The synthetic molecule stauprimide impairs cell growth and migration in triple-negative breast cancer.

Stauprimide, a semi-synthetic derivative of staurosporine, is known mainly for its potent differentiation-enhancing properties in embryonic stem cells. Here, we studied the effects of stauprimide in cell growth and migration of triple-negative breast cancer cells in vitro, evaluating its potential antitumoral activity in an orthotopic mouse model of breast cancer in vivo. Our results from survival curves, EdU incorporation, cell cycle analysis and annexin-V detection in MDA-MB-231 cells indicated that stauprimide inhibited cell proliferation, arresting cell cycle in G2/M without induction of apoptosis. A decrease in the migratory capability of MDA-MB-231 was also assessed in response to stauprimide. In this work we pointed to a mechanism of action of stauprimide involving the modulation of ERK1/2, Akt and p38 MAPK signalling pathways, and the downregulation of MYC in MDA-MB-231 cells. In addition, orthotopic MDA-MB-231 xenograft and 4T1 syngeneic models suggested an effect of stauprimide in vivo, increasing the necrotic core of tumors and reducing metastasis in lung and liver of mice. Together, our results point to the promising role of stauprimide as a putative therapeutic agent in triple-negative breast cancer.

Low-dose radiotherapy to the lungs using an interventional radiology C-arm fluoroscope: Monte Carlo treatment planning and dose measurements in a postmortem subject.

Objective.The goal of this study was to use Monte Carlo (MC) simulations and measurements to investigate the dosimetric suitability of an interventional radiology (IR) c-arm fluoroscope to deliver low-dose radiotherapy to the lungs.Approach.A previously-validated MC model of an IR fluoroscope was used to calculate the dose distributions in a COVID-19-infected patient, 20 non-infected patients of varying sizes, and a postmortem subject. Dose distributions for PA, AP/PA, 3-field and 4-field treatments irradiating 95% of the lungs to a 0.5 Gy dose were calculated. An algorithm was created to calculate skin entrance dose as a function of patient thickness for treatment planning purposes. Treatments were experimentally validated in a postmortem subject by using implanted dosimeters to capture organ doses.Main results.Mean doses to the left/right lungs for the COVID-19 CT data were 1.2/1.3 Gy, 0.8/0.9 Gy, 0.8/0.8 Gy and 0.6/0.6 Gy for the PA, AP/PA, 3-field, and 4-field configurations, respectively. Skin dose toxicity was the highest probability for the PA and lowest for the 4-field configuration. Dose to the heart slightly exceeded the ICRP tolerance; all other organ doses were below published tolerances. The AP/PA configuration provided the best fit for entrance skin dose as a function of patient thickness (R2 = 0.8). The average dose difference between simulation and measurement in the postmortem subject was 5%.Significance.An IR fluoroscope should be capable of delivering low-dose radiotherapy to the lungs with tolerable collateral dose to nearby organs.

[Effectiveness of peri-articular infiltration with local anesthetic and adjuvants for post-surgical pain control in total knee replacement]. / Eficacia de la infiltración periarticular con anestésico local y adyuvantes para control del dolor postquirúrgico en la artroplastía total de rodilla.

INTRODUCTION: Total knee arthroplasty (TKA) is one of the most successful orthopedic treatments, however, it has been associated with severe postsurgical pain in 30-60% of patients. We propose that infiltration of the articular capsule of the knee during surgery will decrease postsurgical pain. MATERIAL AND METHODS: Experimental, randomized, double-blind study in patients undergoing unilateral TKA between April 2018 and January 2019. Patients were divided into two groups, the first infiltration with placebo and the second with anesthetic solution and adjuvants (fentanyl, epinephrine and ketorolac). Pain was measured with the visual analog scale (VAS) at 4, 6, 8, 12, 18, 24, 36 and 48 hours postsurgical, as well as the consumption of opioid analgesics and antiemetics. RESULTS: 20 patients in each group, with a follow-up of 4 weeks. There were no significant differences in demographic characteristics between the two groups. Better control of postsurgical pain was observed in the group that received infiltration with anesthetic and adjuvant, as well as a decrease in the consumption of opioid analgesics and antiemetics. There was no difference in bleeding or in the incidence of infections between the two groups. CONCLUSION: Peri-capsular infiltration is a safe and effective method, as part of multimodal analgesia in total knee arthroplasty, as it decreases postsurgical pain, opioid and antiemetic use and does not increase postsurgical bleeding.

