Successful mechanical thrombectomy for terminal ICA bullet embolism: A case report.

Bullet embolism after high velocity penetrating trauma is a rare event that can have devastating and wide-ranging effects distant from the original site of injury. A 29-year-old presented with multiple gunshot wounds to the chest, back, abdomen, and lower extremities but no penetrating head injury. After proper resuscitation, the patient was noted to have left-sided hemiparesis and computed tomography angiography of the head showed a bullet fragment that had traveled to the right M1 segment of the middle cerebral artery resulting in occlusion of the vessel. Mechanical thrombectomy was performed in an attempt to remove the bullet fragment but this was unsuccessful as the fragment was firmly lodged in the blood vessel. Aspiration of clot distal to the fragment was then performed in hopes of preventing a large volume ischemic event which was angiographically successful resulting in TICI 2c revascularization. This case demonstrates that thrombectomy can be safely and successfully performed distal to a lodged foreign body.

Pleural Effusion and Malnutrition Are Associated With Worse Early Outcomes After Liver Transplant.

INTRODUCTION: Pulmonary complications after liver transplantation (LT) have previously been associated with longer hospital stays and ventilator time, and higher mortality. This study reports the outcomes for a specific pulmonary complication, pleural effusion, in LT recipients. METHODS: Records from a single transplant center were analyzed retrospectively for all adult LT patients. Patients with documented pleural effusion by radiographic imaging within 30 days pre- or post-transplant were considered as cases. Outcomes included length of hospital stay, discharge disposition, hospital readmission, discharge with home oxygen, and 1-year survival. RESULTS: During the 4-year study period, 512 LTs were performed, with 107 patients (21%) developing a peri-transplant pleural effusion. In total, 49 patients (10%) had a pre-transplant effusion, 91 (18%) had a post-transplant effusion, and 32 (6%) had both. Characteristics associated with the presence of any pleural effusion included an increasing model for end-stage liver disease score, re-transplantation, diagnosis of alcoholic liver disease, low protein levels, and sarcopenia. Effusion patients had longer hospital stays (17 vs 9 days, P < .001) and higher likelihood of discharge to a care facility (48% vs 21%, P < .001). Ninety-day readmission occurred in 69% of effusion patients (vs 44%, P < .001). One-year patient survival with any effusion was 86% (vs 94%, P < .01). CONCLUSIONS: Overall, 21% of recipients developed a clinically significant peri-transplant pleural effusion. Pleural effusion was associated with worse outcomes for all clinical measures. Risk factors for the development of pleural effusion included higher MELD score (>20), re-transplantation, alcoholic liver disease, and poor nutrition status, including poor muscle mass.

How I do it: neuromonitoring-guided clipping of high-riding basilar tip aneurysm.

BACKGROUND: Clipping of basilar tip aneurysms presents unique challenges due to the risk of perforator compromise and subsequent disabling stroke. METHOD: Herein, we describe the correct trajectory of the clip applier to clip basilar tip aneurysms through an orbitozygomatic approach to prevent perforator injury and discuss management of intraoperative neuromonitoring changes. CONCLUSION: We anticipate that this video and illustration will aid surgeons as they treat complex wide-necked basilar tip aneurysms with microsurgical clipping.

Mechanical Thrombectomy for Sequential Bilateral Middle Cerebral Artery Occlusions in a Patient With Recurrent Cryptogenic Strokes: A Case Report.

Recurrent sequential mechanical thrombectomy for cryptogenic large vessel occlusion (LVO) can lead to excellent clinical outcome. A 68-year-old right-handed male presented with an acute proximal right middle cerebral artery (MCA) ischemic syndrome and underwent successful revascularization by mechanical thrombectomy with normal functional recovery. He was treated with dual antiplatelet therapy for 2 months following discharge, however later discontinued clopidogrel due to side effects. He then developed a recurrent, contralateral MCA occlusion 16 months later and once again received emergent endovascular reperfusion therapy with excellent neurological outcome. He has remained on off-label empiric oral anticoagulation since and has not had recurrent stroke nor evidence of cerebral ischemia. Favorable clinical outcomes can be achieved in patients despite recurrent LVO who underwent emergent mechanical thrombectomy. Optimal antithrombotic secondary stroke prevention strategies following embolic stroke of unknown source remains uncertain as recent evidence does not support rivaroxaban or dabigatran over aspirin. The benefit of apixaban over aspirin for the prevention of recurrent cerebral ischemia is under current investigation.

The Optimal Surgical Approach to Intradural Spinal Tumors: Laminectomy or Hemilaminectomy?

