Optic nerve sheath fenestration: Current status in France and comparison of 6 different surgical approaches.

PURPOSE: Optic nerve sheath fenestration (ONSF) is a surgical procedure commonly performed in the Anglo-Saxon countries for the treatment of medically refractory idiopathic intracranial hypertension (IIH). We chose to compare 6 different trans-orbital surgical approaches to ONSF. We also desired to determine the number of optic nerve decompression procedures performed in France in 2019 and 2020. METHODS: Four fresh frozen orbits were dissected at the University of Nice anatomy laboratory. We performed the following surgical approaches: (i) eyelid crease, (ii) lid-split, (iii) medial transconjunctival with medial rectus disinsertion, (iv) medial transconjunctival without rectus disinsertion, (v) lateral transconjunctival and (vi) lateral orbitotomy. For each surgical approach, we measured the distance between the incision and the optic nerve dura mater. We also extracted data from the French National PMSI (Programme de Médicalisation des Systèmes d' Information) database from January 2019 through December 2020 to determine the annual number of optic nerve decompression procedures. RESULTS: The lid crease and medial transconjunctival approaches provided the shortest distance to the optic nerve (average 21mm and 24mm, respectively) and the lowest levels of difficulty compared to the other surgical routes. A total of 23 and 45 optic nerve decompressions were performed in France in 2019 and 2020, respectively. Among them, only 2 and 7 procedures, respectively, were performed through a trans-orbital approach. CONCLUSION: Upper lid crease incision and medial transconjunctival approaches are the most direct and easiest surgical routes when performing an ONSF. We found that ONSF was rarely performed in France. We strongly recommend close cooperation between ophthalmologists, neurologists, neurosurgeons and interventional radiologists.

Immunohistochemistry usage profile in a Malaysian tertiary hospital's histopathology laboratory.

INTRODUCTION: Immunohistochemistry (IHC) was commenced in 1986 at the Department of Pathology, University of Malaya Medical Centre, Kuala Lumpur and its usage has grown for the past 30 over years, hence it was felt that a review was timely in view of the scarcity of literature on IHC usage. MATERIALS AND METHODS: All cases received by the Department of Pathology for histopathological examination between 1 July 2018 and 30 June 2019 were retrieved from the Laboratory Information System (LIS). All the IHC requests over this period were tabulated, with the exception of renal, muscle, rectal and nerve biopsies with their pre-defined algorithms for stains and cytological specimens. IHC stains performed solely for purpose of directing targeted treatment were also not included. RESULTS: Immunohistochemistry was performed in 2044 (21.1%) of the total of 9686 cases, with a total of 5969 IHC stains performed i.e. 2.9 (5969/2044) IHC stains per case. All 91 antibodies available were used at least once during the study. 14 histopathologists (5 with < 10-years and 9 with ≥ 10-years postgraduate specialist experience) reported on the cases with no significant difference (p=0.90) in their usage of IHC stains. Among the most common IHC stains used, requests for Ki67 and MNF116 showed higher standard deviations compared with p63, CK7 and S100 among the histopathologists. From the relatively higher standard deviation for Ki67 and MNF116 it appeared that there was a greater difference in the requesting pattern between histopathologists for these two antibodies. CONCLUSION: The rate of use of IHC in our centre seems compatible with that of an academic centre. Personal preferences of the histopathologists, rather than years of postgraduate specialist experience appeared to influence the rate of usage and choice of antibodies.

Acquired perforating calcific collagenosis in a drug addict with rhabdomyolysis and transient hypercalcemia.

