BACKGROUND:Patients with glioma undergoing radiation therapy have been found to have elevated cerebrovascular risk. Bevacizumab, commonly used in this population for radiation necrosis, tumor recurrence, and cerebral edema, has prothrombotic and hemorrhagic effects, though its influence on stroke presentation in this population remains poorly characterized. METHODS:We performed a retrospective analysis of patients with glioma who developed stroke following cranial radiation therapy within the PRoGREss institutional registry. Bevacizumab exposure was ascertained at the time of the stroke event. Stroke subtype, severity, antithrombotic use, and discharge functional status were compared between patients with and without concurrent bevacizumab exposure. RESULTS:Of 910 registry patients, 91 (10.0%) developed stroke following cranial radiation. At the time of stroke, 59 (64.8%) were receiving bevacizumab and 32 (35.2%) were not. Intraparenchymal hemorrhage occurred numerically more often in bevacizumab-exposed patients (32.2% vs. 15.6%), though this difference was not statistically significant (Fisher's Exact p = 0.13). Among patients with IPH, concurrent therapeutic anticoagulation was substantially more prevalent in the bevacizumab-exposed group (31.6% vs. 0.0%, Fisher's Exact p = 0.28). CONCLUSIONS:In this exploratory cohort of 91 patients with stroke after cranial radiation, bevacizumab exposure at the time of stroke was not independently associated with intraparenchymal hemorrhage. The observed numerical difference was not statistically significant and was substantially confounded by higher rates of concurrent therapeutic anticoagulation in the bevacizumab-exposed group. The primary hypothesis generated by these data is that concurrent bevacizumab and therapeutic anticoagulation may together confer meaningful hemorrhagic risk in this population, warranting dedicated prospective investigation.
OBJECTIVE:To evaluate whether direct subventricular zone (SVZ) contact and quantitative tumor-SVZ distance among non-contacting tumors are independently associated with progression-free survival (PFS) and overall survival (OS) in adult diffuse gliomas, and to explore the association between SVZ proximity and recurrence topography. METHODS:This retrospective single-center cohort included 80 adults with WHO grade 2-4 diffuse gliomas. Direct SVZ contact was defined as a tumor-SVZ distance of 0 mm; distance among non-contacting tumors was analyzed continuously. Cox models were adjusted for age, WHO grade, and IDH mutation status, with grade-stratified sensitivity analyses. Fine-Gray regression explored the association between SVZ proximity (≤5 mm) and non-local first recurrence. RESULTS:Direct SVZ contact was present in 43 patients, while 37 had non-contacting tumors. After adjustment, neither direct SVZ contact nor continuous distance among non-contacting tumors was significantly associated with OS (HR 1.43, 95% CI 0.49-4.20, p = 0.518; HR 1.02 per 1-mm increase, 95% CI 0.95-1.10, p = 0.585) or PFS (HR 1.94, 95% CI 0.68-5.51, p = 0.213; HR 1.01 per 1-mm increase, 95% CI 0.94-1.08, p = 0.848). Grade-stratified analyses were consistent with the primary findings. SVZ proximity was associated with a higher subdistribution hazard of non-local first recurrence (SHR 2.23, 95% CI 1.01-4.90, p = 0.046). CONCLUSION:Neither direct SVZ contact nor quantitative distance among non-contacting tumors showed a statistically significant independent association with OS or PFS. Wide confidence intervals and the limited sample size preclude definitive exclusion of clinically relevant associations. The association between SVZ proximity and non-local recurrence should be considered exploratory and requires external validation.
