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Metaxas V, Dimitroukas C, Efthymiou F, Delis H, Gatzounis G, Tzortzidis F, Zampakis P, Theofanopoulos A, Constantoyannis C, Panayiotakis G. Assessment of organ doses, peak skin doses and effective doses in patients undergoing anterior cervical discectomy and fusion utilising VirtualDose-IR software. Radiat Prot Dosimetry 2024; 200:164-174. [PMID: 38016804 PMCID: PMC10875322 DOI: 10.1093/rpd/ncad286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 10/09/2023] [Accepted: 11/03/2023] [Indexed: 11/30/2023]
Abstract
In this study, the effect of patient- and procedure-related parameters on organ doses (ODs), peak skin dose (PSD) and effective dose (E) during anterior cervical discectomy and fusion (ACDF) was evaluated. Patient- and procedure-related parameters, as well as fluoroscopy time, kerma-area product (KAP), cumulative air-kerma (Kair) and incident Kair, were analysed for 50 ACDF procedures performed with a mobile C-arm. These parameters were inserted in VirtualDose-IR software implementing sex-specific and body mass index (BMI)-adjustable anthropomorphic phantoms to calculate OD, PSD and E. The BMI, gender and type of implants did not significantly affect KAP, incident Kair, PSD and E. However, the type of fusion significantly affected the E. The single fusions in C5/C6 resulted in significantly higher KAP, incident Kair and E than C4/C5 levels, while those performed in C6/C7 resulted in significantly higher E and PSD than C4/C5 levels. The thyroid, oesophagus and salivary glands received the largest doses in all groups studied. The BMI did not significantly affect ODs. The salivary glands absorbed significantly higher doses in males than females, while the extrathoracic region's dose significantly increased for multi- than single-level fusions. The fusions in C6/C7 resulted in significantly higher oesophagus and thyroid doses than C3/C4 and C4/C5 levels, as well as fusions performed in C5/C6 compared with C4/C5 levels. The data presented here could be used by the neurosurgeons as a comparator for future studies in optimising radiation protection during ACDF procedures in the operating theatre by keeping the ODs, PSD and E as low as reasonably practicable.
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Affiliation(s)
- Vasileios Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Christos Dimitroukas
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
- Department of Medical Physics, University Hospital of Patras, 26504 Patras, Greece
| | - Fotios Efthymiou
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Harry Delis
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
| | - George Gatzounis
- Department of Neurosurgery, University Hospital of Patras, 26504 Patras, Greece
- Department of Neurosurgery, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Fotios Tzortzidis
- Department of Neurosurgery, University Hospital of Patras, 26504 Patras, Greece
| | - Petros Zampakis
- Department of Radiology, University Hospital of Patras, 26504 Patras, Greece
- Department of Radiology, School of Medicine, University of Patras, 26504 Patras, Greece
| | | | - Constantine Constantoyannis
- Department of Neurosurgery, University Hospital of Patras, 26504 Patras, Greece
- Department of Neurosurgery, School of Medicine, University of Patras, 26504 Patras, Greece
| | - George Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, 26504 Patras, Greece
- Department of Medical Physics, University Hospital of Patras, 26504 Patras, Greece
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Boulieris S, Zampakis P, Panagoulias I, Mouzaki A, Constantoyannis C, Theofanopoulos A, Panagiotopoulos V. Intraluminal assessment of inflammatory factors in patients with intracranial aneurysms. Acta Neurochir (Wien) 2023; 165:3685-3695. [PMID: 37882876 DOI: 10.1007/s00701-023-05851-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/13/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The formation, growth, and rupture of intracranial aneurysms (IA) are due to several pathophysiological mechanisms, including focal hemodynamic injury and inflammation of the arterial wall. We investigated the differences between venous, parent artery, and intra-aneurysmal blood by measuring inflammatory factors and antibodies in patients with ruptured (rIA) or unruptured intracranial aneurysms (uIA). METHOD A prospective study was performed in patients who presented with IA and required endovascular treatment. Blood was drawn from the lumen of the aneurysm sac, the parent artery, and the peripheral veins, to determine the serum concentrations of complement factors C3, C4, IgG, IgM, IgA antibodies, and C-reactive protein (CRP). RESULTS Thirty-six patients (15 with uIA and 21 with rIA) were enrolled in the study. In both groups, C3, C4, IgM, IgG, and IgA showed a gradual decrease from venous to intra-aneurysmal samples, but only IgG in the parent artery and intra-aneurysmal samples reached a significant decrease in uIA compared with venous samples. Accordingly, C3 and IgG concentrations in the intra-aneurysmal samples showed a significant decrease in rIA compared with venous samples. A significant increase in CRP concentrations was observed in parent artery and intra-aneurysmal samples from patients with rIA compared with patients with uIA; a significant increase in C3 concentrations was observed in parent artery samples from patients with rIA compared with patients with uIA, and a significant decrease in IgM concentrations was observed in venous, parent artery, and intra-aneurysmal samples from patients with rIA compared with patients with uIA. CONCLUSIONS A decrease in C3 and IgG in the aneurysm sac indicates activation of the complement system in the arterial wall. CRP in the aneurysm sac and lumen of the parent artery was significantly increased in ruptured compared with unruptured aneurysms, whereas venous, parent artery, and intra-aneurysmal IgM were decreased in ruptured compared with unruptured aneurysms. These results argue for the role of an ongoing inflammatory process in aneurysms leading to their growth and rupture.
