TMD-Unet: Triple-Unet with Multi-Scale Input Features and Dense Skip Connection for Medical Image Segmentation.

Deep learning is one of the most effective approaches to medical image processing applications. Network models are being studied more and more for medical image segmentation challenges. The encoder-decoder structure is achieving great success, in particular the Unet architecture, which is used as a baseline architecture for the medical image segmentation networks. Traditional Unet and Unet-based networks still have a limitation that is not able to fully exploit the output features of the convolutional units in the node. In this study, we proposed a new network model named TMD-Unet, which had three main enhancements in comparison with Unet: (1) modifying the interconnection of the network node, (2) using dilated convolution instead of the standard convolution, and (3) integrating the multi-scale input features on the input side of the model and applying a dense skip connection instead of a regular skip connection. Our experiments were performed on seven datasets, including many different medical image modalities such as colonoscopy, electron microscopy (EM), dermoscopy, computed tomography (CT), and magnetic resonance imaging (MRI). The segmentation applications implemented in the paper include EM, nuclei, polyp, skin lesion, left atrium, spleen, and liver segmentation. The dice score of our proposed models achieved 96.43% for liver segmentation, 95.51% for spleen segmentation, 92.65% for polyp segmentation, 94.11% for EM segmentation, 92.49% for nuclei segmentation, 91.81% for left atrium segmentation, and 87.27% for skin lesion segmentation. The experimental results showed that the proposed model was superior to the popular models for all seven applications, which demonstrates the high generality of the proposed model.

Corrigendum to "Speed Improvement in Image Stitching for Panoramic Dynamic Images during Minimally Invasive Surgery".

[This corrects the article DOI: 10.1155/2018/3654210.].

A transgenic inducible GFP extracellular-vesicle reporter (TIGER) mouse illuminates neonatal cortical astrocytes as a source of immunomodulatory extracellular vesicles.

Extracellular vesicles (EVs) are cellular derived particles found throughout the body in nearly all tissues and bodily fluids. EVs contain biological molecules including small RNAs and protein. EVs are proposed to be transferred between cells, notably, cells of the immune system. Tools that allow for in vivo EV labeling while retaining the ability to resolve cellular sources and timing of release are required for a full understanding of EV functions. Fluorescent EV fusion proteins are useful for the study of EV biogenesis, release, and identification of EV cellular recipients. Among the most plentiful and frequently identified EV proteins is CD9, a tetraspanin protein. A transgenic mouse containing a CRE-recombinase inducible CAG promoter driven CD9 protein fused to Turbo-GFP derived from the copepod Pontellina plumata was generated as an EV reporter. The transgenic inducible GFP EV reporter (TIGER) mouse was electroporated with CAG-CRE plasmids or crossed with tamoxifen inducible CAG-CRE-ERT2 or nestin-CRE-ERT2 mice. CD9-GFP labeled cells included glutamine synthetase and glial fibrillary acidic protein positive astrocytes. Cortical astrocytes released ~136 nm EVs that contained CD9. Intraventricular injected EVs were taken up by CD11b/IBA1 positive microglia surrounding the lateral ventricles. Neonatal electroporation and shRNA mediated knockdown of Rab27a in dorsal subventricular zone NSCs and astrocytes increased the number of CD11b/IBA1 positive rounded microglia. Neonatal astrocyte EVs had a unique small RNA signature comprised of morphogenic miRNAs that induce microglia cytokine release. The results from this study demonstrate that inducible CD9-GFP mice will provide the EV community with a tool that allows for EV labeling in a cell-type specific manner while simultaneously allowing in vivo experimentation and provides evidence that EVs are required immunomodulators of the developing nervous system.

Speed Improvement in Image Stitching for Panoramic Dynamic Images during Minimally Invasive Surgery.

Minimally invasive surgery (MIS) minimizes the surgical incisions that need to be made and hence reduces the physical trauma involved during the surgical process. The ultimate goal is to reduce postoperative pain and blood loss as well as to limit the scarring area and hence accelerate recovery. It is therefore of great interest to both the surgeon and the patient. However, a major problem with MIS is that the field of vision of the surgeon is very narrow. We had previously developed and tested an MIS panoramic endoscope (MISPE) that provides the surgeon with a broader field of view. However, one issue with the MISPE was its low rate of video stitching. Therefore, in this paper, we propose using the region of interest in combination with the downsizing technique to improve the image-stitching performance of the MISPE. Experimental results confirm that, by using the proposed method, the image size can be increased by more than 160%, with the image resolution also improving. For instance, we could achieve performance improvements of 10× (CPU) and 23× (GPU) as compared to that of the original method.

