Ultra-Early (<5 Hours) Decompression for Thoracolumbar Spinal Cord Injury: A Case Series

Early surgical decompression within 24 hours for traumatic spinal cord injury (SCI) is associated with improved neurological recovery. However, the ideal timing of decompression is still up for debate. The objective of this study was to utilize our retrospective single-institution series of ultra-early (<5 hours) decompression to determine if ultra-early decompression led to improved neurological outcomes and was a feasible target over previously defined early decompression targets. Retrospective data on patients with SCI who underwent ultra-early (<5 hours) decompression at a level one metropolitan trauma center were extracted and collected from 2015-2018. American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement was the primary outcome, with ASIA Motor score improvement and complication rate as secondary outcomes. Four individuals met the criteria for inclusion in this case series. All four suffered thoracolumbar SCI. All patients improved neurologically by AIS grade, and there were no complications directly related to ultra-early surgery. Given the small sample size, there was no statistically significant difference in outcomes compared to a control group who underwent early (5-24 hour) decompression in the same period. Ultra-early decompression is a feasible and safe target for thoracolumbar SCI and may lead to improved neurological outcomes without increased risk of complications. This case series can help create the foundation for future, larger studies that may definitively show the benefit of ultra-early decompression.

Microsurgical intraluminal obliteration of type IV perimedullary arteriovenous fistula with an in situ hemostatic agent: illustrative case

BACKGROUND

Spinal arteriovenous fistulas (SAVFs) are underdiagnosed entities that can lead to severe morbidity from spinal cord dysfunction or hemorrhage. Treatment options include endovascular embolization or direct surgical obliteration at the level of the arteriovenous shunt. The authors present a case of intraluminal microsurgical access for occlusion with a hemostatic agent of a type IV SAVF near the conus medullaris as an alternative to clip occlusion to avoid nerve root compromise.

OBSERVATIONS

Temporary microsurgical clipping of the SAVF led to nerve root compromise detected via intraoperative monitoring. Instead, the authors advanced elongated pieces of a hemostatic agent directly into the arterial lumen via arteriotomy to create direct obliteration of the fistula without intraoperative monitoring changes.

LESSONS

In patients unable to tolerate clipping of the SAVF because of nerve root involvement and neurophysiological signal decline, open access of the vessels and direct intraluminal obliteration using a hemostatic agent should be considered as an alternative method of fistula occlusion.

Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation.

METHODS

We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up.

RESULTS

Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r2 = 0.90).

CONCLUSION

Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.

Delayed Post-cholecystectomy Gallbladder Fossa Abscess Due to Citrobacter freundii

While laparoscopic cholecystectomy has become the treatment of choice for cholecystitis, complications such as abscess development can result even years after the intervention. We present a case of a patient with a remote history of laparoscopic cholecystectomy now diagnosed with gallbladder fossa abscess infected with Citrobacter freundii, a low-virulence pathogen typically seen in iatrogenic urinary tract infections. Subsequent conjoint percutaneous drainage and long-term antibiotics resulted in both clinical and radiological improvement for the patient. Therefore, in the absence of recent events or risk factors for developing an abdominal wall abscess, a previous remote history of surgical intervention needs to be considered for the possible etiology, especially those with low incidences and long latency periods such as Citrobacter.

Duodenal Adenocarcinoma in the Setting of Bariatric Surgery: A Perfect Storm for Wernicke's Encephalopathy

Wernicke's encephalopathy (WE) is a condition resulting from thiamine deficiency that typically presents with acute neurologic symptoms including ataxia, eye movement disorders, and altered mental status. Though classically seen in patients with alcohol use disorder, it can also occur as a complication of bariatric surgery and gastrointestinal cancers. Here, we present a patient with a history of gastric band surgery and an intact alimentary tract. She presented with acute, intractable vomiting and epigastric abdominal pain, incompletely relieved by deflating her gastric band, and was found to have duodenal adenocarcinoma causing partial duodenal obstruction. She was then found to have binocular diplopia, horizontal nystagmus, dizziness, reduced proprioception, and pins-and-needles numbness in her bilateral lower extremities, and there was concern for gait instability; thus, WE was suspected. The patient was treated with high-dose thiamine repletion, and her symptoms resolved shortly thereafter. WE is rare in patients who have undergone gastric band surgery, and to our knowledge, this is the first case of WE in a patient with concurrent duodenal adenocarcinoma. This case illustrates that patients with a history of bariatric surgery may be more susceptible to developing WE in the face of a new gastrointestinal insult, such as duodenal cancer.

