Lumboperitoneal shunts for the treatment of idiopathic normal pressure hydrocephalus.

The standard of care for idiopathic normal pressure hydrocephalus (iNPH) is placement of a ventriculoperitoneal (VP) shunt. However, VP shunts require intracranial intervention and are associated with notable postoperative complications, with some groups reporting complication rates for VP shunts ranging from 17 to 33%, along with failure rates up to 17.7%. Lumboperitoneal (LP) shunts are an alternative for cerebrospinal fluid diversion that do not require intracranial surgery, thus providing utility in patients where intracranial surgery is not possible or preferred. Here we retrospectively reviewed our 25 patients with LP horizontal-vertical (LP-HV) shunts placement for initial treatment for iNPH from 2014 to 2019. All patients had preoperative gait dysfunction, 16 (64%) had urinary incontinence, and 21 (84%) exhibited cognitive insufficiency. Two weeks post-shunt placement, 23/25 (92%) patients demonstrated improvement in gait, 11/16 (68%) had improvement in incontinence, and 14/21 (66%) had improvement cognitive insufficiency. At six months or greater follow up 13/20 (65%) had improvement in gait, 7/15 (47%) showed improvement in incontinence, and 11/15 (73%) demonstrated improvement in cognitive function. Six patients (24%) required at least one revision of the LP shunt. Shunt malfunctions resulted from CSF leak in one patient, shunt catheter migration in two patients, peritoneal catheter pain in one patient, and clinical symptoms for overdrainage in two patients. Thus, we demonstrate that LP-HV shunt placement is safe and efficacious alternative to VP shunting for iNPH, resulting in notable symptomatic improvement and low risk of overdrainage, and may be considered for patients where cranial approaches should be avoided.

Social Media in Neurosurgery: A Systematic Review.

OBJECTIVE: Social media has been used increasingly in neurosurgery by individuals. We aimed to identify demographics and preferences of social media use, describe the scope of social media use, and characterize its utility. METHODS: A systematic review was conducted using PubMed, Embase, and Scopus databases. Titles and abstracts from articles identified in the search were read and selected for full-text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for relevant data. RESULTS: Of 431 resultant articles, 29 were included. Patients and caregivers most commonly used Facebook and Twitter, whereas nearly 50% of neurosurgeons used LinkedIn and Doximity. Patient and caregiver users of social media tended to be <35 years old. Content of posts varied from requesting/providing information (∼40%) to seeking emotional support/forming connections (∼30%). A total of 20.6% of videos were irrelevant to clinical neurosurgery. Factual accuracy of most videos was poor to inadequate. Social media use was associated with greater academic impact for neurosurgical departments and journals. Posts with photos and videos and weekend posts generated 1.2-2 times greater engagement. CONCLUSIONS: Patients and caregivers who use social media are typically younger than 35 years old and commonly use Facebook or Twitter. Neurosurgeons prefer Doximity and LinkedIn. Social media yields information regarding common symptoms and uncovers novel symptoms. Videos are poor-to-inadequate quality and often irrelevant to clinical neurosurgery. Optimizing social media use will augment the exchange of ideas regarding clinical practice and research and empower patients and caregivers.

Surgical Site Infection, Readmission, and Reoperation After Posterior Long Segment Fusion.

