Clinical characteristics of aneurysmal subarachnoid hemorrhage in the elderly over 75; would temporal muscle be a potential prognostic factor as an indicator of sarcopenia?

Temporalis muscle thickness as a predictor of functional outcome after reperfusion therapies for acute ischemic stroke: a retrospective, cohort study

BACKGROUND

Sarcopenia, defined as the loss of skeletal muscle mass, has been associated with a worse functional outcome after stroke. Measurement of temporal muscle thickness (TMT) has been introduced as an easily obtainable surrogate marker to identify patients with sarcopenia. Our study aims to investigate the correlation between pre-stroke sarcopenia, measured by TMT assessment, and functional outcome in patients treated with revascularization procedures for acute ischemic stroke.

METHODS

We included consecutive adult patients who underwent thrombolysis, endovascular thrombectomy or both for acute ischemic stroke at our Centre from January 2020 to June 2022. Besides collecting baseline clinical and neuroradiological features, TMT was measured on brain computed tomography scans according to a standardized protocol. Modified Rankin Scale (mRS) scores at 3 months represented the main endpoint of functional outcome.

RESULTS

A total of 261 patients were available for the analysis. In univariate models, patients with excellent outcomes (mRS = 0-1) were younger, had higher TMT values and lower pre-event disability and stroke severity. In multivariate models higher TMT values resulted independently associated with reduced mortality (Odds Ratio 0.708, 95% Confidence Interval 0.538-0.930, p = 0.013). Age, diabetes, brain bleeding events and stroke severity were found to be predictors of mortality, too.

CONCLUSIONS

Our retrospective analysis shows that in patients who underwent revascularization treatments for ischemic stroke TMT is as an independent predictor of survival easily obtainable from the baseline CT scan. Further investigation is required to confirm the role of sarcopenia assessment and TMT measurement in the prognostication toolkit of this disease.

Association between the Thickness or Area of the Temporal Muscle and Skeletal Muscle Mass in Bioimpedance Analysis

INTRODUCTION

Sarcopenia associated with stroke can significantly impact patient prognosis; however, the current standard diagnostic methods for sarcopenia are rarely used in stroke patients. Therefore, the aim of the current study was to investigate whether the temporal muscle thickness (TMT) or area (TMA) could serve as a surrogate marker for measuring skeletal muscle mass.

METHODS

This retrospective chart review study was conducted on 244 participants from March 2018 to February 2020. The TMT and TMA were measured at the supraorbital roof level using brain CT or T1-weighted MR imaging obtained from participants. The skeletal muscle mass and skeletal muscle index (SMI) and whole-body phase angle (WBPA) at 50 kHz were collected. Pearson correlation analysis was used to assess the relationship between the TMT or TMA and the results of the bioimpedance analysis.

RESULTS

The mean TMT showed significant positive correlations with skeletal muscle mass (male, r = 0.520; female, r = 0.706), SMI (male, r = 0.426; female, r = 0.582), and WBPA (male, r = 0.295; female, r = 0.232). The mean TMA showed significant positive correlations with skeletal muscle mass (male, r = 0.490; female, r = 0.657), SMI (male, r = 0.289; female, r = 0.473), and WBPA (male, r = 0.232; female, r = 0.243).

CONCLUSION

We observed moderate to strong positive correlations between body composition analysis measured by BIA and TMT or TMA, suggesting that TMT or TMA could serve as a reliable surrogate marker for identifying low skeletal muscle mass in cerebrovascular disease.

Temporal Muscle Swelling after Clipping Surgery with Frontotemporal Craniotomy Is Associated with Immediate Postcraniotomy Headache

Immediate postcraniotomy headache frequently occurs within the first 48 h after surgery. The mechanisms underlying immediate postcraniotomy headache are not yet fully understood, and effective treatments are not yet established. This study aimed to identify the factors associated with immediate postcraniotomy headache in patients who underwent clipping surgery with frontotemporal craniotomy and to examine the effects of these factors on postcraniotomy headache. A total of 51 patients were included in this study. Immediate postcraniotomy headache was defined as pain with numerical rating scale score ≥4 on postoperative day 7. Sixteen patients (31.4%) had immediate postcraniotomy headache. The headache-positive group had a higher incidence of preoperative analgesic use (50.0% vs. 5.7%, respectively, p < 0.001), increased temporal muscle swelling ratio (137.0%±30.2% vs. 112.5%±30.5%, respectively, p = 0.01), and higher postoperative analgesic use (12.9±5.8 vs. 6.7±5.2, respectively, p < 0.001) than the headache-negative group. The risk factors independently associated with immediate postcraniotomy headache were preoperative analgesic use and temporal muscle swelling by >115.15% compared with the contralateral side in the receiver operating characteristic analysis. Postcraniotomy headache was significantly more common in patients with preoperative analgesic use and temporal muscle swelling than in those without (p < 0.001 and p = 0.002, respectively). Altogether, patients with immediate postcraniotomy headache had greater preoperative analgesic use, greater temporal muscle swelling ratio, and higher postoperative analgesic use than those without. Thus, temporal muscle swelling is a key response to immediate postcraniotomy headache.

Changes in temporal muscle dimensions and their clinical impact in out-of-hospital cardiac arrest survivors

Objective

This study investigates temporal muscle atrophy in out-of-hospital cardiac arrest patients post-resuscitation, seeking associations with neurological outcomes and factors associated with atrophy.

Methods

Using data from six Japanese intensive care units, adult patients' post-resuscitation who underwent head computed tomography scans on admission and two to five days post-admission were assessed. Temporal muscle area, thickness, and density were quantified from a single cross-sectional image. Patients were categorized into 'atrophy' or 'no atrophy' groups based on median daily temporal muscle atrophy rates. The primary outcome was changes in temporal muscle dimensions between admission and follow-up two to five days later. Secondary outcomes included assessing the impact of temporal muscle atrophy on 30-day survival, as well as identifying any clinical factors associated with temporal muscle atrophy.

Results

A total of 185 patients were analyzed. Measurements at follow-up revealed significant decreases in temporal muscle area (214 vs. 191 mm2, p < 0.001), thickness (4.9 vs. 4.7 mm, p < 0.001), and density (46 vs. 44 HU, p < 0.001) compared to those at admission. The median daily rate for temporal muscle area atrophy was 2.0% per day. There was no significant association between temporal muscle atrophy and 30-day survival (hazard ratios, 0.71; 95% CI, 0.41-1.23, p = 0.231). Multivariable logistic regression found no clinical factors significantly associated with temporal muscle atrophy.

Conclusions

Temporal muscle atrophy in post-resuscitation patients occurs rapidly at 2.0% per day. However, there was no significant association with 30-day mortality or any identified clinical factors. Further investigation into its long-term functional implications is warranted.

Endovascular coiling versus neurosurgical clipping in the management of aneurysmal subarachnoid haemorrhage in the elderly: a multicenter cohort study

The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0-2 at 3 months (OR = 2.45 [95%CI:1.16-5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10-0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97-4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12-0.90];p = 0.025). Age, admission WFNS score I-III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I-III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.

