Anatomic Considerations Guiding Single Versus Multiportal Endoscopic Approaches for Resection of Juvenile Nasopharyngeal Angiofibroma: Cases Series With Graded Multicorridor Resections

BACKGROUND

Juvenile nasopharyngeal angiofibromas (JNAs) are characterized by expansive and destructive growth, often invading the midline/paranasal sinuses, pterygopalatine fossa, and infratemporal fossa and can extend into the orbit, cavernous sinus, or intracranially.

OBJECTIVE

To evaluete the major benefits of the extended endoscopic endonasal approach (EEA) for JNA resection as compared with more traditional and invasive transpalatal and transfacial approaches. When JNAs extend into lateral anatomic compartments, the optimal operative trajectory often requires additional approach strategies or surgical staging.

METHODS

We retrospectively reviewed 8 cases of large JNAs arising in symptomatic adolescent boys (University of Pittsburgh Medical Center Stages II, III, and V) and discuss anatomic and tumor considerations guiding the decision of a pure EEA vs combined EEA and sublabial transmaxillary approach (Caldwell-Luc).

RESULTS

A pure extended EEA was used in 6 JNA cases (UPMC Stages II-III); a multiportal EEA + Caldwell-Luc maxillotomy was used in 2 cases. One of the 2 patients (UPMC Stage V) previously treated with multiportal EEA + Caldwell-Luc maxillotomy underwent staged left temporal/transzygomatic craniotomy, obtaining gross total resection. Seven patients ultimately underwent complete removal without recurrence. One patient with a small residual JNA (UPMC II) underwent stereotactic radiosurgery without progression to date.

CONCLUSION

JNAs with lateral extension into the infratemporal fossa often benefited from additional lateral exposure using a Caldwell-Luc maxillotomy. Cases with significant skull base and/or dural involvement may undergo staged surgical treatment; temporalis + transzygomatic craniotomy is often useful for second-stage approaches for residual tumor in these lateral infratemporal or intracranial regions. SRS should be considered for residual tumor if additional surgery is not warranted.

One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System

INTRODUCTION AND IMPORTANCE

Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities.

CASE PRESENTATION

This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance.

CLINICAL DISCUSSION

Among the 124 patients diagnosed with bile duct stones, thirteen (10.5 %) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4 %. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5 years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4 mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5 min and 183.3 min, respectively. The average length of postoperative hospital stay was 3.5 days, and no instances of mortality or complications were recorded during the study.

CONCLUSION

One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.

Transcarotid artery revascularization (TCAR) stenting or angioplasty for intracranial carotid artery stenosis: Case series and novel application

BACKGROUND

Carotid artery stenting is associated with a higher rate of stroke compared to carotid endarterectomy (CEA). This is likely due to procedural emboli resulting from plaque disruption. The transcarotid artery revascularization (TCAR) method aims to reduce the stroke rate by flow-reversal. TCAR, which has yet to be utilized for intracranial atherosclerotic disease (ICAD), may be particularly valuable given the lack of surgical treatment options for intracranial arterial stenosis.

OBJECTIVE

Presented here are five cases of angioplasty or stenting that demonstrate the feasibility of TCAR for intracranial Internal Carotid Artery (ICA) stenosis treatment.

METHODS

Five cases were reviewed retrospectively and summarized using PROCESS and CARE guidelines.

RESULTS

All patients who underwent intervention between the petrous and ophthalmic segment of the ICA had no new neurologic deficit nor detected embolic stroke. One patient experienced an asymptomatic 5 mm hemorrhage on postoperative routine Computed Tomography (CT) head imaging.

CONCLUSIONS

This highlights a new method for treating intracranial ICA stenosis with a potentially reduced stroke risk. Given the historically higher stroke rates for cervical ICA stenting compared to carotid artery endarterectomy, this method may improve the previously higher stroke rates in endovascular carotid artery treatment, compared to CEA. Although this series is small, it illustrates a novel use for a rising technique that should be further evaluated in a larger study to validate its efficacy as a new treatment modality for surgically inaccessible intracranial disease.

Total Knee Arthroplasty in Unrecognized Septic Arthritis-A Descriptive Case Series Study

BACKGROUND

Synovitis, like that associated with chronic bacterial arthritis, is a very rare finding during the implantation of knee endoprostheses. In such cases, we fix the knee prostheses with cement containing two antibiotics and carry out a course of systemic antibiotic administration. The aim was to analyze these cases for incidence, detection of bacteria, risk factors, and outcome.

METHODS

Out of 7534 knee replacements between January 2013 and December 2020, 25 cases were suspected during the surgical procedure to have suffered from bacterial arthritis and were treated accordingly. Total synovectomy was carried out, whereby five intraoperative synovial samples were examined bacteriologically, and the complete synovitis was analyzed histologically. The mean follow-up was 65.3 ± 27.1 (24-85) months.

RESULTS

In nine cases (0.12%), the diagnosis of bacterial arthritis was made histologically and by clinical chemistry (elevated CRP), and in two of these cases, pathogen verification was performed. Eight of these nine patients had previously had injections or surgery associated with the corresponding knee joint or had an underlying immunomodulatory disease. None of the patients developed a periprosthetic infection at a later stage.

CONCLUSION

With an incidence of 0.12%, it is rare to unexpectedly detect bacterial synovitis during surgery. Total synovectomy, use of bone cement with two antibiotics, and immediate systemic antibiotic therapy seem to keep the risk of periprosthetic infection low.

Single surgeon case series of myelomeningocele repairs in a developing world setting: Challenges and lessons

Purpose

Neural Tube Defects are the second most common group of birth malformations following congenital heart anomalies, with myelomeningoceles being the most severe manifestation (MMC). They require expedited surgical repair, preferably within 72 ​h of birth. In low- and middle-income countries (LMIC) where resources are limited, timing to MMC repair is not optimal and leads to undesirable outcomes. The purpose of this study was to determine whether a proactive approach in a setting from a LMIC could achieve repair within 72 ​h.

Methods

A concerted effort to expedite repair of all neonates referred with a MMC was undertaken from 01 January 2014 to 1 August 2015. A consensus was reached between neonatologists and neurosurgeons that neonates born or admitted with a MMC are referred immediately to surgeons and that repair will be performed within 72 ​h of birth. Hospital records of neonates who had MMC repaired during this period were reviewed for infant characteristics and hospital outcomes.

Results

24 patients with a MMC were operated upon by the senior author (CP) during the study period. Only 13 of these patients were born at the treating institution and 11 were referred from outside hospitals. Most MMCs were in the lumbosacral region and mean MMC surface area was 19.4 ​cm². Mean time to repair for the entire series was 13.6 days. Patients born at the treating institution has a mean time to repair of 10.5 days and patients referred from outside had a mean time to repair of 17.3 days. Series wide, only 21% of neonates were operated upon in less than 72 ​h.

Conclusion

Despite a pro-active commitment to repairing MMCs within 72 ​h for the duration of this series, satisfactory time to repair was not achieved. Late referral, referral from outside hospitals and operating theatre availability were the predominant factors leading to delay in MMC repair. Nevertheless, time to repair in our series was significantly shorter than that reported in MMC repair series based in similar environments. This suggests that even if the gold-standard of a 72-h window cannot be achieved, neonates benefit from much quicker repair when a concerted effort to minimise repair time is employed. This study also highlights the urgent need to address health care constraints in LMIC to improve outcomes for this vulnerable group.

Superior Sternoclavicular Dislocation Treated with Costoclavicular Ligament Reconstruction Using Autograft: A Case Report

CASE

We describe a case of a traumatic superior dislocation of the sternoclavicular joint (SCJ) due to an isolated rupture of the costoclavicular ligament (CCL). A magnetic resonance imaging (MRI) scan demonstrated the CCL rupture with preservation of the anterior and posterior SCJ ligaments. This was successfully treated with an isolated hamstring tendon reconstruction of the CCL, resulting in a satisfactory outcome at 1 year after the procedure.

CONCLUSION

Isolated CCL reconstruction with a hamstring tendon in a patient with a superior SCJ dislocation provided a satisfactory outcome.

Assessment of the Antimicrobial Effectiveness of Herbal Root Canal Irrigants (Propolis, Triphala, and Aloe Vera) and Chlorhexidine Against Enterococcus Faecalis

BACKGROUND

Complete microbial eradication from the root canal and 3-dimensional obturation of the canal space are necessary for an efficient root canal procedure.

AIM

The current research was conducted to assess the antimicrobial effectiveness of herbal root canal irrigants and Chlorhexidine against Enterococcus faecalis.

MATERIALS AND METHODS

The brain heart infusion (BHI) broth was used to grow the E. faecalis (ATCC) bacterial culture overnight before it was inoculated onto Mueller-Hinton agar plates. Agar-well diffusion was used to measure antibacterial inhibition. Respective propolis, Triphala, aloe vera, and chlorhexidine irrigants were added to the appropriate wells in agar plates and incubated for 24 hours at 37°C. Each well's bacterial inhibition zone was measured and recorded. Statistics were used to tabulate and analyze the results.

