Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress

Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.

An Androsterone-H2 @C60 hybrid: Synthesis, Properties and Molecular Docking Simulations with SARS-Cov-2

Invited for this month's cover are the collaborating groups of Dr. Margarita Suárez at Universidad de La Habana, Cuba, and Dr. Nazario Martín at Universidad Complutense de Madrid, Spain, together with groups at other institutions worldwide. The Front Cover shows a representation of the H₂ @C₆₀ hybrid molecule with a dehydroepiandrosterone moiety interacting with the active site of the SARS Cov-2. Read the full text of the article at 10.1002/cplu.202000770.

An Androsterone-H2 @C60 hybrid: Synthesis, Properties and Molecular Docking Simulations with SARS-Cov-2

We report the synthesis and characterization of a fullerene‐steroid hybrid that contains H₂@C₆₀ and a dehydroepiandrosterone moiety synthesized by a cyclopropanation reaction with 76 % yield. Theoretical calculations at the DFT‐D3(BJ)/PBE 6‐311G(d,p) level predict the most stable conformation and that the saturation of a double bond is the main factor causing the upfield shielding of the signal appearing at −3.13 ppm, which corresponds to the H₂ located inside the fullerene cage. Relevant stereoelectronic parameters were also investigated and reinforce the idea that electronic interactions must be considered to develop studies on chemical‐biological interactions. A molecular docking simulation predicted that the binding energy values for the protease‐hybrid complexes were −9.9 kcal/mol and −13.5 kcal/mol for PL^pro and 3CL^pro respectively, indicating the potential use of the synthesized steroid‐H₂@C₆₀ as anti‐SARS‐Cov‐2 agent.

Fiber-based angular filtering for high-resolution Brillouin spectroscopy in the 20-300 GHz frequency range

Brillouin spectroscopy emerges as a promising non-invasive tool for nanoscale imaging and sensing. One-dimensional semiconductor superlattice structures are eminently used for selectively enhancing the generation or detection of phonons at few GHz. While commercially available Brillouin spectrometers provide high-resolution spectra, they consist of complex experimental techniques and are not suitable for semiconductor cavities operating at a wide range of optical wavelengths. We develop a pragmatic experimental approach for conventional Brillouin spectroscopy that can integrate a widely tunable excitation-source. Our setup combines a fibered-based angular filtering and a spectral filtering based on a rotating single etalon and a double grating spectrometer for sequential reconstruction of Brillouin spectra. This configuration allows probing confined acoustic phonon modes in the 20-300 GHz frequency range with excellent laser rejection and high spectral resolution. Remarkably, our scheme based on the excitation and collection of the enhanced Brillouin scattering signals through the optical cavity allows for better angular filtering with decreasing phonon frequency. It can be implemented for the study of cavity optomechanics and stimulated Brillouin scattering over broadband optical and acoustic frequency ranges.

Langmuir-Blodgett fabrication of large-area black phosphorus-C60 thin films and heterojunction photodetectors

Black phosphorus (BP) has emerged as a promising two-dimensional (2D) semiconductor for applications in electronics, optoelectronics, and energy storage. As is the case for many 2D materials, the fabrication of large-area BP thin films remains a considerable challenge. Here, we report the assembly of BP nanosheets into compact thin films using the Langmuir-Blodgett (LB) technique. The overlapping stacking between BP nanosheets is suppressed when the nanosheets are surrounded by fullerene C₆₀ molecules due to physisorption. This allows for the fabrication of large-area BP films (20 mm × 18 mm) with a homogenous nanosheet distribution and negligible oxidation. The fabricated films show measurable absorption up to 2.3 μm. We use these films as active layers to demonstrate mm-sized BP heterojunction photodetectors with mA W^-1 scale responsivities from the visible to the near-infrared. Photodetector internal quantum efficiencies at 660 nm and 808 nm are 5% and 1%, respectively.

