Medisch Centrum Haaglanden

Intraneural ganglion cysts (IGCs) are mucinous lesions that originate from adjacent synovial joints. According to the articular theory, synovial fluid tracks from a joint into the parent nerve through an articular branch. In uncommon sites such as the sural nerve, this connection can be difficult to identify. This report illustrates the use of a preoperative intra-articular fluorescein injection as a tool to identify the articular branch during surgery. A 60-year-old woman presented with lateral foot pain, numbness, and a palpable mass along the left sural distribution. MRI showed a large cyst extending along the course of the sural nerve with connection to the subtalar joint. Fluorescein was injected preoperatively into this joint to detect the articular branch intraoperatively with ultraviolet illumination. The connection was transected at the joint origin, and the cyst was decompressed, preserving the parent nerve. Postoperatively, the patient had complete pain relief and sensory recovery, and MRI at 3 and 8 months confirmed resolution of the cyst. Sural IGCs conform to the articular theory and can be managed effectively by transection of the articular branch. Preoperative intra-articular fluorescein injection is a useful tool to detect the articular branch that can be difficult to find in sural IGCs. https://thejns.org/doi/10.3171/CASE251018.

European data regarding ethnic disparities in health-related quality of life (HRQOL) post- stroke is scarce and none used the Patient-Reported Outcomes Measurement Information System (PROMIS). This study explores whether ethnicity is related to HRQOL using PROMIS and cognitive function after stroke in the Netherlands. Patients hospitalized with a first-ever stroke were included. Outcome assessments included the PROMIS Profile, the EuroQoL-5D-3 L for HRQOL and the PROMIS Cognitive Function for cognitive functioning. Measurements were done at admission, after 3 and 12 months (EQ-5D and EQ-5D-VAS only at 12 months). Ethnicity (migration background yes/no), demographics and stroke characteristics were collected. Outcomes were compared between patients with and without a migration background by a multivariate linear mixed-effects model, adjusted for age, sex, education level, severity of stroke and other relevant variables at baseline were also included (smoking before admission, acute intervention in case of an ischemic stroke and length of hospital stay). 262 patients were included of which 74 (28.2%) had a migration background. This group had worse scores compared to patients without a migration background, with a significant difference at admission for the physical function (estimate = 3.30, SE = 1.25, p = 0.01), at three months for anxiety (estimate=-2.95, SE = 1.48, p = 0.05) and twelve months for sleep disturbance (estimate=-5.43, SE = 1.61, p < 0.01). The EQ-5D index and EQ-5D VAS at twelve months follow-up was also significantly lower in this group compared to patients without a migration background (respectively adjusted B -0.09 (95% CI -0.17; -0.01)) and adjusted B -7.27 (95% CI (-13.99; -0.56)). Up to twelve months, stroke patients with a migration background had worse scores and a different trajectory regarding several domains of HRQOL compared to patients without a migration background.

Currently, evidence-based guidelines for the frequency and intensity of follow-up of systemic sclerosis (SSc) patients are not available. Based on expert opinion, an annual extensive evaluation is recommended. A multidisciplinary Care Pathway that integrates this annual extensive evaluation at the Leiden University Medical Center has shown increased patient satisfaction, decreased healthcare utilization, and improved outcomes in SSc patients (1, 2). However, for a subgroup of SSc patients with relatively mild disease, this annual extensive evaluation might be redundant. Therefore, this study aims to evaluate whether assessment in a regular outpatient clinic setting is an acceptable alternative to extensive annual evaluation in the Care Pathway in SSc patients with a low risk of disease progression. This study is designed as a multicenter (n = 3) non-inferiority randomized controlled trial. SSc patients are categorized into three categories for risk of disease progression (low, intermediate, or high) based on a previously published risk prediction model (3). Patients with a predicted low or intermediate risk of disease progression are randomized between (1) follow-up in the outpatient clinic (intervention) and (2) follow-up via usual care according to the annual Care Pathway (control group). The year after the "study visit," all patients are evaluated in the Care Pathway. In this study, 250 patients will be recruited and randomized. The primary outcome is healthcare utilization, which will be assessed via questionnaires. Secondary outcome measures include disease progression, patients' perception of disease and care, and health-related quality of life. Healthcare utilization is defined as the number of contacts with a healthcare professional and will be analyzed using descriptive statistics and linear regression analysis. There is an unmet need for tailor-made care for SSc patients in accordance with disease activity, and evidence-based guidelines regarding the follow-up of SSc patients are lacking. This is the first randomized controlled trial evaluating the optimal follow-up for SSc patients at low risk of disease progression. Results of this study will show whether routine assessment at the outpatient clinic is an acceptable alternative to assessment in a standardized care setting including an annual 6-min walk test, an ECG, lab, mRSS, and a pulmonary function test. ClinicalTrials.gov NCT05103553. Registered on October 11, 2021.