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Affiliation(s)
- Spyridon Boulieris
- Department of Neurosurgery, University Hospital of Patras, Patras, Greece.
| | - Petros Zampakis
- Department of Interventional Neuroradiology/Endovascular Neurosurgery, University Hospital of Patras, Patras, Greece
| | - Ioannis Panagoulias
- Laboratory of Immunohematology, Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, Patras, Greece
| | - Athanasia Mouzaki
- Laboratory of Immunohematology, Division of Hematology, Department of Internal Medicine, Medical School, University of Patras, Patras, Greece
| | | | | | - Vasilios Panagiotopoulos
- Department of Neurosurgery, University Hospital of Patras, Patras, Greece
- Department of Interventional Neuroradiology/Endovascular Neurosurgery, University Hospital of Patras, Patras, Greece
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Theofanopoulos A, Fermeli D, Vekios D, Bizos A, Marangos M, Constantoyannis C, Panagiotopoulos V, Assimakopoulos SF. Successful treatment of pan-drug resistant Acinetobacter baumannii nosocomial meningitis/ventriculitis by combined intravenous and intrathecal colistin-tigecycline administration: a case series. Infez Med 2023; 31:103-107. [PMID: 36908383 PMCID: PMC9994833 DOI: 10.53854/liim-3101-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/25/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND This study aims to evaluate the efficacy of combined intraventricular and intravenous co-administration of colistin and tigecycline in the management of pan-drug resistant Acinetobacter baumannii meningitis/ventriculitis. METHODS In this case series we report 3 patients with healthcare-associated ventriculitis/meningitis caused by pan-drug resistant Acinetobacter baumannii that were treated with combined colistin and tigecycline administration through both intraventricular and intravenous routes. RESULTS All patients were administered colistin intraventricularly at a dose of 250.000 IU q.d. and intravenously at 9 million IU loading dose, followed after 12 hours by maintenance dose of 4.5 million IU every 12 hours and tigecycline intraventricularly at a dose of 10 mg b.i.d. and intravenously at 200 mg loading dose followed after 12 hours by 100 mg every 12 hours. In patients with a calculated creatinine clearance of less than 60 ml/min, according to the Cockcroft-Gault formula, the maintenance dose of colistin was reduced based on a modified formula. All patients had a favourable clinical and microbiological response with evidence of CSF sterilization. CONCLUSIONS Taking advantage of the synergistic action of combined colistin and tigecycline through administration both intraventricularly and intravenously may be a promising salvage option for critically ill patients with pan-drug resistant A. baumannii CNS infection.