RESULTS

Chlorhexidine indicated the maximum inhibitory zone against E. faecalis, subsequently propolis and Triphala, and the lowest by A. vera extract.

CONCLUSION

Propolis, Triphala, and aloe vera were tested herbal remedies that demonstrated an inhibitory zone against E. faecalis. These irrigants are therefore, suitable for use as root canal irrigating solutions.

Management of cesarean scar ectopic pregnancies at an academic referral center: A case series

OBJECTIVES

To describe treatment and outcomes of patients with confirmed cesarean scar ectopic pregnancy (CSEP) at a tertiary referral center.

STUDY DESIGN

We reviewed a deidentified family planning clinical database for patients seen by our subspecialty service for CSEP from January 2017 through December 2021 in this case series. We extracted referral information, final diagnosis, management, and outcome measures including estimated blood loss, secondary procedures, and treatment complications.

RESULTS

Of 57 cases referred for suspected CSEPs, 23 (40%) had confirmed diagnoses; one additional case was diagnosed during clinic evaluation for early pregnancy loss. Most (n = 50 [88%]) referrals occurred in the last 2 years of the 5-year study period. Of 24 confirmed CSEP cases, eight were pregnancy losses at the time of diagnosis. Fourteen cases were ≤50 days gestation or gestational size (7 [50%] pregnancy losses) and 10 >50 days gestation (range 39-66 days). We treated all 14 patients ≤50 days primarily with suction aspiration under ultrasound guidance in an operating room with no complications and estimated blood loss of 14 ± 10 mL. Of the 10 patients>50 days (maximum 66 days), seven were managed with primary aspiration of which five were uncomplicated. We treated one patient (57 days) had primary intrauterine double-catheter balloon with immediate hemorrhage requiring uterine artery embolization followed by an uncomplicated suction aspiration.

CONCLUSIONS

Patients with confirmed CSEPs at 50 days or less gestation or gestational size can likely be primarily treated with suction aspiration with low risk for significant adverse outcomes. Treatment success and complications are directly related to gestational age at treatment.

IMPLICATIONS

Ultrasound-guided suction aspiration monotherapy should be considered for primary CSEP treatment up to 50 days and, with continued experience, may be reasonable beyond 50 days gestation. Invasive treatments or those that require multiple days and visits, such as methotrexate or balloon catheters, are not necessary for early CSEPs.

Multiple logistic regression model to predict bile leak associated with subtotal cholecystectomy

BACKGROUND

There are no prediction models for bile leakage associated with subtotal cholecystectomy (STC). Therefore, this study aimed to generate a multivariable prediction model for post-STC bile leakage and evaluate its overall performance.

METHODS

We analysed prospectively managed data of patients who underwent STC by a single consultant surgeon between 14 May 2013 and 21 December 2021. STC was schematised into four variants with five subvariants and classified broadly as closed-tract or open-tract STC. A contingency table was used to detect independent risk factors for bile leakage. A multiple logistic regression analysis was used to generate a model. Discrimination and calibration statistics were computed to assess the accuracy of the model.

RESULTS

A total of 81 patients underwent the STC procedure. Twenty-eight patients (35%) developed bile leakage. Of these, 18 patients (64%) required secondary surgical intervention. Multivariable logistic regression revealed two independent predictors of post-STC bile leak: open-tract STC (odds ratio [OR], 7.07; 95% confidence interval [CI], 2.191-25.89; P = 0.0170) and acute cholecystitis (OR, 5.449; 95% CI, 1.584-23.48; P = 0.0121). The area under the receiver-operating characteristic curve was 82.11% (95% CI, 72.87-91.34; P < 0.0001). Tjur's pseudo-R2 was 0.3189 and the Hosmer-Lemeshow goodness-of-fit statistic was 4.916 (P = 0.7665).

CONCLUSIONS

Open-tract STC and acute cholecystitis are the most reliable predictors of bile leakage associated with STC. Future prospective, multicentre studies with higher statistical power are needed to generate more specific and externally validated prediction models for post-STC bile leaks.

Optimizing Workflow in Combined Petrosectomy Approaches: Surgical Technique and Case Series

BACKGROUND AND OBJECTIVE

The combined petrosectomy is one of the workhorse skull base approaches to the petroclival region. Traditionally, this approach starts with a temporosuboccipital craniotomy, followed by the mastoidectomy/anterior petrosectomy, and completed with the dural opening/tumor resection. This sequence of events (neurosurgery-neuro-otology-neurosurgery) involves at least 2 handoffs and change of surgical teams and instrumentation. This report describes a resequencing of events and a modification of the technique used to craft the temporosuboccipital craniotomy, with aims to reducing handoffs between surgical teams and improving operating room workflow.

METHODS

Adhering to PROCESS guidelines, a case series is provided in addition to the surgical technique and surgical images.

RESULTS

The technique for performing a combined petrosectomy is described with illustrations. This description shows that the temporal bone drilling may be performed before the craniotomy to allow for direct visualization of the dura and sinuses before completing the craniotomy. In doing so, only 1 transition between the otolaryngologist and neurosurgeon is necessary, thereby improving operating room workflow and time management. A series of 10 patients is presented, showing the feasibility of this procedure and providing operative details that were previously absent in the peer-reviewed literature.

CONCLUSIONS

Combined petrosectomy, although often performed in a 3-step manner with the neurosurgeon starting the craniotomy, can be performed as described here in a 2-step manner, with similar outcomes and reasonable operating time.

Predictors of postoperative performance status after surgical management of infratemporal fossa malignancies

Infratemporal fossa (ITF) tumors are difficult to access surgically due to anatomical constraints. Moreover, aggressive ITF carcinomas and sarcomas necessitate aggressive treatment strategies that, along with tumor-related symptoms, contribute to decreases in patient performance status. To assess factors that predict postoperative performance in patients undergoing surgery for ITF tumors. We reviewed medical records for all patients surgically treated for an ITF malignancy between January 1, 1999, and December 31, 2017, at our institution. We collected patient demographics, preoperative performance, tumor stage, tumor characteristics, treatment modalities, pathological data, and postoperative performance data. The 5-year survival rate was 62.2%. Higher preoperative Karnofsky Performance Status (KPS) score (n = 64; p < 0.001), short length of stay (p = 0.002), prior surgery at site (n = 61; p = 0.0164), and diagnosis of sarcoma (n = 62; p = 0.0398) were predictors of higher postoperative KPS scores. Percutaneous endoscopic gastrostomy (PEG) (n = 9; p = 0.0327), and tracheostomy tube placement (n = 20; p = 0.0436) were predictors of lower postoperative KPS scores, whereas age at presentation (p = 0.72), intracranial tumor spread (p = 0.8197), and perineural invasion (n = 40; p = 0.2195) were not. Male patients and patients with carcinomas showed the greatest decreases in KPS scores between pretreatment and posttreatment. Higher preoperative KPS score and short length of stay were the best predictors of higher postoperative KPS scores. This work provides treatment teams and patients with better information on outcomes for shared decision-making.

Chest tube thoracostomy: A simple life-saving procedure with potential hazardous risks

INTRODUCTION AND IMPORTANCE

Chest tube thoracostomy is a simple life-saving procedure with many benefits but comes with significant potential morbidity. Potentially all intra-thoracic organs are at risk of possible injury as well as peritoneal.

CASE PRESENTATION

We present four patients who had chest tube thoracostomy with potential complications fortunately were managed promptly and recovered fully.

CLINICAL DISCUSSION

Complications related to tube thoracostomy is reported up to 25 % especially when done under emergency conditions. While the procedure is reported safe, it's associated morbidity is not well described. Additionally, clinicians are urged to follow standard operating procedures and address the potential complications with consent to their patients.

CONCLUSION

Chest tube thoracostomy is an invasive life-saving procedure performed across various clinical ranks and sub-specialties. It has potential life-threatening risks and complications therefore clinicians should be well trained to identify such complications and address accordingly.

Treatment of neuropathic unstable knee osteoarthritis by a condylar, rotating-hinge prosthesis with cementless pentagonal stem: a case series

INTRODUCTION AND IMPORTANCE

Total knee arthroplasty (TKA) in the neuropathic unstable knee (NUK) setting is classically a challenging orthopedic problem due to intraoperative technical difficulties and a higher frequency of periprosthetic complications. More recently, satisfactory results have been reported using improved constraints, stems and revision-type TKA components. The study aims to present long-term results of a small case series with NUK osteoarthritis reconstructed by a condylar, semi-constrained prosthesis with a polygonal, hydroxyapatite-coated (HA-coated) press-fit stem.

CASE PRESENTATION

From 2009 through 2010, three knees in three patients with advanced NUK arthropathy underwent TKAs in our institution using the PENTA® prosthesis. The average age at surgery was 44 years (32-58). The patients were followed up for a mean period of 124 months (120-128). The etiology of NUK was determined to be poliomyelitis sequela in 2 cases and spinal cord injury in one case. Functional outcomes were assessed with Knee Society (KS) Knee and Function Scores, and radiological outcomes were evaluated with ISOLS radiographic implant scores. Patients were monitored for complications clinically and radiologically.