Acquired perforating calcific collagenosis (APCC), which is characterized by the calcification of dermal collagen fibers with subsequent transepidermal elimination and perforation, is an extremely rare entity. Thus far, it has only been reported in a patient with direct contact exposure to calcium chloride. Here, we report a unique case of APCC occurring in a drug addict admitted for rhabdomyolysis. The present case is a 20-year-old male patient hospitalized for drug-related rhabdomyolysis and multiple organ damage. During hospitalization, he gradually developed unusual skin rashes. There were multiple confluent umbilicated and keratotic erythematous to brownish papules and plaques with scratch-like linear plaques on his lower abdomen, inguinal areas and gluteal sulci. Also, multiple well-demarcated flesh-colored rough, hard and thin plaques with a "crepe paper"-like texture were found on the bilateral popliteal fossae, olecranon fossae and axillae. The histopathology of two biopsied lesions demonstrated acquired perforating calcific collagenosis. The lesions appeared during the rhabdomyolysis-related hypercalcemia phase and resolved spontaneously after the calcium level returned to normal. This is the first reported case of disseminated APCC occurring during transient hypercalcemia due to rhabdomyolysis.

Modification of cerebral vascular anatomy induced by Leo stent placement depending on the site of stenting: A series of 102 cases.

BACKGROUND AND PURPOSE: Recent studies demonstrated the capacity of stents to modify cerebral vascular anatomy. This study evaluates arterial anatomy deformation after Leo stent placement according to the stenting site and the impact on the immediate postoperative and six-month degree of aneurysmal occlusion. MATERIALS AND METHODS: A total of 102 stents were placed against the neck of aneurysms situated in the anterior cerebral circulation. Aneurysms were classified into two groups: The first was called the distal group (n = 62) and comprised aneurysms situated in the middle cerebral and anterior communicating arteries and the second was called the proximal group (n = 40) and comprised aneurysms in other sites. The stented arterial segment was classified as deformed or non-deformed by blinded review and superimposition of anonymised films before and after stenting. The degree of occlusion was determined immediately postoperatively and at six months. RESULTS: Significantly, anatomical deformity was observed in the distal group compared to the proximal group (85% vs 28%). No significant difference was observed between the two groups in terms of postoperative degree of occlusion. At six months, a significant difference was observed between the two groups: three recurrences in the distal group vs 10 recurrences in the proximal group. Two (3%) recurrences were observed in the deformed group vs 11 (31%) recurrences in the non-deformed group. CONCLUSIONS: Arterial deformity induced by stenting is even more marked for distal aneurysms. The recurrence rate is smaller when the stent placement results in an arterial anatomical change. The percentage of recurrence is lower when anatomy was amended by stent implantation.

Multidisciplinary efforts toward sustained road safety benefits: integrating place-based and people-based safety analyses.

RELEVANT LOCAL INJURY EPIDEMIOLOGY: In Hong Kong, there were, on average, about 19 596 traffic crashes involving 157 deaths and 21 106 injured persons each year between 2006 and 2011. Scientific analyses were conducted by geographers and engineers primarily using the police crash database. Medical professionals have been analysing road traffic injury data from hospital discharge summaries. Moreover, community leaders have been trying to promote local safe communities. BEST PRACTICES: This paper describes the effort of a multidisciplinary team to address road safety problems and to sustain road safety benefits through a public health approach. The multidisciplinary team comprised a geographer, an engineer, medical professionals and community leaders. The project covered four tasks, namely data integration, identification of hazardous road locations, crash analysis and engineering study, and knowledge exchange through various activities involving a WHO-designated local safe community. IMPLEMENTATION: The crash and hospital databases for a district in Hong Kong with 500 000 population were integrated. Based on the integrated database, the public health and people-based approach was adopted to identify hazardous road locations--hot zones--using geographical information systems. Specific hot zones having strong patterns of common factors were considered as treatable locations with a combination of low-cost remedial measures. The benefits of the project are sustained through various activities engaging the general public and major stakeholders. RESEARCH AGENDA: More research should be conducted on how institutional support, scientific research and community involvement can be fruitfully combined to achieve the ultimate goal of sustained road safety benefits for people at the community level.

Endovascular treatment of renal aneurysms: a series of 18 cases.

