Persistent Mullerian duct syndrome with polycystic ovary in a young adult: A rare case report

Persistent Mullerian Duct Syndrome (PMDS) is a type of pseudohermaphroditism that occurs in males. It is an autosomal recessive type of familial disease that is commonly associated with a history of consanguinity. We have documented this case of a 22-year-old adult male who came with acute right iliac pain; after an ultrasound scan and hormone investigations, he was diagnosed with polycystic ovarian syndrome (PCOS).

Modified Iliac Screw in Lumbopelvic Fixation After Sacral Tumor Resection: A Single-Center Case Series

BACKGROUND

Traditional iliac screw, S2-alar iliac screw, and modified iliac screw are the 3 common techniques for lumbopelvic fixation. The application of the modified iliac technique in sacral spinal tumors has been rarely reported.

OBJECTIVE

To report the feasibility and safety of modified iliac screws after sacral tumor resection and their preliminary clinical outcomes.

METHODS

Twenty-seven patients who underwent sacral tumor resection with modified iliac screw fixation between August 2017 and August 2021 at our center were clinically and radiographically evaluated.

RESULTS

A total of 59 iliac screws were inserted by freehand according to the anatomic landmarks. The mean operation time was 207 minutes (range, 140-435 minutes). The average estimated blood loss was 1396 mL (300-4200 mL). Computed tomography scans showed that 2 (3.4%) screws penetrated the iliac cortex, indicating a 96.6% implantation accuracy rate. There were no iatrogenic neurovascular or visceral structure complications observed. The mean minimal distances from the screw head to the skin were 24.9 and 25.8 mm on the left and right sides, respectively. The mean minimal distances from the screw head to the horizontal level of the posterior superior iliac spine were 7.9 and 8.3 mm on the left and right sides, respectively. Two patients (7.4%) underwent reoperation for wound infection. At the latest follow-up, no patient had complications of screw head prominence, pseudarthrosis, or instrument failure.

CONCLUSION

The modified iliac screw is characterized by its minimal invasiveness and simplicity of placement. It is an ideal alternative for lumbopelvic fixation after sacral tumor resection.

Prognostic Factors for Surgically Managed Spontaneous Spinal Epidural Hematoma: A Single-Center Case Series of 18 Patients

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare pathology, which carries a significant morbidity.

OBJECTIVE

To review our institutional experience of surgically managed patients with SSEH, seeking to better understand clinical prognostic factors related to postoperative outcomes and thereby improve counseling of patients before treatment.

METHODS

All patients who underwent surgical management of SSEH between September 2011 and 2021. Baseline and postoperative clinical and radiological characteristics are presented, including the American Spinal Injury Association grade (ASIA). Statistical analyses were performed using Stata 13.1.

RESULTS

Eighteen patients were identified in total (11 male patients and 7 female patients) with a median age of 59.5 (range 3-83) years. The most common spinal region affected was cervicothoracic (33.3%). Limb weakness (94.4%) and urinary dysfunction (83.3%) represented the most common presenting symptoms. Preoperatively, the presence of spinal cord edema on imaging was associated with worse preoperative Medical Research Council (MRC) grade ( P = .033), female sex was associated with preserved saddle sensation ( P = .04), and patients receiving antiplatelet medication were associated with a higher risk of preoperative axial back pain ( P = .005). Higher postoperative MRC grade was associated with higher preoperative ASIA ( P = .012) and MRC grade ( P = .005), and preservation of saddle sensation ( P = .018). Postoperative improvements in axial back pain were associated with higher preoperative ASIA grade ( P = .035) and anticoagulation treatment ( P = .029).

CONCLUSION

Neurosurgical intervention for SSEH yields positive outcomes and benefits patients. Patients with higher preoperative ASIA, MRC grade, and those presenting with preserved saddle sensation may experience further improved clinical outcomes after intervention.

The Rationale Behind Transcirculation Neuroendovascular Interventions: Literature Review Through a Case-Series Approach

BACKGROUND

With the development of advanced endovascular techniques and materials, neurointerventionalists can perform challenging and complex cases that were previously difficult to perform. Transcirculation approaches could be a useful tool used in complicated cases, providing access to the target vessel, through the contralateral or opposite circulation, when anterograde access is difficult or nonachievable.

OBJECTIVE

To retrospectively review cerebrovascular interventions performed through a transcirculation approach performed by staff at our Institution.

METHODS

English-language studies, published until August 2022, reporting transcirculation interventions in the cerebrovascular circulation were retrospectively collected. Type of intervention, number of cases, rationale, and complications were analyzed. Furthermore, similar cases performed by staff currently at our institution were also reviewed and described.

RESULTS

Including our cases, a total of 273 transcirculation treatment approaches have been reported. Intracranial aneurysm embolization, stroke thrombectomies, intra-arterial ophthalmic chemotherapy, arteriovenous malformationss, arteriovenous fistulas embolizations, and intracranial angioplasty and stenting are common indications. Reason for using a retrograde approach were stent/balloon-assisted coiling of wide neck aneurysm in 116 cases, difficult angulation of branch in 91 cases, occlusion of parent vessel in 55 cases, and bailout/other in 11 cases.

CONCLUSION

Transcirculation approaches can be considered for cases where conventional anterograde treatment options are not feasible or as a bailout strategy in failed or complicated treatment attempts. They represent a strategy to consider when facing challenging cases, and if performed by experienced and dedicated neurointerventionalists, they can represent a safe alternative.

Long-Term Results of Endoscopic Endonasal Marsupialization of Rathke Cleft Cysts With Bioabsorbable Steroid-Eluting Stents-Technical Case Series and Review of the Literature

BACKGROUND

Rathke cleft cysts (RCCs) are common benign skull-base lesions arising from embryologic remnants of Rathke pouch. Though frequently asymptomatic, RCCs can become symptomatic because of compression of adjacent neural structures. Transcranial and neuroendoscopic surgical treatments have been described for symptomatic RCCs, but recurrence rates remain as high as 30%. Bioabsorbable steroid-eluting (BASE) stents significantly decrease adhesions and recurrent ostia obstruction after endoscopic sinus surgery. We sought to use BASE stents to aid marsupialization of symptomatic RCCs.

OBJECTIVE

To present long-term results of our initial experience with endoscopic-endonasal fenestration and placement of BASE stents for RCCs.

METHODS

Patients undergoing neuroendoscopic transsphenoidal fenestration of RCCs with BASE stent placement were identified and their medical records retrospectively reviewed.

RESULTS

Four patients underwent neuroendoscopic transsphenoidal fenestration and BASE stent placement from March 2016 to April 2018 for symptomatic RCCs. After the cyst contents were evacuated, a BASE stent was deployed in the cyst fenestration to prevent cyst wall regrowth or closure and facilitate marsupialization to the sphenoid sinus. No perioperative complications were encountered, and all patients reported symptom resolution by 2 weeks postoperatively. Postoperative endoscopic evaluation demonstrated epithelization of the cyst wall opening and patent marsupialization into the sphenoid sinus in all cases. After a mean follow-up of 56 ± 12 months, all patients remained asymptomatic with baseline visual function and no radiographic evidence of recurrence.

CONCLUSION

Bioabsorbable steroid-eluting stent placement is a safe, facile, viable augmentation of neuroendoscopic technique for symptomatic RCCs with the potential to reduce long-term recurrence rates.

Management of Cesarean Scar Ectopic Pregnancies at an Academic Referral Center: A Case Series

OBJECTIVE

To describe treatment and outcomes of patients with confirmed cesarean scar ectopic pregnancy (CSEP) at a tertiary referral center.

STUDY DESIGN

We reviewed a de-identified family planning clinical database for patients seen by our subspecialty service for CSEP from January 2017 through December 2021 in this case series. We extracted referral information, final diagnosis, management, and outcome measures including estimated blood loss (EBL), secondary procedures and treatment complications.

RESULTS

Of 57 cases referred for suspected CSEPs, 23 (40%) had confirmed diagnoses; one additional case was diagnosed during clinic evaluation for early pregnancy loss. Most (n=50 [88%]) referrals occurred in the last 2 years of the 5-year study period. Of 24 confirmed CSEP cases, 8 were pregnancy losses at the time of diagnosis. Fourteen cases were ≤50 days gestation or gestational size (7 [50%] pregnancy losses) and 10 >50 days gestation (range 39-66 days). We treated all 14 patients ≤50 days primarily with suction aspiration under ultrasound guidance in an operating room with no complications and EBL of 14±10 mL. Of the ten patients >50 days (maximum 66 days), 7 were managed with primary aspiration of which 5 were uncomplicated. We treated one patient (57 days) had primary intrauterine double-catheter balloon with immediate hemorrhage requiring uterine artery embolization followed by an uncomplicated suction aspiration.