Test-Retest Reliability of Time-Domain EEG Features to Assess Cognitive Load Using a Wireless Dry-Electrode System

Human Machine Interfaces (HMIs) can provide critical support and improve daily task functionality for prosthesis users or social interaction for patients with locked-in syndrome using an assistive communication device. One goal in the development of sophisticated HMIs is to reduce the cognitive load (CL) they place on the user to promote the use of the technology. Electroencephalogram (EEG)-derived measures collected with wired wet-electrode systems have been used to assess CL in laboratory environments and have demonstrated acceptable test-retest reliability. Assessment of CL during real-world unconstrained HMI operation, however, requires the use of a wireless dry-electrode EEG system which provides easier electrode application and untethered movement. However, the test-retest reliability of wireless dry-electrode systems to quantify CL has not been explored. Ensuring the consistent capture of CL-related signals across multiple sessions is critical if these devices are to be used to assess how improvements in HMIs affect CL. Therefore, the current study used a wireless dry-electrode EEG system to compare Evoked Response Potential (ERP) features of a simple auditory oddball task to measure CL during two separate testing sessions a week apart. ERPs of 11 subjects were recorded while participants performed a virtual task at two difficulty levels. A significant correlation was found between the P300 component of the ERPs and subjective ratings of CL during both testing sessions. Furthermore, there was a statistically significant test-retest reliability for this same ERP feature and similar signal-to-noise ratios (SNRs) across sessions.Clinical Relevance- This is an initial step in validating wireless dry-electrode EEG systems to assess cognitive load across multiple sessions. The evidence presented is critical if dry-wireless EEG systems are to be used to identify aspects of HMIs that reduce CL in clinical and real-life environments. Assessing CL in unconstrained environments can better inform clinicians and technology developers in their design of future HMIs.

UPLC-MS/MS-based molecular networking and NMR structural determination for the untargeted phytochemical characterization of the fruit of Crescentia cujete (Bignoniaceae)

The fruit pulp of Crescentia cujete is traditionally used in folk medicine for the treatment of a variety of respiratory conditions and gastrointestinal disorders. Due to the lack of a comprehensive phytochemical description of the fruit of this plant, its active compounds and rational quality control parameters have not yet been described. An untargeted metabolomics approach combining UPLC-MS/MS-based molecular networking with conventional isolation and NMR methods was carried out for the phytochemical profiling of the fruit pulp of Crescentia cujete. Sixty-six metabolites, including nine n-alkyl glycosides, twenty-three phenolic acid derivatives (such as cinnamoyl and benzoyl derivatives), fifteen flavonoids, four phenylethanoid derivatives and fifteen iridoid glycosides were identified at different levels of confirmation: eighteen confirmed structures (Level 1), six probable structures (Level 2) and forty two tentative candidates (Level 3). Among these, all four phenylethanoid derivatives were described for the first time within this species. In addition, 8-epi-eranthemoside, crescentiol A and crescentiol B were reported as three undescribed iridoid glucosides. The use of molecular networking has resulted in a detailed phytochemical overview of this species. This work provides a useful tool for further development and validation of appropriate analytical methods for routine quality control assessment of commercially available products containing the fruit of this species and further interpretation of their related pharmacological effects.

Female Veterans' Experiences With VHA Treatment for Military Sexual Trauma

Provider validation and support for females' experiences as well as a range of therapies are essential treatments for female veterans with military sexual trauma.

Recent advances in objectifying pain using neuroimaging techniques

The pursuit of a physiological indicator of noxious stimulation is desirable as it has the potential to provide mechanistic information regarding acute pain and may ultimately improve pain management strategies. Currently, there are no specific neurophysiological markers of pain to evaluate treatments. Recent attempts to identify neural correlates of pain have focused on different neuroimaging modalities. The purpose of this review is to discuss common neuroimaging techniques and findings thus far.

