Isolated subependymal giant cell astrocytoma (SEGA) in the absence of clinical tuberous sclerosis: two case reports and literature review

PURPOSE

Subependymal giant cell astrocytoma (SEGA) is a WHO grade I pediatric glioma arising in 5-15% of patients with tuberous sclerosis (TSC). Rare cases of isolated SEGA without TSC have been described. The etiology, genetic mechanisms, natural history, and response to treatment of these lesions are currently unknown. We describe two such cases of isolated SEGA with follow-up.

METHODS

Retrospective review was performed at a single institution to describe the clinical course of pathology-confirmed SEGA in patients with germline testing negative for TSC mutations.

RESULTS

Two cases of isolated SEGA were identified. Genetic analysis of the tumor specimen was available for one, which revealed an 18 base pair deletion in TSC1. Both cases were managed with surgical resection, one with preoperative embolization. In spite of a gross total resection, one patient experienced recurrence after three years. Treatment with an mTOR inhibitor led to a significant interval reduction of the mass on follow-up MRI. The patient tolerated the medication well for 6 years and is now off of treatment for 2 years with a stable lesion.

CONCLUSION

Cases of SEGA outside of the context of TSC are exceedingly rare, with only 48 cases previously described. The genetic mechanisms and treatment response of these lesions are poorly understood. To date, these lesions appear to respond well to mTOR inhibitors and may behave similarly to SEGAs associated with TSC. However, given that experience is extremely limited, these cases should be followed long term to better understand their natural history and treatment response.

Anti-HEV seroprevalence and rate of viremia in a German cohort of dogs, cats, and horses

Hepatitis E virus (HEV) genotype 3 infections in Germany are mainly transmitted zoonotically through the consumption of swine meat. Furthermore, there is evidence that pets might come into contact with HEV, but the relevance of companion animals as possible sources of HEV transmission in Germany still needs to be defined. A monitoring study was therefore carried out on dogs, cats, and horses from Germany. In total 365 serum samples from pets (124 dogs, 119 cats, and 122 horses) were tested for HEV by PCR and for anti-HEV antibodies by a commercial ELISA. The HEV seroprevalence determined by the sero-assay varied significantly between dogs (10%), cats (6%), and horses (2%). Liver injury-related enzymes, alanine transaminase (ALT), and aspartate transaminase (AST) showed no differences between HEV-positive or negative animals. None of the pet serum samples tested positive for PCR. This serological study suggests that dogs and cats are significantly exposed to HEV in Germany, while horses are of minor relevance.

Awake, Transforaminal Endoscopic Lumbar Spine Surgery in Octogenarians: Case Series

BACKGROUND

Optimal approaches for treating surgical spine pathology in very geriatric patients, such as those over the age of 80, remain unclear.

OBJECTIVE

To describe outcomes of awake, transforaminal endoscopic surgical treatment for patients 80 years old and older presenting with lumbar radiculopathy.

STUDY DESIGN

Retrospective case review.

METHODS

The records of 52 consecutive patients who underwent awake transforaminal lumbar endoscopic decompression surgery performed by a single surgeon at a single institution between 2014 and 2019 were retrospectively reviewed. All included patients were followed for at least one year after surgery.

RESULTS

Transforaminal surgeries performed were discectomies (21), foraminotomies (7), redo foraminotomies post-laminectomy (5), fusion explorations (13), facet cyst resections (3), spondylolisthesis decompressions (2), and a decompression for metastatic disease (1). Seven patients (13.5%) required repeat surgery at the treated level during the one-year follow-up. For the remaining 45 patients, at one-year follow-up, preoperative visual analog scale (VAS) for leg pain and Oswestry disability index (ODI) improved from 6.9 (± 1.4) and 40.5% (± 11.5) to 1.8 (± 1.4) and 12.0% (± 10.8), respectively. The only complication of the procedure was a single durotomy (2%).

LIMITATIONS

Single-center, retrospective case review with a relatively small number of cases with diverse clinical pathology. A multi-center case study with a larger number of patients with a more homogeneous case pathology would be more revealing.

CONCLUSIONS

Endoscopic spine surgery offers octogenarians a safe and effective option for the treatment of lumbar degenerative spine disease and may represent a valuable treatment strategy in a growing patient population.

Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

Background

Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI).