Probing for congenital nasolacrimal duct obstruction.

BACKGROUND: Congenital nasolacrimal duct obstruction (NLDO) is a common condition causing excessive tearing in the first year of life. Infants present with excessive tearing or mucoid discharge from the eyes due to blockage of the nasolacrimal duct system, which can result in maceration of the skin of the eyelids and local infections, such as conjunctivitis, that may require antibiotics. The incidence of nasolacrimal duct obstruction in early childhood ranges from 5% to 20% and often resolves without surgery. Treatment options for this condition are either conservative therapy, including observation (or deferred probing), massage of the lacrimal sac and antibiotics, or probing the nasolacrimal duct to open the membranous obstruction at the distal nasolacrimal duct. Probing may be performed without anesthesia in the office setting or under general anesthesia in the operating room. Probing may serve to resolve the symptoms by opening the membranous obstruction; however, it may not be successful if the obstruction is due to a bony protrusion of the inferior turbinate into the nasolacrimal duct or when the duct is edematous (swollen) due to infection such as dacryocystitis. Additionally, potential complications with probing include creation of a false passage and injury to the nasolacrimal duct, canaliculi and puncta, bleeding, laryngospasm, or aspiration. OBJECTIVES: To assess the effects of probing for congenital nasolacrimal duct obstruction. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2016, Issue 8); MEDLINE Ovid (1946 to 30 August 2016); Embase.com (1947 to 30 August 2016); PubMed (1948 to 30 August 2016); LILACS (Latin American and Caribbean Health Sciences Literature Database; 1982 to 30 August 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), last searched 14 August 2014; ClinicalTrials.gov (www.clinicaltrials.gov), searched 30 August 2016; and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), searched 30 August 2016. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared probing (office-based or hospital-based under general anesthesia) versus no (or deferred) probing or other interventions (observation alone, antibiotic drops only, or antibiotic drops plus massage of the nasolacrimal duct). We did not include studies that compared different probing techniques or probing compared with other surgical procedures. We included studies in children aged three weeks to four years who may have presented with tearing and conjunctivitis. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion and independently extracted data and assessed risk of bias for the included studies. We analyzed data using Review Manager software and evaluated the certainty of the evidence using GRADE. MAIN RESULTS: We identified two RCTs and no ongoing studies; one of the included RCTs was registered. The studies reported on 303 eyes of 242 participants who had unilateral or bilateral congenital nasolacrimal duct obstruction. For both included studies, the interventions compared were immediate office-based probing to remove the duct obstruction versus deferred probing, if needed, after 6 months of observation or once the child reached a certain age.The primary outcome of the review, treatment success at 6 months, was reported partially in one study. Treatment success was not reported at this time point for all children in the immediate probing group; however, 77 of 117 (66%) eyes randomized to deferred probing had resolved without surgery 6 months after randomization and 40 (34%) eyes did not resolve without probing. For children who had unilateral NLDO, those randomized to immediate probing had treatment success more often than those who were randomized to deferred probing (RR 1.41, 95% CI 1.12 to 1.78; 163 children; moderate-certainty evidence). Treatment success for all children was assessed in the study at age 18 months; as an ad hoc analysis in the included study, results were presented separately for children with unilateral and bilateral NLDO (RR 1.13, 95% CI 0.99 to 1.28 and RR 0.86, 95% CI 0.70 to 1.06, respectively; very low-certainty evidence).In the other small study (26 eyes of 22 children), more eyes that received immediate probing were cured within one month after surgery compared with eyes that were randomized to deferred probing and analyzed at age 15 months (RR 2.56, 95% CI 1.16 to 5.64). We considered the evidence to be low-certainty due to imprecision from the small study size and risk of bias concerns due to attrition bias.One study reported on the number of children that required reoperation; however, these data were reported only for immediate probing group. Nine percent of children with unilateral NLDO and 13% with bilateral NLDO required secondary procedures.One study reported cost-effectiveness of immediate probing versus deferred probing. The mean cost of treatment for immediate probing was less than for deferred probing; however, there is uncertainty as to whether there is a true cost difference (mean difference USD -139, 95% CI USD -377 to 94; moderate-certainty evidence).Reported complications of the treatment were not serious. One study reported that there were no complications for any surgery and no serious adverse events, while the other study reported that bleeding from the punctum occurred in 20% of all probings. AUTHORS' CONCLUSIONS: The effects and costs of immediate versus deferred probing for NLDO are uncertain. Children who have unilateral NLDO may have better success from immediate office probing, though few children have participated in these trials, and investigators examined outcomes at disparate time points. Determining whether to perform the procedure and its optimal timing will require additional studies with greater power and larger, well-run clinical trials to help our understanding of the comparison.