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Affiliation(s)
| | - Dionysia Fermeli
- University Hospital of Patras, Department of Neurosurgery, Patras,
Greece
| | - Dionysios Vekios
- University Hospital of Patras, Department of Internal Medicine, Division of Infectious Diseases, Patras,
Greece
| | - Aristeidis Bizos
- University Hospital of Patras, Department of Internal Medicine, Division of Infectious Diseases, Patras,
Greece
| | - Markos Marangos
- University Hospital of Patras, Department of Internal Medicine, Division of Infectious Diseases, Patras,
Greece
| | | | | | - Stelios F. Assimakopoulos
- University Hospital of Patras, Department of Internal Medicine, Division of Infectious Diseases, Patras,
Greece
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Bafiti V, Ouzounis S, Chalikiopoulou C, Grigorakou E, Grypari IM, Gregoriou G, Theofanopoulos A, Panagiotopoulos V, Prodromidi E, Cavouras D, Zolota V, Kardamakis D, Katsila T. A 3-miRNA Signature Enables Risk Stratification in Glioblastoma Multiforme Patients with Different Clinical Outcomes. Curr Oncol 2022; 29:4315-4331. [PMID: 35735454 PMCID: PMC9221847 DOI: 10.3390/curroncol29060345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/17/2022] Open
Abstract
Malignant gliomas constitute a complex disease phenotype that demands optimum decision-making as they are highly heterogeneous. Such inter-individual variability also renders optimum patient stratification extremely difficult. microRNA (hsa-miR-20a, hsa-miR-21, hsa-miR-21) expression levels were determined by RT-qPCR, upon FFPE tissue sample collection of glioblastoma multiforme patients (n = 37). In silico validation was then performed through discriminant analysis. Immunohistochemistry images from biopsy material were utilized by a hybrid deep learning system to further cross validate the distinctive capability of patient risk groups. Our standard-of-care treated patient cohort demonstrates no age- or sex- dependence. The expression values of the 3-miRNA signature between the low- (OS > 12 months) and high-risk (OS < 12 months) groups yield a p-value of <0.0001, enabling risk stratification. Risk stratification is validated by a. our random forest model that efficiently classifies (AUC = 97%) patients into two risk groups (low- vs. high-risk) by learning their 3-miRNA expression values, and b. our deep learning scheme, which recognizes those patterns that differentiate the images in question. Molecular-clinical correlations were drawn to classify low- (OS > 12 months) vs. high-risk (OS < 12 months) glioblastoma multiforme patients. Our 3-microRNA signature (hsa-miR-20a, hsa-miR-21, hsa-miR-10a) may further empower glioblastoma multiforme prognostic evaluation in clinical practice and enrich drug repurposing pipelines.
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Affiliation(s)
- Vivi Bafiti
- Institute of Chemical Biology, National Hellenic Research Foundation, 11635 Athens, Greece; (V.B.); (S.O.); (C.C.); (G.G.)
| | - Sotiris Ouzounis
- Institute of Chemical Biology, National Hellenic Research Foundation, 11635 Athens, Greece; (V.B.); (S.O.); (C.C.); (G.G.)
| | - Constantina Chalikiopoulou
- Institute of Chemical Biology, National Hellenic Research Foundation, 11635 Athens, Greece; (V.B.); (S.O.); (C.C.); (G.G.)
| | - Eftychia Grigorakou
- Biomedical Engineering Department, University of West Attica, 11243 Athens, Greece; (E.G.); (D.C.)
| | - Ioanna Maria Grypari
- Department of Pathology, School of Medicine, University of Patras, 26504 Patras, Greece; (I.M.G.); (V.Z.)
| | - Gregory Gregoriou
- Institute of Chemical Biology, National Hellenic Research Foundation, 11635 Athens, Greece; (V.B.); (S.O.); (C.C.); (G.G.)
- American Community Schools (ACS), 15234 Athens, Greece;
| | - Andreas Theofanopoulos
- Department of Neurosurgery, University Hospital of Patras, 26504 Patras, Greece; (A.T.); (V.P.)
| | | | | | - Dionisis Cavouras
- Biomedical Engineering Department, University of West Attica, 11243 Athens, Greece; (E.G.); (D.C.)
| | - Vasiliki Zolota
- Department of Pathology, School of Medicine, University of Patras, 26504 Patras, Greece; (I.M.G.); (V.Z.)
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, University of Patras Medical School, 26504 Patras, Greece;
| | - Theodora Katsila
- Institute of Chemical Biology, National Hellenic Research Foundation, 11635 Athens, Greece; (V.B.); (S.O.); (C.C.); (G.G.)
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Drakopoulou M, Giannopoulou A, Zampakis P, Messinis L, Theofanopoulos A, Constantoyannis C, Panagiotopoulos VE. Suction thrombectomy using a microcatheter as a salvage method for acute distal occlusion during cerebral aneurysm embolization: A case report. Brain Circ 2022; 8:112-116. [PMID: 35909705 PMCID: PMC9336589 DOI: 10.4103/bc.bc_5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/05/2022] Open
Abstract
The aneurysm coiling process presents a risk of thromboembolic complications, mostly in patients with ruptured aneurysms, given the fact that they cannot receive antiplatelet therapy. Management strategies include medical anticoagulation or antiplatelet therapy, intra-arterial thrombolysis, and mechanical thrombectomy using direct aspiration first-pass technique or stent retrievers. We report our own experience of using an Excelsior SL-10 Microcatheter (Stryker, Fremont, California, USA) with an internal diameter of 0.0165”, originally designed for coil delivery, for contact aspiration of a thrombotic occlusion of a distal anterior cerebral artery during coiling of a broad-based trilobar anterior communicating artery aneurysm. The clot was removed under continuous manual aspiration, and complete recanalization has been accomplished. Mechanical thrombectomy through microcatheter aspiration may be a safe and feasible treatment option for acute distal artery occlusions, especially in the case of tortuous distal vessels during embolization of cerebral aneurysms.