STUDY DESIGN: Retrospective case series. OBJECTIVE: We sought to identify risk factors associated with surgical site infection (SSI) after posterior long segment spinal fusion (PLSF). SUMMARY OF BACKGROUND DATA: Patients who undergo PLSF may be at elevated risk of SSI. Identifying factors associated with SSI in these operations can help risk stratify patients and tailor management. METHODS: We analyzed PLSFs-seven or more levels-at our institution from 2000 to 2015. Data on patients' clinical characteristics, procedural factors, and antimicrobial management were collected. Multivariable analysis identified factors independently associated with outcomes of interest. RESULTS: In 628 cases, SSI was associated with steroid use (P = 0.024, odds ratio [OR] = 2.54) and using cefazolin (P < 0.001, OR = 4.37) or bacitracin (P = 0.010, OR 3.49) irrigation, as opposed to gentamicin or other irrigation. Gram-positive infections were more likely with staged procedures (P = 0.021, OR 4.91) and bacitracin irrigation (P < 0.001, OR = 17.98), and less likely with vancomycin powder (P = 0.050, OR 0.20). Gram-negative infections were more likely with a history of peripheral arterial disease (P = 0.034, OR = 3.21) or cefazolin irrigation (P < 0.001, OR 25.47). Readmission was more likely after staged procedures (P = 0.003, OR = 3.31), cervical spine surgery (P = 0.023, OR = 2.28), or cefazolin irrigation (P = 0.039, OR = 1.85). Reoperation was more common with more comorbidities (P = 0.022, OR 1.09), staged procedures (P < 0.001, OR = 4.72), cervical surgeries (P = 0.013, OR = 2.36), more participants in the surgery (P = 0.011, OR = 1.06), using cefazolin (P < 0.001, OR = 3.12) or bacitracin (P = 0.009, OR = 3.15) irrigation, and higher erythrocyte sedimentation rate at readmission (P = 0.009, OR = 1.04). Washouts were more likely among patients with more comorbidities (P = 0.013, OR = 1.16), or who used steroids (P = 0.022, OR = 2.92), and less likely after cervical surgery (P = 0.028, OR = 0.24). Instrumentation removal was more common with bacitracin irrigation (p = 0.013, OR = 31.76). CONCLUSION: Patient factors, whether a procedure is staged, and choice of antibiotic irrigation affect the risk of SSI and ensuing management required.Level of Evidence: 4.

Radiographic assessment of surgical treatment of post-traumatic syringomyelia.

Context: Symptomatic post-traumatic syringomyelia can affect the quality of life in patients whose neurologic function has already been impacted by a spinal cord injury.Objective: To investigate the radiographic and clinical outcomes following surgery for syringomyelia, we present a literature review along with a case series from a single surgeon's experience.Methods: A retrospective review was conducted on patients with post-traumatic syringomyelia who were treated by a single surgeon. Thirty-four patients who underwent surgical treatment consisting of syrinx fenestration, lysis of adhesions, and duraplasty were identified. In addition, a narrative literature review was conducted with a primary focus on diagnosis and management of post-traumatic syringomyelia.Results: Literature review suggests that regardless of age, sex, vertebral location, or severity of trauma, patients who experience a spinal cord injury should be closely monitored for post-traumatic syringomyelia. Retrospective review of our 34 patients revealed 24 patients for whom pre- and post- operative MRI was available. The predominant location of the injury was cervical (15). The average syrinx length, measured in spinal segments, was similar when comparing pre- and post-operative MRIs; average syrinx length was 5.5 and 5.4 spinal segments, respectively. In contrast, syrinx axial dimension was decreased in 16 of the patients post-operatively and stable or increased in the other eight. The change in syrinx size did not correlate with clinical outcomes.Conclusion: Current surgical treatment of post-traumatic syringomyelia involves restoration of normal CSF flow dynamics; further prospective work is needed to correlate the clinical state, radiographic measures, and efficacy of surgical intervention.

Patient Education in Neurosurgery: Part 1 of a Systematic Review.

BACKGROUND: Patient education has become increasingly important in neurosurgery. However, little is known regarding how to comprehensively educate neurosurgical patients. In the first part of a 2-part systematic review, we identify baseline patient understanding and educational needs, examine existing patient education materials, and characterize shortcomings in neurosurgical patient education practices. Our findings may guide neurosurgeons, departments, and professional associations in improving communication with patients. METHODS: A 2-part systematic review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were read and selected for full text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes. RESULTS: Of 1617 resultant articles, 41 were included. Patient comprehension was low. Patient informational needs differed across patients and between patients and neurosurgeons. Patient informational needs were often unmet, promoting dissatisfaction. Written educational materials from government agencies, professional associations, neurosurgery departments, neurosurgeons, or widely read Web sites were written at a reading level above the recommended reading level, with complex topics written at a higher level. Information found on hospital and university Web sites was poor quality because of self-marketing and lack of reference to peer-reviewed literature. Educational videos created by universities and hospitals were poor quality. CONCLUSIONS: Current in-clinic discussions and education materials show shortcomings, promoting poor comprehension. Neurosurgeons, departments, and professional organizations can act to improve the effectiveness of patient education initiatives. This policy will better inform patients, increase rapport between neurosurgeons and patients, and improve patient decision making and satisfaction.

Patient Education in Neurosurgery: Part 2 of a Systematic Review.

