BackgroundIdiopathic intracranial hypertension (IIH) is strongly associated with spontaneous skull-base cerebrospinal fluid (CSF) leaks. Venous sinus stenting (VSS) has proven effective for the treatment of IIH. Hence, its role in spontaneous skull-base CSF leaks is being explored actively.MethodsWe performed a systematic literature search across EMBASE, MEDLINE, Scopus, The Cochrane Library, and Google Scholar to identify studies reporting the use of VSS for spontaneous skull-base CSF leaks. Studies with pediatric patients, non-English articles, and nonspontaneous leaks were excluded. Failure of treatment (persistence / recurrence of CSF leak) was regarded as the primary outcome.ResultsEight studies with 62 patients undergoing VSS for spontaneous skull-base CSF leaks were included. Mean age of the patients was 51.9 years; 87.5% were females. Obesity was highly prevalent, with a mean body mass index of 33.9 kg/m2 (4 studies). IIH was noted in 74.6% patients (7 studies). Twenty-six patients (41.9%) underwent VSS alone whereas 36 patients (58.1%) underwent surgical repair + VSS. Seven patients (11.3%) had a failure of treatment. Three failures from one study could not be definitively ascribed to either of the groups. Hence, the estimated failure rate for VSS alone ranged from 18.6% (95% CI [0.02 - 0.46]) to 26.4% (95% CI [0.11 - 0.46]), whereas that for surgical repair + VSS ranged from 5.5% (95% CI [0.00 - 0.16]) to 12.2% (95% CI [0.01 - 0.32]). Furthermore, the estimated rate for resolution of concomitant IIH-related symptoms was 88.7% (95% CI [0.75 - 0.98%]). Majority of the studies did not report any serious complications or mortality related to VSS.ConclusionVSS has a potential role in the management of spontaneous skull-base CSF leaks. Its exact indications as a standalone treatment versus as an adjuvant to surgical repair, and the predictors for successful treatment remain to be defined.

BACKGROUND Pedicle screw impingement on vessel walls has the potential for complications due to pulsatile effects and wall erosion. Artifacts from spinal instrumentation create difficulty in accurately evaluating this interface. The authors present the first case of intravascular ultrasound (IVUS) used to characterize a pedicle screw breach into the aortic lumen. OBSERVATIONS A 21-year-old female with surgically corrected scoliosis underwent computed tomography angiography (CTA) 3 years postoperatively, which revealed a pedicle screw within the thoracic aorta lumen. Metal artifact distorted the CTA images, which prompted the decision to use intraoperative IVUS. The IVUS confirmed the noninvasive imaging findings and guided final decisions regarding aortic endograft size and location during spine hardware revision. LESSONS For asymptomatic patients presenting with pedicle screws malpositioned in or near the aorta, treatment decisions revolve around the extent of vessel wall penetration. Intraluminal depth can be obscured by artifact on computed tomography or magnetic resonance imaging or inadequately evaluated by a transesophageal echocardiogram. In our intraoperative experience, IVUS confirmed the depth of vessel lumen violation by a single pedicle screw and no wall penetration by two additional screws of concern. This was useful in deciding on thoracic endovascular aortic repair graft size and landing zone and facilitated safe spinal instrumentation removal and revision.

BACKGROUND:Currarino syndrome is a rare disorder that classically presents with the triad of presacral mass, anorectal malformation, and spinal dysraphism. The presacral mass is typically benign, although malignant transformation is possible. Surgical treatment of the mass and exploration and repair of associated dysraphism are indicated for diagnosis and symptom relief. There are no previous reports of Currarino syndrome in an androgen-insensitive patient.OBSERVATIONS:A 17-year-old female patient presented with lack of menarche. Physical examination and laboratory investigation identified complete androgen insensitivity. Imaging analysis revealed a presacral mass lesion, and the patient was taken to surgery for resection of the mass and spinal cord untethering. Intraoperative ultrasound revealed a fibrous stalk connecting the thecal sac to the presacral mass, which was disconnected without the need for intrathecal exploration. The presacral mass was then resected, and pathological analysis revealed a mature cystic teratoma. Postoperatively, the patient recovered without neurological or gastrointestinal sequelae.LESSONS:Diagnosis of incomplete Currarino syndrome may be difficult but can be identified via work-up of other disorders, such as androgen insensitivity. Intraoperative ultrasound is useful for surgical decision making and may obviate the need for intrathecal exploration during repair of dysraphism in the setting of Currarino syndrome.

