Intracranial hemorrhage in critically ill patients hospitalized for COVID-19

In this study, we report three cases of spontaneous intracranial hemorrhage in patients who were initially hospitalized at our tertiary care center in Washington, DC with symptoms of COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all three patients, who were critically ill, requiring intubation and ventilatory support. During their protracted hospitalizations, subsequent imaging disclosed intracranial hemorrhages, including intracerebral and subarachnoid hemorrhages, in the context of anticoagulation and coagulopathy. We believe this is related to the tropism of SARS-CoV-2 to the endothelial lining of the cerebral vasculature via their angiotensin-converting enzyme (ACE) II receptors. Given our findings, we advocate heightened vigilance for intracerebral hemorrhage events, and scanning when practicable, in COVID-19 patients which have prolonged ventilatory support and depressed neurologic examinations.     

Robot-assisted neurosurgery versus conventional treatment for intracerebral hemorrhage: A systematic review and meta-analysis

The aim of this review is to determine the efficacy and safety of robotic surgery for intracranial hemorrhage (ICH). PICO question was formulated as: whether robot-assisted neurosurgery is more effective and safer than conventional treatment for ICH with respect to drainage time, complications, operation time, extent of evacuation and neurological function improvement. We searched PubMed, Web of Science, Wiley Online, OVID, Embase, Cochrane Library, Clinical Trails, Current Controlled Trials, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), OpenGrey and references of related papers. Key words included robot, robotic, hematoma, hemorrhage and neurosurgery. Then we used Microsoft Excel to collect data. Except from qualitative analysis, we did meta-analysis using Review Manager 5.3. 9 papers were included in qualitative synthesis, 6 in meta-analysis for rebleeding rate and 4 in analysis for operative and drainage time. Qualitative synthesis showed shorter operative time and drainage time, a larger extent of evacuation, better neurological function improvement and less complications in robotic group, while meta-analysis suggested that robot-assisted surgery reduced rebleeding rate compared to other surgical procedures, but whether it is superior to conservative treatment in preventing rebleeding still needs more proof. Meta-analysis for operative and drainage time should be explained cautiously because a significant heterogeneity existed and we supposed that differences in baseline characteristics might influence the results. Finally, we drew a conclusion that robotic neurosurgery is a safe and effective approach which is better than conventional surgery or conservative treatment with respect to rebleeding rate, intracranial infection rate and neurological function improvement.     

Non-myxoma neoplastic cerebral aneurysms: A systematic review

Neoplastic cerebral aneurysms (NCAs) are highly rare lesions characterized by invasion of cancerous cells within the wall of an artery leading to aneurysm formation. While NCAs caused by myxomas are well characterized in the clinical literature, rarer etiologies have also been reported and are typically associated worse clinical outcomes. We performed the first PRISMA-compliant systematic literature review of true, non-myxoma neoplastic cerebral aneurysms using the PubMed/MEDLINE, Embase, Scopus, and Google Scholar databases. Data of interest included age, sex, aneurysm size, number of aneurysms, aneurysm location, neoplasm type, aneurysm treatments, cancer treatments, risk of rupture, intracerebral hemorrhage prevalence, subarachnoid hemorrhage prevalence, and survival at 90 and 180 days. A total of 50 studies met our inclusion criteria. The mean age of the patient population was 37.4 years (SD: ±16.8) and had an overall female preponderance (39/50, 78%). Of these NCA cases, 29/50 (58.0%) were choriocarcinomas, 10/50 (20.0%) were related to lung cancer, and 11/50 (22.0%) had other origins of variable pathologies. 90-day survival rates were 60.0% (15/25) for choriocarcinomas, 28.6% (2/7) for the lung cancer group, and 14.3% (1/7) for the other origins group. 180-day survival rates were 52.0% (13/25) for the choriocarcinoma group, 14.3% (1/7) for the lung cancer group, and 0% (0/7) for the other origins group. Prognosis of NCA patients ultimately depends on the course of disease progression and cancer management. Further research is needed to better understand optimal treatment modalities for patients with NCAs.     

Early prediction of clinical outcomes in patients with aneurysmal subarachnoid hemorrhage using computed tomography texture analysis

Radiological evaluation of subarachnoid hemorrhage (SAH) is often subject to interobserver variability. The aim of this study was to retrospectively detect computed tomography (CT) texture parameters in the early postictal state to predict cerebral vasospasm, delayed cerebral ischemia (DCI), and functional outcome in aneurysmal SAH using quantitative CT texture analysis (CTTA) via a commercially available software program and routine CT images. 40 patients with aneurysmal SAH surgically treated at the Keio University Hospital during a four-year period were analyzed. CT texture analyses were performed using a commercially available software program (Synapse Vincent). The following texture parameters of blood clots in the subarachnoid space and cerebral edema were assessed: mean CT value, entropy, skewness, and kurtosis. The mean CT value of blood clots in the subarachnoid space was significantly associated with cerebral vasospasm, DCI, and functional outcome. The mean CT value ≥ 49.64 Hounsfield units (HU) predicted cerebral vasospasm with a sensitivity and specificity of 85.7% and 61.5%, respectively (area under the curve [AUC] = 0.758). The mean CT value ≥ 49.95 HU predicted DCI with a sensitivity and specificity of 100% and 60.6%, respectively (AUC = 0.810). The mean CT value ≥ 53.00 HU predicted poor functional outcome with a sensitivity and specificity of 56.3% and 91.7%, respectively (AUC = 0.747). CTTA using a commercially available software program demonstrated that the mean CT value of clots in the subarachnoid space in the early postictal state could predict vasospasm, DCI, and clinical outcome with a high sensitivity and specificity.