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Intro: Space weather induced geomagnetic storms have been associated with an increased risk of stroke occurrence. Data on image-proven, temporally related large vessel occlusion stroke (LVO) and geomagnetic storms are lacking. We sought to investigate this potential association to determine whether space weather forecasts can be used to predict incoming cluster events. Methods: Data from a Comprehensive Stroke Center were collected from January 1, 2017, to April 15, 2022. Space weather data were downloaded from the World Data Centre for Geomagnetism, Kyoto homepage (http://wdc.kugi.kyoto-u.ac.jp/kp/index.html#LIST) The indications for mechanical endovascular reperfusion (MER) were in accordance with the Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Univariate binary logistic regression was performed to assess the potential associations between space weather data and LVO MER cases with 48 hour lag effect. Geomagnetic activity was defined by the National Oceanic and Atmospheric Administration’s (NOAA) Space Weather Prediction Centre (SWPC) space weather scales. Results: Of the 1931 days included in this study, there were 538 (27.86%) days with at least one LVO MER (450 (23.3%) with 1, 81 (4.19%) with 2, and 7 (0.36%) with 3. There were 1784 days without geomagnetic storm activity and 147 days with minor to severe storms. 290 MER cases occurred out 1014 days of minimal activity (28.6%) 133 MER cases out 497 days of unsettled activity (26.76%) 0.91(0.72-116), 78 MER cases out of 273 days of active activity (28.57%) 1.00(0.74-1.34), 25 MER cases out 109 days of minor storm (22.94%) 0.74(0.47-1.19) and 12 MER cases out of the 38 days of moderate to extreme storms (31.58%) 1.15(0.57-2.31) p-value 0.697. Conclusion: There was no statistically significant association with geomagnetic storms and the occurrence of large vessel stroke interventions taking into consideration a 48 hour lag effect. Comprehensive stroke center readiness is of utmost importance, but space weather forecasts are unlikely to be helpful in predicting LVO stroke cluster events.

Study Design This is a retrospective, cohort analysis of multi-institutional database. Objective This study was designed to analyze the impact of drain use following elective anterior cervical discectomy and fusion (ACDF) surgeries. Summary of Background Data After ACDF, a drain is often placed to prevent postoperative hematoma. However, there has been no high quality evidence to support its use with ACDF despite the theoretical benefits and risks of drain placement. Methods The Michigan Spine Surgery Improvement Collaborative database was queried to identify all patients undergoing elective ACDF between February 2014 and October 2019. Cases were divided into two cohorts based on drain use. Propensity-score matching was utilized to adjust for inherent differences between the two cohorts. Measured outcomes included surgical site hematoma, length of stay, surgical site infection, dysphagia, home discharge, readmission within 30 days, and unplanned reoperation. Results We identified 7,943 patients during the study period. Propensity-score matching yielded 3,206 pairs. On univariate analysis of matched cohorts, there were no differences in rate of post-operative hematoma requiring either return to OR or readmission. We noted patients with drains had a higher rate of dysphagia (4.6% vs 6.3%; p = 0.003) and had longer hospital stay (p < 0.001). On multivariate analysis, drain use was associated with significantly increased length of stay (RR 1.23, 95% CI 1.13-1.34; p < 0.001). There were no significant differences in other outcomes measured. Conclusion Our analysis demonstrated that drain use is associated with significant longer hospital stay.

BACKGROUND: The aim of this study was to investigate the changes to spinopelvic sagittal alignment following minimally invasive (MIS) lumbar interbody fusion, and the influence of such changes on postoperative discharge disposition. METHODS: The Michigan Spine Surgery Improvement Collaborative was queried for all patients who underwent transforaminal lumbar interbody fusion (TLIF)or lateral lumbar interbody fusion (LLIF) procedures for degenerative spine disease. Several spinopelvic sagittal alignment parameters were measured, including sagittal vertical axis (SVA), lumbar lordosis, pelvic tilt, pelvic incidence, and pelvic incidence-lumbar lordosis mismatch. Primary outcome measure—discharge to a rehabilitation facility—was expressed as adjusted odds ratio (ORadj) following a multivariable logistical regression. RESULTS: Of the 83 patients in the study population, 11 (13.2%) were discharged to a rehabilitation facility. Preoperative SVA was equivalent. Postoperative SVA increased to 8.0 cm in the discharge-to-rehabilitation division versus a decrease to 3.6 cm in the discharge-to-home division (P