Multicenter clinical and imaging evaluation of targeted radiofrequency ablation (t-RFA) and cement augmentation of neoplastic vertebral lesions

Background

Treatment of spinal metastatic lesions by radiofrequency ablation (RFA) before cementation can potentially help in local tumor control and pain relief. This is often limited by access and tumor location. This study reports multicenter clinical and imaging outcomes following targeted RFA (t-RFA) and cement augmentation in neoplastic lesions of the spine.

Material and methods

A retrospective multicenter study of 49 patients with 72 painful vertebral lesions, evaluated for clinical and imaging outcomes following RFA and cement augmentation of spinal metastatic lesions, was undertaken. Visual Analogue Pain score (VAS) and Oswestry Disability Index (ODI) were obtained before and 2–4 weeks after treatment. Pre- and post-procedure imaging examinations including MRI and positron emission tomography (PET) were also evaluated.

Results

Mean ablation time was 3.7±2.5 min (range 0.92–15). Mean VAS scores decreased from 7.9±2.5 pre-procedure to 3.5±2.6 post-procedure (p<0.0001). Mean ODI scores improved from 34.9±18.3 to 21.6±13.8 post-procedure (p<0.0001). Post-contrast MRI resulted in a predictable pattern of decreased tumor volume and an enhancing rim. Metabolically active lesions in pre-procedure PET scans (n=10 levels) showed decreased fluorodeoxyglucose activity after ablation.

Conclusions

t-RFA followed by vertebral augmentation in malignant vertebral lesions resulted in significant pain reduction and functional status improvement, with no major complications. t-RFA permitted access to vertebral lesions and real-time accurate monitoring of the ablation zone temperature. Post-procedure MRI and PET examinations correlated with a favorable tumor response and helped to monitor tumor growth and the timing of adjuvant therapy.

Vertebral augmentation versus conservative therapy for emergently admitted vertebral compression deformities: an economic analysis

BACKGROUND

Vertebral augmentation (VA) performed on inpatients with painful osteoporotic vertebral compression fractures (VCFs) has been shown to facilitate discharge, decrease analgesic requirements, and improve pain.

OBJECTIVE

The purpose of our study was to compare the overall cost, length of stay, and readmission data for patients hospitalized with painful osteoporotic VCFs, treated either medically or with inpatient VA.

SETTING

A single academic medical center.

STUDY DESIGN

Economic analysis

METHODS

Patients admitted with VCF over a 30-month period were identified using ICD-9 codes. The total length of stay, hospitalization costs, average daily cost, and 30-day readmission rates were compared between those who underwent VA and those managed nonoperatively. A subgroup analysis was performed with an age matched group of controls as well. Two-tailed t-tests were used for statistical significance.

RESULTS

Thirty-nine inpatients underwent VA; 61 levels were augmented. Their average age was 81.7 years. There were 209 patients who were treated nonoperatively for VCF. Their average age was 72.7 years, a significant age difference from the VA group (P < 0.01). The VA patients' average length of stay was 13.8 days, compared to 8.1 days in the medically managed group (P < 0.01). Average total costs were $26,074 in the VA group and $15,507 in the medically managed group (P < 0.01). The daily costs of admission were $2,040 in the VA group and $2,069 in the medically managed group (P = 0.85). The readmission rates related to VCF were 0% in the VA group; 5.2% in the medically managed group; and 7.7% in the age-matched control group. Of those who underwent VA, 43% experienced delays in care related to anticoagulation or medical comorbidities.

LIMITATIONS

The study is retrospective and uses billing data as a marker for total cost of care, The study does not account for cost differences between vertebroplasty and kyphoplasty.

CONCLUSION

Inpatient VA can be cost effective as demonstrated by the same daily cost between the VA and medically managed groups. Early identification and consultation can facilitate VA and rapid discharge. Anticoagulation issues and medical comorbidities can delay VA and lengthen hospital stays. Hospital admitted patients with painful osteoporotic VCF who are managed conservatively and discharged are at risk for readmission.