CLINICAL DISCUSSION

KS knee scores improved from a mean of 12,3 (0-37) preoperatively to 71,3 (65-77) and KS function scores improved from a mean of 1,7 (0-5) preoperatively to 68,3 (55-80) at the latest follow-up. Radiological outcomes were excellent according to ISOLS scores, and no complications were observed.

CONCLUSION

Although this is a small case series, the significant improvement in functional scores, excellent radiological outcome, and implant survival at the end of a long follow-up period warrants TKA with a semi-constrained hinged implant in the setting of NUK. PENTA® prosthesis offers a good choice of implant with its hydroxyapatite-coated, press-fit, pentagonal stem and precisely designed rotating hinge.

Hypothermia With Paradoxical Symptoms: A Case Series of Cesarean Deliveries With Intrathecal Morphine

Women receiving intrathecal morphine for cesarean delivery may experience hypothermia with paradoxical symptoms of sweating, nausea, and shivering. Despite being relatively rare in comparison to commonly experienced symptoms of perioperative hypothermia, hypothermia with paradoxical symptoms affects early maternal recovery and comfort. The cause is undetermined, and treatment approaches vary. Regular active-warming strategies may not be tolerated because of the paradoxical symptoms of sweating and feeling overheated. This case series aims to explore the phenomenon through the evaluation of health care records of women receiving intrathecal morphine for cesarean delivery at a single, tertiary health care institution in Australia from 2015 to 2018. We also summarize published literature to review treatment approaches used in the care of women experiencing profound heat loss while feeling overheated.

Interventions for the Management of Mandibular Coronoid Process Fractures: A Systematic Review

Background

The fracture of the coronoid process of mandible is one of the rarest fractures seen and the paucity of literature on the topic reflects the same. Despite the low incidence rate, the complications maybe grave which is why proper management is important. The treatment is controversial also because of the absence of standardized treatment protocol. This systematic review aims to compare the outcome of various treatment modalities available.

Methods

Registered under PROSPERO: CRD42020200700. Systematic research was conducted across databases like PubMed, Google Scholar, Pro Quest, Wiley Online. All clinical studies done till January 2021 which included participants above 14 years of age were included. Case reports, case series and studies not mentioning the treatment plan were excluded. The studies were shortlisted by the authors based on the eligibility criteria. Risk of bias was assessed using the MINORS tool and JBI checklist.

Results

A total of five studies were included. Four were retrospective studies and one was a retrospective case-controlled study. Two studies reported high, two moderate and one low risk of bias. Various treatment modalities were reported for the management of coronoid process fractures including conservative management, ORIF and coronoidectomy. Most authors preferred conservative management in asymptomatic cases and surgical management in symptomatic cases.

Discussion

No randomized control trials were found on the topic. Majority of the articles were case reports. Conservative management was preferred in minimally displaced fractures of coronoid process. However, in presence of displaced coronoid process fractures causing impediment of mandibular function surgical management is preferred.

Guillan-barre syndrome during COVID-19 pandemic: a case series from Syria

The Coronavirus was first discovered in December 2019 and quickly it turned into a pandemic called coronavirus disease 2019 (COVID-19). The main symptoms of infection with this virus were constitutional and respiratory symptoms. However, one-third of COVID-19 patients also developed neurologic manifestations, including Guillan-Barre syndrome (GBS), which was one of the most critical complications.

Case presentation

In this paper, the authors present seven patients who suffered from GBS after being infected with the Coronavirus or in conjunction with the infection. Nerve conduction studies showed axonal type in four patients, and demyelinating type in three patients. Neurological symptoms were the initial symptoms in two patients and the presence of COVID-19 was later discovered. Most of the patients had an excellent recovery.

Conclusion

In the medical literature, many articles have mentioned the association of GBS with the Coronavirus, and it is considered the most common peripheral neurologic complication for the virus, but this article is considered one of the very few articles that were published from the Middle East, especially from Syria. Guillain-Barre's occurrence after infections is known, and the Coronavirus is one of the most important viruses of the era, which incited an increase in the number of Guillain-Barre patients.

Defining Occult High-Risk Cysts of the Pineal Region: A Case Series

BACKGROUND

Absence of hydrocephalus on neuroimaging may impart a false sense of security for patients with pineal cysts. In this case series, we characterize a subset of patients with pineal cysts having an occult presentation. Unifying features of worsening paroxysmal headaches suggesting intermittent obstructive hydrocephalus and radiographic evidence of third ventricular invagination characterize these patients as high risk.

OBJECTIVE

To define features of occult, high-risk pineal cysts and outcomes of endoscopic cyst fenestration.

METHODS

Charts were retrospectively reviewed for patients with pineal cysts evaluated at our institution between 2018 and 2021 who underwent endoscopic cyst fenestration. To capture cysts presenting as occult, patients were excluded if hydrocephalus was noted at presentation. Relevant clinical history, imaging, operative data, and clinical outcomes were reviewed.

RESULTS

Of 50 pineal cyst patients, 4 satisfied inclusion criteria. All patients presented with worsening paroxysmal headaches. In addition, 75% (3/4) also experienced intermittent syncope. Patients exhibited no hydrocephalus (n = 3) or fluctuating ventricular size on longitudinal imaging (n = 1). In all cases, high-resolution sagittal 3-dimensional T2 magnetic resonance imaging demonstrated invagination of the cyst anteriorly into the posterior third ventricle. All patients underwent endoscopic cyst fenestration with complete symptom resolution (mean follow-up of 20.6 months; range 3.5-37.4 months).

CONCLUSION

The clinical history for occult, high-risk pineal cysts is notable for worsening paroxysmal headaches and episodic alterations of consciousness suggesting intermittent obstructive hydrocephalus. Because ventricular size can appear normal on standard imaging protocols, clinical suspicion should trigger workup with high-resolution magnetic resonance imaging designed to detect these cysts. Endoscopic cyst fenestration is a safe and efficacious management strategy.

Stereoelectroencephalography Implantation Using Frameless Neuronavigation and Varioguide: Prospective Analysis of Accuracy and Safety in a Case Series of 11 Patients

BACKGROUND

Stereoencephalography (SEEG) is becoming a widespread diagnostic procedure for drug-resistant epilepsy investigation. Techniques include frame-based and robot-assisted implantation, and more recently, frameless neuronavigated systems (FNSs). Despite its recent use, the accuracy and safety of FNS are still under investigation.

OBJECTIVE

To assess in a prospective study the accuracy and safety of a specific FNS use for SEEG implantation.

METHODS

Twelve patients who underwent SEEG implantation using FNS (Varioguide [Brainlab]) were included in this study. Data were collected prospectively and included demographic data, postoperative complications, functional results, and implantation characteristics (i.e., duration and number of electrodes). Further analysis included accuracy at entry point and target using measurements of the euclidean distance between planned and actual trajectories.

RESULTS

Eleven patients underwent SEEG-FNS implantation from May 2019 to March 2020. One patient did not undergo surgery because of a bleeding disorder. The mean target deviation was 4.06 mm, and mean entry point deviation was 4.2 mm, with insular electrodes significantly more deviated. Results excluding insular electrodes showed a mean target deviation of 3.66 mm and a mean entry point deviation of 3.77 mm. No severe complications occurred; a few mild to moderate adverse events were reported (1 superficial infection, 1 seizure cluster, and 3 transient neurologic impairments). The mean implantation duration by electrodes was 18.5 minutes.

CONCLUSIONS

Implantation of depth electrodes for SEEG using FNS seems to be safe, but larger prospective studies are needed to validate these results. Accuracy is sufficient for noninsular trajectories but warrant caution for insular trajectories with statistically significantly less accuracy.

Intramedullary Spinal Cord Abscess Management: Case Series, Operative Video, and Systematic Review

BACKGROUND

Intramedullary spinal cord abscess (ISCA) is an extremely rare disease, which has had fewer than 250 reported cases since its initial description in 1830. The condition is limited to level V evidence, limiting the ability for surgeons to characterize and treat it.

OBJECTIVE

To report the cases of 2 patients with ISCA and their surgical management: a 59-year-old woman who presented with progressive right hemiparesis and a 69-old man who presented with acute gait instability and significant bilateral shoulder pain. In addition, to report findings from a systematic literature review and associated logistic regression analysis.

METHODS

A MEDLINE and Embase search was conducted using the keywords "intramedullary," "spinal cord," "abscess," and "tuberculoma" and the results were screened for case reports. A logistic regression model was fit 100 times on data to retrieve predictor odds ratios.

RESULTS

Two hundred case reports of ISCA were identified between 1965 and 2022. Logistic regression determined that the only variables of significance were age (P < 0.01) and antibiotics (P < 0.05).

CONCLUSIONS

Treatment of ISCAs has significantly improved over the years. However, ISCAs are still poorly understood. Our recommendations can be used to guide diagnosis and treatment.