BACKGROUND: Increasing focus has been placed on patient education to optimize care. In the second part of a 2-part systematic review, we characterize the scope of interventions specifically created to improve neurosurgery patient education, assess the effectiveness of these interventions, and extract features of existing interventions that may be incorporated into future patient education interventions. Our findings may help promote the creation of effective, patient-centered educational interventions. METHODS: A 2-part systematic review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were read and selected for full text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes. RESULTS: Of 1617 resultant articles, 33 were included. Print materials, electronic materials, models, and interventions using multiple modalities improved patient knowledge, decreased anxiety, and increased satisfaction. Electronic materials were preferred. Interventions using multiple modalities engaging multiple sensory systems were reported most beneficial. Video was rated the most effective medium for reinforcing spoken conversation between neurosurgeons and patients. Three-dimensional models decreased the time required for preoperative patient conversation but could be perceived as emotionally confronting. Virtual reality was preferred to patient models. CONCLUSIONS: Electronic interventions using multiple modalities in concert with each other may be most effective. Interventions should incorporate baseline knowledge and health literacy and address patient concerns and needs in a manner that is valid cross-contextually, uses clear communication, and is continuous. These interventions will improve the patient-friendliness of discussions with patients.

The Impact of Perioperative Arterial Infarct on Recurrence, Functional Outcomes, and Survival in Glioblastoma Patients.

Background: Perioperative infarcts are a known complication that can occur during the resection of glioblastoma (GBM). Recent studies suggest that gross total and even "supra-total" resections may be associated with an increased survival but the rate of complications, including perioperative ischemia, may increase with these more aggressive resection strategies. However, little is known about the impact that perioperative infarcts have on survival, functional outcomes, and tumor recurrence patterns. Our study attempted to quantify and characterize the functional consequences of a perioperative infarct, as well as risk factors associated with occurrence. Methods: Seventy-three patients with a diagnosis of GBM and perioperative ischemia by MRI were identified from the electronic medical record system. We obtained demographic, prognostic, and stroke risk factor data. Infarct volumes were calculated from diffusion-weighted MRI scans, and subjects were segregated into an infarct cohort or a control cohort based on whether the identified lesion appeared to be an infarct in an arterial distribution or instead appeared to be expected postoperative changes. A multivariate statistical analysis was performed on the dataset. Results: Median age was 58.6 years, median post-op KPS (Karnofsky Performance Status) was 90, and median extent of resection (based on MRI) was 97.8%. Overall, perioperative arterial infarcts were uncommon (2.0%), did not have a statistically significant impact on survival (17.9 vs. 18.9 months), did not worsen neurologic function, and did not alter the pattern of recurrence. Conclusion: Perioperative arterial infarcts were uncommon in our patients despite aggressive resection and when present had no impact on survival or neurologic function. Given the clear benefit of maximal tumor resection, the risk of perioperative infarct should not deter maximal safe resection.

Using artificial intelligence (AI) to predict postoperative surgical site infection: A retrospective cohort of 4046 posterior spinal fusions.

OBJECTIVES: Machine Learning and Artificial Intelligence (AI) are rapidly growing in capability and increasingly applied to model outcomes and complications within medicine. In spinal surgery, post-operative surgical site infections (SSIs) are a rare, yet morbid complication. This paper applied AI to predict SSIs after posterior spinal fusions. PATIENTS AND METHODS: 4046 posterior spinal fusions were identified at a single academic center. A Deep Neural Network DNN classification model was trained using 35 unique input variables The model was trained and tested using cross-validation, in which the data were randomly partitioned into training n = 3034 and testing n = 1012 datasets. Stepwise multivariate regression was further used to identify actual model weights based on predictions from our trained model. RESULTS: The overall rate of infection was 1.5 %. The mean area under the curve (AUC), representing the accuracy of the model, across all 300 iterations was 0.775 (95 % CI [0.767,0.782]) with a median AUC of 0.787. The positive predictive value (PPV), representing how well the model predicted SSI when a patient had SSI, over all predictions was 92.56 % with a negative predictive value (NPV), representing how well the model predicted absence of SSI when a patient did not have SSI, of 98.45 %. In analyzing relative model weights, the five highest weighted variables were Congestive Heart Failure, Chronic Pulmonary Failure, Hemiplegia/Paraplegia, Multilevel Fusion and Cerebrovascular Disease respectively. Notable factors that were protective against infection were ICU Admission, Increasing Charlson Comorbidity Score, Race (White), and being male. Minimally invasive surgery (MIS) was also determined to be mildly protective. CONCLUSION: Machine learning and artificial intelligence are relevant and impressive tools that should be employed in the clinical decision making for patients. The variables with the largest model weights were primarily comorbidity related with the exception of multilevel fusion. Further study is needed, however, in order to draw any definitive conclusions.

