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1 August 2022, 6:09 pm

1. Chalif EJ, Murray RD, Mozaffari K, et al. Malignant pineal parenchymal tumors in adults: a National Cancer Database analysis. Neurosurgery 2022;90:807–15

Pineal parenchymal tumors (PPTs) are rare tumors of the pineal gland that account for <1% of primary central nervous system tumors in adults. Although these tumors are heterogeneous and display a wide degree of morphological variation, the World Health Organization (WHO) Classification of Tumors separates these into 5 distinct histological entities: pineocytoma (WHO grade I), PPT of intermediate differentiation (PPTID, WHO grade II/III), pineoblastoma (PB, grade IV), papillary tumor of the pineal region (PTPR, WHO grade II/III), and the recently characterized desmoplastic myxoid SMARCB1-mutant.

The National Cancer Database was queried for histologically confirmed PPT diagnosed from 2007 to 2016. Univariate and multivariate Cox regressions were used to evaluate the prognostic impact of covariates. Kaplan–Meier survival curves were generated for comparative subanalyses.

Of the 251 patients who met inclusion criteria, 172 had PPTs of intermediate differentiation (PPTID) and 79 had pineoblastoma. A plurality of patients with pineoblastomas were treated with trimodal therapy (39.1%), whereas patients with PPTID were commonly treated with either surgery alone or surgery and radiation (33.7% each). Factors independently associated with improved overall survival include younger patient age, female sex, lower comorbidity score, lower tumor grade, and treatment with surgery or radiation. Subanalyses confirm the effect of radiation on survival in patients with grade III PPTID with subtotal resection; however, no survival benefit of adjuvant radiation is demonstrated in patients with grade II PPTID with subtotal resection.

The authors conclude that although radiotherapy and surgery were found to increase survival in all patients with PPT, there was no demonstrable survival benefit of adjuvant radiation in surgically treated patients with grade II PPTID.

6 figures, 2 tables with no imaging

2. Hannan CJ, Hammerbeck-Ward C, Pathmanaban ON,

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13 July 2022, 5:26 pm

1. Huynh J, Donovan J, Phu NH, et al. Tuberculous meningitis: progress and remaining questions. Lancet Neurol 2022;21:450–64. Available from: http://dx.doi.org/10.1016/S1474-4422(21)00435-X

Tuberculosis affects 10 million people globally each year, of which an estimated 2–5% have tuberculous meningitis. The true incidence of tuberculous meningitis is unknown; however, tuberculous meningitis is the leading cause of bacterial brain infections in settings with a high tuberculosis burden, disproportionately affecting young children and individuals with HIV. Here, the authors review advances made in the past 7 years concerning the pathogenesis, diagnosis, and treatment of tuberculous meningitis, emphasizing areas of uncertainty and updating Reviews published in The Lancet Neurology in 2005 and 2013. This Review focuses mainly on adult tuberculous meningitis and briefly emphasizes novel research advances in pediatric tuberculous meningitis, including important clinical trials on its management.

Confirming a diagnosis of tuberculous meningitis is challenging because it requires detection of M tuberculosis in CSF. CSF Ziehl-Neelsen staining and microscopy is rapid, inexpensive, and can be performed in many laboratories with few resources. However, a study of 618 individuals with tuberculous meningitis in Vietnam, South Africa, and Indonesia reported that its sensitivity was generally poor (ie, approximately 30%) and was not improved by adaptations to enhance staining of intracellular bacteria. PCR-based tests, such as GeneXpert MTB/RIF and GeneXpert MTB/RIF Ultra (Cepheid, Sunnyvale, CA, USA), are rapid and offer identification of rifampicin resistance. Although these tests are useful when positive, the negative predictive values of GeneXpert MTB/RIF is insufficient to rule out tuberculous meningitis. Large-volume CSF sampling and meticulous processing steps are essential to optimize the performance of smear, culture, and nucleic acid amplification tests.

Brain MRI features that predict future outcome and treatment response are poorly defined. Tools based on artificial intelligence and machine learning are being developed to enable an unbiased and automated assessment of …

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5 June 2022, 7:51 pm

1.         Stevens MN, Gallant JN, Feldman MJ, et al. Management of postradiation late hemorrhage following treatment for HPV-positive oropharyngeal squamous cell carcinoma. Head Neck 2022;44:1079–85. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/35150023/

Acute hemorrhage is an uncommon but potentially deadly complication for patients with head and neck cancer, especially in patients receiving RT. Previous reports have focused on hemorrhage following RT in all head and neck subsites without isolating HPV-positive malignancies. In this article, the authors focus specifically on patients with previously treated HPV-positive OPSCC given (1) the increasing prevalence and survival of this population and (2) the critical role RT plays in its treatment. They detail patient characteristics and cancer treatments leading to hemorrhagic events and include the acute interventions used in these life-threatening situations to better characterize this patient population.

