Treatment of Ethmoidal Dural Arteriovenous Fistulae Using Supraorbital Keyhole Subfrontal Approach.

Due to a unique cortical venous drainage pattern without sinus drainage, ethmoidal dural arteriovenous fistula (DAVF) are uncommon cerebral vascular lesions that carry a high risk of brain bleeding and neurologic deficit. Surgical intervention has been found to have a lower complication rate and a more satisfactory obliteration rate than endovascular treatment among the various DAVF treatment options. The supraorbital keyhole subfrontal approach is one of the least invasive and appropriate surgical techniques for addressing the anterior fossa vascular lesion in eDAVFs. We describe two men, ages 60 and 71, who underwent this surgical intervention to treat asymptomatic Cognard type IV eDAVFs. Complete obliteration with a detached fistulous point and skeletonization was accomplished with the aid of intraoperative neuronavigation. Thus, we suggest that a suitable surgical method for the treatment of eDAVFs would be to use a supraorbital keyhole subfrontal approach.

Enhanced Anti-Tumor Activity in Mice with Temozolomide-Resistant Human Glioblastoma Cell Line-Derived Xenograft Using SN-38-Incorporated Polymeric Microparticle.

Glioblastoma multiforme (GBM) has remained one of the most lethal and challenging cancers to treat. Previous studies have shown encouraging results when irinotecan was used in combination with temozolomide (TMZ) for treating GBM. However, irinotecan has a narrow therapeutic index: a slight dose increase in irinotecan can induce toxicities that outweigh its therapeutic benefits. SN-38 is the active metabolite of irinotecan that accounts for both its anti-tumor efficacy and toxicity. In our previous paper, we showed that SN-38 embedded into 50:50 biodegradable poly[(d,l)-lactide-co-glycolide] (PLGA) microparticles (SMPs) provides an efficient delivery and sustained release of SN-38 from SMPs in the brain tissues of rats. These properties of SMPs give them potential for therapeutic application due to their high efficacy and low toxicity. In this study, we tested the anti-tumor activity of SMP-based interstitial chemotherapy combined with TMZ using TMZ-resistant human glioblastoma cell line-derived xenograft models. Our data suggest that treatment in which SMPs are combined with TMZ reduces tumor growth and extends survival in mice bearing xenograft tumors derived from both TMZ-resistant and TMZ-sensitive human glioblastoma cell lines. Our findings demonstrate that combining SMPs with TMZ may have potential as a promising strategy for the treatment of GBM.

Injectable SN-38-embedded Polymeric Microparticles Promote Antitumor Efficacy against Malignant Glioma in an Animal Model.

Malignant glioma (MG) is extremely aggressive and highly resistant to chemotherapeutic agents. Using electrospraying, the potent chemotherapeutic agent 7-ethyl-10-hydroxycamptothecia (SN-38) was embedded into 50:50 biodegradable poly[(d,l)-lactide-co-glycolide] (PLGA) microparticles (SMPs). The SMPs were stereotactically injected into the brain parenchyma of healthy rats and intratumorally injected into F98 glioma-bearing rats for estimating the pharmacodynamics and therapeutic efficacy. SN-38 was rapidly released after injection and its local (brain tissue) concentration remained much higher than that in the blood for more than 8 weeks. Glioma-bearing rats were divided into three groups-group A (n = 13; stereotactically injected pure PLGA microparticles), group B (n = 12; stereotactically injected Gliadel wafer and oral temozolomide), and group C (n = 13; stereotactic and intratumoral introduction of SMPs). The SMPs exhibited significant therapeutic efficacy, with prolonged survival, retarded tumor growth, and attenuated malignancy. The experimental results demonstrated that SMPs provide an effective and potential strategy for the treatment of MG.

Brain computerized tomography reading in suspected acute ischemic stroke patients: what are essentials for medical students?