INTRODUCCIÓN: La artroplastía total de rodilla (ATR) es uno de los tratamientos ortopédicos más exitosos; sin embargo, se ha asociado a dolor postquirúrgico intenso en 30-60% de los pacientes. Nosotros planteamos que la infiltración de la cápsula articular de la rodilla durante la cirugía disminuirá el dolor postquirúrgico. MATERIAL Y MÉTODOS: Estudio experimental, aleatorio, doble ciego, en pacientes sometidos a ATR unilateral entre Abril de 2018 a Enero de 2019. Los pacientes fueron divididos en dos grupos, el primero infiltración con placebo y el segundo con solución anestésica y adyuvantes (fentanilo, epinefrina y ketorolaco). Se cuantificó mediante escala visual análoga (EVA) del dolor a las cuatro, seis, ocho, 12, 18, 24, 36 y 48 horas postquirúrgicas, así como del consumo de analgésicos opioides y antieméticos. RESULTADOS: Veinte pacientes en cada grupo, con un seguimiento de cuatro semanas. No hubo diferencias significativas en las características demográficas entre ambos grupos. Se observó un mejor control del dolor postquirúrgico en el grupo que recibió infiltración con anestésico y adyuvante, además de una disminución en el consumo de analgésicos opioides y antieméticos. No hubo diferencia en sangrado ni en la incidencia de infecciones entre ambos grupos. CONCLUSIÓN: La infiltración pericapsular es un método seguro y eficaz, como parte de la analgesia multimodal en la artroplastía total de rodilla, ya que disminuye el dolor postquirúrgico, el consumo de opioides y antieméticos y no incrementa el sangrado postquirúrgico.

Core-binding factor leukemia hijacks the T-cell-prone PU.1 antisense promoter.

The blood system serves as a key model for cell differentiation and cancer. It is orchestrated by precise spatiotemporal expression of crucial transcription factors. One of the key master regulators in the hematopoietic systems is PU.1. Reduced levels of PU.1 are characteristic for human acute myeloid leukemia (AML) and are known to induce AML in mouse models. Here, we show that transcriptional downregulation of PU.1 is an active process involving an alternative promoter in intron 3 that is induced by RUNX transcription factors driving noncoding antisense transcription. Core-binding factor (CBF) fusions RUNX1-ETO and CBFß-MYH11 in t(8;21) and inv(16) AML, respectively, activate the PU.1 antisense promoter that results in a shift from sense toward antisense transcription and myeloid differentiation blockade. In patients with CBF-AML, we found that an elevated antisense/sense transcript and promoter accessibility ratio represents a hallmark compared with normal karyotype AML or healthy CD34+ cells. Competitive interaction of an enhancer with the proximal or the antisense promoter forms a binary on/off switch for either myeloid or T-cell development. Leukemic CBF fusions thus use a physiological mechanism used by T cells to decrease sense transcription. Our study is the first example of a sense/antisense promoter competition as a crucial functional switch for gene expression perturbation by oncogenes. Hence, this disease mechanism reveals a previously unknown Achilles heel for future precise therapeutic targeting of oncogene-induced chromatin remodeling.

Implementación y evaluación de un protocolo de analgesia multimodal en el reemplazo total primario de rodilla que incluye bloqueo de canal de aductores guiado por ultrasonografía más infiltración de anestésico local periarticular / Implementation and evaluation of a multimodal analgesia protocol for total knee arthroplasty including ultrasound-guided adductor canal block and periarticular local anesthetic infiltration