BACKGROUND Insular gliomas pose a significant surgical challenge due to the insula’s delicate surrounding functional and vascular anatomy. Insular gliomas are conventionally treated with open surgical resection augmented by several surgical adjuvants. Despite advancements in technology and surgical techniques, surgical resection of insular gliomas has been associated with frequent and potentially severe morbidity. Laser interstitial thermal therapy (LITT) is a novel, cytoreductive, and less-invasive treatment option for glioma. OBJECTIVE We describe the first-ever series of patients with insular glioma treated with staged LITT with or without subsequent craniotomy. METHODS A retrospective institutional database identified patients with insular glioma who underwent staged LITT treatments. Clinical, histopathological, and volumetric lesional characteristics were obtained. Procedural characteristics, morbidity, overall survival (OS), and progression-free survival (PFS) were determined. RESULTS Between 2019-2022, 11 patients with insular glioma were treated in stages with a total of 21 LITT procedures with or without subsequent craniotomy. Four patients had Diffuse Astrocytoma (IDHmt/TP53+), one Gemistocytic Astrocytoma (IDHmt/TP53+), three Anaplastic Astrocytoma (IDHmt/TP53+), one Anaplastic Oligodendroglioma (IDHmt/1p19q codel), one secondary GBM (IDHmt/TP53+), and one GBM (IDHwt/TP53-). Six patients were treated with LITT alone, while five patients were treated with LITT followed by a craniotomy for complete resection. Patients had a median tumor volume of 31.5 cm3 (9.58, 97) and a mean extent of ablation±resection of 97.68% (S.D. 5.4). At a median follow-up of 12.59 months, patients had a median PFS of 12.88 months and an OS of 14.46 months. No patients had a change in KPS following LITT. Two patients had a decrease in KPS following surgery. CONCLUSION We present the first-ever reported series of insular glioma treated with staged LITT with/without subsequent resection. We found that staged treatment of insular gliomas with LITT is safe, effective, and a minimally invasive option that avoids the potentially significant morbidity associated with conventional surgery.

Meningiomas represent a phenotypically and genetically diverse group of tumors which often behave in ways that are not simply explained by their pathologic grade. The genetic landscape of meningiomas has become a target of investigation as tumor genomics have been found to impact tumor location, recurrence risk, and malignant potential. Additionally, targeted therapies are being developed that in the future may provide patients with personalized chemotherapy based on the genetic aberrations within their tumor. This review focuses on the most common genetic mutations found in meningiomas of all grades, with an emphasis on the impact on tumor location and clinically relevant tumor characteristics. NF-2 and the non-NF-2 family of genetic mutations are summarized in the context of low-grade and high-grade tumors, followed by a comprehensive discussion regarding the genetic and embryologic basis for meningioma location and phenotypic heterogeneity. Finally, targeted therapies based on tumor genomics currently in use and under investigation are reviewed and future avenues for research are suggested. The field of meningioma genomics has broad implications on the way meningiomas will be treated in the future, and is gradually shifting the way clinicians approach this diverse group of tumors.