PURPOSE: To retrospectively analyze the results and complications of the endovascular treatment of 18 renal aneurysms. METHODS: From 2002 to 2011, 15 patients (aged 31-76), with 18 renal aneurysms, were admitted in our institution for treatment by embolization. Except one, all were wide-necked aneurysms. One aneurysm was treated by occluding the parent artery considering its distal location; a small-necked aneurysm was treated by simple coiling, and the remaining 16 were embolized utilizing adjunctive techniques to protect the parent artery. We analyzed the rates of technical success, complication and clinical consequence, post-operative occlusion and recurrence. RESULTS: There was a 100% technical success rate. 15 aneurysms showed a total occlusion on the post-treatment angiogram. 2 aneurysms demonstrated neck remnants, and one had an intrasaccular residual in-flow. Two minor post-operative complications were encountered but resolved over time. No delayed clinical complications were observed and the long-term angiographic follow-up demonstrated stability of the occlusion of the target renal aneurysm with no major recurrence. CONCLUSION: Complications of the embolization of renal aneurysms are rare. Endovascular treatment should therefore be considered at first for the treatment of renal aneurysms.

Endovascular treatment of recurrent coiled aneurysms: assessment of complications and rebleeding during a decade in a single center.

Recurrence is the main drawback of aneurysmal coiling. Additional coiling must sometimes be considered in patients with reopened aneurysms and expose the patient to the risk of a new procedure. Our purpose was to assess the procedural complications of additional endovascular treatments in patients with previously coiled but recurrent aneurysms treated by two neurointerventionalists during a decade in a single center. Between 1999 and 2009, 637 intracranial aneurysms were coiled and had a clinical and angiographic follow-up at our institution. Following the first embolization, 44 aneurysms were retreated with coils and 11 were retreated a second time. Retreatment was decided when a recurrence showed at angiographic follow-up. Early retreatments, performed in the first month after an incomplete or failed initial coiling, were excluded. We retrospectively analysed the procedural complications, rebleeding, clinical and angiographic outcomes of the retreatments. No death or bleeding occurred in these 55 additional procedures. We had three periprocedural thromboembolic complications and the procedural permanent morbidity was 1.8%. Clinical and angiographic follow-ups ranged from six months to nine years (mean: 37 months, median: 36 months). Thirty-seven of the 44 retreated aneurysms (84%) showed a stable occlusion at follow-up. Seven showed a recurrence but were not retreated due to the stability of the packing. No rebleeding was observed during the follow-up period. Our results show that endovascular treatment of recurrent aneurysms is associated with a low procedural risk.

Endovascular angioplasty before resection of a sphenoidal meningioma with vascular encasement.

We describe a case of sphenoid wing meningioma presenting with cerebral infarction due to extended vascular encasement in which endovascular angioplasty was performed before surgery to avoid perioperative ischemia. A severe stenosis involved the intracranial internal carotid artery and the proximal segments of the middle and anterior cerebral arteries. Endovascular dilatation was followed by complete surgical resection. Preoperative mild aphasia and hemiparesia resolved completely after surgery. Endovascular angioplasty of arterial trunks and their branches can be proposed before the resection of skull base meningiomas encasing these arteries to decrease the risk of perioperative brain ischemia related to their surgical manipulation or vasospasm.

Multiple costimulatory blockade in the peripheral nerve allograft.

BACKGROUND: In the nerve allograft model, costimulation blockade has permitted good regeneration but is still inferior to the nerve isograft. We hypothesize that a short course of multiple costimulatory pathway blockade will be more effective in inhibiting the redundancy of the immune response and improve nerve regeneration through the nerve allograft. METHODS: The murine sciatic nerve allograft model was used to reconstruct a 1 cm sciatic nerve gap. Treatment consisted of the inhibition of the CD40, CD28/B7 and ICOS pathways and was compared with only single or double costimulation blockade. Assessment methods included quantitative histomorphometry and ELISPOT assay to quantify the host immune response after 3 weeks post-operatively. RESULTS: Triple costimulation blockade permitted regeneration through the nerve allograft that was equivalent to the nerve isograft. A short course of three doses was more effective than a single dose for all combinations tested. ELISPOT assay demonstrated minimal in vitro immune response with a short course of double or triple pathway-blocking agents. CONCLUSION: Costimulation blockade, especially with the simultaneous inhibition of multiple pathways, remains a promising strategy to promote regeneration through the peripheral nerve allograft, and may be uniquely suited to the temporary immunosuppressive requirements of the peripheral nerve allograft.