BACKGROUND: Few systematic methods prioritize the image education in medical students (MS). We hope to develop a checklist of brain computerized tomography (CT) reading in patients with suspected acute ischemic stroke (AIS) for MS and primary care (PC) physicians. METHODS: Our pilot group generated the items indicating specific structures or signs for the checklist of brain CT reading in suspected AIS patients for MS and PC physicians. These items were used in a modified web-based Delphi process using the online software "SurveyMonkey". In total 15 panelists including neurologists, neurosurgeons, neuroradiologists, and emergency department physicians participated in the modified Delphi process. Each panelist was encouraged to express feedback, agreement or disagreement on the inclusion of each item using a 9-point Likert scale. Items with median scores of 7-9 were included in our final checklist. RESULTS: Fifty-two items were initially provided for the first round of the Delphi process. Of these, 35 achieved general agreement of being an essential item for the MS and PC physicians. The other 17 of the 52 items in this round and another two added items suggested by the panelists were further rated in the next round. Finally, 38 items were included in the essential checklist items of brain CT reading in suspected AIS patients for MS and PC physicians. CONCLUSIONS: We established a reference regarding the essential items of brain CT reading in suspected AIS patients. We hope this helps to minimize malpractice and a delayed diagnosis, and to improve competency-based medical education for MS and PC physicians.

Heterozygous FUT1 Mutations Causing a Para-Bombay Phenotype.

BACKGROUND: To study a case of para-Bombay phenotype caused by compound heterozygous mutation of the FUT1 gene. METHODS: We performed an agglutination examination to anti-H serum. Secretor status was determined in order to assess the presence of soluble blood group substances. Genotyping of ABO and FUT1 genes were also performed. RESULTS: Our results showed the presence of A and H antigens in the saliva. Based on these results, the patient in the present case was diagnosed to have a para-Bombay A phenotype. Direct DNA sequencing of the patient's ABO gene indicated A1v/O1vgenotype. FUT1 gene sequence analysis revealed that the patient harbored the compound heterozygous mutations c.881_882delTT (p.Phe294Cysfs) and c.551_552delAG (p.Glu184Valfs). CONCLUSIONS: In summary, our findings support that the occurrence of a heterozygous mutation in FUT1, 547delAG/880delTT, is the most common mutation in Taiwanese.

Probable pathogenesis, diagnosis, and management of untreated arteriovenous malformation with cyst formation: case report and literature review.

Arteriovenous malformations (AVMs) usually manifest as headaches, seizures, focal neurological signs, and spontaneous intracerebral or subarachnoid hemorrhages. An untreated AVM with associated cyst formation is extremely rare, and the probable pathogenesis is unclear. We propose and discuss the possible pathogenesis of this condition and its diagnosis and management. A 26-year-old male presented with a generalized tonic-clonic seizure. Computed tomography showed a cystic lesion in the left frontal lobe and magnetic resonance imaging revealed a complex composition within the lesion, without a flow-voiding signal. Therefore, the initial diagnosis was oligodendroglioma and surgical treatment was performed. However, intraoperatively, engorged reddish nodule-like vessels with a cystic capsule and intra-cyst brown and sticky fluid were found. The nodule-like vessels and cystic capsule were resected completely. The patient's postoperative course was uneventful, with an excellent neurological outcome and no further seizures. Pathological examination of the surgical specimen revealed the typical microscopic appearance of an AVM, with numerous thin-walled vascular channels and deposits of hemosiderin in fibrous tissue. In conclusion, an untreated AVM with associated cyst formation is extremely rare, and the mechanism of formation is unclear. We propose a probable pathogenesis. Preoperative diagnosis, intraoperative management, and postoperative follow-up are equally crucial in dealing with this extremely rare condition. Cystic tumors associated with arteriovenous malformations (AVMs) are uncommon and are usually a complication of stereotactic radiosurgery (Ilyas et al. in J Neurosurg. https://doi.org/10.3171/2016.12.JNS162478 , 2017) or form after a hemorrhage (Daniels et al. in Radiology 133:393-394, 1979). Untreated AVMs with large cysts or cystic tumors are rare, with only five cases reported in the literature (Table 1). Here, we present a case of an untreated AVM associated with cystic formation, or a cystic tumor, in the left frontal lobe.

Biodegradable hybrid-structured nanofibrous membrane supported chemoprotective gene therapy enhances chemotherapy tolerance and efficacy in malignant glioma rats.