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Affiliation(s)
- Maria Drakopoulou
- Department of Neurosurgery, University Hospital of Patras, Patras, Greece
| | | | - Petros Zampakis
- Department of Neuroendovascular Surgery and Interventional Neuroradiology, University Hospital of Patras, Patras, Greece
| | - Lambros Messinis
- Department of Neuropsychology, University Hospital of Patras, Patras, Greece
| | | | | | - Vasileios Evangelos Panagiotopoulos
- Department of Neurosurgery, University Hospital of Patras, Patras, Greece.,Department of Neuroendovascular Surgery and Interventional Neuroradiology, University Hospital of Patras, Patras, Greece
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Theofanopoulos A, Zampakis P, Antoniadou E, Papadakos D, Fermeli D, Constantoyannis C, Messinis L, Panagiotopoulos V. Spontaneous thoracolumbar epidural hematoma in an apixaban anticoagulated patient. Surg Neurol Int 2021; 12:256. [PMID: 34221587 PMCID: PMC8247671 DOI: 10.25259/sni_434_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/19/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Spontaneous spinal epidural hematomas (SSEHs) are often attributed to anticoagulation. Although they are rare, they may contribute to significant morbidity and mortality. Case Description: An 83-year-old female with a history of atrial fibrillation on apixaban, presented with 4 days of back pain, progressive lower extremity weakness and urinary retention. When the patient’s MRI showed a dorsal thoracolumbar SSEH, the patient underwent a T10–L3 laminectomy for hematoma evacuation. Within 2 postoperative months, her neurological deficits fully resolved. Conclusion: Apixaban is associated with SSEH resulting in severe neurological morbidity and even mortality. Prompt MRI imaging followed by emergency surgical decompressive surgery may result in full resolution of neurological deficits.
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Affiliation(s)
- Andreas Theofanopoulos
- Department of Neurosurgery, University of Patras, University Hospital of Patras, Achaia, Greece
| | - Petros Zampakis
- Department of Radiology and Interventional Neuroradiology, University of Patras, University Hospital of Patras, Achaia, Greece
| | - Eleftheria Antoniadou
- Department of Rehabilitation, Rehabilitation Clinic, University of Patras, University Hospital of Patras, Achaia, Greece
| | - Dimitrios Papadakos
- Department of Neurosurgery, University of Patras, University Hospital of Patras, Achaia, Greece
| | - Dionysia Fermeli
- Department of Neurosurgery, University of Patras, University Hospital of Patras, Achaia, Greece
| | | | - Lambros Messinis
- Department of Neurology and Psychiatry, Neuropsychology Section, University of Patras, University Hospital of Patras, Patras, Achaia, Greece
| | - Vasileios Panagiotopoulos
- Department of Neurosurgery and Endovascular Neurosurgery, University of Patras, University Hospital of Patras, Patras, Achaia, Greece
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Fermeli DD, Theofanopoulos A, Papadakos D, Boulieris S, Constantoyannis C. Hemorrhage of a Cavernous Hemangioma of the Brainstem Presenting with Fever of Unknown Origin: A Case Report. Am J Case Rep 2021; 22:e930437. [PMID: 34031354 PMCID: PMC8165496 DOI: 10.12659/ajcr.930437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient: Male, 42-year-old Final Diagnosis: Brainstem cavernoma Symptoms: Headache • fever Medication: — Clinical Procedure: — Specialty: Neurosurgery
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Affiliation(s)
- Dionysia D Fermeli
- Department of Neurosurgery, University Hospital of Patras, Patras, Greece
| | | | | | - Spiros Boulieris
- Department of Neurosurgery, University Hospital of Patras, Patras, Greece
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Panagiotopoulos V, Theofanopoulos A, Kourakli A, Symeonidis A, Krisela V, Mastronikolis NS, Zampakis P. Ruptured infectious ICA pseudoaneurysm into the sphenoid sinus after maxillofacial infection, successfully treated by selective embolization. Surg Neurol Int 2021; 12:191. [PMID: 34084619 PMCID: PMC8168689 DOI: 10.25259/sni_52_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/03/2021] [Indexed: 11/04/2022] Open
Abstract