Abstract Purpose: There is a recent trend towards rapid discharge after endoscopic endonasal transsphenoidal surgery (EETS). We aimed to identify factors related to in-hospital complications and 30-day readmissions to help inform postoperative care practices. Methods: This is a retrospective analysis of patients that underwent EETS for resection of a tumor. Primary outcomes included complications and 30-day readmission. Results: Transient diabetes insipidus occurred in 37% of patients with a complication. Complication was associated with bedrest, occurring in 15.4% of patients without no bedrest, in 24.5% of patients with bedrest of 2-3 days, and in 54.6% of patients with >3 days of bedrest (p=0.02). The median length of stay was 6 days and 4 days in patients with and without a complication, respectively (p<0.0001). Readmission within 30 days occurred in 9.5% of cases, most commonly due to hyponatremia. 30-day readmission was associated with American Society of Anesthesiologists (ASA) class, where 12.5%, 5.9%, and 37.5% patients with ASA class 2, 3, and 4 were readmitted in 30 days, respectively (p=0.02). A maximum tumor diameter (TDmax) of 20-29 mm was associated with readmission, occurring in 20.9% of those patients (p=0.01). EOR was not associated with postoperative complication or with 30-day readmission. Conclusion: In-hospital complication was associated with increased duration of postoperative bedrest, although no causative relationship can be established based on this data. Preoperative anticoagulation usage, increasing ASA class, and TDmax 20-29 mm may help predict 30-day readmission after EETS. EOR was not associated with complications or 30-day readmission.

Background: The placement of the distal catheter of a ventriculoperitoneal shunt (VPS) can be challenging in patients with a large body habitus. Given the complications associated with ventriculoperitoneal shunts and known infection risk of obese patients, new techniques for VPS placement that bypass the abdominal fat must be sought. By avoiding the abdominal fat, decreased complications and infection risk may be possible. The objective of this technical document is to describe a laparoscopic approach to the abdominal cavity during ventriculoperitoneal shunt surgery that makes use of a direct tunneling technique into the peritoneal space. Methods: We performed a ventriculoperitoneal shunt placement with distal catheter implantation under laparoscopic guidance. Tunneling of the distal abdominal catheter was done through the abdominal fascia directly, without creation of a stab incision for the insertion site. Intraoperative video recording was obtained using video footage from OPTIVIEW camera. Results: We have found this technique to be feasible and useful for patients with large body habitus. By eliminating the incision overlying the catheter there is decreased risk for infection by skin flora and overall decreased risk of complications. Conclusion: Our technique of tunneling directly into the abdominal cavity is both novel and feasible. To our knowledge this is the first time this technique has been described. We believe that further study of this technique in a case series may highlight its advantages in a certain subpopulation of patients requiring VPS.

The coexistence of separate and distinct primary intracranial tumors is rare. Specifically, there are no previous reports of a colloid cyst coexisting with a pituitary macroadenoma. We present the case of a 40-year-old male with a colloid cyst associated with mild enlargement of the right lateral ventricle and a coexistent pituitary macroadenoma with compression of the optic apparatus. An endoscopic endonasal transsphenoidal surgery (EETS) for resection of the pituitary mass was performed first due to the patient's complaints of acute visual changes. He then underwent a right frontal craniotomy for resection of the colloid cyst one month later. The patient recovered without residual deficits in vision, and he did not require ventricular shunting after removal of the colloid cyst. We aimed to discuss our decision-making process and the management of these coexistent lesions.

Central venous catheters are a common practice in critical care medicine. These lines are of particular importance when a patient needs large volume resuscitation or medications that cannot be infused through a peripheral line. Even though central venous catheters are frequently utilized, they are associated with potentially significant risks that one must be aware of when attempting placement. The anatomy and pertinent complications are key for any healthcare professional to be aware of during this procedure. As such, vascular injury has been described in the literature, but vertebral artery injury and common repair techniques are less common. Primary repair of the second vertebral artery segment is infrequently detailed in the literature and this report describes pertinent case details and plan of action for identification and repair of iatrogenic vertebral artery injury following catheter placement.

Uterine leiomyomas are rare in the adolescent population with only 19 reported cases in the literature. Interestingly, these masses represent a common presentation of gynecologic tumors with increasing age. We report a case of a 15-year-old female who presented with six months of abdominal pain and loose stools. Menstruation began at 11 years of age and she had no gravida history. Workup with ultrasound demonstrated a large pelvic mass presumed to be of ovarian origin. Diagnostic laparoscopy was performed identifying a large uterine mass. An open Pfannenstiel incision was made for complete resection. The mass weighed 526 g and was 11 × 9 × 9cm.The patient remains asymptomatic at 6 month follow up.