Management and outcome of intracranial hemorrhage in patients with left ventricular assist devices.

OBJECTIVE: As the use of left ventricular assist devices (LVADs) has expanded, cerebrovascular complications have become an increasing source of morbidity and mortality in this population. Intracranial hemorrhage (ICH) in particular remains a devastating complication in patients who undergo LVAD placement with no defined management guidelines. The authors therefore reviewed surgical and anticoagulation management and outcomes of patients with LVADs who presented to their institution with ICH. METHODS: This retrospective cohort study assessed outcomes of patients who underwent LVAD placement at a single institution between 2007 and 2016 and in whom imaging demonstrated ICH. RESULTS: During the study period, 281 patients had a HeartMate II or HeartWare LVAD placed. There were 37 episodes of ICH (recurrent in 3 cases). ICHs were categorized as intraparenchymal hemorrhage (IPH; n = 22, 59%), subdural hemorrhage (SDH; n = 6, 16%), and subarachnoid hemorrhage (SAH; n = 9, 24%). Neurosurgical intervention was deemed necessary in 27.3%, 66.7%, and 0% of patients with IPH, SDH, and SAH, respectively; overall survival > 30 days for each type of hemorrhage was 41%, 83%, and 89%, respectively. No patients had LVAD thrombus as a result of reversal of anticoagulation. Combined with prior reports, good outcomes are seen more often following surgery for SDH than for IPH (57% vs 7%, p = 0.004) in patients who underwent VAD placement. CONCLUSIONS: Patients with IPH who undergo LVAD placement have poor outcomes regardless of anticoagulation reversal or neurosurgical intervention, whereas those with SDH may have good outcomes with medical and surgical intervention, and those with SAH appear to do well without anticoagulation reversal or surgery. When needed, anticoagulation reversal was not associated with an increase in LVAD thrombosis in this series.

Using machine learning to predict 30-day readmissions after posterior lumbar fusion: an NSQIP study involving 23,264 patients.

OBJECTIVE: Unplanned preventable hospital readmissions within 30 days are a great burden to patients and the healthcare system. With an estimated $41.3 billion spent yearly, reducing such readmission rates is of the utmost importance. With the widespread adoption of big data and machine learning, clinicians can use these analytical tools to understand these complex relationships and find predictive factors that can be generalized to future patients. The object of this study was to assess the efficacy of a machine learning algorithm in the prediction of 30-day hospital readmission after posterior spinal fusion surgery. METHODS: The authors analyzed the distribution of National Surgical Quality Improvement Program (NSQIP) posterior lumbar fusions from 2011 to 2016 by using machine learning techniques to create a model predictive of hospital readmissions. A deep neural network was trained using 177 unique input variables. The model was trained and tested using cross-validation, in which the data were randomly partitioned into training (n = 17,448 [75%]) and testing (n = 5816 [25%]) data sets. In training, the 17,448 training cases were fed through a series of 7 layers, each with varying degrees of forward and backward communicating nodes (neurons). RESULTS: Mean and median positive predictive values were 78.5% and 78.0%, respectively. Mean and median negative predictive values were both 97%, respectively. Mean and median areas under the curve for the model were 0.812 and 0.810, respectively. The five most heavily weighted inputs were (in order of importance) return to the operating room, septic shock, superficial surgical site infection, sepsis, and being on a ventilator for > 48 hours. CONCLUSIONS: Machine learning and artificial intelligence are powerful tools with the ability to improve understanding of predictive metrics in clinical spine surgery. The authors' model was able to predict those patients who would not require readmission. Similarly, the majority of predicted readmissions (up to 60%) were predicted by the model while retaining a 0% false-positive rate. Such findings suggest a possible need for reevaluation of the current Hospital Readmissions Reduction Program penalties in spine surgery.

Impact of CrossFit-Related Spinal Injuries.