Restenosis after balloon angioplasty for cerebral vasospasm.

Transluminal balloon dilatation for symptomatic vasospasm after subarachnoid hemorrhage is effective, and clinical studies have shown that it achieves long-lasting dilatation of spastic cerebral arteries. Delayed arterial renarrowing has not been reported. Here we report the case of a 58-year-old woman who presented asymptomatic and permanent restenosis after angioplasty for cerebral vasospasm.

Identification of SOX4 target genes using phylogenetic footprinting-based prediction from expression microarrays suggests that overexpression of SOX4 potentiates metastasis in hepatocellular carcinoma.

A comprehensive microarray analysis of hepatocellular carcinoma (HCC) revealed distinct synexpression patterns during intrahepatic metastasis. Recent evidence has demonstrated that synexpression group member genes are likely to be regulated by master control gene(s). Here we investigate the functions and gene regulation of the transcription factor SOX4 in intrahepatic metastatic HCC. SOX4 is important in tumor metastasis as RNAi knockdown reduces tumor cell migration, invasion, in vivo tumorigenesis and metastasis. A multifaceted approach integrating gene profiling, binding site computation and empirical verification by chromatin immunoprecipitation and gene ablation refined the consensus SOX4 binding motif and identified 32 binding loci in 31 genes with high confidence. RNAi knockdown of two SOX4 target genes, neuropilin 1 and semaphorin 3C, drastically reduced cell migration activity in HCC cell lines suggesting that SOX4 exerts some of its action via regulation of these two downstream targets. The discovery of 31 previously unidentified targets expands our knowledge of how SOX4 modulates HCC progression and implies a range of novel SOX4 functions. This integrated approach sets a paradigm whereby a subset of member genes from a synexpression group can be regulated by one master control gene and this is exemplified by SOX4 and advanced HCC.

Late-onset post-transplant lymphoproliferative disease presenting as massive occult gastrointestinal haemorrhage.

Post-transplant lymphoproliferative disease (PTLD) is a widely-recognised complication of solid organ transplants with a myriad of clinical presentations. We report a 56-year-old Chinese woman who developed PTLD 17 years after a renal transplant. She initially presented with constitutional symptoms, and a diagnosis of diffuse large B-cell lymphoma was confirmed on liver biopsy. Staging computed tomography demonstrated widespread adenopathy. Initial treatment consisted of reduction of immunosuppression and Rituximab. Prior to institution of chemotherapy, she presented with life-threatening melaena. Laparotomy revealed a mid-jejunal ulcerating tumour which was resected. Histology confirmed necrotic diffuse large B-cell lymphoma and the cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) chemotherapy regime was subsequently commenced. The aim of this case report is to highlight the unique challenges in the management of PTLD in the context of an acute abdomen.

Prospective evaluation of transient elastography for the diagnosis of hepatic fibrosis in Asians: comparison with liver biopsy and aspartate transaminase platelet ratio index.

BACKGROUND: Transient elastography (TE) is a reliable non-invasive predictor of hepatic fibrosis, but data on TE in Asians are limited. AIM: To evaluate prospectively the accuracy of TE for diagnosis of hepatic fibrosis in Asians compared with APRI (aspartate transaminase to platelet ratio index). METHODS: One hundred and twenty consecutive patients who underwent liver biopsy were enrolled. TE (Fibroscan) was performed by two independent operators. Fibrosis was graded by two independent pathologists using the METAVIR classification. Area under receiver operating curves (AUROC) were used to evaluate the accuracy of TE and APRI in diagnosing significant fibrosis (F >or= 2) and cirrhosis (F4). RESULTS: Predominant aetiologies were hepatitis B (48%), non-alcoholic steatohepatitis (14%) and hepatitis C (8%). TE was unsuccessful in five patients (4.2%) because of small inter-costal space (three patients), obesity and ascites. There was good correlation between TE and fibrosis (r = 0.606). AUROC for diagnosis of significant fibrosis was 0.856 (95% CI 0.779-0.932) for TE and 0.673 (95% CI 0.568-0.777) for APRI. AUROC for diagnosis of cirrhosis was 0.924 (95% CI 0.857-0.990) for TE and 0.626 (95% CI 0.437-0.815) for APRI. Optimal TE value was 9.0 kPa for diagnosis of significant fibrosis and 16.0 kPa for cirrhosis with specificity/sensitivity/PPV/NPV/accuracy of 82.6%/85.2%/80.9%/86.7%/84.1% and 88.9%/82.7%/32.0%/98.8%/83.2%, respectively. CONCLUSIONS: Transient elastography is a reliable predictor of hepatic fibrosis in Asians. Failure of TE in Asians is commonly because of small inter-costal space. TE is superior to APRI for non-invasive diagnosis of hepatic fibrosis and cirrhosis.

