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Samiya Abi Jaoude, Matthieu Peyre, Vincent Degos, Stéphane Goutagny, Béatrice Parfait, and Michel Kalamarides

OBJECTIVE

Intracranial meningiomas occur in about half of neurofibromatosis type 2 (NF2) patients and are very frequently multiple. Thus, estimating individual meningiomas’ growth rates is of great interest to tailor therapeutic interventions. The Asan Intracranial Meningioma Scoring System (AIMSS) has recently been published to estimate the risk of tumor growth in sporadic meningiomas. The current study aimed to determine predictors of rapid meningioma growth in NF2 patients and to evaluate the AIMSS score in a specific NF2 cohort.

METHODS

The authors performed a retrospective analysis of 92 NF2 patients with 358 measured intracranial meningiomas that had been observed prospectively between 2012 and 2018. Tumor volumes were measured at diagnosis and at each follow-up visit. The growth rates were determined and evaluated with respect to the clinicoradiological parameters. Predictors of rapid tumor growth (defined as growth ≥ 2 cm3/yr) were analyzed using univariate followed by multivariate logistic regression to build a dedicated predicting model. Receiver operating characteristic (ROC) curves to predict the risk of rapid tumor growth with the AIMSS versus the authors’ multivariate model were compared.

RESULTS

Sixty tumors (16.76%) showed rapid growth. After multivariate analysis, a larger tumor volume at diagnosis (p < 0.0001), presence of peritumoral edema (p = 0.022), absence of calcifications (p < 0.0001), and hyperintense or isointense signal on T2-weighted MRI (p < 0.005) were statistically significantly associated with rapid tumor growth. It is particularly notable that the genetic severity score did not seem to influence the growth rate of NF2 meningiomas. In comparison with the AIMSS, the authors’ multivariate model’s prediction did not show a statistically significant difference (area under the curve [AUC] 0.82 [95% CI 0.76–0.88] for the AIMSS vs AUC 0.86 [95% CI 0.81–0.91] for the authors’ model, p = 0.1).

CONCLUSIONS

The AIMSS score is valid in the authors’ cohort of NF2-related meningiomas. It adequately predicted risk of rapid meningioma growth and could aid in decision-making in NF2 patients.

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Aymeric Amelot, Maximilien Riche, Samuel Latreille, Vincent Degos, Alexandre Carpentier, Bertrand Mathon, and Anne-Marie Korinek

OBJECTIVE

The authors sought to evaluate the roles of perioperative antibiotic prophylaxis in noninstrumented spine surgery (NISS), both in postoperative infections and the impact on the selection of resistant bacteria. To the authors’ knowledge, only one prospective study recommending preoperative intravenous (IV) antibiotics for prophylaxis has been published previously.

METHODS

Two successive prospective IV antibiotic prophylaxis protocols were used: from 2011 to 2013 (group A: no prophylactic antibiotic) and from 2014 to 2016 (group B: prophylactic cefazolin). Patient infection rates, infection risk factors, and bacteriological status were determined.

RESULTS

In total, 2250 patients (1031 in group A and 1219 in group B) were followed for at least 1 year. The authors identified 72 surgical site infections, 51 in group A (4.9%) and 21 in group B (1.7%) (p < 0.0001). A multiple logistic regression hazard model identified male sex (HR 2.028, 95% CI 1.173–3.509; p = 0.011), cervical laminectomy (HR 2.078, 95% CI 1.147–3.762; p = 0.016), and postoperative CSF leak (HR 43.782, 95% CI 10.9–189.9; p < 0.0001) as independent predictive risk factors of infection. In addition, preoperative antibiotic prophylaxis was the only independent favorable factor (HR 0.283, 95% CI 0.164–0.488; p < 0.0001) that significantly reduced infections for NISS. Of 97 bacterial infections, cefazolin-resistant bacteria were identified in 26 (26.8%), with significantly more in group B (40%) than in group A (20.9%) (p = 0.02).

CONCLUSIONS

A single dose of preoperative cefazolin is effective and mandatory in preventing surgical site infections in NISS. Single-dose antibiotic prophylaxis has an immediate impact on cutaneous flora by increasing cefazolin-resistant bacteria.