INTRODUCTION: Exercise-related injuries (ERIs) are a common cause of nonfatal emergency department and hospital visits. CrossFit is a high-intensity workout regimen whose popularity has grown rapidly. However, ERIs due to CrossFit remained under investigated. METHODS: All patients who presented to the main hospital at a major academic center complaining of an injury sustained performing CrossFit between June 2010 and June 2016 were identified. Injuries were classified by anatomical location (eg, knee, spine). For patients with spinal injuries, data were collected including age, sex, body mass index (BMI), CrossFit experience level, symptom duration, type of symptoms, type of clinic presentation, cause of injury, objective neurological examination findings, imaging type, number of clinic visits, and treatments prescribed. RESULTS: Four hundred ninety-eight patients with 523 CrossFit-related injuries were identified. Spine injuries were the most common injuries identified, accounting for 20.9%. Among spine injuries, the most common location of injury was the lumbar spine (83.1%). Average symptom duration was 6.4 months ± 15.1, and radicular complaints were the most common symptom (53%). A total of 30 (32%) patients had positive findings on neurologic examination. Six patients (6.7%) required surgical intervention for treatment after failing an average of 9.66 months of conservative treatment. There was no difference in age, sex, BMI, or duration of symptoms of patients requiring surgery with those who did not. CONCLUSIONS: CrossFit is a popular, high-intensity style workout with the potential to injure its participants. Spine injuries were the most common type of injury observed and frequently required surgical intervention.

Economic Value in Minimally Invasive Spine Surgery.

PURPOSE OF REVIEW: The field of spine surgery remains a unique target in the transition to value-based care. While spine surgery has benefited from new medical technologies, including minimally invasive surgery (MIS), these technologies may be a key driver in rising US healthcare costs. As such, MIS needs to clear an economic value threshold through a rigorous evaluation of the outcomes they provide and costs they incur. In this article, we review recent MIS surgery literature from the perspective of economic value. RECENT FINDINGS: Many studies report modest all-in cost savings and direct procedural cost equivalence for minimally invasive approaches relative to open surgeries. In terms of quality, studies found lower blood loss, length of stay, and infectious complications with MIS surgery but evidence on QALYs was mixed. In the past 5 years, there has been increasing research interest in defining economic value in MIS surgery. However, a significant amount of heterogeneity in research quality and methodology persists. Therefore, MIS surgery has the potential to be of high economic value, though this is not yet definitive. Future research should continue to focus on high-quality cost-effectiveness studies with clear methodologies to further elucidate economic value in MIS surgery.

CrossFit and rhabdomyolysis: A case series of 11 patients presenting at a single academic institution.

OBJECTIVES: CrossFit is an increasingly popular high intensity work out program geared towards high repetition and intensity done in short intervals. Recently, documented cases of rhabdomyolysis (muscle necrosis and extreme muscle breakdown) after CrossFit participation have become increasingly concerning to physicians and participants alike. DESIGN: Retrospective cohort study. METHODS: All patients who presented to the main hospital at a major academic center complaining of an injury sustained performing CrossFit between June 2010 and June 2016 were identified by the key phrases 'CrossFit', 'crossfit', 'Crossfit' or 'cross fit'. RESULTS: 523 patients incurred injuries associated with CrossFit activities. 11 patients presented to our institution ultimately received a diagnosis of rhabdomyolysis (2.1%). The average age of Rhabdomyolysis patient was 34.9 years, with 81.9% of patients being male. The average BMI was 24.2, and the average experience level was beginner (54.5%). The most common presenting symptom was dark urine (90.9%), followed by upper extremity pain (54.5%). Average symptom duration was 2.9days with 81.8% of patients presenting initially to the ED. The average hospital stay was roughly 2.9 days, and patients had an average of 1.44 clinical follow up visits. CONCLUSION: CrossFit participation poses significant risks to participants including exercise induced rhabdomyolysis. Further study is needed in order to raise awareness of this issue and further quantify risk factors that may promote injury during participation.

Machine Learning for the Prediction of Cervical Spondylotic Myelopathy: A Post Hoc Pilot Study of 28 Participants.