CONCLUSION

Patients with confirmed CSEPs at 50 days or less gestation or gestational size can likely be primarily treated with suction aspiration with low risk for significant adverse outcomes. Treatment success and complications are directly related to gestational age at treatment.

Sonolucent Cranioplasty in Extracranial to Intracranial Bypass Surgery: Early Multicenter Experience of 44 Cases

BACKGROUND

The new sonolucent cranioplasty implant (clear polymethyl methacrylate, PMMA) adds functionality besides surgical reconstruction. One possible application uses the transcranioplasty ultrasound (TCUS) technique after PMMA cranioplasty to assess graft patency of extracranial-intracranial (EC-IC) bypass procedures.

OBJECTIVE

To report our early multicenter experience.

METHODS

This is a multicenter analysis of consecutive EC-IC bypass patients from 5 US centers (2019-2022) with closure postbypass using PMMA implant.

RESULTS

Forty-four patients (median age 53 years, 68.2% females) were included. The most common indication for bypass was Moyamoya disease/syndrome (77.3%), and superficial temporal artery to middle cerebral artery bypass was the most common procedure (79.5%). Pretreatment modified Rankin Scales of 0 and 1 to 2 were noted in 11.4% and 59.1% of patients, respectively. Intraoperative imaging for bypass patency involved a combination of modalities; Doppler was the most used modality (90.9%) followed by indocyanine green and catheter angiography (86.4% and 61.4%, respectively). Qualitative TCUS assessment of graft patency was feasible in all cases. Postoperative inpatient TCUS confirmation of bypass patency was recorded in 56.8% of the cases, and outpatient TCUS surveillance was recorded in 47.7%. There were no cases of bypass failure necessitating retreatment. Similarly, no implant-related complications were encountered in the cohort. Major complications requiring additional surgery occurred in 2 patients (4.6%) including epidural hematoma requiring evacuation (2.3%) and postoperative surgical site infection (2.3%) that was believed to be unrelated to the implant.

CONCLUSION

This multicenter study supports safety and feasibility of using sonolucent PMMA implant in EC-IC bypass surgery with the goal of monitoring bypass patency using TCUS.

The Management of Hydrocephalus in Midline Posterior Fossa Cystic Collections: Surgical Outcome From a Retrospective Single-Center Case Series of 54 Consecutive Pediatric Patients

BACKGROUND

Hydrocephalus frequently occurs with midline posterior fossa cystic collections. The classification of this heterogeneous group of developmental anomalies, including Dandy-Walker malformation, persisting Blake's pouch, retrocerebellar arachnoid cysts, and mega cisterna magna, is subject of debate. The absence of diagnostic criteria is confusing regarding the ideal management of PFCC-related hydrocephalus.

OBJECTIVE

To decipher the surgical strategy for the treatment of children with PFCC-related hydrocephalus through a retrospective analysis of the surgical outcome driven by their clinical and radiological presentation.

METHODS

This study enrolled patients operated of symptomatic PFCC-related hydrocephalus. Clinical and MRI features were examined, as well as the surgical outcome. Unbiased subgroup classification of the patients was performed with multiple component analysis as a function of imaging characteristics and hierarchical clustering on principal component. Outcome was assessed with binomial logistic regression and Kaplan-Meier analysis.

RESULTS

Fifty-four patients were included between 2007 and 2021. Multiple component analysis suggested that cerebellar and vermian hypoplasia, vermian rotation, basal-tentorial angle, and fastigial angle were strongly correlated. Hierarchical clustering and the distribution of the patients in the bidimensional plot showed the clear segregation of 3 major clusters, which correlated with the radiological diagnosis (P < .01). Binomial logistic regression and survival analysis showed that endoscopic third ventriculostomy was an effective treatment for patients with persisting Blake's pouch, while failing to control hydrocephalus in most of patients with Dandy-Walker malformation.

CONCLUSION

Preoperative MRI in patients with PFCC-related hydrocephalus is essential to better define the diagnosis. The choice of treatment strategy notably relies on correct radiological diagnosis.

Understanding fluorescence time curves during ileal pouch-anal anastomosis with or without vascular ligation

BACKGROUND

Intraoperative indocyanine green fluorescence angiography (ICG-FA) may be of added value during pouch surgery, in particular after vascular ligations as lengthening maneuver. The aim was to determine quantitative perfusion parameters within the efferent/afferent loop and explore the impact of vascular ligation. Perfusion parameters were also compared in patients with and without anastomotic leakage (AL).

METHODS

All consenting patients that underwent FA-guided ileal pouch-anal anastomosis (IPAA) between July 2020 and December 2021 were included. After intravenous bolus injection of 0.1 mg/kg ICG, the near-infrared camera (Stryker Aim 1688) registered the fluorescence intensity over time. Quantitative analysis of ICG-FA from standardized regions of interests on the pouch was performed using software. Fluorescence parameters were extracted for inflow (T₀, T_max, F_max, slope, Time-to-peak) and outflow (T_90% and T_80%). Change of management related to FA findings and AL rates were recorded.

RESULTS

Twenty-one patients were included, three patients (14%) required vascular ligation to obtain additional length, by ligating terminal ileal branches in two and the ileocolic artery (ICA) in one patient. In nine patients the ICA was already ligated during subtotal colectomy. ICG-FA triggered a change of management in 19% of patients (n = 4/21), all of them had impaired vascular supply (ligated ileocolic/ terminal ileal branches). Overall, patients with intact vascular supply had similar perfusion patterns for the afferent and efferent loop. Pouches with ICA ligation had longer T_max in both afferent as efferent loop than pouches with intact ICA (afferent 51 and efferent 53 versus 41 and 43 s respectively). Mean slope of the efferent loop diminished in ICA ligated patients 1.5(IQR 0.8-4.4) versus 2.2 (1.3-3.6) in ICA intact patients.

CONCLUSION

Quantitative analysis of ICG-FA perfusion during IPAA is feasible and reflects the ligation of the supplying vessels.

Distal intestinal obstruction syndrome in a child with cystic fibrosis

The aim of the study – to analyze the clinical case of a child with distal intestinal obstruction syndrome in cystic fibrosis. A 9.5 year old patient was admitted to the Gastroenterology Department of the Republican Specialized Scientific and Practical Center of Pediatrics with complaints of an increase in abdominal circumference, increased peristalsis, weakness, lethargy, swelling in the limbs, loose stools, and weight loss. From the anamnesis: from the age of 6 years it was observed periodic vomiting, not associated with food intake. At the age of 8 years, the condition worsened, bloating joined the vomiting. At the place of residence, the diagnosis was made “Acute intestinal obstruction. Volvulus of the sigmoid colon”. Over the next 6 months, the condition was relatively satisfactory, and then stool disorders began – 3–4 times a day and bloating. Considering the presence of steatorrhea, changes in the pancreas on ultrasound and MSCT, the child was referred to a geneticist, the result of a sweat test was 86.0 mEq/l. The diagnosis was made: Cystic fibrosis, mixed form. Syndrome of distal intestinal obstruction. Partial intestinal obstruction. Severe PEI, celiac disease and HIV were excluded. On the background of the therapy, the child’s condition improved relatively. Within a month after discharge, the condition was satisfactory, and then worsened again. After 3 months, the girl was re-hospitalized with the same complaints. After consulting the surgeons, recommendations were given to perform the operation due to the appearance of signs of partial lower intestinal obstruction, but the relatives signed a voluntary refusal of the operation, the child was taken home against receipt. The girl was discharged with the final diagnosis: Cystic fibrosis, mixed form, severe course. Syndrome of distal intestinal obstruction. Partial lower intestinal obstruction. Syndrome of exudative enteropathy, severe PEI. The girl died 2 weeks after discharge. Distal intestinal obstruction syndrome (DIOS) may be misunderstood by those who are not familiar with cystic fibrosis. Pediatric gastroenterologists, surgeons should be alert when this condition is detected in combination with other symptoms indicating cystic fibrosis.

Allergic and Infectious complications of Etonogestrel Implant Placements: A Case Series

Patients rarely experience complications at time of Etonogestrel subdermal contraceptive implant placement. Few case reports describe infection or allergy as a complication at time of implant insertion. In this case series, we discuss three infections and one allergic reaction following Etonogestrel implant placement, review 6 previous case reports of 8 cases of infection or allergy and discuss management of these complications. We highlight differential diagnosis when encountering a placement complication, considerations of dermatologic conditions when placing Etonogestrel implants, and discuss when to consider removal of the implant when a complication occurs.