Influence of Patient and Technical Variables on Combined Direct and Indirect Cerebral Revascularization: Case Series

BACKGROUND

Cerebral bypass for flow augmentation is an important technique for selected neurosurgical patients, with multiple techniques used (direct, indirect, or combined).

OBJECTIVE

To assess the impact of patient and technical variables on direct and indirect bypass flow after combined revascularization.

METHODS

This was a retrospective, single-institution review of patients undergoing direct superficial temporal artery-to-middle cerebral artery bypass with indirect encephaloduro-myosynangiosis for moyamoya disease and steno-occlusive cerebrovascular disease over a 2-year period. We evaluated the effect of baseline patient characteristics, preoperative imaging characteristics, and operative variables on direct and indirect patency grades.

RESULTS

Twenty-six hemispheres (8 moyamoya disease and 18 steno-occlusive cerebrovascular disease) in 23 patients were treated with combined revascularization. The mean patient age was 53.4 ± 19.1 years. Direct bypass patency was 96%. Over a mean follow-up of 8.3 ± 5.4 months, there were 3 strokes in the treated hemispheres (11.5%). The mean modified Rankin Scale score improved from 1.3 ± 1.1 preoperatively to 0.7 ± 0.8 postoperatively. Preservation of the nondonor superficial temporal artery branch was associated with a lower direct bypass grade ( P < .01), whereas greater mean time to maximum perfusion (Tmax)> 4 and >6 seconds and mismatch volumes were associated with higher direct bypass grades ( P < .05). Tmax >4-second volume inversely predicted indirect bypass patency.

CONCLUSION

Patient and technical variables may influence the relative contributions of the direct and indirect components of combined revascularizations.

The Role of Near Infrared Spectroscopy in Diagnosing Stump Ischaemia in Patients with Below Knee Amputation: Case Reports

Introduction

Functional near infrared spectroscopy (fNIRS) can be used to quantify stump oxygen saturation (SaO₂) as one of many possible causes of pain following major amputation. Although commonly used for cerebral perfusion monitoring during carotid or cardiac surgery, it can also be used to monitor tissue perfusion in the lower limb and predict healing following below knee amputation (BKA). The aim of this study was to measure the SaO₂ trend as there is no validated oxygen threshold to diagnose insufficient flow into the arterial collateral network currently.

Report

NIRS was used to measure SaO₂ while performing treadmill exercise. Two BKA patients with chronic stump pain were asked to perform treadmill exercise while using their prosthesis and NIRS optode applied to the posterior stump to monitor SaO₂. Cases 1 and 2 showed a decline in SaO₂ of 25% and 18%, respectively, while walking on the prosthesis. After superficial femoral artery (SFA) recanalisation and stenting, Case 1 showed improvement by maintaining SaO₂ between 54% and 60% throughout treadmill exercise. In Case 2, perfusion could not be further improved, and the patient underwent through knee amputation.

Discussion

fNIRS detected compressive ischaemia and exercise induced ischaemia as mechanisms of stump pain. Findings provided the multidisciplinary team with objective information, aiding decision making to treat stump pain.

Parameatal urethral cyst: A case series of three rare cases and literature review

INTRODUCTION AND IMPORTANCE

Parameatal urethral cyst is a rare benign congenital urethral disorder with limited reports in the literature. The formation of the cyst is believed due to the obstruction of the paraurethral duct. This disorder usually does not produce symptoms even though, in an advanced case, urinary retention and flow disturbance may occur.

CASE PRESENTATION

Herewith, we report case series of parameatal urethral cysts in 5, 11, and 17 years old boys treated with complete surgical cyst excision. The first was 11 years-old-boy with asymptomatic 7 mm swelling in his urethral meatus. The second case was a 5 years-old-boy with 5 mm swelling in his urethral meatus with the complaint of urinary stream distortion. The third case involved a 17-year-old adolescent with a 4 mm cystic bulge in his urethral meatus that caused urinary distortion.

CLINICAL DISCUSSIONS

In these cases, the cysts were completely removed with surgical excision and the patients underwent circumcision. Histological examination revealed a cyst wall lined with squamous and columnar epithelium. Good cosmetic result without any recurrent mass and voiding difficulties was reported after 2 weeks of follow-up.

CONCLUSIONS

This study reported three cases of parameatal urethral cysts late presentation at an older age due to no prior symptoms. The patients were managed with surgical excision of the cyst resulting in good cosmesis outcome and without recurrence.

Do Case Reports on Total Mandibular, Extended, and Bilateral Total Temporomandibular Joint Reconstruction Prostheses Adhere to the Surgical CAse REport Guidelines?

PURPOSE

The Surgical CAse REport (SCARE) guidelines are a standardized format for reporting surgical cases. The aim of this study was to evaluate the completeness of case reports documenting alloplastic reconstruction of large craniomaxillofacial defects involving total mandibular, bilateral, and extended temporomandibular joint in major high-quality craniomaxillofacial journals, based on the SCARE guidelines.

METHODS

An extensive online search was performed according to the Priority Reporting Items for Systematic Reviews and Meta-Analyses statement in PubMed, Embase, Scopus, Google Scholar, and Dimensions databases to identify relevant case reports. Each selected case report was assessed on 16 topics (38 items) of the SCARE guidelines, using a scoring scale of "0" (No/noncompliance), "1" (Yes/compliance), and 2" (unclear). The completeness of reporting (COR) score was calculated as the ratio of "yes" responses to "total" (ie, yes + no + unclear) responses. Adequacy of case reporting was denoted by a COR score of 70% or more.

RESULTS

A total of 35 case reports were selected, where the male to female patients ratio was 3:4 cases, mean ± standard deviation (SD) age: 34.9 ± 16.7 years, mean ± SD follow-up duration: 17.0 ± 12.9 months, and number of patients with left, right, and bilateral temporomandibular joint reconstruction prostheses were 16, 10, and 09, respectively. The mean ± SD COR score for all 35 case reports and the individual item of the SCARE guidelines was 70.2 ± 10.5% and 66.5 ± 31.2%, respectively. The minimum and maximum COR score was found for "Keywords" (0.0%) and "Introduction" (100%) and "Clinical Findings" (100%), respectively. Adequate reporting was found for 20/35 (57%) case reports.

CONCLUSIONS

This study revealed that case reports in major high-quality craniomaxillofacial journals suffer from insufficient reporting. Widespread adoption of available standards, such as SCARE guidelines, is proposed to improve the quality and robustness of case reporting.

Bach Mai Procedure for complete mesocolic excision, central vascular ligation, and D3 lymphadenectomy in total laparoscopic right hemicolectomy: a prospective study

PURPOSE

Total laparoscopic right hemicolectomy with complete mesocolic excision (CME), central vascular ligation (CVL), and D3 lymphadenectomy is still the most challenging colon procedures for gastrointestinal surgeons. We herein report the technical details and our preliminary experience of Bach Mai Procedure - a novel-combining (cranial, medial to lateral, and caudal) approach with early resection of the terminal ileum.

METHODS

The dissection stage was central vascular isolation and ligation by a combined multiple approaches in the following four steps: cranial approach, dissecting along the inferior aspect of pancreatic isthmus to reveal the middle colic vessels and the anterior aspect of the superior mesentery vein and then exposed the right gastroepiploic vein and the trunk of Henle; medial-to-lateral approach, exposing the surgical axis - the superior mesenteric vascular axis and then early resection of the terminal ileum to open the dissection from the bottom up; and caudal approach, radical ligation of the ileocecal artery and right colic artery (central vascular ligation), lymph node dissection (D3 lymphadenectomy), and resecting the Toldt fascia of the colon to release the entire right colon from the abdominal wall.

RESULTS

In 12 months, there were 32 cases of primary right-sided colon malignancies that have undergone tLRH_{D3, CME/CVL} based on the Bach Mai Procedure. In 3 cases (9.4%), the tumor site was hepatic flexure. The median of lymph node number (LNN) was 38, with the maximum number which was 101. No serious postoperative complications (grade 3 or higher) neither inhospital mortality was detected.

CONCLUSION

This Bach Mai procedure, a novel-combining approach with early resection of the terminal ileum, is technically feasible and safe for tLRH_{D3, CME/CVL}. Further investigations and follow-up must be proceeded to evaluate the long-term outcomes of our technique.

The uncommon complications of Meckel’s diverticulum: A single center case series study and literature review

Introduction and importance

Meckel’s diverticulum is the most common congenital true diverticula of the gastrointestinal tract with 4–9% life time risk of complications. It is difficult to diagnose preoperatively other than having high index of suspicion. Therefore, the aim of this case series is to present the rare presentation of this disease and create awareness for clinician to deliver early intervention so that associated mortality and morbidity will be minimized.

Case presentation

Here we present four cases of Meckel’s diverticulum managed in single center during a period of one year. Two cases were presented as isolated gangrenous Meckel’s diverticulum with small bowel obstruction. The remaining two were: an adult male patient operated for generalized peritonitis as a result of perforated Meckel’s diverticulitis and a child with intussusception in which Meckel’s diverticulum was secondarily obstructed.