Comparison of outcomes between clipping and endovascular coiling in anterior choroidal artery aneurysm: a systematic review

SAH (subarachnoid hemorrhage) caused by aneurysm rupture has the greatest mortality rate, with nearly 50% of patients unable to survive beyond 1 month after the attack. Anterior choroidal artery (AChA) aneurysms are one of the most difficult to treat among the numerous types of aneurysms. Until now, some neurosurgeons employed shearing while others employed coiling. In this trial, researchers will compare surgical clipping and endovascular coiling treatments for anterior choroidal artery aneurysms in terms of mortality, rebleeding, retreatment, and post-procedure outcomes. Using the PubMed electronic database, the Cochrane library, the Medline Database, the Directory of Open Access Journals, and EBSCHOHOST, a systematic review compared surgical clipping and endovascular coiling in all cases of choroidal artery aneurysm. There were 17 studies that met the eligibility requirements, with a total of 1486 patients divided into groups that underwent clipping (1106) or endovascular coiling (380). The mortality rate for clipping is 1.8%, while the mortality rate for endovascular coiling is 2.34%. Rebleeding occurs in 0% of patients undergoing endovascular coiling and 0.73% of patients undergoing clipping. Retreatment of clipping was 0.27%, while endovascular coiling was 3.42%. Post-complication procedures occurred in 11.12% of patients undergoing endovascular clipping and 15.78% of patients undergoing endovascular coiling. The intervention technique of clipping has a reduced rate of mortality, reoperation, and post-operative complications. Endovascular coiling results in a reduced rate of rebleeding than clipping.

Serum concentration-guided intravenous magnesium sulfate administration for neuroprotection in patients with aneurysmal subarachnoid hemorrhage: a retrospective evaluation of a 12-year single-center experience

Delayed cerebral infarction (DCI) is a major cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). The benefits of magnesium sulfate as an alternative treatment are controversial, and most previous studies examined its benefits only as adjunctive treatment to traditional nimodipine. We retrospectively analyzed aSAH patients records with magnesium sulfate between 2010 and 2021. We aimed for a serum magnesium concentration of 2-2.5 mmol/l between post-hemorrhage days 3 and 12. The patients were separated in three groups based on average serum magnesium concentration (magnesium >2 mmol/l, reduced magnesium 1.1-1.9 mmol/l, and no magnesium). Additionally, we assessed delayed cerebral infarction (DCI) and clinical outcome at follow-up, using the modified Rankin Scale (mRS), categorized in favorable (0-3) and unfavorable outcome (4-5). In this analysis, 548 patients were included. Hereof, radiological evidence of DCI could be found in 23.0% (n = 126) of patients. DCI rates were lower if patients' average serum magnesium was higher than 2 mmol/l (magnesium 18.8%, n = 85; reduced magnesium 38.3%, n = 23; no magnesium 51.4%, n = 18; p < 0.001). Also, at the last follow-up, patients in the group with a higher serum magnesium concentration had better outcome (favorable outcome: magnesium 64.7%, n = 293; reduced magnesium 50.0%, n = 30; no magnesium 34.3%, n = 12; p < 0.001). This 12-year study reveals the value of serum concentration-guided magnesium administration in aSAH patients. Our findings demonstrate the safety and efficacy when titrated to a serum concentration of 2-2.5 mmol/l. We observed higher rates of delayed cerebral infarction and unfavorable outcomes in patients with serum concentrations below 2 mmol/l.

The relation of sarcopenia and disability in multiple sclerosis

BACKGROUND

The relation of sarcopenia and disability in MS is unknown.

OBJECTIVE

To investigate the relation of temporal muscle thickness (TMT) and disability.

METHODS

A cohort of 132 people who presented with a clinically isolated syndrome (CIS) suggestive of MS at a mean age of 30.0 years, were prospectively followed clinically and with MRI over 30-years. TMT and expanded disability status scale (EDSS) were assessed at baseline, one- five- ten- fourteen- twenty- and thirty-year follow-up.

RESULTS

At 30-years, 27 participants remained classified as having had a CIS, 34 converted to relapsing remitting MS, 26 to secondary progressive MS, and 16 had died due to MS. Using linear mixed effect models with subject nested in time, greater annualized TMT-thinning was seen in individuals who developed MS (-0.04 mm/a, 95%CI: -0.07 to -0.01, p = 0.023). In those who converted to MS, a thinner TMT was reached at 14- (p = 0.008), 20- (p = 0.002) and 30-years (p< 0.001). TMT was negatively correlated with EDSS at 20-years (R=-0.18, p = 0.032) and 30-years (R-0.244, p = 0.005). Longitudinally, TMT at earlier timepoints was not predictive for 30-year clinical outcomes.

CONCLUSION

TMT thinning is accelerated in MS and correlated with disability in later disease stages, but is not predictive of future disability.

Initial Temporal Muscle Thickness and Area: Poor Predictors of Neurological Outcome in Aneurysmal Subarachnoid Hemorrhage in a Central European Patient Cohort

The temporalis muscle area (TMA) has been proclaimed as a surrogate parameter for estimating skeletal muscle mass. Pilot studies in Asian populations suggested temporal muscle thickness (TMT) and TMA as prognostic factors for neurological outcomes in aneurysmal subarachnoid hemorrhage (aSAH) patients. This study aimed to validate these findings in a larger European patient cohort. We retrospectively analyzed age, sex, aneurysm location, treatment, World Federation of Neurosurgical Societies (WFNS) grade, Fisher score, and modified Rankin Score (mRS) at six months in patients with aSAH. TMT and TMA measurements were obtained from initial native CT scans. Logistic regression with the dichotomized six-month mRS as the outcome incorporating TMT, weighted average of TMT, or TMA as predictors was performed. Of the included 478 patients, 66% were female, the mean age was 56, and 48% of patients had an mRS of three to six after six months. The mean TMT at the level of the Sylvian fissure was 5.9 (±1.7) mm in males and 4.8 (±1.8) mm in females. The mean TMA was 234.5 (±107.9) mm2 in females and 380 (±134.1) mm2 in males. WFNS grade (p < 0.001), Fisher score (p < 0.001), and age (p < 0.05) correlated significantly with the mRS after six months. No correlation was found between mRS after six months and the TMT at the Sylvian fissure (p = 0.3), the weighted average of TMT (p = 0.1), or the TMA (p = 0.1). In this central European patient cohort of 478 individuals, no significant associations were found between TMT/TMA and neurological outcomes following aSAH. Further prospective studies in diverse patient populations are necessary to determine the prognostic value of TMA and TMT in aSAH patients.

Association of gut microbiome with risk of intracranial aneurysm: a mendelian randomization study

OBJECTIVE

To investigate the potential causal link between genetic variants associated with gut microbiome and risk of intracranial aneurysm (IA) using two-sample mendelian randomization (MR).

METHODS

We performed two sets of MR analyses. At first, we selected the genome-wide statistical significant(P < 5 × 10^-8) single nucleotide polymorphisms (SNPs) as instrumental variables (IVs). Then, we selected the locus-wide significant (P < 1 × 10^-5) SNPs as IVs for the other set of analyses to obtain more comprehensive conclusions. Gut microbiome genetic association estimates were derived from a genome-wide association study (GWAS) of 18,473 individuals. Summary-level statistics for IA were obtained from 79,429 individuals, which included 7,495 cases and 71,934 controls.

RESULTS

On the basis of locus-wide significance level, inverse variance weighted(IVW) showed that Clostridia [(odds ratio (OR): 2.60; 95% confidence interval (CI): 1.00-6.72, P = 0.049)], Adlercreutzia (OR: 1.81; 95% CI: 1.10-2.99, P = 0.021) and Victivallis (OR: 1.38; 95% CI: 1.01-1.88, P = 0.044) were positively related with the risk of unruptured intracranial aneurysm(UIA); Weighted median results of MR showed Oscillospira (OR: 0.37; 95% CI: 0.17-0.84, P = 0.018) was negatively with the risk of UIA and Sutterella (OR: 1.84; 95% CI: 1.04-3.23, P = 0.035) was positively related with the risk of UIA; MR-Egger method analysis indicated that Paraprevotella (OR: 0.32; 95% CI: 0.13-0.80, P = 0.035) was negatively with the risk of UIA and Rhodospirillaceae (OR: 13.39; 95% CI: 1.44-124.47, P = 0.048) was positively related with the risk of UIA. The results suggest that Streptococcus (OR: 5.19; 95% CI: 1.25-21.56; P = 0.024) and Peptostreptococcaceae (OR: 4.92; 95% CI: 1.32-18.32; P = 0.018) may increase the risk of UIA according to genome-wide statistical significance thresholds.