Introducción: La anestesia regional guiada por ultrasonografía es una técnica segura y efectiva para el manejo del dolor postoperatorio. Este estudio evalúa la implementación de un protocolo analgésico para el reemplazo total primario de rodilla (RTPR). Métodos: Estudio observacional ambispectivo de cohortes no aleatorizado, realizado en un grupo de pacientes llevados a RTPR que recibieron infiltración de anestésico local periarticular más bloqueo del canal de aductores (IAL+BCA) como parte de un nuevo protocolo analgésico, frente a un grupo previo que recibió catéter perineural femoral más bloqueo del nervio ciático (CPF+BNC). La valoración de la intensidad del dolor se realizó utilizando la escala verbal numérica (EVN). El desenlace principal fue el dolor postoperatorio inmediato a las 24 y 48 horas. Se evaluó el cumplimiento de metas de rehabilitación física a las 48 horas como desenlace secundario. Resultados: Se analizaron 112 pacientes (67 en IAL + BCA y 45 en CPF + BNC). Ambas poblaciones fueron comparables en variables demográficas. La mediana del dolor en reposo en el primer y segundo día postoperatorios fue EVN 2/10 para ambos grupos. El promedio del dolor en movimiento en el segundo día postoperatorio fue EVN 5/10 para los pacientes con IAL + BCA y 4/10 para los pacientes con CPF + BNC, p = 0,073. El porcentaje de pacientes que cumplieron el 80 % o más de las metas de rehabilitación fue similar en ambos grupos (p = 0,201). Conclusiones: Ambas técnicas son equivalentes en el manejo analgésico postoperatorio del RTPR durante las primeras 48 horas. A pesar de que es conocido que la técnica de IAL + BCA genera menos compromiso motor del cuádriceps, esto no se reflejó en un mejor desempeño durante la rehabilitación física, posiblemente por un insuficiente control analgésico a las 48 horas.(AU)

Background: Ultrasound-guided regional anesthesia is a safe and effective technique in postoperative pain management. This study evaluates the implementation an analgesic protocol for total knee arthroplasty (TKA) including different nerve blocks. Methods: An observational ambispective non randomized cohort study was performed between a group of patients undergoing TKA who received local infiltration analgesia plus adductor canal block (LIA+ACB) as part of a new analgesic protocol against a previous group who received perineural femoral catheter plus sciatic nerve block (PFC+SNB). The measurement of pain intensity was made using the numerical rating scale (NRS). The main outcome was the immediate postoperative pain, at 24 and 48 hours. The fulfillment of physical rehabilitation goals was evaluated as a secondary outcome. Results: 112 patients were analyzed (67 in LIA+ACB and 45 in PFC+SNB). Both groups were comparable in demographic characteristics. The median pain at rest on the first and second postoperative days was NRS 2/10 for both groups. The average pain on movement on the second postoperative day was NRS 5/10 for patients with LIA+ACB and 4/10 for patients with PFC+SNB, p=0,073. The percentage of patients who fulfilled ≥80% of the rehabilitation goals was similar in both groups (p=0,201). Conclusions: In the TKA postoperative analgesic management, both techniques are equivalent during the first 48 hours. Although it is known that the LIA+ACB technique generates less motor impairment of the quadriceps muscle, this was not reflected on better performance during physical rehabilitation, possibly due to insufficient analgesic control at 48 hours.(AU)

A Multicenter Pilot Study on the Clinical Utility of Computational Modeling for Flow-Diverter Treatment Planning.

BACKGROUND AND PURPOSE: Selection of the correct flow-diverter size is critical for cerebral aneurysm treatment success, but it remains challenging due to the interplay of device size, anatomy, and deployment. Current convention does not address these challenges well. The goals of this pilot study were to determine whether computational modeling improves flow-diverter sizing over current convention and to validate simulated deployments. MATERIALS AND METHODS: Seven experienced neurosurgeons and interventional neuroradiologists used computational modeling to prospectively plan 19 clinical interventions. In each patient case, physicians simulated 2-4 flow-diverter sizes that were under consideration based on preprocedural imaging. In addition, physicians identified a preferred device size using the current convention. A questionnaire on the impact of computational modeling on the procedure was completed immediately after treatment. Rotational angiography image data were acquired after treatment and compared with flow-diverter simulations to validate the output of the software platform. RESULTS: According to questionnaire responses, physicians found the simulations useful for treatment planning, and they increased their confidence in device selection in 94.7% of cases. After viewing the simulations results, physicians selected a device size that was different from the original conventionally planned device size in 63.2% of cases. The average absolute difference between clinical and simulated flow-diverter lengths was 2.1 mm. In 57% of cases, average simulated flow-diverter diameters were within the measurement uncertainty of clinical flow-diverter diameters. CONCLUSIONS: Physicians found computational modeling to be an impactful and useful tool for flow-diverter treatment planning. Validation results showed good agreement between simulated and clinical flow-diverter diameters and lengths.

A Patient Dose-Reduction Technique for Neuroendovascular Image-Guided Interventions: Image-Quality Comparison Study.