Transseptal interforniceal endoscopic removal of superiorly recessed colloid cysts

OBJECTIVE

Transforaminal endoscopic colloid cyst resection is well described. However, some anatomical colloid cyst variants may warrant a modified approach. Rarely, colloid cysts separate the forniceal columns and grow superiorly within the leaflets of the septum pellucidum. Thus, the authors' goal was to characterize the imaging features, clinical presentation, surgical strategy, and outcomes of patients with this superiorly recessed colloid cyst variant.

METHODS

A retrospective evaluation of patients who underwent endoscopic resection of colloid cysts from 1999 to 2020 was performed. The patients were dichotomized depending on whether the cyst was located predominately below the forniceal columns or was superiorly recessed (forniceal column separation with variable intraseptal extension). This comparative cohort study focused on clinical presentation, imaging features, operative technique, and patient outcome.

RESULTS

In total, 182 patients were identified. Seventeen patients had colloid cysts that were defined as superiorly recessed and underwent transseptal interforniceal removal, and 165 patients underwent a standard transforaminal approach. Patients had similar demographic characteristics. However, transseptal cysts were on average larger (17.8 mm vs 11.4 mm, p < 0.0001), and these patients had a greater frontal-occipital horn ratio (0.45 vs 0.41, p = 0.012). They were also more likely to have undergone a previous resection (p = 0.02). The two cohorts had similar surgical outcomes, with no differences in extent of resection, recurrence, or complications.

CONCLUSIONS

Superiorly recessed intraseptal colloid cysts are larger and tend to splay the bodies of the fornix, thus requiring a parasagittal transseptal interforniceal endoscopic approach. This achieves complete removal with comparatively negligible morbidity or rare recurrence (5.9%).

Availability and Readability of Spinal Cord Injury Online Information Materials for Spanish Speaking Population in Neurosurgical Academic Programs: A Nationwide Study

BACKGROUND

Recent publications have demonstrated that information has been transmitted inappropriately to the lay person in different pathologies. This limitation is also observed in Spanish language. We evaluate the availability and readability of online patient education material (PEM) on spinal cord injury (SCI) information for the Spanish-speaking population from academic neurosurgery residency programs in the United States.

METHODS

This is a descriptive analysis of online SCI PEM from neurosurgical residency programs websites. We assess the availability of information in Spanish using a modification of a previously published classification. To assess accessibility, we calculated the time spent and the number of clicks to find the information in Spanish. We calculated the readability of the material using the "Indice Flesch-Szigriszt" (INFLESZ), which determines the difficulty of readability of health-related material in Spanish.

RESULTS

A total of 116 accredited neurosurgery residency programs comprised our cohort. Ten (9%) programs had available "mirrored" information in Spanish from its original version in English, 9 (8.1%) used a translation software, 79 (71.2%) provide interpreter services, and 3 (2%) did not have written information or information about translation services. A mean of 72.9 seconds (SD +/- 71.2) were required to have access to the Spanish information or contact information for translation services. Twelve (57.1%) websites with written Spanish information had an INFLESZ score above 55.00, which translates as an appropriate readability level for the general population.

CONCLUSIONS

More than half of the academic neurosurgery programs or affiliated hospital websites do not provide written informative material about SCI in Spanish. When available, the information is not always transmitted with a level of readability appropriate for the layperson. Most of the websites provide translation or interpreter services that are not directly related to SCI.

Use of emerging technologies to enhance the treatment paradigm for spontaneous intraventricular hemorrhage

The presence of intraventricular hemorrhage (IVH) portends a worse prognosis in patients presenting with spontaneous intracerebral hemorrhage (ICH). Intraventricular hemorrhage increases the rates of hydrocephalus, ventriculitis, and long-term shunt dependence. Over the past decade, novel medical devices and protocols have emerged to directly treat IVH. Presently, we review new technological adaptations to treating intraventricular hemorrhage in an effort to focus further innovation in treating this morbid neurosurgical pathology. We summarize current and historical treatments as well as innovations in IVH including novel procedural techniques, use of the Integra Surgiscope, use of the Artemis evacuator, use of BrainPath, novel catheter technology, large bore external ventricular drains, the IRRAflow, the CerebroFlo, and the future directions of the field. Technology and medical devices for both surgical and nonsurgical methods are advancing the treatment of IVH. With many promising new technologies on the horizon, prospects for improved clinical care for IVH and its etiologies remain hopeful.

