Retrospective Evaluation of the Effect of Lumbar Sympathetic Blockade on Pain Scores, Fontaine Classification, and Collateral Perfusion Status in Patients with Lower Extremity Peripheral Arterial Disease.

Background and Objectives: The aim of this retrospective study was to evaluate the effect of lumbar sympathetic block (LSB) on pain scores, Fontaine Classification, and collateral perfusion status in patients with lower extremity peripheral artery disease (PAD), in whom revascularization is impossible. Material and Methods: Medical records of 21 patients with PAD who underwent LSB with a combination of local anesthetics, steroids, and patient follow-up forms containing six-month follow-ups between January 2020 and March 2021 were retrospectively reviewed. Numeric Rating Scale (NRS), Pain Detect Questionnaire (PDQ) scores, Fontaine Classification Stages, and collateral perfusion status (collateral diameter and/or development of neovascularization) evaluated by arterial color Doppler Ultrasound (US) from the medical records and follow-up forms of the patients were reviewed. Results: NRS and PDQ scores were significantly lower, and regression of the Fontaine Classification Stages was significantly better after the procedure at the first, third, and sixth month than at the baseline values (p < 0.001). Only four patients (19%) had collaterals before the procedure. An increase in the collateral diameter after LSB was noted in three out of four patients. Before the procedure, 17 patients had no prominent collateral. However, in thirteen of these patients, after LSB, neovascularization was detected during the six-month follow-up period (three patients in the first month, seven patients in the third month, and thirteen patients in the sixth month). The number of patients evolving neovascularization after LSB was found to be statistically significant at the third and sixth months compared to the initial examination (p < 0.001). Conclusions: LSB with the use of local anesthetic and steroids in patients with lower extremity PAD not only led to lower NRS and PDQ scores, but also resulted in regressed Fontaine Classification Stages and better collateral perfusion status.

Percutaneous Ventriculoatrial Shunting as a Salvage Method in the Pediatric Hydrocephalus Patients with Peritoneal Problems.

AIM: To evaluate the efficacy of percutaneous ventriculoatrial shunting as a salvage method for pediatric patients with abdominal complications. MATERIAL AND METHODS: Data obtained from 9 patients with ventriculoperitoneal shunt dysfunctions owing to abdominal complications, who underwent ventriculoatrial shunting as salvage treatment at a single institution between January 2019 and September 2021 were retrospectively analyzed. All operations were conducted under the guidance of intraoperative fluoroscopy and ultrasound. RESULTS: The mean age of the enrolled patients was 8.1 ± 1.2 years (2-15 years). Six (67%) patients were male and 3 (33%) were female. The mean number of the patients? ventriculoperitoneal shunt revisions until atrial catheter placement was 7.5 times. The reasons for intraperitoneal catheter failure included peritoneal adhesions in 4 (44.5%) patients, pseudocyst formation in 3 (33.3%), and peritonitis in 2 (22.2%). Seven patients from the study cohort had no problem after ventriculoatrial shunt placement. Only 1 patient had shunt dysfunction related to the ventricular catheter, and ventricular catheter and shunt valve revision was performed 26 months after ventriculoatrial shunt placement. The atrial catheter of the patient was intact. One patient died from the progression of her primary disease (medulloblastoma in the 4 < sup > th < /sup > ventricle), which was unrelated to the ventriculoatrial shunt. CONCLUSION: Percutaneous ventriculoatrial shunting under the guidance of intraoperative fluoroscopy and ultrasound is a safe, effective, and easy alternative in patients with peritoneal complications and a history of multiple operations.

The Use of Pre-Chemoradiotherapy Total Masseter Muscle Volume as a Novel Predictor of Radiation-Induced Trismus in Locally Advanced Nasopharyngeal Carcinoma Patients.

