Cerebellitis as a neurosurgical disease in pediatrics

The diagnostic evaluation and role of neurosurgery in the treatment of cerebellitis is unclear. We explore the diagnostic evaluation and subsequent role of neurosurgical intervention in pediatric cerebellitis in a case series, highlighting the diagnostic work up and treatments applied. A retrospective review was conducted of all pediatric patients diagnosed with cerebellitis for whom neurosurgery was consulted at a single center from June 2008 to February 2019. Nine patients, four males (44.4%) and five females (55.6%) were identified. Common presenting symptoms were headache (n = 6, 66.7%), emesis (n = 5, 55.6%), and altered mental status (n = 4, 44.4%). Six (66.7%) had associated infections. Imaging abnormalities included tonsillar ectopia (n = 8, 88.9%), bilateral cerebellar T2 hyperintensity (n = 6, 66.7%), and obstructive hydrocephalus (n = 6, 66.7%). Management included antibiotics, antivirals, corticosteroids, mannitol, and hypertonic saline. Four (44.4%) required external ventricular drain (EVD) placement for a mean 11 days (SD 6.8, range 4–20) for hydrocephalus; none required additional neurosurgical interventions. Seven patients (77.8%) required ICU care for a mean 11.7 days (SD 14.0 range 1–42). At follow-up (mean 20.8 months, SD 28.7, range 0.6–64.9), two patients (n = 2, 22.2%) recovered completely, and six (66.7%) were functionally dependent (mRS > 2); the most common residual deficit was cognitive impairment (n = 5, 55.6%). Neurosurgical consultation should be considered in pediatric patients with cerebellitis. In our experience, temporary CSF diversion via an EVD is employed nearly half of the time. The presence of hydrocephalus requiring neurosurgical intervention may be a predictor of severe disease and poor outcome.     

Fourth ventricular neurocystercercosis presenting with acute hydrocephalus

Neurocysticercosis is an infection caused by the larvae of the pork tapeworm Taenia solium. Parenchymal lesions commonly present with seizure activity and intraventricular lesions can cause hydrocephalus. A 33-year-old female patient presented in a comatose state with acute hydrocephalus and a fourth ventricle lesion. She underwent placement of an external ventricular drain. Resection of the fourth ventricle lesion through a suboccipital approach allowed for restoration of normal cerebrospinal fluid (CSF) flow and relief of midbrain compression. The lesion was resected intact and the patient returned to normal neurological function. No CSF diversion procedure was necessary. The patient was discharged on cysticidal and steroid therapy. We concluded that surgical resection of lesions in the fourth ventricle attributed to neurocysticercosis is appropriate when brainstem compression is prominent. Resection may also avoid the need for permanent CSF diversion. We also reviewed the evidence-based management strategies described in the literature.     

神经内镜脑室应用解剖学研究与临床应用

目的研究脑室的神经内镜解剖学特点,探讨其临床应用价值.方法在15例尸颅标本及20例脑积水患者术中用神经内镜观察侧脑室、第三脑室的解剖结构.采用神经内镜治疗脑积水20例,其中行ETV 16例,1例行透明隔造瘘术,3例行脑室-腹腔分流术,并分析其临床和影像学结果.结果脉络丛、室间孔、乳头体及导水管开口等是内镜经额角人路观察侧脑室和第三脑室的重要＂路标＂.20例脑积水患者治疗后,19例症状好转,影像学复查脑室缩小的14例;1例脑转移瘤引起的脑积水患者,术后3月死亡.并发脑膜炎1例,发热2例,1例切口愈合不良,4例ETV术后并发头皮下少量积聚液,出血2例.结论经额角入路观察范围最大,是脑室内神经内镜手术的最常用入路.对于多种原因引起的梗阻性脑积水患者ETV有很好的效果.慎重选择造瘘部位和器械对于避免出血等严重并发症有重要意义.     