Clinical discussion

The less frequent complications of Meckel’s diverticulum are more challenging to diagnose. It carries higher rate of morbidities since early diagnosis is difficult; especially, isolated axial torsion of the Meckel’s diverticulum that we are presenting in this case series. Therefore it is prudent to consider for a pain originating from central abdomen which gets diffuse in the meantime unlike symptoms of complicated appendicitis as symptomatic Meckel’s diverticulum.

Conclusion

The rare complications of Meckel’s diverticulum need high index of suspicion to diagnose as their symptoms mimic other pathologies which cause diffuse abdominal pain. Timely intervention can prevent hospital mortality, morbidity and decrease duration of hospital stay.

Highlights

Surgery as an Effective Therapy for Ulnar Nerve Neuropathic Pain Caused by Gunshot Wounds: A Retrospective Case Series

BACKGROUND

Peripheral nerve injuries remain a major medical problem worldwide and are associated with multiple causes, including gunshot wounds (GSWs), which are the second most common cause of brachial plexus injuries in peacetime and the main, or only, cause reported in wartime studies. The ulnar nerve (UN) is one of the most affected nerves. Peripheral nerve trauma may cause intense neuropathic pain, which is very difficult to control. Particularly UN gunshot injuries may impact individual daily life, as injuries to this nerve result in both sensory and motor deficits within the hand. We evaluated the improvement of neuropathic pain after surgical treatment in a consecutive series of 20 patients with UN injury due to GSWs.

METHODS

This single-center, retrospective, consecutive case series included 20 patients with UN injuries due to GSWs, who presented with excruciating neuropathic pain and underwent surgical treatment between 2005 and 2017.

RESULTS

Of injuries, 13 occurred in the right upper limb (65%); 12 patients had a high UN injury (60%). Regarding associated injuries, 8 patients had bone injuries (40%), and 4 patients had arterial injuries (20%). A neuroma in continuity was detected in 8 cases (40%), and 4 patients (20%) had shrapnel lodged within the UN. All patients had severe neuropathic pain and functional deficit, with a mean visual analog scale score of 8.45 ± 1.4 and a mean reduction of 6.95 points 12 months after surgery; 10 patients (50%) had a British Medical Research Council score ≥M3.

CONCLUSIONS

Surgery is an effective treatment for neuropathic pain from GSWs. Early isolated external neurolysis is associated with better pain management and functional outcomes postoperatively.

Persistent Mullerian duct syndrome with polycystic ovary in a young adult: A rare case report

Persistent Mullerian Duct Syndrome (PMDS) is a type of pseudohermaphroditism that occurs in males. It is an autosomal recessive type of familial disease that is commonly associated with a history of consanguinity. We have documented this case of a 22-year-old adult male who came with acute right iliac pain; after an ultrasound scan and hormone investigations, he was diagnosed with polycystic ovarian syndrome (PCOS).

Male genital trauma caused by self-mutilation: A first case series report in Indonesia

INTRODUCTION AND IMPORTANCE

Genital self-mutilation (GSM) is a rare phenomenon with a spectrum ranging from a superficial laceration to complete amputation of the external genitalia. These could result in severe impairment of genitourinary functions. Psychotic disorder adds to the complexity of the patients. Since GSM is underreported, we report the first case series in Indonesia.

CASE PRESENTATION

Four included patients comprised different injuries to the external genitalia, from a superficial laceration to penile amputation. Notably, these patients exhibited psychotic traits. Initial management consisted of bleeding control, debridement, and primary suturing. Depending on the extent of the injury, the repair comprised of spermatic cord ligation, penile reconstruction using a skin flap, defect closure with urethral spatulation, and exploration. We successfully managed all the patients surgically before undergoing psychotherapy to improve the patient's overall well-being and to reduce the risk of similar reoccurrence of GSM behavior.

CLINICAL DISCUSSION

The majority of GSM cases were associated with psychotic disorders. The current reports' injuries include penile laceration, total penile amputation, unilateral castration, and combined injury to the penis and scrotum. Although most GSM is not life-threatening, it may cause emergent, complex, and serious complications such as massive hemorrhage and severe infections. Appropriate investigations with systematic treatment strategies are required, especially in complex cases.

CONCLUSION

The incidence of genital self-mutilation necessitates a prompt evaluation of organ viability and the possibility of preserving tissue for optimal urinary and sexual outcomes. Interdisciplinary collaboration is required as the primary concern for management in cases of genital self-mutilation involving male genitalia and underlying psychological disorders.

Stereotactic Radiosurgery for Vestibular Schwannoma in Neurofibromatosis Type 2: An International Multicenter Case Series of Response and Malignant Transformation Risk

BACKGROUND

Vestibular schwannomas (VSs) related to neurofibromatosis type 2 (NF2) are challenging tumors. The increasing use of stereotactic radiosurgery (SRS) necessitates further investigations of its role and safety.

OBJECTIVE

To evaluate tumor control, freedom from additional treatment (FFAT), serviceable hearing preservation, and radiation-related risks of patients with NF2 after SRS for VS.

METHODS

We performed a retrospective study of 267 patients with NF2 (328 VSs) who underwent single-session SRS at 12 centers participating in the International Radiosurgery Research Foundation. The median patient age was 31 years (IQR, 21-45 years), and 52% were male.

RESULTS

A total of 328 tumors underwent SRS during a median follow-up time of 59 months (IQR, 23-112 months). At 10 and 15 years, the tumor control rates were 77% (95% CI: 69%-84%) and 52% (95% CI: 40%-64%), respectively, and the FFAT rate were 85% (95% CI: 79%-90%) and 75% (95% CI: 65%-86%), respectively. At 5 and 10 years, the serviceable hearing preservation rates were 64% (95% CI: 55%-75%) and 35% (95% CI: 25%-54%), respectively. In the multivariate analysis, age (hazards ratio: 1.03 [95% CI: 1.01-1.05]; P = .02) and bilateral VSs (hazards ratio: 4.56 [95% CI: 1.05-19.78]; P = .04) were predictors for serviceable hearing loss. Neither radiation-induced tumors nor malignant transformation were encountered in this cohort.

CONCLUSION

Although the absolute volumetric tumor progression rate was 48% at 15 years, the rate of FFAT related to VS was 75% at 15 years after SRS. None of the patients with NF2-related VS developed a new radiation-related neoplasm or malignant transformation after SRS.

The SCARE 2023 guideline: updating consensus Surgical CAse REport (SCARE) guidelines

BACKGROUND

The Surgical CAse REport (SCARE) guidelines were first published in 2016 as a tool for surgeons to document and report their surgical cases in a standardised and comprehensive manner. However, with advances in technology and changes in the healthcare landscape, it is important to revise and update these guidelines to ensure they remain relevant and valuable for surgeons.

MATERIALS AND METHODS

The updated guidelines were produced through a Delphi consensus exercise. Members of the SCARE 2020 guidelines Delphi group, editorial board members, and peer reviewers were invited to participate. Potential contributors were contacted by e-mail. An online survey was completed to indicate their agreement with the proposed changes to the guideline items.

RESULTS

A total of 54 participants were invited to participate and 44 (81.5%) completed the survey. There was a high degree of agreement among reviewers, with 36 items (83.7%) meeting the threshold for inclusion.

CONCLUSION

Through a completed Delphi consensus exercise we present the SCARE 2023 guidelines. This will provide surgeons with a comprehensive and up-to-date tool for documenting and reporting their surgical cases while highlighting the importance of patient-centred care.

Triple penile fracture: A rare case report and review of literature

INTRODUCTION AND IMPORTANCE

Penile fracture is uncommon entity that rarely involves all the three erectile bodies (the two corpora carvenosa and corpus spongiosum). The diagnosis is clinical as most cases presents with typical signs and symptoms.

CASE PRESENTATION

We present a case of young man who sustained penile fracture involving the two corpora cavernosum and corpus spongiosum with associated urethral injury that was successfully repaired primarily.

CLINICAL DISCUSSION

In this case apart from MRI confirming the diagnosis it showed the injury to involve all the three corpora bodies as well as the urethral. Although MRI is reserved for controversial cases, when available, apart from just confirming the diagnosis, it can help in showing the extent of the injury and assist surgeon in management. Primary repair of the erectile bodies as well as the urethral gives excellent outcome.

CONCLUSION

This case reminds surgeons the possibility of having such extensive injury with promising outcome if properly managed.

Experience and Balance: Long-Term Trends in Preferred Skull Base Approach for a Case Series of Cavernous Malformation Resections

BACKGROUND

Skull base approaches are a foundation of modern cerebrovascular surgery; however, their application over time has varied.

OBJECTIVE

To assess trends in skull base approach selection for cavernous malformation (CM) resection.

METHODS

This is a retrospective case series of all first-time CM resections by a single surgeon from 1997 to 2021. Cases were classified by craniotomy and approach. Four sets of common comparator skull base approaches were identified by coauthor consensus: pterional and orbitozygomatic; retrosigmoid, extended retrosigmoid (xRS), and far-lateral; suboccipital and torcular; and trans-cerebellar peduncle (MCP) and transcerebellopontine angle. Counts were binned by 5-year or 10-year clusters for descriptive statistical assessment of temporal trends.

