Metachronous ureteral metastasis of clear cell renal cell carcinoma in a duplex collecting system 1 year after nephrectomy

While renal cell carcinoma is known to metastasise in an unpredictable pattern, even after resection of a primary tumour, delayed ureteric metastasis is a very rarely reported phenomenon. In this case report, we describe a case of ipsilateral metachronous ureteric metastasis in a patient with a complete duplex collecting system. This case demonstrates some useful strategies in the diagnosis and treatment of renal cell carcinoma in this context. To our knowledge, this is the first case report of delayed ureteric metastasis of a renal clear cell carcinoma in a patient with a duplex collecting system.

Ability of FFR-CT to detect the absence of hemodynamically significant lesions in patients with high-risk NSTE-ACS admitted in the emergency department with chest pain, study design and rationale

BACKGROUND

In the era of High-sensitive troponin (hs-Tn), up to 50% of patients with a mild increase of hs-Tn will finally have a normal invasive coronary angiogram. Fractional Flow Reserve (FFR) derived from coronary computed tomographic angiography (FFR-CT) has never been used as a non-invasive tool for the diagnosis of coronary artery disease in patients with high-risk acute coronary syndrome without ST segment elevation (NSTE-ACS).

AIMS

The study aims to determine the role of coronary CT angiography and FFR-CT in the setting of high-risk NSTE-ACS.

METHODOLOGY

We will conduct a prospective trial, enrolling 250 patients admitted with high-risk NSTE-ACS who will rapidly undergo a coronary CT angiography and then a coronary angiography with FFR measurements. Results of coronary CT, FFR-CT and coronary angiography (± FFR) will be compared.

POTENTIAL SIGNIFICANCE

In conclusion, non-invasive identification of patients with high-risk NSTE-ACS who could avoid coronary angiography would reduce procedure related risks and medical costs.

Radio-pathological review of a metastatic renal cell carcinoma within a meningioma: A case report of collision tumor

We report a case of a collision tumor, a meningioma complicated with metastasis from a primary renal cell carcinoma. A 75-year-old man, with known history of renal cell carcinoma, and 10-year history of stable meningioma developed neurological symptoms. Computed tomography and magnetic resonance imaging revealed left frontal intracranial extra-axial mass with imaging criteria suspicious for an atypical meningioma or hemangiopericytoma. Given the history of a known primary, the possibility of brain metastasis was included. Pathology confirmed the presence of metastatic renal cell carcinoma nidus with a surrounding meningioma. Tumor-to-tumor metastasis or collision tumor is a very rare phenomenon. Atypical radiologic findings with positive history of a primary extracranial tumor should raise the suspicion of potential metastases.

Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version)

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies.

TRANSLATIONAL POTENTIAL OF THIS ARTICLE

New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life.

Natural Course and Diagnosis of Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

Lumbar spinal stenosis (LSS) is defined as a degenerative disorder showing a narrowing of the spinal canal. The diagnosis is straightforward in cases with typical neurogenic claudication symptoms and unequivocal imaging findings. However, not all patients present with typical symptoms, and there is obviously no correlation between the severity of stenosis and clinical complaint. The radiologic diagnosis of LSS is widely discussed in the literature. The best diagnostic test for the diagnosis of LSS is magnetic resonance imaging (MRI). However, canal diameter measurements have not gained much consensus from radiologists, whereas qualitative measures, such as cerebrospinal fluid space obliteration, have achieved greater consensus. Instability can best be defined by standing lateral radiograms and flexion-extension radiograms. For cases showing typical neurogenic claudication symptoms and unequivocal imaging findings, the diagnosis is straightforward. However, not all patients present with typical symptoms, and there is obviously no correlation between the severity of stenosis (computed tomography and MRI) and clinical complaint. In fact, recent MRI studies have shown that mild-to-moderate stenosis can also be found in asymptomatic individuals. Routine electrophysiological tests such as lower extremity electromyography, nerve conduction studies, F-wave, and H-reflex are not helpful in the diagnosis and outcome prediction of LSS. The electrophysiological recordings are complementary to the neurologic examination and can provide confirmatory information in less obvious clinical complaints. However, in the absence of reliable evidence, imaging studies should be considered as a first-line diagnostic test in the diagnosis of degenerative LSS.