Kidney adysplasia and variable hydronephrosis, a new mutation affecting the odd-skipped related 1 gene in the mouse, causes variable defects in kidney development and hydronephrosis.

Many genes, including odd-skipped related 1 (Osr1), are involved in regulation of mammalian kidney development. We describe here a new recessive mutation (kidney adysplasia and variable hydronephrosis, kavh) in the mouse that leads to downregulation of Osr1 transcript, causing several kidney defects: agenesis, hypoplasia, and hydronephrosis with variable age of onset. The mutation is closely associated with a reciprocal translocation, T(12;17)4Rk, whose Chromosome 12 breakpoint is upstream from Osr1. The kavh/kavh mutant provides a model to study kidney development and test therapies for hydronephrosis.

Effect of dietary monosaccharides on Pseudomonas aeruginosa virulence.

BACKGROUND: Pseudomonas aeruginosa is an opportunistic, gram-negative pathogen associated with many hospital-acquired infections and disease states. In particular, P. aeruginosa has been identified as a crucial factor in the pathogenesis of neonatal necrotizing enterocolitis (NEC). This condition presents more frequently in infants fed a formula-based diet, which may be a result of the specific monosaccharide content of this diet. We hypothesized that P. aeruginosa would express virulence genes differentially when exposed to monosaccharides present in formula versus those in human milk. METHODS: Using the results of a metabolomics study on infant diets and their resulting fecal samples, we identified several monosaccharides that distinguished milk from formula diets. Of these compounds, four were found to be metabolized by P. aeruginosa. We subsequently grew P. aeruginosa in tryptic soy broth (TSB) supplemented with these four monosaccharides and used quantitative reverse transcriptase-polymerase chain reaction to measure the expression of 59 major P. aeruginosa virulence genes. The results were standardized to an external control of P. aeruginosa grown in TSB alone. RESULTS: P. aeruginosa did not respond differentially to the monosaccharides after 6 h of growth. However, after 24 h, the organism grown in arabinose (present in formula), xylose (present in human milk), and galactose (present in both formula and feces from milk-fed infants) displayed a significant increase in the expression of virulence genes in all categories. In contrast, P. aeruginosa grown in mannose (present in the feces of milk-fed infants) displayed a significant decrease in virulence gene expression. CONCLUSION: These results demonstrate the importance of nutrient content on the relative expression of virulence genes in pathogens that colonize commonly the gut of infants. Understanding the effect of current dietary formulas on virulence gene expression in various gut-colonizing pathogens may present a new approach to elucidating the differences between human milk and formula in the development of NEC.

Locoregional MYCN-amplified neuroblastoma.

MYCN-amplification is strongly associated with other high-risk prognostic factors and poor outcome in neuroblastoma. Infrequently, amplification of MYCN has been identified in localized tumors with favorable biologic features. Outcome for these children is difficult to predict and optimal treatment strategies remain unclear. We report a 5-month-old who presented with an MYCN-amplified INSS stage 3, pelvic neuroblastoma. The tumor had favorable histology, hyperdiploidy, and lacked 1p36 and 11q23 aberrations. Although the patient met the criteria for high-risk neuroblastoma, because of the discordant prognostic markers we elected to treat her according to an intermediate-risk protocol. She remains event-free more than 18 months.

Postsymptomatic restoration of SMN rescues the disease phenotype in a mouse model of severe spinal muscular atrophy.