CONCLUSION

This MR analysis indicates that there exists a beneficial or detrimental causal effect of gut microbiota composition on IAs.

Association of temporalis muscle thickness with functional outcomes in patients undergoing endovascular thrombectomy

INTRODUCTION

Temporalis muscle thickness (TMT) is a surrogate marker for sarcopenia. This study investigated the association of TMT with clinical outcomes in patients receiving endovascular thrombectomy (EVT) for stroke involving acute large vessel occlusion (LVO).

MATERIAL AND METHODS

We enrolled consecutive patients who had undergone EVT between September 2014 and December 2021 at three thrombectomy-capable institutes. TMT was measured through preprocedural computerized tomography angiography. The clinical variables affecting TMT were investigated. The associations between TMT and clinical functional outcomes, defined using the modified Rankin scale, were also studied.

RESULTS

A total of 657 patients were included (mean age: 72.0 ± 12.7 years; male: 52.1%). The mean TMT was 6.35 ± 1.84 mm. Younger age, male sex, higher body mass index, and premorbid functional independence were associated with larger TMT in both univariate and multivariate linear regression (P <.05). Ordinal logistic regression revealed that TMT was associated with better clinical outcomes at 90 days (P_trend = 0.047); multivariate logistic regression indicated that larger TMT was an independent predictor (adjusted odds ratio: 1.14, 95% confidence interval: 1.03-1.27, P = 0.02) of favorable functional independence (modified Rankin scale score: 0-2). The effect was stronger in older patients (≥80 years) than younger patients, as revealed by interaction modeling analysis (P_interaction = 0.06).

CONCLUSION

TMT is associated with age, sex, body mass index, and premorbid functional status. Larger TMT is associated with better outcomes after EVT. The effects of TMT are more pronounced in older adults, indicating that sarcopenia may have influence on stroke outcomes.

Predictive Values of White Blood Cell Count in Peripheral Blood at Admission on In-Hospital Complications and 90-Day Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: Insights from the LongTEAM Registry

PURPOSE

This study aimed to explore the relationship between white blood cells (WBCs) at admission and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH).

PATIENTS AND METHODS

We analyzed data from patients with aSAH between January 2015 and September 2021 who were included in the LongTEAM (Long-term Prognosis of Emergency Aneurysmal Subarachnoid Hemorrhage) registry study. WBC is classified into four groups according to the quartile. We used the logistic model for in-hospital complications, mortality, modified Rankin scale (mRS) at discharge and 90 days to examine the relationship between WBC and clinical outcomes. We used WBC levels near odds ratio (OR) = 1 (Q1) in restricted cubic splines as the reference to evaluate whether there is a nonlinear relationship between WBC and clinical outcomes. Another Kaplan-Meier method was used to analyze the relationship between WBC levels and the risk of developing pneumonia.

RESULTS

Of the 988 patients included, the results showed that compared with patients in the Q1 group, patients in the highest quartile (Q4) had an increased incidence of 90-day unfavorable outcomes after adjusting the confounders (adjusted OR = 1.81, 95% CI = 1.02-3.20, p = 0.042), which may be caused by the increased incidence and risk of pneumonia (adjusted OR = 2.06, 95% CI = 1.30-3.29, p = 0.002; adjusted hazard ratio [HR]=1.63, 95% CI = 1.13-2.36, p < 0.001). The restricted cubic spline indicated that the incidence of developing pneumonia and 90-day unfavorable outcomes rises with increasing WBC levels (p for nonlinear = 0.135 and 0.113).

CONCLUSION

Patients with higher WBC at admission were associated with an increased incidence of 90-day unfavorable outcomes, which might be related to pneumonia.

Diagnostic Utility of Temporal Muscle Thickness as a Monitoring Tool for Muscle Wasting in Neurocritical Care

Temporalis muscle (TM) atrophy has emerged as a potential biomarker for muscle wasting. However, its diagnostic utility as a monitoring tool in intensive care remains uncertain. Hence, the objective of this study was to evaluate the diagnostic value of sequential ultrasound- and computed tomography (CT)-based measurements of TM thickness (TMT). With a prospective observational design, we included 40 patients without preexisting sarcopenia admitted to a neurointensive care unit. TMT measurements, performed upon admission and serially every 3−4 days, were correlated with rectus femoris muscle thickness (RFT) ultrasound measurements. Interrater reliability was assessed by Bland Altmann plots and intraclass correlation coefficient (ICC). Analysis of variance was performed in subgroups to evaluate differences in the standard error of measurement (SEM). RFT decline was paralleled by ultrasound- as well as CT-based TMT measurements (TMT to RFT: r = 0.746, p < 0.001; CT-based TMT to ultrasound-based RFT: r = 0.609, p < 0.001). ICC was 0.80 [95% CI 0.74, 0.84] for ultrasound-based assessment and 0.90 [95% CI 0.88, 0.92] for CT-based TMT measurements. Analysis of variance for BMI, Heckmatt score, fluid balance, and agitation showed no evidence of measurement errors in these subgroups. This study demonstrates the clinical feasibility and utility of ultrasound- and CT-based TMT measurements for the assessment of muscle wasting.

Relevance of presenting risks of frailty, sarcopaenia and osteopaenia to outcomes from aneurysmal subarachnoid haemorrhage

INTRODUCTION

Aneurysmal subarachnoid haemorrhage (aSAH) is a condition with significant morbidity and mortality. Traditional markers of aSAH have established their utility in the prediction of aSAH outcomes while frailty markers have been validated in other surgical specialties. We aimed to compare the predictive value of frailty indices and markers of sarcopaenia and osteopaenia, against the traditional markers for aSAH outcomes.

METHODS

An observational study in a tertiary neurosurgical unit on 51 consecutive patients with ruptured aSAH was performed. The best performing marker in predicting the modified Rankin scale (mRS) on discharge was selected and an appropriate threshold for the definition of frail and non-frail was derived. We compared various frailty indices (modified frailty index 11, and 5, and the National Surgical Quality Improvement Program score [NSQIP]) and markers of sarcopaenia and osteopaenia (temporalis [TMT] and zygoma thickness), against traditional markers (age, World Federation of Neurological Surgery and modified Fisher scale [MFS]) for aSAH outcomes. Univariable and multivariable analysis was then performed for various inpatient and long-term outcomes.

RESULTS

TMT was the best performing marker in our cohort with an AUC of 0.82, Somers' D statistic of 0.63 and Tau statistic 0.25. Of the frailty scores, the NSQIP performed the best (AUC 0.69), at levels comparable to traditional markers of aSAH, such as MFS (AUC 0.68). The threshold of 5.5 mm in TMT thickness was found to have a specificity of 0.93, sensitivity of 0.51, positive predictive value of 0.95 and negative predictive value of 0.42. After multivariate analysis, patients with TMT ≥ 5.5 mm (defined as non-frail), were less likely to experience delayed cerebral ischaemia (OR 0.11 [0.01 - 0.93], p = 0.042), any complications (OR 0.20 [0.06 - 0.069], p = 0.011), and had a larger proportion of favourable mRS on discharge (95.0% vs. 58.1%, p = 0.024) and at 3-months (95.0% vs. 64.5%, p = 0.048). However, the gap between unfavourable and favourable mRS was insignificant at the comparison of 1-year outcomes.