Quadriplegia, an Unusual Outcome After Anterior Cervical Discectomy and Fusion: A Case Report

CASE

A 68-year-old woman who underwent a C5 to C6 anterior cervical discectomy and fusion (ACDF) surgery presented with new-onset postoperative quadriplegia. During discectomy, intraoperative neurophysiological monitoring alerted of a spinal cord (SC) dysfunction. The surgery was halted, and measures to ensure adequate SC perfusion were initiated. In the next 2-week follow-up, patient's motor deficit progressively improved.

CONCLUSIONS

We report an unusual and devastating outcome of new-onset quadriplegia after an elective ACDF and highlight the relevance of intraoperative monitoring during cervical spine surgery to early recognize and treat SC impending injury.

Colloid cysts of the third ventricle in children

OBJECTIVE

The rarity of colloid cysts in children makes it difficult to characterize this entity and offer meaningful advice on treatment. Infrequent case reports exist, but to date there has been no age-specific assessment. The purpose of this study was to define any differences between children and adults who are evaluated and treated for colloid cysts of the third ventricle.

METHODS

Patients with colloid cysts were reviewed and stratified by age. Individuals ≤ 18 years of age were defined as pediatric patients and those > 18 years of age as adults. Clinical and radiographic data, treatment, and postoperative outcomes were compared between both groups. Bivariate analysis was conducted using the Fisher exact test for categorical variables and Mann-Whitney U-test for continuous variables.

RESULTS

Of 132 endoscopic resections (121 primary, 10 secondary, and 1 tertiary) of a colloid cyst, 9 (6.8%) were performed in pediatric patients (mean age 14.1 years, range 9-18 years) and 123 (93.2%) were performed in adult patients (mean age 43.8 years, range 19-73 years). Cases were found incidentally more commonly in pediatric than adult patients (66.7% vs 37.4%, p > 0.05), and pediatric patients had lower rates of hydrocephalus than adult patients (11.1% vs 63.4%, p < 0.05). Acute decompensation at presentation was found in 8 adults (6.5%) but no children. Complete cyst removal (88.9% vs 90.2%, p > 0.05) and length of stay (1.6 days vs 2.9 days, p > 0.05) were not significantly different between the groups. Postoperative complications (6.5% in adults, 0% in children) and recurrence (2.4% in adults, 0% in children) were rare in both groups, and there were no treatment-related deaths. The mean postoperative radiological follow-up was longer in pediatric patients (45 months, range 4-89 months) than adults (44.1 months, range 1-171 months).

CONCLUSIONS

While differences exist between children and adults regarding colloid cyst presentation, these are in keeping with the predicted evolution of a slow-growing lesion. Consistent with this observation, children had lower rates of hydrocephalus and a smaller mean maximal cyst diameter. Contrary to the published literature, however, sudden deterioration was not observed in pediatric patients but occurred in adult patients. In this limited pediatric sample size, the authors have not recorded any postoperative complications or recurrences to date. These encouraging results with endoscopic removal may positively impact future decisions related to children given their protracted life expectancy and projected rates of progression.

Time from image acquisition to endovascular team notification: a new target for enhancing acute stroke workflow

OBJECTIVE

To quantify the time between initial image acquisition (CT angiography (CTA)) and notification of the neuroendovascular surgery (NES) team, a potentially high yield time window to target for optimization of endovascular thrombectomy (ET) treatment times.

METHODS

We reviewed our multihospital database for all patients with a stroke with emergent large vessel occlusion treated with ET between January 1, 2017 and August 5, 2020. We dichotomized patients into rapid (≤20 min) and delayed (>20 min) notification times and analyzed treatment characteristics and outcomes.

RESULTS

Of 367 patients with ELVO undergoing ET for whom notification data were available, the median time from CTA to NES team notification was 24 min (IQR 12-47). The median total treatment time was 180 min (IQR 129-252). The median times from CTA to NES team notification for rapid (n=163) and delayed (n=204) cohorts were 11 (IQR 6-15) and 43 (IQR 30-80) min, respectively (p<0.001). The median overall times to reperfusion were 134 min (IQR 103-179) and 213 min (IQR 172-291), respectively (p<0.001). The delayed patients had a significantly lower National Institutes of Health Stroke Scale (NIHSS) score on presentation (15 (IQR 9-20) vs 16 (IQR 11-22), p=0.03), were younger (70 (IQR 60-79) vs 77 (IQR 64-85), p<0.001), and more often presented with posterior circulation occlusion (16.7% vs 7.4%, p<0.01). The group with rapid notification time had a statistically larger median improvement in NIHSS score from admission to discharge (6 (IQR 0.5-14) vs 5 (IQR 0.5-10), p=0.04).