BACKGROUND AND PURPOSE: The ROI-dose-reduced intervention technique represents an extension of ROI fluoroscopy combining x-ray entrance skin dose reduction with spatially different recursive temporal filtering to reduce excessive image noise in the dose-reduced periphery in real-time. The aim of our study was to compare the image quality of simulated neurointerventions with regular and reduced radiation doses using a standard flat panel detector system. MATERIALS AND METHODS: Ten 3D-printed intracranial aneurysm models were generated on the basis of a single patient vasculature derived from intracranial DSA and CTA. The incident dose to each model was reduced using a 0.7-mm-thick copper attenuator with a circular ROI hole (10-mm diameter) in the middle mounted inside the Infinix C-arm. Each model was treated twice with a primary coiling intervention using ROI-dose-reduced intervention and regular-dose intervention protocols. Eighty images acquired at various intervention stages were shown twice to 2 neurointerventionalists who independently scored imaging qualities (visibility of aneurysm-parent vessel morphology, associated vessels, and/or devices used). Dose-reduction measurements were performed using an ionization chamber. RESULTS: A total integral dose reduction of 62% per frame was achieved. The mean scores for regular-dose intervention and ROI dose-reduced intervention images did not differ significantly, suggesting similar image quality. Overall intrarater agreement for all scored criteria was substantial (Kendall τ = 0.62887; P < .001). Overall interrater agreement for all criteria was fair (κ = 0.2816; 95% CI, 0.2060-0.3571). CONCLUSIONS: Substantial dose reduction (62%) with a live peripheral image was achieved without compromising feature visibility during neuroendovascular interventions.

Vaginal-cuff control and toxicity results of a daily HDR brachytherapy schedule in endometrial cancer patients

PURPOSE: To analyze the vaginal-cuff local control (VCC) and toxicity in postoperative endometrial carcinoma patients (EC) underwent high-dose-rate brachytherapy (HDR-BT) administered daily. Materials and methods: 154 consecutive patients received postoperative HDR-BT for EC from January 2007 to September 2011. FIGO-staging I-IIIC2 patients were divided into two groups according to risk classification: Group 1 (94/154) included high-risk or advanced disease patients and Group 2 (60/154) included intermediate-risk EC patients. Group 1 underwent external beam irradiation (EBI) plus HDR-BT (2 fractions of 5 Gy) and Group 2 underwent HDR-BT alone (4 fractions of 5 Gy). Toxicity evaluation was done with RTOG scores for bladder and rectum, and the objective criteria of LENT-SOMA for vagina. Results: With a median follow-up of 46.7 months (36.6-61 months) only two patients developed vaginal-cuff recurrence in Group 1 (2.1 %) and none in group 2 (0 %). Early toxicity in Group 1 appeared 5.3 % in rectum, 7.5 % in bladder (G1-G2) and 2.1 % in vagina (G1); late toxicity was present in 7.3 % in rectum (all G1-G2 but 1 G3) and in 27.7 % in vagina (all G1-G2 but one G4). In Group 2, 6.7 % developed acute G1-G2 bladder and 6.6 % acute vaginal (G1-G2) toxicity. No late rectal or bladder toxicity was observed; 21.7 % of G1-G2 presented late problems in vagina. Conclusions: The present HDR-BT schedule of 2 fractions of 5 Gy after EBI and 4 fractions of 5 Gy administered daily showed excellent results in terms of VCC and toxicity

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Vaginal-cuff control and toxicity results of a daily HDR brachytherapy schedule in endometrial cancer patients.