Functional outcome after surgical treatment of spinal meningioma

ObjectiveSpace-occupying spinal meningiomas (SM), commonly diagnosed due to gradual neurological deterioration, are treated surgically by decompression and tumor resection. In this series of patients with surgically treated SM, we determined individual predictors of functional outcome in the context of intraoperative neuromonitoring (IOM).MethodsThis retrospective study included 45 patients (39 women, 6 men; mean age 63 years). We reviewed pre- and postoperative charts, surgical reports, radiographic data for demographics, use of IOM, duration of symptoms, histopathology, co-morbidities, radiographic extension, surgical strategy, neurological performance (Japanese Orthopedic Association Score [JOA score]. Median follow-up was 34 months (12–190 months).ResultsMost frequent surgical approaches were laminectomy (71.1%, n = 32) and hemi-laminectomy (28.9%, n = 13). Predominant SM site was the thoracic spine (55.6%, n = 25). Most common symptoms were sensory deficits (77.8%, n = 35), gait disorders (55.6%, n = 25), motor deficits (42.2%, n = 19), and radiating pain (37.8%, n = 17). Simpson grade 1 resection was achieved in 6 patients, most common type of resection was Simpson grade 2 in 36 patients. During follow-up, 80.0% of patients had fully recovered sensory deficits (p < 0.001), 76.0% of patients with preoperative gait disorders had been asymptomatic (p < 0.001), and motor deficits in 12/19 (63.1%). Pain had decreased significantly from admission to follow-up (p = 0.001). IOM was used in 20 (44.4%) patients. Postoperatively, 6 (13.3%) patients had developed a new neurological deficit, 4 of them operated without IOM.ConclusionResection of SM with IOM showed good recovery, excellent functional results with low surgical morbidity.     

Increase of complement fragment C5a in cerebrospinal fluid during exacerbation of neuromyelitis optica

Complement is thought to play a pivotal role in neuromyelitis optica (NMO) pathogenesis. Anaphylatoxins (C3a, C4a, and C5a), produced in complement activation, have proinflammatory potential, and thereby may play an important role. We measured concentrations of anaphylatoxins in CSF and sera, obtained from patients with NMO (n = 15), multiple sclerosis (MS) (n = 15), and other neurological disease (OND) (n = 12), and evaluated their clinical implications. The CSF–C5a levels were elevated significantly in NMO patients, especially in patients with multiple enhanced lesions on MRI. The CSF–C5a levels correlated with the severity of exacerbation. Our results may provide a rationale for anti-complement therapies of NMO.     

Using deep learning convolutional neural networks to automatically perform cerebral aqueduct CSF flow analysis

Since the development of phase-contrast magnetic resonance imaging (PC-MRI), quantification of cerebrospinal fluid (CSF) flow across the cerebral aqueduct has been utilized for diagnosis of conditions such as normal pressure hydrocephalus (NPH). This study aims to develop an automated method of aqueduct CSF flow analysis using convolution neural networks (CNNs), which can replace the current standard involving manual segmentation of aqueduct region of interest (ROI). Retrospective analysis was performed on 333 patients who underwent PC-MRI, totaling 353 imaging studies. Aqueduct flow measurements using manual ROI placement was performed independently by two radiologists. Two types of CNNs, MultiResUNet and UNet, were trained using ROI data from the senior radiologist, with PC-MRI studies being randomly divided into training (80%) and validation (20%) datasets. Segmentation performance was assessed using Dice similarity coefficient (DSC), and CSF flow parameters were calculated from both manual and CNN-derived ROIs. MultiResUNet, UNet and second radiologist (Rater 2) had DSCs of 0.933, 0.928, and 0.867, respectively, with p < 0.001 between CNNs and Rater 2. Comparison of CSF flow parameters showed excellent intraclass correlation coefficients (ICCs) for MultiResUNet, with lowest correlation being 0.67. For UNet, lower ICCs of −0.01 to 0.56 were observed. Only 3/353 (0.8%) studies failed to have appropriate ROIs placed by MultiResUNet, compared to 12/353 (3.4%) failed cases for UNet. In conclusion, CNNs were able to measure aqueductal CSF flow with similar performance to a senior neuroradiologist. MultiResUNet demonstrated fewer cases of segmentation failure and more consistent flow measurements compared to the widely adopted UNet.     