Methods

We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression.

Results

We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression.

Conclusions

Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.

Interrater Reliability in the Measurement of Flow Characteristics on Color-Coded Quantitative DSA of Brain AVMs

BACKGROUND AND PURPOSE

Hemodynamic features of brain AVMs may portend increased hemorrhage risk. Previous studies have suggested that MTT is shorter in ruptured AVMs as assessed on quantitative color-coded parametric DSA. This study assesses the interrater reliability of MTT measurements obtained using quantitative color-coded DSA.

MATERIALS AND METHODS

Thirty-five color-coded parametric DSA images of 34 brain AVMs were analyzed by 4 neuroradiologists with experience in interventional neuroradiology. Hemodynamic features assessed included MTT of the AVM and TTP of the dominant feeding artery and draining vein. Agreement among the 4 raters was assessed using the intraclass correlation coefficient.

RESULTS

The interrater reliability among the 4 raters was poor (intraclass correlation coefficient = 0.218; 95% CI, 0.062-0.414; P value = .002) as it related to MTT assessment. When the analysis was limited to cases in which the raters selected the same image to analyze and selected the same primary feeding artery and the same primary draining vein, interrater reliability improved to fair (intraclass correlation coefficient  = 0.564; 95% CI, 0.367-0.717; P < .001).

CONCLUSIONS

Interrater reliability in deriving color-coded parametric DSA measurements such as MTT is poor so minor differences among raters may result in a large variance in MTT and TTP results, partly due to the sensitivity and 2D nature of the technique. Reliability can be improved by defining a standard projection, feeding artery, and draining vein for analysis.

Case report of a cervical myelomalacia caused by a thoracolumbar intradural disc herniation leading to intracranial hypotension

A 50-year-old patient was admitted with symptoms of intracranial hypotension. MRI revealed a cervical myelomalacia caused by engorged epidural veins leading to a stenosis of the spinal canal. This condition is rarely described in patients with hydrocephalus and ventricular shunts suffering from chronic overdrainage. However, the reason in this patient was a CSF leak caused by an intradural disc herniation at T12/L1. After surgery, symptoms resolved and the cervical myelomalacia and the swollen epidural veins disappeared on postoperative MRI. In patients with engorged cervical epidural veins without a ventricular shunt, a CSF leak has to be considered.

Isolated cervical extraosseous intradural chordoma attached to the C5 nerve root: a case report

Background

As chordomas are slow growing and locally invasive with high recurrence rates, initial recommendations include complete surgical resection with or without radiation therapy. A large proportion of recurrences occur years after initial resection necessitating lengthy follow-up. The novel biomarker brachyury and the repurposing of pharmaceutical products have the potential to substantially impact long-term recurrence rates.

Case presentation

A 43-year-old woman presented with an isolated, cervical extraosseous intradural extramedullary chordoma attached to a nerve root underwent a C3-5 laminectomy, C3-5 lateral mass screw instrumentation, and mass resection. All symptoms resolved by the 12-month postoperative follow-up visit.

Conclusions

This is the first report of an isolated, cervical extraosseous intradural extramedullary chordoma attached to a nerve root, and this case adds to the previous six Type IV chordomas in the literature. Unfortunately, the very rare form of extraosseous intradural chordoma is poorly understood: the lack of detailed knowledge in how they are differentiated from other forms of chordoma confounds the development of optimal treatment strategies and follow-up guidelines.

The incidence of symptomatic postoperative epidural hematoma after minimally invasive lumbar decompression: A single institution retrospective review

OBJECTIVE

Postoperative epidural hematoma (PEDH) after minimally invasive lumbar laminectomy (MILL) can lead to significant morbidity and healthcare cost. The incidence is not well characterized in the literature as compared with traditional open techniques. Our aim was to define the incidence of PEDH after MIS lumbar decompression procedures and evaluate strategies for reduction of PEDH.

PATIENTS AND METHODS

A retrospective review of a prospectively collected database was queried from January 2013 to September 2018 for all patients that underwent a minimally invasive lumbar laminectomy or laminotomy, with or without discectomy, for which the goal was decompression alone. Charts were reviewed to see the operation type and whether the patient developed a postoperative epidural hematoma.