Chronic inflammation plays a critical role in the pathogenesis of atherosclerosis. Currently, the mechanism(s) by which inflammation contributes to this disease are not entirely understood. Inflammation is known to induce oxidative stress, which can lead to lipid peroxidation. Lipid peroxidation can result in the production of reactive by-products that can oxidatively modify macromolecules including DNA, proteins, and lipoproteins. A major reactive by-product of lipid peroxidation is malondialdehyde (MDA). MDA can subsequently break down to form acetaldehyde (AA). These two aldehydes can covalently interact with the epsilon (ε)-amino group of lysines within proteins and lipoproteins leading to the formation of extremely stable, highly immunogenic malondialdehyde/acetaldehyde adducts (MAA-adducts). The aim of this study was to investigate the inflammatory response to MAA-modified human serum albumin (HSA-MAA) and low-density lipoprotein (LDL-MAA). We found that animals injected with LDL-MAA generate antibodies specific to MAA-adducts. The level of anti-MAA antibodies were further increased in an animal model of atherosclerosis fed a Western diet. An animal model that combined both high fat diet and immunization of MAA-modified protein resulted in a dramatic increase in antibodies to MAA-adducts and vascular fat accumulation compared with controls. In vitro exposure of endothelial cells and macrophages to MAA-modified proteins resulted in increased fat accumulation as well as increased expression of adhesion molecules and pro-inflammatory cytokines. The expression of cytokines varied between the different cell lines and was unique to the individual modified proteins. The results of these studies demonstrate that different MAA-modified proteins elicit unique responses in different cell types. Additionally, the presence of MAA-modified proteins appears to modulate cellular metabolism leading to increased accumulation of triglycerides and further progression of the inflammatory response.

Purpose: Cerebral cavernous malformations are common central nervous system vascular malformations. They are typically a discrete, well-circumscribed cluster of thin-walled vascular sinusoids with a characteristic “mulberry” or “popcorn” appearance on magnetic resonance imaging and are often surrounded by hemosiderin deposits and gliosis. These malformations can present in a variety of ways. The purpose of this paper is to demonstrate presentations of cavernous malformations through cases with associated imaging. Materials/Methods: 14 cases of cerebral cavernous malformations were retrospectively selected from a single institution from 2009 to 2019. The cases include classically appearing lesions as well as association with developmental venous anomaly and capillary telangiectasia. Results: Variations included are large partially calcified lesions, hemorrhagic lesions, atypically shaped lesions, and lesions lacking the “popcorn” appearance or hemosiderin rim. Also presented is a case with multiple lesions and cases displaying the widespread locations of lesions. Locations include the cerebrum, cerebellar vermis, medulla, periaqueductal midbrain, spinal cord, and extradural intracranial cavernous sinus. Conclusion: These cases and literature review illustrate how cerebral cavernous malformations can present. While often asymptomatic, the lesions can cause hemorrhage, seizures, and neurological deficits. They can present in atypical ways or masquerade as non-vascular lesions making diagnosis a difficult task.

Introduction: Chronic inflammation plays a critical role in the pathogenesis of atherosclerosis by inducing oxidative stress and the production of the highly immunogenic malondialdehyde-acetaldehyd...

Objective-Abdominal aortic aneurysms are inflammatory in nature and are associated with some risk factors that also lead to atherosclerotic occlusive disease, most notably smoking. The purpose of our study was to identify differential cytokine expression in patients with abdominal aortic aneurysm and those with atherosclerotic occlusive disease. Based on this analysis, we further explored and compared the mechanism of action of IL (interleukin)-1 beta versus TNF-alpha (tumor necrosis factor-alpha) in abdominal aortic aneurysm formation. Approach and Results-IL-1 beta was differentially expressed in human plasma with lower levels detected in patients with abdominal aortic aneurysm compared with matched atherosclerotic controls. We further explored its mechanism of action using a murine model and cell culture. Genetic deletion of IL-1 beta and IL-1R did not inhibit aneurysm formation or decrease MMP (matrix metalloproteinase) expression. The effects of IL-1 beta deletion on M1 macrophage polarization were compared with another proinflammatory cytokine, TNF-alpha. Bone marrow-derived macrophages from IL-1 beta(-/-) and TNF-alpha(-/-) mice were polarized to an M1 phenotype. TNF-alpha deletion, but not IL-1 beta deletion, inhibited M1 macrophage polarization. Infusion of M1 polarized TNF-alpha(-/-) macrophages inhibited aortic diameter growth; no inhibitory effect was seen in mice infused with M1 polarized IL-1 beta(-/-) macrophages. Conclusions-Although IL-1 beta is a proinflammatory cytokine, its effects on aneurysm formation and macrophage polarization differ from TNF-alpha. The differential effects of IL-1 beta and TNF-alpha inhibition are related to M1/M2 macrophage polarization and this may account for the differences in clinical efficacy of IL-1 beta and TNF-alpha antibody therapies in management of inflammatory diseases.