Adenocarcinoma of the anal transitional zone after double stapled ileal pouch-anal anastomosis for ulcerative colitis.

The development of adenocarcinoma in the anal transitional zone, after restorative proctocolectomy for ulcerative colitis, is rare. We report the first Asian and sixth known case. A 41-year-old Indian lady had a long standing history of ulcerative colitis. Restorative proctocolectomy and stapled ileal pouch-anal anastomosis without mucosectomy was performed. She remained asymptomatic until 3 years later when she complained of discomfort on defecation. A poorly differentiated adenocarcinoma in the anal transition zone was diagnosed and she subsequently underwent an abdomino-perineal resection. The previously reported cases in the literature are reviewed. We also discuss the suggested surveillance for high-risk patients who have undergone an ileal-anal pouch anastomosis.

Giant intracerebral telangiectasia in a case of blue rubber-bleb nevus syndrome.

Blue rubber-bleb nevus syndrome is a rare condition that consists of multiple venous malformations involving several organ systems, mainly the skin and gastrointestinal tract. Involvement of the central nervous system is particularly rare. We describe a patient with a huge intracerebral telengiectasia revealed by a progressive neurological deficit.

Significance of serum hepatocyte growth factor levels in patients with hepatocellular carcinoma undergoing hepatic resection.

BACKGROUND: Hepatocyte growth factor (HGF) is a potent hepatocyte mitogen and may stimulate the proliferation and invasiveness of human hepatocellular carcinoma (HCC) cells through the c-met receptor. This study evaluates the significance of serum HGF levels in patients undergoing HCC resection. STUDY DESIGN: The peripheral and portal sera and HCC and non-tumorous tissues of 40 HCC patients, with tumor TNM stage I (n=12), II (n=17), and III (n=11) diseases, who underwent hepatic resection were prospectively collected. Serum HGF levels were determined by enzyme-linked immunosorbent assay. The c-met protein expressions were examined by immunohistochemistry. Median follow-up time was 69 months. RESULTS: The prehepatectomy portal HGF levels (median, 622pg/mL) were significantly higher than peripheral HGF levels (564pg/mL) (P=0.026). The posthepatectomy portal HGF levels (699pg/mL) were significantly higher than prehepatectomy portal HGF levels (P<0.001). C-met expression was detected in 87.5% HCC and in 85.0% non-tumorous liver tissues. By Cox multivariate analysis, posthepatectomy portal HGF level >699pg/mL (P<0.001), multiple tumors (P=0.042), and TNM stages II (P=0.019) and III (P=0.009) were independent factors related with survival. Patients with a posthepatectomy portal HCG level >699pg/mL and with a positive c-met expression in HCC tissue have the worst survival. CONCLUSIONS: In HCC patients, high peripheral and portal HGF serum levels related with poor prognosis after hepatic resection. Hepatocyte growth factor and c-met receptor can be targets of future HCC postoperative treatment.

Translation elongation factor eEF1A2 is essential for post-weaning survival in mice.

