Baptist Medical Center Jacksonville

The detection rate of contralateral hilar involvement in NSCLC during EBUS-TBNA staging is not well established. We conducted a retrospective observational single-center study of all EBUS-TBNA staging examinations performed from 2016 through 2020 to determine the incidence of PET and CT negative N3 hilar metastasis by EBUS-TBNA in patients with radiographic T1-T4, N0-N3, M0 NSCLC. A total of 516 patients underwent EBUS-TBNA sampling of contralateral hilar lymph nodes. Metastatic non-small cell lung cancer was detected in one or more contralateral hilar lymph node stations in 5 patients (0.97%). Four of these patients had radiographic N2 or N3 disease on PET imaging. Patients with mediastinal N2/N3 disease by PET scan were at higher risk of having occult contralateral hilar disease as compared with mediastinal N0/N1 by PET (P=0.017). In individuals radiographically staged as mediastinal N3 by CT scan, 14 (95% CI: 3-78) patients would need to undergo EBUS-TBNA sampling of a CT negative contralateral hilar lymph node to identify malignant involvement of the latter. In cases radiographically staged as mediastinal N3 by PET scan, 25 (95% CI: 6-141) patients would need to undergo EBUS-TBNA sampling of a PET-negative contralateral hilar lymph node to identify malignancy involvement in this location. In patients with NSCLC undergoing EBUS staging for radiographic N0/N1 disease by PET, it is reasonable to not sample the contralateral hilar lymph node stations. In radiographic N2/N3 disease by PET or CT, sampling the contralateral hilar lymph node stations appears to be justified.

Reliable assessment of prognosis after aneurysmal subarachnoid hemorrhage (SAH) is essential to inform clinical decision-making and prevent premature assumptions of poor outcome. The enhanced SAH (eSAH) score combines three routinely available variables-age, Glasgow Coma Scale (GCS), and subarachnoid hemorrhage blood volume (SAHV)-to provide an objective framework for early outcome stratification. SAHV is estimated using the ABC/2-derived ellipsoid method applied across five major cisternal compartments on non-contrast CT. While the eSAH score has shown promise in initial derivation studies, its external performance and calibration have not yet been validated across diverse healthcare settings. We conducted a retrospective cohort study using consecutive data from two high-volume tertiary centers: one in a high-income country (the United States) and one in a middle-income country (Brazil). Non-aneurysmal SAH cases were excluded. The eSAH score was validated to predict discharge functional outcomes (modified Rankin Scale, mRS) and mortality, using discrimination (area under the ROC curve, AUC) and calibration metrics and was compared to the World Federation of Neurosurgical Societies (WFNS) score. A total of 472 patients were included. The eSAH score demonstrated moderate discriminative performance, with AUCs of 0.78 for unfavorable functional outcome and 0.799 for in-hospital mortality. Each one-point increase in the score was associated with a 2.14-fold increase in the odds of poor outcome (95% CI, 1.84-2.50; p < 0.0001) and a 2.14-fold increase in the odds of mortality (95% CI, 1.78-2.57; p < 0.001). The WFNS score yielded slightly lower AUCs (0.76 and 0.75, respectively). The eSAH score provides a simple, generalizable framework for early prognostication after aneurysmal SAH, performing consistently across two markedly different healthcare systems. Although its discriminative power remains moderate, its objective structure and reliance on measurable imaging features make it ideally suited for integration with artificial intelligence to enable automated, precise, and scalable SAHV quantification. Such integration may substantially enhance prognostic accuracy and support more equitable, data-driven neurocritical care worldwide.

Abstract Introduction: Primary central nervous system lymphoma (PCNSL) in patients with HIV/AIDS is difficult to treat due to severe immunosuppression, opportunistic infections, and reduced marrow reserve, which limit tolerance to intensive chemotherapy and radiotherapy. Radiosurgery offers a targeted treatment option, but its success depends on immune recovery, particularly adequate CD4 restoration through HAART. Additionally, molecular mediators such as MYC, CD44, and RGS13 influence tumor biology, immune evasion, and radiosensitivity, underscoring the need for an integrated therapeutic approach. Methods: We retrospectively analyzed 89 patients with HIV/AIDS-associated PCNSL who underwent stereotactic radiosurgery. Clinical variables included demographics, CD4 count at diagnosis and prior to radiosurgery, ART status, treatment combinations, and survival outcomes. Subgroup analyses stratified outcomes by CD4 thresholds (&lt; 100 vs ≥ 100 cells/µL) and timing of HAART initiation. In addition, we explored the functional relevance of MYC, CD44, and RGS13 as described in prior patent publications and translational studies, focusing on their implications for proliferation, survival signaling, and therapeutic resistance. Results: Patients treated with radiosurgery alongside HAART had significantly better survival than those receiving radiosurgery alone. A CD4 count ≥ 100 cells/µL before treatment was key for durable response, local control, and survival. Early HAART initiation promoted immune recovery and enhanced radiosurgical benefit, consistent with guideline recommendations on optimizing immunity before cytotoxic therapy. Molecular findings linked MYC and CD44 to resistance and aggressiveness, while RGS13 may influence B-cell signaling and radiosensitivity. Conclusion: The study shows that immune restoration through HAART is essential for successful radiosurgery in HIV/AIDS-related PCNSL. Optimal outcomes require early HAART initiation and CD4 recovery (≥ 100 cells/µL), while radiosurgery alone is insufficient. Future trials should integrate radiosurgery with immune-based and molecularly guided strategies to improve survival.