Viability of maxillary bone harvesting by using different osteotomy techniques. A pilot study

The use of autogenous grafts is still considered in bone regeneration surgeries. However, the bone cell viability of such grafts after being harvested from donor sites remains a matter of debate. The aim of the present study is to evaluate particulated and block bone cell viability, in terms of presence or absence of apoptosis and necrosis, obtained from different maxillary intra-oral harvesting methods: bone scraper, rotary carbide burs and piezoelectric device. Five healthy patients were enrolled in the study. The patients required sinus augmentation by lateral window approach. The bone was harvested by the bone scraper, piezoelectric device and rotary surgical instrument. The samples were processed with the Annexin V/FITC (fluorescein isothiocyanate stain) kit and were analyzed by means of Fluoresence-Activated Cell Sorted (FACS) technique. Within the limitations of this pilot study, the results indicated that autogenous bone chips collected from the three harvesting methods presented a large percentage of apoptotic cells, although large scale production of necrotic cells was not detected. In summary, although rotary surgical instrument and piezoelectric devices are frequently used instruments for oral osteotomy, fresh autogenous bone chips collected from them did not present a viable bone cell source.

Cyberknife radiosurgery in treating trigeminal neuralgia

PURPOSE

To assess the short term efficacy of Cyberknife stereotactic radiosurgical treatment of trigeminal neuralgia (TN).

METHODS

17 consecutive patients with medically or surgically refractory unilateral TN were treated with Cyberknife radiosurgery. Using superimposed CT cisternogram and MR images, the target segment of the trigeminal nerve was consistently defined as a 6 mm length of nerve approximately 2-3 mm distal to the dorsal root entry zone of the brainstem. A radiosurgical rhizotomy was performed with the Cyberknife utilizing a single collimator to deliver an average maximum dose of 73.06 Gy (range 72.91-73.73) to the target.

RESULTS

Follow-up data were available for 16 of the 17 patients post-treatment (range 1-27 months, average 11.8 months). Overall, 14 of 16 (88%) patients responded favorably with either partial or complete relief of symptomatology. 11 of these patients were successfully free of all pain at some point in their post-treatment course, with seven patients pain free to the last follow-up visit (average 5.0 months, range 1-13 months). Symptoms recurred in four patients, taking place at 3, 7.75, 9 and 18 months after Cyberknife therapy. Only two patients reported side effects. One patient developed a bothersome feathery dysesthesia while the second patient reported a non-bothersome mild jaw hypoesthesia. There were no substantial complications related to stereotactic radiosurgery.

CONCLUSION

Cyberknife radiosurgery is a viable treatment alternative in patients with TN with competitive efficacy demonstrated in our group of patients while minimizing adverse effects.

Percutaneous therapy for symptomatic synovial cysts

Synovial cysts have long been known to create radicular pain in the spine, with the clinical effect mimicking a disk herniation. These cysts have traditionally been treated with open surgical therapy. Now a minimally invasive, image-guided approach to treatment is available to relieve this problem, using a simple percutaneous needle stick and injection. This article describes the technical aspects and precautions needed for this intervention.

Vertebral body reconstruction: techniques and tools

Vertebral augmentation techniques use image guidance for the percutaneous placement of spinal implants that stabilize a painful osteoporotic or pathologic vertebral compression fracture. The initial implant, acrylic bone cement, was injected through a bone needle into the vertebral body, a procedure referred to as vertebroplasty. A modification of this procedure, kyphoplasty, entails the temporary use of an inflatable balloon tamp before cement injection. Other techniques and the equipment required to perform these vertebral augmentation procedures have evolved significantly during the past two decades. It is now possible to perform vertebral body reconstruction in patients with painful fractures of compromised vertebrae with excellent outcomes in terms of sustainable pain relief and marked reduction in patient morbidity.