CONCLUSIONS

Time delays from initial CTA acquisition to NES team notification can prevent expedient treatment with ET. Process improvements and automated stroke detection on imaging with automated notification of the NES team may ultimately improve time to reperfusion.

Initial Experience With a Full Endoscopic Facet Fusion in Combination With Endoscopic Interbody Fusion

Background

Facet fusion has been described in open and minimally invasive approaches to promote fusion. Our objective is to describe the technique of an endoscopic facet decortication and allograft placement as an adjunct to an interbody fusion.

Methodology

This was a descriptive analysis of patients who underwent endoscopic interbody fusion combined with facet fusion and percutaneous screw placement. General demographics, clinical presentation, length of stay, follow-up, and outcome were gathered. The technique involves endoscopic access to the Kambin’s triangle, discectomy/endplate preparation, expandable cage/allograft insertion, and percutaneous pedicle screw placement. A midline incision was performed, and the endoscope was advanced over the facet joints at the desired level. After removing the soft tissue with grasping forceps, cautery was used to disrupt the facet capsule. An articulating high-speed bur was used to drill inside and over the dorsal surface of the joint. Finally, allograft chips were placed through the endoscope cannula.

Results

From May 2019 to December 2019, four patients underwent endoscopic interbody fusion. All were female, with a mean age of 67.5 years (SD: 12.7). All had chronic low back pain and radiculopathy associated with Grade 1 spondylolisthesis. Two (50%) of the patients underwent two-level fusion. The median hospital stay was two days. Two (50%) reported improvement of both low back and radiculopathy symptoms. None of the patients had a significant complication or required reoperation in eight months’ mean follow-up.

Conclusions

Facet decortication and allograft placement are feasible using an endoscopic approach in conjunction with interbody fusion.

Syringomyelia Resolution Following Chiari Surgery: A Novel Scale for Communication and Research

BACKGROUND

The pathophysiological connection between Chiari malformation and syringomyelia is accepted. Debate remains, however, how can we best define changes in syringomyelia following surgery.

OBJECTIVE

To introduce a grading system focusing on syrinx reduction based on routinely and reproducible radiological information, and provide a suggestion of the application of this scale for prediction of patient's prognoses.

METHODS

Data from 48 patients with Chiari malformation and syringomyelia were compiled. We calculated syrinx cross-sectional area by approximating an ellipse in the largest axial plane. We compared the percentage of reduction or enlargement following surgery. The percentage change was grouped into four grades: Grade 0 = Increasing size, grade I ≤ 50% reduction, grade II = 50% to 90% reduction, grade III ≥ 90% reduction.

RESULTS

A total of 89.6% of patients had syrinx improvement after surgery. A total of 5 patients were grade 0, 14 were grade I, 20 patients were grade II, and 9 patients met criteria for grade III. The mean postoperative syrinx area was 24.1 mm2 (0-169 mm2) with a mean syrinx reduction of 62.7%.

CONCLUSION

Radiological improvement of syringomyelia can be mathematically defined and standardized to assist in communication in outcome-based trials. Radiological resolution is expected most patients.

"Staying Home"-Early Changes in Patterns of Neurotrauma in New York City During the COVID-19 Pandemic

OBJECTIVE

New York City is the epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic in the United States. Traumatic brain injury accounts for a significant proportion of admissions to our trauma center. We sought to characterize the effect of the pandemic on neurotraumas, given the cancellation of nonessential activities during the crisis.

METHODS

Retrospective and prospective reviews were performed from November 2019 to April 2020. General demographics, clinical status, mechanism of trauma, diagnosis, and treatment instituted were recorded. We dichotomized the data between pre-COVID-19 (before 1 March) and COVID-19 periods and compared the differences between the 2 groups. We present the timeline of events since the beginning of the crisis in relation to the number of neurotraumas.

RESULTS

A total of 150 patients composed our cohort with a mean age of 66.2 years (standard deviation ±18.9), and 66% were male. More males sustained neurotrauma in the COVID-19 period compared with the pre-COVID-19 (60.4% vs. 77.6%, P = 0.03). The most common mechanism of trauma was mechanical fall, but it was observed less frequently compared with the pre-COVID-19 period (61.4% vs. 40.8; P = 0.03). Subdural hematoma, traumatic subarachnoid hemorrhage, and intracerebral contusion accounted for the most common pathologies in both periods. Nonoperative management was selected for most patients (79.2 vs. 87.8%, P = 0.201) in both periods.

