Identification of predictive factors for better outcomes in LINAC-based radiation treatment for cerebral cavernous malformation

The effectiveness of radiation therapy in the treatment of cerebral cavernous malformations (CCM) remains debatable. However, numerous studies have shown a reduction in hemorrhage risk following radiotherapy for CCM. Therefore, herein, we share our experiences utilizing linear accelerator (LINAC)-based radiation for treating CCMs, with the aim of identifying the key factors influencing the therapeutic outcomes. We conducted a retrospective review of all patients with non-brainstem CCMs who underwent radiation treatment, as recorded in the NOVALIS registry at our institution. T2-weighted MR images were used for volumetric assessments using the iPlan radiotherapy planning software. To determine the independent predictors of nidus volume reduction and perilesional brain edema (PBE), we performed multivariate Cox regression analysis to calculate hazard ratios. Twenty patients with 31 non-brainstem CCMs were enrolled in this study. Analysis revealed age as an independent predictive factor for both nidus volume reduction and PBE after radiation treatment for CCM. Furthermore, a single fraction dose of 17 Gy or more was identified as an independent predictor of nidus volume decrease, while a single fraction dose of 18 Gy or more was found to be an independent risk factor for PBE in patients with CCM following LINAC-based radiation therapy. LINAC-based radiation therapy for non-brainstem CCMs with a single fraction radiation dose between 16.5 and 17.5 Gy, or a biologically equivalent dose of approximately 120 Gy, may be the most effective at reducing nidus volume and limiting side effects, particularly in patients under the age of 55 years. We further observed that the risk of PBE increased as the maximum radiation dose delivered to a 1 cc volume of the surrounding normal brain exceeded approximately 17.3 Gy. Therefore, we believe that calculating the D1cc of the normal brain may help to predict the occurrence of PBE when radiotherapy is administered to non-brainstem CCMs.

Stroke recurrence and osteoporotic conditions in postmenopausal patients with atherosclerotic ischemic stroke

Recurrence after stroke is common, and associated with a high mortality rate. Degradation of the elastic tissue in the arterial wall has been shown to aggravate atherosclerosis in blood vessels. Considering that type 1 collagen is present in both bone and vascular smooth muscle cells, we explored whether osteoporotic conditions affect the likelihood of stroke recurrence in postmenopausal women following atherosclerotic ischemic stroke. To determine actual bone mineral density (BMD), the Hounsfield unit values in the frontal skull were evaluated using brain computed tomography (CT) scans taken at admission. A multivariate Cox regression analysis was also performed to examine if osteoporosis could independently predict stroke recurrence in postmenopausal patients with large artery atherosclerosis (LAA) or small vessel occlusion (SVO) stroke. This study included 2130 consecutive patients (both males and females aged 50 and older) with acute LAA or SVO strokes. After adjusting for all covariates, hypothetical osteoporosis was identified as an independent predictor of stroke recurrence in female patients ≥50 years with acute LAA or SVO stroke (hazard ratio, 1.84; 95 % confidence interval, 1.05 to 3.24; p = 0.034). Our findings showed that osteoporosis could potentially affect the recurrence of ischemic stroke in postmenopausal patients with LAA or SVO stroke.

Significant Genes Associated with Mortality and Disease Progression in Grade II and III Glioma

BACKGROUND

The Wnt/β-catenin pathway plays a critical role in the tumorigenesis and maintenance of glioma stem cells. This study aimed to evaluate significant genes associated with the Wnt/β-catenin pathway involved in mortality and disease progression in patients with grade II and III glioma, using the Cancer Genome Atlas (TCGA) database.

METHODS

We obtained clinicopathological information and mRNA expression data from 515 patients with grade II and III gliomas from the TCGA database. We performed a multivariate Cox regression analysis to identify genes independently associated with glioma prognosis.

RESULTS

The analysis of 34 genes involved in Wnt/β-catenin signaling demonstrated that four genes (CER1, FRAT1, FSTL1, and RPSA) related to the Wnt/β-catenin pathway were significantly associated with mortality and disease progression in patients with grade II and III glioma. We also identified additional genes related to the four significant genes of the Wnt/β-catenin pathway mentioned above. The higher expression of BMP2, RPL18A, RPL19, and RPS12 is associated with better outcomes in patients with glioma.

CONCLUSIONS

Using a large-scale open database, we identified significant genes related to the Wnt/β-catenin signaling pathway associated with mortality and disease progression in patients with grade II and III gliomas.