CONCLUSION

TMT, as a marker of sarcopaenia, correlated well with the presenting status, and outcomes of aSAH. Frailty, as defined by NSQIP, performed at levels equivalent to aSAH scores of clinical relevance, suggesting that, in patients presenting with acute brain injury, both non-neurological and neurological factors were complementary in the determination of eventual clinical outcomes. Further validation of these markers, in addition to exploration of other relevant frailty indices, may help to better prognosticate aSAH outcomes and allow for a precision medicine approach to decision making and optimization of best outcomes.

Temporal muscle thickness as an independent prognostic imaging marker in newly diagnosed glioblastoma patients: a validation study

Background

Previous studies have recognized temporal muscle thickness (TMT) as a prognostic marker in glioblastoma, but clinical implementation is hampered due to studies’ heterogeneity and lack of established cutoff values. The aim of this study was to assess the validity of recent proposed sex-specific TMT cutoff values in a real-world population of genotyped primary glioblastoma patients.

Methods

We measured TMT in preoperative MR images of 328 patients. Sex-specific TMT cutoff values were used to divide patients into “at risk of sarcopenia” or “normal muscle status”. Kaplan-Meier analyses and stepwise multivariate Cox-Regression analyses were used to assess the association with overall survival (OS) and progression-free survival (PFS). The association with occurrence of complications and discontinuation of glioblastoma treatment was investigated using odds ratios (OR).

Results

Patients at risk of sarcopenia had a significantly higher risk of progression and death than patients with normal muscle status, which remained significant in the multivariate analyses (OS HR = 1.437; 95%CI: 1.046–1.973; P = .025 and PFS HR = 1.453; 95%CI: 1.037–2.036; P = .030). Patients at risk of sarcopenia also had a significantly higher risk of early discontinuation of treatment (OR = 2.45; 95%CI: 1.011–5.952; P = .042) and a significantly lower chance of receiving second-line treatment (OR = 0.23; 95%CI: 0.09–0.60; P = .001). There was no association with the occurrence of complications.

Conclusions

Our study confirms external validity of the use of proposed sex-specific TMT cutoff values as an independent prognostic marker in newly diagnosed glioblastoma patients. This simple, noninvasive marker could improve patient counseling and aid in treatment decision processes or trial stratification.

Skeletal muscle atrophy and myosteatosis are not related to long-term aneurysmal subarachnoid hemorrhage outcome

The prognosis of aneurysmal subarachnoid hemorrhage (aSAH) is highly variable. This study aims to investigate whether skeletal muscle atrophy and myosteatosis are associated with poor outcome after aSAH. In this study, a cohort of 293 consecutive aSAH-patients admitted during a 4-year period was retrospectively analyzed. Cross-sectional muscle measurements were obtained at the level of the third cervical vertebra. Muscle atrophy was defined by a sex-specific cutoff value. Myosteatosis was defined by a BMI-specific cutoff value. Poor neurological outcome was defined as modified Rankin Scale 4-6 at 2 and 6-month follow-up. Patient survival state was checked until January 2021. Generalized estimating equation was performed to assess the effect of muscle atrophy / myosteatosis on poor neurological outcome after aSAH. Cox regression was performed to analyze the impact of muscle atrophy and myosteatosis on overall survival. The study found that myosteatosis was associated with poor neurological condition (WFNS 4-5) at admission after adjusting for covariates (odds ratio [OR] 2.01; 95%CI 1.05,3.83; P = .03). It was not associated with overall survival (P = .89) or with poor neurological outcomes (P = .18) when adjusted for other prognostic markers. Muscle atrophy was not associated with overall survival (P = .58) or neurological outcome (P = .32) after aSAH. In conclusion, myosteatosis was found to be associated with poor physical condition directly after onset of aSAH. Skeletal muscle atrophy and myosteatosis were however irrelevant to outcome in the Western-European aSAH patient. Future studies are needed to validate these finding.

Temporal Muscle and Stroke-A Narrative Review on Current Meaning and Clinical Applications of Temporal Muscle Thickness, Area, and Volume

BACKGROUND

Evaluating muscle mass and function among stroke patients is important. However, evaluating muscle volume and function is not easy due to the disturbances of consciousness and paresis. Temporal muscle thickness (TMT) has been introduced as a novel surrogate marker for muscle mass, function, and nutritional status. We herein performed a narrative literature review on temporal muscle and stroke to understand the current meaning of TMT in clinical stroke practice.

METHODS

The search was performed in PubMed, last updated in October 2021. Reports on temporal muscle morphomics and stroke-related diseases or clinical entities were collected.

RESULTS

Four studies reported on TMT and subarachnoid hemorrhage, two studies on intracerebral hemorrhage, two studies on ischemic stroke, two studies on standard TMT values, and two studies on nutritional status. TMT was reported as a prognostic factor for several diseases, a surrogate marker for skeletal muscle mass, and an indicator of nutritional status. Computed tomography, magnetic resonance imaging, and ultrasonography were used to measure TMT.

CONCLUSIONS

TMT is gradually being used as a prognostic factor for stroke or a surrogate marker for skeletal muscle mass and nutritional status. The establishment of standard methods to measure TMT and large prospective studies to further investigate the relationship between TMT and diseases are needed.

Successful Mechanical Thrombectomy for Acute Middle Cerebral Artery Occlusion in a Centenarian

Clinical trials have proven the efficacy and beneficial therapeutic outcomes of endovascular therapy in patients with major arterial occlusion. However, its efficacy for very elderly patients, such as nonagenarians or centenarians, is not well established. In this case report, we describe the successful use of mechanical thrombectomy for the management of stroke in a centenarian. The 100-year-old woman with severe right-sided paralysis and total aphasia was admitted to our hospital approximately 30 min from the onset of symptoms. The National Institutes of Health Stroke Scale score was 24 at admission, and three-dimensional computed tomography angiography revealed occlusion in the M1 segment of left middle cerebral artery. She had persistent atrial fibrillation and was diagnosed with colon cancer one month prior to the admission. The modified Rankin Scale score before the stroke was 1, and she was generally independent. The patient successfully underwent mechanical thrombectomy, and recanalization with thrombolysis in cerebral infarction grade 3 was accomplished 129 minutes after the onset. The patient made a remarkable recovery with a National Institutes of Health Stroke Scale score of 4 at 48 h and was discharged home with a modified Rankin Scale score of 2 on day 8. Thus, mechanical thrombectomy can be performed with a good outcome even in centenarians.

Temporal muscle thickness as a prognostic marker in newly diagnosed glioblastoma patients: translational imaging analysis of the CENTRIC EORTC 26071-22072 and CORE trials

PURPOSE

To investigate the prognostic relevance of temporal muscle thickness (TMT) as a surrogate parameter of skeletal muscle status in patients with newly diagnosed glioblastoma.

METHODS

We assessed TMT in cranial magnetic resonance images (MRI) of 755 patients enrolled in the CENTRIC EORTC 26071-22072 study (n=508) and CORE study (n=247). We used predefined sex-specific TMT cutoff values to categorize "patients at risk of sarcopenia" and "patients with normal muscle status" at baseline. Furthermore, we categorized patients according to the extent of TMT loss over time. Associations with progression-free survival (PFS) and overall survival (OS) were evaluated using the Cox model adjusted for other exploratory variables.

RESULTS

Patients at risk of sarcopenia (CENTRIC; n=158/508, 31.1%; CORE; n=87/247, 35.2%) at baseline had significantly higher risk of progression and death than patients with normal muscle status in both study cohorts (CENTRIC: PFS=HR 0.16, 95% CI: 0.12, 0.21, p<0.001; OS=HR 0.341, 95% CI: 0.27, 0.44, p < 0.001; CORE: PFS=HR 0.29, 95% CI: 0.21, 0.39, p<0.001; OS=HR 0.365, 95% CI: 0.27, 0.49, p<0.001). Similar results were obtained in multivariate Cox models adjusted for other important prognostic parameters. The extent of TMT loss over time showed a significant inverse correlation with median OS times in patients at risk for sarcopenia (CENTRIC: p<0.001, CORE: p=0.005), but not in patients with normal baseline muscle mass (CENTRIC: p=0.538, CORE: p=0.28).

