tumourigenesis. Pre- and post-operative serum from 36 malignant glioma patients and 36 controls was analysed using the Bio-Plex Pro Angiogenesis and Cytokines Assay (Bio-Rad, USA). Amongst the molecules tested, the serum concentration of follistatin was significantly higher in patients than in controls. Moreover, the serum concentration of follistatin of the patients postoperatively was significantly reduced compared to that preoperatively. Factors such as age and gender did not affect the concentrations of follistatin measured in the serum of patients pre- and post-operatively as well as healthy controls. This is the first report of follistatin as potential biomarker for the detection of malignant gliomas.

Objective: To present the initial results of Botulinum-A toxin (BTA) injection in patients with long-standing multiple sclerosis (MS) and urethral leakage of urine in spite of indwelling suprapubic catheters (catheter bypassing). Methods: Study of three patients treated with cystoscopic injection of BTA IU (Allergan). Telephone interviews were made at four- to six-week intervals. Continence status and patient satisfaction were recorded before and after treatment. Results: Patient 1 remained dry at 48 weeks post injection. Patient 2 became incontinent again after 40 weeks. The third patient was continent when interviewed at 27 weeks following injection, but died two weeks later. The patients were very satisfied with the procedure and there were no complications related to BTA. Conclusions: Intradetrusor BTA injection is a very effective and safe treatment for intractable catheter bypassing in patients with neurogenic detrusor overactivity.