Objective Pediatric oculomotor nerve schwannomas are rare and challenging lesions due to the high morbidity associated with surgical intervention and their proximity to critical structures limiting the opportunity for stereotactic radiosurgery. We aim to report and review the novel use of fractionated Cyberknife (Accuray, Inc., Sunnyvale, California, USA) stereotactic radiotherapy in pediatric patients with oculomotor schwannomas. Methods A systematic review of PubMed, Embase, and Cochrane was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two patients, ages 8 and 10 years, with tumor volumes of 0.1 cm3 and 0.2 cm3, respectively, were treated with fractionated Cyberknife radiotherapy at our institution. A total dose of 45–50 Gy was administered over 25 fractions (1.8–2.0 Gy per fraction) to the 82%−84% isodose line. Serial magnetic resonance imaging was obtained for long-term follow-up (56–58 months). Results We found 14 articles published between 1982 and 2018 that reported a total of 18 pediatric patients with intracranial oculomotor schwannomas. No previously described cases of pediatric intracranial oculomotor schwannomas were treated with radiation therapy. In both of our patients, radiographic tumor control was achieved at a mean follow-up of 57 months, with 1 patient displaying a decrease in tumor volume. Neither patient exhibited any worsening of their presenting symptoms, nor did either patient develop any new neurocognitive deficits following treatment. Conclusions Fractionated Cyberknife radiotherapy is an effective and well-tolerated treatment option for intracranial oculomotor nerve schwannomas with excellent tumor control rates, similar to surgical and radiosurgical techniques, while sparing critical surrounding structures.

Background Although pre-injury antithrombotic agents, including antiplatelets and anticoagulants, are historically associated with expansion of traumatic intraparenchymal hemorrhage (tIPH), the literature has poorly elucidated the actual risk of hematoma expansion on repeat computed tomography (CT). The objective was to determine the effect of antithrombotic agents on hematoma expansion in tIPH by comparing patients with and without pre-injury antithrombotic medication. Methods The volume of all tIPHs over a 5-year period at an academic Level 1 trauma center was measured retrospectively. The initial tIPH was divided into 3 equally sized quantiles. The third tercile, representing the largest subset of tIPH, was then removed from the study population because these patients reflect a different pathophysiologic mechanism that may require a more acute and aggressive level of care with reversal agents and/or operative management. Per institutional policy, all patients with small- to moderate-sized hemorrhages received a 24-hour stability CT scan. Patients who received reversal agents were excluded. Results Of the 105 patients with a tIPH on the initial head CT scan, small- to moderate-sized hemorrhages were Conclusions In small- to moderate-sized tIPH, withholding antithrombotic agents without reversal may be sufficient.

INTRODUCTION Laser Interstitial thermal therapy (LITT) is a minimal-access procedure for intracranial tumors that are either refractory to standard treatment paradigms or difficult to access via conventional open surgery. OBJECTIVE To evaluate predictors of local disease control following LITT in patients with primary and secondary brain tumors. METHODS Single-center retrospective cohort study of all consecutive LITT ablations between 2014 and 2019. Demographic and procedural characteristics analyzed with respect to local disease control at 6 months. Chi-square tests for categorical variables, T-tests/Wilcoxon Rank-Sum tests for continuous variables for parametric and non-parametric data, respectively. Poisson regression models were used to approximate relative risk (RR) with 95% confidence intervals. RESULTS A total of 76 patients underwent LITT with a median follow up of 12.3 months; pathology at time of ablation was glioblastoma multiforme (GBM, 36%), WHO grade III primary CNS (24%), low grade CNS (20%), and metastatic lesions (19%) with respective local control rates of 26%, 20%, 29%, and 26%. Pathology of GBM (RR 0.46, 0.21-1.02, p=0.055) and a 5-year increase in age at the time of ablation (RR 0.91, 0.83-0.99, p=0.028) were associated with a lower likelihood of local control at 6 months. Preoperative Karnofsky performance status (KPS) of 100 (RR 2.04, 1.13-3.69, p=0.019) was associated with a higher likelihood of local control. Extent of ablation (EOA) demonstrated a direct relationship with local control; when EOA=100% local control was 59%, with this rate dropping down to 21% when EOA=90%. Tumor location, lesion volume, gender, BMI, ethnicity, or whether there existed multiple foci of disease at the time of ablation had no strong association with local control. CONCLUSION Our series demonstrates that preoperative performance status and age were strong predictors of local disease control following LITT. Incomplete ablation and histology of high-grade glioma portended a higher risk of local recurrence.