OBJECTIVE:White matter hyperintensities (WMH) are common on magnetic resonance imaging in migraine, but their mechanisms remain unclear. We examined associations of systemic inflammatory and atherogenic indices with WMH burden in migraine without major vascular risk factors. METHODS:This retrospective case-control study included 320 participants: migraine with Fazekas grade 0 (n = 112), migraine with Fazekas grades 1-3 (n = 118), and healthy controls (n = 90). C-reactive protein (CRP), systemic immune-inflammation index (SII), atherogenic index of plasma (AIP), and total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio were analyzed. Current smoking, current alcohol use, DSM-5 alcohol use disorder, and body mass index (BMI) ≥ 30 kg/m2 were exclusion criteria. RESULTS:Age and sex distributions were similar across groups. CRP was higher in migraine patients with Fazekas grades 1-3 than in those with Fazekas 0 and controls (p < 0.001). The TC/HDL-C ratio was elevated in the Fazekas 1-3 group compared with both comparison groups (p < 0.001). AIP was also higher with WMH (p = 0.001), whereas SII did not differ. Fazekas grade correlated with disease duration, monthly headache days, and TC/HDL-C ratio (all p < 0.001). In multivariable analysis, disease duration, monthly headache days, CRP, and TC/HDL-C ratio were independently associated with WMH presence. CONCLUSIONS:Among migraine patients without major vascular risk factors, WMH were associated with greater disease chronicity and increased inflammatory and atherogenic indices, supporting an inflammation-related vascular hypothesis. Their clinical significance remains uncertain. Prospective studies should determine whether effective migraine prophylaxis modifies these markers or WMH incidence and progression.
Background Although contemporary hemispheric epilepsy surgery has largely shifted toward functional disconnection and hemispherotomy, complete anatomical approaches may retain a role in selected patients, including as rescue procedures after failed disconnection. In the 1980s, a modified anatomical hemispherectomy was developed at the Radcliffe Infirmary at the University of Oxford, incorporating an extended extradural dissection to reduce delayed haemorrhagic complications. The long-term efficacy of this approach in refractory epilepsy and related comorbidities has not previously been evaluated. Methods We performed a retrospective observational study and systematic review. Clinical data were obtained from patients undergoing modified hemispherectomy at our institution between 1983 and 1996. A systematic search of MEDLINE, EMBASE, and Scopus (inception–December 2024) was conducted according to PRISMA guidelines. Studies including ≥10 patients with postoperative seizure outcomes reported after ≥5 years’ mean or median follow-up were included. Epilepsy aetiology and surgical techniques were categorized using predefined criteria. Outcomes focused on seizure freedom at final follow-up, complications and neurocognitive outcomes where reported. Statistical analyses employed parametric or non-parametric testing with significance set at p≤0.05. Results In our patient cohort (n=49), most patients presented with focal onset seizures with secondary generalisation (59%) and an acquired aetiology (65%). Within five years of surgery, 63% achieved seizure freedom. Anti-seizure medications were discontinued in 51%, of whom 80% remained seizure-free at long-term follow-up. Neurodevelopmental improvement was observed in 69% and behavioural improvement in 80% of individuals. Seizure freedom was significantly associated with gains in neurocognitive (OR 9.6, 95%:CI 2.36–32.70) and behavioural (OR 6.5, 95%:CI 1.48–25.59) outcomes. Postoperative complications occurred in 16 patients (33%), more than half of which were wound infections (9, 56%). The systematic review included 58 studies, 77% from high-income countries, and demonstrated a median seizure freedom rate of 74% at last follow-up (median 5.7 years, IQR 5.1–7.0), with functional hemispherectomies showing superior outcomes. Conclusions This study presents the largest systematic review of hemispherectomies to date and provides new insight into a surgical modification that influenced the evolution of modern epilepsy surgery.