RESULTS

1004 cases were identified and reviewed. The overall PEDH rate was 1.4 % (14/1004). 78.5 % (11/14) of cases involved at least a single level laminectomy. 21.4 % (3/14) involved a laminotomy alone or with discectomy. 64.3 % (9/14) of patients presented with a neurological deficit.

CONCLUSIONS

The rate of PEDH after MIS lumbar decompression procedures is 1.4 %. A majority of patients presented with a neurological deficit.

P3641Matrix Metalloproteinase-2 polymorphisms are associated with prognosis of patients with symptomatic coronary artery disease

Background

Matrix Metalloproteinase-2 (MMP-2) is involved in regulation and proliferation of vascular and endothelial cells and is therefore an important component of atherosclerotic vessels. Inhibition of MMP-2 activity is associated with improvement of cardiac function in animal models after myocardial infarction. MMP-2 single nucleotide polymorphisms (SNPs) might alter MMP-2 expression and therefore influence prognosis in patients with symptomatic coronary artery disease (CAD).

Methods and results

Genotyping for selected MMP-2 SNPs variants (rs2241145, rs2285053, rs2287076, rs243865, rs7201) was performed in 943 consecutive patients with symptomatic CAD. All patients were followed-up for all-cause death (ACD), myocardial infarction (MI) and ischemic stroke (IS) for 360 days. The primary combined endpoint (CE) consisted of either first occurrence of ACD, and/or MI, and/or IS. Secondary endpoints were defined as the single events of ACD or MI. Homozygous carriers of major allele (rs2241145, rs2287076) showed significantly better event-free survival than carriers of the minor allele for CE (Log rank = 0.022 and Log rank= 0.015, respectively). Furthermore, homozygous carriers of major allele (rs2241145, rs2285053, rs2287076) showed significantly better event-free survival for ACD (Log rank= 0.047, Log rank= 0.006 and Log rank= 0.023, respectively). In multivariate analysis, MMP-2 rs2241145, rs2287076 and rs2285053 were significantly and independently associated with CE and ACD.

Figure 1

Conclusions

MMP-2 rs2241145, rs2287076 and rs2285053 are associated with prognosis and might be valuable for further risk stratification in CAD patients.

Acknowledgement/Funding

DFG, KFO 274, CRC TR 240

P3643Junctional Adhesion Molecule-A (JAM-A) polymorphisms influence serum levels of soluble JAM-A and are associated with long term prognosis in coronary artery disease

Aims

Junctional adhesion molecule A (JAM-A/F11R) is a cell adhesion molecule. Membrane associated JAM-A mediates platelet aggregation, secretion, adhesion, and spreading. Plasma levels of JAM-A are elevated in hypertension and atherosclerosis. This study was designed to investigate the impact of JAM-A single nucleotide polymorphisms (SNPs) on circulatory JAM-A levels and prognosis in patients with symptomatic coronary artery disease (CAD).

Methods and results

JAM-A SNP analysis (JAM-A F11R rs2774276 and rs790056) was performed in 943 patients with symptomatic CAD. All patients were tracked for all-cause death (ACD), myocardial infarction (MI), and ischemic stroke (IS) for 1080 days. The primary combined endpoint (CE) was defined as a composite of ACD and/or MI and/or IS. Secondary endpoints were defined as the single events of ACD and MI. Homozygote carriers of the minor allele (F11R rs2774276 and rs790056) showed significantly worse event-free survival for MI when compared with major allele carriers (Log rank = 0.011 and log rank = 0.031, respectively). No significant differences could be shown for the CE and ACD. Of note, in multivariate analysis, both SNPs were significantly and independently associated with MI. Furthermore, serum levels of soluble JAM-A were elevated in homozygote carriers of minor allele when compared to major allele carriers. Finally, serum levels of soluble JAM-A were significantly elevated in patients with MI when compared to stable CAD (p=0.036).

Figure 1

Conclusion

JAM-A SNPs are associated with prognosis in patients with symptomatic coronary artery disease. Furthermore, JAM-A SNPs might influence serum concentration of soluble JAM-A. Finally, serum concentration of soluble JAM-A is higher in patients with myocardial infarction when compared to stable coronary artery disease. These findings suggest JAM-A as a valuable biomarker for risk stratification and tailoring therapies in patients with coronary artery disease.