Background: Haematological malignancies are ranked as the highest in incidence. Adiponectin (ADIPOQ), the most abundant circulating adipocytokine, plays a major role in the regulation of insulin sensitivity, metabolism, and hematopoiesis. Various ADIPOQ gene polymorphisms are associated with an increased risk of different cancers. However, to the best of our knowledge, the association between ADIPOQ T45G (rs2241766) single nucleotide polymorphism (SNP) and leukemia is unknown. Aim: This study aimed to investigate the association between ADIPOQ (rs2241766) and the clinicopathological status of Egyptian leukemia patients. Materials and Methods: A case-control design was used, including 80 leukemia patients and 70 healthy controls. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used for genotyping. Survival analysis and biochemical investigations including hematological and lipid profiles, liver and kidney functions in addition to anthropometric measurements were also determined. Results: A significant positive correlation between ADIPOQ gene T45G (rs2241766) SNP and leukemia incidence was detected. The G allele was more frequent in leukemia patients compared to the T allele. Kaplan-Meier analysis revealed that the SNP rs2241766was associated with the patient’s event-free survival but not the overall survival. In addition, G carriers, hyperglycemia, and hyperuricemia patients had a significantly shorter median EFS compared with T carriers, normoglycaemia, and normoglycemia patients. Conclusion: The current study shows an association between the SNP (rs2241766) and leukemia incidence and prognosis in Egyptian patients. Furthermore, an association between the rs2241766 and high prevalence of hyperglycemia and dyslipidemia in the G allele carrier’s leukemia patients was also evident.

BACKGROUND Opioids are prescribed routinely after cranial surgery despite a paucity of evidence regarding the optimal quantity needed. Overprescribing may adversely contribute to opioid abuse, chronic use, and diversion. OBJECTIVE To evaluate the effectiveness of a system-wide campaign to reduce opioid prescribing excess while maintaining adequate analgesia. METHODS A retrospective cohort study of patients undergoing a craniotomy for tumor resection with home disposition before and after a 2-mo educational intervention was completed. The educational initiative was composed of directed didactic seminars targeting senior staff, residents, and advanced practice providers. Opioid prescribing patterns were then assessed for patients discharged before and after the intervention period. RESULTS A total of 203 patients were discharged home following a craniotomy for tumor resection during the study period: 98 who underwent surgery prior to the educational interventions compared to 105 patients treated post-intervention. Following a 2-mo educational period, the quantity of opioids prescribed decreased by 52% (median morphine milligram equivalent per day [interquartile range], 32.1 [16.1, 64.3] vs 15.4 [0, 32.9], P

Ischemic infarction of the corpus callosum is a rare condition due to its rich vascular supply and therefore has been infrequently reported. Here, we present a case of a patient who developed a delayed infarct of the corpus callosum in the body. The condition was characterized by bilateral lower extremity weakness and visual disturbances following intraventricular hemorrhage managed with ventriculostomy. Understanding the anatomy and function of the corpus callosum is crucial to understanding the etiology of infarctions as well as their clinical significance. It is also essential to distinguish between relatively common post-shunting changes and true infarction and to recognize the limited consequences of corpus callosum infarction. Increased awareness of this rare infarct would help to prevent unnecessary interventions and increase the ability of the physician to provide optimal care for the patient.