PURPOSE: To analyze the vaginal-cuff local control (VCC) and toxicity in postoperative endometrial carcinoma patients (EC) underwent high-dose-rate brachytherapy (HDR-BT) administered daily. MATERIALS AND METHODS: 154 consecutive patients received postoperative HDR-BT for EC from January 2007 to September 2011. FIGO-staging I-IIIC2 patients were divided into two groups according to risk classification: Group 1 (94/154) included high-risk or advanced disease patients and Group 2 (60/154) included intermediate-risk EC patients. Group 1 underwent external beam irradiation (EBI) plus HDR-BT (2 fractions of 5 Gy) and Group 2 underwent HDR-BT alone (4 fractions of 5 Gy). Toxicity evaluation was done with RTOG scores for bladder and rectum, and the objective criteria of LENT-SOMA for vagina. RESULTS: With a median follow-up of 46.7 months (36.6-61 months) only two patients developed vaginal-cuff recurrence in Group 1 (2.1 %) and none in group 2 (0 %). Early toxicity in Group 1 appeared 5.3 % in rectum, 7.5 % in bladder (G1-G2) and 2.1 % in vagina (G1); late toxicity was present in 7.3 % in rectum (all G1-G2 but 1 G3) and in 27.7 % in vagina (all G1-G2 but one G4). In Group 2, 6.7 % developed acute G1-G2 bladder and 6.6 % acute vaginal (G1-G2) toxicity. No late rectal or bladder toxicity was observed; 21.7 % of G1-G2 presented late problems in vagina. CONCLUSIONS: The present HDR-BT schedule of 2 fractions of 5 Gy after EBI and 4 fractions of 5 Gy administered daily showed excellent results in terms of VCC and toxicity.

Endovascular intracranial treatment of acute ischemic strokes.

Acute ischemic stroke (AIS) is the leading cause of long-term disability and the second cause of death worldwide. Intravenous (IV) tissue plasminogen activator (tPA) remains the only FDA-approved treatment for AIS. The use of IV tPA in AIS related to large-vessel occlusion (LVO) has shown low recanalization rates and poor clinical outcomes. Over the last decade, endovascular treatment has demonstrated safety and effectiveness in the management of LVO-associated AIS due to the evolution of endovascular techniques and technologies, beginning with intraarterial thrombolysis, aspiration, self- expanding intracranial stents, and now retrievable stents. With the recent publication of the results of 5 randomized controlled studies, mechanical thrombectomy in combination with IV tPA demonstrated significant radiographic and clinical benefit over traditional strategies with IV tPA alone. In light of these results, endovascular therapy has been placed at the forefront of stroke treatment, redefining the standard of care. This review presents the evolution of endovascular treatment of AIS resulting from LVO; provides an analysis of the initial and latest RCTs; and discusses the association between endovascular mechanical thrombectomy and clinical outcomes, functional outcomes, and rates of revascularization, intracranial hemorrhage, morbidity, and mortality. Finally, shortcomings of the recent technological advances, such as clot fragmentation, and potential solutions to overcome these drawbacks are presented.

The transcription factor PlagL2 activates Mpl transcription and signaling in hematopoietic progenitor and leukemia cells.

Cytokine signaling pathways are frequent targets of oncogenic mutations in acute myeloid leukemia (AML), promoting proliferation and survival. We have previously shown that the transcription factor PLAGL2 promotes proliferation and cooperates with the leukemia fusion protein Cbfß-SMMHC in AML development. Here, we show that PLAGL2 upregulates expression of the thrombopoietin receptor Mpl, using two consensus sites in its proximal promoter. We also show that Mpl overexpression efficiently cooperates with Cbfß-SMMHC in development of leukemia in mice. Finally, we demonstrate that PlagL2-expressing leukemic cells show hyper-activation of Jak2 and downstream STAT5, Akt and Erk1/2 pathways in response to Thpo ligand. These results show that PlagL2 expression activates expression of Mpl in hematopoietic progenitors, and that upregulation of wild-type Mpl provides an oncogenic signal in cooperation with CBFß-SMMHC in mice.

Bilateral paramedian thalamic and mesencephalic infarcts after basilar tip aneurysm coiling: role of the artery of Percheron.

Aneurysm embolization using Guglielmi detachable coils (GDC) is gaining acceptance as a viable alternative for surgery in the treatment of aneurysms. Recent reports describe a significant rate of thromboembolic complications. Thalamic and midbrain blood supply can arise from complex anatomical variations. The rare variation: "artery of Percheron", is a solitary arterial trunk arising from one of the proximal segments of a posterior cerebral artery and supplies the paramedian thalami and rostral midbrain bilaterally. We describe a patient that underwent elective endovascular treatment for a basilar tip aneurysm using GDC and stents in each PCA; 12 hours later patient was comatose and not following commands. Sequential magnetic resonance imaging (MRI) of brain showed bilateral paramedian thalamic and mesencephalic infarcts presumably secondary to artery of Percheron occlusion. Thromboembolic event related to the use of the GDC embolization and stents is a rare clinical sequelae, but catastrophic. The use of antiplatelets agents should be reinforced in the scenario. When bilateral medial thalamic and midbrain infarcts are found, occlusion of the artery of Percheron should be considered. Angiography may not b helpful and lack of visualization of the artery does not exclude its presence. In this case the MRI findings confirmed the presence of the infarction based on the anatomical distribution.