Acknowledgement/Funding

DFG-KFO274, CRC/Transregio 240

Contralateral Minimally Invasive Laminectomy for Resection of a Synovial Cyst: 2-Dimensional Operative Video

Synovial cysts of the lumbar spine result from degeneration of the facet capsule, and their prevalence may be as high as 10% in symptomatic patients. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption, minimizes soft-tissue trauma, and limits disruption of the ligamentous and bony structures. Additionally, by approaching contralateral, the cyst/dura interface is better visualized especially at the depths of the lateral recess. Seeing the full extent of this interface from an ipsilateral approach is very difficult without decompressing the cyst, which, in turn, makes dissecting and separating the remaining cyst wall more difficult and increases the risk of durotomies.1,2

 We report the case of a 53-yr-old female who presented with persistent left leg pain in an L5 distribution that was associated with some mild lower back pain. She was refractory to conservative management that included physical therapy along with a series of epidural steroid injections. She was noted to have some weakness with dorsiflexion on the left side and as absent a straight leg raise. Given the predominance of her leg over her back symptoms along with the patient's age, a minimally invasive contralateral approach for resection of the synovial cyst was offered as opposed to more traditional decompression and fusion. Institutional Review Board approval and patient consent for solitary case reports are not needed at our institution.

Morphological classification of the tubercle of insertion of the transverse atlantal ligament: A computer tomography-based anatomical study of 200 subjects

BACKGROUND AND PURPOSE

The atlantal tubercle is the attachment point of the transverse atlantal ligament, the main stabilizer of the atlantoaxial complex. No system of classification of the tubercle exists in the literature. We aimed to develop a morphologically based classification system of the atlantal tubercle to aid clinicians who deal with craniocervical pathology.

MATERIALS AND METHODS

A retrospective review of computed tomography (CT) scans of the cervical spine was performed. The morphology of the atlantal tubercle was classified into four variants: rounded (classical), pointed, flattened, and hypoplastic. Age, presence, and morphological type were recorded.

RESULTS

A total of 200 CT scans were identified and reviewed. The tubercle was present bilaterally in all patients. Patients were equally distributed over various age ranges. The following morphological types were recorded: rounded (227/400; 56.8%), pointed (13/400; 3.3%), flattened (126; 31.5%), and hypoplastic (34/400; 8.5%). The same type was seen bilaterally in 68% (135/200) of patients. Morphological types appear equally on the right and left side of the atlas.

CONCLUSIONS

The first morphologically based classification system of the atlantal tubercle utilizing CT is presented. Morphology type, especially hypoplastic type, may confer an increased risk for subsequent need for posterior fusion.

In vitro supplementation with unsaturated fatty acids improves boar sperm viability after storage at 6 °C

Liquid preservation of the cold-sensitive boar sperm at a lesser temperature than the standard 17 °C would reduce bacterial growth and minimize the use of antibiotics. There was assessment, therefore, of the capacity of individual fatty acids bound to fatty acid free BSA to improve sperm survival at 6 °C because oxidative stress and lipid degradation are prominent detrimental factors. Different effects of the fatty acids were observed. Supplementation with naturally occurring fatty acids (linolenic, linoleic, oleic, palmitoleic acid), which may become metabolically incorporated into sperm lipids, increased the number of motile and progressively motile sperm after 2 days of storage during a thermo-resistance test (5 h at 38 °C) to that of control samples preserved at 17 °C in pure Beltsville Thawing Solution. With the exception of linolenic acid, all naturally occurring fatty acids enhanced the number of sperm with active mitochondria after 3 days of storage. Palmitoleic acid was the most effective supplement with effects already present when sperm were re-warmed for 30 min after 2 and 7 days of storage. The non-endogenous, non-integrated timnodonic acid (20:5) had no effect on sperm variables. Because the application of individual fatty acids attached to BSA had differing effects in preserving boar sperm at 6 °C, the use of combinations of fatty acids could be more efficacious than with use of natural lipid supplements for low temperature preservation of sperm.

Defining and measuring 'eczema control': an international qualitative study to explore the views of those living with and treating atopic eczema

Background

Atopic eczema (also known as eczema) is a chronic, inflammatory skin condition that often afflicts patients’ health and well‐being. The Harmonising Outcome Measures for Eczema (HOME) initiative recommends that ‘long‐term control of eczema’ is measured in all clinical trials 3 months or longer in duration. However, little has been published on what eczema control means to those living with or treating atopic eczema.