Chemotherapy is ineffective for treating malignant glioma (MG) because of the low therapeutic levels of pharmaceuticals in tumour tissues and the well-known tumour resistance. The resistance to alkylators is modulated by the DNA repair protein O6-alkylguanine-DNA alkyltransferase (AGT). O6-benzylguanine (O6-BG) can irreversibly inactivate AGT by competing with O6-methylguanine and has been confirmed to increase the therapeutic activity of alkylators. We developed hybrid-structured poly[(d,l)-lactide-co-glycolide] nanofibrous membranes (HSNMs) that enable the sequential and sustained release of O6-BG and two alkylators (carmustine and temozolomide [TMZ]). HSNMs were surgically instilled into the cerebral cavity of pathogen-free rats and F98 glioma-bearing rats. The release behaviours of loaded drugs were quantified by using high-performance liquid chromatography. The treatment results were compared with the rats treated with intraperitoneal injection of O6-BG combined with surgical implantation of carmustine wafer and oral TMZ. The HSNMs revealed a sequential drug release behaviour with the elution of high drug concentrations of O6-BG in the early phase, followed by high levels of two alkylators. All drug concentrations remained high for over 14 weeks. Tumour growth was slower and the mean survival time was significantly prolonged in the HSNM-treated group. Biodegradable HSNMs can enhance therapeutic efficacy and prevent toxic systemic effects.

Targeted concurrent and sequential delivery of chemotherapeutic and antiangiogenic agents to the brain by using drug-loaded nanofibrous membranes.

Glioblastoma is the most frequent and devastating primary brain tumor. Surgery followed by radiotherapy with concomitant and adjuvant chemotherapy is the standard of care for patients with glioblastoma. Chemotherapy is ineffective, because of the low therapeutic levels of pharmaceuticals in tumor tissues and the well-known tumor-cell resistance to chemotherapy. Therefore, we developed bilayered poly(d,l)-lactide-co-glycolide nanofibrous membranes that enabled the sequential and sustained release of chemotherapeutic and antiangiogenic agents by employing an electrospinning technique. The release characteristics of embedded drugs were determined by employing an in vitro elution technique and high-performance liquid chromatography. The experimental results showed that the fabricated nanofibers showed a sequential drug-eluting behavior, with the release of high drug levels of chemotherapeutic carmustine, irinotecan, and cisplatin from day 3, followed by the release of high concentrations of the antiangiogenic combretastatin from day 21. Biodegradable multidrug-eluting nanofibrous membranes were then dispersed into the cerebral cavity of rats by craniectomy, and the in vivo release characteristics of the pharmaceuticals from the membranes were investigated. The results suggested that the nanofibrous membranes released high concentrations of pharmaceuticals for more than 8 weeks in the cerebral parenchyma of rats. The result of histological analysis demonstrated developmental atrophy of brains with no inflammation. Biodegradable nanofibrous membranes can be manufactured for long-term sequential transport of different chemotherapeutic and anti-angiogenic agents in the brain, which can potentially improve the treatment of glioblastoma multiforme and prevent toxic effects due to systemic administration.

Upfront Gamma Knife Surgery for Giant Central Neurocytoma.

BACKGROUND: In this report, we present the results of using upfront Gamma Knife surgery (GKS) in the management of giant central neurocytoma (CNC) (volume >50 mL) without the initial removal of the tumor mass. CASE DESCRIPTIONS: Two patients underwent GKS for histologically proven CNC. Clinical and imaging studies were performed to evaluate the response to treatment. GKS involved delivery doses of 12 or 13 Gy to the tumor margin at the isodose line of 50%. Tumor response to GKS appeared as early as 4-6 months after GKS, at which point a dramatic reduction in volume was observed. No adverse effects of radiation or new neurologic deficits were observed in either of the cases. In case 1, we observed a reduction in tumor volume from 69 to 20 mL at 6 months and a further reduction to 10.3 mL at 86 months. In case 2, we observed a reduction in tumor volume from 62 to 31 mL at 4 months with a further reduction to 22.5 mL at 30 months. The female patient (case 1) showed mild weakness in the right lower limb after the minimal surgical removal of tumor using the cortical approach. No additional neurologic deficits were observed after GKS. The young male patient (case 2) presented a complete recovery without any signs of headache at 3 months after GKS. CONCLUSIONS: Based on this initial experience, it appears that GKS is an effective treatment for CNC and may be used for upfront management in cases of indolent clinical symptoms, even when the tumor is very large.

