Faculty Bibliography

BACKGROUND:Endovascular thrombectomy (EVT) is the gold standard for acute ischemic stroke (AIS) with large vessel occlusion (LVO). However, concomitant intracranial hemorrhage (ICH) might render AIS-LVO patients ineligible for EVT in real-life practice. OBJECTIVE:To provide robust evidence regarding the outcomes of EVT in AIS-LVO patients with concomitant ICH. METHODS:We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data analysis was performed using OpenMetaAnalyst software. We assessed the pooled incidence rate with a 95 % confidence interval (CI) for qualitative data and analyzed the pooled mean difference (MD) with a 95 % CI for continuous data. The pooled effect size for all outcomes was calculated using the DerSimonian and Laird random-effects model. RESULTS:Six studies were included in the meta-analysis. The overall incidence rate of successful revascularization was 85.3 % (95 % CI: 75.8 %-94.7 %), with rates of 76.1 % for ipsilateral hemorrhages and 66.1 % for contralateral hemorrhages. Functional independence was achieved in 20 % of patients (95 % CI: 4.8 %-36.8 %), with rates of 23 % for ipsilateral and 27.7 % for contralateral hemorrhages. Mortality was reported at 52 % (95 % CI: 34.9 %-69 %), with a higher rate of 52.6 % for ipsilateral hemorrhages compared to 36.8 % for contralateral hemorrhages. CONCLUSION/CONCLUSIONS:This meta-analysis indicates that EVT is feasible in AIS patients with concurrent ICH, yet it is associated with poor functional outcomes and high mortality rates. Careful patient selection is essential to optimize the outcomes, and further research is needed to enhance outcomes for these high-risk patients.

INTRODUCTION/BACKGROUND:Meningiomas that progress despite surgery and radiotherapy represent an unmet medical need. Expression of PD-1 and PDL-1 has been demonstrated in meningiomas and is proportional to tumor grade, suggesting a potential role for anti-PD-1/anti-PDL-1 inhibitor therapy. We explored the potential role of immunotherapy for recurrent meningiomas by describing progression-free survival (PFS) and overall survival (OS) in a single-center patient sample. METHODS:This is a retrospective chart review of patients with meningioma who were treated with PD-1 inhibitors at UPMC Hillman Cancer Center. Any patient over age 18 who received immunotherapy was included in this study. Patients received treatment until development of disease progression, intolerable toxicities or adverse events, death, or oncologist decision. Serial radiographic assessments were made every 3-6 months. RESULTS:Between January 2015 and November 2021, eight patients received anti-PD-1 therapy. All patients underwent tumor resection and radiosurgery, and four patients received prior systemic therapy. Six out of eight patients experienced symptomatic perilesional edema and three patients experienced exacerbation of seizures. Median PFS was 7 months (95% CI 1-24) and median OS was 1.75 years (95% CI 1.5-4.0). In patients with positive PD-1/PD-L1 expression, median PFS was 2 years and median OS was 3 years. CONCLUSION/CONCLUSIONS:Anti-PD-1 therapy was associated with a manageable safety profile in patients with recurrent meningiomas. Patients with WHO Grade III tumors and positive PD-1/PD-L1 expression were noted to have increased PFS and OS, suggesting a potential role for immunotherapy in these patients, but further studies are needed to investigate this in a larger patient population.

AIM:Femtosecond laser assisted cataract surgery is associated with pupillary constriction. This study aims to look at patient and surgical factors predisposing to abnormal pupil behaviour during FLACS. METHODS:This prospective observational study included all patients undergoing FLACS in the Princess of Wales Hospital, Bridgend, UK between February and June 2017. Pupils were measured at three time points; immediately before and after laser pre-treatment, and at the start of surgery. Pupil behaviour during surgery was noted in descriptive terms, patient demographic, co-morbidities, eye measurements, suction on time, shifting time and laser energy levels were recorded. RESULTS:Seventy-three eyes were included. Average patient age was 74.84 ± 9.1 years. Mean horizontal pupil sizes immediately before and after femto pre-treatment were 7.87 ± 0.87 mm and 7.7 ± 0.89 mm respectively (P < 0.0005). Mean horizontal pupil size at the start of surgery was 6.83 ± 1.43 mm (P < 0.0005). Short capsulotomy-pupil distance (P = 0.01), shallower anterior chamber (P = 0.0012), smaller pre-operative pupil size (P = 0.045) and longer suction on time (P = 0.0019) were significantly associated with intra-operative miosis during FLACS. Sustained mydriasis was observed in eyes in whom topical diclofenac was used within 2 h of surgery. CONCLUSIONS:FLACS can result in significant pupil miosis. Eyes particularly at risk are ones with smaller pre-operative pupils and shallower anterior chambers and those subjected to longer suction on time. Well-timed NSAIDs application could be protective against this phenomenon.

A 33-year-old female patient presented with diplopia and left eye ptosis 26 weeks into her first pregnancy. No investigation was conducted at the time and her symptoms subsided 4 weeks post partum. This same phenomenon occurred during second pregnancy at 20 weeks of gestation, with patient becoming symptom-free again 6 weeks after giving birth. MRI revealed a lesion in the left cavernous sinus in keeping with a meningioma. Due to the surgically challenging location, the lesion was treated with gamma knife radiosurgery. To date, the patient remains asymptomatic with no progression on follow-up imaging 9 years on.

While occasional hiccups are normal, their persistent recurrence is distressing and may have an underlying aetiology. Patients with recurrent hiccups may undergo a long journey and see many physicians before the diagnosis is finally made. The purpose of this report is to increase awareness of central nervous system lesions as a possible cause for recurrent hiccups and provide an illustrative case of an otherwise fit man presenting with ongoing hiccups caused by a medullary haemangioblastoma.