Primary peritoneal clear cell carcinoma. A case report and literature review

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Primary peritoneal malignant tumors are exceptional and clear cell carcinoma is extremely rare.

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We describe the clinical-pathological and immunohistochemical data.

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Recognition of this tumor in this uncommon location represents a diagnostic challenge.

Primary peritoneal malignant tumors are exceptional. Among them, clear cell carcinoma is extremely rare, being only thirteen cases previously reported in the literature since 1990. We report a case of a 48-year-old Caucasian woman who was treated at the University General Hospital of Alicante. She consulted because of progressive abdominal pain over the last seven months, with the initial diagnosis of renal-ureteral colic. Ultrasound and computed tomography of the abdomen and pelvis revealed a 25 × 15 cm, well-defined cystic lesion with papillary projections, centrally located in the abdomen. The radiology report suggested a primary ovarian tumor versus peritoneal implant as the first option. The patient underwent an exploratory laparotomy showing a large cystic mass located in the urinary bladder peritoneum, firmly attached to the mesentery. The entire abdominal tumor was completely excised, and total hysterectomy with bilateral salpingo-oophorectomy and infra-colical omentectomy were performed. The final histological study revealed a new case of primary peritoneal clear cell carcinoma located in the urinary bladder peritoneum, firmly attached to the mesentery. Grossly, it was well-circumscribed and multicystic with papillary growth involving part of the inner wall. Microscopically, it showed tubulocystic and papillary patterns with highly atypical tumor cells. After an extensive immunohistochemical analysis, the most relevant finding was an ARID1A loss that was corroborated by molecular analysis showing an ARID1A deletion. The patient received systemic chemotherapy with carboplatin and paclitaxel protocol (Å ~ 4 cycles). Patient follow-up after the eighth month showed peritoneal implants predominantly in the right diaphragmatic cupule that were histologically confirmed as recurrence. She has just received another six cycles of chemotherapy with carboplatin and paclitaxel. Recognition of primary peritoneal clear cell carcinoma in this uncommon location, and exclude metastasis from the ovary, represents a diagnostic challenge.

HTLV-1c associated bronchiolitis in an Aboriginal man from central Australia

We describe the first case of HTLV associated bronchiolitis to be associated with HTLV-1c subtype infection. An Aboriginal man with HTLV-1 infection was repeatedly admitted to Alice Springs Hospital, central Australia, with hypercapnic respiratory failure from the age of 28 years. High resolution CT chest findings were consistent with bronchiolitis and large numbers of lymphocytes were found in bronchoalveolar lavage fluid (BALF). After extensive investigations failed to find a cause, he was tested for HTLV-1 and found to have a high HTLV-1c proviral load (6.8 %) in peripheral blood leukocytes and in BALF (4.7 %). The administration of systemic corticosteroids resulted in a rapid clinical response; however, he did not continue treatment after discharge and died due to respiratory failure in the community.

Sarcopenia in Cirrhosis: Fallout on Liver Transplantation

BACKGROUND

Liver transplantation (LT) is a game changer in cirrhosis. Poor muscle mass defined as sarcopenia may potentially upset the LT scoreboard.

AIM

To assess the prevalence and impact of sarcopenia on the intraoperative and early postoperative outcomes in Indian patients undergoing LT.

METHODS

Pre LT, single-slice routine computed tomography images at L3 vertebra of 115 LT recipients were analyzed, to obtain cross-sectional area of six skeletal muscles normalized for height in m² - skeletal muscle index (SMI; cm²/m²). SMI< 52.4 in males and <38.5 in females was called sarcopenia. The intraoperative, postoperative outcome parameters and 90-day mortality were compared between sarcopenics and nonsarcopenics.