Concurrent Chemotherapy of Malignant Glioma in Rats by Using Multidrug-Loaded Biodegradable Nanofibrous Membranes.

Glioblastoma multiforme has a poor prognosis and is highly chemoresistant. In this study, we implanted biodegradable 1,3-bis[2-chloroethyl]-1-nitroso-urea-, irinotecan-, and cisplatin-eluting poly[(d,l)-lactide-co-glycolide] (BIC/PLGA) and virgin nanofibrous membranes on the brain surface of C6 glioma-bearing rats in concurrent and virgin groups, respectively. The concentrations of all applied drugs were significantly higher in the brain than in the blood for more than 8 weeks in all studied rats. Tumor growth was more rapid in the vehicle-treated group, and tumor volumes were significantly higher in the vehicle-treated group. Moreover, the average survival time was significantly shorter in the vehicle-treated group (P = 0.026), and the BIC/PLGA nanofibrous membranes significantly reduced the risk of mortality (P < 0.001). Furthermore, the results suggested that the BIC/PLGA nanofibers reduced the malignancy of C6 glioma. The experimental findings indicate that the multianticancer drug (i.e., BIC)-eluting PLGA nanofibers are favorable candidates for treating malignant glioma.

Phase-contrast magnetic resonance imaging for the evaluation of wall shear stress in the common carotid artery of a spontaneously hypertensive rat model at 7T: Location-specific change, regional distribution along the vascular circumference, and reproducibility analysis.

PURPOSE: To measure wall shear stress (WSS) in the common carotid arteries (CCA) of a spontaneously hypertensive rat (SHR) model and a normotensive Wistar Kyoto rat (WKY) model by 2D phase-contrast magnetic resonance imaging (PC-MRI). MATERIALS AND METHODS: PC-MRI was performed on 7 SHR and 7 WKY at ages of 4 and 7months at a 7T scanner. Images in the middle CCA (CCAmid) and in the bifurcation of CCA (CCAbifur) were acquired. The WSS values for differentiating characteristics between two models were calculated. Further, its location-specific change, regional distribution along the CCA circumference, and the reproducibility were evaluated. RESULTS: In the 4-month-old rats, SHR showed lower temporal averaged WSS (WSSavg) and peak systolic WSS (WSSs) in the CCAbifur in comparison with WKY (WSSavg: 0.95±0.18 vs. 1.30±0.36N/m(2) (P<0.01); WSSs: 1.68±0.70 vs. 3.22±2.49N/m(2) (P<0.05)). We observed the same trends in the 7-month-old rats. In the SHR model, the WSSavg was lower in the CCAbifur than in the CCAmid. The regional distribution of WSSavg along the circumference of CCA showed lower values in WKY, particularly in posterior segments of CCAbifur. The intra-observer, intra-scan and inter-scan reproducibility was acceptable and the disagreements were ranged from -0.05 to 0.06N/m(2). CONCLUSION: This study evaluated WSS in SHR and WKY models by 2D PC-MRI. High reproducibility analyses further indicated the reliability of measurements of WSS in the CCA of SHR and WKY models using PC-MRI at 7T.

Concurrent delivery of carmustine, irinotecan, and cisplatin to the cerebral cavity using biodegradable nanofibers: In vitro and in vivo studies.

Glioblastoma multiforme (GBM) is the most common primary malignant brain tumor, and the prognosis of patients afflicted with GBM has been dismal, exhibiting progressive neurologic impairment and imminent death. Even with the most active regimens currently available, chemotherapy achieves only modest improvement in the overall survival. New chemotherapeutic agents and novel approaches to therapy are required for improving clinical outcomes. In this study, we used an electrospinning technique and developed biodegradable poly[(d,l)-lactide-co-glycolide] nanofibrous membranes that facilitated a sustained release of carmustine (or bis-chloroethylnitrosourea, BCNU), irinotecan, and cisplatin. An elution method and a high-performance liquid chromatography assay were employed to characterize the in vitro and in vivo release behaviors of pharmaceuticals from the nanofibrous membranes. The experimental results showed that the biodegradable, nanofibrous membranes released high concentrations of BCNU, irinotecan, and cisplatin for more than 8 weeks in the cerebral cavity of rats. A histological examination revealed progressive atrophy of the brain tissues without inflammatory reactions. Biodegradable drug-eluting nanofibrous membranes may facilitate sustained delivery of various and concurrent chemotherapeutic agents in the cerebral cavity, enhancing the therapeutic efficacy of GBM treatment and preventing toxic effects resulting from the systemic administration of chemotherapeutic agents.