BACKGROUND:Aneurysmal subarachnoid hemorrhage (aSAH), as a hemorrhagic stroke, accounts for approximately 5% of all strokes but disproportionately affects adults in their fourth and fifth decades during peak productive years, carrying a neuropsychiatric burden extending far beyond the acute event. Despite advances in neurovascular and surgical technique, long-term psychiatric and cognitive consequences of aSAH remain incompletely characterized. Delayed cerebral ischemia (DCI), occurring in 20-30% of survivors, has been proposed as a key neuropsychiatric driver, yet its independent contribution to seizure, dementia, and mood disorders beyond surgical treatment itself has not been quantified in large propensity-matched studies. Whether treatment modality differentially affects these outcomes also remains unresolved. We sought to determine five-year neuropsychiatric outcome rates in surgically confirmed aSAH and the independent contributions of DCI and surgical approach. METHODS:Retrospective cohort study using the TriNetX federated electronic health record network with five years of follow-up within 2013-2020. Adults with raptured aSAH confirmed by surgical treatment were identified. Three propensity-matched comparisons were performed: aSAH versus matched population controls; aSAH with DCI versus aSAH without DCI; and aSAH with DCI versus matched controls. A fourth comparison examined clipping versus coiling. Primary outcomes included incident seizure disorder, composite dementia, depression, and mood/anxiety disorders over five years, representing the dominant post-stroke chronic disease burden in hemorrhagic stroke survivors. RESULTS:Among 8231 aSAH patients, 2131 (25.9%) developed DCI; 2024 (24.6%) underwent surgical clipping and 6207 (75.4%) endovascular coiling. Compared with matched controls, aSAH was associated with significantly elevated risks of seizures (RR 13.87 [95% CI 9.65-19.94], p < 0.001), composite dementia (RR 3.62 [95% CI 2.80-4.68], p < 0.001), and depression (RR 2.19 [95% CI 1.89-2.53], p < 0.001). Within the aSAH cohort, DCI was associated with higher seizure risk (RR 1.43, p < 0.001), whereas associations with composite dementia and mood disorders did not reach statistical significance. Compared with matched controls, DCI patients faced markedly elevated seizure risk (RR 16.69 [95% CI 9.57-29.12], p < 0.001) and composite dementia risk (RR 4.58 [95% CI 3.01-6.97], p < 0.001). Surgical clipping was independently associated with higher seizure disorder (RR 1.48 [95% CI 1.19-1.83], p < 0.001) and composite dementia (RR 1.46 [95% CI 1.08-1.98], p = 0.013) risks versus coiling. Kaplan-Meier analysis demonstrated progressively diverging neuropsychiatric event curves over five years, with DCI patients carrying the highest cumulative burden (HR 2.55 versus controls, p < 0.001). CONCLUSIONS:aSAH carries a substantial and progressive long-term neuropsychiatric burden. DCI was associated with higher seizure risk, whereas associations with dementia and mood disorders did not reach statistical significance. Clipping was associated with higher seizure and composite dementia risks than coiling. These findings support long-term neuropsychiatric follow-up but require cautious interpretation because infarct characteristics, aneurysm location, and operative approach were unavailable. As a hemorrhagic stroke subtype with a distinct younger demographic profile, aSAH demands neuropsychiatric surveillance pathways currently absent from stroke care guidelines globally.
BACKGROUND:Transradial access is increasingly used in neuroendovascular procedures because it improves patient comfort and reduces access-site complications compared with transfemoral approaches. Most reported experience concerns right radial access, and the role of left wrist access is less well characterized. We evaluated left wrist access for diagnostic cerebral angiography and neuroendovascular intervention. METHODS:We retrospectively reviewed patients who underwent neuroendovascular procedures using left wrist access at a single university health system between April 2019 and August 2025. Procedural success required catheterization of all intended vessels and, for interventions, completion of the planned treatment. RESULTS:141 patients underwent procedures via left wrist access: 76 diagnostic angiograms (53.9%) and 65 interventions (46.1%). Pathology was predominantly posterior circulation in both cohorts. Left vertebral artery anatomy was the primary indication, and the left vertebral artery was the most frequently catheterized vessel. Procedural success was 76 of 76 (100%) for diagnostic procedures and 62 of 65 (95.4%) for interventions; the three aborted interventions were stopped for anatomical reasons unrelated to access. Median examination and fluoroscopy durations were 80 and 8.1 min for diagnostic procedures and 131 and 38.3 min for interventions. No access-site complications requiring intervention occurred. CONCLUSIONS:Left wrist arterial access was successful for cervicocerebral angiography and posterior fossa intervention, its main limitation being the absence of reliable guide catheter support for anterior circulation intervention. Patients were selected for this route when their anatomy favored it, so these findings apply to a selected population and do not establish absolute equivalence or superiority to other routes.