Environmental performance of construction waste: Comparing three scenarios from a case study in Catalonia, Spain

The main objective of this paper is to evaluate environmental impacts of construction wastes in terms of the LIFE 98 ENV/E/351 project. Construction wastes are classified in accordance with the Life Program Environment Directive of the European Commission. Three different scenarios to current waste management from a case study in Catalonia (Spain) have been compared: landfilling, recycling and incineration, and these scenarios were evaluated by means of Life Cycle Assessment. The recommendations of the Catalan Waste Catalogue and the European Waste Catalogue have been taken into account. Also, the influence of transport has been evaluated. Results show that in terms of the Global Warming Potential, the most environmentally friendly treatment was recycling, followed by incineration and lastly landfilling. According to the influence of treatment plants location on the GWP indicator, we observe that incineration and recycling of construction wastes are better than landfilling, even for long distances from the building site to the plants. This is true for most wastes except for the stony types, than should be recycled close to the building site. In summary, data from construction waste of a Catalan case study was evaluated using the well established method of LCA to determine the environmental impacts.

Toxic effects of digested, composted and thermally-dried sewage sludge on three plants

In order to evaluate potential toxic effects of stabilized sewage sludge that are currently applied to agricultural soils, three types of municipal sewage sludge and one pig slurry were subjected to phytotoxicity assays using three plants (Brassica rapa, Lolium perenne and Trifolium pratense). Equivalent batches of aerobically and anaerobically-digested sludge (F) from two municipal wastewater treatment plants, were composted (C) or thermally dried (T). In addition, one anaerobically-digested and thermally-dried pig slurry (P) was tested. A seedling growth test was performed in accordance with the OECD Guideline 208A, using seed emergence and shoot length as endpoints to identify the inhibition of plants growing in increasing doses of sludge. A correlation analysis between EC50 and physico-chemical parameters or the pollutant burden of the biosolids was also calculated. In all tests, lower germination rates were observed for T. pratense than for L. perenne and B. rapa. A moderate stimulatory effect on shoot length at low doses was observed for the three plants. In these wastes, a strong positive correlation was found between higher values of EC50 (less toxicity) and the stability degree of their organic matter, and a negative correlation between EC50 and total N, hydrolysable N or NH4-N content. No correlations were found with heavy metal or organic pollutant content in those wastes. Results indicate that digested sludge, thermally-dried sludge and thermally-dried pig slurry have non-negligible short term phytotoxic effects, and confirm that composting is an effective sludge treatment for the reduction of phytotoxicity.

Differences on nitrogen availability in a soil amended with fresh, composted and thermally-dried sewage sludge

Anaerobically-digested sludge called fresh sludge (F), composted sludge (C) and thermally-drying sludge (T), all from the same batch, were applied to the surface of a calcareous Udic Calciustept with loamy texture. Dosage equivalent was 10 t ha(-1) of dry matter. The concentration of mineral nitrogen (ammonium and nitrate) in the soil was measured in order to estimate the effects of the post-treatments to which the different kinds of sewage sludge are subjected in relation to the availability of N in the surface layer of the soil. The most significant differences in NH(4)-N and NO(3)-N concentrations due to the transformation of the organic matter were observed during the first three weeks following soil amendment. Thermally-dried and composted sludge initially displayed higher concentrations of ammonium and nitrate in soil. Five months after the amendment, soil applied with fresh sludge showed the highest concentrations of NH(4)-N and NO(3)-N (6.1 and 36.6 mg kg(-1), respectively). It is clear that the processes of composting and thermal-drying influence the bioavailability of nitrogen from the different types of sewage sludge.

I can hear you yet cannot comprehend: a case of pure word deafness

This report describes a 25-year-old man with acute head trauma and brain damage resulting in pure word deafness. Bilateral temporal lobe pathology was confirmed by brain imaging and functional brain studies. A brief discussion about the difference between pure word deafness and other aphasias, as well as anatomic correlation is provided.