The genes significantly associated with an improved prognosis and long-term survival of glioblastoma

BACKGROUND AND PURPOSE

Glioblastoma multiforme (GBM) is the most devastating brain tumor with less than 5% of patients surviving 5 years following diagnosis. Many studies have focused on the genetics of GBM with the aim of improving the prognosis of GBM patients. We investigated specific genes whose expressions are significantly related to both the length of the overall survival and the progression-free survival in patients with GBM.

METHODS

We obtained data for 12,042 gene mRNA expressions in 525 GBM tissues from the Cancer Genome Atlas (TCGA) database. Among those genes, we identified independent genes significantly associated with the prognosis of GBM. Receiver operating characteristic (ROC) curve analysis was performed to determine the genes significant for predicting the long-term survival of patients with GBM. Bioinformatics analysis was also performed for the significant genes.

RESULTS

We identified 33 independent genes whose expressions were significantly associated with the prognosis of 525 patients with GBM. Among them, the expressions of five genes were independently associated with an improved prognosis of GBM, and the expressions of 28 genes were independently related to a poorer prognosis of GBM. The expressions of the ADAM22, ATP5C1, RAC3, SHANK1, AEBP1, C1RL, CHL1, CHST2, EFEMP2, and PGCP genes were either positively or negatively related to the long-term survival of GBM patients.

CONCLUSIONS

Using a large-scale and open database, we found genes significantly associated with both the prognosis and long-term survival of patients with GBM. We believe that our findings may contribute to improving the understanding of the mechanisms underlying GBM.

Risk Factors for Prevertebral Soft Tissue Swelling Following Single-Level Anterior Cervical Spine Surgery

OBJECTIVE

Anterior cervical spine surgery (ACSS) is a common surgical procedure used to treat cervical spinal degenerative diseases. One of the complications associated with ACSS is prevertebral soft tissue swelling (PSTS), which can result in airway obstruction, dysphagia, and other adverse outcomes. This study aims to investigate the correlation between various cervical sagittal parameters and PSTS following single-level ACSS, as well as to identify independent risk factors for PSTS.

METHODS

A retrospective study conducted at a single institution. The study population included all patients who underwent single-level ACSS between January 2014 and December 2022. Patients with a history of cervical spine surgery or trauma were excluded from the study. The presence and severity of PSTS was assessed by reviewing pre- and postoperative imaging studies. The potential risk factors for PSTS that were examined include patient age, sex, body mass index, tobacco use, comorbidities, serum albumin levels, operative time, implant type, implanted level, and various cervical spine sagittal parameters. Multivariate linear regression analysis was performed to identify the independent risk factors for PSTS.

RESULTS

A total of 62 consecutive patients who underwent single-level ACSS over a 8-year period at a single institution were enrolled in this study. Only preoperative segmental angle showed positive correlation with PSTS among various cervical spine sagittal parameters (r=0.36, p=0.005). Artificial disc replacement showed a negative correlation with PSTS (β=-0.38, p=0.002), whereas the use of demineralized bone matrix (DBM) had a positive impact on PSTS (β=0.33, p=0.009). We found that male sex, lower preoperative serum albumin, and implantation of upper cervical level (above C5) were independent predictors for PSTS after single-level ACSS (β=1.21; 95% confidence interval [CI], 0.27 to 2.15; p=0.012; β=-1.63; 95% CI, -2.91 to -0.34; p=0.014; β=1.44; 95% CI, 0.38 to 2.49; p=0.008, respectively).

CONCLUSION

Our study identified male sex, lower preoperative serum albumin levels, and upper cervical level involvement as independent risk factors for PSTS after single-level ACSS. These findings can help clinicians monitor high-risk patients and take preventive measures to reduce complications. Further research with larger sample sizes and prospective designs is needed to validate these findings.

Is Fetal-Type Posterior Cerebral Artery a Risk Factor for Recurrence in Coiled Internal Carotid Artery-Incorporating Posterior Communicating Artery Aneurysms? Analysis of Conventional Statistics, Computational Fluid Dynamics, and Random Forest With Hyper-Ensemble Approach

BACKGROUND

The fetal-type posterior cerebral artery (FPCA) has been regarded as the risk factor for recurrence in coiled internal carotid artery-incorporating posterior communicating artery (ICA-PCoA) aneurysm. However, it has not been proven in previous literature studies.

OBJECTIVE

To reveal the impact of FPCA on the recurrence of ICA-PCoA aneurysms using conventional statistical analysis, computational fluid dynamics (CFD) simulation, and random forest with hyper-ensemble approach (RF with HEA).