OBJECTIVE:To validate CTA-based tuberculum sellae-anterior clinoid process (TS-ACP) classification against operative distal dural ring (DDR) assessment and evaluate prespecified interoptic geometry for selective contralateral interoptic clipping. METHODS:This registry cohort included 105 adults undergoing microsurgical clipping of paraclinoid internal carotid artery aneurysms during 2011-2024. Two blinded reviewers retrospectively applied TS-ACP classification and interoptic criteria to preoperative CTA; DSA provided complementary anatomical characterization. The principal clinical safety endpoint was permanent visual worsening at 12 months. Between-approach analyses were exploratory because corridor selection was nonrandomized and anatomy-driven. RESULTS:Seventy-five patients underwent ipsilateral and 30 contralateral interoptic clipping. TS-ACP classification matched operative DDR assessment in 95/105 aneurysms (90.5%; κ = 0.76). For identifying the operative intradural category, sensitivity was 100%, specificity 70.0%, and negative predictive value 100%. Favorable geometry was more frequent with contralateral selection (76.7% vs 32.0%; p < 0.001; OR 6.98, 95% CI 2.63-18.52) and remained associated after excluding multiple-aneurysm operations (OR 13.93, 95% CI 2.88-67.37). Permanent visual worsening occurred in 7/75 ipsilateral and 1/30 contralateral cases (p = 0.43); the study was underpowered for comparative safety inference. CTA/DSA-confirmed complete occlusion was achieved in 79/85 patients (92.9%). CONCLUSIONS:TS-ACP classification provided a high-sensitivity CTA-based estimate of the operative intradural category, and prespecified geometry was strongly associated with contralateral corridor selection. No excess permanent visual morbidity was observed in carefully selected contralateral cases, but sparse events, anatomical differences, and nonrandomized selection preclude robust comparative safety conclusions.
BACKGROUND:Depression is a common comorbidity among patients with trigeminal neuralgia (TN). Although microvascular decompression (MVD) provides durable pain relief for medically refractory TN, prior studies have associated depression with poorer outcomes in heterogeneous TN cohorts. Whether this relationship exists specifically in Type 1 TN (TN1) remains unclear. This study evaluated whether documented preoperative depression was associated with early or long-term pain outcomes following MVD for TN1. METHODS:We retrospectively reviewed MVD procedures performed for classical TN1 at a single academic institution between 2016 and 2025. Depression status was determined by retrospective review of documented diagnoses in the electronic medical record at the time of surgery. Primary outcomes included pain relief at first, last, and long-term (>1 year) follow-up using the Barrow Neurological Institute (BNI) scale, with BNI IIIb-V considered inadequate pain relief. Time-to-recurrence was evaluated using Cox and Kaplan-Meier analysis. RESULTS:Among 289 MVD procedures, median follow-up was 7.16 months [IQR: 0.66-33.6]; among 131 patients with >1 year follow-up, median follow-up was 35.3 months [IQR: 22.9-61.2]. Forty-nine patients (17.0%) had documented depression. Patients with documented depression were younger (p < 0.001) and more often female (p = 0.004). Adequate pain relief at first, last, and long-term follow-up did not differ by documented depression status (p = 1.00, p = 0.794, and p = 0.471, respectively). Recurrence-free pain relief was similar between patients with and without documented depression (p = 0.723). CONCLUSION:This study did not identify a statistically significant association between documented preoperative depression and postoperative pain outcomes following MVD for TN1. Given its prevalence, depression remains an important consideration in TN care.
OBJECTIVES:Newly diagnosed acetylcholine receptor (AChR)-positive generalized myasthenia gravis (gMG) is typically managed with corticosteroids, but long-term exposure carries substantial adverse effects. We evaluated the safety and effectiveness of rituximab (RTX) as the first and the only add-on to steroid therapy in AChR-positive gMG within two years from diagnosis. MATERIALS AND METHODS:We studied 24 adults who received RTX within 24 months from gMG diagnosis (mean 9.3 ± 7.1 months). This was a retrospective, single-center observational cohort study including consecutive eligible patients. Clinical outcomes (MG-ADL, MGFA-PIS), corticosteroid doses, and AChR antibody titers were assessed at baseline and 3, 6, and 12 months. RESULTS:Mean age at RTX initiation was 63 ± 15 years; 10 patients (41.7%) were ≥ 65 and 4 (17%) had thymoma. Follow-up averaged 15.5 ± 6.9 months. Patients were stratified as steroid responders (n = 16), partial responders (n = 5), and refractory (n = 3). MG-ADL scores improved from 1.9 ± 2.4-0.32 ± 0.78 at 6-months and 0.0 at 12 months. Corticosteroid dose decreased from 22.4 ± 9.0 mg/day at initiation to 11.4 ± 4.7 mg/day at 6 months and 7.7 ± 2.2 mg/day at 12 months. At 6-months, 61% achieved or maintained pharmacological remission and 30% minimal manifestations; at 12-months, 64% were in remission and 36% had minimal manifestations. AChR antibody titers declined by ~70% at both time points. No serious RTX-related adverse events requiring treatment discontinuation were observed. CONCLUSIONS:Our study highlights RTX's dual role both as a steroid-sparing maintenance therapy and as an early immunosuppressive option for steroid partial responders in addition to refractory AChR-positive gMG patients.