Predictors of shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid haemorrhage.

INTRODUCTION: Chronic hydrocephalus is a common complication that can occur after aneurysmal subarachnoid haemorrhage (SAH). The purpose of this study was to investigate clinical risk factors that could predict the occurrence of shunt-dependent chronic hydrocephalus after aneurysmal SAH. METHODS: Eighty-eight consecutive patients who underwent either surgery or transarterial endovascular embolization as a treatment for cerebral aneurysm within 72 h -after experiencing SAH from March 2005 to July 2006 were studied retrospectively to assess the risk factors that might predict shunt-dependent chronic hydrocephalus. Clinical and demographic factors were examined, including age, sex, initial admission mean arterial blood pressure (MABP), blood sugar level at admission, fever frequency, initial external ventricular drainage (EVD), Fisher grade, Hunt and Hess grade, intraventricular haemorrhage (IVH) and treatment methods to define predictors of shunt-dependent hydrocephalus. The length of hospital stay and modified Rankin scale recorded 6 months after SAH were also evaluated; these parameters were compared between the shunt-dependent and non-shunt-dependent groups. RESULTS: Of the 88 patients, 22 (25%) underwent shunt placement to treat their chronic hydrocephalus. The average length of hospital stay was 33.9 days for the shunt-treated group and 14 days for the non-shunt-treated group. The non-shunt-treated group scored an average of 1.05 on the modified Rankin scale compared with 2.77 for the shunt-treated group. A univariate analysis revealed that several admission variables were associated with long-term shunt-dependent hydrocephalus: (1) increased age (p = 0.023); (2) initial admission MABP (p = 0.027); (3) a high Fisher grade (p = 0.031); (4) a poor admission Hunt and Hess grade (p = 0.030); (5) the presence of IVH (p = 0.029), and (6) initial EVD (p < 0.0001). The factor most commonly associated with shunt-dependent hydrocephalus over the course of hospital days was fever frequency (p < 0.0001). CONCLUSIONS: Chronic hydrocephalus after aneurysmal SAH has a multifactorial aetiology. Understanding the risk factors that predict the occurrence of chronic hydrocephalus may help neurosurgeons to expedite permanent cerebrospinal fluid diversion, which could decrease both the cost and length of hospital stay and prevent further complications.

Comparison of the therapeutic effect of teriparatide with that of combined vertebroplasty with antiresorptive agents for the treatment of new-onset adjacent vertebral compression fracture after percutaneous vertebroplasty.

STUDY DESIGN: Comparing a prospective group of 32 patients, who underwent percutaneous vertebroplasty (PVP) and who were treated with teriparatide for at least 18 months after a new-onset adjacent vertebral compression fracture (VCF), and compared it with a retrospective group of 33 patients, who received antiresorptive agents combined with repeated PVPs for post-PVP new-onset adjacent VCFs. OBJECTIVE: This comparative study aimed to assess the immediate and mid-term efficacy and safety of teriparatide for treating new adjacent VCFs after vertebroplasty. SUMMARY OF BACKGROUND DATA: Vertebroplasty may provoke fractures in adjacent, nonaugmented vertebrae. Subsequent VCFs can occur much sooner and more frequently after PVPs. Antiresorptive agents do not effectively prevent new-onset VCFs or prompt pain relief. Treatment with teriparatide is effective and rapid in increasing spinal bone mineral density (BMD) and in decreasing vertebral fracture risk in patients with osteoporosis. METHODS: Relevant clinical data were compared between a prospective group of patients who received teriparatide and a retrospective group of patients who received antiresorptive agents and repeated PVPs for new-onset adjacent VCFs after PVP. RESULTS: Data in prospective group, including visual analogue scale scores and BMD were compared with those in a retrospective group. In group A, only 1 new-onset VCF occurred during the mean follow-up period of 22.56 months. In group B, 5 patients (6 vertebrae) developed new-onset VCFs after the second PVP, and 2 of these 5 patients had additional new VCFs after the third PVP. Teriparatide significantly reduced the risk of new VCFs after vertebroplasty (odds ratio=0.18; 95% confidence interval, 0.02-1.64). The increase of lumbar spine BMD was 26.32% after 18 months of treatment with teriparatide and 4.62% after 18 months of treatment with antiresorptive agents. In addition, at the 18-month follow-up, mean visual analogue scale scores had decreased from 8.03±1.97-1.37±0.52 in the teriparatide group and from 7.91±1.95-4.23±1.21 in the antiresorptive group. CONCLUSIONS: For the treatment of new-onset adjacent VCF after PVPs, the therapeutic effects of teriparatide is better than that of the combined vertebroplasty and an antiresorptive agent in fracture prevention, BMD change, and sustained pain relief.