Pure endoscopic expanded endonasal approach for olfactory groove and tuberculum sellae meningiomas

The expanded endoscopic endonasal (EEE) approach for the removal of olfactory groove (OGM) and tuberculum sellae (TSM) meningiomas is currently becoming an acceptable surgical approach in neurosurgical practice, although it is still controversial with respect to its outcomes, indications and limitations. Here we provide a review of the available literature reporting results with use of the EEE approach for these lesions together with our experience with the use of the endoscope as the sole means of visualization in a series of patients with no prior surgical biopsy or resection. Surgical cases between May 2006 and January 2013 were retrospectively reviewed. Twenty-three patients (OGM n = 6; TSM n = 17) were identified. In our series gross total resection (GTR) was achieved in 4/6 OGM (66.7%) and 11/17 (64.7%) TSM patients. Vision improved in the OGM group (2/2) and 8/11 improved in the TSM group with no change in visual status in the remaining three patients. Post-operative cerebrospinal fluid (CSF) leak occurred in 2/6 (33%) OGM and 2/17 (11.8%) TSM patients. The literature review revealed a total of 19 OGM and 174 TSM cases which were reviewed. GTR rate was 73% for OGM and 56.3% for TSM. Post-operative CSF leak was 30% for OGM and 14% for TSM. With careful patient selection and a clear understanding of its limitations, the EEE technique is both feasible and safe. However, longer follow-ups are necessary to better define the appropriate indications and ideal patient population that will benefit from the use of these newer techniques.     

Phase-contrast cine MRI revealing en valve mechanism in spontaneous third ventriculostomy: Report of a case and literature review

A 50-year-old epileptic woman affected by hydrocephalus due to aqueductal stenosis was admitted to the hospital because of headache, dysarthria, and mild lateral pulsion. Cranial computed tomography (CT) revealed left cerebellar hemorrhage. Subsequent magnetic resonance imaging (MRI) of the brain demonstrated an enlarged ventricular system unchanged from prior studies. Flow-sensitive phase-contrast (PC) cine magnetic resonance imaging showed flow absence through the aqueduct and flow pulsations through the third ventricle floor in systole and diastole, consistent with spontaneous third ventricle patency. On stationary tissue images, the third ventricle floor and the mamillary body were displaced downward at systole and upward at diastole. Stenosis of the cerebral aqueduct of Sylvius was also shown. Retrospective evaluation of the sagittal T2-weighted images disclosed flow void at the level of the third ventricle floor. On–off movements of the third ventricle floor could account for chronic hydrocephalus persistence by an en valve mechanism. Spontaneous third ventriculostomy (STV) was diagnosed on the basis of these findings.     

导水管梗阻所致巨大脑室脑积水的内镜治疗

目的 探讨导水管梗阻所致巨大脑室脑积水手术治疗的指征及并发症预防.方法 神经内镜下共治疗32例巨大脑室脑积水患者,其中25例行经额入路第三脑室底造瘘术,1例行经额小脑上池囊肿造瘘术,5例行枕下入路内镜下后颅窝囊肿切除、囊腔枕大池造瘘,1例行经枕下入路导水管成形术.结果 术后随访1-4年,32例具有行走不稳、尿失禁、智商下降、精神运动发育迟缓的患者中,26例症状明显改善,6例症状未继续进展.6例术前存在高颅压症状患者术后症状改善,除1例出现硬膜下积液外,无其他严重并发症发生.结论 巨大脑室脑积水并非内镜手术治疗禁忌,凡影像检查确定为导水管梗阻所致的巨大脑室脑积水,均应积极手术治疗,改进手术方法 可以避免严重并发症的发生.     