Bioaccumulation of heavy metals in Dactylis glomerata L. growing in a calcareous soil amended with sewage sludge

The total and DTPA-extractable concentrations of Pb, Ni, Zn, Cu, Cr and Cd were measured in a calcareous soil amended with different doses of sewage sludge under field conditions. The same metals were also measured in the roots and leaves of Dactylis glomerata at the end of the first vegetative period after the sludge was added. The root concentrations of all the metals were unrelated to their concentrations in the soil. Leaf concentrations of Zn and Cr correlated with total (Zn) and DTPA-extractable (Zn and Cr) concentrations in the soil. DTPA extraction did not appear to be very useful for evaluating the bioavailability of metals in this kind of soil as it gave very low correlation coefficients with leaf content (r = 0.684, P = 0.0049 for Zn and r = 0.557, P = 0.0249 for Cr). Concentrations of Pb, Ni, Cu, and Cd in roots and leaves of Dactylis glomerata were unrelated to the total or DTPA-extractable concentrations in the sludge-amended soil.

Management of Potato Late Blight in the Peruvian Highlands: Evaluating the Benefits of Farmer Field Schools and Farmer Participatory Research

Farmer field school programs incorporating farmer participatory research (FPR-FFS) have the potential to provide important benefits to their participants and to other farmers who benefit from improved cultivars and management techniques. An FPR-FFS program in San Miguel, Cajamarca, Peru, has been in place since 1999 with an emphasis on management of potato late blight, caused by Phytophthora infestans, the most important problem facing Andean potato growers. Farmers' knowledge of late blight was surveyed to determine useful components for the FPR-FFS curriculum. The benefits to participants of FPR-FFS programs were evaluated first by measuring knowledge of late blight management of participants and nonparticipants. Studies of the Peruvian FPR-FFS program indicate that participants are more knowledgeable and that their expertise further increases after an additional year of participation. The benefits to participants can be evaluated more directly by comparing the productivity of participants' farms compared with nonparticipants' farms. For the Peruvian FPR-FFS program, participants had significantly higher average levels of productivity. The benefits of FPR-FFS programs for the development of better cultivars and management techniques can be evaluated indirectly in terms of improved estimates of performance. Estimates of the overall performance of a particular cultivar or technique become more precise as data from more sites are included in calculating the estimate. A more direct evaluation of benefits from FPR-FFS input may be based on the ability of farmers in FPR-FFS programs to eliminate undesirable genotypes and to recommend desirable genotypes based on criteria in addition to those used by breeders.

The insula: anatomic study and MR imaging display at 1.5 T

BACKGROUND AND PURPOSE

The insula is important for gustatory sensation, motor speech control, vestibular function, and sympathetic control of cardiovascular tone. The purpose of this study was to test two hypotheses: 1) gross anatomic study of the insula will disclose reproducible patterns of insular structure, and 2) analysis of MR appearance will enable physicians to recognize these patterns on imaging studies.

METHODS

Gross insular anatomy was determined in 16 normal human cadaveric hemispheres. The 1.5-T MR images of 300 insulae were analyzed to determine the gyral and sulcal patterns displayed; their relationship to the Heschl gyrus, to the overlying opercula, and to the vertical planes perpendicular to the Talairach-Tournoux baseline at the anterior commissure (VAC) and posterior commissure (VPC); their continuity into the orbitofrontal cortex; and appropriate landmarks for the anterior border, apex, and posterior border of the insula.

RESULTS

MR images displayed the central sulcus of the insula (97%); the anterior (99%), middle (78%), and posterior (98%) short insular gyri that converge to the apex (100%) anteriorly; and the anterior (99%) and posterior (58%) long insular gyri posteriorly. The middle short gyrus was often hypoplastic (33%). The anterior intersections of the internal and external capsules typically delimit the anterior insular border (87%). VAC intersects the anterior insula (99%), usually at the precentral sulcus. The Heschl gyrus circumscribes the posteroinferior insula (100%). VPC demarcates the posterior insular border (94%).