Objectives

To (i) develop understanding of what eczema control means to patients, carers and clinicians and (ii) explore the feasibility and acceptability of different ways of measuring eczema control in the long term.

Methods

Online focus groups explored patients/carers experiences in the UK, the United States, the Netherlands, France, Sweden and Japan, and an international online survey gathered views of clinicians. The framework method was used to analyse the focus groups, and thematic analysis was used to analyse survey data. All findings were integrated into a theoretical framework to create overarching themes that cut across these diverse groups.

Results

Eight focus groups with patients (16 years+) and eight groups with carers of children took place (N = 97). Sixty‐two people took part in the survey. Eczema control was described as a multifaceted construct involving changes in disease activity, the treatment and management of the condition and psychological, social and physical functioning. Patient/carer measurement allows personal accounts and frequent measurement, whilst clinician measurement was deemed less subjective. The burden on patients/carers and issues for analysing and interpreting data should be considered.

Conclusions

This study formed the basis of judging the content validity and feasibility of measurement instruments/methods to assess control of eczema in clinical trials. This online approach to an international qualitative study is an example of how core outcome set developers with limited resources can engage with multiple stakeholder groups on an international basis to inform consensus meeting discussions.

Middle Fossa Approach for Resection of an Intracanalicular Vestibular Schwannoma

Objective  This video was aimed to demonstrate the middle fossa approach for the resection of an intracanalicular vestibular schwannoma.

Design  Present study is a video case report.

Setting  The operative video is showing a microsurgical resection.

Participant  The patient was a 59-year-old man who presented with worsening headache and right-side hearing loss. He was found to have a right intracanalicular vestibular schwannoma. After weighing risks and benefits, he chose surgery to remove his tumor. Since his hearing remained “serviceable,” a middle fossa approach was chosen.

Main Outcome Measures  Pre- and postoperative patient photographs evaluated the muscles of facial expression as a marker for facial nerve preservation.

Results  A right middle fossa craniotomy was performed which allowed access to the floor of the middle cranial fossa. The greater superficial petrosal nerve (GSPN) and arcuate eminence were identified. Using these two landmarks, the internal acoustic canal (IAC) was localized. After drilling the petrous bone, the IAC was unroofed. The facial nerve was identified by stimulation and visual inspection and the tumor was separated from it with microsurgical dissection. In the end, the tumor was fully resected. Both the facial and cochlear nerves were preserved. Postoperatively, the patient experienced no facial palsy and his hearing is at baseline.

Conclusion  With radiosurgery gaining increasing popularity, patients with intracanalicular vestibular schwannomas are frequently treated with it, or are managed with observation. The middle fossa approach is therefore becoming a “lost art,” but as demonstrated in this video, remains an effective technique for tumor removal and nerve preservation.

The link to the video can be found at: https://youtu.be/MD6o3DF6jYg .

The Difference in Surgical Site Infection Rates Between Open and Minimally Invasive Spine Surgery for Degenerative Lumbar Pathology: A Retrospective Single Center Experience of 1442 Cases

BACKGROUND

Surgical site infection (SSI) in spinal surgery contributes to significant morbidity and healthcare resource utilization. Few studies have directly compared the rate of minimally invasive surgery (MIS) SSI with open surgery.

OBJECTIVE

To investigate whether MIS techniques had a lower SSI rate in degenerative lumbar procedures as compared with traditional open techniques.

METHODS

A single-center, retrospective review of a prospectively collected database was queried from January 2013 to 2016 for adult patients who underwent lumbar decompression and/or instrumented fusion for which the surgical indication involved degenerative disease. The SSI rate was determined for all procedures as well as in the open and minimally invasive groups. Risk factors associated with SSI were also reviewed for each patient.

RESULTS

A total of 1442 lumbar spinal procedures were performed during this time period. Of these, there were 961 MIS and 481 open (67% vs 33%, respectively). The overall SSI rate was 1.5% (21/1442). The surgical site infection rate for MIS was less than open techniques (0.5% vs 3.3%; P = .0003). For decompression only, the infection rate for MIS and open was 0.4% vs 3.9% (P = .04), and for decompression with fusion it was 0.7% vs 2.6%, respectively (P = .68).