RESULTS

Sarcopenia was found in 47.8% of patients [M (90.4%); age, 46.3 ± 10; BMI, 24.5 ± 4.3 kg/m2; child A:B:C = 1%:22%:77%; MELD, 20.6 ± 6.3; etiology alcohol: nonalchohol = 53%:47%; Charlson Comorbidity Index (CCI) > 3:≤3 = 56.5%:43.5%]. Sarcopenics vs. Nonsarcopenics; early postoperative complications: [sepsis, 49(89%) vs. 33(55%), P = 0.001; neurologic complications, 16(29.6%) vs. 5(8.8%), P = 0.040; Clavien-Dindo Classification ≥3-24 (43.6%):15 (25.4%),P = 0.041; ancillary parameters (days), duration of ventilation [median (range)] 1.5(1-3) vs. 1 (1-2), P = 0.021; intensive care unit (ICU) stay 12 (8-16) vs. 10 (8-12), P = 0.024; time to ambulation 9 (7-11) vs. 6 (5-7), P = 0.001; drain removal 18.7 ± 7.3 vs. 14.4 ± 6.2, P = 0.001; need for tracheostomy 5 (9%) vs. 0 (%), P = 0.017; preoperative prevalence of acute kidney injury, comorbidities and requirement for dialysis, intraoperative blood loss & inotropic support were significantly higher in sarcopenics. Ninety-day mortality was comparable between sarcopenics 5 (9.09%) and nonsarcopenics 4 (6.6%) P = 0.63. SMI (OR: 0.83; 95% CI: 0.71-0.97, P = 0.016; Acute on chronic liver failure (ACLF) presentation 12.5 (1.65-95.2), P = 0.015 and intraoperative blood loss 3.74 (0.96-14.6), P = 0.046 were predictors of 90-day mortality.

CONCLUSION

Almost 50% of LT recipients had sarcopenia, who had a higher incidence of postoperative sepsis, neurological complications, longer ICU stay and ventilatory support. Low SMI, ACLF presentation, and intraoperative blood loss were the independent predictors of early mortality.

Shunt-Bronchial Fistula with Coughing Up and Swallowing of Cerebrospinal Fluid: Rare Complication of Ventriculopleural Shunt

BACKGROUND

Erosion of the distal catheter into lung parenchyma is an extremely rare complication of ventriculopleural shunt placement.

CASE DESCRIPTION

We report a 51-year-old woman with a history of parasagittal meningioma invading the sagittal sinus who presented with recurrent pneumonia after placement of a ventriculopleural shunt. A nuclear study revealed accumulation of radiotracer material sequentially in the right hemithorax, trachea, mainstem bronchi, stomach, and bowel. The ventriculopleural shunt had eroded into the patient's lung parenchyma, with the effect of cerebrospinal fluid draining into the respiratory system and then being coughed up and swallowed into the gastrointestinal system.

CONCLUSION

Surgeons should be aware of the potential complication of a ventriculopleural shunt eroding through the lung parenchyma to cause a shunt-bronchial fistula with persistent coughing and recurrent pneumonias. Shuntogram nuclear imaging may be useful in the diagnosis of the complication.

Intestinal malrotation in a patient who underwent radical cystectomy and ileal conduit construction: A case report

A 74-year-old male underwent laparoscopic radical cystectomy for invasive bladder cancer with open surgery for lymph node dissection and urinary diversion (ileal conduit). During the surgery, intestinal malrotation was diagnosed and Ladd procedure was performed. Ileal conduit was performed on the left side after considering the course of mesentery. Although a final diagnosis was reached during the surgery in this case, the presence of intestinal malrotation can be suspected based on the findings of contrast-enhanced computed tomography images obtained before the surgery. Images should be carefully inspected to detect intestinal malrotation when planning urinary diversion involving the intestinal tract.