RESULTS

In total, 372 primary CM resections met the study criteria and were included. Orbitozygomatic approach use increased during the second 5-year period, after which the pterional approach rapidly became and remained the preferred approach. During the first two 5-year periods, the far-lateral approach was preferred to the retrosigmoid and xRS approaches, but the xRS approach grew in popularity and accounted for >50% of operations in this comparator group. Trans-MCP use compared with the transcerebellopontine angle approach closely mirrored the change in xRS use. The midline suboccipital approach accounted for a larger proportion (range, 62%-88%) of cases than the torcular approach (range, 12%-38%) across all periods.

CONCLUSION

The xRS and trans-MCP approaches have been increasingly used over time, while the orbitozygomatic and far-lateral approaches have become less common. These trends seem to reflect versatility, efficiency, and safety of these techniques.

Incomplete common mesentery with Ladd's band and Meckel's diverticulum: A rare cause of small bowel obstruction

INTRODUCTION AND IMPORTANCE

The common mesentery is an abnormal rotation of the primitive intestinal loop or omphalomesenteric loop. It is not necessarily symptomatic, but a clinical presentation of acute bowel obstruction on the band or volvulus can reveal it. We report a case of small bowel obstruction due to Ladd's band and Meckel's diverticulum on the incomplete common mesentery.

PRESENTATION OF CASE

We report a case of a 54-year-old man with no previous abdominal surgery who experienced periumbilical abdominal pain and vomiting. Physical examination revealed a diffusely tender and distended abdomen. Laboratory data showed a biological inflammatory syndrome. An abdominal CT scan revealed a small bowel mechanical obstruction with a double transitional level under the umbilical without a loop enhancement. An emergent laparotomy was performed. We found an incomplete common mesentery. The small bowel obstruction was due to a Ladd's band attrapping the Meckel's diverticulum. This association was responsible for dilating ileal loops at the superior part of the mechanical obstruction with necrosis of 30 cm of the small bowel. We have sectioned the congenital band and resected the necrotic segment, followed by an intestinal anastomosis. The postoperative follow-up was uneventful.

CLINICAL DISCUSSION

Incomplete common mesentery with Ladd's band and Meckel's diverticulum is an extremely rare association. Causing a small bowel obstruction remains an uncommon complication and circumstance of discovery. This complication presents a life-threatening condition. An abdominal CT scan could help for the diagnosis in some cases. Surgery is the standard treatment in most cases.

CONCLUSION

The association of incomplete common mesentery with Ladd's band and Meckel's diverticulum is uncommon and should be known to avoid intraoperative misdiagnose.

Intraoperative angiography via popliteal artery access for spinal neurovascular lesions: an institutional experience and systematic review

BACKGROUND

Intraoperative DSA is used to confirm complete obliteration of neurovascular pathologies. For spinal neurovascular lesions, femoral access can be challenging given the need to flip the patient after sheath placement. Similarly, radial access can be complicated by arch navigation difficulties. Vascular access via the popliteal artery represents an appealing alternative option; however, data regarding its utility and efficacy in these cases are limited.

METHODS

A retrospective series of four consecutive patients between July 2016 and August 2022 who underwent intraoperative spinal DSA via the popliteal artery was analyzed. Additionally, a systematic review was conducted to collect previously reported such cases. Collective patient demographics and operative details are presented to consolidate the available evidence supporting popliteal access.

RESULTS

Four patients met the inclusion criteria from our institution. The systematic review yielded six previously published studies reporting 16 additional transpopliteal access cases. Of the 20 total cases (mean±SD age 60.8±17.2 years), 60% were men. Most treated lesions were dural arteriovenous fistulas (80%) located in the thoracic spine (55%) or cervical spine (25%). The left popliteal artery was most accessed and the highest visualized level was the craniocervical junction. All outcomes were either stable or improving after surgery, and no complications were observed.

CONCLUSIONS

We report the safety and feasibility of transpopliteal access for intraoperative DSA in the prone position in four cases in addition to 16 previously reported cases in the literature. Our case series highlights popliteal artery access as an alternative to transfemoral or transradial access in this setting.

Burr hole as a management for extra axial hematomas in a low-resource setting

INTRODUCTION AND IMPORTANCE

In a low-resource setting, the availability of neurosurgeons and neurosurgical equipment for neurosurgery has proved to be a challenge for the management of extra-axial hematomas hence general surgeons perform burr hole surgeries for emergencies.

CASE PRESENTATION

We share our experience with three patients who presented with extra-axial hematomas and managed successfully in our institute with craniostomy as the surgical approach.

CLINICAL DISCUSSION

Traumatic brain injury is a major global health burden as it is a leading cause of death among the middle-aged population. Mortality associated with brain injury is highest in low- and middle-income countries. From our experience, we had good outcome in terms of improved Glasgow Coma Scale and overall clinical status in those who underwent burr hole surgery for extra axial hematoma.

CONCLUSION

The need for neurosurgeons in sub-Saharan Africa is high but training comes at a cost hence general surgeons can perform life-saving emergency procedures with good outcomes.

Prognostic Factors for Surgically Managed Spontaneous Spinal Epidural Hematoma: A Single-Center Case Series of 18 Patients

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a rare pathology, which carries a significant morbidity.

OBJECTIVE

To review our institutional experience of surgically managed patients with SSEH, seeking to better understand clinical prognostic factors related to postoperative outcomes and thereby improve counseling of patients before treatment.

METHODS

All patients who underwent surgical management of SSEH between September 2011 and 2021. Baseline and postoperative clinical and radiological characteristics are presented, including the American Spinal Injury Association grade (ASIA). Statistical analyses were performed using Stata 13.1.

RESULTS

Eighteen patients were identified in total (11 male patients and 7 female patients) with a median age of 59.5 (range 3-83) years. The most common spinal region affected was cervicothoracic (33.3%). Limb weakness (94.4%) and urinary dysfunction (83.3%) represented the most common presenting symptoms. Preoperatively, the presence of spinal cord edema on imaging was associated with worse preoperative Medical Research Council (MRC) grade ( P = .033), female sex was associated with preserved saddle sensation ( P = .04), and patients receiving antiplatelet medication were associated with a higher risk of preoperative axial back pain ( P = .005). Higher postoperative MRC grade was associated with higher preoperative ASIA ( P = .012) and MRC grade ( P = .005), and preservation of saddle sensation ( P = .018). Postoperative improvements in axial back pain were associated with higher preoperative ASIA grade ( P = .035) and anticoagulation treatment ( P = .029).

CONCLUSION

Neurosurgical intervention for SSEH yields positive outcomes and benefits patients. Patients with higher preoperative ASIA, MRC grade, and those presenting with preserved saddle sensation may experience further improved clinical outcomes after intervention.

Modified Iliac Screw in Lumbopelvic Fixation After Sacral Tumor Resection: A Single-Center Case Series

BACKGROUND

Traditional iliac screw, S2-alar iliac screw, and modified iliac screw are the 3 common techniques for lumbopelvic fixation. The application of the modified iliac technique in sacral spinal tumors has been rarely reported.

OBJECTIVE

To report the feasibility and safety of modified iliac screws after sacral tumor resection and their preliminary clinical outcomes.

METHODS

Twenty-seven patients who underwent sacral tumor resection with modified iliac screw fixation between August 2017 and August 2021 at our center were clinically and radiographically evaluated.

RESULTS

A total of 59 iliac screws were inserted by freehand according to the anatomic landmarks. The mean operation time was 207 minutes (range, 140-435 minutes). The average estimated blood loss was 1396 mL (300-4200 mL). Computed tomography scans showed that 2 (3.4%) screws penetrated the iliac cortex, indicating a 96.6% implantation accuracy rate. There were no iatrogenic neurovascular or visceral structure complications observed. The mean minimal distances from the screw head to the skin were 24.9 and 25.8 mm on the left and right sides, respectively. The mean minimal distances from the screw head to the horizontal level of the posterior superior iliac spine were 7.9 and 8.3 mm on the left and right sides, respectively. Two patients (7.4%) underwent reoperation for wound infection. At the latest follow-up, no patient had complications of screw head prominence, pseudarthrosis, or instrument failure.

CONCLUSION

The modified iliac screw is characterized by its minimal invasiveness and simplicity of placement. It is an ideal alternative for lumbopelvic fixation after sacral tumor resection.

L-2-hydroxyglutaric aciduria - review of literature and case series

L-2-hydroxyglutaric aciduria (L2HGA) is an autosomal recessive, slowly progressive neurodegenerative disease characterized by psychomotor delay and cerebellar dysfunction. The biochemical hallmark is increased concentrations of L2HG in body fluids. Brain MRI exhibits characteristic centripetal extension of the white matter involvement that differentiates it from other leukodystrophies. The authors report two sisters from Pakistan with L2HGA with 4 years of follow-up. The authors have also compared the clinical outcome of our patients with 45 previously reported patients with L2HGA for whom treatment and clinical outcome was reported.