The Roof of the 4th Ventricle Seen From Inside: Endoscopic Anatomic Illustration-A Case Series

BACKGROUND

The anatomy of the roof of the fourth ventricle has been illustrated in many laboratory investigations, but in vivo reports of the roof anatomy and its variants are still lacking.

OBJECTIVE

To describe the topographical anatomy of the roof of the fourth ventricle explored through a transaqueductal approach that overcomes cerebrospinal fluid depletion, displaying in vivo anatomic images possibly quite close to normal physiological conditions.

METHODS

We critically reviewed the intraoperative video recordings of our 838 neuroendoscopic procedures, selecting 27 cases of transaqueductal navigation that provided good quality image details of the anatomy of the roof of the fourth ventricle. Twenty-six patients affected by different forms of hydrocephalus were therefore categorized into three groups: Group A: blockage of the aqueduct-aqueductoplasty, Group B: communicating hydrocephalus, and Group C: tetraventricular obstructive hydrocephalus.

RESULTS

Group A has shown what the roof of a normal fourth ventricle really looks like albeit the structures seemed overcrowded because of the narrow space. Images from groups B and C paradoxically allowed a more distinct identification of the roof structures flattened by ventricular dilation, making them more comparable with the topography traced on the laboratory microsurgical studies.

CONCLUSION

Endoscopic in vivo videos and images provided a novel anatomic view and an in vivo redefinition of the real topography of the roof of the fourth ventricle. The relevant role of cerebrospinal fluid was defined and outlined, as well as the effects of hydrocephalic dilation on some structures on the roof of the fourth ventricle.

Stereotactic Radiosurgery for Vestibular Schwannoma in Neurofibromatosis Type 2: An International Multicenter Case Series of Response and Malignant Transformation Risk

BACKGROUND

Vestibular schwannomas (VSs) related to neurofibromatosis type 2 (NF2) are challenging tumors. The increasing use of stereotactic radiosurgery (SRS) necessitates further investigations of its role and safety.

OBJECTIVE

To evaluate tumor control, freedom from additional treatment (FFAT), serviceable hearing preservation, and radiation-related risks of patients with NF2 after SRS for VS.

METHODS

We performed a retrospective study of 267 patients with NF2 (328 VSs) who underwent single-session SRS at 12 centers participating in the International Radiosurgery Research Foundation. The median patient age was 31 years (IQR, 21-45 years), and 52% were male.

RESULTS

A total of 328 tumors underwent SRS during a median follow-up time of 59 months (IQR, 23-112 months). At 10 and 15 years, the tumor control rates were 77% (95% CI: 69%-84%) and 52% (95% CI: 40%-64%), respectively, and the FFAT rate were 85% (95% CI: 79%-90%) and 75% (95% CI: 65%-86%), respectively. At 5 and 10 years, the serviceable hearing preservation rates were 64% (95% CI: 55%-75%) and 35% (95% CI: 25%-54%), respectively. In the multivariate analysis, age (hazards ratio: 1.03 [95% CI: 1.01-1.05]; P = .02) and bilateral VSs (hazards ratio: 4.56 [95% CI: 1.05-19.78]; P = .04) were predictors for serviceable hearing loss. Neither radiation-induced tumors nor malignant transformation were encountered in this cohort.

CONCLUSION

Although the absolute volumetric tumor progression rate was 48% at 15 years, the rate of FFAT related to VS was 75% at 15 years after SRS. None of the patients with NF2-related VS developed a new radiation-related neoplasm or malignant transformation after SRS.

Surgical Strategy and Application of Robotic-Assisted Benign Sacral Neurogenic Tumor Resection

BACKGROUND

Robotic surgery may be advantageous in neurogenic sacral tumor resection but only a few studies reported robotic-assisted neurogenic sacral tumor resection.

OBJECTIVE

To propose a new surgical strategy for robotic-assisted benign sacral neurogenic tumor resection and introduce the ultrasonic osteotomy surgical system in robotic surgery.

METHODS

Twelve patients who had robotic-assisted primary benign sacral neurogenic tumor resection between May 2015 and March 2021 were included. Our surgical strategy divides tumors into 4 types. Type I: Presacral tumors with diameter <10 cm. Type II: Narrow-base tumors involving the sacrum with diameter <10 cm. Type III: Broad-base tumors involving the sacrum with diameter <10 cm. Type IV: Tumors involving sacral nerve roots ≥2 levels and/or with diameter ≥10 cm.

RESULTS

Five type I, 5 type II, and 1 type III patients underwent tumor resection via an anterior approach, and 1 type IV patient via a combined approach. The median operation time, blood loss, and postoperative hospital stay of type I and II were much less than those of type IV. The ultrasonic osteotomy surgical system facilitated osteotomy in 2 type II and 1 type III patients. Eleven patients had total resections, and 1 type III patient had a partial resection. During the follow-up period of 7.9 to 70.9 months (median: 28.5 months), no local recurrences or deaths were noted.

CONCLUSION

With the largest single-center series to our knowledge, this surgical strategy helped to guide robotic-assisted benign sacral neurogenic tumor resection. The ultrasonic osteotomy surgical system was effective for type II and III.

A Retrospective Analysis of Pedicle Screw Placement Accuracy Using the ExcelsiusGPS Robotic Guidance System: Case Series

BACKGROUND

Robotic guidance has become widespread in spine surgery. Although the intent is improved screw placement, further system-specific data are required to substantiate this intention for pedicle screws in spinal stabilization constructs.

OBJECTIVE

To determine the accuracy of pedicle screws placed with the aid of a robot in a cohort of patients immediately after the adoption of the robot-assisted surgery technique.

METHODS

A retrospective, Institutional Review Board-approved study was performed on the first 100 patients at a single facility, who had undergone spinal surgeries with the use of robotic techniques. Pedicle screw accuracy was graded using the Gertzbein-Robbins Scale based on pedicle wall breach, with grade A representing 0 mm breach and successive grades increasing breach thresholds by 2 mm increments. Preoperative and postoperative computed tomography scans were also used to assess offsets between the objective plan and true screw placements.

RESULTS

A total of 326 screws were analyzed among 72 patients with sufficient imaging data. Ages ranged from 21 to 84 years. The total accuracy rate based on the Gertzbein-Robbins Scale was 97.5%, and the rate for each grade is as follows: A, 82%; B, 15.5%; C, 1.5%; D, 1%; and E, 0. The average tip offset was 1.9 mm, the average tail offset was 2.0 mm, and the average angular offset was 2.6°.

CONCLUSION

Robotic-assisted surgery allowed for accurate implantation of pedicle screws on immediate adoption of this technique. There were no complications attributable to the robotic technique, and no hardware revisions were required.

Factors Predicting Cerebrospinal Fluid Leaks in Microvascular Decompressions: A Case Series of 1011 Patients

BACKGROUND

Microvascular decompression (MVD) using a retrosigmoid approach is a highly effective, open-surgical procedure for neurovascular conflict in the posterior fossa, although there is a risk of postoperative cerebrospinal fluid (CSF) leak.

OBJECTIVE

To identify factors associated with postoperative CSF leakage after MVD.

METHODS

We retrospectively reviewed all patients who underwent MVDs at our institution from 2007 to 2020. Patient demographics, clinical diagnoses, and procedural characteristics were recorded and compared. Factors leading to CSF leak were analyzed using χ 2 , univariate, and multivariate regression.

RESULTS

Of 1011 patients who underwent MVDs, 37 (3.7%) presented with postoperative CSF leaks. In univariate analysis, the use of Cranios/Norian to obliterate the air cells was protective against CSF leak ( P = .01). Craniotomies ( P = .002), the use of dural substitutes such as Durepair ( P = .04), dural onlays such as DuraGen ( P = .04), muscle/fascia ( P = .03), and titanium mesh cranioplasty >5 cm ( P = .03) were associated with CSF leak. On multivariate analysis, only the presence of craniotomies ( P = .04) and nonprimary dural closure ( P = .03) were significant risk factors for CSF leak. When excluding the 34 (3.4%) patients who underwent a craniotomy, the lack of primary dural closure still remained significantly associated with postoperative CSF leak ( P = .04).

CONCLUSION

Our results represent one of the largest series of posterior fossa surgeries for a uniform indication in North America. Our study demonstrates increased risk for postoperative CSF leak when craniotomies are performed and when primary dural closure is not established. Given the small sample of patients who received a craniotomy, however, future studies corroborating this finding should be performed.

Head-Mounted Augmented Reality in the Planning of Cerebrovascular Neurosurgical Procedures: A Single-Center Initial Experience

BACKGROUND

Augmented reality (AR) technology has played an increasing role in cerebrovascular neurosurgery over the last 2 decades. Hence, we aim to evaluate the technical and educational value of head-mounted AR in cerebrovascular procedures.

