Intracranial Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A Case Report and Review of the Literature.

We describe a case of severe headaches, double vision, and progressive vision loss secondary to a ruptured intracranial cyst (IAC) in a 31-year-old woman with no relevant past medical history. The case is peculiar because drainage of the subdural hygroma led to a minimal improvement in vision with persistent elevated intracranial pressure (ICP). Further exploration revealed transverse sinus stenosis necessitating stenting. Evaluation post-stenting showed marked reduction of ICP and improvement in symptoms. This report underscores the importance of comprehensive work-up and suspicion of multiple underlying etiologies that may be crucial to complete resolution of presenting symptoms in some cases. We provide an overview of the clinical indications and evidence for venous sinus stenting in treating idiopathic intracranial hypertension (IIH).

Disseminated Coccidioidomycosis to the Spine-Case Series and Review of Literature.

Coccidioidomycosis is a fungal infectious disease caused by the Coccidioides species endemic to Southwestern United States. Symptomatic patients typically present as community-acquired pneumonia. Uncommonly, in about 1% of infections, hematogenous extra pulmonary systemic dissemination involving skin, musculoskeletal system, and meninges occur. Disseminated spinal infection is treated with antifungal drugs and/or surgical treatment. A retrospective review of medical records at our institution was done between January 2009 to December 2018 and we present three cases of spinal coccidioidomycosis and review the current literature. Disseminated coccidioidomycosis can lead to spondylitis that can present as discitis or a localized spinal or paraspinal abscess. Spinal coccidioidomycosis is typically managed with antifungal treatments but can include surgical treatment in the setting poor response to medical therapy, intractable pain, presence of neurological deficits due to compression, or structural spinal instability.

Retrospective Analysis of EMG-evoked Potentials in Cortical Bone Trajectory Pedicle Screws.

STUDY DESIGN: This is a retrospective analysis of electromyographic (EMG) stimulation thresholds of 64 cortical bone trajectory (CBT) screws. OBJECTIVE: The authors seek to determine whether recordings below stimulation threshold correlate with CBT screw pedicle breach on computed tomographic imaging, and to explore which specific nerve roots are most at risk with this new trajectory. SUMMARY OF BACKGROUND DATA: Intraoperative EMG monitoring has been utilized to verify accurate placement of pedicle screws. Although CBT screws are becoming increasingly popular, to the authors' knowledge there are no existing evaluations of the accuracy of intraoperative triggered EMG (tEMG) monitoring in this trajectory. MATERIALS AND METHODS: Retrospective analysis of EMG stimulation thresholds of 64 CBT screws placed in patients at NYU Langone Medical Center from 2015-2017. EMG results including threshold values and muscle group stimulated were correlated with screw positioning determined on postoperative or intraoperative computed tomographic imaging. RESULTS: In total, 4.7% of EMG threshold values indicated true breach, 1.6% were falsely positive for breach, 76.5% showed true absence of breach, 17.1% failed to reveal a present breach though 0% of medial breaches were undetected. L4 screws showed tEMG responses from adductor longus in 22%, L5 screws, from rectus femoris in 16.7%, and S1 screws from tibialis anterior in 50%. CONCLUSIONS: tEMG testing is effective for medial breaches in CBT screws. In addition, there is evidence that bicortical placement of these screws causes lower stimulation values due to distal breach. Importantly, it seems that this is due in part to stimulation of the exiting nerve root at the level above.

Temporary stent scaffolding during aneurysm coiling.

We report a case of temporary Solitaire FR stent (Covidien, Mansfield, MA, USA) scaffolding to reduce coil herniation during embolization of a large neck anterior communicating artery aneurysm. In contrast to classic stent-assisted coiling, the fully retrievable stent is recaptured prior to detachment of the last coil. The presented technical nuance hence does not require institution of prolonged antiplatelet coverage. But the door is left open for coil-repositioning in case of coil basket instability. Permanent stent redeployment remains a fall-back option if critical hardware conflict occurs. In comparison to classic balloon remodeling, the presented method may offer easier distal access, particularly in tortuous arterial anatomy. Temporary occlusion of the parent artery, side branches, and perforators is also avoided. Given its specific potential advantages, temporary stent scaffolding using the fully retrievable Solitaire FR device may find its niche as a bailout option, primarily in a very specific subset of distally located wide neck aneurysms.

Usefulness of soluble endoglin as a noninvasive measure of left ventricular filling pressure in heart failure.

Progressive left ventricular (LV) dysfunction induces expression of the cytokine transforming growth factor-ß1. Endoglin (CD105) is a transforming growth factor-ß1 co-receptor that is released into the circulation as soluble endoglin (sEng). The objective of the present study was to assess the serum levels of sEng in patients with heart failure and to identify the predictive value of sEng for detecting elevated left ventricular end-diastolic pressures (LVEDPs). We measured the sEng levels in 82 consecutive patients with suspected LV dysfunction referred for determination of left heart filling pressures using cardiac catheterization. Among these subjects, the sEng levels correlated with the LVEDP (R = 0.689; p <0.0001), irrespective of the LV ejection fraction. Using a receiving operating characteristic curve, the sEng levels predicted an LVEDP of ≥16 mm Hg with an area under the curve of 0.85, exceeding the measured area under the curves for both atrial and brain natriuretic peptide, currently used biomarkers for heart failure diagnosis (atrial natriuretic peptide 0.68 and brain natriuretic peptide 0.65; p <0.01 vs sEng). In 10 subjects receiving medical therapy guided by invasive hemodynamic monitoring for heart failure, decreased a pulmonary capillary wedge pressure was associated with a reduced sEng level (R = 0.75, p = 0.008). Finally, compared to 25 healthy controls, the sEng levels were elevated in subjects with suspected LV dysfunction (3,589 ± 588 vs 4,257 ± 966 pg/ml, respectively, p <0.005) and correlated directly with the New York Heart Association class (R = 0.501, p<0.001). In conclusion, circulating levels of sEng are elevated in patients with increased LVEDP and New York Heart Association class, irrespective of the LV ejection fraction. sEng levels also decreased in association with a reduced cardiac filling pressure after diuresis. These findings have identified circulating sEng as a sensitive measure of elevated left heart filling pressures.