Persistent collection of antibiotic ointment masquerading as a lipoma arising at a surgical site

Antibiotic ointments are often used to treat or prevent infections in surgical wounds. However, due to a dearth of reports on adverse effects, the complications of the use of such ointments, especially possible long-term effects, are largely unknown. We experienced a unique case of a cystic lesion that developed after surgical site infection treated with gentamicin ointment in a 62-year-old man who underwent subtotal glossectomy for tongue cancer. The antibiotic ointment that was applied following abscess drainage remained there, replacing the abscess cavity and forming an oval mass. The lesion was found incidentally on follow-up MR examination to monitor cancer recurrence. On both T1- and T2-weighted images, it showed high-intensity reflecting oily base material, constituting the ointment, which appeared to be a fat-containing tumor such as a lipoma that had arisen at the surgical site. Echo-guided drainage extracted the ointment, which was seemingly unaltered from the time it was applied 11 months before. We describe the clinical course and imaging findings to acknowledge this potential adverse effect associated with topical antibiotic treatment for surgical site infection.

Image-Guided Percutaneous Management of Skull and Spine Giant Cell Tumors: Case Report of 2 Challenging Cases Successfully Treated with Doxycycline Sclerotherapy

Background

A giant cell tumor (GCT) of bone is a benign, locally aggressive tumor that is often challenging to treat. When complete resection is not possible, curettage with or without adjuvants is the most common treatment. The high frequency of local recurrence and risk of injury to adjacent structures can limit this surgical approach, especially with skull and spine lesions.

Case Description

We report 2 cases of axial skeleton GCTs, 1 in the skull of a 58-year-old woman in whom operative management failed, who experienced local recurrence, and 1 in the cervical spine of an 8-year-old girl that grew extracompartmentally to surround her brachial plexus. Both patients were referred to us because of the surgically challenging nature of their tumors. After completion of the same percutaneous doxycycline sclerotherapy protocol previously described for aneurysmal bone cysts (ABCs), both patients were considered cured and were able to return to normal activities without loss of pretreatment function. After 4 and 10 years of follow-up, respectively, there has been no tumor recurrence in either patient.

Conclusions

We successfully treated 2 patients with very challenging axial skeleton GCTs using a percutaneous doxycycline sclerotherapy protocol previously shown to have success with ABCs. We believe that this minimally invasive procedure should be considered a potential alternative treatment for GCTs, especially axial skeleton lesions, which may not be easily approached with standard surgical techniques.

A novel abdominal wall entry suction device to increase Veress needle safety: A prospective cohort pilot study

Background

In laparoscopic surgery, the Veress needle technique is most often used to initiate a pneumoperitoneum. Although low, entry-related injuries of the intestines and major vascular structures occur in 0.04–0.1% of cases. Up to 50% of these injuries remain undiagnosed at the time of surgery, resulting in mortality rates between 2.5 and 30%. In an effort to minimize such injuries we objectively assessed a novel abdominal wall entry suction device (AWESD) that was hypothesized to lift the abdominal wall and create an additional post-peritoneum safe margin for safer Veress needle introduction.

Materials and methods

A prospective pilot study was conducted in which CT-scans with and without AWESD application (centered above the umbilicus) were assessed to determine its effect on the distance from the linea alba to the intestines, vena cava and abdominal aorta. Paired measurements were subjected to the Wilcoxon signed rank test.

Results

Twelve participants were included. The AWESD significantly increased the median distance towards the intestines in the axial and sagittal plane (P = 0.01 and P = 0.006) from 0.93 (Inter Quartile Range (IQR): 0.33–1.51) and 0.85 (IQR: 0.32–1.47) to 1.35 (IQR: 0.39–2.27) and 1.25 (IQR: 0.42–2.10) centimeters, respectively. Similarly, for the median axial distances towards the vena cava and abdominal aorta (both P = 0.002) that were increased from 10.00 (IQR: 7.18–11.12) and 9.33 (IQR: 6.55–10.28) to 13.23 (IQR: 11.76–14.31) and 12.49 (IQR: 10.98–13.32) centimeters, respectively.