METHODS

This is a single-center retrospective study of patients who underwent open surgery for cranial and spinal cerebrovascular lesions between April and August 2022. In all cases, the Medivis Surgical AR platform and HoloLens 2 were used for preoperative and intraoperative (preincision) planning. Surgical plan adjustment due to the use of head-mounted AR and subjective educational value of the tool were recorded.

RESULTS

A total of 33 patients and 35 cerebrovascular neurosurgical procedures were analyzed. Procedures included 12 intracranial aneurysm clippings, 6 brain and 1 spinal arteriovenous malformation resections, 2 cranial dural arteriovenous fistula obliterations, 3 carotid endarterectomies, two extracranial-intracranial direct bypasses, two encephaloduroangiosynostosis for Moyamoya disease, 1 biopsy of the superficial temporal artery, 2 microvascular decompressions, 2 cavernoma resections, 1 combined intracranial aneurysm clipping and encephaloduroangiosynostosis for Moyamoya disease, and 1 percutaneous feeder catheterization for arteriovenous malformation embolization. Minor changes in the surgical plan were recorded in 16 of 35 procedures (45.7%). Subjective educational value was scored as "very helpful" for cranial, spinal arteriovenous malformations, and carotid endarterectomies; "helpful" for intracranial aneurysm, dural arteriovenous fistulas, direct bypass, encephaloduroangiosynostosis, and superficial temporal artery-biopsy; and "not helpful" for cavernoma resection and microvascular decompression.

CONCLUSIONS

Head-mounted AR can be used in cerebrovascular neurosurgery as an adjunctive tool that might influence surgical strategy, enable 3-dimensional understanding of complex anatomy, and provide great educational value in selected cases.

Laparoscopic Sleeve Gastrectomy in Monozygotic Twins: Report of the First Case

Obesity is an epidemic disease that is believed to link to other pathologies as well as life-threatening cardiovascular pathology. Here we report a case of monozygotic twins who successfully lost weight following laparoscopic sleeve gastrectomy at the end of the 18-month follow-up period. We aimed to determine the factors affecting the weight loss outcome after sleeve gastrectomy in monozygotic twins. The twins' initial BMIs were 37.1 kg/m2 and 40.2 kg/m2, respectively. Twin A's excess weight loss was 48.4%, 61.3%, 80.6%, 96.8%, and 112.9% at three, six, nine, 12 and 18 months, while Twin B's in the third, sixth, ninth, 12th and 18th months was 23.1%, 41%, 51.3%, 61.5% and 71.8%. On the third, sixth, ninth, 12th, and 18th months of Twin A, the total weight loss was 15.8%, 20%, 26.3%, 31.6%, and 36.8%. In Twin B in the third, sixth, ninth, 12th, and 18th months, it was 8.7%, 15.5%, 19.4%, 23.3%, and 27.2%. When the twins were compared in terms of excess weight loss and total weight loss at 18 months, Twin A was more successful than Twin B. Especially at this point, Twin B's having a child (three years old) at a young age, her low compliance with the recommendations in the post-operative period and her difficulty in changing her lifestyle, environmental factors are as important as hereditary factors in achieving weight loss and a healthy body mass index (BMI) range.

Closed system paravertebral abscess evacuation on spinal infection: A case series

INTRODUCTION

Paravertebral abscess is a common complication of spondylitis tuberculosis which has high prevalence in Indonesia. Surgical intervention such as open surgery or endoscopic debridement is needed to remove and drainage the abscess in addition to chemotherapy. However, this surgeries have several complications such as soft tissue damage and abscess contamination to the healthy tissue. We reported closed system strategy to evacuate the paravertebral abscess on spinal infection.

METHODS

The technique is performed by orthopaedic team under guidance of the C-Arm and ultrasound sonography (USG) in March-June 202. The needle which connected to 20 cc syringe is inserted into the lesion to aspirate the abscess. After evacuation of the abscess, 2-g broad spectrum antibiotic is injected through the needle to eradicate the bacteria locally.

RESULTS

We performed the closed system paravertebral abscess evacuation in three patients, a 30-year-old male, 43-year-old male, and 22-year-old female. All the patients had back pain and limitation spine movement due to pain and were diagnosed with spondylitis and paravertebral abscess based on the plain radiography and magnetic resonance imaging (MRI). It reported that up to 2000 cc abscess can be evacuated with this micro invasive technique.

CONCLUSION

The closed system is a micro-invasive procedure result in minimal soft tissue injury and faster recovery. It succesfully remove paravertebral abscess followed by direct antibiotic eradication on spinal infection.

Posterior Petrous Meningiomas: Surgical Classification and Postoperative Outcomes in a Case Series of 130 Patients Operated via the Retrosigmoid Approach

OBJECTIVE

A standardized definition and classification of primary posterior petrous meningiomas (PPMs) is lacking, with consequent challenges in comparing different case series. This study aimed to provide an anatomical description and classification of PPMs analyzing a homogeneous series of patients operated via the retrosigmoid approach.

METHODS

PPMs originate laterally to the petro-occipital fissure within the venous ring composed of the superior petrosal, sigmoid, inferior petrosal, and cavernous sinuses. We proposed a classification based on tumor site of origin, direction of growth relative to the internal acoustic meatus, and cranial nerves' displacement. Four types of PPMs were defined: retromeatal (type A), meatal (type B), premeatal (type C), and broad-based (type D). We performed a retrospective analysis of 130 consecutive patients with PPMs who underwent surgery as first-line treatment.

RESULTS

The PPM classification predicted clinical presentation, postoperative morbidity, and resection rates. Headache, hydrocephalus, and cerebellar deficits were more common in type A (59.0%, 37.7%, 49.2%) and type D (66.7%, 66.7%, 33.3%). Hypoacusia/anacusia was more common in type B (87.5%), while trigeminal hypoesthesia/anesthesia was more common in type C (85.0%). After surgery, patients with type A and D PPMs were at higher risk to develop cerebellar deficits (11.5%-22.2%), whereas patients with type B and C PPMs presented with hypoacusia/anacusia (12.5%) and trigeminal deficits (10.0%), respectively. The near-total resection rate was higher in type A (91.8%), followed by types B (82.5%), C (80.0%), and D (77.8%) PPMs.

CONCLUSIONS

The PPM surgical classification has an operative and prognostic relevance. In expert hands, the retrosigmoid approach represents a safe and effective approach to remove PPMs.

Spinal Intradural Arachnoid Cysts in Adults: An Institutional Experience and Literature Review

BACKGROUND

Adult spinal intradural arachnoid cysts are rare pathologic entities with an unclear etiopathogenesis. These lesions can be dichotomized into primary (idiopathic) or secondary (related to inflammation, intradural surgery, or trauma) etiologies. Limited series have depicted optimal management strategies and clinical outcomes.

OBJECTIVE

To illustrate our experience with spinal intradural arachnoid cysts and to present a literature review of surgically treated cysts to elucidate the clinical and anatomic differences between etiologies.

METHODS

Institutional review revealed 29 patients. Various data were extracted from the medical record. Initial and follow-up symptomatologies of the surgical cohort were compared. The literature review included case series describing cysts managed surgically.

RESULTS

From patients treated surgically at our institution (22), there was a significant reduction in thoracic back pain postoperatively ( P = .034). A literature review yielded 271 additional cases. Overall, primary and secondary lesions accounted for 254 and 39 cases, respectively. Cysts of secondary origin were more likely localized ventral to the spinal cord ( P = .013). The rate of symptomatic improvement after surgical intervention for primary cysts was more than double than that of secondary cysts ( P < .001). Compared with primary etiologies, the rates of radiographic progression ( P = .032) and repeat surgery ( P = .041) were each more than double for secondary cysts.

CONCLUSION

Surgical intervention for spinal intradural arachnoid cysts improves thoracic back pain. The literature supports surgical intervention for symptomatic primary spinal intradural arachnoid cysts with improved clinical outcomes. Surgery should be cautiously considered for secondary cysts given worse outcomes.

Complications Related to Deep Brain Stimulation Lead Implantation: A Single-Surgeon Case Series

BACKGROUND

Deep brain stimulation (DBS) is the mainstay of surgical treatment for movement disorders, yet previous studies have shown widely varying complication rates. Given the elective nature of DBS surgery, minimizing surgical complications is imperative.

OBJECTIVE

To evaluate short-term and long-term complications related to DBS lead implantation surgeries performed by an experienced surgeon and provide an updated benchmark comparison for other DBS centers and alternative therapies.