Clinical features and surgical outcomes of high-grade spinal meningiomas: Report of 19 cases and literature review

High-grade spinal meningiomas (SMs) are extremely rare lesions. The true incidence, clinical features and prognosis of SMs are still unclear. To elucidate this information by using institutional data and to provide an updated review of the literature. Nineteen consecutive patients harboring 20 high-grade SMs were identified, including 15 (78.9%) female patients, with a mean age of 37.8 ± 14.9 years. The 20 tumors were most frequently located in the lumbar and lumbosacral segment (n = 6, 30.0%), followed by the cervical segment (n = 5, 25.0%), thoracolumbar junction (n = 4, 20.0%), thoracic (n = 3, 15.0%) and cervicothoracic junction (n = 2, 10.0%). The mean number of affected spinal levels was 2 ± 1. Simpson grade II and III resection were achieved for sixteen (80.0%) and four (20.0%) tumors, respectively. During a mean follow-up of 79.6 ± 39.9 months, three tumors (15.0%) recurred. Fourteen patients (73.7%) achieved excellent outcomes, three (15.7%) remained stable, one (5.3%) deteriorated, and one (5.3%) died. High-grade SMs are rare entities which consist of 5.7% SM. These lesions tend to affect young patients, with atypical meningioma being the most common pathological subtype. In our study, surgery was an effective means of treatment. Close observation is warranted after surgery because of the high recurrence rate. Recurrent patients can still benefit from a second surgery.     

中脑导水管脑脊液动力学MRI研究

目的　无损伤性探测中脑导水管脑脊液动力学在临床实践中的意义。方法　应用 Ｃｉｎｅ Ｍ Ｒ Ｉ,测定了５３ 例患者中脑导水管脑脊液动力学指标（ 峰值流速、峰值流量、到头端峰值时间及 Ｃ Ｓ Ｆ 流动图） 。依据临床诊断,５３ 例分为五组： Ａ 对照组, Ｂ 交通性脑积水组, Ｃ 梗阻性脑积水组, Ｄ 颅内大脑半球占位性病变组, Ｅ 脑萎缩组。结果　 Ａ 组呈等动力学, Ｂ 组呈高动力学, Ｃ 组表现为高、等、低动力学, Ｄ组和 Ｅ 组为低动力学。结论　中脑导水管脑脊液流动的峰值流速、峰值流量、到头端峰值的时间以及脑脊液流动图对颅内某些疾患的诊断、鉴别诊断是有用的。同时,可以探讨脑积水分流指征及分流的有效性。     

Surgical treatment and outcomes of intramedullary tumors by minimally invasive approach

Intramedullary tumors are uncommon neoplasms which, without treatment, can cause neurologic morbidity or mortality. The goal of the treatment is complete surgical resection with a minimally invasive approach while preserving neurological status and also spinal stability. Out of 1972 patients with tumors of the spinal canal treated between 1994 and 2017, 168 intramedullary tumors of 417 intradural tumors have been presented. All patients had undergone one surgical resection. The mean age is 43 ± 12 years (range 11–67 years). Tumors were subdivided into 4 groups: cervically located-tumors (n = 43), cervicothoracic-region-tumors (n = 32), thoracic-region-tumors (n = 57), and lumbosacral-region-tumors (n = 36). The mean follow-up time was 37 ± 29 months. Gross-total resection rate was higher in cervical located intramedullary tumors compared to the thoracic intramedullary tumors. Cervical intramedullary tumors showed better postoperative functional outcome than the thoracic intramedullary lesions. In intramedullary tumors, extending more than 3 spinal segments, postoperative worsening was significantly increased. A minimally invasive approach (the bilateral decompression via unilateral hemilaminectomy) was used to remove the tumor while preserving spinal stability. Perioperative permanent morbidity was very low. Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Patients with thoracic intramedullary tumors and tumor extension of more than three segments were at a higher risk for permanent morbidity. The minimally invasive approach allowed complete removal of the intramedullary tumors, and adequate preservation of vertebral stability while providing a good postoperative course.     