BACKGROUND: Cervical spondylotic myelopathy (CSM) severity and presence of symptoms are often difficult to predict based simply on clinical imaging alone. Similarly, improved machine learning techniques provide new tools with immense clinical potential. METHODS: A total of 14 patients with CSM and 14 controls underwent imaging of the cervical spine. Two different artificial neural network models were trained; 1) to predict CSM diagnosis; and 2) to predict CSM severity. Model 1 consisted of 6 inputs including 3 common imaging scales for the evaluation of cord compression, alongside 3 objective magnetic resonance imaging measurements. The outcome for model 1 was binary to predict CSM diagnosis. Model 2 consisted of 23 input variables derived from probabilistic volume mapping measurements of white matter tracts in the region of compression. The outcome of model 2 was linear, to predict the modified Japanese Orthopedic Association (mJOA) score. RESULTS: Model 1 was used in predicting CSM. The mean cross-validated accuracy of the trained model was 86.50% (95% confidence interval, 85.16%-87.83%) with a median accuracy of 90.00%. Area under the curve (AUC) was calculated for each repetition. Average AUC for each repetition was 0.947 with a median AUC of 1.0. Average sensitivity, specificity, positive predictive value, and negative predictive value were 90.25%, 85.05%, 81.58%, and 91.94%, respectively. Model 2 was used in modeling mJOA. The mJOA model predicted scores, with a mean and median error of -0.29 mJOA points and -0.08 mJOA points, respectively, mean error per batch was 0.714 mJOA points. CONCLUSIONS: Machine learning provides a promising method for prediction, diagnosis, and even prognosis in patients with CSM.

Glioblastoma-Derived IL6 Induces Immunosuppressive Peripheral Myeloid Cell PD-L1 and Promotes Tumor Growth.

PURPOSE: Upregulation of programmed death-ligand 1 (PD-L1) on circulating and tumor-infiltrating myeloid cells is a critical component of GBM-mediated immunosuppression that has been associated with diminished response to vaccine immunotherapy and poor survival. Although GBM-derived soluble factors have been implicated in myeloid PD-L1 expression, the identity of such factors has remained unknown. This study aimed to identify factors responsible for myeloid PD-L1 upregulation as potential targets for immune modulation. EXPERIMENTAL DESIGN: Conditioned media from patient-derived GBM explant cell cultures was assessed for cytokine expression and utilized to stimulate naïve myeloid cells. Myeloid PD-L1 induction was quantified by flow cytometry. Candidate cytokines correlated with PD-L1 induction were evaluated in tumor sections and plasma for relationships with survival and myeloid PD-L1 expression. The role of identified cytokines on immunosuppression and survival was investigated in vivo utilizing immunocompetent C57BL/6 mice bearing syngeneic GL261 and CT-2A tumors. RESULTS: GBM-derived IL6 was identified as a cytokine that is necessary and sufficient for myeloid PD-L1 induction in GBM through a STAT3-dependent mechanism. Inhibition of IL6 signaling in orthotopic murine glioma models was associated with reduced myeloid PD-L1 expression, diminished tumor growth, and increased survival. The therapeutic benefit of anti-IL6 therapy proved to be CD8+ T-cell dependent, and the antitumor activity was additive with that provided by programmed death-1 (PD-1)-targeted immunotherapy. CONCLUSIONS: Our findings suggest that disruption of IL6 signaling in GBM reduces local and systemic myeloid-driven immunosuppression and enhances immune-mediated antitumor responses against GBM.

Association of CD40 SNPs with Moyamoya in a Chinese children population.

Background: The etiology of Moyamoya disease (MMD) remains unknown to a large extent. Immune and inflammation dysfunction may play a role in the pathogenesis of this rare disease. Coexisting Kawasaki disease (KD) with MMD were reported and both diseases have a feature of vasculopathy, raising the hypothesis that there may be some common pathologic factors. We investigated single nucleotide polymorphisms (SNPs) previously identified in KD and performed a genetic analysis among Chinese pediatric patients with MMD. Results: We analyzed patients' DNA for the SNPs in B lymphoid tyrosine kinase, CD40, and coatomer protein complex beta-2 subunit, which had been associated with KD by literatures. Genotyping was performed by sequencing the genetic regions containing the SNPs with customized primers. A total of 5 genotype polymorphisms were examined among 48 pediatric MMD cases and 50 healthy controls. The mean age of MMD children was 6.72 ± 3.63 years old, while 7.31 ± 3.79 in controls. We found two SNPs of CD40 were associated with MMD. Polymorphisms rs4813003 major allele CC and rs1535045 minor allele TT were significantly higher in MMD cases. The other SNPs showed no statistical difference between MMD cases and controls. Conclusions: Our findings provide evidence that there may be a relationship between MMD and auto-immune dysfunction. We hypothesize that these genetic features may lead to the pathogenesis within the vascular wall. Further study regarding whether CD40 can function as the personalized target of MMD should be investigated in future.

