The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines

Percutaneous Screw Distraction for Anatomic Restoration: Case Series

BACKGROUND AND OBJECTIVES

Percutaneous pedicle screw fixation with distraction reduces morbidity after traumatic thoracolumbar burst fractures; however, there are substantial limitations, particularly for correction of kyphosis. The use of fixed-angle screws may offer improved anatomic restoration, facilitating greater postdistraction vertebral height restoration and spinal canal fragment reduction. We examined the radiographic results of distraction across fixed-angle screws immediately after surgery and in long-term follow-up.

METHODS

Demographic and clinical characteristics were captured for patients with traumatic thoracolumbar fractures undergoing percutaneous pedicle screw fixation by a single surgeon. Radiographic measurements were collected at predistraction, postdistraction, and long-term follow-up time points. Paired t -tests, Student's t -tests, Mann-Whitney U tests, and χ 2 tests were used to assess data where appropriate.

RESULTS

The case series included 22 patients (77.3% male; mean age 42.0 ± 18.4 years). Hounsfield density consistent with osteopenia was seen in 13.6% of patients at the time of injury. Sporting injuries and motor vehicle accidents were common (both 31.8%). Most injuries occurred at L1 (45.5%). Upon long-term follow-up, the mean injured-level predistraction cross-sectional area improved from 2.1 to 2.9 cm 2 ( P < .01). Compared with the superadjacent level, the injured-level cross-sectional canal area improved by 28.6% ( P < .01). Vertebral body index also improved significantly (18.8° mean change, P < .01). The mean bisegmental Cobb angle improved by 6.2° ( P = .01), and injured vertebral body compression decreased by 22.4% ( P < .01). Significant improvement in correction was achieved with experience, with final technique yielding superior cross-sectional area ( P = .04) and compression ratios ( P = .03).

CONCLUSION

Distraction across fixed-angle percutaneous screw instrumentation systems stabilizes traumatic thoracolumbar burst fractures, corrects deformity, and decompresses the spinal canal. Further comparative research is necessary to demonstrate whether outcomes are different between percutaneous instrumentation vs open fusion for thoracolumbar trauma.

Exploration of epileptic networks in temporal lobe encephaloceles with stereotactic EEG: Electroclinical characteristics and surgical outcomes

OBJECTIVE

Temporal lobe encephaloceles (TLEN) have been implicated as a cause of temporal lobe epilepsy (TLE), the treatment which is primarily surgical; however, there is no clear consensus on the optimal surgical approach, because it is unclear whether TLE related to TLEN can be addressed by a restricted encephalocele resection or if a more extensive resection is required. The aim of the current article is to report the clinical and electrophysiological profile of patients with TLE secondary to TLEN who underwent stereotactic electroencephalography (SEEG) implantation to identify the epileptogenic network.

METHODS

A retrospective review was performed of patients with TLE related to TLEN who underwent SEEG implantation. Medical charts were reviewed for demographic data, the results of noninvasive and invasive investigations, and operative details. Surgical outcomes were based on Engel classification with at least 6 months follow-up.

RESULTS

Nine patients were identified. The mean age at epilepsy onset was 28 years (range, 15-41 years), and 7/9 patients were female. Scalp EEG revealed interictal epileptiform activity most often maximum in the frontotemporal and/or temporal regions. A discrete TLEN was often not identified on initial imaging, but was identified during re-review or at the time of surgery. Seizure onset zones during SEEG were localized to the mesial temporal structures, the temporal pole, or both. One patient became seizure-free following SEEG and another refused further surgery. Of the 7 patients who underwent epilepsy surgery, 5/7 underwent an anterior temporal lobectomy-surgical outcomes were favorable, with 5/7 achieving Engel I outcomes.

SIGNIFICANCE

Invasive SEEG monitoring demonstrated ictal onsets may not be restricted to the TLEN, and often the temporal pole and mesial structures are involved at seizure onset. Ictal propagation patterns vary significantly, which may be related to the underlying pathology and explain the variability in semiology. These findings may inform surgical treatment options.

PLAIN LANGUAGE SUMMARY

Temporal lobe encephaloceles can cause intractable epilepsy, although their presence may be missed on routine imaging. The management of encephaloceles is primarily surgical; however, the optimal surgical approach can be unclear. Invasive monitoring with SEEG may help characterize the epileptogenic network and result in more optimal surgical outcomes.

Bilateral spontaneous internal carotid artery dissection; a treatment dilemma: A case report and literature review

INTRODUCTION

Spontaneous carotid artery dissection in association with exercise is well known. A bilateral occurrence is a rarely reported finding. SVS guidelines discussed the role of antiplatelets and anticoagulants in management, however, management of dissections associated with pseudoaneurysm formation is still controversial. Herein, we report a case of walking-induced spontaneous bilateral carotid artery dissection complicated by a unilateral pseudoaneurysm formation treated conservatively with satisfactory outcome.

CASE PRESENTATION

A 41-year-old male presented with a sudden severe headache, blurred vision, and transient right upper limb weakness after a long walk. Initial CT angiography showed bilateral carotid artery dissection. The patient was managed conservatively with antiplatelet therapy and close follow up. Follow-up imaging showed gradual resolution of the dissection bilaterally and a stable right internal carotid artery pseudoaneurysm. Five years later, the patient remained asymptomatic with shrinking ICA pseudoaneurysm.

DISCUSSION

Bilateral spontaneous carotid artery dissection is a rare condition that can present with stroke-like symptoms, including visual changes and motor deficits, as observed in the presented case. Conservative management with antiplatelet therapy showed a favorable outcome, aligning with the recommendations of the SVS guideline. The role of antiplatelet therapy in managing pseudoaneurysms as a complication of dissection remains controversial, with endovascular interventions generally preferred despite reported complications. However, in our case, conservative management with antiplatelet therapy showed satisfactory outcomes, as supported by some recent studies.

CONCLUSION

The reported case presents a rare occurrence of spontaneous bilateral carotid artery dissection complicated by a unilateral pseudoaneurysm formation. Conservative treatment with antiplatelets is associated with good outcomes, and potentially in highly selected patients complicated with pseudoaneurysm formation.

Surgical management of anterior sacral meningoceles: an illustrated case series and review of the literature

BACKGROUND

Anterior sacral meningocele (ASM) is an uncommon variant of spinal dysraphism. Surgical correction for this condition is challenging and optimal corrective approaches are uncertain.

OBJECTIVE

To share our experience of managing this rare condition using the posterior trans-sacral approach and provide a contemporary review of the literature.

METHODS

Retrospective review of case notes, operative records, and imaging of eligible patients treated via the posterior trans-sacral approach between 2006 and 2020 at our regional neurosciences centre.

RESULTS

Three patients, two females and one male with a mean age of 30 years (range 16-38), were treated. Presenting symptoms included lower abdominal pain and recurrent miscarriages. Patients underwent corrective surgery using the posterior approach involving a sacral laminectomy, durotomy and closure of the communicating fistula. A single patient required reoperation due to early recurrence. Another patient proved challenging because of a very large sacral fistula and required two procedures due to the development of high-pressure headaches secondary to a recurrence. All patients improved symptomatically postoperatively and remained symptom free at the last clinic follow-up and have been discharged. Following review of the literature, only two other non-syndromic cases have been described.

CONCLUSIONS

ASM is an uncommon congenital abnormality, typically presenting with mass effect symptoms secondary to a presacral cystic mass. Surgical management using a posterior approach to close the meningeal sac is feasible and less invasive than an anterior approach. Long term clinical outcomes in our series were satisfactory.

Insights into the Medial Pectoral Nerve Transfer for Shoulder Abduction in Brachial Plexus Injuries: A Retrospective Case Series Analysis

BACKGROUND

Treatment priority in C5, C6, and C7 brachial plexus root avulsion is the recovery of shoulder function through reinnervation of shoulder muscles. The medial pectoral nerve is a potential donor for axillary nerve transfer, but outcomes are sparsely reported. This study reports the results of medial pectoral nerve transfer to the axillary nerve.

METHODS

We conducted a retrospective analysis of 12 patients with traumatic brachial plexus injury (C5, C6, and C7 root avulsion) who underwent medial pectoral nerve transfer to the axillary nerve. Sociodemographic and clinical characteristics, including electromyography findings, were documented. We assessed postoperative shoulder abduction strength and range of motion. Statistical analyses compared presurgery and postsurgery outcomes and contrasted our results with those from a study using spinal accessory nerve transfer to the suprascapular nerve.

RESULTS

Postsurgery, the mean shoulder abduction range of motion was 65.45°, with a median strength of M2. Significant improvement was noted compared to preoperative values. However, outcomes did not significantly surpass those from spinal accessory nerve transfer. Electromyography showed a low incidence of motor unit action potentials in the deltoid.

CONCLUSIONS

Medial pectoral nerve transfer to the axillary nerve did not yield superior results in shoulder abduction and deltoid reinnervation in our group of patients. At present, different nerve donors may also need to be considered for deltoid muscle reinnervation in patients with C5, C6, and C7 root avulsion to achieve better shoulder abduction recovery.

Use of a large-bore 088 intracranial access support catheter for delivery of large intracranial devices: case series with the TracStar LDP in 125 cases

BACKGROUND

The delivery of neuroendovascular devices requires a robust proximal access platform. This demand has previously been met with a 6Fr long sheath (8Fr guide) that is placed in the proximal internal carotid artery (ICA) or vertebral artery segments. We share our experience with the first 0.088 inch 8Fr guide catheter designed for direct intracranial access.

METHODS

We retrospectively reviewed a prospectively maintained IRB-approved institutional database of the senior authors to identify all cases where the TracStar Large Distal Platform (LDP) was positioned within the intracranial vasculature, defined as within or distal to the petrous ICA, vertebral artery (V3) segments, or transverse sinus. Technical success was defined as safe placement of the TracStar LDP within or distal to the described distal vessel segments with subsequent complication-free device implantation.

RESULTS

Over the 41-month study period from January 2020 to June 2023, 125 consecutive cases were identified in whom the TracStar LDP was navigated into the intracranial vasculature for triaxial delivery of large devices, 0.027 inch microcatheter and greater, for aneurysm treatment (n=108, 86%), intracranial angioplasty/stenting (n=15, 12%), and venous sinus stenting (n=2, 1.6%). All cases used a direct select catheter technique for initial guide placement (no exchange). Posterior circulation treatments occurred in 14.4% (n=18) of cases. Technical success was achieved in 100% of cases. No vessel dissections occurred in any cases.