METHODS

Vascular parameters and clinical information from patients who underwent coil embolization ICA-PCoA aneurysms from January 2011 to December 2016 were obtained. Conventional statistical analysis was applied to a total of 95 cases obtained from patients with a follow-up of more than 6 months. For CFD simulation, 3 sets of three-dimensional models were used to understand the hemodynamical characteristics of various FPCAs. The RF with HEA was applied to reinforce the clinical data analysis.

RESULTS

The conventional statistical analysis fails to reveal that FPCA is a risk factor. CFD analysis shows that the diameter of FPCA alone is less likely to be a risk factor. The RF with HEA shows that the impact of FPCA is also minor compared with that of the packing density in the recurrence of coiled ICA-PCoA aneurysms.

CONCLUSION

The gathered results of all 3 analyses show more clear evidence that FPCA is not a risk factor for coiled ICA-PCoA aneurysms. Hence, we may conclude that FPCA itself is doubtful to be the major risk factor in the recurrence of coiled ICA-PCoA aneurysms.

DKK3 expression is associated with immunosuppression and poor prognosis in glioblastoma, in contrast to lower-grade gliomas

PURPOSE

We previously reported that expression of dickkopf-3 (DKK3), which is involved in the Wnt/β-catenin pathway, is significantly associated with prognosis in patients with glioblastoma multiforme (GBM). The aim of this study was to compare the association of DKK3 with other Wnt/β-catenin pathway-related genes and immune responses between lower grade glioma (LGG) and GBM.

METHODS

We obtained the clinicopathological data of 515 patients with LGG (World Health Organization [WHO] grade II and III glioma) and 525 patients with GBM from the Cancer Genome Atlas (TCGA) database. We performed Pearson's correlation analysis to investigate the relationships between Wnt/β-catenin-related gene expression in LGG and GBM. Linear regression analysis was performed to identify the association between DKK3 expression and immune cell fractions in all grade II to IV gliomas.

RESULTS

A total of 1,040 patients with WHO grade II to IV gliomas were included in the study. As the grade of glioma increased, DKK3 showed a tendency to be more strongly positively correlated with the expression of other Wnt/β-catenin pathway-related genes. DKK3 was not associated with immunosuppression in LGG but was associated with downregulation of immune responses in GBM. We hypothesized that the role of DKK3 in the Wnt/β-catenin pathway might be different between LGG and GBM.

CONCLUSION

According to our findings, DKK3 expression had a weak effect on LGG but a significant effect on immunosuppression and poor prognosis in GBM. Therefore, DKK3 expression seems to play different roles, through the Wnt/β-catenin pathway, between LGG and GBM.

Identification of genes from ten oncogenic pathways associated with mortality and disease progression in glioblastoma

Glioblastoma multiforme (GBM) is the most malignant brain tumor with an extremely poor prognosis. The Cancer Genome Atlas (TCGA) database has been used to confirm the roles played by 10 canonical oncogenic signaling pathways in various cancers. The purpose of this study was to evaluate the expression of genes in these 10 canonical oncogenic signaling pathways, which are significantly related to mortality and disease progression in GBM patients. Clinicopathological information and mRNA expression data of 525 patients with GBM were obtained from TCGA database. Gene sets related to the 10 oncogenic signaling pathways were investigated via Gene Set Enrichment Analysis. Multivariate Cox regression analysis was performed for all the genes significantly associated with mortality and disease progression for each oncogenic signaling pathway in GBM patients. We found 12 independent genes from the 10 oncogenic signaling pathways that were significantly related to mortality and disease progression in GBM patients. Considering the roles of these 12 significant genes in cancer, we suggest possible mechanisms affecting the prognosis of GBM. We also observed that the expression of 6 of the genes significantly associated with a poor prognosis of GBM, showed negative correlations with CD8+ T-cells in GBM tissue. Using a large-scale open database, we identified 12 genes belonging to 10 well-known oncogenic canonical pathways, which were significantly associated with mortality and disease progression in patients with GBM. We believe that our findings will contribute to a better understanding of the mechanisms underlying the pathophysiology of GBM in the future.

