A critical analysis of surgery for occult tethered cord syndrome.

INTRODUCTION: Tethered cord syndrome (TCS) is an amalgamation of neurological, urological, orthopedic, and dermatologic signs and symptoms with radiographic evidence of a thickened filum and low-lying conus. Surgical sectioning of the filum and disconnection of any tethering entities such as dermal sinus tracts or lipomas has been shown to improve outcomes. The manifestation of TCS symptoms in the absence of a low-lying conus has been referred to as occult tethered cord syndrome (OTCS) and is much less well reviewed in the literature. To date, there has only been one randomized controlled trial examining the effect of intervention in OTCS; therefore, contemporary data is often elicited from limited cohorts. OBJECTIVE: To perform a comprehensive literature review of management in OTCS and evaluate treatment response rates to sectioning of the filum terminale. RESULTS: Seventeen papers met inclusion criteria for our review. Sample sizes ranged from 8 to 60 children, and results were mixed, often dependent on study design, definition of typical OTCS symptoms, and follow-up intervals. Symptomatic improvement was observed in > 50% of patients for all but one study; however, the recurrence rates were highly variable. CONCLUSION: The data regarding the efficacy of surgical treatment in OTCS is mixed and merits more rigorous scientific examination with strict and clear parameters regarding symptomatic operationalization and follow-up time points to monitor for TCS recurrence.

Venous sinus stenting for the treatment of isolated pulsatile tinnitus: Results of a prospective trial.

OBJECTIVES: This prospective study evaluates the effectiveness and safety of venous sinus stenting for patients with isolated pulsatile tinnitus and lateral sinus stenosis. METHODS: Patients with isolated pulsatile tinnitus and lateral sinus stenosis with a minimum trans stenotic gradient of 4 mm Hg were treated with stenting. Pulsatile tinnitus before and after treatment was assessed with the Tinnitus Handicap Inventory (THI). Periprocedural adverse events, neurological complications, clinical and radiographic follow-up were also recorded. RESULTS: A total of 42 patients (41 females and 1 male) were included in the study (median age of 37.5 years). Thirty patients had post-stenotic fusiform and 12 had post-stenotic saccular venous sinus aneurysm. In addition to stenting, coils were used to treat the patients with saccular venous aneurysms. The median follow-up was 5 months (range 1 to 34 months). Most patients had complete (39/42) or near-complete (2/42) resolution of their pulsatile tinnitus post-procedure. There were no serious adverse events. CONCLUSION: Stenting of the lateral venous sinus is a safe and effective treatment for patients with isolated pulsatile tinnitus due to venous sinus stenosis.

Magnetic resonance venography for 3-dimensional live guidance during venous sinus stenting.

PURPOSE: The purpose of this study was to report the technique for intraprocedural guidance of endovascular Venous Sinus Stenting procedures using 3-Dimensional (3D) Magnetic Resonance Venography (MRV) as an overlay on live biplanar fluoroscopy. MATERIALS AND METHODS: Venous sinus stenting procedures performed between April and December, 2017 with 3D MRV fusion for live guidance were reviewed in this study. A thin-slice, contrast-enhanced MR Venogram was used to create 2 3D models - vessels and skull - for procedural guidance via augmented fluoroscopy (Vessel ASSIST, GE Healthcare, Chicago, IL). The skull model was used in the registration of the 3D overlay on both the frontal and lateral planes, which required 1-2 min of procedural time. The vessel model was used to mark landmarks such as the cortical vein ostia and stenosis on the 3D overlay fused with biplanar fluoroscopy. The retrospective imaging review was conducted by 3 neurointerventionalists and relied on a consensus confidence ranking on a 3-point Likert scale from 1- low confidence to 3- high confidence. The neurointerventionalists first reviewed the conventional 2-dimensional pre-stent deployment fluoroscopy images and then reviewed the corresponding images with the 3D MRV overlay. They ranked their confidence in their understanding of cortical venous anatomy for each group. Statistical analysis was performed using a Paired T Test at a 99% confidence interval. RESULTS: Ten cases were included in the retrospective image review. Operator confidence regarding the location of cortical veins was significantly increased using 3D MRV fusion during venous sinus stenting procedures (1.9 vs 2.9, p = .001). CONCLUSION: 3-Dimensional MRV fusion is feasible and helpful in understanding the venous sinus anatomy and location of important cortical veins during venous sinus stenting procedures.