CONCLUSION

The TracStar LDP is an 0.088 inch 8Fr guide catheter that can establish direct intracranial access with an acceptable safety profile. This can be achieved in a wide range of neurointerventional cases with a high rate of technical success.

Long-term outcomes after acute primary angle closure: case series from Moorfields Eye Hospital, UK

BACKGROUND

There is limited data regarding the morbidity and progression to primary angle closure glaucoma in those presenting with acute primary angle closure (APAC) in the UK. We aim to report on the vision and intraocular pressure (IOP) outcomes and treatment required after an APAC episode and to identify any risk factors that could predict worse outcomes.

METHODS

A retrospective observational case series review including 117 consecutive patients (121 eyes) attending Moorfields Eye Hospital, at a tertiary referral unit in the UK, with APAC was performed.

RESULTS

Most patients (73%) had visual acuities of ≥6/12, meeting the UK driving standard, at the final follow-up. Only 15% (17 eyes) had severe visual impairment, as defined by the WHO, in the affected eye, of which 6.6% (eight eyes) were due to glaucoma. The delayed presentation was linked to a higher need for further medical treatment (OR=2.83, 95% CI 1.09 to 7.40, p=0.03). Patients who underwent phacoemulsification were at lower risk of having blindness in the affected eye (OR 0.18, 95% CI 0.05 to 0.69, p=0.01), having elevated IOP (OR 0.10, 95% CI 0.01 to 0.75, p=0.02) or requiring further medical treatment (OR 0.34, 95% CI 0.12 to 0.99, p=0.04). Older age (OR 1.26, 95% CI 1.08 to 1.48, p<0.01) was associated with worse visual outcomes.

CONCLUSIONS

APAC causes low long-term visual and treatment morbidity in this largely Caucasian patient group in the UK. Phacoemulsification as a treatment may enhance visual outcomes and reduce the need for further IOP-lowering treatment.

Subtemporal Approach for the Treatment of Ruptured and Unruptured Distal Basilar Artery Aneurysms: Is There a Contemporary Use?

BACKGROUND AND OBJECTIVES

Distal basilar artery aneurysms (DBAs) are high-risk lesions for which endovascular treatment is preferred because of their deep location, yet indications for open clipping nonetheless remain. The subtemporal approach allows for early proximal control and direct visualization of critical posterior perforating arteries, especially for posterior-projecting aneurysms. Our objective was to describe our clinical experience with the subtemporal approach for clipping DBAs in the evolving endovascular era.

METHODS

This was a retrospective, single-institution case series of patients with DBAs treated with microsurgery over a 21-year period (2002-2023). Demographic, clinical, and surgical data were collected for analysis.

RESULTS

Twenty-seven patients underwent clipping of 11 ruptured and 16 unruptured DBAs with a subtemporal approach (24 female; mean age 53 years). Ten patients had expanded craniotomies for treatment of additional aneurysms. The aneurysm occlusion rate was 100%. Good neurological outcomes as defined by the modified Rankin Scale score ≤2 and Glasgow Outcome Scale score ≥4 were achieved in 21/27 patients (78%). Two patients died before hospital discharge, one from vasospasm-induced strokes and another from an intraoperative myocardial infarction.

CONCLUSION

These results demonstrate that microsurgical clip ligation of DBAs using the subtemporal approach remains a viable option for complex lesions not amenable to endovascular management.

Use of indocyanine green-human serum albumin complexes in fluorescence image-guided laparoscopic anatomical liver resection: a case series study (with video)

BACKGROUND

This study aimed to investigate the feasibility and efficacy of near-infrared fluorescence-guided laparoscopic anatomical hepatectomy (LAH) using a novel indocyanine green (ICG)-human serum albumin complex (HSA) in patients with hepatocellular carcinoma.

METHODS

Clinical data of hepatocellular carcinoma patients who underwent ICG-HSA fluorescence-guided LAH at our center from January 2024 to April 2024 were prospectively collected and analyzed. Ultraviolet absorption spectroscopy was used to test the absorption and stability of ICG-HSA complex solutions under different conditions. After determining the optimal ratio, the complex was administered intravenously during surgery to perform negative staining via Glissonean pedicle isolation. LAH was performed along the fluorescence-demarcated boundaries.

RESULTS

Thirty-one patients were included (24 men; mean age, 54.61 ± 13.54 years). The median maximum tumor diameter was 2.80 (interquartile range [IQR], 2.00-4.00) cm. S8 segmentectomy (22.6%) and right posterior segmentectomy (19.4%) were the most common resections performed. Successful fluorescence negative staining was achieved in all patients using ICG and HSA at a 1:6 molar ratio at room temperature. Mean operation time was 297.58 ± 85.53 min, Median intraoperative blood loss was 100.0 mL (IQR, 50.0-200.0). The median surgical margin distance was 0.90 cm (IQR, 0.40-1.50). The postoperative complication rate was 45.2% (35.5% Clavien-Dindo grade I and 9.7% grade II). The median length of hospital stay was 5.0 days (IQR, 4.0-5.0).

CONCLUSION

ICG-HSA-assisted LAH is safe and feasible. Compared with free ICG, the novel ICG-HSA complex exhibits better optical properties and in vivo stability, which can improve the accuracy of intraoperative liver segment localization and optimize the anatomical dissection plane. It has the potential to become an ideal fluorescent imaging agent for anatomical hepatectomy.

Safety of risdiplam in spinal muscular atrophy patients after short-term treatment with nusinersen

INTRODUCTION/AIMS

Following the approval of risdiplam, there are more possibilities for disease-modifying therapy (DMT) in children with spinal muscular atrophy (SMA). Non-treatment-naïve subjects with SMA involved in the JEWELFISH study, designed to evaluate the safety and tolerability of risdiplam, were required to undergo a washout period before receiving risdiplam. This study aims to investigate the safety of administering risdiplam in patients within 90 days of receiving treatment with nusinersen.

METHODS

Data were collected on SMA patients who had undergone treatment with nusinersen, and who then received risdiplam within 90 days of their last dose of nusinersen, including demographic characteristics, information on treatment with nusinersen and risdiplam, adverse events, and laboratory assessments in a follow-up period of 90 days, presented as median (range).

RESULTS

A total of 15 children with SMA were reported, including 8 males and 7 females. The median number of doses of previous nusinersen treatment received was 8 (6-17) doses, and the median age at first risdiplam treatment was 4.3 (1.9-11.2) years. Specifically, 8 children received risdiplam 30 days or less after their most recent nusinersen treatment, 2 at 31-60 days after nusinersen, and 5 at 61-89 days post-nusinersen. Adverse events of pyrexia, pneumonia, vomiting and rash were reported in 4 patients.

DISCUSSION

Our study showed good safety data on patients who received risdiplam following nusinersen within the washout period of 90 days. This supplements the JEWELFISH study in the era of DMT, providing additional guidance for clinicians, but additional data from other centers is needed.

Impact of an In-Hospital postoperative imaging after uncomplicated elective posterior lumbar fixation: A case series

PURPOSE

Following spinal fixation, postoperative imaging is routinely performed. The value of routine postoperative imaging and its impact on the surgical decision remains uncertain, especially in degenerative cases. Moreover, routine postoperative imaging is not free and is an ionizing radiation. This study investigated the value of postoperative imaging after uneventful uncomplicated elective posterior lumbar fixation.

METHODS

This case series retrospectively reviewed the medical records of patients who underwent elective posterior lumbar fixation surgeries at our institution within two years. A series of 98 cases met our selection criteria. Their mean age was 51.2 years. We reviewed the decisions taken after performing the routine postoperative images. We searched for further diagnostic or imaging studies, revision surgery, or an extended hospital stay.

RESULTS

We found no particular decision was made after performing the postoperative imaging after uneventful uncomplicated elective posterior lumbar fixation surgeries. Moreover, there was no change in the hospital stay or the regular postoperative clinical management for all the included patients. No revision surgery was required based on the postoperative routine images.

CONCLUSIONS

We found that routine postoperative imaging after posterior fixation of a degenerative lumbar spine is of limited value. A randomized, controlled study is helpful to confirm this finding.

Exploring the Potential Use of Virtual Reality with a Supraorbital Keyhole Craniotomy for Anterior Skull Base Meningiomas: Two Case Reports

INTRODUCTION

A supraorbital keyhole craniotomy (SOKC) is a novel alternative to frontal craniotomies for accessing the anterior fossa for resecting tumors and clipping aneurysms; however, its implementation is limited in patients at a high risk of complications. We present two cases involving the use of augmented reality (AR) and virtual reality (VR) for patient selection and preoperative planning for a supraorbital tumor resection of anterior fossa meningiomas.

METHODS

This is a prospective, single-center case series at a research institute. We identified patients with an anterior or middle fossa meningioma regardless of age, gender, and tumor characteristics who could undergo an SOKC and MRI. The preoperative planning was performed with the BrainLab Magic Leap AR/VR platform. The meningiomas were resected through the SOKC under neuronavigation.

RESULTS

We identified two cases: a 37-year-old male with a meningioma in the sellar region and an 84-year-old male with a right anterior fossa meningioma, both confirmed by MRI. Both patients had a complete tumor resection by a minimally invasive SOKC after preoperative planning with the AR/VR platform. Postoperatively, hyponatremia complicated the first case, while the second case developed an intracranial hemorrhage. They both recovered after the appropriate interventions.

CONCLUSIONS

The use of an SOKC for anterior skull base meningiomas should be individualized after considering the lesion characteristics, vascular control needs, and the surgeon's expertise. VR/AR-assisted preoperative evaluation and planning will optimize the patient selection and surgical outcomes. We can utilize VR/AR technologies to identify patients that will benefit from an SOKC and expand the implementation of the approach beyond its current limitations.

Laparoscopic extraperitoneal approach for lateral lymph node dissection for patients with metachronous lateral pelvic lymph node metastases following surgery for rectal cancer: a case series and short-term outcomes

BACKGROUND

There have been few reports of a totally extraperitoneal approach for laparoscopic lateral lymph node dissection (LLND) for patients with metachronous lateral pelvic lymph node metastases following surgery for rectal cancer. Therefore, this study reports the short-term outcomes of LLND via an extraperitoneal approach.