CONCLUSIONS

A decrease in the frequency of neurotraumas was observed during the COVID-19 crisis concomitant with the increase in COVID-19 patients in the city. This trend began after the cancellation of nonessential activities and implementation of social distancing recommendations.

Transpedicular Approach for Ventral Epidural Abscess Evacuation in the Cervical Spine

OBJECTIVE

Spinal epidural abscess may require prompt surgical intervention. Ventral cervical abscesses pose a particular challenge regarding the approach for surgical evacuation. The aim of this article was to describe the technical nuances of a posterior transpedicular cervical approach for evacuation of a ventral epidural abscess.

METHODS

After a standard laminectomy, a foraminotomy was performed to identify the exiting nerve root. Then the medial aspect of the pedicle below the nerve was drilled. This allowed the insertion of a dissector to reach the ventral epidural space and drain the contents in conjunction with suction and irrigation. The posterolateral aspect of the superior endplate of the respective vertebra could be further drilled at this point, allowing access to the disc space with minimal retraction of the exiting nerve root.

RESULTS

Two patients underwent emergent evacuation of a ventral epidural abscess in the cervical spine using this technique. Radiographic and clinical improvement was evident after evacuation of the abscesses in both cases.

CONCLUSIONS

Access to the ventral epidural space is feasible using a transpedicular approach in the cervical spine for evacuation of an epidural abscess.

Emergent Large Vessel Occlusion Stroke During New York City's COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings

BACKGROUND AND PURPOSE

The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak.

METHODS

This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period.

RESULTS

Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; P=0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; P=0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); P=0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], P≤0.0001).

CONCLUSIONS

More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.

Initial Stroke Thrombectomy Experience in New York City during the COVID-19 Pandemic

New York City has become the global epicenter of the coronavirus 2019 (COVID-19) pandemic. Despite a massive shift in health care resources, cerebrovascular disease continues to be a substantial burden. We review the first 10 patients undergoing thrombectomy following a series of governmental and institutional policy changes diverting resources to the care of critically ill patients with COVID-19. Ten patients with emergent large-vessel occlusion underwent thrombectomy between March 23 and April 1, 2020. Five patients tested positive for the COVID-19 virus. Successful reperfusion was achieved in 9 of 10 patients, at a median time of 37 minutes from vascular access. The postprocedural NIHSS score improved by an average of 7.7 points. Of the 5 patients positive for COVID-19, none have experienced a critical respiratory illness. We report the early incidence of COVID-19 positivity in patients with emergent large-vessel occlusion and demonstrate that thrombectomy continues to be an efficacious option, as well as safe for health care providers.

Persistent Syringomyelia After Posterior Fossa Decompression for Chiari Malformation

BACKGROUND

Chiari malformation (CM) is often comorbid with syringomyelia. The treatment of CM via posterior fossa decompression (PFD) may not improve syringomyelia in up to 40% of patients, based on historical cohorts. Management of these patients is problematic, as both reoperation and syrinx shunting have high failure rates in the long term.

METHODS

We retrospectively reviewed our cases in which patients with CM type 1 or 1.5 and syringomyelia underwent PFD without postoperative improvement in syringomyelia. Symptomatology and radiographic measurements were collected at presentation and on the first and latest available postoperative scans and analyzed. We present 2 cases to illustrate the challenges in the management of these patients.

RESULTS

Our cohort consisted of 48 consecutive patients with CM and syringomyelia who underwent PFD. Of these, 41 patients had postoperative improvement in or resolution of syringomyelia. We subsequently studied the cohort of 7 patients who underwent PFD with (n = 5) or without (n = 2) durotomy and demonstrated worsening of syringomyelia following surgery. This cohort had mean (±SEM) preoperative syrinx area of 23.9 ± 10.0 mm². Postoperatively, the mean syrinx area increased to 40.5 ± 9.6 mm² and 57.3 ± 12.5 mm² on the first and latest postoperative scans available (P = 0.02), for an increase of 106.9% ± 94.4% and 186.0% ± 107.4% (P = 0.04). Presenting symptoms included occipital headache, paresthesias, visual deterioration, and paraspinal pain. On last follow-up (mean 13.9 ± 4.9 months), the majority of symptoms were resolved in this cohort, despite persistence of syringomyelia.