CASE PRESENTATION

The authors report two sisters with L2HGA from Pakistan born to consanguineous parents. The 15- and 17-year-old girls presented with psychomotor delay, seizures, ataxia, intentional tremors, and dysarthria. Both had normal anthropometric measurements for age. Exaggerated tendon reflexes and bilateral sustained ankle clonus were observed in addition to cerebellar signs. Urine organic acids analysis showed marked excretion of 2-hydroxyglutaric acid, chiral differentiation of 2-hydroxyglutaric acid showed it to be L2HGA. Brain MRI of the 15-year-old showed diffuse subcortical white matter changes evident by T2/FLAIR hyperintense signals bilaterally, particularly in the frontal region in the centripetal distribution with some diffusion restriction along involvement of globus pallidus. The characteristic MRI pattern raised the suspicion of L2HGA. Targeted L2HGDH sequencing identified a homozygous pathogenic variant, c.829C>T (p.Arg227*) in L2HGDH gene in both girls. Both parents were heterozygous carriers of the familial variant.

CONCLUSION

Neuroradiological features of centripetal subcortical leukoencephalopathy with basal ganglia and dentate nuclei involvement are rather specific to L2HGA and should lead to further biochemical investigations to look for L2HGA and L2HGDH gene sequencing.

Neck Sinus Post-Thyroidectomy Secondary to Retained Oxidized Regenerated Cellulose: A Case Report

The present study aims to report the first case of chronic neck sinus post-thyroidectomy caused by oxidized regenerated cellulose (ORC). A 55-year-old female patient underwent a total thyroidectomy operation. Three months after the surgery, the patient presented with persistent purulent discharge and sinus at the site of the drain. A CT scan of the neck showed a fistula tract, deep-neck fluid collection, and bilateral paratracheal high-density lesions at the thyroid bed, suggesting infected foreign bodies. The patient underwent surgery, during which the mesh of the ORC was found nonresorbed at the paratracheal space. The treatment involved neck exploration with the removal of all retained material and excision of the sinus tract. The patient had a favorable outcome following the surgical excision of the sinus tract and the removal of retained hemostatic materials. Further research is needed to explore the risk factors and preventive measures for neck sinus formation to enhance the safety and outcomes of thyroidectomy.

Long-Term Results of Endoscopic Endonasal Marsupialization of Rathke Cleft Cysts With Bioabsorbable Steroid-Eluting Stents-Technical Case Series and Review of the Literature

BACKGROUND

Rathke cleft cysts (RCCs) are common benign skull-base lesions arising from embryologic remnants of Rathke pouch. Though frequently asymptomatic, RCCs can become symptomatic because of compression of adjacent neural structures. Transcranial and neuroendoscopic surgical treatments have been described for symptomatic RCCs, but recurrence rates remain as high as 30%. Bioabsorbable steroid-eluting (BASE) stents significantly decrease adhesions and recurrent ostia obstruction after endoscopic sinus surgery. We sought to use BASE stents to aid marsupialization of symptomatic RCCs.

OBJECTIVE

To present long-term results of our initial experience with endoscopic-endonasal fenestration and placement of BASE stents for RCCs.

METHODS

Patients undergoing neuroendoscopic transsphenoidal fenestration of RCCs with BASE stent placement were identified and their medical records retrospectively reviewed.

RESULTS

Four patients underwent neuroendoscopic transsphenoidal fenestration and BASE stent placement from March 2016 to April 2018 for symptomatic RCCs. After the cyst contents were evacuated, a BASE stent was deployed in the cyst fenestration to prevent cyst wall regrowth or closure and facilitate marsupialization to the sphenoid sinus. No perioperative complications were encountered, and all patients reported symptom resolution by 2 weeks postoperatively. Postoperative endoscopic evaluation demonstrated epithelization of the cyst wall opening and patent marsupialization into the sphenoid sinus in all cases. After a mean follow-up of 56 ± 12 months, all patients remained asymptomatic with baseline visual function and no radiographic evidence of recurrence.

CONCLUSION

Bioabsorbable steroid-eluting stent placement is a safe, facile, viable augmentation of neuroendoscopic technique for symptomatic RCCs with the potential to reduce long-term recurrence rates.

The Rationale Behind Transcirculation Neuroendovascular Interventions: Literature Review Through a Case-Series Approach

BACKGROUND

With the development of advanced endovascular techniques and materials, neurointerventionalists can perform challenging and complex cases that were previously difficult to perform. Transcirculation approaches could be a useful tool used in complicated cases, providing access to the target vessel, through the contralateral or opposite circulation, when anterograde access is difficult or nonachievable.

OBJECTIVE

To retrospectively review cerebrovascular interventions performed through a transcirculation approach performed by staff at our Institution.

METHODS

English-language studies, published until August 2022, reporting transcirculation interventions in the cerebrovascular circulation were retrospectively collected. Type of intervention, number of cases, rationale, and complications were analyzed. Furthermore, similar cases performed by staff currently at our institution were also reviewed and described.

RESULTS

Including our cases, a total of 273 transcirculation treatment approaches have been reported. Intracranial aneurysm embolization, stroke thrombectomies, intra-arterial ophthalmic chemotherapy, arteriovenous malformationss, arteriovenous fistulas embolizations, and intracranial angioplasty and stenting are common indications. Reason for using a retrograde approach were stent/balloon-assisted coiling of wide neck aneurysm in 116 cases, difficult angulation of branch in 91 cases, occlusion of parent vessel in 55 cases, and bailout/other in 11 cases.

CONCLUSION

Transcirculation approaches can be considered for cases where conventional anterograde treatment options are not feasible or as a bailout strategy in failed or complicated treatment attempts. They represent a strategy to consider when facing challenging cases, and if performed by experienced and dedicated neurointerventionalists, they can represent a safe alternative.

Retrovesical hydatid cyst: an unusual location of hydatid disease about a case series

Hydatid disease is an endemic zoonosis in regions with temperate climates where pastoral farming is common. Retrovesical localization is rare. Given the rarity of this entity, the lack of personal clinical experience, and the difficulty with detecting early symptoms, the diagnosis remains elusive for years.

Methods

This is a 30-year retrospective, descriptive and analytic study of seven patients who were hospitalized and operated on in the Department of Urology during 30 years (1990-2019).

Outcomes

The average patient age was 54 years (range: 28-76). Signs of bladder irritation were the predominant presenting complaint. No cases of hydaturia were noted. Preoperative diagnosis was based on ultrasonography and serology tests. Hydatid serology was positive for three patients. In three cases, a hydatid cyst of the liver was associated. A partial cystopericystectomy was performed for five patients, it was total for one patient. The resection of the prominent dome was realized once. No cystovesical fistula was found. The mean postoperative stay was 16 days. The postoperative course was uneventful for five patients. Urinary fistula occurred in one patient. One case of infection of the residual cavity was observed. One patient had a retroperitoneal cyst recurrence requiring reoperation.

Conclusion

The preoperative diagnosis of retrovesical hydatid cysts is based mainly on ultrasonography. Open surgery is the treatment of choice. Different approaches are possible. Given the rarity of this entity, management should be guided by experienced experts.

The Impact of the Preferred Reporting Items for Case Reports in Endodontics (PRICE) 2020 Guidelines on the Reporting of Endodontic Case Reports

Aim The aim of this study is to evaluate the impact of the Preferred Reporting Items for Case reports in Endodontics (PRICE) 2020 guideline on the reporting of published endodontic case reports (CRs). Methodology All case reports published in the International Endodontic Journal, European Endodontic Journal, Journal of Endodontics and Restorative Dentistry and Endodontics, in the year before and after the release of PRICE 2020, were included for analysis. Two panels comprising dentists scored case reports against a scoring system adapted from the guideline. Individual items were scored up to a maximum of 1; scores were then summated to provide an overall maximum of 47 for each CR. Each report provided an overall percentage adherence, and panel agreement was calculated using the intraclass correlation coefficient (ICC). Disagreement on scoring was discussed until a consensus was reached. Scores before and after PRICE guideline publication were compared using an unpaired two-tailed t test. Results A total 19 CRs were identified in both the pre- and post-PRICE guideline publication. Mean adherence to PRICE 2020 increased by 7.9% (p=0.003) from 70.0%±8.89 to 77.9%±6.23 following its publication. Agreement between panels was moderate (ICC pre-PRICE: 0.673 {p=0.011}; ICC post-PRICE: 0.742 {p=0.003}). Items 1a, 6c, 6e, 6f, 6g, 6j, 6q, 6s, 7a, 9a, 11a, 12c and 12d experienced a fall in compliance. Conclusion The PRICE 2020 guideline has resulted in a modest improvement in the reporting of endodontic case reports. Greater awareness and a wider acceptance and implementation of the guideline in endodontic journals are needed to improve adherence to the novel guideline.