CONCLUSION

TMT identifies ambulatory patients with newly diagnosed glioblastoma at risk for progressive sarcopenia and adverse outcomes. Early intervention may prevent skeletal muscle loss and improve patient outcome.

Deep Learning-Based Functional Independence Measure Score Prediction After Stroke in Kaifukuki (Convalescent) Rehabilitation Ward Annexed to Acute Care Hospital

Introduction

Prediction models of functional independent measure (FIM) score after kaifukuki (convalescent) rehabilitation ward (KRW) are needed to decide the treatment strategies and save medical resources. Statistical models were reported, but their accuracies were not satisfactory. We made such prediction models using the deep learning (DL) framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan).

Methods

Of the 559 consecutive stroke patients, 122 patients were transferred to our KRW. We divided our 122 patients’ data randomly into halves of training and validation datasets. Prediction One made three prediction models from the training dataset using (1) variables at the acute care ward admission, (2) those at the KRW admission, and (3) those combined (1) and (2). The models’ determination coefficients (R²), correlation coefficients (rs), and residuals were calculated using the validation dataset.

Results

Of the 122 patients, the median age was 71, length of stay (LOS) in acute care ward 23 (17-30) days, LOS in KRW 53 days, total FIM scores at the admission of KRW 85, those at discharge 108. The mean FIM gain and FIM efficiency were 19 and 0.417. All patients were discharged home. Model (1), (2), and (3)’s R² were 0.794, 0.970, and 0.972. Their mean residuals between the predicted and actual total FIM scores were -1.56±24.6, -4.49±17.1, and -2.69±15.7.

Conclusion

Our FIM gain and efficiency were better than national averages of FIM gain 17.1 and FIM efficiency 0.187. We made DL-based total FIM score prediction models, and their accuracies were superior to those of previous statistically calculated ones. The DL-based FIM score prediction models would save medical costs and perform efficient stroke and rehabilitation medicine.

Temporal Muscle Thickness is an Independent Prognostic Biomarker in Patients with Glioma: Analysis of 261 Cases

Purpose

Temporal muscle thickness (TMT) has been proposed as a novel surrogate marker for skeletal muscle mass in head and neck malignancies. This study investigated the TMT prognostic relevance with gliomas and evaluated the influence of TMT values on survival in patients with gliomas of different grades and IDH subtypes.

Methods

The patients’ TMT was measured on contrast-enhanced T1-weighted magnetic resonance images before surgical treatment. Patients were divided into two cohorts based on their median TMT values. The Kaplan–Meier curve was used to compute the overall survival (OS) of different categories and all gliomas. Univariate and multivariate Cox regression analyses were conducted to assess the association between OS and TMT, hematological markers, and other clinical factors in glioma patients. Moreover, the clinical diagnostic efficiency of single and combination biomarkers was evaluated using receiver operating characteristic curve analysis.

Results

We retrospectively analyzed 261 patients with newly diagnosed glioma between November 2016 and May 2020 at Hunan Cancer Hospital. Cox analysis indicated that higher TMT (HR 0.286, P< 0.001) and higher KPS score (HR 0.629, P= 0.012) were protective prognostic factors and IDH wildtype status (HR 2.946, P< 0.001), RDW > 12.6 (HR 1.513, P= 0.036), and NLR > 4 (HR 1.560, P= 0.042) were poor prognostic factors for gliomas. Subsequently, patients with thicker TMT were found to have significantly better overall survival (P<0.001) than patients with thinner TMT among WHO III and WHO IV grade and patients with or without IDH mutation. TMT was considered a better single biomarker than recently prevalent hematological biomarkers for predicting high-grade [0.856 (0.797–0.916)] and IDH- wild-type [0.864 (0.786–0.941)] gliomas.

Conclusion

This study suggests that TMT is a positive biomarker for clinical prognosis in gliomas and that patients with thicker TMT have greater overall survival for gliomas of different grades and IDH subtypes.

Flow Diversion in Acute Sub Arachnoid Haemorrhage: A Single Centre Five Year Experience

OBJECTIVES

The role of flow-diversion in acute sub-arachnoid haemorrhage (SAH) is controversial. Many of the published data warns of high rates of procedure-related complications and aneurysmal rebleed. This study evaluates the safety, efficacy, clinical and angiographic outcomes of acute flow-diversion at our institute.

METHODS

The institutional database from June 2015 to June 2020 was retrospectively reviewed for aneurysmal SAH (aSAH) treated with flow diversion. Clinical presentation, procedural details, complications, anti-platelet usage, rebleeding and aneurysm occlusion rates and outcomes were recorded.

RESULTS

22 (59% females; median age 56 years) consecutive patients were identified. None of them were on regular antiplatelets/anticoagulation in the 15-days preceding the treatment. The mean aneurysm diameter was 5.4 mm and the median delay to flow-diversion was 2 days. Almost 73% (16/22) of patients had adjunctive coiling in the same session. There was no aneurysmal rebleed at a median follow up of 8.5 months and 86.3% (19/22 patients) had good clinical outcomes (3-month MRS 0-2). Adverse events related to the flow diversion procedure were seen in 3 patients; none of them had a medium to long-term clinical consequence. Three patients died from complications of SAH, unrelated to the procedure. Vascular imaging follow-up was available for 20 patients and the complete aneurysm occlusion rate was 95%.

CONCLUSION

Flow-diversion could be a reasonably safe and effective technique for treating ruptured aneurysms in appropriately selected patients when conventional options of surgical clipping and coiling are considered challenging.

Easily Created Prediction Model Using Automated Artificial Intelligence Framework (Prediction One, Sony Network Communications Inc., Tokyo, Japan) for Subarachnoid Hemorrhage Outcomes Treated by Coiling and Delayed Cerebral Ischemia

Introduction Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes and delayed cerebral ischemia (DCI) are needed to decide the treatment strategy. Automated artificial intelligence (AutoAI) is attractive, but there are few reports on AutoAI-based models for SAH functional outcomes and DCI. We herein made models using an AutoAI framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to other previous statistical prediction scores. Methods We used an open dataset of 298 SAH patients, who were with non-severe neurological grade and treated by coiling. Modified Rankin Scale 0-3 at six months was defined as a favorable functional outcome and DCI occurrence as another outcome. We randomly divided them into a 248-patient training dataset and a 50-patient test dataset. Prediction One made the model using training dataset with 5-fold cross-validation. We evaluated the model using the test dataset and compared the area under the curves (AUCs) of the created models. Those of the modified SAFIRE score and the Fisher computed tomography (CT) scale to predict the outcomes. Results The AUCs of the AutoAI-based models for functional outcome in the training and test dataset were 0.994 and 0.801, and those for the DCI occurrence were 0.969 and 0.650. AUCs for functional outcome calculated using modified SAFIRE score were 0.844 and 0.892. Those for the DCI occurrence calculated using the Fisher CT scale were 0.577 and 0.544. Conclusions We easily and quickly made AutoAI-based prediction models. The models' AUCs were not inferior to the previous prediction models despite the easiness.

Temporal muscle thickness is associated with the severity of dysphagia in patients with acute stroke

BACKGROUND

Post-stroke dysphagia is a common and expensive complication of acute stroke. The relationship between dysphagia and skeletal muscle loss (sarcopenia) has been recently highlighted. This study aimed to determine the relationship between temporal muscle thickness (TMT) measured by head magnetic resonance imaging (MRI) and dysphagia in patients with acute stroke.

