Subarachnoid hemorrhage due to pituitary adenoma apoplexy-case report and review of the literature

Pituitary apoplexy (PA) may be complicated by development of subarachnoid hemorrhage (SAH). We conducted a literature review to evaluate the rate of PA-associated tumor rupture and SAH. We conducted a systematic literature search (PubMed, Web of Science, Medline) for patients with PA-associated SAH and report a case SAH following PA. Suitable articles, case series, and case reports were selected based on predefined criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). We reviewed included publications for clinical, radiological, surgical, and histopathological parameters.We present the case of a patient with PA developing extensive SAH whilst on the MRI who underwent delayed transsphenoidal resection. According to our literature review, we found 55 patients with a median age of 46 years; 18 (32.7%) were female. Factors associated with PA-related SAH were hypertension, diabetes mellitus, prior trauma, anticoagulant, and/or antiplatelet therapy. The most common presenting symptoms included severe headache, nausea and/or vomiting, impaired consciousness, and meningeal irritation. Acute onset was described in almost all patients. Twenty-two of the included patients underwent resection. In patients with available outcome, 45.1% had a favorable outcome, 10 (19.6%) had persisting focal neurological deficits, 7 developed cerebral vasospasms (12.7%), and 18 (35.3%) died. Mortality greatly differed between surgically (9.1%) and non-surgically (44.8%) treated patients. PA-associated SAH is a rare condition developing predominantly in males with previously unknown macroadenomas. Timely surgery often prevents aggravation or development of severe neuro-ophthalmological defects and improves clinical outcome.

Laser Interstitial Thermal Therapy in a Large Thalamic Glioma with Long-Term Remission: A Case Report

INTRODUCTION

Thalamic gliomas pose a particular therapeutic challenge as complete resection is rarely achieved due to the deep and eloquent location. Laser interstitial thermal therapy (LITT) may provide a valuable management option for deep-seated gliomas that are not accessible with open surgery.

CASE PRESENTATION

A 57-year-old woman presented with a rapidly progressive large thalamic glioblastoma. Opting for full ablation, we selected a challenging trajectory to maximize the possibility of full ablation. At 2.4 cm in diameter, the tumour was larger than recommended for LITT; nevertheless, three laser ablations along a single trajectory resulted in macroscopic ablation without complications. Adjuvant radio-chemotherapy was started soon after surgery without radiological recurrence 1.5 years after the initial surgery.

CONCLUSION

This case demonstrates the potential when thalamic tumours are managed with timely LITT treatment and meticulous trajectory planning. Moreover, it highlights the need for close interdisciplinary management with neurosurgeons, neuropathologists, neuroradiologists, and neurooncologists.

Posterior Fossa Approaches Using the Leksell Vantage Frame with a Virtual Planning Approach in a Series of 10 Patients-Feasibility, Accuracy, and Pitfalls

The open-face design of the Leksell Vantage frame provides many advantages. However, its more rigid, contoured design offers less flexibility than other frames. This is especially true for posterior fossa approaches. This study explores whether these limitations can be overcome by tailored frame placement using a virtual planning approach. The posterior fossa was accessed in ten patients using the Leksell Vantage frame. Frame placement was planned with the Brainlab Elements software, including a phantom-based (virtual) pre-operative planning approach. A biopsy was performed in all patients; in four, additional laser ablation surgery was performed. The accuracy of virtual frame placement was compared to actual frame placement. The posterior approach was feasible in all patients. In one case, the trajectory had to be adjusted; in another, the trajectory was switched from a right- to a left-sided approach. Both cases showed large deviations from the initially planned frame placement. A histopathological diagnosis was achieved in all patients. The new Leksell Vantage frame can be used to safely target the posterior fossa with a high diagnostic success rate and accuracy. Frame placement needs to be well-planned and executed. This can be facilitated using specific software solutions as demonstrated.

Sotorasib Shows Intracranial Activity in Patients with <b><i>KRAS G12C-</i></b>Mutated Adenocarcinoma of the Lung and Untreated Active Brain Metastases

Treatment with sotorasib has shown intracranial complete responses and continued intracranial stabilization in <i>KRAS G12C-</i>mutated non-small-cell lung carcinoma (NSCLC) patients with previously treated, stable brain metastases in a post hoc analysis of the ongoing CodeBreaK 100 trial. We present the case of a patient with <i>KRAS G12C-</i>mutant adenocarcinoma of the lung with active untreated brain metastases with a nearly complete intracranial response only 6 weeks after start of sotorasib illustrating the benefit of sotorasib in patients with active, previously untreated brain metastases in <i>KRAS G12C-</i>mutated NSCLC.