METHODS

A total of 10 patients underwent LLND through a laparoscopic extraperitoneal approach in our hospital since October 2018. Patients with suspected resectable lateral lymph node recurrence after surgery for rectal cancer on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography CT (PET-CT) were selected for this procedure.

RESULTS

Nine of the 10 cases were completed using this procedure, but one case was converted to an intraperitoneal approach. The median operative time was 231 min, and the median estimated blood loss was 10 ml. There was one case of wound infection, but no other postoperative complications were seen. In one patient, no metastases were found in the retrieved lymph nodes.

CONCLUSION

The short-term outcomes of LLND through a laparoscopic extraperitoneal approach were acceptable. Because this procedure can be performed without violating the peritoneum, it is less invasive than the conventional intraperitoneal approach and is useful for metachronous lateral pelvic lymph node metastases.

Central nervous system solitary fibrous tumors: Case series in accordance with the WHO 2021 reclassification. Framework for patient surveillance

PURPOSE

Solitary fibrous tumors (SFTs) are a rare type of mesenchymal tumors. The World Health Organization reclassified SFTs in 2021. Currently, guidelines concerning treatment and follow-up are lacking. We performed a retrospective case series with reclassification of SFTs, according to the most recent WHO classification, to explore tumor-behavior. The purpose is to build a framework for long-term patient surveillance.

METHODOLOGY

A retrospective case study was performed according to the PROCESS guidelines. Inclusion criteria were: patients operated on between 2013 and 2023 in two neurosurgical centers with the diagnosis of 'hemangiopericytoma' or SFT on histopathological stains. Patients were excluded if the original stains of the primary tumor were unavailable. The following demographic, radiologic and therapeutic parameters were included in the review: age, sex, original and reclassified anatomopathological diagnosis, location, extent of resection, use of postoperative radiotherapy, location of and time to recurrence, location of-and time to metastasis, and survival. Histological material was re-examined by experienced neuropathologists.

RESULTS

Ten patients were identified with a solitary fibrous tumor of the central nervous system (CNS) (three females) between 2013 and 2023. Age at diagnosis ranged from 38 up to 81. Eight patients were treated by gross total resection (GTR) and postoperative radiotherapy (RT) was applied in five cases. Initial WHO grading consisted of three grade I, two grade II, and six grade III lesions. Reclassification according to the WHO 2021 classification of CNS tumors resulted in seven reclassifications, all towards a lower grade. Four patients showed local recurrence, six to eight years after diagnosis, and five patients developed systemic metastases, nine to 13 years after diagnosis.

DISCUSSION

Although rare, SFT should be included in the differential diagnosis of intracranial tumors with extra-axial growth patterns. The current histological grade according to the WHO 2021 does not seem to account for local recurrence rate or systemic metastasis. When a solitary fibrous tumor is presumed, gross total resection is the recommended treatment. Lifelong patient follow-up is necessary due to the risk of delayed recurrence and distant metastasis, even after gross-total resection. We would advocate for the use of CT thorax-abdomen or full body PET in the detection of systemic metastases at diagnosis and during follow-up, however optimal intervals remain unclear.

Laparoscopic and thoracoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation for esophageal cancer: a prospective multicenter case-series outcome

INTRODUCTION

To mitigate gastroparesis as well as other post-operative complications, we undertook a prospective multicenter study to assess the feasibility, safety, and efficacy in the short-term outcomes of laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation.

METHODS

A prospective descriptive study on 37 patients with laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation from January 2019 to March 2023. The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated.

RESULTS

In our study, all patients were male, with dysphagia as the predominant symptom (45.9%). Esophageal cancer incidence was similar between middle and lower thirds. Nodules were the primary finding on esophagoscopy (48.6%). Preoperative pyloric dilation averaged 31.2 min without complications. Surgical duration ranged from 225 to 400 min (mean 305). Gastric tube fluid volume averaged 148.9 ± 110.66 ml per day. Among 34 post-operative cases underwent gastric transit scans, most had non-dilated stomachs with efficient pyloric drug circulation. Three cases required prolonged ventilation, precluding pyloric circulation scans. Four patients developed chylous fistula, one requiring chest tube embolization. Recurrent laryngeal nerve damage occurred in 10.8% of cases.

CONCLUSION

After evaluating esophageal cancer patients undergoing laparoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation, it was found that this procedure is safe, effective, and significantly reduces postoperative gastroparesis and related complications.

Onyx prevents the bleeding of ruptured aneurysms during interventional embolization

Endovascular treatment has been acknowledged as an effective treatment for intracranial aneurysms, showcasing favorable clinical outcomes and providing robust protection against rebleeding and rupture. Notably, during the endovascular procedure, significant complications include intraprocedural aneurysmal rupture (IAR) induced by microcatheters, microguidewires, or spring coils, along with thromboembolic events, significantly escalating patient mortality and disability. Current approaches against for IARs involve various strategies such as heparin reversal, compression of the common carotid artery or upstream soft guidewire to mitigate blood flow, management of intracranial pressure and blood pressure, and balloon-assisted or unassisted rapid dense embolization of the aneurysm. Nevertheless, these measures may prove insufficient in halting hemorrhage, especially in scenarios where additional coils cannot be added for dense embolization due to inherent limitations. In this context, we introduce a novel strategy for the prompt, safe, and effective cessation of aneurysm bleeding, which involves injecting an appropriate quantity of Onyx into the aneurysm through a microcatheter while safeguarded by an aneurysm-carrying arterial braided stent. Initially, we attempted dense embolization by filling multiple coils. However, in cases where continued coil filling proved unfeasible or failed to sufficiently prevent contrast agent extravasation, we opted for Onyx injection into the aneurysm. Utilizing Onyx effectively prevented further blood extravasation without adversely impacting the aneurysm-carrying artery or distal vessels, leading to favorable prognoses for all patients. This article delineates our embolization strategy, highlighting the efficacy and safety of Onyx injection as an alternative or complementary measure in managing complications arising from endovascular coil embolization.

Non-invasive prehabilitation to foster widespread fMRI cortical reorganization before brain tumor surgery: lessons from a case series

PURPOSE

The objective of this prospective, single-centre case series was to investigate feasibility, clinical outcomes, and neural correlates of non-invasive Neuromodulation-Induced Cortical Prehabilitation (NICP) before brain tumor surgery. Previous studies have shown that gross total resection is paramount to increase life expectancy but is counterbalanced by the need of preserving critical functional areas. NICP aims at expanding functional margins for extensive tumor resection without functional sequelae. Invasive NICP (intracranial neuromodulation) was effective but characterized by elevated costs and high rate of adverse events. Non-invasive NICP (transcranial neuromodulation) may represent a more feasible alternative. Nonetheless, up to this point, non-invasive NICP has been examined in only two case reports, yielding inconclusive findings.

METHODS

Treatment sessions consisted of non-invasive neuromodulation, to transiently deactivate critical areas adjacent to the lesion, coupled with intensive functional training, to activate alternative nodes within the same functional network. Patients were evaluated pre-NICP, post-NICP, and at follow-up post-surgery.

RESULTS

Ten patients performed the intervention. Feasibility criteria were met (retention, adherence, safety, and patient's satisfaction). Clinical outcomes showed overall stability and improvements in motor and executive function from pre- to post-NICP, and at follow-up. Relevant plasticity changes (increase in the distance between tumor and critical area) were observed when the neuromodulation target was guided by functional neuroimaging data.

CONCLUSION

This is the first case series demonstrating feasibility of non-invasive NICP. Neural correlates indicate that neuroimaging-guided target selection may represent a valid strategy to leverage neuroplastic changes before neurosurgery. Further investigations are needed to confirm such preliminary findings.

A clinician's guide to performing a case series study

BACKGROUND

Whilst some guidance exists, the literature is relatively scarce on designing and reporting on case series studies for non-surgical techniques/interventions or interventions that may be considered outside the medical model. This commentary presents a set of thirteen design attributes and an adapted checklist for consideration by clinicians when considering a case series design focused on a non-surgical intervention.

Validation and Safety Profile of a Novel, Noninvasive Fiducial Attachment for Stereotactic Robotic-Guided Stereoelectroencephalography: A Case Series

BACKGROUND AND OBJECTIVES

We developed, tested, and validated a novel, noninvasive, Leksell G frame-based fiducial attachment, for use in stereotactic registration for stereoelectroencephalography (sEEG). Use of the device increased the number of fixed reference points available for registration, while obviating the need for additional scalp incisions. We report here on our experience and safety profile of using the device.

METHODS

We collected registration data using the fiducial device across 25 adult and pediatric patients with epilepsy consecutively undergoing robotic-guided sEEG for invasive epilepsy monitoring, treated between May 2022 and July 2023. ROSA One Brain was used for trajectory planning and electrode implantation. Postoperative clinical and radiographic data were computed and quantified, including mean registration error for all patients. Entry point, target point (TP), and angular errors were measured. Descriptive statistics and correlation coefficients for error were calculated.

RESULTS

Twenty-five patients underwent robotic-guided sEEG implantation (11 patients, bilateral; 10 patients, left unilateral; 4 patients, right). The mean number of electrodes per patient was 18 ± 3. The average mean registration error was 0.77 ± 0.11 mm. All patients were implanted with Ad-Tech depth electrodes. No clinically relevant complications were reported. Analysis of trajectory error was performed on 446 electrodes. The median entry point error was 1.03 mm (IQR 0.69-1.54). The median TP error was 2.26 mm (IQR 1.63-2.93). The mean angular error was 0.03 radians (IQR 0.02-0.05). There was no significant correlation between root mean square error and lead error. Root mean square error did not appreciably change over time, nor were there any significant changes in average angular, entry point, or TP error metrics.

CONCLUSION

A novel, noninvasive, Leksell G frame-based fiducial attachment was developed, tested, and validated, facilitating O-arm-based stereotactic registration for sEEG. This simple innovation maintained an excellent accuracy and safety profile for sEEG procedures in epilepsy patients, with the added advantages of providing additional reference points for stereotactic registration, without requiring additional scalp incisions.

Engineered autologous nasal cartilage for repair of nasal septal perforations: a case series

OBJECTIVE

This phase I clinical trial assessed the use of autologous nasal chondrocyte tissue-engineered cartilage (N-TEC) for functional repair of nasal septal perforations (NSP).

BACKGROUND

The most widely used technique to treat NSP, namely interposition grafting with a polydioxanone (PDS) plate combined with a deep temporal fascia (DTF) graft, is still suboptimal towards patient satisfaction and revision rates.