Postoperative midline shift as secondary screening for the long-term outcomes of surgical decompression of malignant middle cerebral artery infarcts.

Decompressive hemicraniectomy (DC) can save the lives of patients with malignant middle cerebral artery (MCA) infarction. We proposed that postoperative midline shift is important for the long-term outcome of patients with MCA infarction. We conducted a retrospective study of DC in 38 patients with malignant MCA infarction. The long-term outcome was assessed one year after surgery using the modified Rankin Scale (mRS) score. Patients who had midline shift less than the optimal diagnostic cut-off point on the fourth postoperative day were classified as having a successful decompression and the remaining patients were classified in the failed decompression group. The successful decompression group mRS score was 4.20±0.89 one year after surgery and the failed decompression group mRS score was 5.11±0.76 (p<0.0001). Successful decompression, resulting in postoperative midline shift of less than 5mm, was a key factor for beneficial, long-term functional outcomes in patients with malignant MCA infarction.

Ruptured aneurysm of the accessory middle cerebral artery associated with moyamoya disease: a case report.

The accessory middle cerebral artery can provide collateral blood supply in moyamoya disease. We report a case of unilateral moyamoya disease which demonstrates the anatomy of the right accessory middle cerebral artery and a ruptured peripheral aneurysm on the artery. Our patient was a 56-year-old woman who initially suffered from headache and lethargy. Right caudate nucleus hemorrhage with intraventricular extension and spontaneous subarachnoid hemorrhage were found on brain computed tomography. A ruptured peripheral accessory middle cerebral artery aneurysm associated with unilateral moyamoya disease was diagnosed on cerebral angiography. Surgical intervention to excise the peripheral accessory middle cerebral artery aneurysm assisted by frameless navigation guidance to reduce the risk of damage to collateral vessels was done successfully. Histopathology of excised tissue showed this anomaly was a pseudoaneurysm. The management of an aneurysm in moyamoya disease should be modified based on its location and collateral vessels. Prevention of aneurysm bleeding and preservation of collateral vessels during craniotomy are the critical when managing hemorrhagic moyamoya disease. This case suggests that surgical intervention for ruptured intracranial aneurysms is safe with the use of frameless navigation guidance to minimize collateral vessel injuries.

The role of perfusion computed tomography in the prediction of cerebral hyperperfusion syndrome.

BACKGROUND: Hyperperfusion syndrome (HPS) following carotid angioplasty with stenting (CAS) is associated with significant morbidity and mortality. At present, there are no reliable parameters to predict HPS. The aim of this study was to clarify whether perfusion computed tomography (CT) is a feasible and reliable tool in predicting HPS after CAS. METHODOLOGY/PRINCIPAL FINDINGS: We performed a retrospective case-control study of 54 patients (11 HPS patients and 43 non-HPS) with unilateral severe stenosis of the carotid artery who underwent CAS. We compared the prevalence of vascular risk factors and perfusion CT parameters including regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and time to peak (TTP) within seven days prior to CAS. Demographic information, risk factors for atherosclerosis, and perfusion CT parameters were evaluated by multivariable logistic regression analysis. The rCBV index was calculated as [(ipsilateral rCBV - contralateral rCBV)/contralateral rCBV], and indices of rCBF and TTP were similarly calculated. We found that eleven patients had HPS, including five with intracranial hemorrhages (ICHs) of whom three died. After a comparison with non-HPS control subjects, independent predictors of HPS included the severity of ipsilateral carotid artery stenosis, 3-hour mean systolic blood pressure (3 h SBP) after CAS, pre-stenting rCBV index >0.15 and TTP index >0.22. CONCLUSIONS/SIGNIFICANCE: The combination of severe ipsilateral carotid stenosis, 3 h SBP after CAS, rCBV index and TTP index provides a potential screening tool for predicting HPS in patients with unilateral carotid stenosis receiving CAS. In addition, adequate management of post-stenting blood pressure is the most important treatable factor in preventing HPS in these high risk patients.

