BRAF-mutated suprasellar glioblastoma mimicking craniopharyngioma: illustrative case

BACKGROUND

Suprasellar masses commonly include craniopharyngiomas and pituitary adenomas. Suprasellar glioblastoma is exceedingly rare with only a few prior case reports in the literature. Suprasellar glioblastoma can mimic craniopharyngioma or other more common suprasellar etiologies preoperatively.

OBSERVATIONS

A 65-year-old male with no significant history presented to the emergency department with a subacute decline in mental status. Work-up revealed a large suprasellar mass with extension to the right inferior medial frontal lobe and right lateral ventricle, associated with significant vasogenic edema. The patient underwent an interhemispheric transcallosal approach subtotal resection of the interventricular portion of the mass. Pathological analysis revealed glioblastoma, MGMT partially methylated, with a BRAF V600E mutation.

LESSONS

Malignant glioblastomas can mimic benign suprasellar masses and should remain on the differential for a diverse set of brain masses with a broad range of radiological and clinical features. For complex cases accessible from the ventricle where the pituitary complex cannot be confidently preserved via a transsphenoidal approach, an interhemispheric approach is also a practical initial surgical option. In addition to providing diagnostic value, molecular profiling may also reveal therapeutically significant gene alterations such as BRAF mutations.

Initial experience with transcarotid arterial revascularization with flow reversal in the management of symptomatic carotid stenosis

OBJECTIVE

The aim of this study was to evaluate the efficacy of transcarotid arterial revascularization (TCAR) as a viable intervention in the treatment of symptomatic carotid artery stenosis.

METHODS

The authors performed a retrospective review of prospectively collected data of the first 62 consecutive patients treated at Rhode Island Hospital in Providence, Rhode Island, who underwent a TCAR for symptomatic carotid artery stenosis between November 11, 2020, and March 31, 2022. Relevant demographic, comorbidity, and perioperative data were extracted through retrospective chart review. Patients with asymptomatic carotid artery stenosis were excluded. The authors also evaluated patients using pertinent physiological and anatomical high-risk criteria as described in the ROADSTER trial. Risk factors were aggregated to form a composite risk total for every patient. The primary outcome of this study was the 30-day adverse outcome rate of stroke, myocardial infarction, and/or death. Periprocedural stroke was identified by clinical symptoms and radiographic findings. Secondary endpoints included device and procedural success, 30-day mortality, 30-day stroke rate, and postoperative complications.

RESULTS

The authors analyzed the first 62 patients with > 50% symptomatic carotid artery stenosis who underwent TCAR at their institution. The mean age of the cohort was 71.5 years, and the cohort was predominantly male (67.7%). The most common high-risk medical criteria were age older than 75 years (45.3%) and severe coronary artery disease (13.6%). The most common anatomical high-risk criteria were high bifurcation (35.1%) and contralateral stenosis requiring treatment within 30 days (15.8%). Fifty percent of patients had at least 1 medical high-risk criterion, 50% had at least 1 anatomical risk criterion, and 82% of patients had 2 or more high-risk criteria of any kind. Among this group, all patients (100%) underwent successful revascularization, with 1 (1.6%) requiring intraprocedural conversion to carotid endarterectomy. Postprocedurally, there was 1 nondisabling stroke (1.6%) and 3 deaths (4.8%) within 30 days of the procedure, with only 1 death directly attributable to the procedure. One patient (1.6%) experienced a neck hematoma. In total, 4 patients (6.5%) experienced a major complication. The overall complication rate was 8.0%.

CONCLUSIONS

The authors' initial experience with TCAR suggests that it might provide an effective alternative to carotid endarterectomy and carotid artery stenting in the management of symptomatic carotid stenosis in patients with high-risk anatomical and medical characteristics.

Dual antiplatelet use in the management of COVID-19 associated acute ischemic stroke reocclusion

INTRO

SARS-CoV-2 (COVID-19) infection is associated with acute ischemic stroke (AIS), which may be due to a prothrombotic state. Early reports have suggested high rates of reocclusion following mechanical thrombectomy (MT) with poor radiographic and clinical outcomes. We report our early experience using intra-procedural antithrombotics to address SARS-CoV-2 reocclusion.

METHODS

We identified 6 patients that experienced early reocclusion after MT for COVID-19-associated AIS through retrospective chart review abstracting their basic demographics, COVID-19 status, and stroke management. All these patients were treated after reocclusion with aspirin and cangrelor intra-procedurally, the latter of which was converted to ticagrelor post-procedurally. Some patients additionally received argatroban infusion intraprocedurally.