TMOD-20. CASE REPORT: THE ODYSSEY TO THE RIGHT DIAGNOSIS. SURPRISING GLIOBLASTOMA MIMICS

A 57-year-old female presented at the emergency room with acute onset aphasia but unremarkable cCT (incl. angiography and perfusion). Suspecting an ischemic stroke, she received thrombolysis with quick recovery of aphasia. Afterwards, myoclonic jerks of the face and right arm occurred leading to anticonvulsant therapy. Follow-up cMRI surprisingly demonstrated swollen T2w-hyperintense and Gd-enhancing left limbic, temporal and frontal lobes. Suspected herpes-simplex-encephalitis was treated with aciclovir despite unremarkable CSF results (no pleocytosis, no BBB disruption, negative HSV-PCR) on day 2 and follow-up (day 5). Due to persisting cognitive deficits, autoimmune limbic encephalitis was suspected, and intravenous immunoglobulin therapy was added. Three weeks later, she experienced new neurological symptoms (weakness, blurred vision, vomiting, headache). Follow-up brain MRI demonstrated a massive increase of multifocal Gd-enhancing lesions. Partial resection revealed the diagnosis of an IDH-wildtype glioblastoma (GB). Next generation oncogene panel testing demonstrated a GOPC-ROS1 fusion which is rarely found in GB. Due to the gliomatosis-like infiltration of both hemispheres, radiotherapy was deemed to be too toxic. Instead, she received two cycles of lomustine in absence of a MGMT-promotor methylation. Two months later cMRI showed a symptomatic second multilocular progression. 2nd-line therapy with a ROS-inhibitor was rejected, whereupon she died five weeks later. Our case is in several aspects peculiar: It demonstrates that rare GB-mimics (i.e. HSV- and autoimmune limbic encephalitis) can only be ruled out in a fast manner by brain biopsy. Watchful waiting may neglect fast progression of GB leading to the inability to provide optimal treatment (i.e. radiotherapy). Thrombolysis is strictly contraindicated in primary brain tumors, but was unharmful in our case most probably to the early tumor stage without relevant neoangiogenesis. Rare genetic abnormalities like ROS1-fusions which are reported mostly in childhood glioblastoma may be present and serve as a therapeutic target also in adult GB.

Time-resolved characterization of primary emissions from residential wood combustion appliances

Primary emissions from a log wood burner and a pellet boiler were characterized by online measurements of the organic aerosol (OA) using a high-resolution time-of-flight aerosol mass spectrometer (HR-TOF-AMS) and of black carbon (BC). The OA and BC concentrations measured during the burning cycle of the log wood burner, batch wise fueled with wood logs, were highly variable and generally dominated by BC. The emissions of the pellet burner had, besides inorganic material, a high fraction of OA and a minor contribution of BC. However, during artificially induced poor burning BC was the dominating species with ∼80% of the measured mass. The elemental O:C ratio of the OA was generally found in the range of 0.2-0.5 during the startup phase or after reloading of the log wood burner. During the burnout or smoldering phase, O:C ratios increased up to 1.6-1.7, which is similar to the ratios found for the pellet boiler during stable burning conditions and higher than the O:C ratios observed for highly aged ambient OA. The organic emissions of both burners have a very similar H:C ratio at a given O:C ratio and therefore fall on the same line in the Van Krevelen diagram.

Oxidative potential of logwood and pellet burning particles assessed by a novel profluorescent nitroxide probe

This study reports the potential toxicological impact of particles produced during biomass combustion by an automatic pellet boiler and a traditional logwood stove under various combustion conditions using a novel profluorescent nitroxide probe, BPEAnit. This probe is weakly fluorescent but yields strong fluorescence emission upon radical trapping or redox activity. Samples were collected by bubbling aerosol through an impinger containing BPEAnit solution, followed by fluorescence measurement. The fluorescence of BPEAnit was measured for particles produced during various combustion phases: at the beginning of burning (cold start), stable combustion after refilling with the fuel (warm start), and poor burning conditions. For particles produced by the logwood stove under cold-start conditions, significantly higher amounts of reactive species per unit of particulate mass were observed compared to emissions produced during a warm start. In addition, sampling of logwood burning emissions after passing through a thermodenuder at 250 degrees C resulted in an 80-100% reduction of the fluorescence signal of the BPEAnit probe, indicating that the majority of reactive species were semivolatile. Moreover, the amount of reactive species showed a strong correlation with the amount of particulate organic material. This indicates the importance of semivolatile organics in particle-related toxicity. Particle emissions from the pellet boiler, although of similar mass concentration, were not observed to lead to an increase in fluorescence signal during any of the combustion phases.