BACKGROUND: We sought to determine whether pretreatment total masseter muscle volume (TMMV) measures can predict radiation-induced trismus (RIT) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) receiving concurrent chemoradiotherapy (C-CRT). METHODS: We retrospectively reviewed the medical records of LA-NPC patients who received C-CRT and had pretreatment maximum mouth openings (MMO) greater than 35 mm. MMO of 35 mm or less after C-CRT were considered RIT. We employed receiver operating characteristic (ROC) curve analysis to explore the correlation between pre-treatment TMMV readings and RIT status. RESULTS: Out of the 112 eligible patients, 22.0% of them received a diagnosis of RIT after C-CRT. The optimal TMMV cutoff that was significantly linked to post-C-CRT RIT rates was determined to be 35.0 cc [area under the curve: 79.5%; sensitivity: 75.0%; and specificity: 78.6%; Youden index: 0.536] in the ROC curve analysis. The incidence of RIT was significantly higher in patients with TMMV ≤ 5.0 cc than in those with TMMV > 35.0 cc [51.2% vs. 8.7%; Odds ratio: 6.79; p < 0.001]. A multivariate logistic regression analysis revealed that pre-C-CRT MMO ≤ 41.6 mm (p = 0.001), mean masticatory apparatus dose V56.5 ≥ 34% group (p = 0.002), and TMMV ≤ 35 cc were the independent predictors of significantly elevated rates of RIT. CONCLUSION: The presence of a smaller pretreatment TMMV is a reliable and independent novel biological marker that can confidently predict higher RIT rates in LA-NPC patients who receive C-CRT.

Pretreatment Masseter Muscle Volume Predicts Survival in Locally Advanced Nasopharyngeal Carcinoma Patients Treated with Concurrent Chemoradiotherapy.

BACKGROUND AND PURPOSE: Muscle loss is a significant indicator of cancer cachexia and is associated with a poor prognosis in cancer patients. Given the absence of comparable studies, the current retrospective study sought to examine the correlation between the total masseter muscle volume (TMMV) before treatment and the survival outcomes in locally advanced nasopharyngeal cancer (LA-NPC) patients who received definitive concurrent chemoradiotherapy (CCRT). METHODS: A three-dimensional segmentation model was used to determine the TMMV for each patient by analyzing pre-CCRT magnetic resonance imaging. The optimal TMMV cutoff values were searched using receiver operating characteristic (ROC) curve analyses. The primary and secondary endpoints were the relationship between the pre-CCRT TMMV measures and overall survival (OS) and progression-free survival (PFS), respectively. RESULTS: Ninety-seven patients were included in this study. ROC curve analyses revealed 38.0 cc as the optimal TMMV cutoff: ≤38.00 cc (n = 42) and >38.0 cc (n = 55). Comparisons between the two groups showed that the TMMV>38.0 cc group had significantly longer PFS [Not reached (NR) vs. 28; p < 0.01] and OS (NR vs. 71; p < 0.01) times, respectively. The results of the multivariate analysis demonstrated that the T-stage, N-stage, number of concurrent chemotherapy cycles, and TMMV were independent associates of PFS (p < 0.05 for each) and OS (p < 0.05 for each) outcomes, respectively. CONCLUSION: The findings of the current retrospective research suggest that pretreatment TMMV is a promising indicator for predicting survival outcomes in LA-NPC patients receiving definitive CCRT.

Morphometric analysis of the infratemporal fossa using three-dimensional (3D) digital models.

PURPOSE: The infratemporal fossa contains important neurovascular components and is directly related to other anatomical regions and structures. The morphometric distances between the bones forming its borders have not been thoroughly investigated. The aim of this study was to determine the morphometry of the infratemporal fossa. METHODS: 3D models of the skull of 83 individuals were reconstructed from DICOM datasets, from which length, depth and width measurements were determined and compared between genders and the right and left sides. RESULTS: All measurements obtained were significantly different between males and females. There were also significant differences between the left and right sides for depth and width measurements. CONCLUSION: This is the first study to determine and investigate measurements of the infratemporal fossa; as such it provides a comprehensive view of the morphology of the fossa. It provides valuable information for surgical interventions and differential diagnoses of pathologies in this region, as well as enhancing its understanding in medical education.

Structural changes in the side branches and the circle of Willis following the use of flowdiverting stents.

