Systematic Review and Case of Thrombectomy for Pediatric Stroke Due to Myxoma Embolism.

BACKGROUND: Stroke presentation secondary to a cardiac myxoma thromboembolism is rare in the pediatric population. Because of such rarity, the reported cases in the literature are primarily case reports. Additionally, general pediatric stroke management lacks evidence-based guidelines because of its low incidence and lack of clinical trials. In pediatric strokes identified from a cardiac myxoma, the incidence favors boys with the classical presentation of unilateral weakness and aphasia. We present a pediatric patient who presented with strokelike symptoms secondary to an intracranial embolus from a previously undiagnosed cardiac myxoma. METHODS: We performed a systematic review by searching PubMed, Google Scholar, Web of Science, and Embase databases for cases of pediatric myxoma causing stroke (n = 2431) and identified 19 reported uses of surgical management in treating pediatric patients who present with stroke symptoms secondary to a cardiac myxoma thromboembolism. RESULTS: The most common imaging modality was magnetic resonance imaging in 42% of cases, computed tomography in 36.8%, followed by computed tomography angiography in 31.6% of cases. Of these 19 children treated with procedures, 36.8% of pediatric patients aged between 4 and 14 years underwent neurosurgery (n = 7). CONCLUSIONS: We describe an urgent mechanical thrombectomy and share preoperative and postoperative images and pathology slides confirming a stroke from myxoma origin. We provide added insight in the safe use of mechanical thrombectomy as treatment for pediatric strokes secondary to a thromboembolism.

Comparison of pipeline embolization device, flow re-direction endoluminal device and surpass flow diverters in the treatment of intracerebral aneurysms.

OBJECTIVES: The use of flow diversion for the treatment of intracranial aneurysms has gained broad acceptance. Three flow-diverting stents are approved by the Food and Drug Administration for use in the United States. We sought to compare the outcomes and safety profiles between the three devices at our institution. METHODS: A retrospective review of aneurysms treated with pipeline embolization device (PED), flow re-direction endoluminal device (FRED), and SURPASS was performed for aneurysms treated between 2018 and 2022 at our institution. RESULTS: The study cohort consisted of 142 patients. Precisely, 86 aneurysms were treated with a pipeline, 33 aneurysms were treated with FRED, and 23 aneurysms were treated with SURPASS. The 1-year complete occlusion rates were 59.4%, 60%, and 65%, respectively (0.91). Linear regression models found that only adjunctive coiling predicted aneurysm occlusion at 6 months (p = 0.02), but this effect was lost at 1 year and beyond. There was no significant difference in acute thrombotic or acute hemorrhagic complications between the three cohorts. There was a higher rate of delayed hemorrhagic complications in the SURPASS cohort (10%) compared to the PED (1.3%) and FRED (0%) cohorts (p = 0.04). There was also a higher rate of in-stent stenosis in the SURPASS cohort (20%) compared to the PED (5%) and FRED (3.1%) cohorts (p < 0.01). CONCLUSIONS: Treatment with PED, FRED, and SURPASS all resulted in similar complete occlusion rates at 6 months and 1 year. SURPASS was associated with higher in-stent stenosis as well as delayed hemorrhagic complications. Additional future studies evaluating the newest generation of flow-diverting stents with long-term follow-up will be necessary to make any definitive conclusions.

Drainage, Irrigation, and Fibrinolytic Therapy (DRIFT) for Adult Intraventricular Hemorrhage Associated with Primary Hypertensive Hemorrhages Using IRRAflow Self-Irrigating Catheter: A Report of Three Cases and Prior Historical Controls.