INTRODUCTION: There is mounting evidence supporting the role of tryptophan metabolism via the kynurenine pathway (KP) in the pathogenesis of primary brain tumors. Under normal physiological conditions, the KP is the major catabolic pathway for the essential amino acid tryptophan. However, in cancer cells, the KP becomes dysregulated, depletes local tryptophan, and contributes to an immunosuppressive tumor microenvironment. METHODS: We examined the protein expression levels (in 73 gliomas and 48 meningiomas) of the KP rate-limiting enzymes indoleamine 2,3-dioxygenase (IDO) 1, IDO2, and tryptophan 2,3-dioxygenase (TDO2), as well as, the aryl hydrocarbon receptor (AhR), a carcinogenic transcription factor activated by KP metabolites. In addition, we utilized commercially available small-molecules to pharmacologically modulate IDO1, IDO2, TDO2, and AhR in patient-derived glioma and meningioma cell lines (n = 9 each). RESULTS: We observed a positive trend between the grade of the tumor and the average immunohistochemical staining score for IDO1, IDO2, and TDO2, with TDO2 displaying the strongest immunostaining. AhR immunostaining was present in all grades of gliomas and meningiomas, with the greatest staining intensity noted in glioblastomas. Immunocytochemical staining showed a positive trend between nuclear localization of AhR and histologic grade in both gliomas and meningiomas, suggesting increased AhR activation with higher tumor grade. Unlike enzyme inhibition, AhR antagonism markedly diminished patient-derived tumor cell viability, regardless of tumor type or grade, following in vitro drug treatments. CONCLUSIONS: Collectively, these results suggest that AhR may offer a novel and robust therapeutic target for a patient population with highly limited treatment options.

Introduction Laser interstitial thermal therapy (LITT) is a routinely used in treatment of recurrent brain metastases following SRS or open craniotomy. While considered safer than craniotomy, patients do experience neurologic decline following LITT. Identifying which patients are at risk for neurologic deterioration can help better advise patients on the most appropriate treatment options for their tumor. Objective The objective of the present study was to assess the frequency and identify risk factors for neurologic decline following LITT. Methods Data was gathered on patients who underwent LITT for ablation of metastatic brain tumors at our institution between 2014–2019. These cases were analyzed retrospectively and data was collected on patient demographics, tumor characteristics, procedural details, and post-operative complications and outcomes. Pre-operative neurologic function was compared to neurologic status at the 6–12 week post-op visit. Results 16 patients underwent LITT of a total of 18 metastatic lesions during the study time period and were included in the analysis. 7/16 patients demonstrated reduced KPS or worse neurologic function at 6–12 week follow up. 4 patients (25%) demonstrated neurologic deficits that were attributable to the laser ablation procedure, and each of these 4 patients had lesions in eloquent areas. Comparatively, none of the other 12 patients analyzed had eloquent lesions (p = 0.002). The presence of a pre-op neurologic deficit was not predictive of worsening neurologic function following LITT (p = 0.35). Average lesion size in patients who experienced neurologic deficit was 5.69cm3 compared to 3.15cm3 in those that did not (p = 0.1). Conclusion Our complications rate is similar to other published case series (15–44%). LITT, while better tolerated than standard craniotomy, can lead to neurologic decline in patients with brain metastases regardless of lesion size or pre-operative functional status. Eloquence is a significant predictor of neurologic complications following laser ablation.

Animal models have played a key role in elucidating the mechanisms underlying the occurrence, recurrence, and therapeutic treatment of primary brain tumors. In this chapter, we review the various types of human primary brain tumors, describe the general properties of the dominantly used animal model systems, and propose general guidelines to help optimize animal model creation. We also discuss the history and current uses of rodent models in the study of the pathologenesis and treatment of various important types of primary brain tumors, including adult and pediatric glioma, meningioma, medulloblastoma, and CNS lymphoma. Included is an analysis of the role of rodent models in the development of immune-based therapies for brain tumors. Lastly, we summarize the tradeoffs and limitations of currently existing animal models of primary brain tumors and discuss the current outlook for future developments.