Delayed diagnosis of traumatic cervical subluxation in patients with mandibular fractures: a 5-year retrospective study.

BACKGROUND: Mandibular bone fracture associated with traumatic cervical subluxation is a rare injury. The diagnosis of a traumatic cervical subluxation is more easily delayed than other conditions in patients with mandibular bone fractures. The aim of this study is to investigate the incidence of traumatic cervical subluxation associated with mandibular bone fractures. METHODS: This is a retrospective cohort study of 653 consecutive emergency department patients with mandibular bone fractures investigated for evidence of concomitant traumatic cervical subluxation. RESULTS: This study reports on 7 patients (1.07%) with a diagnosis of traumatic cervical subluxation from a cohort of 653 with mandibular bone fractures as a result of motor vehicle accidents. Two of seven patients had their diagnosis made while in the emergency room, thus, 71.43% of these injuries were discovered on studies done up to 10 days after the trauma, including after surgical correction of the mandibular bone fracture. CONCLUSION: The importance of a thorough initial examination (both physical and radiologic) and suspicion of traumatic cervical subluxation in patients with mandibular bone fractures is worth emphasizing as delayed diagnosis and management could result in permanent neurologic injury. We suggest dynamic flexion-extension cervical radiographs and thin-slice computerized tomography scans in patients with mandibular fractures routine as an important and routine practice protocol.

Repeated and multiple new vertebral compression fractures after percutaneous transpedicular vertebroplasty.

STUDY DESIGN: A retrospective study to detect patients with new-onset compression fractures following vertebroplasty. OBJECTIVE: To investigate the characteristics and associated risk factors of new-onset vertebral compression fractures after vertebroplasty. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty is a well-established technique for treating osteoporotic compression fractures. Short-term results are promising, but longer-term studies have suggested a possible accelerated failure rate in the adjacent vertebral body. METHODS.: We retrospectively reviewed patients with osteoporotic compression fractures from January 2000 to June 2006. The patients received percutaneous vertebroplasty with bone cement augmentation. Long-term follow-up radiographically identified the occurrence of vertebral fracture (minimum follow-up 24 months) after an initial vertebral fracture. RESULTS: In 852 patients (1131 vertebrae), 58.8% to 63.8% of new compression fractures after vertebroplasty were adjacent compression fractures. Adjacent fractures occurred much sooner than nonadjacent fractures; (71.9 +/- 71.8 days vs. 286.8 +/- 232.8 days, P < 0.001). In patients who experienced vertebral compression fractures 2 or more times, older age, lower baseline bone mineral density (BMD), and more pre-existing vertebral compression fractures were demonstrated in this study (P < 0.005). The gender and amount of cemented polymethyl methacrylate were not statistically different between Groups A (1 vertebral compression fracture) and B (vertebral compression fracture > or =2 times). CONCLUSION: New-onset vertebral compression fractures occurred repeatedly within a few years after vertebroplasty. New-onset adjacent-level fractures occurred sooner and were more predominate than nonadjacent level fractures. The results of this study suggest that older patient age, lower baseline BMD, and more pre-existing vertebral fractures were found to be risk factors for multiple vertebral compression fractures.

Traumatic internal carotid artery pseudoaneurysm mimicking sphenoid sinus tumor.

Massive epistaxis following blunt craniofacial trauma should alert clinicians to possible traumatic internal carotid artery (ICA) aneurysm. This article describes a case of a 46-year-old female patient with traumatic ICA pseudoaneurysm presenting similar to a sphenoid sinus mass lesion. Massive bleeding occurred during the endoscopic procedure. Brain angiography revealed two lobulated ICA pseudoaneurysms over a cavernous segment. The patient successfully underwent endovascular stent assisted coil embolization. Timely diagnosis and treatment of the ICA psuedoaneurysm produced a favourable outcome.