CONCLUSION

Our study demonstrates a significant 7-fold reduction in SSIs when comparing MIS with open surgery. This significance was also demonstrated with a 10-fold reduction for procedures involving decompression alone. Procedures that require fusion as well as decompression showed a trend towards a decreased infection rate that did not reach clinical significance.

[Instantaneous wave-free ratio (iFR®) in patients with coronary artery disease]

Coronary angiography is considered as the gold standard in the morphological representation of coronary artery stenosis. Coronary angiography is often performed without preprocedural non-invasive proof of ischemia and the assessment of the severity of a coronary lesion by morphology is very subjective. Thus, invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic relevance of coronary artery stenosis and facilitates decision making for percutaneous coronary intervention (PCI) and stenting. The FFR-guided revascularization strategy has been classified as a class IA recommendation in the 2014 ESC/EACTS guidelines on myocardial revascularization. Both the DEFER and the FAME studies showed no treatment advantage of hemodynamically irrelevant stenosis. By use of FFR (and targeted interventions), clinical results could be improved as well as the procedure costs were reduced; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic relevance of coronary stenosis which can be obtained at rest without the use of vasodilators. Regarding periprocedural complications as well as prognosis, iFR® showed non-inferiority compared to FFR in the SWEDEHEART and DEFINE-FLAIR trials.

Delayed Chyle Leak Following Anterior Cervical Spinal Surgery: A Case Report and Management Algorithm

Injury to the thoracic duct during anterior cervical spine surgery is a rare occurrence. A delayed chyle leak following an elective anterior cervical spinal surgery has not been reported in the literature. We present a report of a 59-year-old female with multiple prior neck surgeries who underwent an anterior cervical corpectomy and fusion (ACCF). The patient developed a delayed thoracic duct injury on postoperative day (POD) one, as no injury was noted intraoperatively. She was managed with conservative care involving a low-fat diet along with octreotide which led to the resolution of her symptoms. We present this case report because of its unique presentation and to assist spine surgeons with initial management. Surgeons should have increased awareness when performing anterior cervical approaches to the lower cervical and upper thoracic levels from the left side.

Pediatric Intrafalcine Empyema from a Sinogenic Origin: A Case Report

Sinusitis and otitis are common within the pediatric population. If left untreated, these can extend intracranially and lead to the development of infections in the various intracranial compartments resulting in a high rate of morbidity and mortality. We report the first case of an intrafalcine empyema, absent subdural purulence, in a patient with the likely spread from a sinogenic origin. This case illustrates the novelty of this as a pathological entity as well as the surgical considerations for intrafalcine purulence in the absence of expected subdural collections.

Delayed Temporal Lobe Hemorrhage After Initiation of Acyclovir in an Immunocompetent Patient with Herpes Simplex Virus-2 Encephalitis: A Case Report

Herpes simplex virus (HSV) is the most common cause of non-epidemic, sporadic, acute focal encephalitis in the United States. Inflammation of the vasculature makes them friable and susceptible to hemorrhage. Massive hemorrhage, though rare, can present in a delayed fashion after initiation of acyclovir and often requires surgical intervention. We report a unique case of delayed temporal lobe hemorrhage after initiation of acyclovir in an immunocompetent patient, specifically for its presentation, virology, and surgical management. A 40-year-old left-handed Caucasian female with chronic headaches, along with a 20-pack-year smoking history, presented to an outside facility with one week of diffuse, generalized headache, fever, nausea, and vomiting. Initial cranial imaging was negative for hemorrhage. Cerebrospinal fluid (CSF) studies showed a lymphocytic pleocytosis with elevated protein, along with polymerase chain reaction (PCR) positive staining for HSV, establishing the diagnosis of HSV-2 encephalitis, which is less common in adults. Acyclovir was initiated and one week later while still hospitalized, the patient developed acute altered mental status with cranial imaging showing a large right temporal lobe hemorrhage with significant midline shift. She was transferred to our facility for surgical intervention. Computed tomography angiography (CTA) was negative for any underlying vascular lesion. She was taken to the operating room for a decompressive unilateral (right) hemicraniectomy and temporal lobectomy. She had no postoperative complications and completed a three-week course of acyclovir. She was discharged to acute rehab with plans to return at a later date for cranioplasty. Intracerebral hemorrhage is an uncommon, although possible sequela, of herpes encephalitis. Despite initiation of early antiviral therapy, close monitoring is warranted, given the pathophysiology of the vasculature. Any decline in the neurological exam and/or increasing symptomatology of increased intracranial pressure mandates immediate cranial imaging to evaluate for possible hemorrhage. Emergent surgical intervention is warranted with large temporal lobe hemorrhages.

Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note

Introduction: Suboccipital craniotomy is a workhorse neurosurgical operation for approaching the posterior fossa but carries a high risk of pseudomeningocele and cerebrospinal fluid (CSF) leak. We describe our experience with a simple T-shaped fascial opening that preserves the occipital myofascial cuff as compared to traditional methods to reduce this risk.

Methods: A single institution, retrospective review of prospectively collected database was performed of patients that underwent a suboccipital craniectomy or craniotomy. Patient data was reviewed for craniotomy or craniectomy, dural graft, and/or sealant use as well as CSF complications. A pseudomeningocele was defined as a subcutaneous collection of cerebrospinal fluid palpable clinically and confirmed on imaging. A CSF leak was defined as a CSF-cutaneous fistula manifested by CSF leaking through the wound. All patients underwent regular postoperative visits of two weeks, one month, and three months.

Results: Our retrospective review identified 33 patients matching the inclusion criteria. Overall, our cohort had a 21% (7/33) rate of clinical and radiographic pseudomeningocele formation with 9% (3/33) requiring surgical revision or a separate procedure. The rate of clinical and radiographic pseudomeningocele formation in the myofascial cuff preservation technique was less than standard techniques (12% and 31%, respectively). Revision or further surgical procedures were also reduced in the myofascial cuff preservation technique vs. the standard technique (6% vs 13%).

Conclusions: Preservation of the myofascial cuff during posterior fossa surgery is a simple and adoptable technique that reduces the rate of pseudomeningocele formation and CSF leak as compared with standard techniques.  

Onyx Embolization of a Meningioma with a Dysplastic Aneurysmal Anterior Cerebral Artery Vessel

Preoperative embolization of meningiomas can be safely performed using a variety of embolic agents. Most commonly, the vascular supply from branches of the external carotid artery is the target of embolization. In our report, we detail the treatment of a patient with a parafalcine meningioma that received its supply via branches of the anterior cerebral artery. One of the feeder vessels appeared to contain a dysplastic aneurysmal dilatation of the vessel. Due to patient circumstances, embolization was performed using standard microcatheterization techniques to minimize intraoperative blood loss. We report a rare instance of endovascular treatment of a pial vessel to treat an intracranial meningioma using Onyx.

Measurement of the centrality dependence of the charged-particle pseudorapidity distribution in proton-lead collisions at [Formula: see text] TeV with the ATLAS detector

The centrality dependence of the mean charged-particle multiplicity as a function of pseudorapidity is measured in approximately 1 [Formula: see text]b[Formula: see text] of proton-lead collisions at a nucleon-nucleon centre-of-mass energy of [Formula: see text] [Formula: see text] using the ATLAS detector at the Large Hadron Collider. Charged particles with absolute pseudorapidity less than 2.7 are reconstructed using the ATLAS pixel detector. The [Formula: see text] collision centrality is characterised by the total transverse energy measured in the Pb-going direction of the forward calorimeter. The charged-particle pseudorapidity distributions are found to vary strongly with centrality, with an increasing asymmetry between the proton-going and Pb-going directions as the collisions become more central. Three different estimations of the number of nucleons participating in the [Formula: see text] collision have been carried out using the Glauber model as well as two Glauber-Gribov inspired extensions to the Glauber model. Charged-particle multiplicities per participant pair are found to vary differently for these three models, highlighting the importance of including colour fluctuations in nucleon-nucleon collisions in the modelling of the initial state of [Formula: see text] collisions.