RESULTS

Mean age was 54. There were 3 post-procedural and 3 intra-procedural re-occlusions. After repeat thrombectomy and treatment with aspirin and cangrelor, those with post-procedure reocclusion did not show further reocclusion, while those with intra-procedural reocclusion showed radiographic improvement with intraprocedural cangrelor administration. Outcomes for these patients were poor, with a median mRS of 4. Two patients developed petechial hemorrhage of their stroke which was managed conservatively, and one developed a retroperitoneal hemorrhage from femoral access requiring transfusion. There were no patients who developed new parenchymal hematomas.

CONCLUSION

COVID-19 AIS may be associated with a hypercoagulable state which risks malignant reocclusion complicating MT. We found antithrombotic treatment periprocedural cangrelor with or without argatroban transitioned to oral aspirin with ticagrelor to be a viable method for management of these patients.

Diffuse-type tenosynovial giant cell tumor between the suboccipital bone and posterior C1 arch: illustrative case

BACKGROUND

Tenosynovial giant cell tumor (TGCT) occurs most commonly in the appendicular skeleton and is only rarely found in the vertebral column. Lesions of the craniocervical junction are particularly rare, with only 4 cases reported in the literature. The authors describe the case of a diffuse-type TGCT at the craniocervical junction.

OBSERVATIONS

A patient presented with a 1-year history of right-sided neck pain and bilateral neurological symptoms in the distribution of the right occipital nerve. A 20-mm homogeneously contrast-enhancing mass in the suboccipital and posterior C1 region was discovered on magnetic resonance imaging of the cervical spine. The tumor was operated on via a posterior approach, and gross-total resection (GTR) was achieved. Immunohistochemical (IHC) examination revealed a diffuse-type TGCT. The patient had an uneventful recovery.

LESSONS

TGCT can arise at the craniocervical junction and is easily misdiagnosed because of its rare occurrence. IHC examination of a tumor specimen should be done to confirm the diagnosis. GTR is the objective when treating these tumors, especially when they are the diffuse type, as they have a high recurrence rate. Radiation and small-molecule therapies are viable postoperative therapies if GTR cannot be achieved or in cases of recurrence.

Superficial temporal artery injury and delayed post-cranioplasty infection

OBJECTIVE

Complications after cranioplasty after decompressive craniectomy (DC) have been reported to be as high as 40%. The superficial temporal artery (STA) is at substantial risk for injury in standard reverse question-mark incisions that are typically used for unilateral DC. The authors hypothesize that STA injury during craniectomy predisposes patients to post-cranioplasty surgical site infection (SSI) and/or wound complication.

METHODS

A retrospective study of all patients at a single institution who underwent cranioplasty after decompressive craniectomy and who underwent imaging of the head (computed tomography angiogram, magnetic resonance imaging with intravenous contrast, or diagnostic cerebral angiography) for any indication between the two procedures was undertaken. The degree of STA injury was classified and univariate statistics were used to compare groups.

RESULTS

Fifty-four patients met inclusion criteria. Thirty-three patients (61%) had evidence of complete or partial STA injury on pre-cranioplasty imaging. Nine patients (16.7%) developed either an SSI or wound complication after cranioplasty and, among these, four (7.4%) experienced delayed (>2 weeks from cranioplasty) complications. Seven of 9 patients required surgical debridement and cranioplasty explant. There was a stepwise but non-significant increase in post-cranioplasty SSI (STA present: 10%, STA partial injury: 17%, STA complete injury: 24%, P=0.53) and delayed post-cranioplasty SSI (STA present: 0%, STA partial injury: 8%, STA complete injury: 14%, P=0.26).

CONCLUSIONS

There is a notable but statistically non-significant trend toward increased rates of SSI in patients with complete or partial STA injury during craniectomy.

Revisiting the Resolution of Chiari Malformation in Nonsyndromic Craniosynostosis: A Case of Posterior Cranial Vault Reconstruction in Secondary Pan-Suture Synostosis

BACKGROUND

While commonly seen in syndromic craniosynostosis, the incidence of Chiari malformation (CM) in nonsyndromic craniosynostosis has been reported at 5% and there is a lack of understanding of the pathophysiology and management of CM in this patient population.

CASE DESCRIPTION

We present a 5-year-old male patient who underwent a sagittal craniosynostosis repair at the age of 5 months and returned at the age of 5 years with daily headaches associated with behavioral changes. He was found to have pan-synostoses and radiographic evidence of increased intracranial pressure, including a Chiari malformation. Neurologic and genetic workup was unremarkable. A cranial vault reconstruction was performed, and subsequent imaging demonstrated resolution of previously noted Chiari malformation.