About half of the patients with acute ischaemic stroke treated with endovascular thrombectomy (EVT) remains dependent or dies in the first 90days. Ghrelin is a naturally occurring hormone and mildly excitatory neurotransmitter that improved functional, histological, and cytological recovery in in vitro and in vivo ischaemia-reperfusion models. Acylated ghrelin (i.e. the bioactive form) has shown safety in a range of populations, including patients with cardiovascular or neurodegenerative disease. We hypothesise that treatment with acylated ghrelin improves early recovery and long-term functional outcome in patients with ischaemic stroke treated with EVT. We propose an investigator-initiated, phase 2, randomised, clinical trial with open-label treatment and blinded endpoint assessment in 80 patients with anterior circulation ischaemic stroke treated with EVT and a pre-EVT National Institutes of Health Stroke Scale (NIHSS) score ≥ 10. Patients will be randomised to intravenous acylated ghrelin, 600µg twice daily for 5days and started within 6h of symptom onset, in addition to standard care vs. standard care alone. The primary outcome is the NIHSS score on day 7 adjusted for pre-EVT NIHSS and other relevant baseline characteristics. Secondary outcomes include infarct size on MRI at day 3, adverse events, and functional recovery at 90days. The primary analysis will be a single comparison between the treatment groups of the primary outcome according to the intention-to-treat principle. The primary effect variable will be the adjusted beta for the difference in NIHSS score, estimated with multi-variable linear regression analysis. If administration of acylated ghrelin is found safe and potentially effective in patients with ischaemic stroke treated with EVT, this study can inform the sample size calculation for a subsequent randomised phase 3 trial to assess efficacy. The trial has been approved and registered on ClinicalTrials.gov (NCT05726240). The first patient has been included in November 2024.

Adjuvant chemotherapy in the treatment of endometrial cancer can be difficult to tolerate for older women. This study examined age-related differences in patient preferences for chemotherapy in women with high-risk endometrial cancer. We re-analyzed data from the cross-sectional patient preference study PRETEC-2 to determine the difference between three age groups in minimally desired survival benefit of chemotherapy. For this, patients with high-risk endometrial cancer treated with adjuvant pelvic radiotherapy with or without chemotherapy completed a treatment trade-off questionnaire. Patients also rated the importance they attributed to treatment duration and acute and late side-effects for their decision on chemotherapy, which we analyzed by age group. A total of 171 patients (23% <60years, 40% 60-69years and 37% ≥70years) were included in the analysis. Older patients had a significantly higher median minimally desired survival benefit for preferring chemoradiotherapy (5% for <60years, 8% for 60-69years and 15% for patients ≥70years; (p<0.001)), and had the largest variability in minimally desired survival benefit. For a real-life five-year survival benefit of 5%, fewer older patients preferred the addition of chemotherapy to their treatment regimen (61.5% for <60years, 45.6% for 60-69years and 21.9% for ≥70years; p<0.001). Furthermore, older patients rated both treatment duration (p=0.001) and long-term tingling or numbness (p=0.005) as significantly more important than their younger counterparts. There is more heterogeneity in the desired benefit of chemotherapy among patients aged 70years or more compared to younger patients. This underlines the importance of recognizing individual differences and the need for shared decision-making.

BACKGROUNDRecently, the distribution of subparaneurial ganglion cysts involving the common peroneal and tibial nerves was described based on MRI analysis. Crossover in extreme cases was observed at the sciatic bifurcation through a mechanism comparable to a geyser, enabled by fenestrations in the epi- and paraneurium at the level of the bifurcation. The goal of this study was to investigate whether the geyser theory for crossover holds for other locations.OBSERVATIONSThe authors’ prospectively maintained database of > 1100 cases of intraneural ganglion cysts in the world’s literature was queried for the existence of subparaneurial ganglion cysts at locations other than the knee. A previously unrecognized case involving the ulnar nerve originating from the elbow joint was found. Reinterpretation of the patient’s MRI studies showed circumferential subparaneurial distribution of a cyst over a long distance. Based on their previously reported geyser theory, the authors wondered if crossover had occurred at the level of the medial cord. A fenestration in the epi- and paraneurium at this level was confirmed on histological analysis of a normal cadaveric specimen.LESSONSThis illustrative case shows that the geyser theory also holds in other locations. Surgical treatment of these subparaneurial cysts still follows the principles of the unified articular theory.https://thejns.org/doi/10.3171/CASE25671

IntroductionAlteplase is known to increase the risk of blood-brain barrier integrity disruption, potentiating hemorrhage and edema. Evolving edema reduces chances of good functional outcomes. There is a paucity of studies that investigate the role of alteplase administration in subacute edema progression. Here we aim to associate alteplase administration in combination with the degree of reperfusion on edema, measured by net water uptake.MethodsWe included 115 patients from the MRCLEAN NO-IV trial with baseline, 24-h and 1-week follow-up non-contrast CT scans. The cohort consisted of patients who received intravenous thrombolysis (IVT)+ endovascular treatment (EVT) vs. EVT alone. Net water uptake (NWU) was calculated as a ratio of mean lesion density compared to its homologous, contralateral region-of-interest. Unadjusted linear regression analysis was performed to assess the association between NWU progression and alteplase administration, successful reperfusion [expanded Thrombolysis in Cerebral Infarction (eTICI)2B/3], and excellent reperfusion (eTICI2C/3). Adjusted regression analysis was performed to correct for potential confounders.ResultsIVT administration was not statistically significantly associated with NWU progression. Regardless of treatment arm, there was substantial increase in NWU during the first 24 h and 1 week post-stroke. In adjusted analysis, successful reperfusion was significantly associated with reduced NWU progression at 24 h (β = −4.6; 95% CI: −8.4, −0.80) and 1 week (β = −6.5; 95% CI: −11, −2.3).ConclusionAlteplase administration prior to EVT did not impact the subacute edema progression in our cohort, whereas successful reperfusion was strongly associated with reduced edema progression, particularly at later timepoints. These results suggest that alteplase administration according to current guidelines is unlikely to contribute to accelerated edema progression and emphasize that achieving high-grade reperfusion is crucial for reducing secondary injury.