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Joseph Gabrieli, Frédéric Clarençon, Federico Di Maria, Robert Fahed, Anne-Laure Boch, Vincent Degos, Jacques Chiras, and Nader-Antoine Sourour

Intracranial aneurysms are relatively frequently encountered in patients with brain arteriovenous malformations (BAVMs). They may be located on the circle of Willis, on arterial feeders, or even inside the nidus. Because BAVM-associated aneurysms represent a risk factor of bleeding, the question of the timing and modality of their management remains a matter of debate in unruptured BAVMs. The authors present a case of fatal periprocedural rupture of a flow-related aneurysm (FRA) during the removal of the microcatheter after injection of a liquid embolic agent. A 40-year-old man was treated at the authors' institution for the management of a Spetzler-Martin Grade III left unruptured frontal BAVM, revealed by seizures and a focal neurological deficit attributed to flow steal phenomenon. After a multidisciplinary meeting, endovascular treatment was considered to reduce the flow of the BAVM. A proximal FRA located on the feeding internal carotid artery (ICA) was purposely left untreated because it did not meet the criteria of the authors' institution for preventative treatment (i.e., small size [2.5 mm]). During embolization, at the time of microcatheter retrieval, and after glue injection, the aneurysm unexpectedly ruptured. The aneurysm's rupture was attributed to the stress (torsion/flexion) on the ICA caused by the microcatheter removal. Despite the attempts to manage the bleeding, the patient eventually died of the acute increase of intracranial pressure related to the massive subarachnoid hemorrhage. This case highlights a previously unreported mechanism of FRA rupture during BAVM embolization: the stress transmitted to the parent artery during the removal of the microcatheter.

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Leire Azurmendi, Vincent Degos, Natalia Tiberti, Natacha Kapandji, Paola Sanchez-Peña, Asita Sarrafzadeh, Louis Puybasset, Natacha Turck, and Jean-Charles Sanchez

OBJECT

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high rates of mortality and morbidity. The main predictor for the poor outcome is the World Federation of Neurosurgical Societies (WFNS) scale. However, this scale does not take into account proinflammatory events, such as infection occurring after the aSAH, which could modify the long-term status of patients. The aim of this study was to evaluate neopterin as an inflammatory biomarker for outcome and infection prediction in aSAH patients.

METHODS

Plasma concentrations of neopterin were measured in 61 aSAH patients (22 male and 39 female; mean age [± SD] 52.8 ± 11.8 years) using a commercial ELISA kit. Samples were collected daily for 10 days. Outcome at 12 months was determined using the Glasgow Outcome Scale (GOS) and dichotomized as poor (GOS score 1, 2, or 3) or good (GOS score 4 or 5). Infection was determined by the presence of a positive bacterial culture.

RESULTS

Patients with poor outcome at 12 months had higher concentrations of neopterin than patients with good outcome. In the same way, patients who had an infection during the hospitalization had significantly higher concentrations of neopterin than patients without infection (p = 0.001). Moreover, neopterin concentrations were significantly (p < 0.008) elevated in infected patients 2 days before infection detection and antibiotic therapy.

CONCLUSIONS

Neopterin is an efficient outcome predictor after aSAH. Furthermore, it is able to differentiate between infected and uninfected patients as early as 2 days before clinical signs of infection, facilitating earlier antibiotic therapy and better management.

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Eimad Shotar, Matthieu Debarre, Nader-Antoine Sourour, Federico Di Maria, Joseph Gabrieli, Aurélien Nouet, Jacques Chiras, Vincent Degos, and Frédéric Clarençon

OBJECTIVE

The authors aimed to design a score for stratifying patients with brain arteriovenous malformation (BAVM) rupture, based on the likelihood of a poor long-term neurological outcome.

METHODS

The records of consecutive patients with BAVM hemorrhagic events who had been admitted over a period of 11 years were retrospectively reviewed. Independent predictors of a poor long-term outcome (modified Rankin Scale score ≥ 3) beyond 1 year after admission were identified. A risk stratification scale was developed and compared with the intracranial hemorrhage (ICH) score to predict poor outcome and inpatient mortality.