BACKGROUND: Spontaneous primary intracerebral hemorrhage (ICH) accounts for 10%-15% of strokes and is accompanied by ventricular involvement in 10%-30% of cases. Intraventricular hemorrhage (IVH) is a poor prognostic factor and the current treatment paradigm of external ventricular drainage requires frequent flushing and replacement. Given the documented high rate of failure standard EVD catheters, we sought to determine if the use of the IRRAflow system with the addition of alteplase would be beneficial in this patient population for the treatment of IVH associated with primary hypertensive ganglionic hemorrhages. METHODS: Three patients with ganglionic hemorrhages and IVH underwent treatment with the IRRAflow system at our institution from December 2022 to January 2023. A retrospective review was then performed of patients with primary hypertensive ganglionic hemorrhages and EVD placement at our institution from January 2021 to present day. RESULTS: Three patients underwent treatment with the IRRAflow system and continuous lavage of Tissue Plasminogen Activator (tPA). The IVH was efficiently cleared in all cases and the drains were removed within 8 days in all cases. No patients required replacement of the drain and there were no hemorrhagic complications noted. In our retrospective review, 28 patients were identified who underwent placement of a standard EVD for the treatment of primary hypertensive ganglionic hemorrhages. When patients who had early withdrawal of care were excluded, the average length of EVD treatment was 11.3 days and the EVD replacement rate was 24%. CONCLUSIONS: We demonstrate here that the use of the IRRAflow system for the treatment of primary hypertensive hemorrhages with IVH results in rapid clearance of the IVH without safety concerns. Compared to historical controls there was a decrease in EVD duration, EVD replacement and, ICU LOS.

Cerebral sinus thrombosis as an initial symptom of acute promyelocytic leukemia: Case report and literature review.

Background: Cerebral sinus thrombosis as presentation of acute promyelocytic leukemia (AMPL) is exceptional, with only three cases registered in the literature. Case Description: A 24-year-old female patient was transferred to our center after a car accident. The patient had a witnessed generalized seizure while driving. Computerized tomography (CT) demonstrated a temporal intraparenchymal hemorrhage and CT venogram diagnosed a cerebral sinus thrombosis on the left transverse and sigmoid sinus. The patient underwent surgical evacuation of the hematoma and was treated with anticoagulation 48 h after surgery. Pancytopenia alerted of a possible hematological disorder. The patient was subsequently diagnosed with AMPL and treated with arsenic trioxide. The patient had a complete neurological recovery with no postoperative complications. Conclusion: The management of cerebral sinus thrombosis in patients with AMPL remains controversial. The previous reported cases of cerebral sinus thrombosis preceding the diagnosis of AMPL are reviewed and treatment of cerebral sinus thrombosis with anticoagulation in the setting of intraparenchymal hemorrhage and bleeding disorders is also discussed.

Composite Score Is a Better Reflection of Patient Response to Chronic Pain Therapy Compared With Pain Intensity Alone.

OBJECTIVE: The pain Numeric Rating Scale (NRS) score became standard when pain was introduced as the fifth vital sign in the 1990s. Although plagued with issues, it remains the basis for primary outcome measures in clinical trials for chronic pain therapies. Multidimensional composite scoring that considers all aspects of the chronic pain experience may provide a more meaningful response measure. Herein we propose a multidimensional responder index. MATERIALS AND METHODS: Data were extracted from an ongoing prospective, multicenter study on DeRidder Burst spinal cord stimulation (B-SCS) for chronic back and/or leg pain (NCT03082261). The analysis cohort consisted of subjects who completed the NRS, Pain Catastrophizing Scale (PCS), EuroQol-5D (EQ-5D), and eight-item Patient-Reported Outcomes Measurement Information System Physical Function preoperatively and at 12 months after implant. RESULTS: A principal component analysis showed that each of the four measures contributed equally to the variance in the data set, confirming that pain score should not be used alone. Subjects who failed to respond on NRS responded on both PCS and EQ-5D. Eighty-one percent of subjects responded on at least two measures. The responder algorithm yielded an 84% success rate at both 6- and 12-month time points. CONCLUSIONS: Our study suggests that therapeutic response, similar to the chronic pain experience, is multidimensional. Careful consideration should be made to incorporate composite endpoints in future SCS clinical trials.

Correlation Between Aspects of Perceived Patient Loneliness and Spinal Cord Stimulation Outcomes.