Bilateral paramedian thalamic and mesencephalic infarcts after basilar tipaneurysm coiling: role of the artery of Percheron

Aneurysm embolization using Guglielmi detachable coils (GDC) is gaining acceptance as a viable alternative for surgery in the treatment of aneurysms. Recentreports describe a significant rate of thromboembolic complications. Thalamic and midbrain blood supplycan arise from complex anatomical variations. The rarevariation: "artery of Percheron", is a solitary arterialtrunk arising from one of the proximal segments of aposterior cerebral artery and supplies the paramedianthalami and rostral midbrain bilaterally. We describe apatient that underwent elective endovascular treatment for a basilar tip aneurysm using GDC and stents ineach PCA; 12 hours later patient was comatose and notfollowing commands. Sequential magnetic resonance imaging (MRI) of brain showed bilateral paramedian thalamic and mesencephalic infarcts presumably secondaryto artery of Percheron occlusion. Thromboembolic event related to the use of the GDC embolization and stents is a rare clinical sequelae, but catastrophic. Theuse of antiplatelets agents should be reinforced in the scenario. When bilateral medial thalamic and midbraininfarcts are found, occlusion of the artery of Percheron should be considered. Angiography may not b help fuland lack of visualization of the artery does not excludeits presence. In this case the MRI findings confirmedthe presence of the infarction based on the anatomical distribution (AU)

La técnica endovascular para el manejo de aneurismas está ganando auge como una alternativa a la cirugía abierta. Sin embargo, se han descrito diferentes complicaciones tromboembólicas relacionadas con esta modalidad. El flujo sanguíneo al tálamo y almesencéfalo puede surgir de variaciones anatómicas complejas. La variación infrecuente: "arteria de Percheron", es una rama arterial solitaria que se originadel segmento proximal de una de la arterias cerebralesposteriores.Presentamos un paciente que tuvo un procedimiento endovascular electivo para el tratamiento de un aneurisma de la punta de la arteria basilar; 12 horas después del procedimiento, el paciente estaba clínicamente encoma profundo. La resonancia magnética (RM) cerebral mostró infartos talámicos paramediales bilaterales y mesencefálicos, compatible con la oclusión de la arteriade Percheron.Los eventos tromboembólicos relacionados con eluso de embolización con coil y stents es una rara pero catastrófica secuela. El uso de agentes antiplaquetarios se debe de recomendar en este tipo de situaciones. Cuando existen infartos talámicos paramediales bilaterales y mesencefálicos, la oclusión de la arteria de Percheron sedebe de tener en mente. La angiografía puede no ser demucha utilidad y la falta de visualización de la arteria no excluye su presencia. En este caso los hallazgos en la RM cerebral confirman la presencia de un infarto basado en la distribución anatómica de la arteria de Percheron (AU)

Hemorrhagic stroke with intraventricular extension in the setting of acute posterior reversible encephalopathy syndrome (PRES): case report.

We report the case of an eighteen year-old pregnant female with preeclampsia and florid signs and symptoms of posterior reversible encephalopathy syndrome (PRES) in whom intracerebral hemorrhage was evidenced following delivery. Management included blood pressure control, external ventricular drainage and lumboperitoneal shunt. To our knowledge this is the first report of intracranial hemorrhage occurring concurrently with peripartum acute PRES. This case was successfully treated with good outcome upon conclusion of management, thus making awareness of this potentially fatal complication and its suggested management for successful outcome necessary for neurosurgeons, neurologists and intensivists alike.

Endoscopic management of brainstem injury due to ventriculoperitoneal shunt placement.