Dual-energy CT with tin filter technology for the discrimination of renal lesion proxies containing blood, protein, and contrast-agent. An experimental phantom study

PURPOSE

To differentiate proxy renal cystic lesions containing protein, blood, iodine contrast or saline solutions using dual-energy CT (DECT) equipped with a new tin filter technology (TFT).

MATERIALS AND METHODS

70 proxies (saline, protein, blood and contrast agent) were placed in unenhanced and contrast-enhanced kidney phantoms. DECT was performed at 80/140 kV with and without tin filtering. Two readers measured the CT attenuation values in all proxies twice. An 80/140 kV ratio was calculated.

RESULTS

All intra- and interobserver agreements were excellent (r = 0.93-0.97; p < 0.001). All CT attenuation values were significantly higher in the enhanced than in the unenhanced setting (p < 0.05; average increase, 12.5 ± 3.6 HU), while the ratios remained similar (each, p > 0.05). The CT attenuation of protein, blood and contrast agent solution differed significantly with tin filtering (p < 0.01-0.05). Significant differences were found between the ratios of protein and blood compared to contrast medium solution (each, p < 0.05) and between the ratios of protein and blood in both phantoms with tin filtering (each, p < 0.05).

CONCLUSION

DECT allows discrimination between a proxy renal lesion containing contrast agent and lesions containing protein and blood through their different attenuation at 80 kV and 140 kV. Further discrimination between protein and blood containing proxies is possible when using a tin filter.

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis

OBJECTIVE

in diabetic patients with critical limb ischaemia (CLI) an inferior success rate following infrainguinal bypass surgery is quite often suggested. The aim of this retrospective analysis was, therefore, to evaluate the graft patency and, particularly, the clinical outcome at 1 year in diabetic compared with non-diabetic patients.

MATERIAL AND METHODS

two hundred and eleven patients (diabetics 94; non-diabetics 117) with femorodistal reconstruction for CLI were studied. Groups were comparable with regard to the Fontaine classification, the distribution of vascular risk factors, graft material, distal anastomosis site, and the angiographic runoff grading.

RESULTS

diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004).

CONCLUSIONS

our preliminary results support the view that infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients.

[Simultaneous surgical and technical catheter revascularization of the lower extremity]

Intraoperative balloon angioplasty was performed on 17 patients and 19 arteries undergoing a concomitant vascular reconstructive procedure during the past 24 months. All angioplasties were performed with the aid of digital substraction angiography (DSA) in the operating room. The primary purpose of intraoperative angioplasty was mainly to increase outflow (18) or inflow (1) in conjunction with a planned vascular procedure. Dilatation obviated the need of more extensive vascular reconstruction in these elderly patients.

Differential regulation of proenkephalin gene expression by estrogen in the ventromedial hypothalamus of male and female rats: implications for the molecular basis of a sexually differentiated behavior

The ventrolateral aspect of the ventromedial hypothalamic nucleus (VL-VM) contains many estrogen-concentrating neurons which mediate estrogen facilitation of reproductive behavior. Previous studies have shown that estrogen treatment increases proenkephalin (PE) gene expression in neurons of the VL-VM in ovariectomized female rats, and that enkephalin peptides may stimulate lordosis behavior. To determine whether there is a sex difference in steroid hormone regulation of PE gene expression we have examined the effects of estrogen and testosterone on PE mRNA levels in male rats. Slot blot hybridization analysis of RNA isolated from the ventromedial hypothalamus indicated that estrogen treatment increased PE mRNA levels in the VL-VM of ovariectomized female rats (2.2-fold), but had no measurable effect on PE mRNA levels in gonadectomized males. Testosterone treatment of gonadectomized males also had no effect on PE gene expression. To determine whether the sex difference in estrogen-inducibility of PE gene expression is due to the developmental effects of gonadal steroids, we have investigated the effect of estrogen on PE mRNA levels in the VL-VM of neonatally androgenized female rats. Unlike the genetic male, the androgenized females responded to estrogen treatment with a female-typical increase in PE mRNA levels (1.7-fold). Further, although the androgenized rats clearly exhibited signs of defeminization, they did exhibit estrogen-facilitated lordosis behavior when tested with manual stimulation. The PE mRNA induction in estrogen-treated androgenized rats correlated well with the lordosis scores obtained by manual stimulation testing. These results indicate that estrogen regulation of PE gene expression in the VL-VM is sexually differentiated and support the hypothesis that the enkephalinergic neurons of the VL-VM are involved in the regulation of female reproductive behavior.