An Interpersonal Investigation of Sexual Self-Schemas

A sexual self-schema is a cognitive generalization about sexual aspects of the self. In the current study, we examined how an individual's sexual self-schema influenced the processing of self and partner related sexual information. Specifically, we investigated how sexual self-schemas related to own and partner sexual satisfaction and how they influenced perceptions of partner sexual satisfaction. Participants were 117 heterosexual couples in committed, long-term relationships. Both partners completed measures assessing their sexual self-schemas, their own sexual satisfaction, and perceptions of partner sexual satisfaction. Consistent with our predictions, own sexual schema was associated with own sexual satisfaction. For men, more positive sexual self-schemas were associated with greater sexual satisfaction, and for women, more negative sexual self-schemas were associated with lower sexual satisfaction. For both men and women, there was no significant association between own sexual self-schema and partner sexual satisfaction. Sexual self-schemas directly and indirectly influenced an individual's perception of the partner's sexual satisfaction, such that men and women with more positive sexual self-schemas rated their partners as more sexually satisfied, after controlling for the partner's self-reported level of sexual satisfaction. Our findings demonstrated that sexual self-schemas are relevant to own sexual satisfaction as well as the processing of interpersonally relevant sexual information, specifically one's perceptions of partner sexual satisfaction.

Study of the [Formula: see text] and [Formula: see text] decays with the ATLAS detector

The decays [Formula: see text] and [Formula: see text] are studied with the ATLAS detector at the LHC using a dataset corresponding to integrated luminosities of 4.9 and 20.6 fb[Formula: see text] of pp collisions collected at centre-of-mass energies [Formula: see text] TeV and 8 TeV, respectively. Signal candidates are identified through [Formula: see text] and [Formula: see text] decays. With a two-dimensional likelihood fit involving the [Formula: see text] reconstructed invariant mass and an angle between the [Formula: see text] and [Formula: see text] candidate momenta in the muon pair rest frame, the yields of [Formula: see text] and [Formula: see text], and the transverse polarisation fraction in [Formula: see text] decay are measured. The transverse polarisation fraction is determined to be [Formula: see text], and the derived ratio of the branching fractions of the two modes is [Formula: see text], where the first error is statistical and the second is systematic. Finally, a sample of [Formula: see text] decays is used to derive the ratios of branching fractions [Formula: see text] and [Formula: see text], where the third error corresponds to the uncertainty of the branching fraction of [Formula: see text] decay. The available theoretical predictions are generally consistent with the measurement.

Measurements of the Higgs boson production and decay rates and coupling strengths using pp collision data at [Formula: see text] and 8 TeV in the ATLAS experiment

Combined analyses of the Higgs boson production and decay rates as well as its coupling strengths to vector bosons and fermions are presented. The combinations include the results of the analyses of the [Formula: see text] and [Formula: see text] decay modes, and the constraints on the associated production with a pair of top quarks and on the off-shell coupling strengths of the Higgs boson. The results are based on the LHC proton-proton collision datasets, with integrated luminosities of up to 4.7 [Formula: see text] at [Formula: see text] TeV and 20.3 [Formula: see text] at [Formula: see text] TeV, recorded by the ATLAS detector in 2011 and 2012. Combining all production modes and decay channels, the measured signal yield, normalised to the Standard Model expectation, is [Formula: see text]. The observed Higgs boson production and decay rates are interpreted in a leading-order coupling framework, exploring a wide range of benchmark coupling models both with and without assumptions on the Higgs boson width and on the Standard Model particle content in loop processes. The data are found to be compatible with the Standard Model expectations for a Higgs boson at a mass of 125.36 GeV for all models considered.

Two-particle Bose-Einstein correlations in pp collisions at [Formula: see text] 0.9 and 7 TeV measured with the ATLAS detector

The paper presents studies of Bose-Einstein Correlations (BEC) for pairs of like-sign charged particles measured in the kinematic range [Formula: see text] 100 MeV and [Formula: see text] 2.5 in proton collisions at centre-of-mass energies of 0.9 and 7 TeV with the ATLAS detector at the CERN Large Hadron Collider. The integrated luminosities are approximately 7 [Formula: see text]b[Formula: see text], 190 [Formula: see text]b[Formula: see text] and 12.4 nb[Formula: see text] for 0.9 TeV, 7 TeV minimum-bias and 7 TeV high-multiplicity data samples, respectively. The multiplicity dependence of the BEC parameters characterizing the correlation strength and the correlation source size are investigated for charged-particle multiplicities of up to 240. A saturation effect in the multiplicity dependence of the correlation source size parameter is observed using the high-multiplicity 7 TeV data sample. The dependence of the BEC parameters on the average transverse momentum of the particle pair is also investigated.