Objective Traditionally, laminectomy has been the preferred surgical approach for the resection of intradural spinal tumors. Recent trends towards minimally invasive techniques have generated interest in hemilaminectomy as an effective alternative surgical approach to resect spinal tumors. However, it remains unclear if the potential benefits of hemilaminectomies, used in other routine spinal procedures, apply to intradural spinal tumors. This report presents a six-year single institutional analysis of open resection of intradural tumors using laminectomies as compared to hemilaminectomies. Methods A single institution, multisurgeon, retrospective review of 52 patients undergoing resection of intradural spinal tumors over a six-year period was performed. Estimated blood loss, operative time, post-operative complications, length of stay, and post-operative clinical spinal instability were analyzed and compared between the two surgical techniques. Results The mean follow-up was 34 and 20 months for the laminectomy and hemilaminectomy groups, respectively. There was no statistically significant difference in operative times between the two groups (hemilaminectomy: 250.13±76.44 minutes, laminectomy: 244.49±92.85 minutes; p=0.43). Similarly, there was no difference in overall estimated blood loss (hemilaminectomy: 125±74 cc, laminectomy: 256.05±320.8 cc; p=0.27) or mean hospital length of stay (hemilaminectomy: 4.00±2.12 days, laminectomy: 5.26±3.0 days; p=0.60). No patient in either surgical group had post-operative evidence of clinical spinal instability. Conclusion Hemilaminectomy is a viable approach for the resection of intradural spinal tumors, with similar rates of post-operative complications to laminectomy when using an open surgical approach. The laminectomy allows for bilateral exposure of the entire spinal canal and neural foramina; and continues to be the preferred method for resection of large tumors with complex morphology.

Sacroiliac Joint Fusion System for High-Grade Spondylolisthesis Using "Reverse Bohlman Technique": A Technical Report and Overview of the Literature.

OBJECTIVE/BACKGROUND: High-grade spondylolisthesis (HGS) is a complex clinical problem that poses significant challenges to the treating physician. Contentious debate has continued regarding the most optimal surgical approach for these patients. A variety of transsacral and transvertebral techniques have been described in reported studies. METHODS AND RESULTS: We present 2 cases of low back pain and radicular symptoms. Our 2 patients were a 35-year-old woman and a 26-year-old white woman. The computed tomography and magnetic resonance imaging scans revealed progressive HGS (grade III) that had not been relieved by conservative measures. Both patients underwent transsacral fixation using the reverse Bohlman technique (RBT) at L5-S1 and L4-L5 anterior lumbar interbody fusion combined with posterolateral fusion. At the 9- and 10-month follow-up visits, the patients reported minimal back pain with no radicular symptoms, and the imaging studies showed satisfactory fusion in both patients. CONCLUSIONS: To the best of our knowledge, this is the first report to demonstrate the utility of the sacroiliac joint fusion cage using RBT in patients with HGS with successful clinical outcome. The RBT is safe, feasible, and effective in carefully selected patients.

One-year Incidence of Infection in Pediatric Intestine Transplantation.

BACKGROUND: This study reports the infection rate, location of infection and pathogen causing bacterial, fungal or viral infections in intestine transplant recipients at a pediatric transplant center. METHODS: Records from a pediatric center were reviewed for patients receiving an intestine transplant. Positive cultures and pathology reports were used to diagnose bacterial, fungal and viral infections and also to determine location and infectious agent. Risk for infection was assessed based on liver or colon inclusion, and immunosuppression induction, as part of the intestine transplant. RESULTS: During the study period, 52 intestine transplants were performed on 46 patients. Bacterial, fungal and viral infection rates were 90%, 25% and 75%, respectively. Enterococcus spp. (non-vancomycin-resistant enterococci) were the most common pathogens and were isolated from 52% of patients. Non-vancomycin-resistant enterococci was present in 12% of transplant recipients. Candida spp. were the most common fungal pathogens (23% of patients). Respiratory viral infections were common (44%), and Cytomegalovirus infection rate was 17%. Common sites of infection were bloodstream, urinary and upper respiratory tract. Colon and liver inclusion in the transplant graft was not associated with increased risk of infection, nor was addition of rituximab to the immunosuppression induction protocol. CONCLUSIONS: Postintestine transplant infections are ubiquitous in the pediatric population, including high rates of infection from bacterial, viral and fungal sources. Inclusion of the liver and/or colon as a component of the transplant graft did not appear to greatly impact the infectious risk. Adding rituximab to the immunosuppression induction protocol did not impact on infectious risk.

Post-intestine transplant graft-vs-host disease associated with inclusion of a liver graft and with a high mortality risk.