Efficacy of Cytokine-Induced Killer Cell Immunotherapy for Patients With Pathologically Pure Glioblastoma

The most common malignant central nervous system tumor is glioblastoma multiforme (GBM). Cytokine-induced killer (CIK) cell therapy is a promising type of adoptive cell immunotherapy for various cancers. We previously conducted a randomized clinical trial on CIK cell therapy in patients with GBM. The aim of this study was to evaluate the efficacy of CIK immunotherapy for patients with pathologically pure GBM, using data from our previous randomized clinical trial. The difference between overall survival (OS) and progression-free survival (PFS) according to CIK immunotherapy was analyzed using the Kaplan–Meier method. Hazard ratios were calculated using univariate and multivariate Cox regression analyses to determine whether CIK cell immunotherapy was independently associated with higher OS and PFS in patients with pure GBM. A total of 156 eligible patients were included in the modified intention-to-treat (mITT) population. We confirmed that 125 (80.1%) GBM samples were pure GBM tumors without the presence of other types of tumors. For patients with pure GBM, Kaplan-Meier analysis showed no significant difference in OS between the CIK cell treatment and control groups. However, multivariate Cox regression demonstrated CIK cell immunotherapy as an independent predictor of greater OS (hazard ratio, 0.59; 95% CI, 0.36–0.97; p = 0.038) and PFS (hazard ratio, 0.55; 95% CI, 0.36–0.84; p = 0.001) in patients with pathologically pure GBM in the mITT population. This study showed that CIK cell immunotherapy combined with conventional temozolomide chemoradiotherapy could prolong OS and PFS in patients with newly diagnosed pathologically pure GBM, with no significant adverse events related to treatment. However, unlike the results of multivariate Cox analysis, no statistical significance of CIK cell immunotherapy in OS in Kaplan-Meier analysis raises a question. Further studies are required to validate these results.

Effect of osteoporotic conditions on the development of peritumoral brain edema after LINAC-based radiation treatment in patients with intracranial meningioma

PURPOSE

Disruption of the tumor-brain barrier in meningioma is a crucial factor in peritumoral brain edema (PTBE). We previously reported the possible effect of osteoporosis on the integrity of the arachnoid trabeculae because both the bone and the arachnoid trabeculae are composed of type 1 collagen. We hypothesized that osteoporotic conditions may be associated with PTBE occurrence after radiation treatment in patients with meningioma.

METHODS

A receiver operating characteristic curve analysis was used to identify the optimal cut-off values of mean skull Hounsfield unit for predicting osteopenia and osteoporosis in patients from our registry. Multivariate Cox regression analysis was used to determine whether possible osteoporosis independently predicted PTBE development in patients with meningioma after radiation.

RESULTS

A total of 106 intracranial meningiomas were included for the study. All patients received linear accelerator-based radiation therapy in our hospital over an approximate 6-year period. Multivariate Cox regression analysis identified that hypothetical osteoporosis was an independent predictive factor for the development of PTBE in patients with meningioma after linear accelerator-based radiation treatment (hazard ratio 5.20; 95% confidence interval 1.11-24.46; p = 0.037).

CONCLUSIONS

Our study suggests that possible osteoporotic conditions may affect PTBE development after linear accelerator-based radiation treatment for intracranial meningioma. However, due to the study's small number of patients, these findings need to be validated in future studies with larger cohorts, before firm recommendations can be made.

Effect of Osteoporotic Condition on Ventriculomegaly and Shunt-Dependent Hydrocephalus After Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Hydrocephalus is a common complication in aneurysmal rupture subarachnoid hemorrhage (SAH). As both the bone and arachnoid trabeculae are composed of type 1 collagen, we identified the possible relationship between bone mineral density and ventriculomegaly and shunt-dependent hydrocephalus (SDHC) development after aneurysmal rupture SAH in younger patients.

METHODS

We measured frontal skull Hounsfield unit (HU) values on brain computed tomography upon admission, and mean frontal skull HU values were used instead of T-score value. Hazard ratios were calculated using Cox regression analysis to identify whether osteoporotic condition is an independent predictor for ventriculomegaly and SDHC after surgical clipping for SAH in younger patients.

RESULTS

Altogether, 412 patients (≤65 years) who underwent surgical clipping for primary spontaneous SAH from a ruptured aneurysm were enrolled in this 11-year analysis in 2 hospitals. We observed that the first tertile group of skull HU was an independent predictor of SDHC after SAH compared with the third tertile of skull HU values (hazard ratio, 2.55 [95% CI, 1.25-5.20]; P=0.010). There were no significant interactions between age and skull HU with respect to ventriculomegaly and SDHC in younger patients.

CONCLUSIONS

Our study suggests a relationship between possible osteoporotic conditions and ventriculomegaly and SDHC development after SAH in younger patients. Our findings may be useful in predicting hydrocephalus in young SAH patients using a convenient method of measuring skull HU value on brain computed tomography upon admission.