Complications not only affect patients but also impose a significant psychological burden on physicians. Quantitative data in neurointerventional surgery regarding the 'second victim' phenomenon are lacking. This study aimed to assess the prevalence and severity of post-traumatic stress symptoms among neurointerventionalists after major complications. A survey was developed by a committee of experienced neurointerventionalists and distributed internationally via multiple platforms. Respondents were anonymous. Demographic information, complication type, and institutional support availability were queried. Psychological distress was measured using the validated Impact of Event Scale-Revised (IES-R), which assesses intrusion, avoidance, and hyperarousal domains. Descriptive statistics and regression analyses were performed to identify factors associated with post-traumatic stress symptoms. Of 1042 invited physicians, 503 responded (48%), with 413 completing the full survey (40%). The most common pathology was cerebral aneurysm, and the most frequent complication was hemorrhage. Overall, 64% scored above the IES-R threshold for possible post-traumatic stress disorder (PTSD) (≥24), with many reaching levels (≥37) associated with long-term stress and physiological sequelae. Intrusion was the dominant symptom domain, particularly distressing reminders about the complication. Lack of institutional support was significantly associated with possible PTSD (OR 1.63, 95% CI 1.1 to 2.5, P=0.02). No differences were observed by specialty, but geographic variations were present. High stress scores persisted long after the index event. Complications exert a profound emotional and physiological toll on neurointerventionalists, with high rates of possible PTSD and a strong association with inadequate institutional support. Systematic support programs are urgently needed to safeguard physician well-being and patient safety.

Hydroxychloroquine (HCQ) is an anti-malarial drug safely used in rheumatologic conditions with its various mechanisms on immunomodulation aside from its impact on cardiovascular health. However, multiple systemic effects, from ocular toxicity to cardiotoxicity, were reviewed and reported within adequate weight-based HCQ doses, challenging the need for alternate HCQ monitoring. We report cases with catastrophic adverse events from chronic HCQ use and supratherapeutic blood HCQ levels while within the recommended weight-based dosing. Cases of supratherapeutic HCQ blood levels have emerged despite adherence to weight-based dosing, indicating the necessity for individualized monitoring. This study aims to highlight the toxicities associated with chronic HCQ use along with the limitations of current weight-based dosing guidelines. This also provides a discussion on the unique pharmacokinetics and pharmacodynamics of HCQ in better understanding proposed HCQ blood level monitoring.

BackgroundMiddle meningeal artery embolization (MMAE) is a promising treatment for chronic subdural hematoma (cSDH). Cancer patients are at risk for cSDH due to thrombocytopenia. The efficacy of MMAE in this population has not been studied.MethodsWe conducted a retrospective analysis of 76 patients who underwent 94 MMAEs for cSDH at 12 tertiary centers across North America and Europe between February 2018 and January 2023. We analyzed patient demographics, clinical profiles, procedural details, and outcomes. The primary outcome was cSDH progression, while secondary outcomes included radiographic resolution, mortality, 90-day functional outcomes, functional improvement, and procedural complications.ResultsRadiographic improvement occurred in 88.5% of patients, and technical success was achieved in 96.8%, with comparable rates between the MMAE-only and MMAE + surgery groups. Complications occurred in five patients (5.3%), with no significant difference between groups (6.0% in MMAE vs. 3.7% in MMAE + surgery, p = 0.658). Hemorrhage was reported in four patients (4.3%), and no cases of stroke were recorded. Mortality was 24.5% overall, with a slightly higher rate in the MMAE + surgery group (29.6%) compared to the MMAE-only group (22.4%, p = 0.460). Functional improvement in modified Rankin Scale (mRS) was seen in 15 patients (24.2%), with a significantly greater improvement in the combined group (Δ mRS = 2.625) versus the MMAE-only group (Δ mRS = 0.348, p < 0.001).ConclusionsMMAE is a safe and effective treatment option for managing cSDH in cancer patients. Higher mortality in this population is likely reflective of underlying cancer and comorbidities.