INTRODUCTION Developing and advancing patient-centered care within neuro-oncology is an essential element of any tertiary brain tumor center. Patient-centered care of neuro-oncology patients requires a holistic approach that integrates oncologic treatment with social and psychological support. OBJECTIVE The aim of this study is to evaluate how a Patient Family Advisory Council can be created within an existing brain tumor center and utilized to improve patient-centered care. METHODS Current patients and caregivers were recruited by brain tumor staff to participate in monthly meetings. All participants underwent screening and training by our Patient Education Research Center team. Discussions focused on current and future brain tumor center initiatives, and participants were encouraged to give feedback from the patient perspective. New ideas to improve the patient experience were solicited. RESULTS A total of 15 participants (female = 57%) were recruited, including 10 with grade 3 or higher brain tumors. Monthly meetings, in-person or virtual, were held for two years. Utilizing participant feedback, the group updated our 80-page patient handbook that contained a variety of patient-caregiver focused resources. Participants also provided feedback on other brain tumor center initiatives such as development of a magnet featuring key phone numbers, an easily accessible website URL for emergencies, and numerous updates to the external website. Additional discussions involved development of neuro-oncology care pathways as we move to a stand-alone cancer center facility and initiation of OncoSTAT and palliative services in this population. CONCLUSION Brain tumor patients require a comprehensive oncologic treatment team as well as a wide variety of support services. A Patient Family Advisory Council is an effective method of advancing patient-centered care and a step toward improving the neuro-oncology patient experience.

INTRODUCTION Open craniotomy for tumor carries notable perioperative risks as well as associated prolonged ICU stays. Risks of surgery are increased in elderly patients. In addition, many tumors are not amenable to resection due to their deep or eloquent location. Magnetic resonance-guided laser interstitial thermal ablation (LITT) offers an alternative, minimal-access procedure. OBJECTIVE To examine the safety and efficacy of LITT procedures in elderly brain tumor patients. METHODS Data was gathered on patients over the age of 65 who underwent MRI-guided LITT for ablation of tumor at our institution between 2014-2019. These cases were analyzed retrospectively and data was collected on patient demographics, tumor characteristics, procedural details, and post-operative complications and outcomes. RESULTS 19 patients over the age of 65 underwent LITT during the study time period and were included in the analysis. The average age was 70 years (range 65-81), with a median follow up of 7 months. Patients had an average of 3.5 pre-existing medical comorbidities with a mean pre-operative Karnofsky Performance Score (KPS) of 87 (SD = 10.4). 13 patients underwent LITT for primary CNS tumor and 6 for metastatic lesions. The average lesion volume was 3.44 cm3 with approximately one-third in eloquent areas. An average extent of ablation of 98% was achieved (90-100%). 5/19 patients experience at least one post-op complication including 2 venous thromboembolic events and 1 stroke within 30 days. The average length of stay was 2.3 days, and 13/19 patients were discharged home. No patients experienced new permanent neurological deficits and the average post-operative KPS was 83 (SD = 12.4). 9 patients experienced progression of disease after an average of 155 days, and 11 patients were deceased (average survival = 504 days). CONCLUSION LITT is well tolerated in appropriately selected elderly patients with short post-operative length of stay and minimal surgical morbidity.

INTRODUCTION Glioblastoma (GBM) is uniformly associated with a poor prognosis and inevitable recurrence. Management of recurrent GBM remains unclear, with repeat surgery often employed with varying degrees of success. We evaluated the efficacy of Laser Interstitial Thermal Therapy (LITT) for recurrent GBM when compared to a carefully matched cohort of patients treated with repeat surgical resection. METHODS A retrospective single-institution database was used to identify patients who underwent LITT or surgical resection of recurrent GBM between 2014-2019. LITT patients were matched with surgical resection patients according to baseline demographics, comorbidities, tumor location, and eloquence. Subgroup analysis matching similar patients for tumor volume was also completed. Overall survival (OS) and progression-free survival (PFS) were the primary endpoints. RESULTS A LITT cohort of 20 patients was matched to 50 similar patients who underwent repeat surgical resection. Baseline characteristics were similar between both cohorts apart from tumor volume, which was larger in the surgical cohort (17.5 cc vs. 4.7 cc, p< 0.01). On long-term follow-up, there was no difference in OS (HR, 0.72; 95%CI, 0.36-1.45) or PFS (HR, 0.67; 95%CI, 0.29-1.53) between the LITT and surgical cohorts when controlling for tumor volume. Subgroup analysis of 23 LITT patients matched according to tumor volume with 23 surgical patients with similar clinical characteristics also found no difference in OS (HR, 0.66; 95%CI, 0.33-1.30) or PFS (HR, 0.58; 95%CI, 0.90-1.05) between the cohorts. LITT patients had shorter length of stays (1 vs. 4 days, p< 0.001) and a higher rate of home discharge (84% vs. 67%, p=0.172) compared to the surgical cohort. CONCLUSION After matching for demographic, clinical, and tumor characteristics, there was no difference in outcomes between patients undergoing LITT compared to surgical resection for recurrent GBM. LITT patients had similar survival outcomes yet shorter hospital stays and more favorable dispositions, potentially mitigating post-treatment complications.