Relationship between the atlantodental interval and T1 slope after atlantoaxial fusion in patients with rheumatoid arthritis

BACKGROUND

Atlantoaxial fusion has been widely used for the treatment of atlantoaxial instability (AAI). However, atlantoaxial fusion sacrifices the motion of atlantoaxial articulation, and postoperative loss of cervical lordosis and aggravation of cervical kyphosis are observed. We investigated various factors under the hypothesis that the atlantodental interval (ADI) and T1 slope may be associated with sagittal alignment after atlantoaxial fusion in patients with rheumatoid arthritis (RA).

METHODS

We retrospectively investigated 64 patients with RA who underwent atlantoaxial fusion due to AAI. Radiological factors, including the ADI, T1 slope, Oc-C2 angle, cervical sagittal vertical axis, and C2-C7 angle, were measured before and after surgery.

RESULTS

The various factors associated with atlantoaxial fusion before and after surgery were compared according to the upper and lower preoperative ADIs. There was a significant difference in the T1 slope 1 year after surgery (p = 0.044) among the patients with lower preoperative ADI values. The multivariate logistic regression analysis showed that the preoperative ADI (> 7.92 mm) defined in the receiver-operating characteristic curve analysis was an independent predictive factor for the increase in the T1 slope 1 year after atlantoaxial fusion (odds ratio, 4.59; 95% confidence interval, 1.34-15.73; p = 0.015).

CONCLUSION

We found an association between the preoperative ADI and difference in the T1 slope after atlantoaxial fusion in the patients with RA. A preoperative ADI (> 7.92 mm) was an independent predictor for the increase in the T1 slope after atlantoaxial fusion. Therefore, performing surgical treatment when the ADI is low would lead to better cervical sagittal alignment.

Effects of Possible Osteoporotic Conditions on the Recurrence of Chronic Subdural Hematoma

The recurrence rate of chronic subdural hematoma (CSDH) has been reported to range from 2.3 to 33%. As bridging veins are composed of abundant collagen bundles and bone matrix, we aimed to investigate the possible associations between skull Hounsfield unit (HU) values and the recurrence of CSDH. We retrospectively enrolled patients with CSDH who underwent burr hole surgery. The HU values of the frontal skull were measured on brain CT scans. The cumulative hazard for recurrence was estimated according to predictive factors. To identify the independent predictors associated with the recurrence of CSDH, hazard ratios (HRs) were estimated using multivariate Cox regression analysis. A total of 208 consecutive patients who underwent burr hole trephination for CSDH over a 7-years period at a single institution were enrolled in this study. We found that age, greater midline shift (≥10.5 mm), lower skull HU (<769.5), and diabetes were independent predictors for the recurrence of CSDH (HR 1.06, 95% confidence interval [CI] 1.00–1.12, p = 0.042; HR 5.37, 95% CI 1.48–19.46, p = 0.010; HR 6.71, 95% CI 1.84–24.45, p = 0.004; and HR 3.30, 95% CI 1.05–10.43, p = 0.042, respectively). A relationship between possible low bone mineral density (BMD) and CSDH recurrence was observed. In addition, age, greater preoperative midline shift, and diabetes were also identified as predictive factors for recurrence. We expect that our findings may facilitate our understanding of the possible association between CSDH and BMD.

Current Status of Neurosurgical and Neurointensive Care Units in Korea : A Brief Report on Nationwide Survey Results

Objective

The purpose of this study is identify the operation status of the neurosurgical care units (NCUs) in neurosurgical residency training hospitals nationwide and determine needed changes by comparing findings with those obtained from the Korean Neurosurgical Society (KNS) and Korean Society of Neurointensive Care Medicine (KNIC) survey of 2010.

Method

This survey was conducted over 1 year in 86 neurosurgical residency training hospitals and two neurosurgery specialist hospitals and focused on the following areas : 1) the current status of the infrastructure and operating systems of NCUs in Korea, 2) barriers to installing neurointensivist team systems, 3) future roles of the KNS and KNIC, and 4) a handbook for physicians and practitioners in NCUs. We compared and analyzed the results of this survey with those from a KNIC survey of 2010.

Results

Seventy seven hospitals (87.5%) participated in the survey. Nineteen hospitals (24.7%) employed a neurointensivist or faculty member; Thirty seven hospitals (48.1%) reported high demand for neurointensivists, and 62 hospitals (80.5%) stated that the mandatory deployment of a neurointensivist improved the quality of patient care. Forty four hospitals (57.1%) believed that hiring neurointensivist would increase hospital costs, and in response to a question on potential earnings declines. In terms of potential solutions to these problems, 70 respondents (90.9%) maintained that additional fees were necessary for neurointensivists’ work, and 64 (83.1%) answered that direct support was needed of the personnel expenses for neurointensivists.