RESULTS

One hundred thirty-five patients with 139 independent hemorrhagic events related to BAVM rupture were included in this analysis. Multivariate logistic regression followed by stepwise analysis showed that consciousness level according to the Glasgow Coma Scale (OR 6.5, 95% CI 3.1–13.7, p < 10−3), hematoma volume (OR 1.8, 95% CI 1.2–2.8, p = 0.005), and intraventricular hemorrhage (OR 7.5, 95% CI 2.66–21, p < 10−3) were independently associated with a poor outcome. A 12-point scale for ruptured BAVM prognostication was constructed combining these 3 factors. The score obtained using this new scale, the ruptured AVM prognostic (RAP) score, was a stronger predictor of a poor long-term outcome (area under the receiver operating characteristic curve [AUC] 0.87, 95% CI 0.8–0.92, p = 0.009) and inpatient mortality (AUC 0.91, 95% CI 0.85–0.95, p = 0.006) than the ICH score. For a RAP score ≥ 6, sensitivity and specificity for predicting poor outcome were 76.8% (95% CI 63.6–87) and 90.8% (95% CI 81.9–96.2), respectively.

CONCLUSIONS

The authors propose a new admission score, the RAP score, dedicated to stratifying the risk of poor long-term outcome after BAVM rupture. This easy-to-use scoring system may help to improve communication between health care providers and consistency in clinical research. Only external prospective cohorts and population-based studies will ensure full validation of the RAP scores' capacity to predict outcome after BAVM rupture.

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Robert Fahed, Federico Di Maria, Charlotte Rosso, Nader Sourour, Vincent Degos, Sandrine Deltour, Flore Baronnet-Chauvet, Anne Léger, Sophie Crozier, Joseph Gabrieli, Yves Samson, Jacques Chiras, and Frédéric Clarençon

OBJECTIVE

Contrary to acute ischemic stroke involving the anterior circulation, no randomized trial has yet demonstrated the safety and effectiveness of endovascular management in acute basilar artery occlusion (BAO). Recently developed thrombectomy devices, such as stentrievers and aspiration systems, have helped in improving the endovascular management of acute ischemic stroke. The authors sought to assess the impact of these devices in the endovascular treatment of acute BAO.

METHODS

A retrospective analysis of 34 consecutive patients treated in Pitié-Salpêtrière Hospital for acute BAO was carried out. All patients had undergone an endovascular procedure. In addition to the global results in terms of safety and effectiveness (recanalization rate and 3-month clinical outcome based on the modified Rankin Scale [mRS]), the authors aimed to determine if the patients treated with the most recently developed devices (i.e., the Solitaire stentriever or the ADAPT catheter) had better angiographic and clinical outcomes than those treated with older endovascular strategies.

RESULTS

The overall successful recanalization rate (thrombolysis in cerebral infarction score 2b–3) was 50% (17 of 34 patients). A good clinical outcome (mRS score 0–2 at 3-month follow-up) was achieved in 11 (32.3%) of 34 patients. The mortality rate at 3-month follow-up was 29.4% (10 of 34 patients). Patients treated with the Solitaire stentriever and the ADAPT catheter had a higher recanalization rate (12 [92.3%] of 13 patients vs 5 [23.8%] of 21 patients, p = 0.0002) and a shorter mean (± SD) procedure duration (88 ± 31 minutes vs 126 ± 58 minutes, p = 0.04) than patients treated with older devices.

CONCLUSIONS

The latest devices have improved the effectiveness of mechanical thrombectomy in acute BAO. Their use in further studies may help demonstrate a benefit in the endovascular management of acute BAO.