Spinal muscular atrophy (SMA) is a common neuromuscular disorder in humans. In fact, it is the most frequently inherited cause of infant mortality, being the result of mutations in the survival of motor neuron 1 (SMN1) gene that reduce levels of SMN protein. Restoring levels of SMN protein in individuals with SMA is perceived to be a viable therapeutic option, but the efficacy of such a strategy once symptoms are apparent has not been determined. We have generated mice harboring an inducible Smn rescue allele and used them in a model of SMA to investigate the effects of turning on SMN expression at different time points during the course of the disease. Restoring SMN protein even after disease onset was sufficient to reverse neuromuscular pathology and effect robust rescue of the SMA phenotype. Importantly, our findings also indicated that there was a therapeutic window of opportunity from P4 through P8 defined by the extent of neuromuscular synapse pathology and the ability of motor neurons to respond to SMN induction, following which restoration of the protein to the organism failed to produce therapeutic benefit. Nevertheless, our results suggest that even in severe SMA, timely reinstatement of the SMN protein may halt the progression of the disease and serve as an effective postsymptomatic treatment.

Common denominators in retained orbital wooden foreign body.

PURPOSE: To identify some of the common denominators in the diverse presentation of retained orbital wooden foreign bodies. METHODS: A review of 9 cases of previously unrecognized retained orbital wooden foreign bodies. Intervention included surgical removal of the foreign bodies in 8 cases and fistula repair in 1 case after spontaneous foreign body extrusion. Outcome measures included return of normal vision, absence of motility disturbance, and resolution of pain, inflammation, eyelid abnormalities, and other symptoms. RESULTS: Presenting symptoms were diverse and included motility disturbance (5 of 9 patients), conjunctival injection with or without discharge (5 of 9 patients), decreased vision (4 of 9 patients), draining fistula (4 of 9 patients), and localized pain or sensation of tightness in the eyelid (4 of 9 patients). Uncommon symptoms included proptosis (2 of 9 patients), ptosis (2 of 9 patients), lower eyelid retraction (2 of 9 patients), and pain on ocular movement (1 of 9 patients). The interval between the injury and the diagnosis of retained wooden foreign body ranged from 10 days to 42 weeks. CONCLUSION: Occasionally, not all of the wooden pieces are removed at the time of initial orbital exploration, despite best efforts. Signs and symptoms of retained orbital wooden foreign body vary greatly. There is no single specific diagnostic or pathognomonic finding. Heightened awareness and a high index of suspicion are keys to proper diagnosis. It is important to have a properly worded consent that includes the possibility of residual wooden foreign bodies and the need for subsequent surgical exploration.

A SMN missense mutation complements SMN2 restoring snRNPs and rescuing SMA mice.

Spinal muscular atrophy (SMA) is an autosomal recessive neurodegenerative disease. Loss of the survival motor neuron (SMN1) gene, in the presence of the SMN2 gene causes SMA. SMN functions in snRNP assembly in all cell types, however, it is unclear how this function results in specifically motor neuron cell death. Lack of endogenous mouse SMN (Smn) in mice results in embryonic lethality. Introduction of two copies of human SMN2 results in a mouse with severe SMA, while one copy of SMN2 is insufficient to overcome embryonic lethality. We show that SMN(A111G), an allele capable of snRNP assembly, can rescue mice that lack Smn and contain either one or two copies of SMN2 (SMA mice). The correction of SMA in these animals was directly correlated with snRNP assembly activity in spinal cord, as was correction of snRNA levels. These data support snRNP assembly as being the critical function affected in SMA and suggests that the levels of snRNPs are critical to motor neurons. Furthermore, SMN(A111G) cannot rescue Smn-/- mice without SMN2 suggesting that both SMN(A111G) and SMN from SMN2 undergo intragenic complementation in vivo to function in heteromeric complexes that have greater function than either allele alone. The oligomer composed of limiting full-length SMN and SMN(A111G) has substantial snRNP assembly activity. Also, the SMN(A2G) and SMN(A111G) alleles in vivo did not complement each other leading to the possibility that these mutations could affect the same function.

Evisceration techniques and implant extrusion rates: A retrospective review of two series and a survey of ASOPRS surgeons.