METHODS

Patients ( n =5, all female, age range: 23-54 years) had a 0.5-2.0 cm diameter NSP. N-TEC was manufactured by expansion and 3D culture of autologous nasal septum chondrocytes into Chondro-Gide collagen membranes. N-TEC was then shaped intraoperatively and enveloped in the harvested DTF before suturing it into the NSP. Safety (primary outcome) was assessed by the number of serious adverse reactions (SAR) until 12 months. Secondary outcomes included feasibility, assessed by surgical graft manipulation, and efficacy, assessed using subjective scoring (nasal obstruction symptom evaluation, NOSE, and visual analog scale, VAS, scores) and objective breathing function tests. Structural closure of NSP after 12 months was defined using endoscopy and computed tomography (CT) scans.

RESULTS

NSP treatment by N-TEC implantation was safe and feasible, as no SAR and no challenge in graft manipulation was recorded for any of the patients. One year postoperative, subjective scoring improved in all patients, unless already optimal (average improvement of 23 and 28.6 points out of 100, respectively, for NOSE and VAS scores). Objective respiratory function overall confirmed - with the exception of one case - the observations above (average improvement of 172 ml/s). NSP were closed and the mucosae completely healed in three patients.

CONCLUSION

Autologous N-TEC is a valid treatment for NSP and warrants further clinical tests.

Vestibular schwannoma surgery in the ninth decade of life: a case series

BACKGROUND AND PURPOSE

Large symptomatic Vestibular Schwannoma (VS) often requires surgical resection, regardless the patient's age. The aim of this study was to assess the surgical outcomes of patients in their ninth decade of life.

METHODS

This monocenter retrospective observational study included patients aged 80 years or older who underwent VS surgery between 2009 and 2020. We retrospectively analyzed their immediate post-surgical and long-term outcomes and complications.

RESULTS

Thirteen octogenarians who underwent VS surgery were included, with average age of 83.2 ± 1.97 years old (median 83.5, range 80-86 years). One patient had a Koos-Grade II tumor, and 12 patients had a grade IV. All patients had a preoperative ASA score ≤ 3 and underwent surgery in the supine position. Twelve patients underwent a pre-planned partial resection (PR) and one had a gross-total resection (GTR). Good facial function (House-Brackmann grade ≤ 2) was achieved in 10 patients (77%). We reported three Clavien-Dindo grade ≤ 3 treatment-related complications and no life-threatening complication. Two patients experienced tumor recurrence after PR.

CONCLUSION

In this series of patients who underwent VS surgery in their ninth decade of life, surgical outcomes were acceptable. Therefore, age alone should not serve as a contraindication for surgery. Preplanned PR is a reasonable attitude in elderly patients.

Negative pressure wound therapy for the management of deep brain stimulation-related surgical site infections: A retrospective case series

The management of deep brain stimulation (DBS)-related surgical site infection (SSI) is challenging. This article aimed to report the efficacy of negative pressure wound therapy (NPWT) in treating DBS-related SSI while preserving all DBS devices. As a retrospective case series in a single center, localized DBS-related SSI was treated with complete debridement and NPWT, with preserving all DBS devices. Successful infection control was defined as no clinical or microbiological evidence of recurrent infection 3 months after NPWT. Five patients (three females, two males, median age: 64 years) received NPWT for their DBS-related SSI. The infection was located in the chest, parietal, and retroauricular areas. Only one patient had the extension wires removed due to the heavy contamination, while no DBS devices were removed in the other patients. All patients showed successful infection control without any remarkable side effects 3 months after debridement and NPWT. These findings suggest that NPWT may effectively promote wound healing with a high probability of preserving all DBS devices in DBS-related SSI.

EQUATOR Network Mapping Review for Dysphagia Research

PURPOSE

The EQUATOR Network is an international initiative aimed at improving published health research through use of reporting guidelines. We conducted a review to determine the extent to which EQUATOR Network guidelines contain recommendations relevant for dysphagia research in human subjects.

METHOD

We downloaded all 542 EQUATOR Network guidelines on November 8, 2022. Each guideline was reviewed by two independent raters and judged for relevance to dysphagia and related fields (e.g., otolaryngology, gastroenterology). Dysphagia-relevant guidelines pertaining to quantitative human subjects research were further inspected to identify reporting guidance regarding (a) general research elements (e.g., data collection, statistical methods), (b) participant characteristics (e.g., demographics, accrual, randomization), (c) screening and clinical/noninstrumental assessments, (d) videofluoroscopic examinations, (e) flexible endoscopic examinations, (f) other instrumentation in swallowing research, (g) dysphagia treatment, (h) patient-/care provider-reported outcome measures, and (i) any other narrowly specified focus relevant for research on swallowing. Discrepancies were resolved by consensus.

RESULTS

Of 542 guidelines, 156 addressed quantitative research in human subjects relevant to dysphagia. Of these, 104 addressed general research elements and 108 addressed participant characteristics. Only 14 guidelines partially addressed the other topics of interest, and none addressed elements relevant to reporting videofluoroscopic or endoscopic assessments of swallowing.

CONCLUSIONS

We were unable to find guidelines with specific relevance to reporting key methods in dysphagia research. This lack of guidance illustrates a gap that hinders the critical appraisal of research quality in the field of dysphagia. Our review highlights the need to develop dysphagia-specific tools for critical appraisal and guidance regarding adequate research reporting.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25014017.

Decoding pediatric spinal tumors: a single-center retrospective case series on etiology, presentation, therapeutic strategies, and outcomes

INTRODUCTION

Spinal tumors (ST) often result in dire prognosis, carrying risks such as permanent paralysis, sensory loss, and sphincter dysfunction. Data on their incidence and etiology in pediatric populations are markedly scant. Our study investigates the etiology, clinical manifestation, treatment, and outcomes of pediatric ST.

METHODS

We conducted a retrospective review of our institutional pediatric oncology and neurosurgery database, examining 14 patients under 18 years admitted with ST due to oncological diseases since 2005. We analyzed the clinical presentations, evaluations, molecular diagnostics and treatments for these patients.

RESULTS

The study spanned 15 years and included 14 pediatric patients, each diagnosed with distinct spinal tumor entity. The mean patient age was approximately 19.6 ± 10.1 months. Severe axial pain along the vertebral column was observed in 13 patients, while acute neurological deterioration manifested in 7 patients. As a first-line intervention, 13 patients underwent decompressive surgery through laminectomy and tumor resection, and only one patient received chemotherapy solely. Before surgery, seven patients were unable to walk; post-surgery, six of them regained their ability to ambulate. The diagnosis encompassed a range of neoplasms: two instances of Ewing sarcoma, 3 instances of teratoma, one case presenting an atypical teratoid Rhabdoid tumor, two instances each of low-grade astrocytoma and neuroblastoma, and single instances of ependymoma, meningioma, rhabdomyosarcoma, and embryonal tumors with multilayered rosettes (ETMRs). Three patients succumbed two years after initiating therapy.

CONCLUSION

Despite their rarity, intraspinal tumors in pediatric patients pose substantial therapeutic challenges. The intertwined complexities of the disease entity and the patient's neurological status demand swift initiation of an individualized therapeutic strategy. This crucial step helps optimize outcomes for this patient cohort, who frequently grapple with debilitating health conditions. Inclusion of these patients within a registry is mandatory to optimize treatment outcomes due to their rarity in pediatric population.

Efficacy, safety, and impact of fluorescein in frameless stereotactic needle biopsies - a case series

Stereotactic needle biopsy stands as a crucial method for diagnosing intracranial lesions unsuitable for surgical intervention. Nonetheless, the potential for sampling errors lead to innovative approaches to enhance diagnostic precision. This study contrasts the outcomes of patients undergoing fluorescein-assisted frameless stereotactic needle biopsy with those receiving traditional biopsies to evaluate the impact on diagnostic accuracy and safety. This study included patients with contrast-enhancing intracranial lesions, comprising a prospective group undergoing fluorescein-assisted biopsies and a retrospective group undergoing conventional biopsies at the same institution. We've collected data on demographics, procedural specifics, diagnostic outcomes, and postoperative events. A comparative analysis involved 43 patients who received fluorescein-assisted biopsies against 77 patients who underwent conventional biopsies. The average age was 60.5 years. The fluorescein group exhibited a 93% success rate in diagnosis, markedly higher than the 70.1% in the non-fluorescein group (OR = 5.67; 95%IC: 1.59-20.24; p < 0.01). The rate of complications was statistically similar across both cohorts. Despite its established value, stereotactic needle biopsy is susceptible to inaccuracies and complications. The application of fluorescence-based adjuncts like 5-ALA and fluorescein has been investigated to improve diagnostic fidelity and reduce risks. These technologies potentially minimize the necessity for multiple biopsies, decrease surgical duration, and provide immediate verification of tumor presence. Fluorescein-assisted stereotactic biopsy emerges as an effective, secure alternative to conventional methods.

Experience Using Gentian Violet-Free Dyes for Tissue Visualization

BACKGROUND

 Gentian violet ink is used as a skin marker in various surgical procedures, including neurosurgery. The dye is also used to visualize the edges of blood vessels during bypass surgery. However, gentian violet ink carries the risks of carcinogenicity and venous injury, which causes microvascular thrombosis. In this study, we compare the gentian violet-free dye C.I. Basic Violet 4 (BV4) and gentian violet. The usefulness, in terms of color, and formation of microvascular thrombosis in anastomosis were compared.

METHODS

 We used the gentian violet-free dye in 20 cases involving 3 vascular anastomoses. The bone cutting lines on the bone surface, superior temporal artery, and middle cerebral artery were drawn using BV4 and gentian violet ink.

RESULTS

 The colors of BV4 and gentian violet ink were similar. No thrombus formation was observed at the vascular anastomosis when using BV4.

CONCLUSION

 BV4 can be used similarly to gentian violet ink. No adverse effects such as thrombus formation in microvascular anastomosis were experienced when BV4 was used.

Treatment of single gingival recessions using biofunctionalized collagen matrix: A case series

BACKGROUND

Connective tissue graft substitutes have been used widely to overcome autogenous graft limitations. Nevertheless, they do not provide comparable results in the treatment of periodontal and peri-implant soft tissue defects. Based on the principles of tissue-engineered materials, injectable platelet-rich fibrin (i-PRF) has been combined with collagen matrices (CMs) to enhance their clinical efficacy. To the best of our knowledge, this is the first case series demonstrating the use of i-PRF for the biofunctionalization of a volume-stable collagen matrix (VCMX) as an adjunct to coronally advanced flap (CAF) to treat single gingival recession (GR) defects.