CONCLUSION

The two hypotheses were proved correct. The insula shows reproducible patterns of gross anatomy that are demonstrable on routine clinical MR images obtained at 1.5 T.

The sacrum: pathologic spectrum, multimodality imaging, and subspecialty approach

The sacrum is a structure that is imaged by both general and subspecialty radiologists. A wide variety of disease processes can involve the sacrum either focally or as part of a systemic process. Plain radiographs, although limited in evaluation of the sacrum, should be carefully examined when abnormalities of the sacrum are suspected. Cross-sectional imaging, particularly computed tomography and magnetic resonance (MR) imaging, plays a crucial role in identification, localization, and characterization of sacral lesions. Congenital lesions of the sacrum, including sacral agenesis and meningocele, are optimally imaged with MR. The most common sacral neoplasm is metastatic disease. Primary neoplasms of the sacrum, which include giant cell tumor, chordoma, and teratoma, are infrequent. Infection of the sacrum or sacroiliac joint is most often due to contiguous spread from a suppurative focus. A wide variety of arthritic disorders such as ankylosing spondylitis and osteoarthritis can involve the sacroiliac joints as part of a localized or systemic process. Sacral fractures related to acute trauma or repetitive stress are difficult to diagnose and treat. Knowledge of these abnormalities and familiarity with the imaging of these processes will allow radiologists of all subspecialties to contribute to the diagnosis and management of sacral disorders.

"Alone, I wouldn't have known what to do": a qualitative study on social support during labor and delivery in Mexico

This article presents some of the most relevant qualitative results of a trial to evaluate the effects of the provision of psychosocial support to first-time mothers during labor, childbirth and in the immediate postpartum period in a social security hospital in Mexico City. The article focuses on the experiences of mothers who have received psychosocial support from a doula (the term doula is used to identify a woman who provides continuous support to a woman during labor. delivery and the immediate postpartum period) and compares them with the experiences of those women who gave birth following normal hospital routine. Sixteen in-depth interviews were held with women in the immediate post partum period (eight of whom had been accompanied by a doula and eight who had not) before they were discharged from hospital, and the results were analyzed using qualitative techniques. The interviews showed that the women accompanied by a doula had a more positive childbirth experience. The differences between both groups related to their perceptions of the childbirth experience; the treatment they received from hospital staff; the information they were given and how well they understood it; their perception of hospital routines; their feelings about cesarean sections and, spatial and temporal perceptions. The most important difference between the two groups was the way they expressed their feelings about their own labor, their sense of control and their self-perception.

Clinical and radiologic evaluation of optic pathway lesions

The clinical evaluation can often suggest the level of a visual pathway lesion; however, several different types of pathological processes, can produce the same visual field deficit. Imaging evaluation with CT and/or MRI can help to localize and characterize these diverse types of pathology. A radiological differential diagnosis can then be suggested which, in turn, facilitates patient management. In certain instances, the specific cause of a visual field defect can be identified with the radiological evaluation.

Magnetic resonance imaging of traumatic cervical nerve injuries

Posttraumatic cervical injuries represent a spectrum of injuries ranging from simple traction to frank nerve root avulsion with meningocele formation. The authors describe 3 patients with cervical nerve injuries, depicted by magnetic resonance imaging, highlighting unusual imaging manifestations.

Delayed deterioration after head trauma due to traumatic aneurysm

Closed head trauma is fairly common in our industrialized society. A small percentage of affected patients develop traumatic intracranial aneurysms, which rupture an average of three weeks following injury resulting in sudden neurological deterioration. The case of a patient with a traumatic aneurysm is presented. A high index of suspicion is necessary to diagnose these lesions, for which surgical treatment is recommended.