Conclusion

We hope the results of this survey will guide successful implementation of neurointensivist systems across Korea.

Does the skull Hounsfield unit predict shunt dependent hydrocephalus after decompressive craniectomy for traumatic acute subdural hematoma?

Background and purpose

Posttraumatic hydrocephalus affects 11.9%–36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury and necessitates a ventriculo-peritoneal shunt placement. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull Hounsfield unit (HU) values and shunt-dependent hydrocephalus (SDHC) in patients that received cranioplasty after DC for traumatic acute subdural hematoma (SDH).

Methods

We measured HU values in the frontal bone and internal occipital protuberance from admission brain CT. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off skull HU values for predicting SDHC in patients receiving cranioplasty after DC due to traumatic acute SDH. We investigated independent predictive factors for SDHC occurrence using multivariable logistic regression analysis.

Results

A total of 162 patients (>15 years of age) were enrolled in the study over an 11-year period from two university hospitals. Multivariable logistic analysis revealed that the group with simultaneous frontal skull HU ≤797.4 and internal occipital protuberance HU ≤586.5 (odds ratio, 8.57; 95% CI, 3.05 to 24.10; P<0.001) was the only independent predictive factor for SDHC in patients who received cranioplasty after DC for traumatic acute SDH.

Conclusions

Our study reveals a potential relationship between possible low bone mineral density and development of SDHC in traumatic acute SDH patients who had undergone DC. Our findings provide deeper insight into the association between low bone mineral density and hydrocephalus after DC for traumatic acute SDH.

Significance of skull osteoporosis to the development of peritumoral brain edema after LINAC-based radiation treatment in patients with intracranial meningioma

Background and purpose

Disruption of the tumor-brain barrier in meningioma plays a critical role in the development of peritumoral brain edema (PTBE). We hypothesized that osteoporotic conditions may be associated with PTBE occurrence after radiation in patients with intracranial meningioma.

Methods

We measured Hounsfield units (HU) of the frontal skull on simulation brain CT in patients who underwent linear accelerator (LINAC)-based radiation treatment for intracranial meningioma. Receiver operating characteristic curve analysis was performed to determine the optimal cut-off values for several predictive factors. The cumulative hazard for PTBE was estimated and classified according to these factors. Hazard ratios were then estimated to identify independent predictive factors associated with the development of PTBE after radiation in intracranial meningioma patients.

Results

A total of 83 intracranial meningiomas in 76 patients who received LINAC-based radiation treatment in our hospital over an approximate 5-year period were included for the study. We found mean frontal skull HU ≤630.625 and gross tumor volume >7.194 cc to be independent predictors of PTBE after radiation treatment in patients with meningioma (hazard ratio, 8.41; P = 0.019; hazard ratio, 5.92; P = 0.032, respectively). In addition, patients who were ≥65 years showed a marginally significant association with PTBE.

Conclusions

Our study suggests that possible osteoporotic conditions, large tumor volume, and older age may be associated with PTBE occurrence after LINAC-based radiation treatment for intracranial meningioma. In the future we anticipate that these findings may enhance the understanding of the underlying mechanisms of PTBE after radiation in meningioma patients.

Association between cerebral atrophy and osteoporotic vertebral compression fractures

PURPOSE

Osteoporotic vertebral compression fractures (OVCFs) have a serious impact on people's health and quality of life. The purpose of this study was to analyze brain volume in patients with osteoporosis using brain magnetic resonance imaging (MRI) and to investigate the relationship with osteoporotic vertebral compression fractures.

MATERIALS AND METHODS

We included 246 patients with osteoporosis who underwent thoracolumbar radiographs and brain MRI at our hospital. Clinical data on age, sex, bone mineral density, height, weight, osteoporosis medication, hypertension, diabetes, alcohol drinking, and smoking were collected. Intracranial cavity, brain parenchyma, and lateral ventricles volumes were measured using brain MRI with a semiautomated tool.

RESULTS

We founded an independent correlation between age and volume percentages of the brain parenchyma and lateral ventricles. We observed a statistically significant decrease in volume percentage of the brain parenchyma and an increase in volume percentage of the lateral ventricles with increasing age. In addition, we confirmed that patients with OVCF showed a significantly lower volume percentage of brain parenchyma than patients without OVCF.