Conclusion

The AWESD significantly increased the distances between the peritoneum and main intra-abdominal structures. However, conclusions on subsequent increased safety cannot be drawn as high-volume studies are required to determine its clinical relevance.

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Veress needle related injuries are rare but associated with high mortality rates.

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A novel abdominal entry suction device to increase Veress needle safety was studied.

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The device increased the distance between peritoneum and intra-abdominal structures.

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The increased distance was greatest for the vena cava and abdominal aorta.

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Despite the increased distances, the devices' clinical relevance remains unknown.

Computed tomography features and surgical treatment of superior mesenteric artery syndrome: A case report

Introduction: Superior mesenteric artery (SMA) syndrome is described as compression of the third part of the duodenum between SMA and aorta with resultant obstruction and dilatation of proximal duodenum and stomach. Virtually, any condition associated with weight reduction may predispose the patient to SMA syndrome. Case presentation: A 17-year-old boy complaining from persistent vomiting, dull abdominal pain, anorexia, and weight loss for long time presented to the pediatric surgery department. Computed tomography (CT) of the abdomen was prescribed to look for the cause of persistent vomiting and bulging of the epigastrium. Contrast Enhanced CT revealed decreased aortomesenteric angle and aortomesenteric distance causing compression of third part of duodenum with resultant marked distension of proximal duodenum, stomach, and even esophagus. The patient underwent laparotomic gasterojujenostomy. Conclusion: SMA syndrome is a rare clinical entity. CT can well delineate this abnormality. SMA syndrome can be treated with both conservative and surgical approaches.

Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines

Objective

The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden.

Methods

Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes.

Results

Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P = 0.01).

Conclusions

This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons.

Community-acquired Escherichia coli meningitis and spondylodiscitis in an adult patient with discoid lupus erythematosus

Acute bacterial meningitis has a high impact on adult mortality worldwide. Community-acquired Escherichia coli meningitis (CA-ECM) is a rare and poorly described condition and the available knowledge is based on low evidence research, mainly from case reports. We describe a case of CA-ECM in Portugal in an adult patient with discoid lupus erythematosus under immunomodulatory therapy. A 73-year-old woman was admitted to the emergency department with fever and altered mental status over 48 h. Cerebrospinal fluid analysis showed 185 leukocytes/μL, including 85% neutrophils, hypoglycorrhachia (less than 5 mg/dL) and elevated protein of 423 mg/dL with positive culture for Escherichia coli. She was treated with ceftriaxone. Imaging studies also demonstrated spondylodiscitis and arthritis. She responded well to antimicrobial therapy and completed the treatment as an outpatient.

Radiation-induced sarcoma in a 10-year survivor with stage IV EGFR-mutated lung adenocarcinoma

A 70-year-old Japanese man with stage IV EGFR-mutated lung adenocarcinoma complained of right mild back pain. The patient had been heavily treated with several cytotoxic or molecular targeted agents for 10 years and received a palliative radiation therapy of 2^nd sacral vertebra 5 years ago. Computed tomography showed the abnormal lesion in right iliopsoas muscle. A pathological examination confirmed undifferentiated pleomorphic sarcoma, consistent with the diagnosis of radiation-induced sarcoma (RIS). Since RIS is a rare late-onset complication of radiation therapy, to our knowledge, this is the first report of RIS that was associated with advanced lung cancer and detected after palliative radiation therapy. The careful long-term follow-up is thus necessary even after palliative radiation therapy and we have to be aware of the existence of RIS.

