In conjunction with intravenous immunoglobulin, low-dose ASA in acute KD is not inferior to high-dose ASA for reducing the risk of CA abnormalities.

B rain metastases are a significant source of illness and death among cancer patients 8 and will eventually develop in about 20%-40% of patients with a primary extracranial neoplasm. 9 The intent of current optimal case management remains mostly palliative. Resection has been shown to improve neurological symptoms, improve functional independence, and increase survival times. 19 However, surgery alone is associated with a 46%-59% rate of local recurrence, presumably because Early Gamma Knife stereotactic radiosurgery to the tumor bed of resected brain metastasis for improved local control Object. Optimal case management after surgical removal of brain metastasis remains controversial. Although postoperative whole-brain radiation therapy (WBRT) has been shown to prevent local recurrence and decrease deaths, this modality can substantially decrease neurocognitive function and quality of life. Stereotactic radiosurgery (SRS) can theoretically achieve the same level of local control with fewer side effects, although studies conclusively demonstrating such outcomes are lacking. To assess the effectiveness and safety profile of tumor bed SRS after resection of brain metastasis, the authors performed a retrospective analysis of 110 patients who had received such treatment at the Centre Hospitalier Universitaire de Sherbrooke. They designed the study to identify risk factors for local recurrence and placed special emphasis on factors that could potentially be addressed.Methods. Patients who had received treatment from 2004 through 2013 were included if they had undergone surgical removal of 1 or more brain metastases and if the tumor bed was treated by SRS regardless of the extent of resection or prior WBRT. All cases were retrospectively analyzed for patient and tumor-specific factors, treatment protocol, adverse outcomes, cavity outcomes, and survival for as long as follow-up was available. Univariate and multivariate Cox regression analyses were performed to identify risk factors for local recurrence and predictors of increased survival times.Results. Median patient age at first SRS treatment was 58 years (range 37-84 years). The most frequently diagnosed primary tumor was non-small cell lung cancer. The rate of gross-total resection was 81%. The median Karnofsky Performance Scale score was 90%. Tumor bed SRS was performed at a median of 3 weeks after surgery. Median follow-up and survival times were 10 and 11 months, respectively. Actuarial local control of the cavity at 12 months was 73%; median time to recurrence was 6 months. According to multivariate analysis, risk factors for recurrence were a longer surgery-to-SRS delay (HR 1.625, p = 0.003) and a lower maximum radiation dose delivered to the cavity (HR 0.817, p = 0.006). Factors not associated with increased recurrence were subtotal or piecemeal resections, prior WBRT, histology of the primary tumor, and larger cavity volume. No factors predictive of survival were identified. Symptomatic radiation-induced enhancement occurred in 6% of patients and leptomeninge...

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BackgroundChronic subdural hematoma (CSDH) is one of the most frequent reason for cranial neurosurgical consultation. There is no widely accepted medical treatment for this condition. Herein, we present the protocol for the Tranexamic Acid (TXA) in Chronic Subdural Hematomas (TRACS) trial aiming at determining whether TXA can increase the rate of CSDH resolution following conservative management, lower the number of required surgical procedures and decrease the rate of CSDH recurrence following surgical evacuation.MethodsTRACS is a multicenter, double-blind, randomized, parallel-design, placebo-controlled, phase IIB study designed to provide preliminary efficacy data as well as feasibility, safety and incidence data required to plan a larger definitive phase III trial.Consecutive patients presenting with a diagnosis of chronic subdural hematoma will be screened for eligibility. Exclusion criteria include: specific risk factors for thromboembolic disease, anticoagulant use or contraindication to TXA. A total of 130 patients will be randomized to receive either 750 mg of TXA daily or placebo until complete radiological resolution of the CSDH or for a maximum of 20 weeks. CSDH volume will be measured on serial computed tomography (CT) scanning. Cognitive function tests, quality of life questionnaires as well as functional autonomy assessments will be performed at enrollment, at 10 weeks following randomization and at 3 months following treatment cessation. During the treatment period, patients will undergo standard CSDH management with surgery being performed at the discretion of the treating physician. If surgery is performed, the CSDH and its outer membrane will be sampled for in vitro analysis.The primary outcome is the rate of CSDH resolution by 20 weeks without intervening unplanned surgical procedure. Secondary outcomes include: CSDH volume, incidence of surgical evacuation procedures, CSDH recurrence, cognitive functions, functional autonomy, quality of life, incidence of complications and length of hospital stay. Planned subgroup analyses will be performed for conservatively versus surgically managed subjects and highly versus poorly vascularized CSDH.DiscussionCSDH is a frequent morbidity for which an effective medical treatment has yet to be discovered. The TRACS trial will be the first prospective study of TXA for CSDH.Trial registrationNCT ID: NCT02568124.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1358-5) contains supplementary material, which is available to authorized users.