CONCLUSION

We observed a significant association between OVCF and volume percentage of brain parenchyma. Degeneration of the brain may lead to a high incidence of falls, and OVCF may occur more frequently in patients with osteoporosis.

LGR5 and Downstream Intracellular Signaling Proteins Play Critical Roles in the Cell Proliferation of Neuroblastoma, Meningioma and Pituitary Adenoma

Leucine-rich repeat-containing G-protein coupled receptor 5 (LGR5) has been reported to play critical roles in the proliferation of various cancer cells. However, the roles of LGR5 in brain tumors and the specific intracellular signaling proteins directly associated with it remain unknown. Expression of LGR5 was first measured in normal brain tissue, meningioma, and pituitary adenoma of humans. To identify the downstream signaling pathways of LGR5, siRNA-mediated knockdown of LGR5 was performed in SH-SY5Y neuroblastoma cells followed by proteomics analysis with 2-dimensional polyacrylamide gel electrophoresis (2D-PAGE). In addition, the expression of LGR5-associated proteins was evaluated in LGR5-inhibited neuroblastoma cells and in human normal brain, meningioma, and pituitary adenoma tissue. Proteomics analysis showed 12 protein spots were significantly different in expression level (more than two-fold change) and subsequently identified by peptide mass fingerprinting. A protein association network was constructed from the 12 identified proteins altered by LGR5 knockdown. Direct and indirect interactions were identified among the 12 proteins. HSP 90-beta was one of the proteins whose expression was altered by LGR5 knockdown. Likewise, we observed decreased expression of proteins in the hnRNP subfamily following LGR5 knockdown. In addition, we have for the first time identified significantly higher hnRNP family expression in meningioma and pituitary adenoma compared to normal brain tissue. Taken together, LGR5 and its downstream signaling play critical roles in neuroblastoma and brain tumors such as meningioma and pituitary adenoma.

Mitochondria damaged by Oxygen Glucose Deprivation can be Restored through Activation of the PI3K/Akt Pathway and Inhibition of Calcium Influx by Amlodipine Camsylate

Amlodipine, a L-type calcium channel blocker, has been reported to have a neuroprotective effect in brain ischemia. Mitochondrial calcium overload leads to apoptosis of cells in neurologic diseases. We evaluated the neuroprotective effects of amlodipine camsylate (AC) on neural stem cells (NSCs) injured by oxygen glucose deprivation (OGD) with a focus on mitochondrial structure and function. NSCs were isolated from rodent embryonic brains. Effects of AC on cell viability, proliferation, level of free radicals, and expression of intracellular signaling proteins were assessed in OGD-injured NSCs. We also investigated the effect of AC on mitochondrial structure in NSCs under OGD by transmission electron microscopy. AC increased the viability and proliferation of NSCs. This beneficial effect of AC was achieved by strong protection of mitochondria. AC markedly enhanced the expression of mitochondrial biogenesis-related proteins and mitochondrial anti-apoptosis proteins. Together, our results indicate that AC protects OGD-injured NSCs by protecting mitochondrial structure and function. The results of the present study provide insight into the mechanisms underlying the protective effects of AC on NSCs.

Association between bone mineral density and brain parenchymal atrophy and ventricular enlargement in healthy individuals

Bone, vascular smooth muscle, and arachnoid trabeculae are composed of the same type of collagen. However, no studies have investigated the relationship between bone mineral density deterioration and cerebral atrophy, both of which occur in normal, healthy aging. Accordingly, we evaluated whether bone mineral density was associated with brain parenchymal atrophy and ventricular enlargement in healthy individuals. Intracranial cavity, brain parenchyma, and lateral ventricles volumes were measured using brain magnetic resonance imaging (MRI) with a semiautomated tool. We included 267 individuals with no history of dementia or other neurological diseases, who underwent one or more dual-energy X-ray absorptiometry scans and brain MRIs simultaneously (within 3 years of each other) at our hospital over an 11-year period. We found that progression of brain parenchymal atrophy was positively associated with bone mineral density after full adjustment (B, 0.94; P < 0.001). In addition, individuals with osteoporosis showed more parenchymal atrophy among those younger than 80 years. In addition, we observed greater ventricular enlargement in individuals with osteoporosis among those older than 80 years. We believe that osteoporosis may play a role in the acceleration of parenchymal atrophy during the early-stages, and ventricular enlargement in the late-stages, of normal aging-related cerebral atrophy.