CONCLUSIONS

In our case, we provided a unique window into the underlying pathophysiology for CM in patients with concurrent nonsyndromic craniosynostosis that we hope will add to the current foundation of literature supporting the intricate relation between cranial vault compliance and Chiari malformation or hindbrain herniation. Furthermore, we provide insight into the management of acquired CM and support isolated cranial vault reconstruction in those who do not appear to have symptomatic suboccipital compression.

Current management of pediatric chiari type 1 malformations

OBJECTIVES

Pediatric Chiari Type 1 Malformations (CM1) are commonly referred for neurosurgical opinion. The ideal management in children regarding surgical and radiographic decision making is not clearly delineated.

PATIENTS AND METHODS

We retrospectively reviewed our cohort of patients age 18 years and younger referred to a single neurosurgeon for CM1. Baseline MRIs of the spine were obtained. Non-operative patients had repeat imaging at 6-12 months. Patients who underwent an operation (decompression with/without duraplasty) had repeat imaging at 6 months.

RESULTS

One hundred and thirty-two patients with mean age of 10 years met inclusion criteria. All patients had post-operative symptomatic improvement. We identified 26 patients with syrinx, 8 with scoliosis, 3 with hydrocephalus, and one had tethered cord. The average tonsillar descent was 8.1 mm in the non-operative group and 11.9 mm in the operative group. Ninety-five patients were managed conservatively (72%). Thirty-seven were offered surgery (28%), and 33 patients underwent intervention; 21 with duraplasty (64%) and 12 without (36%).

CONCLUSIONS

Pediatric patients with CM1 require both clinical and radiographic follow-up. Duraplasty may be performed if decompression fails to relieve symptomatology, but is not always needed. CM1 continues to present a challenge in surgical decision making. Adhering to a treatment paradigm may help alleviate difficult decision-making.

Risk of pulmonary embolism and/or deep venous thrombosis in Asian-Americans

Several reports from Asian countries suggest a low prevalence of pulmonary embolism (PE) and deep venous thrombosis (DVT) in Asians, and sparse US data show that a slightly higher prevalence of PE/DVT in "nonwhites" than in whites is evident in all geographic regions except the Pacific region (California, Oregon, and Washington) where "nonwhites" include a larger proportion of Asians and Hispanics than in other US locations. We prospectively studied PE/DVT hospitalizations in 128,934 persons in relation to traits determined at health examinations in 1978 to 1985. Through 1994, 337 persons were subsequently hospitalized for PE and/or DVT (for PE first, n = 206). Cox proportional-hazards models with 9 covariates were used. In multivariate models, the following RRs (95% confidence intervals) were found for PE/DVT combined: black/white = 1.1 (0.4 to 1.4); Hispanic/white = 0.7 (0.3 to 1.5); and Asian/white = 0.2 (0.1 to 0. 5; p = 0.002). The lower risk of Asians was present in each sex and for persons first hospitalized for either PE or DVT. Covariates with significant positive relations to risk were age, male sex, body mass index, and a composite coronary disease risk/symptom variable; covariates not significantly related were education, marital status, smoking, and alcohol. These data suggest that Asians have very low risk of PE/DVT, which may account for US geographic variations in white/non-white risk differences. Possible explanations include the absence of hazardous mutations or unspecified PE/DVT protective traits in Asians.

Acute dislocation of the patella. A correlative pathoanatomic study

The objective of our study was to elucidate the characteristic pathoanatomy associated with patellar dislocation and report the preliminary results of early surgical repair. Twenty-three patients with documented patellar dislocation had standard radiographs and a magnetic resonance imaging scan. Intraarticular lesions were evaluated and treated arthroscopically followed by an open exploration of the medial aspect of the knee in 16 patients. Twelve patients were observed for a minimum of 2 years after surgical repair (average, 34 months). Eleven patients returned for a follow-up examination. Magnetic resonance imaging revealed effusion (100%), tears of the femoral insertion of the medial patellofemoral ligament (87%), increased signal in the vastus medialis muscle (78%), and lateral femoral condyle (87%) and medial patellar (30%) bone bruises. Arthroscopic examination revealed osteochondral lesions involving the patella and the lateral femoral condyle in 68% of cases. Open surgical exploration revealed tears of the medial patellofemoral ligament off the femur in 15 of 16 patients (94%). After medial patellofemoral ligament repair, none of the patients experienced recurrent dislocation. Overall 58% of the results were considered to be good or excellent and 42% were fair. Fifty-eight percent of the group returned to their previous sport with no or minor limitations.

