Extreme Lateral Transodontoid Approach for Resection of Clival Chordoma: 2-Dimensional Operative Video.

This 15-yr-old girl presented with nasal obstruction and dysphagia of duration 3 mo and 8 to 10 pounds of weight loss. On examination, she had a hoarse voice and left tongue deviation without weakness or myelopathy. Computed tomography (CT) demonstrated an erosive lesion arising from the clivus and left occipital condyle. Magnetic resonance imaging (MRI) demonstrated a T1-isointense, T2-hyperintense, enhancing mass centered at the occipital condyle and extending into the craniovertebral junction (CVJ), causing severe brainstem compression and extending inferiorly to C2 and anteriorly into the retropharyngeal space. The patient underwent transoral biopsy to confirm the diagnosis of chordoma and complete tumor resection via a left extreme lateral transodontoid (ELTO) approach. This approach was chosen because it provides bilateral exposure to the ventral CVJ and retropharyngeal space and allows for complete tumor removal using a single approach, although it requires an experienced surgeon. The ELTO incision should provide adequate exposure for occipitocervical fusion (OCF) after the destabilization of the CVJ. Transposition of the vertebral artery and odontoidectomy are key maneuvers that provide exposure to the ventral CVJ bilaterally. Dural closure is performed primarily and augmented with fat, fibrin glue, and temporary cerebrospinal fluid diversion. Postoperative MRI showed a gross-total resection and decompression of the brainstem at the CVJ. The patient remained in a cervical collar until OCF. Postoperatively, she had left vocal cord paralysis and moderate weakness with left arm abduction at the deltoid. At 2-mo follow-up, she had improved lower cranial neuropathies, tolerated oral intake, and was scheduled to begin proton beam therapy. The patient provided consent for publication.

Clinical presentation and treatment paradigms in patients with hereditary hemorrhagic telangiectasia and spinal vascular malformations.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder that causes angiodysplasia and results in mucocutaneous telangiectasias and arteriovenous malformations of organs. Although central nervous system vascular malformations can occur anywhere along the neuraxis, spinal vascular malformations are rare. We present our experience with the presentation and management of spinal vascular malformations in patients with HHT. Of the more than 800 patients with the diagnosis of HHT screened at our institution from 1995 through 2017, four patients with spinal vascular malformations (age range 1 month-77 years; 2 male, 2 female) were identified, three of whom came to clinical attention after significant neurological deterioration from previously unknown malformations. A review of the literature including our patients demonstrated 29 total spinal arteriovenous fistulas (AVFs) in 28 HHT patients (69% male). The lesions were located predominantly in the thoracic spine (65.5%). Three lesions were not treated, 17 were treated with embolization, 6 were surgically resected, and 3 were treated with embolization and surgery. In 14 cases, the patients presented with hemorrhage of the AVF. Overall, 79% of patients achieved complete or near-complete occlusion, with 75% reporting improvement in neurological function. Discovery of spinal lesions often occurs after neurological decline because current screening protocols do not include evaluation of the patient for spinal lesions. Most patients benefit from intervention, which is tailored to the characteristics of the patient and their malformation. Given the often-severe neurological deficit encountered at presentation, we favor a protocol that screens HHT patients for spinal vascular malformations.

Clinical presentation and treatment paradigms of brain arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectases, and multisystem arteriovenous malformations (AVMs). Brain AVMs typically present at birth and are identified in approximately 10-20% of patients with HHT. A retrospective review was undertaken of all HHT patients with known single or multiple brain AVMs treated at our institution. Thirty-nine patients with brain AVM(s) were diagnosed with HHT. Most patients presented with at least one Curaçao criterion. A total of 78 brain AVMs were identified in 39 patients. Two-thirds of patients had solitary brain AVMs, whereas 33% of patients harbored at least two lesions (range: 2-16). Brain AVMs of the supratentorial cerebral hemispheres comprised 83% of all lesions, whereas infratentorial lesions accounted for only 17%. Of the 55 brain AVMs assigned Spetzler-Martin grading, the majority of patients were Grade 1 (73%), and 23% and 4% were Grades 2 and 3, respectively. Patients were treated with surgery alone (51%), embolization alone (6%), embolization followed by surgery (9%), stereotactic radiosurgery (11%), stereotactic radiosurgery followed by surgery (3%), or observation (20%). Of patients who underwent genetic analysis, 62% possessed mutations in ENG (HHT type 1), whereas 38% had mutations in ACVRL1 (HHT type 2). This robust patient cohort of brain AVMs in 39 patients with HHT advances the collective understanding of this disease's varied presentation, diagnostic workup, genetic underpinnings, and available treatment options.

Biomaterials selectively modulate interactions between human blood-derived polymorphonuclear leukocytes and monocytes.

Implantation of a biomaterial into the body elicits a host foreign body response, during which polymorphonuclear leukocytes (PMNs) and then monocytes (MCs) are recruited to the site of implantation. MCs and MC-derived macrophages are central players in this response because they secrete proinflammatory and/or pro-wound-healing cytokines and growth factors that influence subsequent healing events. Although mechanisms of MC response to biomaterials are often studied in in vitro monoculture models, few studies have investigated how biomaterials modulate PMN-MC paracrine and juxtacrine interactions. To address this, we cultured human blood-derived MCs alone or in the presence of autologous PMN-conditioned medium (PCM) on poly(ethylene glycol) hydrogels, poly(dimethyl siloxane), and tissue culture polystyrene. We also directly co-cultured autologous PMNs and MCs on these biomaterials. PCM increased MC adhesion/viability and expression of IL-1ß and tumor necrosis factor-α in a biomaterial- and time-dependent manner when compared with MCs that were not cultured in PCM. There were also biomaterial- and time-dependent differences in cell adhesion/viability, apoptosis, and expression of IL-6 and IL-8 in the PMN-MC direct co-cultures when compared with the sums of these activities in PMN and MC monocultures. In conclusion, these data suggest that biomaterials selectively modulate PMN-MC paracrine and juxtacrine interactions to influence MC and/or PMN adhesion/viability, apoptosis, and cytokine expression.

Application of MS-based proteomics to study serum protein adsorption/absorption and complement C3 activation on poly(ethylene glycol) hydrogels.

Although the interaction between cells and poly(ethylene glycol) (PEG) hydrogels is well documented, there lacks a thorough investigation into the adsorption of blood proteins on these surfaces which dictates the observed cellular and in vivo host response. Thus, a clear understanding of how surface-bound proteins mediate the unique biological property of PEG hydrogels is fundamentally important. The information obtained will also provide insights into future biomaterial design. In this study, several mass-spectrometrybased proteomic tools coupled with complementary immunoassays were employed to survey the complex surface-bound serum proteome. The adsorption of vitronectin, thrombin, fibrinogen and complement component C3 was significantly lower on PEG hydrogels than on tissue culture polystyrene (TCPS). Although PEG hydrogels mediated lower C3 adsorption than TCPS, the extent of C3 activation between the two surfaces was comparable. Adherent monocyte density was also significantly lower on PEG hydrogels as compared to TCPS. Taken together, these results support the critical role of the complement C3 in mediating monocyte adhesion on biomaterials. Thus we conclude that the biocompatibility of PEG hydrogels both in vitro and in vivo can be partly contributed to their limited C3 interaction and monocyte activity.