[Percutaneous transluminal coronary angioplasty: determination of left ventricular function in physical stress using intravenous digital subtraction angiocardiography]

24 patients with coronary artery disease underwent intravenous digital subtraction angiocardiography at rest and during exercise before and after percutaneous transluminal coronary angioplasty (PTCA). Before PTCA mean pulmonary artery pressure increased pathologically in 20 patients (on average from 22 +/- 4 to 40 +/- 9 mm Hg, p less than 0.001). The increase in cardiac index from 4.2 +/- 1.3 to 6.2 +/- 2.01 I X min-1 X m-2 (p less than 0.01) was achieved by an increase in heart rate from 77 +/- 13 to 119 +/- 16 min-1 (p less than 0.001) as stroke volume remained unchanged during exercise (52 +/- 14 ml X m-2, resting value: 53 +/- 13 ml X m-2). Though end-systolic volume increased from 32 +/- 11 to 41 +/- 13 ml X m-2 (p less than 0.001) and ejection fraction fell from 63 +/- 8% to 56 +/- 10% (p less than 0.005), stroke volume remained unchanged due to an enhanced diastolic filling (EDVI: 86 +/- 19 ml X m-2 at rest, 92 +/- 18 ml X m-2 during exercise, p less than 0.001). After angiographically successful PTCA in 21 of 24 patients average mean pulmonary artery pressure during exercise remained pathologically elevated (36 +/- 9 mm Hg, no significant difference from value before PTCA). It normalized in only 6 of 17 patients. On the other hand there was a marked improvement of left ventricular systolic performance. Ejection fraction during exercise (65 +/- 11%) was higher than before PTCA (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Litter deficits of socially stressed and low status hamster dams

The effects of maternal social stress, induced by pairing pregnant females, and social status, measured by agonistic behavior within pairs, on pup development was investigated in hamsters. Using litters from untreated first pregnancies as a control, 40 dams were housed either alone or paired with another dam during their second pregnancy. Within a pair, the dam with more aggressive and fewer defensive responses than the other was considered dominant. Compared to their first unpaired litters, second litters of paired dams were smaller in number. Comparisons among second litters showed that paired dams, especially submissive dams, had fewer pups than unpaired dams. It was concluded that both maternal social stress and low status increase intrauterine mortality.

[Left ventricular function at rest and during exercise in patients with arterial hypertension. Studies using digital subtraction angiocardiography]

Using digital subtraction angiography, left ventricular function and pulmonary artery pressure at rest and during submaximal exercise (98 +/- 33 watts) were examined in 25 patients with systemic hypertension. All patients had normal coronary arteries and a normal left ventricular function at rest. Heart rate increased in all patients (from 82 +/- 14 to 134 +/- 20 min-1, p less than 0.001). Systolic blood pressure also increased significantly in all patients (from 153 +/- 12 to 190 +/- 14 mmHg, p less than 0.001). End-diastolic and end-systolic volumes did not change on average (89 +/- 22 and 87 +/- 19 ml/m2, 28 +/- 8 and 28 +/- 10 ml/m2, respectively), neither did stroke volume nor ejection fraction (61 +/- 18 and 59 +/- 16 ml/m2, 68 +/- 7 and 67 +/- 9%, respectively). The increase in end-systolic volumes and concomitantly the decrease in ejection fraction during exercise in 8 patients points to an impairment of left ventricular function. This effect is frequently found in ventricles with less distinct hypertrophy. Cardiac index increased in each patient (from 5.1 +/- 2.1 to 8.2 +/- 2.9 I/min/m2, p less than 0.001). This is caused by the increase in heart rate while stroke volume remains unchanged. Mean pulmonary artery pressure increased in all patients from 19 +/- 6 to 35 +/- 10 mmHg on average (p less than 0.001). A pathologic increase could be observed in 18 patients. There was no correlation to angiographic parameters of left ventricular function. The exercise test was stopped in 12 patients mainly because of dyspnea. In 11 of these patients a pathologic increase of mean pulmonary artery pressure was found. As in these patients the angiographic parameters of left ventricular function were normal, the increase in pulmonary pressure is related to an impairment of diastolic function caused by hypertrophy.