Longitudinal cerebrospinal fluid biomarker trajectories along the Alzheimer's disease continuum in the BIOMARKAPD study

IntroductionWithin-person trajectories of cerebrospinal fluid (CSF) biomarkers in Alzheimer's disease (AD) are not well defined.MethodsWe included 467 subjects from the BIOMARKAPD study with at least two serial CSF samples. Diagnoses were subjective cognitive decline (n = 75), mild cognitive impairment (n = 128), and AD dementia (n = 110), and a group of cognitively unimpaired subjects (n = 154) were also included. We measured baseline and follow-up CSF levels of total tau (t-tau), phosphorylated tau (p-tau), YKL-40, and neurofilament light (NfL). Median CSF sampling interval was 2.1 years.ResultsCSF levels of t-tau, p-tau, NfL, and YKL-40 were 2% higher per each year of baseline age in controls (P <.001). In AD, t-tau levels were 1% lower (P <.001) and p-tau levels did not change per each year of baseline age. Longitudinally, only NfL (P <.001) and YKL-40 (P <.02) increased during the study period.DiscussionAll four CSF biomarkers increase with age, but this effect deviates in AD for t-tau and p-tau.     

Transient neurological deterioration due to watershed shift after STA-MCA bypass surgery in acute atherosclerotic occlusion

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery is considered not the primary but the last treatment option for acute atherosclerotic occlusions refractory to medical treatment. We retrospectively evaluated patients who underwent STA-MCA bypass surgery for acute atherosclerotic occlusion intractable to other treatments. From June 2010 to May 2014, 10 patients underwent STA-MCA bypass surgery for acute atherosclerotic occlusion at our hospital. The sites of occlusion were the internal carotid artery (n = 5) and the proximal MCA (n = 5). All 10 patients showed good patency in the anastomosis after bypass surgery, and postoperative cerebral angiography showed a newly formed border zone between the existing collateral blood flow and bypass graft blood flow. Transient neurological deterioration (TND) developed in 4 patients after STA-MCA bypass surgery (40%). All 4 patients showed worsened hemiparesis or aphasia 2–3 days after bypass surgery and improvement in neurological deficits within 1 week after bypass surgery. Diffusion MRI in patients with TND showed new cerebral infarctions near the newly formed border zone. In our series of bypass surgeries for acute atherosclerotic occlusion, postoperative changes in hemodynamic status, also called watershed zone shift, may be one of the causes of new cerebral infarctions near the newly formed border zone.     

One-Minute Dynamic Cerebral Autoregulation in Severe Head Injury Patients and its Comparison with Static Autoregulation. A Transcranial Doppler Study

Objective  To compare dynamic and static responses of cerebral blood flow to sudden or slow changes in arterial pressure in severe traumatic brain injury (TBI) patients. Design  Prospective study. Patients and Methods  We studied 12 severe TBI patients, age 16–63 years, and median GCS 6. We determined the dynamic cerebral autoregulation: response of cerebral blood flow velocity to a step blood pressure drop, and the static cerebral autoregulation: change in cerebral blood flow velocity after a slow hypertensive challenge. Results  During the dynamic response, the median drop in arterial pressure was 21 mm Hg. Dynamic response was graded between 9 (best) and 0 (worst). The median value was 5; four patients showed high values, (8–9), five patients showed intermediate values (4–6). In three patients (value = 0), the CBFV drop was greater than the cerebral perfusion pressure drop, and maintained through 60 s. The static cerebral autoregulation was preserved in 6/11 patients. The comparison between the two showed four different combinations. The five patients with impaired static cerebral autoregulation showed unfavorable outcome. Conclusions  A sharp dynamic vasodilator response could not be sustained, and a slow or absent reaction to a sudden hypotensive challenge could show an acceptable cerebral autoregulation in the steady state. We found that patients with impaired static cerebral autoregulation had a poor outcome, whereas those with preserved static cerebral autoregulation experience favorable outcomes.     

