Juan Sahuquillo-Barris, Jose Lamarca-Ciuro, Jorge Vilalta-Castan, Enrique Rubio-Garcia and Manuel Rodriguez-Pazos
✓ The association of acute subdural hematoma (SDH) and diffuse axonal injury has received little attention in the literature. The authors report the clinicopathological findings in six patients who died of severe head injury in whom computerized tomography revealed acute SDH as the predominant lesion. All patients were injured in road traffic accidents and lost consciousness on impact. The mean total contusion index was 17.4 and severe contusions were seen in only two cases. All patients presented histological criteria of intracranial hypertension (pressure necrosis focus in one or both parahippocampal gyri). Hypoxic brain damage was evident in the postmortem examination of three patients. In three cases, macroscopic hematic lesions were observed in the corpus callosum. All patients had widespread axonal retraction balls disseminated in the white brain matter. Three patients who survived for more than 11 days had microglial clusters. In some patients with a head injury, acute SDH may be only an epiphenomenon of a primary impact lesion of variable severity: that is, a diffuse axonal injury. In these cases, the final outcome is fundamentally dependent on the severity of the subjacent diffuse axonal injury.
Eudaldo M. López-Tomassetti Fernández, Juan Ramón Hernández Hernández, Jose Ceballos Esparragon, Angel Turegano García and Valentin Nuñez Jorge
The authors report the case of a 50-year-old woman with a benign intermuscular lipoma of the gluteus compressing the sciatic nerve in its course through the sciatic notch. This benign soft-tissue tumor extended into the pelvis, displacing the rectum laterally. Resection was necessary to alleviate symptoms and prevent irreversible damage of the nerve. Wide exposure of the piriformis muscle and sciatic nerve via a transgluteal approach allowed safe lesion removal, and thus avoiding a laparotomy to resect the intrapelvic extension of the tumor. This report features a curious case of soft-tissue tumor growth across the sciatic foramen forming an inverted sciatic hernia. The authors' proposed approach was simple and safe and avoided a laparotomy.
Jorge Eduardo Duque Parra, John Barco Ríos and Jhonny Fernando García Aguirre
Ivair Matias Jr., Daoud Hibrahim Elias-Filho, Camila Araújo Bernardino Garcia, Guilherme Henrique Silva, Jorge Mejia, Francisco Romero Cabral, Ana Cláudia Camargo Miranda, Sérgio Gomes da Silva, Luíza da Silva Lopes, Norberto Cysne Coimbra and Hélio Rubens Machado
The objective of this study was to describe a new experimental model of hemispherotomy performed on laboratory animals.
Twenty-six male young adult Wistar rats were distributed into two groups (surgery and control). The nonfluorescent anterograde neurotracer biotinylated dextran amine (BDA; 10,000 MW) was microinjected into the motor cortex area (M1) according to The Rat Brain in Stereotaxic Coordinates atlas to identify pathways and fibers disconnected after the experimental hemispherectomy. SPECT tomographic images of 99mTc hexamethylpropyleneamine oxime were obtained to verify perfusion in functioning areas of the disconnected and intact brain. A reproducible and validated surgical procedure is described in detail, including exact measurements and anatomical relationships. An additional 30 rodents (n = 10 rats per group) were divided into naïve, sham, and hemispherotomy groups and underwent the rotarod test.
Cortico-cortical neural pathways were identified crossing the midline and contacting neuronal perikarya in the contralateral brain hemisphere in controls, but not in animals undergoing hemispherotomy. There was an absence of perfusion in the left side of the brain of the animals undergoing hemispherotomy. Motor performance was significantly affected by brain injuries, increasing the number of attempts to maintain balance on the moving cylinder in the rotarod test at 10 and 30 days after the hemispherotomy, with a tendency to minimize the motor performance deficit over time.
The present findings show that the technique reproduced neural disconnection with minimal resection of brain parenchyma in young adult rats, thereby duplicating the hemispherotomy procedures in human patients.
Aditya Juloori, Jacob A. Miller, Shireen Parsai, Rupesh Kotecha, Manmeet S. Ahluwalia, Alireza M. Mohammadi, Erin S. Murphy, John H. Suh, Gene H. Barnett, Jennifer S. Yu, Michael A. Vogelbaum, Brian Rini, Jorge Garcia, Glen H. Stevens, Lilyana Angelov and Samuel T. Chao
The object of this retrospective study was to investigate the impact of targeted therapies on overall survival (OS), distant intracranial failure, local failure, and radiation necrosis among patients treated with radiation therapy for renal cell carcinoma (RCC) metastases to the brain.
All patients diagnosed with RCC brain metastasis (BM) between 1998 and 2015 at a single institution were included in this study. The primary outcome was OS, and secondary outcomes included local failure, distant intracranial failure, and radiation necrosis. The timing of targeted therapies was recorded. Multivariate Cox proportional-hazards regression was used to model OS, while multivariate competing-risks regression was used to model local failure, distant intracranial failure, and radiation necrosis, with death as a competing risk.
Three hundred seventy-six patients presented with 912 RCC BMs. Median OS was 9.7 months. Consistent with the previously validated diagnosis-specific graded prognostic assessment (DS-GPA) for RCC BM, Karnofsky Performance Status (KPS) and number of BMs were the only factors prognostic for OS. One hundred forty-seven patients (39%) received vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs). Median OS was significantly greater among patients receiving TKIs (16.8 vs 7.3 months, p < 0.001). Following multivariate analysis, KPS, number of metastases, and TKI use remained significantly associated with OS.
The crude incidence of local failure was 14.9%, with a 12-month cumulative incidence of 13.4%. TKIs did not significantly decrease the 12-month cumulative incidence of local failure (11.4% vs 14.5%, p = 0.11). Following multivariate analysis, age, number of BMs, and lesion size remained associated with local failure. The 12-month cumulative incidence of radiation necrosis was 8.0%. Use of TKIs within 30 days of SRS was associated with a significantly increased 12-month cumulative incidence of radiation necrosis (10.9% vs 6.4%, p = 0.04).
Use of targeted therapies in patients with RCC BM treated with intracranial SRS was associated with improved OS. However, the use of TKIs within 30 days of SRS increases the rate of radiation necrosis without improving local control or reducing distant intracranial failure. Prospective studies are warranted to determine the optimal timing to reduce the rate of necrosis without detracting from survival.