METHODS

Seventy participants (43 men and 27 women; mean age, 75.6 ± 12.7 years) were included in this study. TMT was measured by T2-magnetic resonance images within seven days of hospitalization. The severity of dysphagia was assessed using the Functional Oral Intake Scale (FOIS). Participants were classified into three categories according to the severity of dysphagia (severe: FOIS score, 1-3; mild: FOIS score, 4-6; normal: FOIS score, 7). Linear regression analysis was used to determine the independent explanators of dysphagia severity.

RESULTS

Twenty participants (28.6%) had severe dysphagia, 31 participants (44.3%) had mild dysphagia, and 19 participants (27.1%) had normal swallowing function at discharge. The results of the linear regression analysis showed that TMT was a significant explanator of dysphagia severity following stroke, along with age and National Institute of Health Stroke Scale (NIHSS) score (P < 0.05, effect size: f² = 0.72).

CONCLUSIONS

TMT was an independent risk factor for dysphagia in patients with acute stroke. Skeletal muscle loss may be secondarily involved in dysphagia with acute stroke, and measurement of TMT with head MRI is a useful method to assess skeletal muscle loss.

Chronic subdural hematoma in patients over 65 years old: Results of using a postoperative cognitive evaluation to determine whether to permit return to driving

Background:

Chronic subdural hematoma (CSDH) is usually associated with good recovery with burr hole irrigation and postoperative drainage under local anesthesia. In Japan, traffic accidents by the elderly drivers over 65 years old are severely increasing, and there is no consensus on whether or not to return to driving after CSDH treatment. We perform a postoperative cognitive assessment. We retrospectively investigated the return-to-driving rate and associated factors.

Methods:

Of the 45 patients over 65 y.o. and who had usually driven, 30 patients wished to drive again. We performed tests composed of Mini-Mental State Examination (MMSE), line cancellation and line bisection task, Kohs block design test, trail making test (TMT)-A and B, Kana-hiroi test, Rey-Osterrieth complex figure test, and behavioral assessment of the dysexecutive syndrome, in order. When all tests’ scores were better than the cutoff values, we let patients drive again. When some of the scores were worse than the cutoff values, we reevaluated the patients at the outpatient every month. If the patients’ scores could not improve at the outpatient, we recommended them to stop driving.

Results:

Nineteen of 30 patients could return to driving. Worse MMSE, Kohs block design test, TMT-A, TMT-B scores, higher age, dementia, or consciousness disturbance as chief complaints were associated with driving disability.

Conclusion:

CSDH is known as treatable dementia. However, we should perform an objective cognitive assessment before discharge because only 63% of the patients over 65 y.o. who wished to drive could return to driving.

Postsurgical functional outcome prediction model using deep learning framework (Prediction One, Sony Network Communications Inc.) for hypertensive intracerebral hemorrhage

BACKGROUND

Reliable prediction models of intracerebral hemorrhage (ICH) outcomes are needed for decision-making of the treatment. Statistically making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on DL-based functional outcome prediction models for ICH outcomes after surgery. We herein made a functional outcome prediction model using DLframework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to original ICH score, ICH Grading Scale, and FUNC score.

METHODS

We used 140 consecutive hypertensive ICH patients' data in our hospital between 2012 and 2019. All patients were surgically treated. Modified Rankin Scale 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 100 patients training dataset and 40 patients validation dataset. Prediction One made the prediction model using the training dataset with 5-fold cross-validation. We calculated area under the curves (AUCs) regarding the outcome using the DL-based model, ICH score, ICH Grading Scale, and FUNC score. The AUCs were compared.

RESULTS

The model made by Prediction One using 64 variables had AUC of 0.997 in the training dataset and that of 0.884 in the validation dataset. These AUCs were superior to those derived from ICH score, ICH Grading Scale, and FUNC score.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the DL-based model was superior to those of previous statistically calculated models.

Temporal muscle thickness and area are an independent prognostic factors in patients aged 75 or younger with aneurysmal subarachnoid hemorrhage treated by clipping

BACKGROUND

Skeletal muscle mass is an important factor for various diseases' outcomes. As for its indicators, temporal muscle thickness (TMT) and temporal muscle area (TMA) on the head computed tomography are useful, and TMT and TMA were reported as potential prognostic factors for aneurysmal subarachnoid hemorrhage (SAH). We examined the clinical characteristics, including TMT and TMA, of SAH patients aged 75 or younger.

METHODS

We retrospectively investigated 127 SAH patients with all World Federation of Neurosurgical Societies (WFNS) grades and treated by clipping between 2009 and 2019. Clinical outcome was measured with the modified Rankin Scale (mRS) at 6 months, with favorable outcome defined as mRS 0-2. The associations between the clinical variables and the outcomes were analyzed.

RESULTS

The mean age was 60.6 (32-74) years, and 65% were women. The mean ± standard deviation of WFNS grade was 2.8 ± 1.4. TMT and TMA were larger in the favorable outcome group than the poor one. Multivariate analysis revealed that age, smoking, WFNS grade, and TMT or TMA were associated with favorable outcome. Receiver operating characteristic analysis found that the threshold of TMT was 4.9 mm in female and 6.7 mm in male, and that of TMA was 193 mm2 in female and 333 mm2 in male.

CONCLUSION

The odds ratios for TMT and TMA related to clinical outcome were lower than for smoking and WFNS grade; however, on multivariate analysis they remained independent prognostic factors in SAH patients aged 75 or younger treated by clipping. Further studies are needed to confirm these findings.

Measuring and Monitoring Skeletal Muscle Mass after Stroke: A Review of Current Methods and Clinical Applications

OBJECTIVES

Muscle mass at admission is important to survive stroke, and stroke-induced sarcopenia is a serious problem because of its poor prognosis. Muscle mass measurement and monitoring are essential for appropriate rehabilitation and nutrition management. However, few reviews are available about the muscle mass measurement and monitoring after stroke.

MATERIAL AND METHODS

Several methods are used to assess skeletal muscle mass in stroke, such as computed tomography (CT), ultrasound, bioelectrical impedance analysis, dual-energy X-ray absorptiometry, biomarkers, and anthropometrics. We summarized the current methods and clinical applications in stroke.

RESULTS

In stroke, a head CT is used to estimate muscle mass by measuring the temporal muscle. However, it can be conducted retrospectively due to radiation exposure. After stroke, limb muscle atrophy and diaphragm dysfunction are observed using ultrasound. However, ultrasound requires an understanding of the methods and skill. A bioelectrical impedance analysis can be used to assess muscle mass in patients after a stroke unless they have dynamic fluid changes. Dual-energy X-ray absorptiometry is used for follow-up after hospital discharge. Urinary titin N-fragment and serum C-terminal agrin fragment reflect muscle atrophy after stroke. Anthropometrics may be useful with limited resources.

CONCLUSIONS

We summarized the features of each measurement and proved the recent evidence to properly measure and monitor skeletal muscle mass after stroke.

Standard values for temporal muscle thickness in the Japanese population who undergo brain check-up by magnetic resonance imaging

BACKGROUND

Skeletal muscle mass is an important factor for various diseases' outcomes. The psoas muscle cross-sectional area on the abdominal computed tomography (CT), gait speed, and handgrip strength is used to measure it. However, it is difficult to measure the neurological patients' muscle mass or function because (1) we do not perform abdominal CT. (2) Such patients have impaired consciousness, gait disturbance, paresis, and need of rest. Temporal muscle thickness (TMT) on magnetic resonance imaging (MRI) is now attractive for skeletal muscle volume indicator, but the reference values are not established. We herein investigated the standard value of the Japanese TMT using the brain check-up database by MRI.

METHODS

We retrospectively investigated 360 Japanese individuals from two institutions between 2017 and 2019. We measured TMT on the T1-weighted images in the previously reported way. The associations between TMT and other variables were analyzed.

