Lead Toxicity From Intradiscal Retained Bullet Fragment: Management Considerations and Recommendations.

BACKGROUND: Lead toxicity (plumbism) secondary to retained lead missiles in synovial joint spaces is a rare complication after gunshot injuries. Management of lead missiles in the intradiscal space regarding potential lead toxicity is less certain. CASE DESCRIPTION: We reviewed the literature regarding lead toxicity secondary to intradiscal bullets particularly concerning incidence, management, and outcomes. A lack of high-quality published data precludes a meta-analysis from taking place. Only four reports of lead toxicity secondary to missiles in the intradiscal space have been published. Including an additional case presented in this report, our review of the literature has led us to make several management recommendations, largely based on both the available literature and our current report. CONCLUSIONS: First, there is insufficient evidence for removing retained lead missiles solely to mitigate the risk of lead toxicity. Second, chelation therapy in addition to surgical removal of the lead source is a valuable adjunct in the perioperative period and should be undertaken with the assistance of medical toxicology. Third, a retained missile does not mandate a simultaneous stabilization procedure in lieu of other indications based on the data available at this time.

Conservative management of a cervical ligamentum flavum hematoma: Case report.

BACKGROUND: Spontaneous epidural hematoma arising from the ligamentum flavum is a rare cause of acute spinal cord compression. There are only four reports in the cervical spine literature, and all were managed with surgery. Here, we describe an acute case of a spontaneous epidural hematoma arising from the ligamentum flavum in the cervical spine successfully managed without surgery. CASE DESCRIPTION: A 69-year-old woman with a cervical spine epidural hematoma contained within the ligamentum flavum presented with paroxysmal neck pain and stiffness without a history of trauma. The magnetic resonance imaging (MRI) revealed a posterolateral epidural hematoma contained within the ligamentum flavum. As the patient was intact, she was managed conservatively with cervical orthosis. Three months later, she was symptom-free, and the hematoma resolved on the follow-up MRI study. CONCLUSION: Spontaneous epidural hematoma arising from ligamentum flavum is a rare cause of spinal cord compression. Previous reports have described success with surgical decompression. However, initial observation and conservative management may be successful as illustrated in this case.

The history of neurosurgery at the University of Rochester.

The Department of Neurosurgery at the University of Rochester has a long legacy of excellent patient care and innovation in the neurosciences. The department's founder, Dr. William Van Wagenen, was a direct pupil of Harvey Cushing and the first president of the Harvey Cushing Society. His successor, Dr. Frank P. Smith, was also a leader in organized neurosurgery and helped to permanently memorialize his mentor with an endowed fellowship that today is one of the most prestigious training awards in neurosurgery. The first 2 chiefs are honored every year by the department with memorial invited lectureships in their names. The department is home to a thriving multidisciplinary research program that fulfills the lifelong vision of its founder, Dr. Van Wagenen.

Cerebrospinal fluid stimulates leptomeningeal and meningioma cell proliferation and activation of STAT3.

The role of cerebrospinal fluid (CSF) in the pathogenesis of meningiomas is unknown. Cell cultures from three human leptomeninges, five WHO grade I and seven grade II meningiomas were treated with remnant CSF from 22 patients with no central nervous system disease and normal cell indices. Cells were evaluated by CyQUANT for DNA synthesis/cell proliferation and by western blots for phosphorylation/activation of growth regulatory pathways activated in meningiomas including JAK1-STAT3, MEK1-p44/42MAPK, Akt-mTOR and Rb. Analysis of Caspase 3 activation and survivin was also performed. Finally, the effects of PDGF neutralizing antibody and cucurbitacin, a STAT3 inhibitor on CSF stimulation were tested. Compared to controls and the mitogen PDGF-BB, various CSF samples significantly stimulated DNA synthesis/cell proliferation in 20 and 22 week leptomeningeal cultures and all of the grade I and II meningioma cells tested. Collectively CSF samples, from multiple different patients, stimulated DNA synthesis in tests of 23 of 32 grade I and 18 of 28 grade II meningioma cells. CSF stimulated phosphorylation/activation of STAT3 and reduced p44/42 MAPK in the leptomeningeal, all three grade I and 1 of three grade II meningioma cells. CSF did not affect Caspase 3 activity or survivin levels. PDGF neutralizing antibody had no effect on CSF stimulation but cucurbitacin blocked PDGF and CSF stimulation. While there are limitations to the CSF available since they were not from "normal" volunteers, the studies suggest that, in some settings, CSF is potentially mitogenic to leptomeningeal and meningioma cells and may act, in part, via activation of STAT3.

Unilateral subfrontal approach to anterior communicating artery aneurysms: A review of 28 patients.

BACKGROUND: The pterional approach is the most common for AComm aneurysms, but we present a unilateral approach to a midline region for addressing the AComm complex. The pure subfrontal approach eliminates the lateral anatomic dissection requirements without sacrificing exposure. The subfrontal approach is not favored in the US compared to Asia and Europe. We describe our experience with the subfrontal approach for AComm aneurysms treated at a single institution. METHODS: We identified 28 patients treated for AComm aneurysms through the subfrontal approach. Patient records and imaging studies were reviewed. Demographics and case data, as well as clinical outcome at 6 weeks and 1 year were collected. RESULTS: Mean patient age was 48 (range 21-75) years and 64% suffered subarachnoid hemorrhage (SAH). All aneurysms were successfully clipped. Gyrus rectus was resected in 57% of cases, more commonly in ruptured cases. Intraoperative rupture occurred in 11% of cases. The average operative time was 171 minutes. There were two patient deaths. Ninety-two percent of patients had a Glasgow Outcome Scale (GOS) of 5 at 6 weeks. All unruptured patients had a GOS of 5. At 12 months, 96% of all patients had a GOS of 5. CONCLUSIONS: The subfrontal approach provides an efficient avenue to the AComm region, which reduces opening and closing friction but still yields a comprehensive operative window for access to the anterior communicating region.