METHODS

A retrospective chart review of patients who underwent DBS lead implantation surgery by a single surgeon at our institution between 2012 and 2020 was conducted. Demographic and clinical data including surgical complications were collected. A Kaplan-Meier survival analysis was used to evaluate the cumulative risk of lead revision or removal over time. Associations between patient characteristics and various complications were evaluated.

RESULTS

Four hundred fifty-one DBS leads were placed in 255 patients. Thirteen leads and 11 patients required revision. In total, 3.6% (95% CI [1.3%-5.9%]) of patients required revision at 1 year and 4.8% (95% CI [1.9%-7.6%]) at 5 years, with per-lead revision rates of 2.3% (95% CI [0.9%-3.6%]) and 3.3% (95% CI [1.5%-5.1%]), respectively. Less common diagnoses such as Tourette syndrome, post-traumatic tremor, and cluster headache trended toward association with lead revision or removal.

CONCLUSION

DBS performed by an experienced surgeon is associated with extremely low complication rates.

Intrathecal Baclofen and Opioid Therapy: Cerebrospinal Fluid Leak and Infection Incidence, Risk Factors, and Outcomes

BACKGROUND

Intrathecal drug therapy treats medically refractory spasticity and pain. cerebrospinal fluid (CSF) leak or infection can limit efficacy and increase morbidity. We aim to evaluate risk factors and outcomes after CSF leaks and infections requiring reoperation.

MATERIALS AND METHODS

We retrospectively analyzed our 7-year experience of intrathecal baclofen and opioid operations using a protocol designed to limit CSF leakage and infections. Postoperative complication incidence and risk factors for reoperation were compared with published reports. We assessed outcomes after these complications.

RESULTS

We analyzed 282 intrathecal baclofen (ITB) and intrathecal opioid (ITO) therapy operations (mean 2.27-year follow-up). 21% developed CSF leaks overall with similar incidences in ITB and ITO patients (19% vs. 25%, p0.3). Overall, 5% of patients developed deep infections with similar incidences between ITB and ITO cohorts (6% vs. 4%, p0.6). Tobacco use and age <50 years were significantly associated with CSF leak in ITO operations. Underweight body mass index, immunosuppression, tobacco use, and primary implantation were associated with infection. When CSF leak or infection occurred, patients suffered more perioperative adverse events and had elevated 90-day readmission rate compared with those without these complications.

CONCLUSIONS

Our 7-year ITB and ITO therapy using the 8781 Ascenda intrathecal catheter highlights a higher reoperation rate for CSF leak and similar infection incidence to reports using traditional catheters. Multiple modifiable risk factors for CSF leak include recent tobacco use among ITO patients. Body mass index optimization and immunosuppressant elimination may reduce reoperation for infection.

The value of case reports in diagnostic radiography

OBJECTIVE

- This paper sought to explore the value of case reports in diagnostic radiography with regards to current usage, relevance to evidence-based radiography, and educational benefits.

KEY FINDINGS

Case reports are short accounts of novel pathologies, trauma or treatment with a critical review of relevant literature. Examples within diagnostic radiography include the appearances of COVID-19 alongside examination-level scenarios involving image artefacts, equipment failure and patient incidents in radiology. With greatest risk of bias and lowest generalisability, they are considered as low-quality evidence with generally poor citation rates. Despite this, there are examples of significant discoveries or developments initiated with case reports with important patient care implications. Furthermore, they offer educational development for both reader and author alike. Whereas the former learns about an unusual clinical scenario, the latter develops scholarly writing skills, reflective practice and may generate further, more complex, research. Radiography-specific case reports could capture the diverse imaging skills and technological expertise currently under-represented in traditional case reports. Potential avenues for cases are broad and may include any imaging modality where patient care or safety of other persons may illicit a teaching point. This encapsulates all stages of the imaging process, before, during and after patient interaction.

CONCLUSION

Despite being low-quality evidence, case reports contribute to evidence-based radiography, add to the knowledge base, and foster a research culture. However, this is contingent upon rigorous peer-review and adherence to ethical treatment of patient data.

IMPLICATIONS FOR PRACTICE

With the drive to increase research engagement and output at all levels in radiography (student to consultant), case reports may act as a realistic grass-root activity for a burdened workforce with limited time and resources.

Single bundle vs double bundle for anterior cruciate ligament reconstruction evaluated with T2 mapping: A case series

INTRODUCTION

ACL reconstruction is needed to restore the stability and biomechanics properties of the injured knee joints in order to reproduce the function of the native ACL. The single-bundle (SB) and double-bundle (DB) techniques are most commonly used to reconstruct the injured ACL. However, its superiority upon each other is still controversial.

PRESENTATION OF CASE

This study presented a case series of six patients underwent ACL reconstruction, consisted of three patients with SB ACL reconstruction and three patients with DB ACL reconstruction with further T2 mapping for joint instability evaluation. Only two DB patients showed consistent decreased value in every follow-up.

DISCUSSION

ACL tear can generate joint instability. Joint instability is resulted from two mechanisms of relative cartilage overloading. First, there is an abnormal load distribution due to shifting of the center of pressure of the tibiofemoral force, resulting in increased stresses on the articular cartilage of the knee joint. There is also an increase of translation between articular surfaces, resulting in increased shear stresses on the articular cartilage. A trauma of knee joint causes cartilage damage and increased oxidative and metabolic stress of chondrocytes, resulting in chondrocyte senescence acceleration.

CONCLUSION

This case series showed inconsistent results to determine either SB or DB has a better outcome in joint instability, thus further larger studies are needed.

Effect of VMBR Training on Psychological Dimensions of Anxiety and Mental Toughness of Table Tennis Players

Study purpose.  The study was conducted to examine the effects of Visual Motor Behavior Rehearsal (VMBR) Training on sports anxiety and mental toughness of table tennis players after six weeks of the training. Materials and methods. Fifty male state-level table tennis players within the age group of 17 to 23 years were selected from Inspire Table Tennis Academy, Secunderabad, Telangana and divided randomly into two groups, the Control and Main Groups, each one consisting of 25 subjects. The Main Group underwent VMBR Training for six weeks, three times a week, and the Control Group was not involved in any kind of training program except for their daily practice. Measurements of anxiety of all table tennis players with the use of Sports Anxiety Scale-2 (SAS-2) with three dimensions which were somatic, worry and concentration disruption developed by Ronald E. Smith, Frank L. Smoll, Sean P. Cumming, and Joel R. Grossbard in 2006 and Sports Mental Toughness Questionnaire (SMTQ) with three dimensions which were confidence, consistency and control developed by Michael Sheard, Jim Golby, and Anna Van Wersch in 2009 were taken at the beginning of and after the experimental period of six weeks. Results. Significant effect was found in the Main Group at a significance level of 0.05 for dimensions which were sports mental toughness and somatic, worry and concentration disruption from anxiety scale dimensions of table tennis players. Conclusions. The visualization and imagery has been used as an effective tool for enhancing performance. Visual-Motor Behavior Rehearsal is a systematic psychological technique that helps table tennis players in overcoming psychological factors.

Study design methodology in neurosurgical research

Background

Medical research has evolved from individual expert-described opinions and techniques to scientifically designed methodology-based studies. There are different study designs, and selecting an appropriate study design is critical to appropriately answer the research question being investigated.

Main body

A research question may be addressed using different approaches that can be descriptive, analytical, or experimental. The choice of study design is influenced by features as that related to exposure (intervention) and disease (outcome); considerations related to time, resources, ethics and gaps in scientific knowledge that remain to be filled. The purpose of this review is to provide an overview of the basic study designs as it is the foundation of neurosurgical research to provide valid scientific evidence.

Conclusion

Quality in scientific research begins with a clear hypothesis and a well-formulated design. This entails a thorough understanding of the different study designs to choose the best suited to answer the investigated research question.

Thyroglossal duct diseases: presentation and outcomes

OBJECTIVE

The incidence of thyroglossal duct diseases in the general population is about 7%. We aimed to demonstrate the clinical presentations and management of thyroglossal duct diseases.

METHODS

We conducted a retrospective review of all patients who underwent surgery for histopathologically confirmed thyroglossal duct cyst, sinus, or fistula at a single center.

RESULTS

A total of 151 cases were included in this study. There were more female patients (87, 58%) than male patients (64, 42%). The patients' ages ranged from 1 to 63 years old. The most prevalent complaint was painless upper midline neck swelling (93.3%). Most cases were diagnosed as thyroglossal duct cysts (137, 90.7%). Six cases (4%) were associated with carcinoma. All the cases were managed using the modified Sistrunk procedure. There were no procedure-related complications, and five cases of recurrence.

CONCLUSIONS

Although thyroglossal duct cyst is the most common neck anomaly in children, it may also present with various characteristics later in life. This condition can be managed successfully without complications and with a low recurrence rate.