RESULTS

TMT of 214 women and 146 men, ranging from 35 to 84 years old, was investigated. TMT ranged from 3.69 to 16.90 mm. Mean TMT values were significantly higher in men compared to women except for the over 70-year-old cohort. TMT was correlated to weight and body mass index in both sexes.

CONCLUSION

This is the first retrospective study on the standard TMT values from the Japanese brain check-up database. Our results were just reference values, but these would be useful for further investigation in other neurosurgical and neurological diseases regarding muscle volume or sarcopenia.

High protein intake after subarachnoid hemorrhage improves oral intake and temporal muscle volume

BACKGROUND & AIMS

Dysphagia is a common sequela following stroke. Patients with subarachnoid hemorrhage (SAH) often develop atrophy of the temporal muscle, but its clinical significance remains unclear. This study aimed to investigate whether temporal muscle volume (TMV) is related to subsequent oral intake in patients with SAH and evaluate the predictors of temporal muscle atrophy.

METHODS

We performed a retrospective analysis of 60 SAH patients receiving enteral nutrition in the acute hospitalization phase at a single center between 2009 and 2019. The TMV was segmented automatically from computed tomography images and measured on admission and at week 2. Patients with a ≥20% TMV reduction were assigned to the atrophy group (n = 24) and those with a <20% TMV reduction were included in the maintenance group (n = 36). The patients' oral intake status was assessed at week 2 using the Food Intake LEVEL Scale (grade of 7-9 considered good ingestion), and the modified Rankin scale (mRS) was used at discharge (grade of 0-2 considered good prognosis). Additional data on age, sex, body mass index, severity of SAH, and protein intake were collected on day 4.

RESULTS

The maintenance group had significantly better oral intake and mRS scores compared to the atrophy group. TMV maintenance significantly affected oral intake at week 2 and the mRS score at discharge. Multivariable logistic regression analysis revealed that protein intake on day 4 significantly influenced the maintenance of TMV.

CONCLUSIONS

High protein nutrition in the acute stage of SAH contributes to temporal muscle maintenance and improves oral intake.

Evaluation of the Temporal Muscle Thickness as an Independent Prognostic Biomarker in Patients with Primary Central Nervous System Lymphoma

Simple Summary

Primary central nervous system lymphoma (PCNSL) is a rare brain tumor with an exceedingly poor outcome. Although some of the established prognostic parameters in PCNSL patients, such as age, blood-related parameters, or the involvement of deep brain structures, are objectively evaluable, the information about the patient’s physical condition is still based on the subjective perception of the attending physician. The thickness of the temporal muscle has previously shown to be a biomarker of skeletal muscle quantity and quality, and thus be a potential parameter reflecting sarcopenia, which is a main feature of cancer-related cachexia and a well-known prognostic marker in various disease entities. In the current study we show that temporal muscle thickness is an independent and objectively assessable parameter for outcome prognostication in PCNSL patients and may facilitate the selection and stratification of patients for treatment options or clinical trials in the future.

Abstract

In this study, we assessed the prognostic relevance of temporal muscle thickness (TMT), likely reflecting patient’s frailty, in patients with primary central nervous system lymphoma (PCNSL). In 128 newly diagnosed PCNSL patients TMT was analyzed on cranial magnetic resonance images. Predefined sex-specific TMT cutoff values were used to categorize the patient cohort. Survival analyses, using a log-rank test as well as Cox models adjusted for further prognostic parameters, were performed. The risk of death was significantly increased for PCNSL patients with reduced muscle thickness (hazard ratio of 3.189, 95% CI: 2–097–4.848, p < 0.001). Importantly, the results confirmed that TMT could be used as an independent prognostic marker upon multivariate Cox modeling (hazard ratio of 2.504, 95% CI: 1.608–3.911, p < 0.001) adjusting for sex, age at time of diagnosis, deep brain involvement of the PCNSL lesions, Eastern Cooperative Oncology Group (ECOG) performance status, and methotrexate-based chemotherapy. A TMT value below the sex-related cutoff value at the time of diagnosis is an independent adverse marker in patients with PCNSL. Thus, our results suggest the systematic inclusion of TMT in further translational and clinical studies designed to help validate its role as a prognostic biomarker.

Reliability and validity of measuring temporal muscle thickness as the evaluation of sarcopenia risk and the relationship with functional outcome in older patients with acute stroke

BACKGROUND

Pre-stroke sarcopenia associated with poor functional outcomes. However, diagnosis of pre-stroke sarcopenia is often difficult in patients with acute stroke. Thus, we investigated the reliability and validity of measuring temporal muscle thickness (TMT) as an indicator of sarcopenia risk and its relationship with functional outcome in older patients with acute stroke.

METHODS

We conducted a cross-sectional and longitudinal study of the patients with acute elderly stroke in a single neurosurgical hospital. We measured TMT manually using brain computed tomography (CT) by two examiners. Sarcopenia risk, malnutrition risk, inflammation, comorbidities, and modified Rankin Scale (mRS) scores at 3 months after stroke were additionally assessed. Inter-rater reliability of TMT was determined by calculating the intra-class correlation coefficient ([ICC] _2,1). Multiple linear regression analyses was used to determine whether sarcopenia risk was independently associated with TMT, and logistic regression was used to evaluate the relationship between TMT and poor functional outcome (mRS > 3).

RESULTS

A total 289 acute elderly stroke patients (163 men and 126 women; mean age: 76 years) were enrolled in this study. Regarding the reproducibility of TMT, good reliability was found; ICC_2,1 = 0.759 (95 % confidence interval = 0.705-0.804). Multiple linear regression analyses for TMT after adjusting for potential confounders showed that sarcopenia risk was independently associated with TMT in older patients with acute stroke (β = -0.138, p = 0.02). After adjusting for variables, disease severity and comorbidities were the only independent predictors for poor functional outcome, but not TMT.

CONCLUSIONS

TMT measurement using brain CT is a reliable and variable method to evaluate sarcopenia risk, but is not related to functional outcome in older patients with acute stroke.

Easily created prediction model using deep learning software (Prediction One, Sony Network Communications Inc.) for subarachnoid hemorrhage outcomes from small dataset at admission

BACKGROUND

Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes are needed for decision-making of the treatment. SAFIRE score using only four variables is a good prediction scoring system. However, making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on prediction models for SAH outcomes using DL. We herein made a prediction model using DL software, Prediction One (Sony Network Communications Inc., Tokyo, Japan) and compared it to SAFIRE score.

METHODS

We used 153 consecutive aneurysmal SAH patients data in our hospital between 2012 and 2019. Modified Rankin Scale (mRS) 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 102 patients training dataset and 51 patients external validation dataset. Prediction one made the prediction model using the training dataset with internal cross-validation. We used both the created model and SAFIRE score to predict the outcomes using the external validation set. The areas under the curve (AUCs) were compared.

RESULTS

The model made by Prediction One using 28 variables had AUC of 0.848, and its AUC for the validation dataset was 0.953 (95%CI 0.900-1.000). AUCs calculated using SAFIRE score were 0.875 for the training dataset and 0.960 for the validation dataset, respectively.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the model was not so inferior to those of previous statistically calculated prediction models.

The dataset on the characteristics of the intracerebral hemorrhage patients treated by endoscopic hematoma removal or craniotomy

These data present the characteristics of 148 intracerebral hemorrhage (ICH) patients surgically treated. We retrospectively collected data from the medical records of Suwa Red Cross Hospital, including neurological and physiological symptoms, laboratory data, radiological data on admission, complication rate, Glasgow Coma Scale scores on admission or postoperative day 7, and modified Rankin Scale scores at 6 months. Our two articles on the endoscopic hematoma removal and craniotomy for ICH were based on these data [1,2]. This dataset includes detailed laboratory data and radiological features, and it would be useful for reference value for other neurosurgeons or further analysis.