Seeing Floaters: A Case Report and Literature Review of Intraventricular Migration of Silicone Oil Tamponade Material for Retinal Detachment.

BACKGROUND: Intraocular injection of silicone oil is commonly performed during vitrectomy to tamponade the retina in place for treatment of retinal detachment. Although rare, this intravitreal silicone can migrate through the optic nerve and chiasm and enter the cerebral ventricles. CASE DESCRIPTION: Here we present a case report of a patient presenting with headache and intraventricular hyperdensities on a computed tomography (CT) scan, raising a concern for intraventricular hemorrhage. However, the intraventricular hyperdensities were in a nondependent location and moved to a new nondependent location when repeat imaging was performed with the patient in the prone position. We provide a literature review of this phenomenon and discuss the relevant CT and magnetic resonance imaging findings. CONCLUSIONS: Intraocular silicone can rarely migrate into the cerebral ventricular system. Careful review of the clinical history and imaging findings can help distinguish this from other, more dangerous intracranial pathologies.

Sellar plasmacytomas masquerading as pituitary adenomas: A systematic review.

Given the rarity of intracranial plasmacytomas, these lesions are frequently misdiagnosed as pituitary adenomas. We report on the distinguishing characteristics of sellar plasmacytomas from cases in the literature and our experience. A literature search was conducted to collect all documented cases of a plasmacytoma originating in the sellar region. Patient characteristics, medical history, presentation, tumor characteristics, and survival data were collected. An additional case from our institution not previously reported was included. Thirty-one patients with sellar plasmacytomas were studied. Presenting symptoms were most commonly headache (68%), diplopia (65%) and visual field disturbances (10%). Fifteen patients (48%) were initially suspected of having a pituitary adenoma. Pathologic diagnosis of plasmacytoma preceded a finding of multiple myeloma in 14 cases (45%). Thirty patients (90%) had surgical intervention. Adjuvant therapy consisted of radiotherapy for twenty-five patients (81%) and chemotherapy for sixteen (52%). Tumor recurrence was reported for 7 cases (23%). Nine deaths were reported (23%). We demonstrate that cranial nerve involvement is far more common in sellar plasmacytomas than conventional pituitary adenomas. Given the successful management of these tumors with radiotherapy, such deficits, particularly in patients with known multiple myeloma, should impact the diagnostic workup and treatment considerations.

Endoscopic Approach to Clival Chordomas: The Northwestern Experience.

INTRODUCTION: Chordomas are rare primary bone tumors with a low-grade histology but an aggressive clinical behavior characterized by local invasion and recurrence. When occurring in the skull base, their treatment is limited by proximity to critical neurovascular structures. Open surgical approaches can carry high morbidity, making the development of alternative approaches desirable. We describe our experience with endoscopic endonasal approaches to clival chordomas over 13 years. METHODS: We performed a retrospective chart review of patients diagnosed with clival chordomas and treated with an endoscopic endonasal approach between 2003 and 2015 at Northwestern Memorial Hospital. We reviewed presenting symptoms, tumor location and size, extent of resection, complications, recurrence, adjuvant treatment, retreatment, and follow-up duration. RESULTS: A total of 23 charts were reviewed, with 17 included in our final review. Mean age was approximately 48 years. The most common presenting symptom was diplopia present in 70.6% of patients. Mean tumor volume was 20.2 cm3. Gross total resection was achieved in 52.9% of patients. With a mean follow-up period of 63.4 months, 5 patients had a recurrence. The most common complication was cerebrospinal fluid (CSF) leak, which was noted in 6 patients. Tumor volume was significantly higher in patients with CSF leak. No correlation between intradural extension and postoperative CSF leak was noted. CONCLUSIONS: Clival chordoma are challenging entities to treat. The best outcomes are achieved with gross total resection followed by adjuvant radiotherapy treatment. We show that the endonasal endoscopic corridor is a viable alternative approach to these lesions.