Background and Objectives Posterior and transforaminal lumbar interbody fusion (PLIF and TLIF) are very common spine procedures performed today, primarily for degenerative pathology. There are many people each year who undergo primary single level TLIF or PLIF, therefore the acute risk profile is important information for surgeons. Methods A retrospective review was performed on all patients undergoing primary, single level PLIF or TLIF at a tertiary academic medical center. All acute complications within 90-days of surgery, 90-day reoperations, and 30-day readmissions were recorded in addition to baseline patient characteristics and surgical details. Statistical analysis was performed to identify risk factors of postoperative complications. Results 520 patients were identified, of which 44 complications occurred in 66 patients (12.7%), with anemia requiring transfusion (1.5%) and postoperative delirium (1.5%) being the most common medical complications while nerve injury (1.9%) and surgical site infection (1.3%) were the most frequent surgical complications. There were 26 readmissions (5.1%) within 30-days for any reason, and 15 reoperations (3.2%). Revision of malpositioned screw (1.1%) and surgical site infection washout (0.9%) were the most frequent reoperations. History of transient ischemic attack, and greater operation time were identified as risk factors for any postoperative complication occurring on univariate analysis, while multivariate analysis did not reveal any significant risk factors. Conclusion Primary, single level PLIF or TLIF represents a powerful tool for treating lumbar degenerative disease and is relatively well tolerated, with this study demonstrating an overall 90-day complication rate of 12.7% and 3.2% reoperation rate.
OBJECTIVE:To assess the impact of race/ethnicity on adverse events (AEs), in-hospital mortality, and non-routine discharge among BCVI patients. METHODS:A retrospective cohort study was conducted using the American College of Surgeons Trauma Quality Programs Participant Use Files (2017-2023). Multivariable logistic regression analyzed associations between race/ethnicity and clinical outcomes. RESULTS:Among 44,898 BCVI patients, most were non-Hispanic White (NHW, 64.5%), followed by non-Hispanic Black (NHB, 14.9%), Hispanic Latino (HL, 10.5%), and other (10.1%). NHW patients were older and more often injured by falls (27.4%) than NHB (14.9%) and HL (18.2%), p < 0.001. NHB patients had the highest rates of motor vehicle trauma (75.0% vs. 60.5% NHW and 69.7% HL, p < 0.001), AEs (20.5% vs. 17.7% NHW and 19.7% HL, p < 0.001), and longest hospital stays (16.1 ± 21.4 days vs. 12.4 ± 15.1 NHW and 15 ± 18.8 HL, p < 0.001). After adjusting for age, comorbidities, and injury severity, NHB patients had increased odds of AEs (aOR 1.18, 95% CI 1.09-1.28, p < 0.001) and non-routine discharge (aOR 1.11, 95% CI 1.03-1.19, p = 0.004) compared to NHW. HL patients also had higher odds of AEs compared to NHW (aOR 1.11, 95% CI 1.02-1.22, p = 0.022) but lower odds of non-routine discharge (aOR 0.87, 95% CI 0.80-0.95, p < 0.001). CONCLUSIONS:Racial disparities significantly influence BCVI outcomes. NHB and HL patients experienced greater AE risk, with NHB patients also experiencing longer hospitalizations and higher non-routine discharge rates. Targeted interventions are needed to promote equity in trauma care.