Infectious and immune-mediated central nervous system disease in 48 COVID-19 patients

ObjectivesTo summarise and discuss current knowledge about SARS-CoV-2-associated infectious/immune-mediated central nervous system (CNS)-disease.MethodLiterature review.ResultsAltogether 28 articles were found, which reported 48 patients with SARS-CoV-2-associated infectious/immune-mediated CNS-disease. Age ranged from 22 to 79y. There was male preponderance. There were 14 patients with infectious CNS-disease (meningitis (n = 1), encephalitis (n = 5), meningo-encephalitis (n = 5), myelitis (n = 3)), and 34 patients with parainfectious CNS-disease (encephalopathy (n = 18), autoimmune encephalitis (n = 11), acute, disseminated, encephalo-myelitis (n = 3), acute, haemorrhagic, necrotizing encephalopathy (n = 2)). The cerebrospinal fluid (CSF) was tested for SARS-CoV-2 in 40 patients and was positive for the virus in 4 patients with infectious CNS-disease but was negative for the virus in all patients with parainfectious CNS-disease. Immune-modulating treatment may be more effective than virostatics/antibiotics for SARS-CoV-2-associated infectious/parainfectious, non-vascular, non-hypoxic CNS-disease. In patients with autoimmune encephalitis plasmapheresis may be beneficial. Twenty-two patients recovered, 2 did not, and 6 patients died.ConclusionsSARS-CoV-2 can cause infectious/immune-mediated CNS-disease. The CSF is positive for virus-RNA in only few patients with infectious CNS-disease but negative for virus-RNA in immune-mediated CNS-disease, suggesting an immune-mediated pathophysiological mechanism. The outcome of SARS-CoV-2-associated infectious/immune-mediated CNS-disease is favourable in the majority of cases but can be fatal in single cases.     

Choroid plexus perfusion in sickle cell disease and moyamoya vasculopathy: Implications for glymphatic flow

Cerebrospinal fluid (CSF) and interstitial fluid exchange have been shown to increase following pharmacologically-manipulated increases in cerebral arterial pulsatility, consistent with arterial pulsatility improving CSF circulation along perivascular glymphatic pathways. The choroid plexus (CP) complexes produce CSF, and CP activity may provide a centralized indicator of perivascular flow. We tested the primary hypothesis that elevated cortical cerebral blood volume and flow, present in sickle cell disease (SCD), is associated with fractionally-reduced CP perfusion relative to healthy adults, and the supplementary hypothesis that reduced arterial patency, present in moyamoya vasculopathy, is associated with elevated fractional CP perfusion relative to healthy adults. Participants (n = 75) provided informed consent and were scanned using a 3-Tesla arterial-spin-labeling MRI sequence for CP and cerebral gray matter (GM) perfusion quantification. ANOVA was used to calculate differences in CP-to-GM perfusion ratios between groups, and regression analyses applied to evaluate the dependence of the CP-to-GM perfusion ratio on group after co-varying for age and sex. ANOVA yielded significant (p < 0.001) group differences, with CP-to-GM perfusion ratios increasing between SCD (ratio = 0.93 ± 0.28), healthy (ratio = 1.04 ± 0.32), and moyamoya (ratio = 1.29 ± 0.32) participants, which was also consistent with regression analyses. Findings are consistent with CP perfusion being inversely associated with cortical perfusion.     

Poor derivation of Tc-MEP baseline waveforms in surgery for ventral thoracic intradural extramedullary tumor: Efficacy of use of the abductor hallucis in cases with a preoperative non-ambulatory status