A total of 12 patients with HPV-positive OPSCC were included. Six patients had base of tongue (BoT) tumors and 6 patients had tonsil tumors. The majority of patients were male (83%) with a mean age at diagnosis of 58 years. Fifty percent had advanced primary tumors (T3/T4). Median time from completion of chemoradiation to first hemorrhagic event was 186 days (range 66–1466 days). Seven patients (58%) required intervention to secure their airway. All patients were evaluated for endovascular intervention, 6 (50%) were embolized. Eight patients (67%) had a second hemorrhagic event; median time to second bleed was 22 days (range 3–90 days).

CTA was performed for 11 patients and demonstrated active extravasation in 1 patient, pseudoaneurysm (2), a combination of both extravasation and pseudoaneurysm (1), luminal irregularity (5), and no radiographic indication of vessel abnormality (2).

Seven of the 12 patients in the cohort ultimately required tracheostomy to secure their airway. In this study population, once the airway was established, attention was turned to control of hemorrhage with oropharyngeal packing with …

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3 May 2022, 9:13 pm

1. Bonati LH, Jansen O, de Borst GJ, et al. Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022;21:273–83. Available from: http://dx.doi.org/10.1016/S1474-4422(21)00359-8

The benefit of carotid endarterectomy in patients with symptomatic carotid stenosis was established in the final two decades of the past century. In the NASCET trial, the 2-year risk of any ipsilateral stroke (including perioperative events) in patients with severe symptomatic carotid stenosis (≥70% narrowing of the lumen) was reduced from 26% to 9%. Modest benefit was also observed in patients with moderate stenosis (50–69%) by a reduction of stroke risk from 22.2% to 15.7% after 5 years. In the European Carotid Surgery Trial (ECST), endarterectomy prevented stroke only in patients with symptomatic carotid stenosis of 80% or greater, but measurement of the degree of stenosis on angiography differed between the trials. In a pooled analysis of NASCET, ECST, and the smaller Veterans Affairs trial, in which ECST angiograms were reanalyzed using the NASCET method, the absolute 5-year risk reduction from endarterectomy was 15.9% in patients with severe (≥70%) stenosis and 4.6% in patients with moderate (50–69%) stenosis. Thus, the number needed to treat would be six patients with severe symptomatic stenosis, or 22 patients with moderate symptomatic stenosis, had to be operated on to prevent one ipsilateral stroke after 5 years. Furthermore, extracranial-intracranial bypass surgery is not effective to prevent stroke in patients with carotid artery occlusion.

Among patients with symptomatic carotid stenosis, randomized controlled trials have consistently shown that the risk of periprocedural stroke or death is greater with stenting than with endarterectomy. However, this outcome was mainly caused by a higher risk of minor stroke occurring with stenting, and the extra events largely occurred in patients older than 70 years. Conversely, stenting reduces the risk of procedure-related myocardial infarction, cranial nerve palsy, and hematoma …

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4 April 2022, 10:28 pm

1. Pingree GM, Fleming C, Reavey-Cantwell J, et al. Neurosurgical causes of pulsatile tinnitus: contemporary update. Neurosurgery 2022;90:161–69

This review details the most common treatable neurosurgical entities that can present with pulse-synchronous tinnitus: Cervical carotid stenosis, ICA dissection, FMD, Petrous carotid dissection/aneurysm, Cavernous carotid dissection/aneurysm, AVM/AVFs, glomus tumors, and various venous stenoses, and thrombosis, among others.

Patients with internal carotid artery dissection can present unilateral headaches, posterior cervical pain, cranial nerve palsies, oculosympathetic palsy, and cerebral or retinal ischemia. Objective bruits may be detected on arterial auscultation. Pulsatile tinnitus has been reported in 5% to 15% of patients with ICAD but is infrequently the sole presenting symptom. ICADs are typically identified on MRI/ magnetic resonance angiography (MRA) or computed tomography (CT) angiography, or conventional angiography.  Many cases of ICAD are self-limiting, with stenosis resolving in approximately 46% to 90% of patients over a 3- to 6-mo interval. Invasive options such as angioplasty and stenting are reserved for cases of hemodynamically significant stenosis or expanding lesions with progressive stenosis. In the majority of cases of PT secondary to ICAD, PT spontaneously improves together with the arterial injury over the course of 2 to 6 months.

Patients with petrous carotid dissection may present with deafness, vertigo, and facial nerve weakness and even nausea, vomiting, and cranial nerve involvement with more severe diseases. PT can be the sole presenting symptom. As in the cervical carotid, treatment of spontaneous and asymptomatic dissections is typically medical management with antiplatelet medications. Endovascular treatment can be given for patients with increasing pseudoaneurysm size or recurrent ischemia, despite medical management.  Improvement in PT symptoms has been reported after both medical treatment and endovascular treatment of petrous segment dissections.

2 tables, 6 figures with MR, CT and catheter angio

2. Delev D, Hakvoort K, Krüger MT, et al. Choroidal

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