METHODS & RESULTS

The study included 10 patients. Bleeding on probing, probing depth, GR height, clinical attachment level, esthetics, and dentin hypersensitivity were evaluated. After 6 months, a significant GR reduction (RecRed: 2.15 ± 0.7 mm; p = 0.005) and percentage of root coverage (% RC) of 81.13% were observed. Additionally, 40% of the sites showed complete root coverage. Gingival thickness increased 0.64 mm. Patient-centered evaluations demonstrated dentin hypersensitivity and esthetics improvements by the end of follow-up.

CONCLUSION

VCMX biofunctionalized with i-PRF associated with CAF technique showed promising clinical outcomes in the treatment of single RT1 GR defects.

Early epidural lead migration in spinal cord stimulator trials: A case series

Background

Spinal cord stimulation (SCS) devices are routinely trialed to assess pain and functional improvement before permanent lead implantation. Lead migration is a common complication that may cause a loss of therapeutic effect in patients who may otherwise benefit from SCS. The timing of lead migration during the trial period is currently unknown.

Objectives

We hypothesize that significant lead migration may occur early in the SCS trial period, such as postoperative day 1 or 2, which may allow for contact stimulation adjustment to prevent false negative trial results. As such, in this study, we aim to evaluate the incidence and distance of lead migration in early thoracic SCS trial period.

Methods

We performed a case series of 27 patients ≥19 years of age who received differential target multiplexed thoracic SCS trials for chronic neuropathic pain from July 1, 2020 to July 1, 2023. Patients with a neuropathic pain diagnosis failing medical treatment, without structural pathology limiting epidural access, and with psychiatric clearance for suitability are eligible for SCS trials at our center. Pre- and post-flexion radiographs taken immediately after implantation and on postoperative day 1 or 2 were examined to assess the distance of lead migration. Clinically significant lead migration was pre-defined as ≥ 10 mm.

Results

The mean (SD) distances of epidural lead migration on postoperative day 1 or 2 were 18.2 (12.9) mm and 19.1 (13.3) mm for the cephalic and caudal leads, respectively. All migrations were caudad except for one trial. Clinically significant lead migration occurred in 20/27 (74 %) patients.

Conclusion

Clinically significant epidural lead migration occurs in the early SCS trial period.

Completely Minimally Invasive Implant Removal and Transforaminal Lumbar Interbody Fusion for Adjacent Segment Disease: Case Series and Operative Video

BACKGROUND AND OBJECTIVES

Adjacent segment disease is a relatively common late complication after lumbar fusion. If symptomatic, certain patients require fusion of the degenerated adjacent segment. Currently, there are no posterior completely minimally invasive techniques described for fusion of the adjacent segment above or below a previous fusion. We describe here a novel minimally invasive technique for both implant removal (MIS-IR) and adjacent level transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar stenosis.

METHODS

Demographic, surgical, and radiographic outcome data were collected for patients with lumbar stenosis and previous lumbar fusion, who were treated with MIS-IR and MIS-TLIF through the same incision. Radiographic outcomes were assessed postoperatively and complications were assessed at the primary end point of 3 months.

RESULTS

A total of 14 patients (7 female and 7 male), with average age 64.6 years (SD 13.4), were included in this case series. Nine patients had single-level MIS-IR with single-level MIS-TLIF. Three patients had 2-level MIS-IR with single-level MIS-TLIF. Two patients had single-level MIS-IR with 2-level MIS-TLIF. Only 1 patient had a postoperative complication-hematoma requiring same-day evacuation. There were no other complications at the primary end point and no fusion failure at the hardware removal levels to date (average follow-up, 11 months). Average increases in posterior disk height and foraminal height after MIS-TLIF were 4.44, and 2.18 mm, respectively.

CONCLUSION

Minimally invasive spinal IR can be successfully completed along with adjacent level TLIF through the same incisions, via an all-posterior approach.

Intracranial angioleiomyoma: a case series of seven patients and review of the literature

PURPOSE

Angioleiomyoma, predominantly arising from the extremities, is a benign soft tissue tumor. Reports on its intracranial location are rare. We assessed clinical, radiological, and pathological features of intracranial angioleiomyoma (iALM) treated at our neurosurgical institution.

METHODS

We consecutively enrolled all patients with neuropathologically confirmed iALM treated at a single neurosurgical institution between 2013 and 2021. Clinical and imaging data were collected, and histological tissue sections were analyzed. A review of the literature on iALM was conducted.

RESULTS

Seven patients with iALM (four female) with a median age of 45 years (range: 32-76 years) were identified. In three cases, the lesion was found incidentally. In magnetic resonance imaging (MRI), all tumors were hypo- to isointense on T1-weighted, hyperintense on T2-weighted sequences, and gadolinium-enhancing. A strong FLAIR signal was seen in six patients. Surgery consisted of gross total resection in all cases without perioperative complications. Neuropathological staining was positive for smooth muscle actin (SMA) in all lesions. Mature smooth muscle cells arranged around blood vessels were typically observed. The Ki-67 index was ≤ 3%. The patients were discharged after a median of 6 days (range: 4-9 days). During a median follow-up time of 14 months (range: 4-41 months), no tumor recurrence occurred. In the current literature, 42 additional cases of iALM were identified.

CONCLUSION

Intracranial angioleiomyoma is a benign soft tissue tumor treated by gross total resection. Tumor morphology and positive staining for SMA lead to the neuropathological diagnosis.

A consensus guideline on preferred items for reporting case series in homeopathy: The PITCH statement

BACKGROUND

Case series is a valuable tool for sharing clinical experiences and generating research questions in the field of medicine. However, there is a lack of standardized reporting guideline for case series in homeopathy, which limits their utility and comparability. The aim of this study is to develop a reporting guideline for case series in homeopathy using a Delphi consensus process.

METHOD

A group of 21 experts, with experience in reviewing, publishing, or editing case reports or series in homeopathy, were participated in the study. A modified Delphi consensus process was conducted with three rounds of electronic surveys to gather feedback and opinions on the items to be included in the reporting guideline. The GRADE group's nine-point Likert scale was used to rate each item's importance and criticality.

RESULT

The Delphi process resulted in a consensus-based reporting guideline for case series in homeopathy, which includes recommendations for reporting case series in eleven sections, including 'Title,' 'Abstract,' 'Keywords,' 'Introduction,' 'Methods,' 'Results,' 'Discussion,' 'Conclusion,' 'Patient Perspectives,' 'References,' and 'Additional Information.' PITCH comprises a total of 59 items that achieved consensus agreement. Of these, 13 are optional items and 14 items are exclusively applicable for prospective type of case series.

CONCLUSION

The PITCH reporting guideline provides a structured and standardized approach for reporting case series in homeopathy. The authors, journal editors, reviewers, and educators are encouraged to adopt and implement the guideline to enhance the quality of case series in homeopathic publications.

Rescue Lead Implantation After Deep Brain Stimulation for Parkinson's Disease: A Single-Center Experience and Case Series

BACKGROUND AND OBJECTIVES

Despite the well-established efficacy of deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's Disease (PD), there remains a subset of patients with only a moderate improvement in symptoms even with appropriate lead placement and optimal programming. In patients with persistent tremor or dyskinesias, one consideration is the addition of a second "rescue lead" to provide dual stimulation to primary and secondary targets to address the refractory component. This study aimed to assess all "rescue lead" cases from our institution and characterize the patients and their outcomes.

METHODS

Records of all patients with PD treated at our institution between 2005 and 2023 were retrospectively reviewed. Clinical data of all patients treated with a second rescue lead to supplement a positive but inadequate initial DBS response were collected and reviewed.

RESULTS

Of 670 patients with PD treated at our institution during the study period, 7 were managed with a rescue lead. All 7 were initially treated with STN DBS with a partial improvement in underlying symptoms, had confirmed appropriate lead placement, and underwent thorough programming. Four patients underwent rescue with a globus pallidus interna lead for persistent dyskinesias, all with subsequent improvement in their dyskinesias. Three patients had persistent tremors that were treated with a rescue ventrointermediate thalamus stimulation with subsequent improvement in tremor scores. There were no operative complications, and all patients tolerated dual stimulation.

CONCLUSION

For a small subset of patients with PD with persistent dyskinesias or tremors after STN DBS despite optimized lead parameters and adequate lead placement, rescue lead placement offers an effective treatment option.

Transpalpebral/Blepharoplasty Incision and Supraorbital Craniotomy for the Treatment of Ethmoidal Dural Arteriovenous Fistulas: A Case Series

BACKGROUND AND OBJECTIVES

Inherent complex angioarchitecture associated with ethmoidal dural arteriovenous fistulas (dAVFs) can make endovascular treatment methods challenging. Many surgical approaches are accompanied by unfavorable cosmetic results such as facial scarring. Blepharoplasty incision of the eyelid offers a minimal, well-hidden scar compared with other incision sites while offering the surgeon optimal visualization of pathogenic structures. This case series aims to report an initial assessment of the safety and efficacy of supraorbital craniotomy by blepharoplasty transpalpebral (eyelid) incision for surgical disconnection of ethmoidal dAVFs.

METHODS

Retrospective chart review was conducted for all patients who underwent blepharoplasty incision and craniotomy for disconnection of ethmoidal dAVFs at our institution between October 2011 and February 2023. Patient charts and follow-up imaging were reviewed to report clinical and angiographic outcomes as well as periprocedural and follow-up complications.

RESULTS

Complete obliteration and disconnection of ethmoidal dAVF was achieved in all 6 (100%) patients as confirmed by intraoperative angiogram with no resulting morbidity or mortality. Periprocedural complications included one case of transient nasal cerebrospinal fluid leak that was self-limiting and resolved before discharge without intervention.

CONCLUSION

Surgical treatment for ethmoidal dAVFs, specifically by transpalpebral incision and supraorbital craniotomy, is a safe and effective treatment option and affords the surgeon greater access to the floor of the anterior fossa when necessary. In addition, blepharoplasty incision addressed patient concerns for facial scarring compared with other incision sites by creating a more well-hidden, minimal scar in the natural folds of the eyelid for patients with an eyelid crease.