[Digital subtraction angiocardiography: accuracy of measuring left ventricular wall thickness and wall volume during intravenous contrast media injection]

A comparison of left ventricular wall thickness and wall volume determined by intravenous digital subtraction angiocardiography and by conventional left ventricular angiocardiography was performed by linear regression analysis: wall thickness: WDDSA = 0.90 X WDLV , Syx = +/- 0.16 cm, r = 0.74; wall volume: WVOLDSA = 0.87 X WVOLLV , Syx = +/- 48 ml, r = 0.85. Compared to the deviation and scatter of corresponding data measured from two consecutive beats in conventional left ventricular angiocardiographies , the error of determination of wall thickness and wall volume, determined by intravenous digital subtraction angiocardiography, is more pronounced. The regression analysis of wall volumes under rest and bicycle exercise evaluated by digital subtraction angiocardiography revealed a similar inaccuracy ( Syx = +/- 46 ml). This is due to faults in recognition of the inner and outer contours of left ventricular wall. Our results show that measurements of left ventricular wall thickness and wall volumes by means of intravenous digital subtraction angiocardiography can only be performed with greater deviations compared to conventional left ventricular angiocardiograms.

[Reliability of digital subtraction angiocardiography for the evaluation of left ventricular function and physical stress]

The reliability of determinations of left ventricular dimensions from digital subtraction angiocardiographies during exercise using intravenous injection of contrast material was proved in 20 patients. All angiocardiograms could be analyzed qualitatively and quantitatively only by means of the time-interval-difference (TID-) mode. Compared with other mask modes the superiority of the TID-mode results from the close temporal relationship between mask and contrasted frame. Thus, changes in position and brightness of the background structures are small, and left ventricular contours can be determined accurately despite intense respiratory movements. The intra-observer variability of determinations of end-diastolic and end-systolic volumes was +/- 12 ml (i.e. 7.5% of the mean value), corresponding inter-observer variability was +/- 24 ml (i.e. 17% of the mean value), respectively. Intra-observer deviation in determining ejection fraction was 2.8% (i.e. 4.5% of the mean value). The intra-observer variability in determining left ventricular axes was basal +/- 0.40 cm (i.e. 7% of the mean value), equatorial +/- 0.73 cm (i.e. 13% of the mean value) and apical +/- 0.34 cm (i.e. 8% of the mean value). Deviations of corresponding circumferential fiber shortening rates were basal +/- 0.22 s-1 (i.e. 14% of the mean value), equatorial +/- 0.32 s-1 (i.e. 22% of the mean value), and apical +/- 0.18 s-1 (i.e. 13% of the mean value). The results show that left ventricular dimensions can be determined accurately from intravenous angiocardiograms during exercise using digital subtraction angiocardiography.

[Digital subtraction angiocardiography: accuracy of left ventricular volume determination using intravenous injection of contrast medium]

The usefulness and accuracy of intravenous digital subtraction angiography of the left ventricle was proved by comparison with conventional left ventricular angiocardiography. During heart catheterization two cineangiograms were performed in 20 patients at rest: one with direct injection of contrast medium into the left ventricle and the other with intravenous injection. The intravenous angiocardiograms were processed by a hardwired digital image-processing system designed by our own group. Image enhancement was obtained by subtracting a mask image from the contrasted image of the left ventricle. The utility of four different mask modes was examined by correlating end-diastolic and end-systolic volumes determined from conventional and intravenous digital subtraction angiocardiograms of the left ventricle respectively. Reliable quantitative results could only be achieved by obtaining mask and contrasted images from the same phase of the cardiac cycle. Using these special mask modes, the standard deviations of the residuals amounted to +/- 33 and +/- 36 ml respectively. The results show that intravenous digital subtraction angiocardiography allows a quantitative determination of left ventricular volumes at rest.

[Measurement and analysis of environmental noise]

In the assessment of community noise, it is important to determine the noise conditions responsible for the disturbance. This can be done with knowledge of the operating conditions and with help of the time history of the noise over an extended period. This information must be gathered in consideration of the appropriate standards and regulations. The spectral distribution of the noise as well as its time history are measured. For noise with impulsive character or containing pure tone components, a factor is added. Psychological factors must be considered. As noise criterion, the corresponding immission limits are applied. The problems of establishing such limits and the most important noise abatements measures are discussed.

Return of EEG activity after electrocerebral silence: two case reports

Two cases, both children, are described, in which there was a return of the electroencephalogram after a period of electrocerebral silence. One child survived for six weeks. Electroencephalographic technique and instrumentation adequately excluded non-cerebral potentials as a source of confusion in the second case. Hypothermia and drug overdosage, known to reversibly depress the electroencephalogram, were not present in either case. The return of EEG activity was associated with improvement in neurological status. It is concluded that the EEG should always be repeated after electrocerebral silence before the determination of cerebral death, and that the applicability of adult criteria of brain death to children is questionable.