BACKGROUND: This study aimed to evaluate the diameter and flow changes in the circle of Willis and side branches following the use of FDSs extending from the middle cerebral artery (MCA) to the internal carotid artery (ICA) for the treatment of aneurysms in the terminal segment of ICA, and the clinical results. METHODS: This study was conducted in a single center between January 2012 and April 2018 in patients with the anterior choroidal artery (AChoA), the posterior communicating artery (PComA), and the ICA terminal segment aneurysms treated with the FDSs. The changes in aneurysm size, arterial structures covered by the FDSs, and changes in the diameter and flow in arteries forming the circle of Willis were retrospectively analyzed. RESULTS: Fourteen patients with a total of 25 aneurysms treated with FDSs extending from MCA to ICA were evaluated. The mean aneurysm fundus size was 5.14 mm (range 1.5-22 mm). Before treatment, the anterior communicating artery (AComA) was patent in all patients. Implanted FDSs covered the anterior cerebral artery (ACA) and AChoA in all patients (100%), nonhypoplasic PComA in two patients (14.28%), and the ophthalmic artery in nine (64.3%). The mean follow-up time was 36.78 ± 22.44 months. In follow-up, there was a decrease in the mean ipsilateral ACA A1 segment diameter from 1.99 ± 0.58 cm to 1.81 ± 0.31 cm (p = 0.01). The mean contralateral A1 segment diameter increased from 1.66 ± 0.48 cm to 1.93 ± 0.42 cm (p = 0.004). All aneurysms were totally occluded. DISCUSSION: If the AComA is patent, ipsilateral anterior circulation can be compensated through modifications in the contralateral ACA A1 segment in patients with ICA terminal segment aneurysms treated with FDSs extended from MCA to ICA and covering ACA. Although covering the anterior choroidal and lenticulostriate arteries by FDSs, ischemic complications may not occur frequently. Thus, this effective therapy can be applied more safely.

A Rare Triplet Found in a Patient With Drug-Resistant Hypertension: Adnexal-Adrenal Sex Cord-Stromal Tumors and Castleman's Disease.

Adrenal and ovarian sex cord-stromal tumors which originate from the ovarian stroma and adrenal cortex, have an extremely low incidence even alone. Castleman's disease is also one of the rare causes of non-neoplastic lymphadenopathy. The aim of this case report was to contribute to the literature by identifying the coexistence of these three pathologies, which are encountered with a low incidence even alone. A 46-year-old female patient had experienced drug-resistant hypertension. In the laboratory test, electrolyte imbalance was detected. Imaging modalities revealed left adrenal and adnexal mass lesions as well as a right paraspinal intramuscular nodular lesion. When hypertension and electrolyte imbalance were evaluated together with their etiology, it was thought that the left adrenal lesion, which also has a chemical shift, may be compatible with functional adenoma. Left adrenalectomy was planned. The ovarian lesion and right paraspinal intramuscular lesion were also excised during the same session with the suspicion that the ovarian lesion may be hormone-active neoplasia and the intramuscular lesion may be a metastasis. The diagnosis of adnexal-adrenal sex cord-stromal tumors and unicentric Castleman's disease were made histopathologically. Radiologically, it should be kept in mind that the radiological manifestations of adrenal sex cord-stromal tumors can be confused with adrenal adenomas. Even when these extremely rare tumors are encountered, avoiding the "satisfaction of search" plays a crucial role in the identification of additional pathologies that can explain the etiology.

Reduction of Hepatopulmonary and Intrahepatic Shunts after Treatment with Sorafenib in Hepatocellular Carcinoma Patients.

PURPOSE: To investigate the reduction of elevated shunts after treatment with sorafenib in hepatocellular carcinoma (HCC) patients planned for transarterial radioembolization (TARE). MATERIALS AND METHODS: Sixteen HCC patients treated with sorafenib were investigated. Shunts were evaluated by SPECT/CT after Technetium-99 m Tc-macroaggregated albumin injection. RESULTS: All patients had high LSF (median 43.5%, range 28-86), and two (12.5%) of them had widespread intrahepatic shunts with concomitants elevated (36%) and acceptable (18%) lung shunt fraction (LSF). The mean duration of the sorafenib use was 134.4 ± 59.2 days. While one patient (6.25%) developed hand-foot syndrome, minor side effects were seen in all patients. After sorafenib use, LSF fell below 20% in eight patients, and TARE was applied to all of them. There was strong negative correlation between the failure of shunt reduction and presence of macrovascular invasion (ρ = - 0.775) and infiltrative tumour type (ρ = - 0.775). CONCLUSION: Sorafenib use may be beneficial in some selected HCC patients with elevated shunts. Expected results may not be obtained in patients with infiltrative tumour type or macrovascular invasion, but patients with nodular tumour type with the absence of macrovascular invasion may be appropriate candidates for shunt reduction with ensuring subsequent TARE. Further investigations with sufficient patient population and standardized protocols of follow-up periods are needed to clarify the values for sorafenib use in HCC patients with evaluated shunts.