Most thoracic intradural extramedullary tumors (IDEMT) are benign lesions that are treated by gross total resection and spinal cord decompression. Intraoperative transcranial-motor evoked potential (Tc-MEP) monitoring is important for reducing postoperative neurological complications. The purpose of this study is to examine the characteristics of Tc-MEP waveforms in surgery for thoracic IDEMT resection based on location of the tumor relative to the spinal cord. The subjects were 56 patients who underwent surgery for thoracic IDEMT from 2010 to 2018. The waveform derivation rate for each lower muscle was examined at baseline and intraoperatively. 56 patients had a mean age of 61.7 years, and 21 (38%) were non-ambulatory before surgery. The tumors were schwannoma (n = 28, 50%), meningioma (n = 25, 45%), and neurofibroma (n = 3, 5%); and the lesions were dorsal (n = 29, 53%) and ventral (n = 27, 47%). There was a significantly higher rate of undetectable waveforms in all lower limb muscles in the ventral group compared to the dorsal group (15% vs. 3%, p < 0.05). In non-ambulatory cases, the derivation rate at baseline was significantly lower for ventral thoracic IDMETs (47% vs. 68%, p < 0.05). The abductor hallucis (AH) had the highest waveform derivation rate of all lower limb muscles in non-ambulatory cases with a ventral thoracic IDMET. Spinal cord compression by a ventral lesion may be increased, and this may be reflected in greater waveform deterioration. Of all lower limb muscles, the AH had the highest derivation rate, even in non-ambulatory cases with a ventral IDEMT, which suggests the efficacy of multichannel monitoring including the AH.     

Primary fatty amides in plasma associated with brain amyloid burden,hippocampal volume,and memory in the European Medical Information Framework for Alzheimer's Disease biomarker discovery cohort

IntroductionA critical and as-yet unmet need in Alzheimer's disease (AD) is the discovery of peripheral small molecule biomarkers. Given that brain pathology precedes clinical symptom onset, we set out to test whether metabolites in blood associated with pathology as indexed by cerebrospinal fluid (CSF) AD biomarkers.MethodsThis study analyzed 593 plasma samples selected from the European Medical Information Framework for Alzheimer's Disease Multimodal Biomarker Discovery study, of individuals who were cognitively healthy (n = 242), had mild cognitive impairment (n = 236), or had AD-type dementia (n = 115). Logistic regressions were carried out between plasma metabolites (n = 883) and CSF markers, magnetic resonance imaging, cognition, and clinical diagnosis.ResultsEight metabolites were associated with amyloid β and one with t-tau in CSF, these were primary fatty acid amides (PFAMs), lipokines, and amino acids. From these, PFAMs, glutamate, and aspartate also associated with hippocampal volume and memory.DiscussionPFAMs have been found increased and associated with amyloid β burden in CSF and clinical measures.     

Arterial fenestrations and their association with cerebral aneurysms

Fenestrations of intracranial arteries and associated aneurysms are rare. The significance of these fenestrations in relation to aneurysms remains unclear. We present four patients with fenestration-associated aneurysms and a comprehensive review of associations with aneurysms and other vascular lesions. A PubMed search of the literature was conducted from 1970–2012 reporting cases of intracranial aneurysms associated with arterial fenestration or duplications. Data were collected on patient presentation, sex, age, aneurysm and fenestration location, aneurysm treatment, and presence of other vascular lesions. We performed a retrospective review of four patients with intracranial fenestrations associated with aneurysms at our institution from 2012–2013. There were 59 cases of fenestrations and associated aneurysms in the literature. Aneurysms were reported as either arising from (n = 50) or adjacent to but distinct from (n = 13) fenestrations. The most common single fenestration location was at the basilar artery (n = 23, 36.5%); however the majority of fenestrations were in the carotid circulation (n = 34, 54.0%). The majority of patients with aneurysms and fenestrations at all locations except those at the anterior communicating artery (70.5%) presented with subarachnoid hemorrhage. Patients with aneurysms arising from a fenestration or adjacent to a fenestration presented with an additional intracranial vascular lesion in 38% and 31% of cases, respectively. The majority of all aneurysms were treated with microsurgical clipping. Aneurysms associated with cerebral arterial fenestrations are most commonly discovered after subarachnoid hemorrhage and are most often located in the carotid circulation. A high index of suspicion must be maintained for an associated vascular lesion if an intracranial fenestration is discovered.