Background Intracranial infectious aneurysms are cerebral aneurysms caused by pathogen-induced inflammation undermining the arterial wall. We present a rare case of inflammatory pseudoaneurysm of cavernous internal carotid artery (ICA). Case Description A 51-year-old female with a recent diagnosis of acute lymphoblastic leukemia developed maxillofacial infection with Pseudomonas and Acinetobacter after chemotherapy onset. Initial plain computed tomography (CT) revealed bony dehiscence of the left ICA canal, as well as bilateral protrusion of the vessel within the sphenoid sinus. Following infection spread into the left sphenoid sinus, she presented with episodes of intermittent epistaxis, without any profound vascular abnormalities on postcontrast CT. CT angiography that was performed 15 days later, due to refractory epistaxis, illustrated a large narrow necked irregular shape pseudoaneurysm of the left paraophthalmic ICA, extending into the ipsilateral sphenoid sinus. The aneurysm was completely occluded by selective embolization without parent or adjacent vessel sacrifice, documented on both intraoperative and follow-up angiogram, with no recurrence of epistaxis. Conclusion Conclusively, ruptured internal carotid infectious aneurysms are rare but potentially fatal causes of epistaxis when extended into the sphenoid sinus. Selective coiling is feasible and can provide definitive treatment of these lesions.
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Affiliation(s)
- Vasileios Panagiotopoulos
- Department of Neurosurgery and Endovascular Neurosurgery, University of Patras, Patra, Achaia, Greece
| | | | - Alexandra Kourakli
- Department of Internal Medicine, Division of Hematology, University of Patras, Patra, Achaia, Greece
| | - Anargyros Symeonidis
- Department of Internal Medicine, Division of Hematology, University of Patras, Patra, Achaia, Greece
| | - Valera Krisela
- Department of Internal Medicine, Division of Hematology, University of Patras, Patra, Achaia, Greece
| | - Nicholas S Mastronikolis
- Department of Otorhinolaryngology, Head and Neck Surgery University of Patras, Patra, Achaia, Greece
| | - Petros Zampakis
- Department of Radiology and Interventional Neuroradiology, University of Patras, Patra, Achaia, Greece
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Papadakos D, Boulieris S, Theofanopoulos A, Fermeli D, Constantoyannis C. Tubular laminectomy and percutaneous vertebroplasty for aggressive vertebral hemangioma. Surg Neurol Int 2021; 12:27. [PMID: 33598343 PMCID: PMC7881512 DOI: 10.25259/sni_888_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Vertebral hemangiomas (VH) are the most common benign vascular neoplasms of the spine. Aggressive VH (AVH) may become symptomatic due to soft-tissue expansion/extraosseous extension into the paraspinal and/or epidural spaces. There are several options for treating painful AVH, including radiotherapy and/or open surgery. Case Description: A 59-year-old male presented with a 2-year history of intermittent back pain and progressive thoracic myelopathy in the past 2 months. MRI revealed a T9 level lesion, with high-intensity signal on both T1 and T2 images and an extraosseous component with significant cord compression. We performed minimally invasive tubular unilateral laminotomy for bilateral decompression of the thoracic spine at the T9 level, followed by bilateral percutaneous vertebroplasty with biopsy. Postoperatively, the pain was immediately relieved, and the myelopathy improved. The biopsy confirmed the diagnosis of a VH. Conclusion: Combining minimally invasive techniques consisting of tubular laminectomy and percutaneous vertebroplasty are safe and effective ways for treating AVHs.
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Affiliation(s)
- Dimitrios Papadakos
- Department of Neurosurgery, University Hospital of Patras, Rio University Hospital, Patras, Achaia, Greece
| | - Spiros Boulieris
- Department of Neurosurgery, University Hospital of Patras, Rio University Hospital, Patras, Achaia, Greece
| | - Andreas Theofanopoulos
- Department of Neurosurgery, University Hospital of Patras, Rio University Hospital, Patras, Achaia, Greece
| | - Dionysia Fermeli
- Department of Neurosurgery, University Hospital of Patras, Rio University Hospital, Patras, Achaia, Greece
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