CONCLUSIONS

In this small cohort of unique patients, syrinx resolution was not achieved via decompression surgery. Despite "radiographic failure," good symptom control was achieved, with most patients remaining or becoming asymptomatic postoperatively, thus supporting our rationale for what has largely been a conservative approach in this population.

Synchronous complex Chiari malformation and cleft palate-a case-based review

BACKGROUND

The association between mid-facial clefts and Chiari malformation in the medical literature has been restricted to patients with syndromic craniofacial abnormalities. A common shared developmental pathway including causative factors for facial clefts and "complex" Chiari malformations, both midline skull base pathologies, seems logical but has not been reported. The coincident presentation of these findings in a single patient, and our subsequent discovery of other patients harboring these mutual findings prompted further investigation.

CASE ILLUSTRATION

We describe the case of a patient born with a cleft palate which was repaired during his first year of life, subsequently presenting as a teenager to our hospital with a severe and symptomatic complex Chiari malformation. We discuss his treatment strategy, suboccipital decompression with occipitocervical fusion and endoscopic anterior decompression surgeries, as well as his favorable radiological and clinical outcome, demonstrated at long-interval follow-up. Furthermore, we review his two pathologies, cleft palate and Chiari malformation, and posit a common embryological linkage.

CONCLUSIONS

The embryologic interaction between the paraxial mesoderm and ectoderm may explain the co-occurrence of cleft palate and complex Chiari malformation in a single patient. Complete radiological, clinical, and genetic evaluation and counseling is advised in this situation and raises the question of whether the presence of a cleft palate independently increases the risk for other skull base developmental abnormalities.

Antagonism of Bacillus spp. isolated from marine biofilms against terrestrial phytopathogenic fungi

We aimed at determining the antagonistic behavior of bacteria derived from marine biofilms against terrestrial phytopathogenic fungi. Some bacteria closely related to Bacillus mojavensis (three isolates) and Bacillus firmus (one isolate) displayed antagonistic activity against Colletotrichum gloeosporioides ATCC 42374, selected as first screen organism. The four isolates were further quantitatively tested against C. gloeosporioides, Colletotrichum fragariae, and Fusarium oxysporum on two culture media, potato dextrose agar (PDA) and a marine medium-based agar [yeast extract agar (YEA)] at different times of growth of the antagonists (early, co-inoculation with the pathogen and late). Overall antagonistic assays showed differential susceptibility among the pathogens as a function of the type of culture media and time of colonization (P < 0.05). In general, higher suppressive activities were recorded for assays performed on YEA than on PDA; and also when the antagonists were allowed to grow 24 h earlier than the pathogen. F. oxysporum was the most resistant fungus while the most sensitive was C. gloeosporioides ATCC 42374. Significant differences in antagonistic activity (P < 0.05) were found between the different isolates. In general, Bacillus sp. MC3B-22 displayed a greater antagonistic effect than the commercial biocontrol strain Bacillus subtilis G03 (Kodiak). Further incubation studies and scanning electronic microscopy revealed that Bacillus sp. MC3B-22 was able to colonize, multiply, and inhibit C. gloeosporioides ATCC 42374 when tested in a mango leaf assay, showing its potential for fungal biocontrol. Additional studies are required to definitively identify the active isolates and to determine their mode of antifungal action, safety, and biocompatibility.

Synergism between the nucleopolyhedroviruses of Autographa californica and Trichoplusia ni

Previous observations on high virulence of Autographa californica multiple nucleopolyhedrovirus (AcMNPV) and Trichoplusia ni single nucleopolyhedrovirus (TnSNPV) acting together led us to test possible synergism between these two nucleopolyhedroviruses (NPVs) on cabbage looper larvae. Because synergism between AcMNPV and the Trichoplusia ni granulovirus (TnGV) has been well established before, these two viruses were included in this study as a positive control. Each virus was assayed separately on first-instar cabbage looper and their LC50s were estimated at 2.33, 0.39 and 462 OB/mm2 diet for AcMNPV, TnSNPV and TnGV, respectively. LC50s of AcMNPV mixed with sub-lethal concentrations of TnSNPV and TnGV increased 8 and 10.7 times, respectively. Synergism between the viruses was analyzed by the ANOVA test for the LC50s, the Plackett and Hewlett's joint-action rate test, and the Tammes-Bakuniak graphic method. All three analyses corroborated the synergism between the viruses. The presence of a putative enhancin in the TnSNPV was analyzed by Southern blot hybridization, using a 1.5 kbp KpnI fragment from the TnGV vef gene as a probe. No hybridization was observed. The occurrence of a new putative synergistic factor in TnSNPV is discussed.