OBJECTIVESteno-occlusive diseases of the cerebral vasculature have been associated with cognitive decline. The authors performed a systematic review of the existing literature on intracranial steno-occlusive disease, including intracranial atherosclerosis and moyamoya disease (MMD), to determine the extent and quality of evidence for the effect of revascularization on cognitive performance.METHODSA systematic search of PubMed/MEDLINE, the Thomson Reuters Web of Science Core Collection, and the KCI Korean Journal Database was performed to identify randomized controlled trials (RCTs) in the English-language literature and observational studies that compared cognitive outcomes before and after revascularization in patients with steno-occlusive disease of the intracranial vasculature, from which data were extracted and analyzed.RESULTSNine papers were included, consisting of 2 RCTs and 7 observational cohort studies. Results from 2 randomized trials including 142 patients with symptomatic intracranial atherosclerotic steno-occlusion found no additional benefit to revascularization when added to maximal medical therapy. The certainty in the results of these trials was limited by concerns for bias and indirectness. Results from 7 observational trials including 282 patients found some cognitive benefit for revascularization for symptomatic atherosclerotic steno-occlusion and for steno-occlusion related to MMD in children. The certainty of these conclusions was low to very low, due to both inherent limitations in observational studies for inferring causality and concerns for added risk of bias and indirectness in some studies.CONCLUSIONSThe effects of revascularization on cognitive performance in intracranial steno-occlusive disease remain uncertain due to limitations in existing studies. More well-designed randomized trials and observational studies are needed to determine if revascularization can arrest or reverse cognitive decline in these patients.

Introduction/purpose Neuroendovascular therapies are increasingly used in treatment of cerebral aneurysms. However, data is sparse on outcomes of various treatment strategies for anterior cerebral artery (ACA) territory. We performed a systematic review and meta-analysis to compare outcomes of treatment strategies for ruptured or unruptured ACA aneurysms from prior high quality published data. Materials and methods We searched MEDLINE, Embase, and Cochrane from January 2000 until January 2018. High quality studies were included that had reported initial morbidity indices, occlusion rates, late follow up data, and operative complications (ischemic, hemorrhagic, retreatment rate) for endovascular coiling vs pipeline flow-diversion vs neurosurgical clipping separately reported for ruptured and unruptured aneurysms of ACA territory. Random-effect or fixed-effect models were used to pool estimates across studies using R software. Results Overall, 1230 ACA aneurysms from 22 studies including 910 (775 ruptured) coiling, 105 pipeline (All unruptured) and 140 clipping (130 ruptured) treatments were identified using a systematic method. For ruptured ACA aneurysms treated with coiling, occlusion rates were 0.86 (0.84–0.89) and 0.85 (0.72–0.93) in immediate and late assessment respectively. Final occlusion rate was 0.96 (0.87–0.99) for ruptured ACA aneurysms treated with clipping. For unruptured ACA aneurysms treated with coiling, occlusion rates were 0.93 (0.85–0.97) and 0.86 (0.73–0.93) in immediate and late assessment respectively. Final occlusion rate was 0.82 (0.71–0.89) for unruptured ACA aneurysms treated with pipeline device. For ruptured ACA aneurysms treated with coiling, secondary ICH occurred in 0.08 (0.07–0.11) (n=731) and retreatment rate was 0.10 (0.05–0.18). For those treated with clipping, ICH occurred in 0.12 (0.03–0.37) and retreatment rate was 0.06 (0.02–0.13) (n=110). No study of ruptured ACA aneurysm treated with pipeline device was eligible to be included in our meta-analysis. For unruptured ACA aneurysms treated with coiling, the risk of ischemic stroke was 0.09 (0.05–0.18) (n=121), ICH occurred in 0.05 (0.02–0.12) (n=121) and retreatment rate was 0.10 (0.05–0.18) (n=100). For those treated with pipeline device, the risk of ischemic stroke was 0.03 (0.01–0.09) (n=103), ICH occurred in 0.04 (0.02–0.11) and retreatment rate was 0.02 (0.01–0.08) (n=105). Meta-analysis was not technically possible for unruptured ACA aneurysm treated with surgical clipping due to small numbers. Conclusion Endovascular and surgical treatment modalities appear safe and effective in treatment of ACA aneurysm. There is a large amount of heterogeneity in reporting baseline characteristics and final outcomes in the literature limiting number of studies for comparison of outcomes by vascular territory. Disclosures H. Saber: None. G. Rajah: None. H. Fadel: None. B. Kolb: None. A. Luqman: None. S. Narayanan: None.