Trigeminal neuralgia (TN) is a rare neuropathic facial pain disorder. Two forms of TN, classical TN (CTN) and atypical TN (ATN), are reported and probably have different aetiologies. The aim of the present study was to evaluate the functional integrity of the diffuse noxious inhibitory controls (DNIC) in (1) a group of patients with classical trigeminal neuralgia (CTN), (2) a group of patients with atypical trigeminal neuralgia (ATN), and (3) a group of healthy controls in order to determine if a descending pain modulation deficit could participate in the pathophysiology of TN pain. DNIC responses of 14 CTN patients, 14 ATN patients and 14 healthy controls were obtained by comparing thermode-induced facial heat pain scores before and after activating DNIC.DNIC was triggered using a standard counter-irritation paradigm (i.e., immersion of the arm in painfully cold water). General sensitivity to pain was also evaluated by measuring mechanical pain thresholds over 18 points located outside the trigeminal territory.Healthy participants and CTN patients showed a 21% and 16% reduction in thermodeinduced pain following the immersion, respectively (all p-values <.01), whereas ATN patients experienced no change (p=.57). ATN patients also had more tender points (mechanical pain thresholds < 4.0 kg) than CTN and healthy controls (all p-values < .05).Taken together, these results suggest that the underlying physiopathology differs between CTN and ATN and that a deficit in descending inhibition may further contribute to the pain experienced by patients with ATN.

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Object Among patients with multiple sclerosis (MS) there is a high incidence of trigeminal neuralgia (TN), and outcomes after treatment seem inferior to those in patients suffering from idiopathic TN. The goal of this study was to evaluate clinical outcomes in patients with MS-related TN after Gamma Knife surgery (GKS) and compare them with those obtained using percutaneous retrogasserian glycerol rhizotomy (PRGR). Methods The authors retrospectively reviewed the charts of 45 patients with MS-related TN. The first procedure undertaken was GKS in 27 patients and PRGR in 18 patients. Pain had been present for a median of 60 months (range 12–276 months) in patients who underwent GKS and 48 months (range 12–240 months) in patients who underwent PRGR. The following outcome measures were assessed in both groups of patients: pain relief (using the Barrow Neurological Institute [BNI] Pain Scale), procedure-related morbidity, time to pain relief and recurrence, and subsequent procedures that were performed. Results The median duration of follow-up was 39 months (range 13–69 months) in the GKS group and 38 months (range 2–75 months) in the PRGR group. Reasonable pain control (BNI Pain Scale Scores I–IIIb) was noted in 22 patients (81.5%) who underwent GKS and in 18 patients (100%) who underwent PRGR. For patients who underwent GKS, the median time to pain relief was 6 months; for those who underwent PRGR, pain relief was immediate. In the GKS group12 patients required subsequent procedures (3 patients for absence of response and 9 patients for pain recurrence), whereas in the PRGR group 6 patients required subsequent procedures (all for pain recurrence). As of the last follow-up, complete or reasonable pain control was finally achieved in 23 patients (85.2%) in the GKS group and in 16 patients (88.9%) in the PRGR group. The morbidity rate was 22.2% in the GKS group (all due to sensory loss and paresthesia) and 66.7% in the PRGR group (mostly hypalgesia, with 2 patients having corneal reflex loss and 1 patient suffering from meningitis). Conclusions Both GKS and PRGR are satisfactory strategies for treating MS-related TN. Gamma Knife surgery has a lower rate of sensory and overall morbidity than PRGR, but requires a delay before pain relief occurs. The authors propose that patients with extreme pain in need of fast relief should undergo PRGR. For other patients, both management strategies can lead to satisfactory pain relief, and the choice should be made based on patient preference and expectations.

The treatment of malignant glial tumours remains a tremendous challenge despite decades of pre-clinical and clinical research. These tumours represent about 80% of all primary brain tumours, and have a universally unfavourable prognosis despite new radiotherapy protocols and chemotherapy regimens.1,2 Thus, research remains active in this field, and therefore commands for pre-clinical models that are valid and predictive. Many animal models, mostly using the rat, have been developed to simulate the behaviour of glioblastoma tumour cells and to study the impact of radiotherapy, 3 chemotherapy, This phenomenon is explained by enhancement of the brain around tumour, the extra-axial tumour growth, and a shrinking factor of 17% related to the fixation process. Nonetheless, the radiological tumour growth paralleled the histological samples. This technology is thus suitable to follow tumour growth in F98 implanted rats. Les images rehaussées en T1 surestimaient toujours la masse tumorale mesurée sur les coupes H&E. Ce phénomène s'explique par le rehaussement du tissu cérébral autour de la tumeur, la croissance tumorale extra-axiale et un facteur de contraction de 17% dû au processus de fixation. Néanmoins, la croissance tumorale observée à l'imagerie évoluait parallèlement à celle observée en anatomopathologie. Cette technologie convient donc au suivi de la croissance tumorale chez les rats porteurs d'un implant F98.