Jugular Paraganglioma Presenting with a Tumor Thrombus Extending from Posterior Fossa to Right Atrium and Multiple Skeletal Metastases.

INTRODUCTION: Paragangliomas are tumors of neuroendocrine origin, may appear in different localizations, and are related to the autonomic nervous system. Paragangliomas are generally asymptomatic and may rarely appear with adrenergic symptoms, and clinical findings depend on the catecholamines they secrete. Extra-adrenal paragangliomas are mostly benign, like all paragangliomas. Malignancy criteria consist of local recurrence, metastasis after total resection, and presence of distant metastasis during primary diagnosis. CASE PRESENTATION: This report presents the case of a 31-year-old man with jugular paraganglioma, multiple skeletal metastases, and a long-segment tumor thrombus. Imaging procedures showed a continuous tumor thrombus extending from the posterior fossa to the right atrium and metastases in C2, T1, T6, T8, L5, and right humerus. Histopathological assessment of the metastasis in C2 identified malignant paraganglioma. Curative surgery was not an option for this patient, hence combined chemotherapy was given. CONCLUSION: In cases of malignant paraganglioma with multiple distant metastases, chemotherapy and radiotherapy are feasible treatment methods.

A Rare Complication of Central Venous Catheterization Interventions: Subdural Effusion.

Central venous catheterization interventions are used in various clinics for diagnostic and treatment purposes. Establishing vascular access is a difficult and critical step, especially in critically ill pediatric patients. Complications include ventricular arrhythmia, air embolism, carotid artery puncture, cardiac tamponade, pneumothorax, hemothorax, artery-vein laceration, thoracic duct injury, and catheter malposition can be observed in patients after central venous catheterization interventions. In this case report, a pediatric case was discussed, in which a central venous catheter was inserted without the usage of imaging methods and without confirming the location and was used, even though no blood return was obtained. It was aimed to draw attention to subdural effusions and spinal canal interventions, which is a rare complication of central venous catheterization interventions. How to cite this article: Misirlioglu M, Horoz OO, Yildizdas D, Ekinci F, Yontem A, Pehlivan UA. A Rare Complication of Central Venous Catheterization Interventions: Subdural Effusion. Indian J Crit Care Med 2022;26(3):384-386.

Clinical and prognostic significance of CD14 (+) HLA-DR (-/low) myeloid-derived suppressor cells in patients with hepatocellular carcinoma received transarterial radioembolization with Yttrium-90.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. For unresectable HCC, transarterial radioembolization (TARE) with Yttrium-90 is a widely used treatment. The aim of this study was to investigate whether monocytic myeloid-derived suppressor cells (M-MDSC) and CD39+ T cells can be non-invasive predictive biomarkers of radiological response and prognosis in patients with HCC treated with TARE. This study was conducted on 39 patients with HCC who were treated with TARE between August 2018 and December 2019 and the control group consisted of 23 healthy volunteers. CD4+, CD8+, CD39+ T cells, Natural killer (NK) cells, myeloid cells (MC) and M-MDSC parameters are examined in the course of TARE treatment with student t test and Kaplan-Meier method. There were statistically significant differences in M-MDSC, CD39+ T cells and MC values between healthy controls and HCC patients. A statistically significant difference was found in M-MDSC and CD4+ T cells values in the HCC patient group who responded to the treatment compared to those who did not. Survival analysis found that patients with lower frequencies (under 3.81%) of M-MDSC showed more prominent differences of overall survival (OS) compared to patients with all high groups. We found that M-MDSC in the peripheral blood might be a useful non-invasive biomarker to predict OS. We have shown for the first time that M-MDSC is correlated with treatment response in HCC patients treated with TARE. Additionally, we have found that the percentage of CD39+ T cells is high in HCC patients and these cells are positively correlated with M-MDSC.

Systemic Aspergillosis: Radiological Findings in a Case With Diffuse Large B Cell Lymphoma Treated by Ibrutinib.

Herein, we present a case of systemic aspergillosis with a fatal outcome in a case with diffuse large B cell lymphoma (DLBCL) treated by ibrutinib. Aspergillosis was suspected clinically and proven microbiologically. Radiological findings were compatible with aspergillosis. We aim to review radiological findings in a case with DLBCL treated with ibrutinib, which is an important tyrosine kinase inhibitor used in lymphoid neoplasias.