Trauma care supported through a global telemedicine initiative during the 2023-24 military assault on the Gaza Strip, occupied Palestinian territory: a case series

BACKGROUND

Hospitals, patients, and health-care workers are legally protected by international humanitarian law and the Geneva Convention. However, since Oct 7, 2023, the health-care system in the Gaza Strip, occupied Palestinian territory, has been under unprecedented direct military attacks by Israel, with support for patients proving to be challenging for the remaining health-care workers. Peer-to-peer telemedicine holds promise for assisting surgeons in high-risk, low-resource environments, but might be of reduced utility in extremely austere settings.

METHODS

We present a patient case series of traumatic injuries shared in an international telemedicine group by the surgical team at Nasser Medical Complex, also known as Nasser Hospital, the largest remaining partially functioning hospital in Gaza. WhatsApp (Meta; Menlo Park, CA, USA), a widely available and user-friendly end-to-end encrypted smartphone application, was used to facilitate consultations for weapon-inflicted injuries. All the presented patient cases were shared after obtaining verbal consent from the patients and discussed through a multidisciplinary team approach. The group was developed into a community with more than 15 specialty and injury-oriented subgroups and over 1000 members who joined through non-targeted social media outreach followed by snowball recruitment. Prospective registration and formal ethics approval in Gaza was impossible because the Ministry of Health, including the local Helsinki Committee, had suspended all operations. In June, 2024, we obtained ethics approval from the local Helsinki committee in Gaza.

FINDINGS

We present 12 select patient case studies from a pool of hundreds of patients admitted to Nasser Hospital between Jan 28 and Feb 12, 2024. Four (33%) of the 12 patients were female and eight (67%) were male, with four patients (33%) being children (younger than 18 years). The age range was between 3 years and 70 years, with a median age of 25 years. Most patients presented with penetrating injuries (11 [92%] of 12), with six patients presenting with wounds secondary to fragment injury, and five patients presenting with wounds due to gunshots. One patient presented with a direct blast injury. The site of reported injuries included head and neck areas (four [33%] of 12), abdomen (four [33%] of 12), chest (three [25%] of 12), pelvis (two [17%] of 12), and limbs (one [8%] of 12). Most patients were lost to follow-up (11 [92%] of 12) and were affected by the invasion of the hospital by the Israeli Defense Forces, which subsequently rendered the hospital non-functional. One patient died following their injury.

INTERPRETATION

The health-care team at the now non-functioning Nasser Hospital in southern Gaza adapted their allocation and distribution of extremely low resources and relied on smartphones for specialised telemedicine outreach purposes. This enhanced the capability of the medical teams in management of mass casualties of military assaults that few are trained to work in. Nonetheless, the options available to a health-care system that is under-staffed, under-served, and under siege, are extremely constrained, regardless of such telemedicine initiatives.

FUNDING

None.

Dissecting and fusiform aneurysms of the superior cerebellar artery: anatomy, clinical presentation, and treatment outcomes

The management of superior cerebellar aneurysms is still controversial. Although several techniques are available, the deep localization of the lesion and the limited number of cases increase the complexity of decision-making for optimal treatment. Only a few cases of dissecting and fusiform aneurysms of the superior cerebellar artery (SCA) are described in the literature, many of which are without long follow-ups. The study aims to offer an exhaustive retrospective analysis of patients affected by SCA fusiform and dissecting aneurysms treated at our institution from 2008 to 2023, highlighting outcomes and complications. Moreover, a comprehensive narrative review was performed. A total of seven patients were treated at our institution. After a title and abstract screen, fifty-five papers met the criteria for inclusion in the review. In our case series, conservative treatment was proposed as the first therapeutic option in four cases (57.1%), while endovascular treatment (EVT) was in three cases (42.9%). A good recovery was observed in 66% of patients presenting with subarachnoid hemorrhage (SAH), while every patient without SAH achieved a good clinical outcome. A poor outcome was observed only in one patient with a dissecting aneurysm causing SAH, who also suffered a pontine infarction. In the literature review, conservative treatment was proposed as a first therapeutic option in eleven cases (16.6%), open microsurgical techniques in 19 patients (28.8%), and EVT in 31 patients (46.9%). Fatal outcome was documented in five patients (7.5%), all characterized by the rupture of the vascular lesion, while 6.1% of cases had non-fatal poor outcomes.

Utilization of a Cortical Xenogeneic Membrane for Guided Bone Regeneration: A Retrospective Case Series

Background: Guided bone regeneration (GBR) is a reliable technique used in vertical and horizontal bone defects. The posterior mandibular region is an area limited by anatomic constraints. The use of resorbable membranes with a cortical component could compensate for the lack of rigidity of resorbable membranes without the complications of non-resorbable membranes. The aim of this study was to evaluate the mean bone gains of a xenogeneic cortical membrane in horizontal and vertical bone defects in comparison with other membranes in the literature. Methods: A porcine cortical membrane was used to perform 7 GBR in the posterior mandibular region of five patients. Preoperative (T0) and six months postoperative (T1) cone beam computed tomography were superimposed to measure the horizontal and vertical bone gain. Implants were positioned at all sites, six months after GBR. Complications and bone resorption around the implants were also documented. Results: The mean horizontal and vertical bone gains were 3.83 ± 1.41 mm and 4.17 ± 1.86 mm, respectively. The analysis of repeatability was 0.997. As many as 40% of patients experienced pain refractory to analgesics. No exposure or infectious phenomenon was observed. Conclusions: This xenogeneic cortical membrane seemed to provide interesting results in the regeneration of horizontal and vertical bone defects. Comparative and prospective studies are necessary to validate the effectiveness of this membrane.

Thyroid Nodule Rupture Following Radiofrequency Ablation for Benign Thyroid Nodules

Importance

Nodule rupture is a rare but serious complication of thyroid radiofrequency ablation (RFA). With growing adoption of thyroid RFA across the US, an understanding of thyroid nodule rupture (TNR) is crucial for recognition, management, and, ultimately, prevention.

Objective

To determine procedural and patient factors that may contribute to TNR and describe experiences in managing TNR while synthesizing existing literature.

Design, Setting, and Participants

This retrospective case series examined all RFA procedures for benign thyroid nodules performed by 2 attending physicians at a single academic referral center between December 2019 and January 2024. A total of 298 consecutive patients underwent RFA for benign thyroid nodules. Criteria for offering RFA included nodules with 2 benign fine-needle aspirations, no suspicious ultrasonography features, a greatest dimension of 2 cm or greater, compressive or cosmetic concerns, and accessibility to a straight needle.

Exposures

All RFAs were performed using ultrasonography guidance using the moving-shot technique and a 7-mm or 10-mm active tip.

Main Outcomes and Measures

The primary outcome was TNR, and measures were procedure, nodule, and patient characteristics that may have contributed to its pathogenesis. Secondary outcomes were nodule volume reduction, thyroid function, and management and sequelae of TNR. The hypothesis on the pathogenesis of TNR was formed before data collection.

Results

Six of 298 patients (2%; 4 women [67%]) with a mean age of 48.5 years (range, 34-65 years) experienced TNR for a mean of 36 days postprocedure (range, 19-54 days). The mean (SD) initial nodule volume among patients with TNR was 31.45 (16.52) mL, and 3 of 6 patients (50%) underwent prior lobectomy. All ruptures were anterior. All patients were treated conservatively, and none required surgery. Five patients recovered completely; the sixth and most recent patient was healing as of last follow-up.

Conclusions and Relevance

There are limited data on the etiology and optimal management of TNR. These 6 cases of anterior rupture suggest that a potential contributor to TNR is thermal and mechanical trauma exerted at the fulcrum point during the moving-shot technique. The use of a smaller active tip (eg, 7 mm) and cessation of energy delivery before this point may help avoid TNR. More robust reporting of this complication may clarify risk factors for and enhance prevention of TNR.

Enhancing the quality of evidence, comparability, and reproducibility in ventriculoatrial shunt research for normal pressure hydrocephalus: A systematic review and VAS-NPH reporting guideline

BACKGROUND

Ventriculoatrial shunt (VAS) is an important treatment option for normal pressure hydrocephalus (NPH). However, clinical studies reporting the use of VAS for NPH lack sufficient standardization for meta-analytic comparisons that could provide robust evidence regarding its use. This study aims to assess the quality of reporting in these studies and develop a reporting guideline checklist to standardize terminology, concepts, and reporting while reinforcing the essential elements to ensure comparability and reproducibility.

METHODS

This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, with no timeframe restriction. The level of evidence of the studies was assessed using the GRADE system, and the rigor used in the publication of the results was assessed concerning adherence to the guidelines indicated by the EQUATOR Network Group. Furthermore, the studies were scrutinized focusing on eight domains: (1) Characteristics of the included studies and baseline characteristics of the patients; (2) Reporting methodology; (3) Pivotal concepts definition; (4) Adverse events assessment; (5) Data writing and reporting; (6) Detailed outcomes reporting; (7) Specific clinical outcomes assessment and reporting; and (8) Complications reporting.

RESULTS

A total of 14 studies with 734 patients and 753 shunts were included in this review, and the assessment exposes notable deficiencies in reporting, specifically in baseline patient details, methodology, and outcome assessments. Only two studies followed reporting guidelines, prompting concerns about comprehensive reporting of adverse events and intraoperative complications. Varied reporting completeness existed for shunt-related issues. The absence of standardized definitions for key concepts and insufficient intervention details were observed. A VAS-NPH reporting guideline, encompassing 36 items across eight domains, was developed to address these shortcomings.

CONCLUSION

This systematic review reveals significant deficiencies in methodological rigor and reporting quality. The proposed VAS-NPH Reporting Guideline covers all essential aspects and is a potential solution to rectify these shortcomings and increase transparency, comparability, and reproducibility. This initiative aims to advance the level of evidence and enhance knowledge regarding the use of VAS in NPH.