Cytotoxic, Antidiabetic, and Antioxidant Study of Biogenically Improvised Elsholtzia blanda and Chitosan-Assisted Zinc Oxide Nanoparticles

In the present study, we have improvised a biogenic method to fabricate zinc oxide nanoparticles (ZnO NPs) using chitosan and an aqueous extract of the leaves of Elsholtzia blanda. Characterization of the fabricated products was carried out with the help of ultraviolet-visible, Fourier transform infrared, X-ray diffraction, field emission scanning electron microscopy, high-resolution transmission electron microscopy, selected area electron diffraction, and energy-dispersive X-ray analyses. The size of the improvised ZnO NP measured between 20 and 70 nm and had a spherical and hexagonal shape. The ZnO NPs proved to be highly effective in the antidiabetic test as the sample showed the highest percentage of enzyme inhibition at 74% ± 3.7, while in the antioxidant test, 78% was the maximum percentage of 2,2-diphenyl-1-picrylhydrazyl hydrate scavenging activity. The cytotoxic effect was investigated against the human osteosarcoma (MG-63) cell line, and the IC₅₀ value was 62.61 μg/mL. Photocatalytic efficiency was studied by the degradation of Congo red where 91% of dye degradation was observed. From the various analyses, it can be concluded that the as-synthesized NPs may be suitable for various biomedical applications as well as for environmental remediation.

Sonolucent Cranioplasty in Extracranial to Intracranial Bypass Surgery: Early Multicenter Experience of 44 Cases

BACKGROUND

The new sonolucent cranioplasty implant (clear polymethyl methacrylate, PMMA) adds functionality besides surgical reconstruction. One possible application uses the transcranioplasty ultrasound (TCUS) technique after PMMA cranioplasty to assess graft patency of extracranial-intracranial (EC-IC) bypass procedures.

OBJECTIVE

To report our early multicenter experience.

METHODS

This is a multicenter analysis of consecutive EC-IC bypass patients from 5 US centers (2019-2022) with closure postbypass using PMMA implant.

RESULTS

Forty-four patients (median age 53 years, 68.2% females) were included. The most common indication for bypass was Moyamoya disease/syndrome (77.3%), and superficial temporal artery to middle cerebral artery bypass was the most common procedure (79.5%). Pretreatment modified Rankin Scales of 0 and 1 to 2 were noted in 11.4% and 59.1% of patients, respectively. Intraoperative imaging for bypass patency involved a combination of modalities; Doppler was the most used modality (90.9%) followed by indocyanine green and catheter angiography (86.4% and 61.4%, respectively). Qualitative TCUS assessment of graft patency was feasible in all cases. Postoperative inpatient TCUS confirmation of bypass patency was recorded in 56.8% of the cases, and outpatient TCUS surveillance was recorded in 47.7%. There were no cases of bypass failure necessitating retreatment. Similarly, no implant-related complications were encountered in the cohort. Major complications requiring additional surgery occurred in 2 patients (4.6%) including epidural hematoma requiring evacuation (2.3%) and postoperative surgical site infection (2.3%) that was believed to be unrelated to the implant.

CONCLUSION

This multicenter study supports safety and feasibility of using sonolucent PMMA implant in EC-IC bypass surgery with the goal of monitoring bypass patency using TCUS.

Understanding fluorescence time curves during ileal pouch-anal anastomosis with or without vascular ligation

BACKGROUND

Intraoperative indocyanine green fluorescence angiography (ICG-FA) may be of added value during pouch surgery, in particular after vascular ligations as lengthening maneuver. The aim was to determine quantitative perfusion parameters within the efferent/afferent loop and explore the impact of vascular ligation. Perfusion parameters were also compared in patients with and without anastomotic leakage (AL).

METHODS

All consenting patients that underwent FA-guided ileal pouch-anal anastomosis (IPAA) between July 2020 and December 2021 were included. After intravenous bolus injection of 0.1 mg/kg ICG, the near-infrared camera (Stryker Aim 1688) registered the fluorescence intensity over time. Quantitative analysis of ICG-FA from standardized regions of interests on the pouch was performed using software. Fluorescence parameters were extracted for inflow (T₀, T_max, F_max, slope, Time-to-peak) and outflow (T_90% and T_80%). Change of management related to FA findings and AL rates were recorded.

RESULTS

Twenty-one patients were included, three patients (14%) required vascular ligation to obtain additional length, by ligating terminal ileal branches in two and the ileocolic artery (ICA) in one patient. In nine patients the ICA was already ligated during subtotal colectomy. ICG-FA triggered a change of management in 19% of patients (n = 4/21), all of them had impaired vascular supply (ligated ileocolic/ terminal ileal branches). Overall, patients with intact vascular supply had similar perfusion patterns for the afferent and efferent loop. Pouches with ICA ligation had longer T_max in both afferent as efferent loop than pouches with intact ICA (afferent 51 and efferent 53 versus 41 and 43 s respectively). Mean slope of the efferent loop diminished in ICA ligated patients 1.5(IQR 0.8-4.4) versus 2.2 (1.3-3.6) in ICA intact patients.

CONCLUSION

Quantitative analysis of ICG-FA perfusion during IPAA is feasible and reflects the ligation of the supplying vessels.

Allergic and Infectious complications of Etonogestrel Implant Placements: A Case Series

Patients rarely experience complications at time of Etonogestrel subdermal contraceptive implant placement. Few case reports describe infection or allergy as a complication at time of implant insertion. In this case series, we discuss three infections and one allergic reaction following Etonogestrel implant placement, review 6 previous case reports of 8 cases of infection or allergy and discuss management of these complications. We highlight differential diagnosis when encountering a placement complication, considerations of dermatologic conditions when placing Etonogestrel implants, and discuss when to consider removal of the implant when a complication occurs.

The Roof of the 4th Ventricle Seen From Inside: Endoscopic Anatomic Illustration-A Case Series

BACKGROUND

The anatomy of the roof of the fourth ventricle has been illustrated in many laboratory investigations, but in vivo reports of the roof anatomy and its variants are still lacking.

OBJECTIVE

To describe the topographical anatomy of the roof of the fourth ventricle explored through a transaqueductal approach that overcomes cerebrospinal fluid depletion, displaying in vivo anatomic images possibly quite close to normal physiological conditions.

METHODS

We critically reviewed the intraoperative video recordings of our 838 neuroendoscopic procedures, selecting 27 cases of transaqueductal navigation that provided good quality image details of the anatomy of the roof of the fourth ventricle. Twenty-six patients affected by different forms of hydrocephalus were therefore categorized into three groups: Group A: blockage of the aqueduct-aqueductoplasty, Group B: communicating hydrocephalus, and Group C: tetraventricular obstructive hydrocephalus.

RESULTS

Group A has shown what the roof of a normal fourth ventricle really looks like albeit the structures seemed overcrowded because of the narrow space. Images from groups B and C paradoxically allowed a more distinct identification of the roof structures flattened by ventricular dilation, making them more comparable with the topography traced on the laboratory microsurgical studies.

CONCLUSION

Endoscopic in vivo videos and images provided a novel anatomic view and an in vivo redefinition of the real topography of the roof of the fourth ventricle. The relevant role of cerebrospinal fluid was defined and outlined, as well as the effects of hydrocephalic dilation on some structures on the roof of the fourth ventricle.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action

OBJECTIVES

To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement.

STUDY DESIGN AND SETTING

A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021.

RESULTS

We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description.

CONCLUSION

Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Surgical Strategy and Application of Robotic-Assisted Benign Sacral Neurogenic Tumor Resection

BACKGROUND

Robotic surgery may be advantageous in neurogenic sacral tumor resection but only a few studies reported robotic-assisted neurogenic sacral tumor resection.

OBJECTIVE

To propose a new surgical strategy for robotic-assisted benign sacral neurogenic tumor resection and introduce the ultrasonic osteotomy surgical system in robotic surgery.

METHODS

Twelve patients who had robotic-assisted primary benign sacral neurogenic tumor resection between May 2015 and March 2021 were included. Our surgical strategy divides tumors into 4 types. Type I: Presacral tumors with diameter <10 cm. Type II: Narrow-base tumors involving the sacrum with diameter <10 cm. Type III: Broad-base tumors involving the sacrum with diameter <10 cm. Type IV: Tumors involving sacral nerve roots ≥2 levels and/or with diameter ≥10 cm.

RESULTS

Five type I, 5 type II, and 1 type III patients underwent tumor resection via an anterior approach, and 1 type IV patient via a combined approach. The median operation time, blood loss, and postoperative hospital stay of type I and II were much less than those of type IV. The ultrasonic osteotomy surgical system facilitated osteotomy in 2 type II and 1 type III patients. Eleven patients had total resections, and 1 type III patient had a partial resection. During the follow-up period of 7.9 to 70.9 months (median: 28.5 months), no local recurrences or deaths were noted.

CONCLUSION

With the largest single-center series to our knowledge, this surgical strategy helped to guide robotic-assisted benign sacral neurogenic tumor resection. The ultrasonic osteotomy surgical system was effective for type II and III.