PURPOSE: To compare implant extrusion rates in two retrospective series of patients, treated by different surgeons, and to determine if there are preferred evisceration and implant insertion techniques among oculoplastic surgeons. METHODS: A retrospective review of cases of evisceration and implant insertion and a survey of oculoplastic surgeons. RESULTS: The implant extrusion rate was zero in the author's series of 53 patients, compared with 27.1% (54 of 192 implants) in series treated by other surgeons. Statistically significant differences were found between the two series in surgical technique, wound care, and duration of antibiotic administration. The author routinely performed posterior sclerotomy, whereas the other surgeons did not. Average implant size was 18.8 mm in the author's series, compared with 13.7 mm in the other series. Antibiotic therapy was administered for 10 to 18 days in the author's series, compared with 28 to 46 days in patients treated by other surgeons. The response rate to the survey was 65% (223 of 343 surveys). Among the surgeons surveyed, immediate and secondary implant techniques were used in nearly equal frequency. Delayed implant technique is used least frequently. Reported implant extrusion rates varied greatly among surgeons, ranging from 0% to 20%. Only 3.9% of surgeons expressed a concern over sympathetic ophthalmia. CONCLUSIONS: Injudicious antibiotic use and smaller implants do not decrease the risk of implant extrusion. The survey revealed that immediate and secondary implant techniques are used with equal frequency. The theoretical risk of sympathetic ophthalmia does not appear to be a concern to most surgeons.

METRO taxonomy - progress report on assessment.

The Medical Education Taxonomy Research Organization (METRO) was formed to map and create terms to comprehensively describe the processes, procedures and concepts of medical education. The terms will be used in a variety of purposes, such as describing content for retrieval from e-learning environments, indexing literature in databases, and extracting and exchanging data for research, such as for BEME systematic reviews. METRO has now completed an extensive set of descriptors for assessment, which are freely available at http://metro2.blogspot.com. The organization welcomes the response and participation of all medical education professionals.

A comparison of implant extrusion rates and postoperative pain after evisceration with immediate or delayed implants and after enucleation with implants.

PURPOSE: To examine implant extrusion rates after evisceration with immediate or delayed implants in patients with culture-proven endophthalmitis. To compare postevisceration and postenucleation pain. METHODS: This prospective, nonrandomized interventional case series included four groups of patients: group 1, 25 endophthalmitis patients undergoing evisceration with immediate implants; group 2, 15 endophthalmitis patients undergoing evisceration with delayed implants; group 3, 31 patients without endophthalmitis undergoing evisceration with immediate implants; and group 4, eight patients undergoing enucleations with implants. Standardized techniques and follow-up schedules were used. Postoperative pain was assessed by weighted frequency of pain medications used during two 48-hour periods. Statistical analysis was performed. Retrospective review of two series of patients undergoing evisceration was performed. RESULTS: No cases of implant extrusion occurred during an average follow-up of 37.9 months. Average implant size was 19.0 mm. Conjunctival dehiscence occurred in one patient. Average total pain scores were 20.8 in endophthalmitis patients with immediate implants; 22.1 in endophthalmitis patients with delayed implants; 20.3 in patients without endophthalmitis and with immediate implants; and 23.1 in patients with enucleations and immediate implant insertions. Retrospective review suggested possible causes of implant extrusion. CONCLUSION: Both immediate and delayed implant techniques appear safe in patients with endophthalmitis, with the former being simpler, more cost-effective, and perhaps less painful. Prolonged antibiotic therapy and smaller implants may render a false sense of security against implant extrusion; good surgical technique and meticulous postoperative wound care are essential. Postenucleation pain appears more severe than postevisceration pain.

METRO--the creation of a taxonomy for medical education.

AIMS: There is a proven and immediate need for a shared vocabulary for medical education in the United Kingdom, both to support the practice of medical education and the research of medical education practice. It would be inefficient to create a complete and independent vocabulary from scratch, the proposed alternative being to create differential terms between the MeSH and BET vocabularies. METHODS: Existing schemas were reviewed against the needs of stakeholders. Seed terms were submitted to the METRO work environment, discussed, scoped and voted upon. RESULTS: A set of procedures, initial terms and recommendations for further development are the principal deliverables from METRO's first phase, while the ongoing second phase will see the creation and testing of an essential branch of descriptors for assessment. CONCLUSIONS: Further work in a number of areas will be required and long-term issues of resourcing and sustainability have yet to be substantially addressed to allow for full adoption by the user community.