Background Candida parapsilosis is an incredibly rare cause of ventriculoperitoneal (VP) shunt infections, with only 1 adult case reported in the literature to date. Case Description We describe the case of a 45-year-old man admitted for a traumatic fall and subsequently treated with VP shunt placement for obstructive hydrocephalus secondary to a cerebellar contusion and intraventricular hemorrhage. Eight months following VP shunt placement, the patient presented with a 2-month history of clear fluid leakage through a dehiscent surgical abdominal wound overlying the distal VP shunt. Cerebrospinal fluid cultures were obtained and grew C. parapsilosis. The patient subsequently underwent VP shunt externalization and began antifungal treatment with intravenous liposomal amphotericin B. Cerebrospinal fluid studies continued to redemonstrate C. parapsilosis infection, for which VP shunt removal and external ventricular drain placement was performed. Three days into treatment with amphotericin B, he endured significant nephrotoxicity necessitating a switch to oral fluconazole. Following 3 weeks of oral fluconazole treatment with negative serial cerebrospinal fluid cultures, the patient underwent external ventricular drain removal and VP shunt insertion. Following the procedure and 22 total days of oral fluconazole treatment, our patient recovered well and was discharged to a rehabilitation facility in stable condition. Conclusions In our report, we describe the clinical course of our patient and offer a review and analysis of the most up-to-date literature concerning C. parapsilosis shunt infections, as well as treatment guidelines for central nervous system candidiasis.

In cancer patients, oxidative stress (OS) plays an important role in the initiation, promotion, progression of disease, in addition to, the continuous exposure to OS throughout the surgical procedure, chemotherapy and radiotherapy. The present study was designated to evaluate the role of vitamin D3 and B6 supplementation in combination with anti-cancer therapies in maintenance the redox status and their impact on angiogenesis, the main step in cancer progression and aggressiveness, as well as on the side effect of surgery, chemotherapy and/or radiotherapy. Our investigations were at two levels, firstly, assessment of chemical parameters for redox status and angiogenic factors, secondly, assessment level of circulating endothelial cells by applying immunoassay using antibodies coupling nanoparticles. Blood samples were collected once from 15 apparently healthy women (GP-I) and four times from 20 BC patients; (GpII)before mastectomy (B. M.), after mastectomy (A. M.), after ending of chemotherapy course (A. C.) and after 3 months later (A.3M) for both subgroups to Monitor the oxidant-antioxidants status (MDA and TAS) and angiogenic biomarkers (VEGF, ES and CECs). Our data reveals that comparing to control group, BC patients show significant elevation of MDA, VEGF and CECs (P