Massive osteolysis of the skull and upper cervical spine. Case report and review of the literature

Massive osteolysis is a type of idiopathic osteolysis in which there is spontaneous onset of bone resorption. Almost any bone in the body can be affected. The authors present the case of a 62-year-old man diagnosed with massive osteolysis of the occipital bone and the upper two cervical vertebrae. Despite extensive pneumocephalus, no neurological sign or spinal instability was evident. In this case 4000 cGy of radiation in 200-cGy fractions was administered to the diseased area while the patient was kept in a Miami-J collar. At the 2-year follow-up examination, arrest of the disease process and new bone formation was evident on radiographic studies.

Transient enlargement of an intracranial aneurysm during pregnancy: case report

BACKGROUND

The association of intracranial aneurysm and pregnancy is uncommon. Hemodynamic stress plays an important role in the growth of aneurysms.

METHODS

The authors report the case of an enlarging cavernous carotid aneurysm in a pregnant 15-year-old young woman.

RESULTS

The aneurysm was initially diagnosed prior to the patient's pregnancy by both cross-sectional imaging and cerebral angiography. Further imaging evaluation was required during pregnancy, which demonstrated significant enlargement of the aneurysm. Following delivery, the lesion decreased in size.

CONCLUSIONS

We review potential factors associated with pregnancy that may increase hemodynamic stress and influence aneurysm growth. Additionally, the management of pregnancy-related intracranial aneurysms is discussed.

Contemporary Management of Cerebrospinal Fluid Rhinorrhea

Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.

Contemporary management of cerebrospinal fluid rhinorrhea

Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.

Popliteal artery thrombosis in a patient with Cogan syndrome: treatment with thrombolysis and percutaneous transluminal angioplasty

A 31-year-old woman with Cogan syndrome (a rare form of systemic vasculitis) was evaluated for a cold, painful left foot with diminished pulses. Arteriography demonstrated thrombosis of the left popliteal artery with evidence of vasculitis. Thrombolytic therapy was begun with initial success but eventual rethrombosis. After reinitiating thrombolytic therapy combined with intraarterial vasodilator therapy, successful angioplasty was performed with sustained results at 6-month follow-up.

Carotid artery occlusion following a karate punch to the neck

A 43-year-old corrections officer developed right neck and posterior head pain following a karate punch to the right side of the neck during self-defense training. One week later, he developed an acute left hemiparesis. Magnetic resonance imaging demonstrated a right hemisphere cerebral infarction and absence of signal flow void in the right internal carotid artery. Carotid ultrasound demonstrated complete occlusion of the right internal carotid artery without evidence of atherosclerotic disease. Carotid occlusion with cerebrovascular infarction is a possible complication of martial arts training involving forceful blows to the neck.

Size of the corpus callosum in cerebral palsy

It has been suggested that the size of the corpus callosum may have diagnostic significance in cerebral palsy, although this relationship is incompletely defined. Ninety-one patients with cerebral palsy had been studied by magnetic resonance imaging in the 5-year period from 1990 to 1994. Fifty-seven of these 91 patients had a technically appropriate midsagittal magnetic resonance image for quantitative morphometric analysis. The ratio of the area of the corpus callosum to the area of the supratentorial brain was compared to published age- and gender-specific norms. Imaging findings were correlated with clinical history and cause of cerebral palsy. The corpus callosum was of normal size in 43 patients and more than 2 standard deviations below the mean in 14 patients. The causes for cerebral palsy included hypoxic ischemic encephalopathy (32), cerebral dysgenesis (8), and porencephalic strokes (6); the etiology could not be established in 11 patients. The size of the corpus callosum was highly correlated with the cause of cerebral palsy, such that all patients with cerebral dysgenesis had hypoplasia of the corpus callosum (one-sided z test, p < 0.0001). Conversely, the callosum was of normal size in 32 of 38 patients with hypoxic ischemic encephalopathy and porencephalic strokes. The presence of a hypoplastic corpus callosum is highly associated with cerebral dysgenesis as a cause for cerebral palsy.