Serratus plane block with sedation for patients submitted to axillary dissection: a prospective case series

Axillary dissection is a standard surgical procedure for stage III skin and soft tissue tumors and is usually performed under general anesthesia. This study aimed to investigate the feasibility of performing axillary dissection with Serratus muscle plane block plus intravenous sedation. Fifteen patients undergoing axillary dissection were prospectively recruited. The patients were evaluated during their pre-operative anesthetic appointment, during their procedure, and at post-operative days 1 and 30. The blockade was performed superficial to the Serratus muscle at the level of fourth rib. Sedation was performed using propofol, fentanyl, dexmedetomidine, and S-ketamine. None of the patients required conversion to general anesthesia. Surgeons showed a highly positive response when asked about the anesthetic technique, and most of them found the technique "indistinguishable" from general anesthesia. The median (interquartile range) pain scores at rest over all time frames was 0 (0-0). Furthermore, no patients developed nausea, hemodynamic instability, or any complications associated with the technique. The Serratus plane block associated with intravenous sedation proved feasible for axillary lymphadenectomy, however, further clinical trials should evaluate potential advantages compared to other techniques.

Surgery as an Effective Therapy for Ulnar Nerve Neuropathic Pain Caused by Gunshot Wounds: A Retrospective Case Series

BACKGROUND

Peripheral nerve injuries remain a major medical problem worldwide and are associated with multiple causes, including gunshot wounds (GSWs), which are the second most common cause of brachial plexus injuries in peacetime and the main, or only, cause reported in wartime studies. The ulnar nerve (UN) is one of the most affected nerves. Peripheral nerve trauma may cause intense neuropathic pain, which is very difficult to control. Particularly UN gunshot injuries may impact individual daily life, as injuries to this nerve result in both sensory and motor deficits within the hand. We evaluated the improvement of neuropathic pain after surgical treatment in a consecutive series of 20 patients with UN injury due to GSWs.

METHODS

This single-center, retrospective, consecutive case series included 20 patients with UN injuries due to GSWs, who presented with excruciating neuropathic pain and underwent surgical treatment between 2005 and 2017.

RESULTS

Of injuries, 13 occurred in the right upper limb (65%); 12 patients had a high UN injury (60%). Regarding associated injuries, 8 patients had bone injuries (40%), and 4 patients had arterial injuries (20%). A neuroma in continuity was detected in 8 cases (40%), and 4 patients (20%) had shrapnel lodged within the UN. All patients had severe neuropathic pain and functional deficit, with a mean visual analog scale score of 8.45 ± 1.4 and a mean reduction of 6.95 points 12 months after surgery; 10 patients (50%) had a British Medical Research Council score ≥M3.

CONCLUSIONS

Surgery is an effective treatment for neuropathic pain from GSWs. Early isolated external neurolysis is associated with better pain management and functional outcomes postoperatively.

Influence of Patient and Technical Variables on Combined Direct and Indirect Cerebral Revascularization: Case Series

BACKGROUND

Cerebral bypass for flow augmentation is an important technique for selected neurosurgical patients, with multiple techniques used (direct, indirect, or combined).

OBJECTIVE

To assess the impact of patient and technical variables on direct and indirect bypass flow after combined revascularization.

METHODS

This was a retrospective, single-institution review of patients undergoing direct superficial temporal artery-to-middle cerebral artery bypass with indirect encephaloduro-myosynangiosis for moyamoya disease and steno-occlusive cerebrovascular disease over a 2-year period. We evaluated the effect of baseline patient characteristics, preoperative imaging characteristics, and operative variables on direct and indirect patency grades.

RESULTS

Twenty-six hemispheres (8 moyamoya disease and 18 steno-occlusive cerebrovascular disease) in 23 patients were treated with combined revascularization. The mean patient age was 53.4 ± 19.1 years. Direct bypass patency was 96%. Over a mean follow-up of 8.3 ± 5.4 months, there were 3 strokes in the treated hemispheres (11.5%). The mean modified Rankin Scale score improved from 1.3 ± 1.1 preoperatively to 0.7 ± 0.8 postoperatively. Preservation of the nondonor superficial temporal artery branch was associated with a lower direct bypass grade (P < .01), whereas greater mean time to maximum perfusion (Tmax)> 4 and >6 seconds and mismatch volumes were associated with higher direct bypass grades (P < .05). Tmax >4-second volume inversely predicted indirect bypass patency.

CONCLUSION

Patient and technical variables may influence the relative contributions of the direct and indirect components of combined revascularizations.

Detection of immunoreactive proteins of Escherichia coli, Streptococcus uberis, and Streptococcus agalactiae isolated from cows with diagnosed mastitis

Introduction

Mastitis is a widespread mammary gland disease of dairy cows that causes severe economic losses to dairy farms. Mastitis can be caused by bacteria, fungi, and algae. The most common species isolated from infected milk are, among others, Streptococcus spp., and Escherichia coli. The aim of our study was protein detection based on both in silico and in vitro methods, which allowed the identification of immunoreactive proteins representative of the following species: Streptococcus uberis, Streptococcus agalactiae, and Escherichia coli.

Methods

The study group included 22 milk samples and 13 serum samples obtained from cows with diagnosed mastitis, whereas the control group constituted 12 milk samples and 12 serum samples isolated from healthy animals. Detection of immunoreactive proteins was done by immunoblotting, while amino acid sequences from investigated proteins were determined by MALDI-TOF. Then, bioinformatic analyses were performed on detected species specific proteins in order to investigate their immunoreactivity.

Results

As a result, we identified 13 proteins: 3 (molybdenum cofactor biosynthesis protein B, aldehyde reductase YahK, outer membrane protein A) for E. coli, 4 (elongation factor Tu, tRNA uridine 5-carboxymethylaminomethyl modification enzyme MnmG, GTPase Obg, glyceraldehyde-3-phosphate dehydrogenase) for S. uberis, and 6 (aspartate carbamoyltransferase, elongation factor Tu, 60 kDa chaperonin, elongation factor G, galactose-6-phosphate isomerase subunit LacA, adenosine deaminase) for S. agalactiae, which demonstrated immunoreactivity to antibodies present in serum from cows with diagnosed mastitis.

Discussion

Due to the confirmed immunoreactivity, specificity and localization in the bacterial cell, these proteins can be considered considered potential targets in innovative rapid immunodiagnostic assays for bovine mastitis, however due to the limited number of examined samples, further examination is needed.

Аre Multivisceral Resections for Gastric Cancer Acceptable: Experience from a High Volume Center and Extended Literature Review?

Introduction  Multivisceral resections (MVRs) in gastric cancer are potentially curable in selected patients in whom clear resection margins are possible. However, there are still uncertain data on their feasibility and safety considering short- and long-term results. The study compares survival, morbidity, mortality, and other secondary outcomes between standard and MVRs for gastric cancer. Materials and Methods  A monocentric retrospective study in patients with gastric adenocarcinoma, covering 2004 to 2020. Of the 336 operable cases, 101 patients underwent MVRs. The remaining 235 underwent standard gastric resections (SGRs), of which 173 patients were in stage T3/T4. To compare survival, a control group of 101 patients with palliative procedures was used-bypass anastomosis or exploration. Results  MVR had a lower survival rate than the SGR but significantly higher than the palliative procedures. The predominant gender in MVR was male (72.3%), with a mean age of 61 years. The perioperative mortality was 3.96% ( n  = 4), and the overall median survival was 28.1 months. The most frequently resected organs were the spleen (67.3%), followed by the pancreas (32.7%) and the liver (20.8%). In 56.4% of the cases two organs were resected, in 28.7% three organs, and in 13.9% four organs. The main complication was bleeding (9.9%). The major postoperative complications in the MVR were 14.85%, and in the SGR 6.4% ( p  < 0.05). Better long-term results were observed in patients who underwent R0 resections compared with R1. Conclusion  Multiorgan resections are characterized by poorer survival and a higher complication rate than gastrectomies. On the other hand, they have better long-term outcomes than palliative procedures. However, MVRs are admissible when performed by an experienced surgical team in high-volume centers.

Simultaneous Anterior Posterior Approach for Single-Position Lateral Lumbar Interbody Fusion with Robotic Assistance: Technical Guidelines and Early Outcomes

BACKGROUND

Lumbar lateral interbody fusion (LLIF) is traditionally performed in 2 stages: placing the interbody cage in the lateral decubitus position, then placing the percutaneous pedicle screw in the prone position. Performing interbody fusion and posterior fixation simultaneously could improve operative efficiency and clinical outcomes associated with longer operative times. We describe the operative steps and report clinical and radiographic outcomes associated with a simultaneous anterior and posterior approach (SAPA) for LLIF.