INTRODUCTION: We report a patient who suffered from brainstem injury following ventriculoperitoneal (VP) shunt placement in the fourth ventricle. DISCUSSION: A 20-year-old man with complex hydrocephalus and trapped fourth ventricle underwent a suboccipital placement of a VP shunt. Postprocedure patient developed double vision. Magnetic resonance imaging showed that the catheter was penetrating the dorsal brainstem at the level of the pontomedullary junction. Patient was referred to our Neuroendoscopic Clinic. Physical exam demonstrated pure right VI cranial nerve palsy. Patient underwent flexible endoscopic exploration of the ventricular system. Some of the endoscopic findings were severe aqueductal stenosis and brainstem injury from the catheter. Aqueductoplasty, transaqueductal approach into the fourth ventricle, and endoscopic repositioning of the catheter were some of the procedures performed. Patient recovered full neurological function. The combination of endoscopic exploration and shunt is a good alternative for patients with complex hydrocephalus. A transaqueductal approach to the fourth ventricle with flexible scope is an alternative for fourth ventricle pathology.

Hemorrhagic stroke with intraventricular extension in the setting of acute posteriorreversible encephalopathy syndrome (PRES): case report

We report the case of an eighteen year-old pregnantfemale with preeclampsia and florid signs andsymptoms of posterior reversible encephalopathy syndrome(PRES) in whom intracerebral hemorrhage wasevidenced following delivery. Management includedblood pressure control, external ventricular drainageand lumboperitoneal shunt. To our knowledge this isthe first report of intracranial hemorrhage occurringconcurrently with peripartum acute PRES. This casewas successfully treated with good outcome upon conclusionof management, thus making awareness of thispotentially fatal complication and its suggested managementfor successful outcome necessary for neurosurgeons,neurologists and intensivists alike (AU)

Describimos el caso de una mujer embarazada de18 años con preeclampsia y signos y síntomas floridosde leucoencefalopatía posterior reversible (LPR) en laque se evidenció la presencia de hemorragia cerebraltras el parto. El tratamiento de la enferma incluyó elcontrol de la presión arterial, la utilización de drenajeventricular externo y la colocación de una válvulalumboperitoneal. En nuestro conocimiento esta es laprimera descripción en la literatura de la concurrenciade hemorragia intracraneal con la LPR. Este casofue satisfactoriamente tratado con un buen resultado,haciendo que la sospecha y el conocimiento de esta posible fatal complicación y su correcto tratamientosea importante para neurocirujanos, neurólogos eintensivistas (AU)

Apoplejía hipofisaria como presentación de recurrencia de craneofaringioma / Pituitary apoplexy as the presenting symptom of a recurrent craniopharyngionma

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Trapped fourth ventricle treated with shunt placement in the fourth ventricle by direct visualization with flexible neuroendoscope.

Shunt placement was the most common procedure used for ventricular dilatation, but in many neurosurgical centers it has been substituted by flexible neuroendoscope; however, none of them had solved the problem of the trapped and dilated fourth ventricle. The combination of the ventricle-peritoneal catheter placement in the center of the fourth ventricle by direct visualization with a flexible neuroendoscope using a single coronal burr-hole has solved this problem. Eleven patients with a trapped fourth ventricle, with previous third ventriculostomy and aqueductal plasty, were treated with this procedure; all patients were evaluated clinically and with computed tomography 8 to 24 months (mean, 18 months) later. Here, we describe the technical procedure.

Identification of genes that synergize with Cbfb-MYH11 in the pathogenesis of acute myeloid leukemia.

Acute myeloid leukemia subtype M4 with eosinophilia is associated with a chromosome 16 inversion that creates a fusion gene CBFB-MYH11. We have previously shown that CBFB-MYH11 is necessary but not sufficient for leukemogenesis. Here, we report the identification of genes that specifically cooperate with CBFB-MYH11 in leukemogenesis. Neonatal injection of Cbfb-MYH11 knock-in chimeric mice with retrovirus 4070A led to the development of acute myeloid leukemia in 2-5 months. Each leukemia sample contained one or a few viral insertions, suggesting that alteration of one gene could be sufficient to synergize with Cbfb-MYH11. The chromosomal position of 67 independent retroviral insertion sites (RISs) was determined, and 90% of the RISs mapped within 10 kb of a flanking gene. In total, 54 candidate genes were identified; six of them were common insertion sites (CISs). CIS genes included members of a zinc finger transcription factors family, Plag1 and Plagl2, with eight and two independent insertions, respectively. CIS genes also included Runx2, Myb, H2T24, and D6Mm5e. Comparison of the remaining 48 genes with single insertion sites with known leukemia-associated RISs indicated that 18 coincide with known RISs. To our knowledge, this retroviral genetic screen is the first to identify genes that cooperate with a fusion gene important for human myeloid leukemia.