INTRODUCTION: This study reports the incidence, anatomic location, and outcomes of graft-vs-host disease (GVHD) at a single active intestine transplant center. METHODS: Records were reviewed for all patients receiving an intestine transplant from 2003 to 2015. Pathology reports and pharmacy records were reviewed to establish the diagnosis, location, and therapeutic interventions for GVHD. RESULTS: A total of 236 intestine transplants were performed during the study period, with 37 patients (16%) developing GVHD. The median time to onset of disease was 83 days, with 89% of affected patients diagnosed in the first year post-transplant. Mortality for affected patients was 54% in the 1 year after GVHD diagnosis. Skin lesions were the most common manifestation of GVHD. Other sites of disease included lungs, bone marrow, oral mucosa, large intestine, and brain. The incidence of GVHD was 16% in adult patients, and slightly lower in pediatric recipients (13%). In adults, increasing graft volume (isolated vs multi-organ) and liver inclusion were associated with increasing risk of GVHD, though this was not seen in pediatric patients. CONCLUSION: Overall, 16% of intestine transplant recipients developed GVHD. GVHD is associated with high mortality, and disease in the lungs, brain, and bone marrow was universally fatal.

Posttransplant complications in adult recipients of intestine grafts without bowel decontamination.

BACKGROUND: Selective digestive decontamination is commonly used to decrease lumenal bacterial flora. Preoperative bowel decontamination may be associated with a lower wound infection rate but has not been shown to decrease risk of intra-abdominal abscess or lower leak rate for enteric anastomoses. Alternatively, the decontamination disrupts the normal flora of the gastrointestinal tract and may affect normal physiology, including immunologic function. This study reports complication rates of an intestine transplant program that has never used bowel decontamination. METHODS: All adult patients who underwent intestine transplant from 2003 to 2015 at a single center were reviewed. Posttransplant complications included intra-abdominal abscess, enteric fistula, and leak from the enteric anastomosis. Viral, fungal, and bacterial infections in the first year after transplant are reported. RESULTS: There were 184 adult patients who underwent deceased donor intestine transplant during the study period. Among these patients, 30% developed an infected postoperative fluid collection, 4 developed an enteric fistula (2%), and 16 had an enteric or anastomotic leak (8%). The rate of any bacterial infection was 91% in the first year, with a wound infection rate of 25%. Fungal infection occurred in 47% of patients. Rejection rates were 55% at 1 y for isolated intestine patients and 17% for multivisceral (liver inclusive) patients. CONCLUSIONS: Among this population of intestine transplant patients in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. Bowel decontamination provides no identifiable benefit in intestine transplantation.

Complications in pediatric intestine transplantation in the absence of peri-operative donor or recipient bowel decontamination.

This study reports the clinical complication and infection rates of an active pediatric IT program that has never utilized bowel decontamination in either the donor or the recipient. All patients undergoing IT from 2003 to 2015 at a single pediatric IT center were reviewed. Post-transplant surgical, infectious, and immunosuppressive complications are reported. There were 52 patients who underwent IT during the study period. Among these patients, 4% developed a postoperative abscess, one developed an enteric fistula (2%), and one had an enteric or anastomotic leak (2%). The rate of any bacterial infection was 90% in the first year, with a wound infection rate of 23%. Any fungal infection occurred in 25% of patients. Any viral infection occurred in 75% of patients. Gastrointestinal viruses were diagnosed in 52% of patients, and cytomegalovirus infections occurred in 17%. Rejection rates were 39% at any time post-transplant (isolated 44% and 35% for multivisceral patients). At this center in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. These findings suggest bowel decontamination may provide no significant benefit in this population of high-risk transplant patients.

Microsatellite primers in Agave utahensis (Asparagaceae), a keystone species in the Mojave Desert and Colorado Plateau.

PREMISE OF THE STUDY: Utah agave (Agave utahensis) and its putative subspecies, A. utahensis subsp. kaibabensis and A. utahensis subsp. utahensis, are keystone species of the Mojave Desert and Colorado Plateau in the southwestern United States. Here we developed microsatellite markers to study population structure and genetic diversity of the two subspecies of A. utahensis. • METHODS AND RESULTS: We analyzed 22,386 454-pyrosequencing large contigs (>400 bp), derived from a genome reduction experiment consisting of A. utahensis accessions, for putative microsatellites. The use of unique multiplex barcodes for each of the Agave accessions allowed for the identification of putatively polymorphic microsatellites based solely on sequence alignment analysis. We report the characteristics of 11 polymorphic microsatellite loci based on a panel of 104 individuals from the two subspecies. The number of alleles per locus varied from three to eight, with an average of 5.5 alleles per locus. Observed and expected heterozygosity values ranged from 0.038 to 0.777 and 0.038 to 0.707, respectively. • CONCLUSIONS: The microsatellites identified here will be invaluable for future studies of population structure, polyploidy, and genetic diversity across the species.