METHODS

Patients who underwent SAPA LLIF performed by a single surgeon over 1 year were retrospectively reviewed. Demographic, clinical, and radiographic data were analyzed, an operative guideline was created, and a learning curve was constructed using operative times.

RESULTS

SAPA LLIF was performed in 11 patients. Three patients experienced transient postoperative femoral nerve plexopathy with symptoms of ipsilateral hip flexion weakness and/or anterior thigh numbness; there were no other complications in the cohort. Radiographically, patients achieved significant increases in disc height (8.3 mm vs. 13.5 mm, P = 0.002) and foraminal height (20.2 mm vs. 25.3 mm, P = 0.0001). Patients showed significant improvements in Oswestry Disability Index (52 vs. 27.8, P = 0.002) and Patient-Reported Outcome Measurement Information System Physical Function (32.6 vs. 39, P = 0.048) and Pain Interference (64.9 vs. 59.6, P = 0.001) at 3 months. A downward trend in operative time was observed for 1-level SAPA LLIF.

CONCLUSIONS

SAPA LLIF is a safe approach for LLIF that results in favorable clinical outcomes. This technique can potentially improve operative efficiency further along the course of a surgeon's learning curve.

Management of Traumatic Atlantooccipital Dissociation at a Level 1 Trauma Center: A Retrospective Case Series

OBJECTIVE

Atlantooccipital dislocation (AOD) is a highly unstable and often neurologically devastating injury to the craniocervical junction that typically results from high-energy trauma. Management of these devastating injuries is complex, with prognostication difficult due to high rates of concomitant intracranial and systemic injuries. This report highlights advances in management of AOD and appropriate implementation of operative adjuncts including neuronavigation and the use of intraoperative neuromonitoring.

METHODS

All patients with AOD presenting to a high-volume, level 1 trauma center between January 2015 and August 2021 were retrospectively identified through a prospectively maintained database of patients presenting with traumatic spine injuries. Medical records, including imaging reports, clinical documentation, and intraoperative neurophysiological reports were reviewed.

RESULTS

A total of 11 patients were identified with patterns of injury consistent with AOD. Fifty-five percent of patients survived until discharge. 73% of patients underwent surgery for stabilization. All 4 patients with preoperative neurologic deficits who underwent surgery had monitorable transcranial motor evoked potentials and somatosensory evoked potentials. Two experienced significant motor recovery postoperatively, and 2 did not survive to discharge. Blunt cerebrovascular injuries were identified in 73% of patients.

CONCLUSION

AOD is encountered with increasing frequency. The identification and management of this specific injury is complicated by the volume and severity of associated injuries, especially concomitant traumatic brain injury. Timely recognition is critical and the use of surgical adjuncts including intraoperative neurophysiologic monitoring and surgical navigation can increase the safety and success of these procedures while also providing prognostic information on potential for motor recovery.

Outcomes of Arterial Bypass for Posterior Circulation Atherosclerosis: A Case Series

BACKGROUND

Extracranial-intracranial bypass is an effective treatment option for moyamoya disease and in well-selected cases of anterior circulation intracranial atherosclerotic disease; however, the effectiveness of bypass is less evident in posterior circulation atherosclerosis. Updated surgical techniques and clinical guidelines necessitate modern appraisal of arterial bypass for symptomatic patients with posterior circulation atherosclerotic disease who are refractory to medical management.

OBJECTIVE

To evaluate the complications, graft patency, and postoperative outcomes of arterial bypass for posterior circulation intracranial atherosclerotic disease.

METHODS

Perioperative records of consecutive bypass patients were retrospectively evaluated to determine the clinical course and surgical outcomes.

RESULTS

Arterial bypass was performed in 8 cases with a median age of 62 years. All 8 patients underwent direct bypass with an autologous occipital artery donor vessel. Recipient vessel selection varied on a case-by-case basis, with the superior cerebellar artery used in 4 cases, the posterior inferior cerebellar artery in 3 cases, and the anterior inferior cerebellar artery in 1 case. There were no significant intraoperative or postoperative complications. Postoperatively, all 8 patients displayed clinical improvement of their preoperative symptoms, with a significant decrease of 2.5 points on the modified Rankin Scale (P < .001). Postoperative imaging confirmed full graft patency in 7 patients and partial patency in 1 patient.

CONCLUSION

Excellent postoperative outcomes and no major complications after posterior circulation arterial bypass for intracranial atherosclerotic disease highlight the utility of this intervention for the treatment of medically refractory or symptomatic posterior circulation intracranial atherosclerotic disease. Larger studies may be valuable to validate these findings.

Clinical features, natural history and outcomes of pseudolymphoma of liver: A case-series and systematic review

BACKGROUND

Pseudolymphoma is a rare, benign, nonspecific condition that forms a mass-like lesion characterized by the proliferation of non-neoplastic lymphocytes. Lacking of specific clinical symptoms, serological markers, and imaging features, the diagnosis is difficult. We reporte five cases of hepatic pseudolymphoma and provide a systematic review of existing literatures to improve our understanding of this rare liver disease.

METHODS

We followed-up five cases of hepatic pseudolymphoma in West China Hospital from January 2002 to January 2022. We also summarized the cases of hepatic pseudolymphoma from January 1981 to December 2021 through the PubMed database and comprehensively analyzed the characteristics of the cases.

RESULTS

The pathologic features of the five cases were characterized by benign lymphoid tissue hyperplasia, lymphoid follicle formation, and a polarized germinal center. Immunohistochemistry, in situ hybridization, and gene rearrangement revealed non-malignant lymphoma. Besides, a total of 116 cases have been reported in the PubMed database from 1981 to 2021. The incidence of hepatic pseudolymphoma is higher in middle-aged and elderly women and has been reported more frequently in Asia. All cases were pathologically diagnosed, among which 85.95% of the patients were treated by surgery.

CONCLUSIONS

Hepatic pseudolymphoma is an extremely rare benign disease, mainly in middle-aged and elderly women. Without distinctive clinical and imaging characteristics, pathological diagnosis is the highly reliable method at present. Thus, in the absence of risk factors for a primary liver tumor or metastatic tumor in middle-aged and elderly women, the possibility of pseudolymphoma should be considered to avoid extensive treatments.

Neuroinflammation and neovascularization in diabetic eye diseases (DEDs): identification of potential pharmacotherapeutic targets

The goal of this review is to increase public knowledge of the etiopathogenesis of diabetic eye diseases (DEDs), such as diabetic retinopathy (DR) and ocular angiosarcoma (ASO), and the likelihood of blindness among elderly widows. A widow's life in North India, in general, is fraught with peril because of the economic and social isolation it brings, as well as the increased risk of death from heart disease, hypertension, diabetes, depression, and dementia. Neovascularization, neuroinflammation, and edema in the ocular tissue are hallmarks of the ASO, a rare form of malignant tumor. When diabetes, hypertension, and aging all contribute to increased oxidative stress, the DR can proceed to ASO. Microglia in the retina of the optic nerve head are responsible for causing inflammation, discomfort, and neurodegeneration. Those that come into contact with them will get blind as a result of this. Advanced glycation end products (AGE), vascular endothelial growth factor (VEGF), protein kinase C (PKC), poly-ADP-ribose polymerase (PARP), metalloproteinase9 (MMP9), nuclear factor kappaB (NFkB), program death ligand1 (PDL-1), factor VIII (FVIII), and von Willebrand factor (VWF) are potent agents for ocular neovascularisation (ONV), neuroinflammation and edema in the ocular tissue. AGE/VEGF, DAG/PKC, PARP/NFkB, RAS/VEGF, PDL-1/PD-1, VWF/FVIII/VEGF, and RAS/VEGF are all linked to the pathophysiology of DEDs. The interaction between ONV and ASO is mostly determined by the VWF/FVIII/VEGF and PDL-1/PD-1 axis. This study focused on retinoprotective medications that can pass the blood-retinal barrier and cure DEDs, as well as the factors that influence the etiology of neovascularization and neuroinflammation in the eye.

Involving Older People With Frailty or Impairment in the Design Process of Digital Health Technologies to Enable Aging in Place: Scoping Review

BACKGROUND

With an increase in life expectancy globally, the focus on digital health technologies that can enhance physical and mental health among older people with frailty and impairment has increased. Similarly, research interest in how digital health technology can promote well-being and self-management of health in older age has increased, including an increased focus on methods for designing digital health technologies that meet the various medical, psychological, and social needs of older population. Despite the increased focus, there remains a necessity to further understand the needs of this population group to ensure uptake and to avoid introduction of additional challenges when introducing technologies, for example, because of poor technological design. The scope is limited to digital health technologies meant to enable older people with frailty and impairment to age in place.