A highly malignant succinate dehydrogenase A‑deficient renal cell carcinoma with bone metastasis misdiagnosed as hereditary leiomyomatosis and renal cell carcinoma: A case report

Succinate dehydrogenase (SDH)-deficient renal cell carcinoma (RCC) is an autosomal dominant syndrome caused by heterozygous pathogenic germline variants of the SDH gene. SDH mutations are associated with an increased risk of developing RCC, although studies describing SDH-deficient RCC are currently limited. The present study reported a case of SDH-deficient RCC with high malignancy and rare bone metastasis. The patient was diagnosed with a right renal mass through B-mode ultrasound imaging and showed a carcinoma embolus in the right renal vein and inferior vena cava through kidney contrast-enhanced computed tomography. A whole-body bone scan showed radionuclide accumulation in the upper end of the left humerus, which indicated possible pathological bone destruction. As a result, surgical resection was performed. The postoperative pathology indicated a high-grade RCC and although the specific classification remained uncertain, hereditary leiomyomatosis and RCC was suspected. Subsequently, a germline mutation of the succinate dehydrogenase complex flavoprotein subunit A gene was identified through high-throughput sequencing (c.1A>G, p. Met1?) and immunohistochemistry demonstrated the loss of succinate dehydrogenase complex flavoprotein subunit B expression. Postoperatively, the patient underwent radiotherapy and targeted therapy. After 6 months of follow-up treatment, there was no indication of recurrence or metastasis on thoracoabdominal CT and whole-body bone scintigraphy. Based on the present report, germline screening should potentially be encouraged in early-onset patients as family history or pathological results may not provide sufficient information for the early, differential diagnosis of SDH-deficient RCC.

Our Experience With 200 Cases of Inguinal Hernia Repair Using the Dynamic Self-Adjusting Prosthesis: A Case Series and Literature Review

Introduction Inguinal hernioplasty (IH) is one of the most frequently performed surgical procedures globally. Today, a variety of surgical techniques and prosthesis types are available for this procedure. Methods At our center, we performed 200 inguinal hernioplasties using the dynamic self-adjusting prosthesis (protesi autoregolantesi dinamica, PAD) from May 1, 2022, to May 31, 2023. Our objective was to retrospectively analyze the outcomes and compare them with the current scientific literature on this surgical technique. Results Our results align with those reported by other authors using the same surgical technique. With the PAD technique, we assessed the type and frequency of adverse events up to 12 months following IH. All patients were male, with an average BMI of 26.6. Among the 200 hernias, 99 were right-sided, 101 were left-sided, 63 were direct, and 137 were indirect. The average length of hospitalization was one day. The most common postoperative complication was hematoma near the surgical site, but no prosthesis displacement was observed. In 71% of patients, analgesics were discontinued within 24 hours. The outcomes of our study are comparable to those reported by the inventor of this surgical technique. Conclusion The procedure has demonstrated safety and effectiveness and could serve as a viable alternative to traditional IH techniques.

The anconeus-triceps lateral flap approach in terrible triad of the elbow: good outcome in a series of ten cases

Introduction

Standard surgical management for the terrible triad of the elbow (TTE) has been established since 2004, yet postoperative complications are common and consensus on optimal management is absent. Different surgical algorithms for treating TTE and their efficacy have been reported worldwide, yet evidence from Vietnam remains limited.

Methods

Ten cases diagnosed with TTE admitted to the Hospital of Traumatology and Orthopedics, a tertiary orthopedic center in Ho Chi Minh City, were presented to demonstrate the effectiveness and rate of postoperative complications following our stepwise surgical procedures using the anconeus-triceps lateral flap approach. The intraoperative "drop sign", quantitative assessment of pain and level of upper arm disability (via VAS and QuickDASH score) was mentioned to assess the algorithm's benefit. All patients' information was retrieved from medical records from August 2022 to January 2024.

Results

All 10 cases required repair of the lateral ligament complex and underwent surgery within 2 days of hospitalization. Immediate postoperative imaging revealed no drop sign, and none of the patients experienced elbow dislocation nor the need for repeated surgery, and a full range of elbow motion was demonstrated at 3-6 months follow-up.

Conclusion

TTE is a challenging injury that almost always obligates surgical correction. The anconeus-triceps lateral flap approach, with its advantages of better visualization and preservation of certain essential stabilizing muscles of the elbow, was demonstrated to yield a high success rate and low postoperative complication rate.

Endoscopic combined intrarenal surgery versus percutaneuos nephrolithotomy for complex pediatric stone disease: A comparative analysis of efficacy and safety

INTRODUCTION

Decision-making for complex pediatric urinary system stone disease is still a challenge for pediatric urologists. The interest in supine percutaneous nephrolithotomy (PCNL) is increasing among centers to achieve high surgical success rates with less morbidity. Despite advanced retrograde intrarenal surgery armamentarium, percutaneous approaches remain the first-line surgical treatment modality for >2 cm and complex renal stones. There are no comparative studies yet in the literature for pediatric endoscopic combined intrarenal surgery (ECIRS) OBJECTIVE: In this study, we aimed to contribute to the literature by evaluating the safety and efficacy of ECIRS by comparing it with PCNL.

STUDY DESIGN

Patients under 18 years of age who underwent PCNL and ECIRS for urinary tract stone disease at our Pediatric Urology department between 2012 and 2024 were included. Preoperative (demographic characteristics, stone characteristics, biochemical parameters), perioperative (duration of surgery, number of accesses, lasing and fluoroscopy times, endoscopic and fluoroscopic stone-free rates) and postoperative (hospital stay, urinary tract infection, complication and radiological stone-free rates) parameters were retrospectively evaluated.

RESULTS

A total of 68 children [28 (41%) girls and 40 (59%) boys] aged 5 (0-17) years were included in the study. ECIRS was performed in 19 (28%), supine in 28 (41%) and prone PCNL in 21 (30%) patients. Age (p = 0.029), Guy's stone score (p < 0.001), S.T.O.N.E. (p < 0.001), and Seoul National University Renal Stone Complexity (S-ReSC) scores (p = 0.001) for preoperative parameters were found to be higher in ECIRS group over both PCNL methods (Summary Table). However, Clinical Research Office of the Endourological Society (CROES) score was seen lower for ECIRS group patients compared to other groups (p = 0.028). Surgery time (in favor of supine over prone PCNL), fluoroscopy time (in favor of ECIRS and Supine PCNL over Prone PCNL), preferred laser type (prone PCNL group was mostly performed with holmium laser, whereas other groups were balanced between Holmium and Thulium Fiber Laser) and exit strategy (the preferred exit strategy was DJ Stent in most of the ECIRS patients, whereas nephrostomy tube was used in some of the PCNL group) showed significant difference among the groups as perioperative parameters (p = 0.042, <0.001, <0.001, <0.001, respectively). Surgery time was lower for supine PCNL compared to prone PCNL. For postoperative parameters, stone-free rates, complication rates and urinary tract infections were similar between the 3 groups, while a difference was detected in terms of length of hospital stay in favor of ECIRS over both supine and prone PCNL (p = 0.006).

DISCUSSION

The current trial suggests that stone-free and complication rates of ECIRS and supine PCNL were similar in the pediatric complex stone patients. Although, the stones in the ECIRS group we found to be more complex. Also, ECIRS was superior to PCNL in terms of fluoroscopy exposure and hospital stay.

CONCLUSION

With the widespread use of new generation ureteral access sheaths and flexible ureterorenoscopes, ECIRS may have an important role in treatment of complex pediatric kidney stones.

Infiltration of nanocarbon into the trachea during thyroidectomy surgery: case series and literature review

Introduction

The presence of metastatic disease in the cervical lymph nodes can affect the recurrence and survival of patients with thyroid cancer. Parathyroid gland injury during surgery can result in hypoparathyroidism, particularly with total thyroidectomy. Injection of carbon nanoparticles into the thyroid will label draining lymph nodes and aid in the visualization of metastatic cervical lymph nodes during a radical operation, sparing accidental damage to the parathyroid glands. Although reported to be useful during surgery, the safety of nanocarbon particles has rarely been investigated, and adverse side effects need to be studied.

Case presentation

The author describes five patients with thyroid cancer who had carbon secretions in the trachea or mucosa after carbon nanoparticles were injected into the thyroid. A patient with carbon secretions in the trachea mucosa recovered but had progressive dyspnoea. Surgical treatment was performed, and a mass was found in the trachea mucosa. After excluding all other possibilities, the author concluded that the mass was caused by nanocarbon suspension.

Discussion

To the author's knowledge, there are no reports on nanocarbon suspension into the mucosa and no consensus has yet been reached on the precise injection site, depth, or dose for injecting carbon nanoparticles before thyroidectomy.

Conclusion

The author suggests that the most appropriate injection depth of nanocarbon suspensions should be no more than 3 mm of the thyroid gland thickness to avoid deep injection into the trachea.

Use of drug-eluting, balloon-expandable resolute onyx coronary stent as a novel treatment strategy for vertebral artery ostial stenosis: Case series

INTRODUCTION

Vertebral artery (VA) ostial stenosis is notoriously difficult to treat using bare-metal stents owing to high rates of restenosis and stent kinking and breakage. We investigated the safety and effectiveness of treatment with a drug-eluting, balloon-expandable coronary stent (Resolute Onyx, Medtronic).

METHODS

Our prospectively maintained database was retrospectively searched for consecutive patients diagnosed with VA ostial stenosis who underwent Resolute Onyx stenting with/without angioplasty between January 1, 2015 and January 1, 2022. Patient demographics and clinical and radiographic presentations were recorded. Occlusion location, stenosis severity, contralateral disease, devices used, and intraprocedural and postprocedural complications were noted. Outcomes were assessed based on new or recurrent stroke, transient ischemic attack (TIA), or intracranial hemorrhage (ICH). Patients were followed up clinically and with radiographic imaging for in-stent stenosis.

RESULTS

Twenty-six patients were included in our study (21 men [80.8%]; mean age 70.3 ± 9.8 years). Symptomatic patients presented with TIA (11/26, 42.3%) and stroke (10/26; 38.5%). Mean stenosis in the study cohort was 74.9 ± 13.0%. One (3.8%) intraprocedural complication was encountered whereby the stent failed to open despite several attempts and was exchanged with a new one without issues. No in-hospital postprocedure stroke, TIA, or mortality was reported. During a mean 16.2 ± 13.6 months' follow up, two patients developed symptomatic in-stent restenosis that was treated with balloon angioplasty.

CONCLUSIONS

We report the first case series of Resolute Onyx drug-eluting stenting including 30-day postprocedure stroke/TIA rates and clinical/radiographic follow up and demonstrate safe and effective treatment of symptomatic and asymptomatic VA ostial stenosis.