OBJECTIVE:Stroke patients often have mental health comorbidities such as depression and suicidal ideation. Stroke is a leading cause of long-term disability and is associated with increased risk of death, with mental illness playing a large role in this relationship. However, the impact of stroke on suicidal ideation among individuals with co-morbid depression is not well understood. We aim to determine if stroke in combination with depression was associated with a higher prevalence and severity of suicidal ideation. METHODS:We performed a retrospective cross-sectional study using data from the National Health and Nutrition Examination Survey, 2011-2018. All respondents were divided into four mutually exclusive categories based on their diagnosis of stroke and depression. Weighted prevalence estimates and 95% confidence intervals (CI) were reported across clinical and demographic categories. Multivariable logistic regression models were used to identify the independent association between stroke, depression, and suicidal ideation. Adjusted odds ratios (AOR) and a p-value of < 0.05 were used to determine statistical significance. RESULTS:The analytic sample included 19,397 participants, of whom 863 (4%) had a history of stroke. Depression was present in 154 (0.7%) participants with stroke and 2709 (11.6%) participants without stroke. The mean age of participants with stroke and depression was 59 years. This group was more likely to be female (64%), non-Hispanic White (67.7%), have more than a high school education (38.9%), and be overrepresented among those living at or below the federal poverty level (69.8%). Stroke was independently associated with an increased risk of suicidal ideation in those with depression (adjusted odds ratio [AOR] = 1.86; 95% CI: 1.21-2.85; p = 0.005) when compared to those with depression but without stroke. Living at or below the poverty level was also independently associated with increased suicidality risk (AOR = 1.39; 95% CI: 1.11-1.74; p = 0.005). CONCLUSION:A history of stroke was found to significantly increase the odds of suicidal ideation in those with depression. These findings can help inform better integrative screening and treatment of mental health among stroke patients, especially those with co-morbid depression.
OBJECTIVE:Primary central nervous system lymphoma (PCNSL) is a rare malignancy in which neurosurgical management is usually limited to stereotactic biopsy, while resection is considered in selected cases. Pre-diagnostic corticosteroids may cause radiological regression ("vanishing tumor"), potentially delaying diagnosis and treatment. METHODS:We conducted a single-center retrospective cohort study of adults (≥18 years) with histopathologically confirmed PCNSL treated between January 2015 and April 2023 at the Institute of Psychiatry and Neurology (Warsaw). Patients were grouped by neurosurgical strategy (stereotactic biopsy vs craniotomy with resection). Vanishing tumor was defined as marked radiological reduction prior to histopathological confirmation. Diagnostic interval was defined as time from index hospital admission to neuropathological diagnosis. Overall survival (OS) was calculated from index hospital admission to death or last contact and analyzed using Kaplan-Meier estimates and log-rank tests. RESULTS:Fifty-six patients were included (mean age 66 years, range 23-82); 40 (71%) underwent biopsy and 16 (29%) resection. Median OS was longer after resection than biopsy (465 vs 149.5 days; log-rank p = 0.029). Vanishing tumor occurred in 12 patients (21%) and was associated with a longer diagnostic interval (median 82 vs 9 days; p < 0.001). Median OS was shorter in patients with vanishing tumor (149.5 vs 356 days), but the difference was not significant (p = 0.313). CONCLUSIONS:In selected, surgically accessible PCNSL cases, resection was associated with longer OS than stereotactic biopsy, although residual confounding cannot be excluded. Vanishing tumor was common and associated with substantial diagnostic delay; corticosteroids should be restricted to clear clinical necessity in suspected PCNSL.
BACKGROUND:Randomized trials suggest that adjunctive middle meningeal artery embolization (MMAE) may reduce recurrence in chronic subdural hematoma (CSDH), but potential sources of variability in treatment effects across studies remain poorly understood. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of MMAE and to explore potential study-level sources of between-study heterogeneity. METHODS:We conducted a systematic review and meta-analysis of randomized controlled trials comparing MMAE plus surgery versus surgery alone, following PRISMA guidelines. Trial sequential analysis (TSA) was prespecified to assess the robustness of pooled findings. Exploratory mixed-effects meta-regression was performed to examine whether aggregate study-level mean age and anticoagulation use were associated with variability in recurrence outcomes. RESULTS:Eight trials including 1961 patients were analyzed. MMAE plus surgery was associated with a reduction in recurrence compared with surgery alone (RR 0.63, 95% CI 0.46-0.85; I² = 0%), and TSA supported this finding. Although conventional meta-analysis suggested a reduction in reoperation, the TSA findings were more sensitive to analytical assumptions and less robust. Exploratory study-level meta-regression analyses suggested possible associations between recurrence outcomes and mean age or anticoagulation use, although these findings should be interpreted as hypothesis-generating only. Safety outcomes were comparable between groups. CONCLUSIONS:Adjunctive MMAE was associated with reduced recurrence in CSDH. Exploratory analyses evaluating aggregate study-level characteristics were limited by the small number of included trials and the use of aggregate-level data, and should be considered hypothesis-generating only. Further prospective studies are needed to better understand variability in treatment effects.