How to Avoid Postoperative Remaining Ossification Mass in Anterior Controllable Antedisplacement and Fusion Surgery

OBJECTIVES

To retrospectively review the cases with ossification of the posterior longitudinal ligament (OPLL) treated with anterior controllable antedisplacement and fusion (ACAF). Patients with postoperative remaining ossification mass (PROM) are analyzed to figure out the causes and preventions of this problem.

METHODS

A total of 115 patients were included. PROM was identified as remaining OPLL existed in the spinal canal other than included in the vertebral-OPLL complex on postoperative computed tomography. The Japanese Orthopaedic Association scoring system was used to evaluate the neurologic status. Surgery-related complications such as cerebrospinal fluid (CSF) leakage and spinal cord or nerve injury were all recorded. The patients with the PROM group and those without the PROM group were compared.

RESULTS

There were 14 patients with wide-base OPLL (12.2%) and 10 patients (8.7%) with PROM among the 115 patients with OPLL. The 10 patients with PROM were all with wide-base OPLL. The average improvement rate of Japanese Orthopaedic Association score in patients without PROM was significantly larger than that in patients with PROM (69.5 ± 22.6% vs. 36.7 ± 22.0, P < 0.01). Incidence rate of postoperative CSF leakage and neural deterioration were significantly higher in patients with PROM than that in patients without PROM (CSF leakage, 40.0% vs. 5.9%; neural deterioration, 50.0% vs. 3.0%). No other complications were observed.

CONCLUSIONS

The occurrence of PROM might cause complications and poor neural function recovery in patients treated with ACAF. Surgical techniques should be noted to avoid PROM in ACAF surgery.

A Case of Cisternal Pilocytic Astrocytoma Diagnosed with the Balanced Steady-State Free Precession Sequence for Magnetic Resonance Imaging: A Rare Cause of Subarachnoid Hemorrhage

Objectives

In approximately 15% of cases of spontaneous subarachnoid hemorrhage (SAH), an obvious source of bleeding cannot be identified by angiography; these are considered cases of SAH of unknown etiology. A rare case of cisternal pilocytic astrocytoma (PA) presenting with SAH is reported. The usefulness of the balanced steady-state free precession (bSSFP) sequence for magnetic resonance imaging (MRI) to detect small cisternal lesions is discussed.

Case Description

The case of a 73-year-old woman who developed repeated SAHs owing to a cisternal PA is presented. She experienced sudden onset of headache and vomiting, and brain computed tomography showed diffuse SAH, whereas angiography demonstrated normal vasculature. Follow-up imaging, including T1-weighted, T2-weighted, T1-weighted contrast-enhanced, and diffusion-weighted MRI, did not show any parenchymal or cisternal lesions, although computed tomography and fluid-attenuated inversion recovery MRI showed SAH in the same region. In contrast, the bSSFP sequence, taken as a different sequence on the same day, showed mixed-intensity reticular lesions in the left basal cistern, while neither hematoma nor positive findings were identified with the other sequences. Based on the radiologic finding and the repeated history of SAH, the lesions were partially removed 2 weeks after onset. Histological examination showed a PA.

Conclusions

Despite being extremely rare, a small cisternal lesion should be considered as a cause of SAH of unknown etiology. The bSSFP sequence may be useful for detecting cisternal lesions that may be missed on the routine MRI sequences.

Refractory De Novo Multiple Cerebral Aneurysms After Radiotherapy and Multistaged "Open" Surgical Treatment for Low-Grade Glioma During Long-Term Follow-Up: A Case Report and Review of the Literature

Background

Radiation-induced aneurysms have been previously reported; however, multiple and repeated de novo aneurysm formation chronologically and anatomically during long-term follow-up have not yet been observed. The pathogenesis of persistent radiation-induced vasculopathy is not fully understood.