Impaired hexose uptake by diploid skin fibroblasts from galactosaemic patients. Connection with cell growth and amino acid metabolism, and possible bearing on late-onset clinical symptoms

In skin fibroblasts of patients presenting with galactosaemia, either from galactose 1-phosphate uridyltransferase or galactokinase deficiency, a deficit in extracellular glucose utilization was observed. This deficit was constant over 3 weeks of continuous cell growth in a medium containing 5.5 mmol/L glucose as the only hexose, and homologous serum. Levels of glucose utilization by deficient skin fibroblasts were stable at about 65-70% of the glucose utilization of control normal skin fibroblasts. Cell morphology was normal, and cell growth was subnormal during this period. However, the energy provision appeared sufficient for cellular needs since cell growth in this glucose medium was observed not to depend on the presence of extracellular glutamine. In contrast, glutamine was required for growth of galactosaemic fibroblasts cultured in medium containing 5.5 mmol/L galactose. If expressed in many cell types, this impaired glucose uptake would be expected seriously to damage highly glucose-dependent tissues such as the central nervous system. This might be of relevance to the persistent neurological damage observed in many galactosaemic patients in spite of their compliance with an early strict galactose-free diet.

Respective effects of glucose and glutamine on the glutamine synthetase activity of human skin fibroblasts

The activity of Glutamine Synthetase (GS) was measured during the growth of human diploid skin fibroblasts cultured for three weeks in the presence or absence of either glucose or glutamine or both. In medium free of both glucose and glutamine, a single late peak in GS activity was observed concomitantly with delayed small cell protein increment. In all media containing either glucose or glutamine or both. GS activity rose sharply during rapid cell growth, displayed a plateau, and then decreased once the cells had reached confluency. The variations in extracellular amino acid levels were also determined and were found to depend on the composition of the medium but not on the cell culture duration. These results demonstrate, for the first time as far as we know, that strong GS activity is present in rapidly growing skin fibroblasts. In contrast to many other mammalian cell types, GS activity in human skin fibroblasts appears not to be subject to regulation by extracellular glutamine. This difference may well be connected with cell differentiation.

Glutamine dependency of human skin fibroblasts: modulation by hexoses

The combined effects of carbohydrates and glutamine were investigated in diploid strains of normal human skin fibroblasts cultured for 21 days under eight different culture conditions: hexose-free medium or medium containing D-glucose, D-galactose, or D-fructose, with or without added glutamine. Cell growth, hexose consumption, lactate production, intracellular glycogen content and extracellular amino acid levels were measured every third to fourth day. In the presence of glutamine, cells reached a higher saturation density in fructose medium than in glucose or galactose medium but per cell consumption of fructose and galactose was much less than that of glucose. Consumption of all three carbohydrates per unit cell growth exhibited three distinct phases: Days 1-3, 3-10, and 10-20, respectively. In the absence of glutamine the rate of cell growth was not altered in glucose or galactose medium, but slowed down considerably in fructose medium. Glutamine deprivation also led to changes in hexose consumption. In hexose-free media the cell growth rate at first was very slow, but rose after 2 or 3 weeks of culture. The levels of extracellular nonessential amino acids varied according to medium and growth phase. One of the most exciting findings was that human fibroblasts are able to maintain a slight excess of glutamine in all media not supplemented with glutamine and, more surprisingly, to synthesize it in a medium containing galactose and glutamine.

Antidiuretic hormone response to osmotic stimulus under fentanyl anaesthesia

The effect of fentanyl anaesthesia on the plasma antidiuretic hormone (ADH) response to osmotic stimulus was studied in eight patients. Eight g (137 mmol) NaCl were rapidly injected intravenously the day before anaesthesia and blood samples were collected 5, 10, 20 and 30 min after the injection. This protocol was repeated in the same subjects, under anaesthesia with thiopental, nitrous oxide and fentanyl before surgical incision. Plasma ADH markedly increased after NaCl administration and was significantly correlated with plasma sodium (r = 0.67, P less than 0.005) when the patients were awake, whereas it did not change over 30 min and was not correlated with plasma sodium (r = 0.18, P greater than 0.05) under fentanyl anaesthesia. This inhibitory effect of anaesthesia occurred in spite of a significant fall in the mean arterial pressure during the study. In order to eliminate the role of overnight fasting, premedication and fluid load, the same protocol was performed in six control patients who were fasted overnight, premedicated and fluid loaded. These results demonstrate that fentanyl anaesthesia abolishes the plasma ADH response to both osmotic and low arterial pressure stimuli.