Lower total protein and absence of neuronavigation are novel poor prognostic factors of endoscopic hematoma removal for intracerebral hemorrhage

OBJECTIVES

Endoscopic hematoma removal is widely performed for the treatment of intracerebral hemorrhage. We investigated the factors related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal.

MATERIALS AND METHODS

From 2013 to 2019, we retrospectively analyzed 75 consecutive patients with hypertensive intracerebral hemorrhage who underwent endoscopic hematoma removal. Their characteristics, including neurological symptoms, laboratory data, and radiological findings were investigated using univariate and multivariate analysis. Complications during hospitalization, Glasgow Coma Scale (GCS) score on day 7, and modified Rankin Scale (mRS) score at 6 months were considered as treatment outcomes.

RESULTS

The mean age of the patients (33 women, 42 men) was 71.8 (36-95) years. Mean GCS scores at admission and on day 7 were 10.3 ± 3.2 and 11.7 ± 3.8, respectively. The mean mRS score at 6 months was 3.8 ± 1.6, and poor outcome (mRS score ranging from 3 to 6 at 6 months) in 53 patients. Rebleeding occurred in 4 patients, and other complications in 15 patients. Multivariate analysis revealed that older age, hematoma in the basal ganglia, lower total protein level, higher glucose level, and absence of neuronavigation were associated with poor outcomes. Of the 75 patients, 9 had cerebellar hemorrhages, and they had relatively favorable outcomes compared to those with supratentorial hemorrhages.

CONCLUSION

Several factors were related to the prognosis of intracerebral hemorrhage after endoscopic hematoma removal. Lower total protein level at admission and absence of neuronavigation were novel factors related to poor outcomes of endoscopic hematoma removal for intracerebral hemorrhage.

Endoscopic hematoma removal of supratentorial intracerebral hemorrhage under local anesthesia reduces operative time compared to craniotomy

The surgical efficacy for supratentorial intracerebral hemorrhage (ICH) remains unknown. We compared the advantages of the widely practiced endoscopic hematoma removal under local anesthesia with that of craniotomy under general anesthesia for ICH. We also focused on our novel operative concept of intentional hematoma leaving technique to avoid further damage to the brain. We retrospectively analyzed 134 consecutive patients (66 endoscopies and 68 craniotomies) who were surgically treated for supratentorial ICH. The characteristics of the 134 patients were as follows: The median (interquartile range) age was 73 (61-82) years. The median Glasgow Coma Scale scores at admission, on day 7, and the median modified Rankin Scale (mRS) score at 6 months were 10 (7-13), 13 (10-14), and 4 (3-5) respectively. The statistical comparison revealed there were no differences in GCS score on day seven between the endoscopy 13 (12-14) and craniotomy group 12 (9-14). No differences were observed in mRS scores at 6 months between the endoscopy 4 (2-5) and craniotomy group 4 (3-5). However, the patients treated with our technique tended to have favorable outcomes. Multivariate analysis revealed the operative time was significantly decreased in the endoscopy group compared to the craniotomy group (p < 0.001).

Temporal muscle thickness and area with various characteristics data of the patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling

These data present the characteristics of patients with subarachnoid hemorrhage who underwent endovascular coiling. We retrospectively collected data from the medical records of Iwaki City Medical Center including physiological symptoms, laboratory data, radiological data on admission, and modified Rankin Scale scores at 6 months. Our article entitled “Temporal Muscle as an Indicator of Sarcopenia is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale at 6 Month of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling” was based on these data [1]. We previously reported similar small dataset of elderly patients with subarachnoid hemorrhage who underwent surgical clipping [2], [3]. However, remarkably, this is the largest and the first dataset on temporal muscle thickness or area of patients of all ages with subarachnoid hemorrhage who underwent endovascular coiling, not surgical clipping.

Sarcopenia in Neurological Patients: Standard Values for Temporal Muscle Thickness and Muscle Strength Evaluation

Temporal muscle thickness (TMT) was investigated as a novel surrogate marker on MRI examinations of the brain, to detect patients who may be at risk for sarcopenia. TMT was analyzed in a retrospective, normal collective cohort (n = 624), to establish standard reference values. These reference values were correlated with grip strength measurements and body mass index (BMI) in 422 healthy volunteers and validated in a prospective cohort (n = 130) of patients with various neurological disorders. Pearson correlation revealed a strong association between TMT and grip strength (retrospective cohort, ρ = 0.746; p < 0.001; prospective cohort, ρ = 0.649; p < 0.001). A low or no association was found between TMT and age (retrospective cohort, R² correlation coefficient 0.20; p < 0.001; prospective cohort, ρ = −0.199; p = 0.023), or BMI (retrospective cohort, ρ = 0.116; p = 0.042; prospective cohort, ρ = 0.227; p = 0.009), respectively. Male patients with temporal wasting and unintended weight loss, respectively, showed significantly lower TMT values (p = 0.04 and p = 0.015, unpaired t-test). TMT showed a high correlation with muscle strength in healthy individuals and in patients with various neurological disorders. Therefore, TMT should be integrated into the diagnostic workup of neurological patients, to prevent, delay, or treat sarcopenia.

Temporal Muscle as an Indicator of Sarcopenia is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale Score at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling

OBJECTIVE

Sarcopenia is defined as the loss of skeletal muscle mass and is considered an important factor for clinical outcomes in various diseases. Recent studies have shown that temporal muscle thickness (TMT) and area (TMA) can be novel indicators of sarcopenia. We examined clinical characteristics, including TMT and TMA, of patients with subarachnoid hemorrhage (SAH) treated by endovascular coiling.

METHODS

A retrospective analysis of 298 patients with SAH who were treated with endovascular coiling from 2009 to 2019 was conducted. Their premorbid modified Rankin Scale (mRS) score was 0-2. The association between the factors and Hunt and Kosnik (H-K) grades on admission and that between the clinical variables and mRS scores 6 months after the operation were analyzed.

RESULTS

In all 298 patients with SAH, Fisher group 4 and TMA <200 mm² were independently associated with H-K grade III-V on admission in the multivariate analysis. In 254 patients with H-K grades I-III on admission, age, H-K grade III, presence of ventriculoperitoneal shunt, presence of postoperative complications, and TMA <200 mm² were independent factors related to poor outcomes in the multivariate analysis.

CONCLUSIONS

The H-K grade on admission was independently associated with TMA. The mRS score 6 months after aneurysm treatment in patients with H-K grades I-III was also independently associated with TMA. Sarcopenia could be one of a few modifiable factors that prevent severe symptoms of SAH and improve outcomes after coiling by strengthened nutrition and physical activity.

Temporal muscle thickness and area with various characteristics data of the elderly patients over 75 with aneurysmal subarachnoid haemorrhage whose World Federation of Neurosurgical Societies grade were I to III

This data informs about the characteristics of elderly patients over 75 with subarachnoid hemorrhage whose World Federation of Neurosurgical Societies (WFNS) grade were I to III. We retrospectively collected data from medical records in our hospital regarding physiological symptoms, laboratory data, radiological data on admission, and outcomes at discharge. Our article entitled “Clinical characteristics of aneurysmal subarachnoid hemorrhage in the elderly over 75; would temporal muscle be a potential prognostic factor as an indicator of sarcopenia? [1]” was based on this data. Remarkably, this is the first dataset on temporal muscle thickness/area and other characteristics of elderly patients over 75 with subarachnoid hemorrhage whose WFNS grade were I to III. Temporal muscle thickness and area were large in the elderly patients with SAH whose outcome were favorable.