Association Between Possible Osteoporosis and Shunt-Dependent Hydrocephalus After Subarachnoid Hemorrhage

Background and Purpose- Pathological obstruction in arachnoid granulations after subarachnoid hemorrhage (SAH) can impede cerebrospinal fluid flow outward to the venous sinus and causing hydrocephalus. Because bone and arachnoid granulations share the same collagen type, we evaluated the possible relation between bone mineral density and shunt-dependent hydrocephalus after SAH. Methods- We measured Hounsfield units of the frontal skull on admission brain computed tomography in patients with SAH. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff Hounsfield unit in skull to predict osteopenia and osteoporosis in a large sample registry. According to the optimal cutoff skull Hounsfield unit values, study patients were then categorized as hypothetical normal, osteopenia, and osteoporosis. Odds ratios were estimated using logistic regression to determine whether the osteoporotic conditions are independent predictive factors for the development of shunt-dependent hydrocephalus after clipping for SAH. Results- A total of 447 patients (alive ≥14 days) with ruptured aneurysm SAH who underwent surgical clipping were retrospectively enrolled in this study during a 9-year period from 2 hospitals. We found that hypothetical osteoporosis was an independent predictor for shunt-dependent hydrocephalus after aneurysmal clipping for SAH after full adjustment for other predictive factors, including age (odds ratio, 2.08; 95% confidence interval, 1.06-4.08; P=0.032). Conclusions- Our study demonstrates a possible relation between possible osteoporosis and hydrocephalus after SAH. Hounsfield unit measurement on admission brain computed tomography may be helpful for predicting hydrocephalus during the clinical course of SAH in patients with osteoporosis or suspected osteoporosis.

Paradoxical relationship between body mass index and bone mineral density in patients with non-small cell lung cancer with brain metastasis

Background and purpose

Low body mass index (BMI) at presentation has been reported to be associated with higher incidence and mortality of lung cancer, but studies on the relationship between brain metastasis and BMI at presentation are lacking. This study aimed to evaluate the association between brain metastasis and BMI and bone mineral density (BMD) in NSCLC.

Methods

We retrospectively enrolled patients with non–small cell lung cancer who underwent brain magnetic resonance imaging with contrast within 3 months of diagnosis. The BMI was collected, and the BMD was measured in Hounsfield unit (HU) on initial staging computed tomography scans. The independent relationship between BMI and BMD was assessed using multivariable linear regression according to the presence of brain metastasis.

Results

A total of 356 consecutive NSCLC patients were enrolled in the study over a 8-year period in a single institution. Lower BMI with higher BMD was an independent predictive factor for brain metastasis in patients with NSCLC, relative to the other group (HR, 2.03; 95% CI, 1.21 to 3.40; P = 0.007). We also found a significant negative correlation between BMI and BMD among patients with NSCLC with brain metastases (B, -3.343; 95% confidence interval, -6.352 to -0.333; P = 0.030).

Conclusions

Brain metastasis may possibly be associated with lower BMI and higher BMD in NSCLC patients. We expect that these results may facilitate future predictions of brain metastases during the clinical course of NSCLC and enhance our understanding of the underlying mechanisms that link brain metastases and lung cancer.

Risk Factors of Delayed Intracranial Hemorrhage Following Ventriculoperitoneal Shunt

Objective

Placement of a ventriculoperitoneal (VP) shunt is a common neurosurgical procedure for cerebrospinal fluid diversion. A rare complication is delayed intracranial hemorrhage (ICH) secondary to VP shunting, and only a few patients with this complication have been reported. We investigate the incidence and risk factors of delayed ICH development following VP shunt placement.

Methods

Over an 11-year period, 167 patients received a VP shunt for hydrocephalus, and of these, 138 patients were eligible for this study. All medical records and computed tomography scans obtained within 48 h after the operation and at postoperative day 7 were reviewed. The risk factors of developing delayed ICH (≥48 hr after VP shunt placement) were analyzed according to the demographic data, including sex and age, original intracranial lesions, co-morbid diseases, and laboratory findings.

Results

Delayed ICH following VP shunt placement developed in 34 (24.6%) of the 138 patients. Risk factors for developing delayed ICH were age (p=0.037) and the partial thromboplastin time (PTT) (p=0.032). Intraventricular hemorrhage after VP shunting was the most common complication, occurring in 16 cases. Hemorrhagic volume was <1 mL in 28 cases and >1 mL in 6 cases.

Conclusion

This study suggests that old age and delayed PTT are major risk factors for developing delayed ICH following VP shunting. Additionally, delayed ICH after VP shunting commonly occurs even when most patients are asymptomatic. Therefore, extra care should be taken to observe and follow-up with patients who have undergone VP shunt placement.