OBJECTIVE

In this study, we aimed to explore how older people with frailty and impairment are involved in various parts of the design processes of digital health technologies and identify gaps or neglected steps in a user-involving design process. This included a focus on recruitment strategies, contributions, and methods used to address the perspectives, needs, and desires of older people with frailty and impairment in the development of digital health technologies.

METHODS

A scoping review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) reporting from February 2021 to April 2021. Literature searches were conducted in PubMed, Scopus, Embase, and IEEE using a search string covering the concepts of health technology, older people, frailty and impairment, user-centered design, and self-management.

RESULTS

In total, 1891 studies were imported for screening from the initial search. A total of 22 studies were included in this review after full-text screening and manual search. Invitation through partners was the most reported recruitment strategy to involve older people with frailty and impairment in the design process of digital health technologies. Furthermore, they were commonly involved in the final evaluation of the development process. Three main gaps identified were the use of outreach approaches to recruit older people with frailty and impairment in the design process of digital health technologies, description of the value of involvement and outcome of the contribution of participants, and knowledge regarding involvement in all parts of the design process.

CONCLUSIONS

Although there is literature on methods for involving older people with frailty and impairment in the design of digital health technology, there is little methodological dialogue on the nuances of how different methods for involvement relate to and shape the outcome of the development process.

Aneurysmal bone cyst of the pelvis: systematic literature review

Aneurysmal bone cysts (ABCs) are rare benign, vascular, and osteolytic bone lesions. Pelvic ABCs account for 8–12% of these tumors and no clear guidelines for their treatment are available. To the best of our knowledge, this is the first systematic literature review regarding pelvic ABCs. Our objective was to identify treatment modalities and assess bone healing, measured as the degree of radiological ossification. Searches were conducted in PubMed, Cochrane Library, and Web of Science. Based on the scarcity of reports, inclusion criteria were kept broad and included primary or recurrent pelvic ABCs, with a minimum follow-up of 1 year and available information on radiological ossification. Data were extracted at the individual patient level and grouped according to treatment modality. Forty-nine studies reporting on 194 patients were included from the study. The level of evidence was low (29 case reports and 20 retrospective case series), and the reporting of outcomes was inconsistent. Five major treatment groups were identified and divided into 11 subgroups. The largest subgroup was curettage (23%), followed by selective arterial embolization (20%). Most ABCs were located in the ilium. Variations in mean tumor size (4.5–22.2 cm) and degree of ossification (60–100%) depended on the treatment modality. Overall, in 77% of the cases, the cyst ossified completely. Recurrence was reported in 22 patients (11%) and two patients (1%) died during the course of the treatment. This systematic review provides the first comprehensive overview of pelvic ABC treatment modalities and their radiological and clinical outcomes. Neoadjuvant scleroembolic treatments appear to be used most in recent years, but further comparative studies and better quality of reporting are needed to determine their effectiveness.

Defining Occult High-Risk Cysts of the Pineal Region: A Case Series

BACKGROUND

Absence of hydrocephalus on neuroimaging may impart a false sense of security for patients with pineal cysts. In this case series, we characterize a subset of patients with pineal cysts having an occult presentation. Unifying features of worsening paroxysmal headaches suggesting intermittent obstructive hydrocephalus and radiographic evidence of third ventricular invagination characterize these patients as high risk.

OBJECTIVE

To define features of occult, high-risk pineal cysts and outcomes of endoscopic cyst fenestration.

METHODS

Charts were retrospectively reviewed for patients with pineal cysts evaluated at our institution between 2018 and 2021 who underwent endoscopic cyst fenestration. To capture cysts presenting as occult, patients were excluded if hydrocephalus was noted at presentation. Relevant clinical history, imaging, operative data, and clinical outcomes were reviewed.

RESULTS

Of 50 pineal cyst patients, 4 satisfied inclusion criteria. All patients presented with worsening paroxysmal headaches. In addition, 75% (3/4) also experienced intermittent syncope. Patients exhibited no hydrocephalus (n = 3) or fluctuating ventricular size on longitudinal imaging (n = 1). In all cases, high-resolution sagittal 3-dimensional T2 magnetic resonance imaging demonstrated invagination of the cyst anteriorly into the posterior third ventricle. All patients underwent endoscopic cyst fenestration with complete symptom resolution (mean follow-up of 20.6 months; range 3.5-37.4 months).

CONCLUSION

The clinical history for occult, high-risk pineal cysts is notable for worsening paroxysmal headaches and episodic alterations of consciousness suggesting intermittent obstructive hydrocephalus. Because ventricular size can appear normal on standard imaging protocols, clinical suspicion should trigger workup with high-resolution magnetic resonance imaging designed to detect these cysts. Endoscopic cyst fenestration is a safe and efficacious management strategy.

Modified Lateral Orbitotomy Approach to Lesions of the Orbital Apex, Superior Orbital Fissure, Cavernous Sinus, and Middle Cranial Fossa

BACKGROUND

The lateral orbitotomy approach (LOA) provides minimally invasive access to the orbit, cavernous sinus region, and middle cranial fossa. Orbital retraction with this approach can nonetheless injure orbital structures, causing unnecessary morbidity.

OBJECTIVE

To describe our clinical experience with the modified LOA (mLOA), wherein the medial aspect of the lateral orbital wall posterior to the orbital rim is preserved.

METHODS

This is a retrospective, single-institution case series of patients undergoing a mLOA for lesions of the orbital apex, superior orbital fissure, cavernous sinus, and middle cranial fossa. The dimensions and variance of selected anatomic parameters relevant to this approach (orbital rim-superior orbital fossa depth, lateral orbital wall angle) were also analyzed using computed tomography scans from 30 adult patients.

RESULTS

Eight patients underwent a mLOA (mean age 54.0 ± 19.6 years; 3 males). Surgical targets included the superior orbital fissure (2; cavernoma and meningioma), sphenoid wing with or without the orbital apex (2; meningioma), cavernous sinus (2; rule out carcinoma and smooth muscle tumor), and anterior/mesial temporal lobe (2; cavernoma). Visual acuity/fields and diplopia was stable or improved in all patients postoperatively. One patient experienced a cerebrospinal fluid leak. On computed tomography analysis, the relevant bony anatomy displayed limited variability, with a mean orbital fossa depth of 42.7 ± 2.8 mm and a lateral orbital wall angle of 44.4° ± 2.7°.

CONCLUSION

The mLOA can provide safe, minimally invasive access to select lesions of the orbital apex, superior orbital fissure, cavernous sinus, and middle cranial fossa. The operative corridor has relatively consistent bony anatomy.

A systematic cohort review of pheochromocytoma-induced typical versus atypical Takotsubo cardiomyopathy

BACKGROUND

A rare presentation of pheochromocytoma (PCC) is catecholamine-induced-cardiomyopathy, or Takotsubo cardiomyopathy (TCM). PCC-induced TCM(PCC-TCM) can present as a typical or atypical type, based on the location of cardiac wall motion abnormalities. In this review, we sought to assess features and outcomes for PCC-TCM, and to compare typical and atypical subtypes.

METHODS

A search was conducted on two databases (PubMed and Embase) for case series or reports on PCC-TCM from 2006 to 2020.

RESULTS

One-hundred-and-two papers with a total of 104 cases of PCC-TCM were retrieved: 67(64.4%) typical and 37(35.6%) atypical subtypes. Overall median age was 50[range:23-86] years, the atypical group about a decade younger(p < 0.001). A female preponderance was seen for either subtype (∼75%). The most common presentations were chest pain(n = 60;58%), dyspnoea(n = 46;44%), and headache(n = 41;39.4%). Those with atypical subtype more often presented with fluid overload (typical:3% versus atypical:60%); acute pulmonary oedema (35% versus 60%); and cardiogenic shock (22% versus 43%) (all p < 0.05). Six patients (6%) died pre-operatively (typical:8% versus atypical:3%; p = 0.32). Non-fatal pre-operative complications occurred more among those with atypical TCM(p < 0.001), specifically cardiac arrest (typical:5% versus atypical:32%) and respiratory failure (9% versus 24%; both p < 0.05). Overall, 98 underwent surgery, majority undergoing laparoscopic adrenalectomy (81%); similar among the subtypes(p = 0.71). No robust data was provided on short-term outcomes, although two patients suffered from post-operative complications.

CONCLUSION

Although quite similar in presentation to either standalone TCM or PCC, PCC-TCM seems to be associated with a higher degree of morbidity and mortality. The atypical PCC-TCM subgroup seems to have a more severe course with possibly a poorer outcome. Further research is needed to make more reliable inferences.