Case Description

A 31-year-old woman presented with intraventricular hemorrhage due to rupture of a right internal carotid artery (ICA) aneurysm that developed 17 years after surgical resection of a low-grade glioma in the right frontal lobe and postoperative radiotherapy (focal, 50 Gy/25 fractions). During glioma follow-up, salvage surgery with adjuvant gamma knife therapy and chemotherapy (ranimustine, vincristine, temozolomide) were performed for recurrence of the glioma. The aneurysm was treated with endovascular coil embolization. However, she experienced repeated intraventricular hemorrhages, and angiography revealed a de novo ICA aneurysm. The de novo aneurysms were treated with endovascular surgery using coil embolization and stenting. At 2 years after the third hemorrhage, the surgical wound became dehiscent, probably due to wound infection, thus epicranial soft tissue reconstruction using vascularized skin flap was performed. Despite multistaged endovascular surgery for the ICA aneurysm, she experienced repeated subarachnoid and intraventricular hemorrhages. Angiography revealed a de novo aneurysm of the right posterior cerebral artery and basilar trunk. She underwent coil embolization and stenting. Despite active management with endovascular surgery and close follow-up, she died after an eighth consecutive intraventricular and intracerebral hemorrhage caused by a de novo large aneurysm of the posterior cerebral artery.

Conclusions

To the best of our knowledge, the present study is the first to report on of refractory and recurring de novo aneurysms treated by multistaged endovascular surgery during a long-term follow-up after radiotherapy and multistaged craniotomy for glioma.

Distal Parent Vessel Occlusion of 2 Superior Cerebellar Artery Fusiform Aneurysms: Report of 2 Cases and Literature Review

Background

Fusiform superior cerebellar artery (SCA) aneurysms are rare, and their management represents a technical challenge. In complex aneurysms, endovascular parent vessel occlusion of the SCA may be a treatment option. Here, we present 2 cases of fusiform SCA aneurysms, 1 ruptured and 1 unruptured, as well as our institution's management with parent vessel occlusion. We also provide a review of the literature.

Cases Description

Case 1: A 42-year-old male was transferred from an outside hospital with subarachnoid hemorrhage. On admission, the patient had a Glasgow Coma Scale score of 8, a Hunt and Hess grade 4, and a Fisher grade 4. A diagnostic angiogram demonstrated a right SCA fusiform lesion with proximal and distal dilatations of 1.45 mm and 5.35 mm long, respectively, likely representing a single dissecting pseudoaneurysm. The distal dilatation was coiled, resulting in parent vessel occlusion. The patient recovered clinically and was discharged in stable condition.

Case 2: A 27-year-old female was transferred from an outside hospital due to a brainstem stroke. A diagnostic angiogram revealed an S2/S3 segment left SCA fusiform lesion, likely representing a dissecting aneurysm. The patient was neurologically intact at admission and managed conservatively. At the 2-month follow-up angiogram, the dissection had extended along the length of the SCA. Consequently, the patient underwent coil embolization of the distal left SCA. At the 6-month follow-up, the vessel remained obliterated and the patient's neurologic status had improved.

Conclusions

Endovascular coil embolization of fusiform SCA aneurysms offers a reasonable and safe treatment approach.

Potential Risks and Limited Indications of the Supraorbital Keyhole Approach for Clipping Internal Carotid Artery Aneurysms

Background

Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results.

Methods

This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation.

Results

Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination <24) was 3.9%. Completely clipped aneurysms did not show any recurrence during the mean follow-up period of 6.3 ± 3.1 years, but the 2 (3.9%) aneurysms with neck remnants showed regrowth.

Conclusions

The risk of neck remnant behind the clip blade is a drawback of supraorbital keyhole clipping. The surgical indication requires preoperative simulation and careful checking of the clip blade state is essential.