Immediate implant placement in extraction sockets with buccal bone dehiscence: A case study

BACKGROUND

Immediate implant placement (IIP) has been associated with a higher risk of esthetic complications and particularly buccal mucosal recession, which can be more pronounced in non-intact sockets or in the presence of thin phenotype in the esthetic zone. Nevertheless, multiple techniques have been published to address IIP in non-intact alveolar sockets with favorable outcomes. The purpose of this study is to present an approach on IIP in sites with buccal bone dehiscence.

METHODS

Three patients requiring extraction of one or multiple teeth in the presence of buccal bone dehiscence were treated with flapless extractions, IIP, guided bone regeneration (GBR), and connective tissue grafting (CTG) through a tunneling approach with a simultaneous use of custom healing abutments.

RESULTS

All sites exhibited 1-2 mm of buccal bone thickness at the level of the implant platform, as well as significant buccal soft tissue thickness with no recession and a favorable development of the emergence profile at 4 months to a year post implant placement.

CONCLUSIONS

IIP in sockets with buccal bone dehiscence can be managed by means of a flapless extraction, GBR and CTG through a tunneling approach exhibiting favorable hard and soft tissue responses.

KEY POINTS

When placing immediate implants in non-intact sockets, simultaneous connective tissue grafting is recommended, especially in the esthetic zone. Bone grafting in immediate implants in sockets with buccal bone dehiscence can be performed through a tunneling approach without the need for open flap approaches. Placement of CHAs over immediate implants may help promote maintenance of the buccolingual ridge contours and overall hard and soft tissue responses.

PLAIN LANGUAGE SUMMARY

Placing dental implants right after tooth extraction can lead to more visible aesthetic issues, especially gum recession. This is more common when the tooth socket is not intact or the gum tissue is thin. However, several techniques have shown good results even in these challenging situations. This study explores a method for implant placement right after tooth extraction in cases where there is bone missing on the socket. Three patients who needed teeth extracted and had bone loss on the outer side of their tooth sockets were treated. The treatment included: Extracting the teeth without cutting the gums, placing implants immediately, using GBR to help regrow bone, adding connective tissue grafts, and using custom healing cups to shape the gum tissue. After treatment, all the sites showed 1-2 mm of new bone on the outer side of the implants and thicker gum tissue without any recession. The gum and bone around the implants looked good 4 months to a year later. In conclusion, IIP in sockets with bone loss on the outer side can be effectively managed with this method, leading to good bone and gum tissue outcomes.

Synovial hemangioma presenting with chronic painful infrapatellar mass: a case report

BACKGROUND

Synovial hemangiomas are rare benign vascular anomalies surrounded by a synovial lining and were first described by Bouchut in 1856. These neoplasms can develop in the intra-articular region, resulting in effusions and knee pain. However, their cause remains unknown. Prompt diagnosis and intervention are critical to prevent chondral damage. Histopathological examination is used to achieve the diagnosis, which is often delayed because of a lack of specific clinical signs. This report describes a unique case in which a painful infrapatellar mass was diagnosed as a synovial hemangioma. The absence of typical magnetic resonance imaging (MRI) findings highlights the importance of arthroscopic excision for diagnosis and symptom relief.

CASE PRESENTATION

A 20-year-old woman presented with persistent anterior left knee pain that became exacerbated when she climbed stairs. Despite previous pain management and physical therapy, she developed a painful lump beneath her patella that worsened over time. She had also undergone arthrocentesis, but this did not relieve her pain. Physical examination revealed a palpable, immobile 5-cm mass along the patellar tendon with limited knee flexion and extension and normal ligament stability. T1-weighted fat-saturated MRI of the left knee with gadolinium-based contrast revealed a lobulated intra-articular mass in Hoffa's fat pad that resembled a soft tissue chondroma. A biopsy of the mass was performed to provide histopathological evidence, confirming the benign nature of the mass. The subsequent excisional arthroscopy, combined with incision enlargement for mass removal, confirmed the histopathologic diagnosis of synovial hemangioma based on the presence of numerous dilated blood vessels and venous proliferation within sections of the synovium. Recovery was complete, and no residual tumor was detected on follow-up MRI after 1 year.

CONCLUSION

This case study emphasizes the importance of arthroscopic excision over open surgery for patients with synovial hemangioma. The minimally invasive nature of arthroscopy combined with the well-encapsulated nature and location of the mass facilitates complete resection.

The innovative double or triple dental abutment-implant: Case study with a 3-to-12-year follow-up

BACKGROUND

The aim of this case study is to present the rationality and scientific evidence of a new design for a double (DA) and triple (TA) dental abutment-implant with their specific new concept of biodynamic optimized peri-implant tissue (BOPiT).

METHODS

The innovative design of these abutments with a paraboloid geometry was based on BOPiT, simultaneously involving the principles of mechanobiology, biotensegrity, and mechanotransduction. Thus, 37 consecutive individuals/43 cases rehabilitated with single dental implant using the innovative DA (n = 28) and TA (n = 15) on 43 implants were included in this case study. The DA and TA support 2 or 3 dental crowns on a single implant, respectively. Clinic and radiographic examinations were presented at T1 (loading after 4 months) and T2 [final examination with an average follow-up time of 7.2 years (>3 to 12 years)].

RESULTS

At T2, mean scores for plaque index, peri-implant bleeding on probing, and peri-implant probing depth were low, depicting healthy peri-implant conditions. All radiographic images showed insignificant annual marginal bone loss (0.022 ± 0.05 mm) when compared to T1, reflecting great bone stability.

CONCLUSION

DA and TA, based on the BOPiT concept, represent an advantageous, simple and non-invasive mechanism for the longevity and healthy regulation of the peri-implant tissues.

Laparoscopic retromuscular hernia repair (LaHRR): a case-series of 17 patients treated with a novel technique for laparoscopic ventral hernia and diastasis repair

INTRODUCTION

Many minimally invasive techniques have been developed over the years to treat primary ventral hernias and rectus abdominis diastasis, all of which have their advantages and disadvantages in terms of complications, reproducibility, and cost. We present a case-series of a novel approach that was safe and reproducible in a cohort of 17 patients.

PATIENTS AND METHODS

All patients in the study underwent the novel procedure between October 2022 and July 2023. We collected data retrospectively, including patient general characteristics, surgical outcomes, and complications. Patient follow-up lasted 12 months to exclude recurrences.

RESULTS

Seventeen patients underwent the procedure for primary uncomplicated ventral hernias and rectus diastasis. The median length of hospital stay was 2 days (IQR 2-3). In 4 out of 17 cases minor complications occurred within 30 days, of which 3 were class I and 1 was a class II complication according to the Clavien-Dindo classification. There were no recurrences.

CONCLUSION

Although limited by a small cohort of patients and a non-comparative study design, our study presents encouraging results in regards to the safety of this technique. More studies with a larger study population are needed to evaluate the benefits and pitfalls of this new technique.[query names].

Dural arteriovenous fistulas in the falx cerebri: case series and literature review

Dural arteriovenous fistulas (DAVFs) within the falx cerebri are infrequently documented and may be linked with the falcine sinus/venous plexus. The falcine sinus/venous plexus, often regarded as a normal venous structure, can exhibit pathological characteristics, differing from the persistent fetal falcine sinus. A retrospective analysis was conducted at a single center to identify all cases of DAVFs within the falx cerebri spanning from 2002 to 2022. Demographic data, fistula features, treatment modalities, clinical outcomes, and fistula closure were collected and analyzed. Additionally, relevant literature on DAVFs in this location was reviewed. Ten cases were identified at our center, supplemented by 13 cases reported in the literature. In our cohort, patients had an average age of 49.4 ± 8.1 years, with a male predominance of 90%. Trans-arterial embolization (TAE) alone achieved immediate complete occlusion in eight cases, while conservative treatment was pursued in two cases. No treatment-related complications or fistula recurrences were observed. In the literature, seven patients underwent direct surgery, three underwent TAE, and one underwent both direct surgery and radiosurgery for complete fistula closure. No instances of fistula recurrence or treatment complications were reported. Dural arteriovenous fistulas within the falx cerebri are rare, with limited literature available. They typically present as aggressive lesions. Treatment options include direct surgery or TAE. However, due to a lack of long-term DSA follow-up, the cure and recurrence rates are unknown for endovasdcular therapy. Further investigation is warranted to elucidate the involvement of the falcine sinus/venous plexus in falx cerebri DAVFs.

"One-and-a-Half" Interdural Transcavernous Pituitary Transposition/Rotation for Protection of Hypophyseal Portal System in Adult Peripheral Retroinfundibular Craniopharyngioma

BACKGROUND AND OBJECTIVES

Craniopharyngiomas originate from the pituitary stalk (PS) and extend along the pituitary-hypothalamic axis. Peripheral retroinfundibular craniopharyngiomas, particularly, may have worse surgery outcomes than other types. This study aims to investigate the advantage of using "one-and-a-half" interdural transcavernous pituitary transposition/rotation to dissect the tumor from the residual stalk and hypophyseal portal system for this subtype of craniopharyngioma.

METHODS

From August 2018 to February 2023, patients with peripheral retroinfundibular craniopharyngioma underwent surgical treatment. We analyzed clinical information, surgical records, imaging, and examination findings. The surgical procedure, including "one-and-a-half" interdural transcavernous pituitary transposition and rotation, was explained. Postoperative follow-up included endocrinological tests, MRI examinations, and urination surveys.

RESULTS

Among the 52 patients diagnosed with craniopharyngioma who underwent surgical treatment, 9 were classified as peripheral retroinfundibular craniopharyngioma, and they received "one-and-a-half" interdural transcavernous pituitary transposition and stalk rotation. In 6 cases, the residual PS and most of the hypophyseal portal system were preserved. Gross total resection was achieved in 5 patients and near total resection in 1 patient. One patient had a transection of the bilateral inferior hypophyseal arteries and 5 unilaterally. None experienced permanent diabetes insipidus, but varying degrees of anterior pituitary dysfunction postoperatively required hormone replacement therapy, which gradually decreased over time.

CONCLUSION

The natural anatomic corridor, "one-and-a-half" interdural transcavernous pituitary transposition, and stalk rotation provide increased working space compared with intradural or extradural pituitary transposition. Simultaneously rotating the tumor and pituitary enables a specific attack angle for lesion dissection after the anteriorly displaced residual stalk is rotated laterally. This approach preserves the residual PS and hypophyseal portal system, avoiding complications of diabetes insipidus and hypopituitarism. In most cases, only one side of the inferior hypophyseal artery needs to be sacrificed, ensuring normal pituitary function.