BACKGROUND:Central retinal artery occlusion (CRAO) is an ophthalmic emergency with poor visual prognosis. Although intravenous thrombolysis (IVT) within 4.5 h may be beneficial, the effectiveness and safety of low-dose alteplase remain uncertain. METHODS:We conducted a retrospective study at three centres in Japan, enrolling patients who presented within 24 h of onset with CRAO or macula-involving branch retinal artery occlusion (BRAO) between June 2021 and September 2024. Patients were analysed if they had baseline best-corrected visual acuity (BCVA) < 20/400, clearly defined symptom onset, absence of proliferative retinopathy or other retinal vascular diseases, and 30-day visual outcome data. Patients were grouped by treatment with IVT using alteplase at 0.6 mg/kg within 4.5 h or non-IVT management. The primary outcome was 30-day BCVA ≥ 20/100; secondary outcome included change in BCVA (logarithm of the minimum angle of resolution [logMAR]); and safety outcomes included intracranial hemorrhage (ICH). RESULTS:Sixteen of 41 registered patients were analysed (70.1 ± 12.6 years; 4 women; 13 had CRAO; 9 received IVT). The primary outcome was achieved in 22.2% (2/9) of the IVT group versus 0% (0/7) of the non-IVT group (p = 0.475). Improvement in logMAR was greater in the IVT than the non-IVT group (median difference 0.45 [95% confidence interval, 0.18-1.20]; p = 0.023). No symptomatic ICH occurred; one IVT-treated patient had asymptomatic ICH. CONCLUSION:IVT using low-dose alteplase within 4.5 h of CRAO (or macula-involving BRAO) onset may be associated with greater visual improvement without apparent safety concerns, although this requires confirmation by larger prospective studies.
INTRODUCTION:Epilepsy surgery is an effective treatment for drug-resistant epilepsy but carries the risk of uncommon yet potentially serious postoperative complications. Among these, remote intracranial hemorrhage (RIH), encompassing remote cerebral and cerebellar hematomas, and pseudohypoxic brain swelling (PHBS) are rare entities that have been hypothesized to be related to excessive cerebrospinal fluid (CSF) drainage. Data on these complications in epilepsy surgery remain limited, and their combined presentation within the same surgical cohort has not been widely documented. METHODS:We retrospectively reviewed patients aged ≥ 18 years who underwent resective or palliative epilepsy surgery (excluding vagal nerve stimulation) between January 1995 and March 2024 at our tertiary epilepsy center. Patients with postoperative remote parenchymal hematomas and/or imaging findings consistent with PHBS were identified. Clinical, surgical, radiological, and follow-up data were analyzed. RESULTS:Among 682 patients, three (0.4%) developed RIH and two (0.29%) developed PHBS in the early postoperative period. RIH cases followed temporal lobectomy or hemispherotomy and demonstrated typical neuroimaging features, including the cerebellar "zebra sign." All had normal preoperative coagulation profiles, an intraoperative drain in place, and favorable long-term neurological outcomes. PHBS cases occurred after subdural and/or depth electrode placement, showing MRI features of the lentiform fork sign and deep nuclear involvement. Notably, one of the two PHBS cases exhibited a distinctive, previously undescribed postoperative EEG finding, abundant triphasic wave discharges involving the bilateral anterior regions with left-sided predominance, which, along with the MRI abnormalities in both cases, resolved completely during follow-up. CONCLUSION:RIH and PHBS are rare but clinically significant complications of epilepsy surgery. Our series is the first to describe reversible EEG and MRI changes in PHBS, presented alongside RIH cases that may share overlapping pathophysiological mechanisms. Early recognition, cessation of CSF drainage when suspected as a contributing factor, and close monitoring are essential to optimize patient outcomes.