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Maximilien Riche, Pauline Marijon, Aymeric Amelot, Franck Bielle, Karima Mokhtari, Marc Pineton de Chambrun, Alexandre Le Joncour, Ahmed Idbaih, Mehdi Touat, Chung-Hi Do, Mamadou Deme, Romain Pasqualotto, Alice Jacquens, Vincent Degos, Eimad Shotar, Lydia Chougar, Alexandre Carpentier, and Bertrand Mathon

OBJECTIVE

The literature shows discrepancies in stereotactic brain biopsy complication rates, severities, and outcomes. Little is known about the timeline of postbiopsy complications. This study aimed to analyze 1) complications following brain biopsies, using a graded severity scale, and 2) a timeline of complication occurrence. The secondary objectives were to determine factors associated with an increased risk of complications and to assess complication-related management and extra costs.

METHODS

The authors retrospectively examined 1500 consecutive stereotactic brain biopsies performed in adult patients at their tertiary medical center between April 2009 and April 2019.

RESULTS

Three hundred eighty-one biopsies (25.4%) were followed by a complication, including 88.2% of asymptomatic hemorrhages. Symptomatic complications involved 3.0% of the biopsies, and 0.8% of the biopsies were fatal. The severity grading scale had a 97.6% interobserver reproducibility. Twenty-three (51.1%) of the 45 symptomatic complications occurred within the 1st hour following the biopsy, while 75.6% occurred within the first 6 hours. Age ≥ 65 years, second biopsy procedures, gadolinium-enhanced lesions, glioblastomas, and lymphomas were predictors of biopsy-related complications. Brainstem biopsy-targeted lesions and cerebral toxoplasmosis were predictive of mortality. Asymptomatic hemorrhage was associated with delayed (> 6 hours) symptomatic complications. Symptomatic complications led to extended hospitalization in 86.7% of patients. The average extra cost for management of a patient with postbiopsy symptomatic complication was $35,702.

CONCLUSIONS

Symptomatic complications from brain biopsies are infrequent but associated with substantial adverse effects and cost implications for the healthcare system. The use of a severity grading scale, as the authors propose in this article, helps to classify complications according to the therapeutic consequences and the patient’s outcome. Because this study indicates that most complications occur within the first few hours following the biopsy, postbiopsy monitoring can be tailored accordingly. The authors therefore recommend systematic monitoring for 2 hours in the recovery unit and a CT scan 2 hours after the end of the biopsy procedure. In addition, they propose a modern algorithm for optimal postoperative management of patients undergoing stereotactic biopsy.

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Lennart Riemann, Daphne C. Voormolen, Katrin Rauen, Klaus Zweckberger, Andreas Unterberg, Alexander Younsi, and the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Investigators and Participants

OBJECTIVE

The aim of this paper was to evaluate the prevalence of postconcussive symptoms and their relation to health-related quality of life (HRQOL) in pediatric and adolescent patients with mild traumatic brain injury (mTBI) who received head CT imaging during initial assessment.

METHODS

Patients aged between 5 and 21 years with mTBI (Glasgow Coma Scale scores 13–15) and available Rivermead Post Concussion Questionnaire (RPQ) at 6 months of follow-up in the multicenter, prospectively collected CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) study were included. The prevalence of postconcussive symptoms was assessed, and the occurrence of postconcussive syndrome (PSC) based on the ICD-10 criteria, was analyzed. HRQOL was compared in patients with and without PCS using the Quality of Life after Brain Injury (QOLIBRI) questionnaire.

RESULTS

A total of 196 adolescent or pediatric mTBI patients requiring head CT imaging were included. High-energy trauma was prevalent in more than half of cases (54%), abnormalities on head CT scans were detected in 41%, and admission to the regular ward or intensive care unit was necessary in 78%. Six months postinjury, 36% of included patients had experienced at least one moderate or severe symptom on the RPQ. PCS was present in 13% of adolescents and children when considering symptoms of at least moderate severity, and those patients had significantly lower QOLIBRI total scores, indicating lower HRQOL, compared with young patients without PCS (57 vs 83 points, p < 0.001).

CONCLUSIONS

Adolescent and pediatric mTBI patients requiring head CT imaging show signs of increased trauma severity. Postconcussive symptoms are present in up to one-third of those patients, and PCS can be diagnosed in 13% 6 months after injury. Moreover, PCS is significantly associated with decreased HRQOL.