OBJECTIVES: Loneliness as a whole has been characterized as a health-related risk factor and is associated with worse outcomes after cardiac procedures. Evidence suggests that chronic pain patients are particularly vulnerable to feeling lonely. We examined the relationship between different aspects of loneliness and one-year postoperative outcomes after spinal cord stimulation (SCS) for chronic pain. MATERIALS AND METHODS: We contacted 69 patients with thoracic SCS who had participated in our prospective outcomes database with one-year follow-up to complete the validated, abbreviated UCLA Loneliness Scale (UCLA-3). We examined responses on question 9 of the Oswestry Disability Index (ODI), question 12 of the Beck Depression Inventory (BDI), and UCLA-3 due to their relevance to different aspects of loneliness. We conducted regression analyses to determine the relationship between aspects of loneliness and pain outcomes. RESULTS: We identified that loss of interest in people, companionship, and feeling excluded were associated with pain outcomes. Loss of interest in people was associated with improvement in pain (NRS worst p = 0.021, r = 0.32, NRS least p = 0.004, r = 0.4; NRS right now p = 0.016, r = 0.33). Companionship and feeling excluded were also associated with pain. We examined the interface between depression and total loneliness and found that while both were related to each other, depression was not associated with pain outcomes. CONCLUSIONS: This study demonstrates an association between loss of interest in people, companionship, and feeling excluded and worse postoperative pain outcomes after receiving SCS. It identifies aspects of loneliness as important factors to consider when predicting the outcomes of SCS therapy for chronic pain control.

Anatomy of the Dorsum of the Foot and Its Relevance for Nonsurgical Cosmetic Procedures.

BACKGROUND: Operative procedures to enhance the aesthetic appearance of the feet are associated with risks. Minimally invasive procedures to volumize the dorsum of the foot are to this point not described. The present study investigates the safety and efficacy of such procedures in a retrospective clinical, anatomical, and ultrasound-based study. METHODS: A total of 106 feet from 53 female patients (mean age, 64.1 ± 8.3 years) were investigated retrospectively after the injection of a commercially available calcium hydroxylapatite product using a single-entry proximal-to-distal fanning injection technique. Anatomical dissections in 20 fresh, nonembalmed feet from 10 human body donors (mean age, 83.1 ± 8.8 years) were dissected, and 20 feet from 10 healthy volunteers (mean age, 26.5 ± 6.2 years) were examined by ultrasound imaging to help guide conclusions. RESULTS: Aesthetic outcome after 3 months was graded by the patients as 4, connoting good improvement (range, 3 to 5). No allergic reactions or other types of adverse events were documented. The layered anatomy of the dorsum of the foot was confirmed by anatomical dissections and ultrasound imaging as follows: skin, dorsal superficial fatty layer, dorsal superficial fascia, dorsal intermediate fatty layer, superficial lamina of the dorsal deep fascia, dorsal deep fatty layer, and deep lamina of the dorsal deep fascia. CONCLUSIONS: Minimally invasive injections of soft-tissue filler in the dorsum of the foot can provide an alternate solution to enhance the aesthetic appearance of feet. The present study provides support for the safety and efficacy of volumizing procedures using a 22-gauge, 50-mm, blunt-tip cannula. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Macrocephaly Secondary to Superior Vena Cava Syndrome.

Cardiac defects in neonates are often associated with neurological or neuroanatomical anomalies. We present a patient who developed macrocephaly secondary to superior vena cava syndrome, resultant from repair of her congenital tetralogy of Fallot. She was managed conservatively with serial imaging and close observation from the neurosurgical aspect, and her head growth stabilized without requiring ventriculoperitoneal shunting after stent placement in her superior vena cava. In patients with macrocephaly secondary to cardiac issues, cerebrospinal fluid diversion is often performed quickly. For our patient - who had no obvious signs of worsening intracranial hypertension or symptoms beyond macrocephaly - treatment of her overall cardiovascular issues was successful in achieving stability of her head circumference growth.

When and why was the phrenicoabdominal branch of the left phrenic nerve placed into the esophageal hiatus in German textbooks of anatomy? An anatomical study on 400 specimens reevaluating its course through the diaphragm.