A new and simple intraoperative method for correction of leg-length discrepancy in total hip arthroplasty

Total hip arthroplasty (THA) can eliminate pain caused by hip joint destruction and correct leg-length discrepancies (LLD). We present a short and simple intraoperative method for LLD correction in THA. We performed 55 primary THAs using this technique. The measurement error was 1.86 ± 1.4 mm, which was within 3 mm in 49 of 55 cases (89%) and within 5 mm in 54 of 55 cases (98%). This method is simple and does not require specialized devices, making it versatile to be used anywhere. No new skin incisions or extra costs are required, which will likely make it attractive to surgeons.

Safety and feasibility of using calcium phosphate hybridization method for quadriceps tendon-bone graft in anterior cruciate ligament reconstruction

Background

To improve tendon-to-bone healing in anterior cruciate ligament (ACL) reconstruction, a novel technique via the calcium phosphate (CaP) hybridization method for tendon graft using an alternate soaking process was developed. The use of the CaP hybridization method for quadriceps tendon-bone (QTB) graft in ACL reconstruction has not been reported in previous studies. Thus, this clinical trial aimed to clarify the safety and feasibility of using CaP hybridization method for quadriceps tendon-bone (QTB) graft in ACL reconstruction.

Methods

Eight patients (average age, 41.6 ± 10.6 years; 2 men and 6 women) with unilateral ACL injury were included in this study. They underwent ACL reconstruction using QTB graft that hybridized CaP. The follow-up period was from 2 months to 4 years (average, 2.4 ± 1.5 years). Cases of adverse events, including tumor formation, infection, fracture, contracture, severe pain, and re-rupture, were recorded. Moreover, clinical results (KT-1000 arthrometry, pivot-shift test, International Knee Documentation Committee grade, Lysholm scale, and sports activity level), and images of graft and bone tunnel (magnetic resonance imaging, arthroscopic appearance, and computed tomography) were also evaluated.

Results

No adverse events were observed in the follow-up periods. Postoperative clinical results showed improvement compared with the preoperative findings. The sports activity level after the surgery became equivalent to that before injury. There was no progression of bone tunnel enlargement.

Conclusions

Using the CaP hybridization method for QTB graft in ACL reconstruction was safe and feasible in the clinical trial. Moreover, this method may improve clinical outcomes. In the future, it is necessary to verify the effect of the CaP hybridization method for QTB graft in ACL reconstruction.

A Dual Approach for the Management of Complex Craniovertebral Junction Abnormalities: Endoscopic Endonasal Odontoidectomy and Posterior Decompression with Fusion

BACKGROUND

Ventral brainstem compression secondary to complex craniovertebral junction abnormality is an infrequent cause of neurologic deterioration in pediatric patients. However, in cases of symptomatic, irreducible ventral compression, 360° decompression of the brainstem supported by posterior stabilization may provide the best opportunity for improvement in symptoms. More recently, the endoscopic endonasal corridor has been proposed as an alternative method of odontoidectomy associated with less morbidity. We report the largest single case series of pediatric patients using this dual-intervention surgical technique. The purpose of this study was to evaluate the surgical outcomes of pediatric patients who underwent posterior occipitocervical decompression and instrumentation followed by endoscopic endonasal odontoidectomy performed to relieve neurologic impingement involving the ventral brainstem and craniocervical junction.

METHODS

Between January 2011 and February 2017, 7 patients underwent posterior instrumented fusion followed by endonasal endoscopic odontoidectomy at our unit. Standardized clinical and radiological parameters were assessed before and after surgery. A univariate analysis was performed to assess clinical and radiologic improvement after surgery.

RESULTS

A total of 14 operations were performed on 7 pediatric patients. One patient had Ehlers-Danlos syndrome, 1 patient had a Chiari 1 malformation, and the remaining 5 patients had Chiari 1.5 malformations. Average extubation day was postoperative day 0.9. Average day of initiation of postoperative feeds was postoperative day 1.0.

CONCLUSIONS

The combined endoscopic endonasal odontoidectomy and posterior decompression and fusion for complex craniovertebral compression is a safe and effective procedure that appears to be well tolerated in the pediatric population.