Translation elongation factor eEF1A, formerly known as EF-1 alpha, exists as two variant forms; eEF1A1, which is almost ubiquitously expressed, and eEF1A2, whose expression is restricted to muscle and brain at the level of whole tissues. Expression analysis of these genes has been complicated by a general lack of availability of antibodies that specifically recognize each variant form. Wasted mice (wst/wst) have a 15.8-kilobase deletion that abolishes activity of eEF1A2, but before this study it was unknown whether the deletion also affected neighboring genes. We have generated a panel of anti-peptide antibodies and used them to show that eEF1A2 is expressed at high levels in specific cell types in tissues previously thought not to express this variant, such as pancreatic islet cells and enteroendocrine cells in colon crypts. Expression of eEF1A1 and eEF1A2 is shown to be generally mutually exclusive, and we relate the expression pattern of eEF1A2 to the phenotype seen in wasted mice. We then carried out a series of transgenic experiments to establish whether the expression of other genes is affected by the deletion in wasted mice. We show that aspects of the phenotype such as motor neuron degeneration relate precisely to the relative expression of eEF1A1 and eEF1A2, whereas the immune system abnormalities are likely to result from a stress response. We conclude that loss of eEF1A2 function is solely responsible for the abnormalities seen in these mice.

Dissection of the posteroinferior cerebellar artery: clinical characteristics and long-term follow-up in five cases.

BACKGROUND AND PURPOSE: Spontaneous isolated posteroinferior cerebellar artery (PICA) dissection is very rare. The aim of the study was to investigate the clinical manifestations, the neuroradiological aspects and the treatment of 5 cases collected in 5 years. METHODS AND RESULTS: From 1999 to 2003, five patients (40-71 years old) were hospitalized for PICA dissection. Two patients presented symptoms after cervical manipulation. No predisposing factor or traumatic cause was described in the other cases. The diagnosis was carried out by cerebral angiography in all the cases: in 4, angiography showed focal stenosis with saccular or fusiform dilatation of the artery at the site of the dissection; in 1 a double lumen aspect was described. One patient presented ischemic manifestations; he was treated with heparin. The others presented subarachnoid hemorrhage (SAH) and were treated by embolization (endovascular sacrifice of the PICA). No ischemic complication and no rebleeding were observed after sacrifice of the PICA. Three patients presented acute hydrocephalus and were treated with surgical derivation. The angiographic and clinical follow-up lasted more than 3 years. We assessed the long-term results with the Glasgow Outcome Score and the modified Rankin Score. A good recovery was achieved for 4 patients (modified Rankin Score 0); one patient who presented SAH and who was in bad clinical state on admission had a Glasgow Outcome Score of 3 and a modified Rankin Score of 4 three years later. CONCLUSION: Clinical course and prognosis are variable in PICA dissections. The treatment depends on the existence of a hemorrhagic event. In the group of patients presenting SAH, endovascular treatment was safe and effective. The long-term clinical results depend mainly on the clinical status on admission.

Clinicopathological significance of survivin expression in patients with hepatocellular carcinoma.

AIMS: Survivin, a newly discovered member of the inhibitor of apoptosis protein family, is suggested to be involved in liver carcinogenesis. The aim was to investigate the clinical significance of survivin expression in resected hepatocellular carcinoma (HCC) and paired adjacent non-tumour tissue. METHODS AND RESULTS: Immunohistochemistry, reverse transcriptase-polymerase chain reaction and Western blots were used to examine survivin mRNA and protein levels in 94 specimens of HCC tissues at different TNM stages and the data were correlated with the clinicopathological profiles. Patients were categorized into those with high tumour survivin protein levels (T-N >or= -1) and those with low levels (T-N < -1). Follow-up data were collected prospectively. mRNA levels of survivin and its splice variants in tumour tissue were significantly higher than in paired non-tumour tissue. However, survivin protein levels in paired non-tumour tissue were significantly higher than in tumour tissue from all three TNM stages. Additionally, high tumour survivin protein levels (T-N >or= -1) correlated with a better prognosis and low levels (T-N < -1) with a worse survival rate. CONCLUSIONS: High cytoplasmic survivin protein levels in HCC tissues seem to be an indicator of better prognosis in HCC patients after resection.