BACKGROUND: The phrenicoabdominal branch of the left phrenic nerve passes between muscle fiber bundles within the costal part of the diaphragm near the pericardium. In most German textbooks of anatomy, however, its passage is described to be found in the esophageal hiatus. The aim of this study was to reevaluate its topography relative to the diaphragm in a multicentric study and to identify the initiation of this description. METHODS: In this multicentric study, the most dorsomedial branch of the left phrenic nerve was identified as the phrenicoabdominal branch in 400 embalmed anatomic specimens of Caucasian origin. The distance between its passage and the apex of the pericardium, the left border of the esophageal hiatus, and the inner aspect of the left sixth rib was measured on the cranial aspect of the diaphragm. Textbooks on human anatomy published in German language between 1700 and 2018 were reviewed for their description of the passage of the left phrenicoabdominal branch through the diaphragm. RESULTS: The first statement on the passage of the left phrenicoabdominal branch through the esophageal hiatus was given in 1791 by Sömmering. Since then, in German textbooks of anatomy, a duality in the description of the passage of the left phrenicoabdominal branch persists. In none of the individuals examined in this study, the left phrenicoabdominal branch passed through the esophageal hiatus. In 99.5% of all cases, it pierced the costal part of the diaphragm dorsal to or at the same level as the apex of the pericardium. The mean distances (standard deviations) were 3.4 (±1.5) cm to the apex of the pericardium, 5.8 (±2.2) cm to the esophageal hiatus, and 5.5 (±1.6) cm to the inner aspect of the left sixth rib. CONCLUSION: The findings on the position of the left phrenicoabdominal branch relative to the diaphragm help to improve topographical knowledge and prevent inadvertent nerve injury during surgical interventions on or near the diaphragm. Further to this, these results may form a substantial basis to adopt the correct description of the passage of the left phrenicoabdominal branch to anatomical textbook knowledge.

The posterior temporal supraSMAS minimally invasive lifting technique using soft-tissue fillers.

BACKGROUND: To investigate the effectiveness of the posterior temporal supraSMAS minimally invasive lifting technique and compared it to experiments performed in fresh human body donors by applying skin vector displacement measurement technology. MATERIALS AND METHODS: A total of 15 patients (14 females/1 male) with a mean age of 37.1 ± 9.4 years and a mean body mass index of 21.4 ± 3.3 kg/m2 were included into this observational analysis. The injection procedure was additionally performed in 2 male and 1 female fresh body donors with a mean age of 85.67 ± 9.7 years and a mean body mass index of 23.83 ± 4.7 kg/m2 . Different grades of skin laxity, variable amounts of product, and the application with and without subcision were tested and measured via three-dimensional reconstructions and surface displacement vectors using Vectra software with VAM module. RESULTS: Esthetic outcome was rated by an independent professional observer and by the patient immediately after the treatment (76.67% ± 17.6% vs 66.67% ± 18.1%) (P = 0.001) and after 1 month (80.00% ± 14.0% vs 75.00% ± 21.1%) (P = 0.19). Skin laxity, subcision, and the application of more than 1.0 cc per side resulted in our experimental setting in a smaller magnitude of skin displacement vectors indicating a reduced lifting effect. CONCLUSION: The posterior temporal supraSMAS minimally invasive lifting procedure seems to be a valid technique to treat temporal volume loss and to reduce the signs of age-related changes in the middle and lower face, ie "marionett line" and jowl deformity.

The layered anatomy of the jawline.

BACKGROUND: To investigate the layered anatomy of the jawline and to provide anatomic background for the formation of the labiomandibular sulcus, the jowl deformity, and the "double-chin" for safe and effective minimally invasive procedures. MATERIALS AND METHODS: Seventy-two fresh-frozen human cephalic cadavers (32 males, 40 females; mean age 75.2 ± 10.9 years, BMI 24.2 ± 6.6 kg/m2 , 99% Caucasian ethnicity) were investigated by layer-by-layer anatomical dissection. Magnet resonance and computed tomographic imaging was additionally carried out to support the anatomical findings. RESULTS: No major neuro-vascular structures were found to run in the subdermal plane or in the subcutaneous fat. The jowl deformity was identified to be caused by the loose adherence of the platysma to the mandible, which occurs posterior (but not anterior) to the mandibular ligament. The formation of the submental sulcus was identified to be caused by the submental septum, an osteo-cutaneous adhesion spanning all facial layers in the submental area. The formation of the labiomandibular sulcus was caused by the change in the subcutaneous fibro-connective arrangement rather than by an underlying adhesion or ligament. CONCLUSION: The layered arrangement of the jawline predisposes this region for subdermal and subcutaneous treatment options located superficial to the platysma. Subdermal subcision procedures might have a beneficial effect on the labiomandibular sulcus as the boundary between the different types of subcutaneous arrangement, which form the sulcus, is being smoothened.