Silicone nasolacrimal intubation with mitomycin-C: a prospective, randomized, double-masked study.

OBJECTIVE: To determine if mitomycin-C (MMC) application during silicone intubation (SI) can effectively substitute for dacryocystorhinostomy (DCR) or Jones tube insertion. DESIGN: A prospective, randomized, double-masked study. PARTICIPANTS: Twenty-four patients (7 males, 17 females; aged 2-69 years) with 27 eyes (three bilateral cases) with an obstructed lacrimal system who were candidates for DCR or Jones tube. METHODS: All study patients underwent SI with application in a randomized, double-masked fashion of MMC or placebo, with the former receiving 0.2 mg/ml MMC for 2 minutes before SI. MAIN OUTCOME MEASURES: Clinical assessment of tearing and discharge; Schirmer I and II tests at 1, 3, 6, and 12 months; and the need for eventual DCR or Jones tube insertion. RESULTS: Follow-up ranged from 13 to 23 months (mean, 18 months; median, 17 months). Seven of the 12 eyes in the MMC group and 8 of the 15 eyes in the placebo group had a successful outcome and remained symptom free. The difference was not statistically significant (P = 0.79). Dacryocystorhinostomy or Jones tube was performed in five eyes in the MMC group and in seven eyes in the placebo group 3 to 18 months later; all had successful outcome and no complications. Untoward effects of MMC application included a slit canaliculus and a transient conjunctival injection. A successful outcome using this combined technique does not appear to correlate with age, gender, laterality, and intraoperative bleeding observed at the punctum or for the duration of symptoms. CONCLUSIONS: Mitomycin-C application during SI did not benefit outcome. Complications from such application were mild and infrequent.

Reassessment of sphenoid dysplasia associated with neurofibromatosis type 1.

BACKGROUND AND PURPOSE: Sphenoid dysplasia associated with neurofibromatosis type 1 is classically thought to be primarily related to abnormal development of the sphenoid bone. We investigated the possibility that these changes may be progressive. METHODS: We conducted a retrospective review of sphenoid bone changes in all patients with craniofacial neurofibromatosis type 1 who had undergone CT (31 patients) and MR imaging (seven patients) at our facility. A review of repeat images of 20 patients permitted analysis of progressive sphenoid bone changes. RESULTS: Eighteen patients had abnormalities of the sphenoid wings, 13 of whom also had enlargement of the middle cranial fossa compatible with descriptions of classic sphenoid dysplasia. All the patients with sphenoid dysplasia had neurofibromas in the ipsilateral superficial temporal fossa that were often contiguous with a radiologically abnormal temporo-squamosal suture. All except one had tumor infiltration in the deep orbit, contiguous with the sphenoid wings. Four patients had radiologic evidence of progressive sphenoid bone changes over time. CONCLUSION: The origin of sphenoid bone changes may be multifactorial. A modified concept of sphenoid dysplasia is proposed that emphasizes interaction between neurofibromas and sphenoid bone during skull development.

Retained orbital wooden foreign body: a surgical technique and rationale.

OBJECTIVE: To emphasize the potential complications of a retained orbital wooden foreign body (WFB) and the rationale of a surgical technique. DESIGN: Two interventional case reports. PARTICIPANTS: Two patients sustained an orbital WFB injury. Both patients had ocular complications despite repeated attempts to remove the suspected residues. INTERVENTION: Computed tomography and magnetic resonance imaging of both patients at different intervals revealed evidence of orbital foreign body migration toward the cranium. A surgical technique combing transcranial and orbital approaches was used to remove the residues. MAIN OUTCOME MEASURES: Preoperative and postoperative vision, proptosis, ocular motility, and various ocular symptoms and signs. RESULTS: In both patients, no postoperative complications were seen, and all preoperative symptoms and signs were resolved at 9- and 19-month follow-ups, respectively. CONCLUSIONS: A retained orbital WFB can cause early or late complications and is known to have the potential to migrate intracranially. In selected patients, a team approach may be the best technique to ensure complete removal.