Bilateral mirror image lumbar spinal dural arterial venous fistula: a rare case and systematic review of the literature.

BACKGROUND: Spinal dural arteriovenous fistulas (SDAVF) are rare with an incidence of 5-10/million annually. They can be difficult to diagnose causing a delay in treatment with significant morbidity. We describe the first case in the literature of a symptomatic mirror lumbar SDAVF which may go unnoticed due to its unique vascular anatomy. CASE DESCRIPTION: A 78-year-old gentleman presented with a progressive deterioration in his walking distance and urinary retention. An initial MRI scan of the whole spine did not show features suggestive of an underlying vascular malformation. During further investigations of neurological causes, the patient continued to have progressive symptoms over a 10-month period resulting in a repeat MRI scan. This showed a new finding of cord oedema without abnormal flow voids. He went on to have vascular imaging which demonstrated a mirror L3 SDAVF and underwent subsequent surgical management. At follow up there was a significant improvement in symptoms. CONCLUSIONS: Completing a systematic review of the literature we find that the mirror lumbar SDAVF in our patient presented in a more aggressive manner with symptoms progressing faster than in single or multi-level SDAVF. Our case demonstrates how this unique vascular anatomy may result in a diagnostic challenge, behaving in an occult way where typical findings are not seen on initial MRI scanning. We provide an argument for early vascular imaging which can result in the treatment of these lesions in a timely manner.

Risk of intracerebral aneurysm rupture during carotid revascularization.

OBJECTIVE: Robust guidelines exist for the treatment of carotid stenosis and intracranial aneurysms independently, however, the management of tandem carotid stenosis and intracranial aneurysms remains uncertain. Although the prevalence of tandem pathologies is small (1.9%-3.2%), treating carotid stenosis can alter intracranial hemodynamics potentially predisposing to aneurysm rupture. In this review, our aim was to assess the safety of intervention in this cohort, by analyzing outcomes from the published literature. METHODS: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to conduct the review. Articles from 1947 to 2012 were searched using EMBASE Classic and EMBASE (November, 1947 -March, 2012) and Ovid MEDLINE(R) In-Process and other NonIndexed Citations and Ovid MEDLINE(R) on Ovid SP, http://ClinicalTrials.gov, http://controlled-trials.com and the Cochrane review database using a predefined search strategy. RESULTS: One hundred forty-one patients from 27 articles were included. Interventions ranged from single (n=104, 74%), staged (n=26, 18%) to simultaneous procedures (n=11, 8%). The largest cohort of patients was treated by carotid endarterectomy alone (n=92, 66%). The majority of patients presented with a symptomatic carotid stenosis and an asymptomatic ipsilateral intracranial aneurysm (n=70, 50%). Five subarachnoid hemorrhages occurred (4% [5/140], three within 30 days of the procedure and two thereafter) of which two were fatal. All five occurred in patients who underwent carotid endarterectomy as a single procedure (5%). Two of the five patients presented with ruptured posterior communicating artery aneurysms. CONCLUSIONS: Published reports of perioperative aneurysm rupture are rare in individuals with tandem carotid stenosis and intracranial aneurysms. This is the first analysis of all published cases. However, it is limited by the small number of studies and the possible underreporting due to publication bias and underdiagnosis where angiography was not performed. Although we report a low incidence of subarachnoid hemorrhage, analysis of registry data with a larger cohort is warranted to confirm these findings.

Giant Sacral Schwannoma Treated with a 360 Approach: A Rare Case and Systematic Review of the Literature.

BACKGROUND: Sacral schwannomas are very rare and typically have a benign nature. They occur in a permissive anatomical location leading to nonspecific symptoms that can result in them going unnoticed before reaching a considerable size. CASE DESCRIPTION: We report a rare case of a giant sacral schwannoma (130 × 110 × 90 mm) in a 38-year-old man originating from the S2 nerve root, encompassing the neural canal with sacral erosion and extension in to the pelvis. The patient presented with a history of abdominal pain associated with increased urinary frequency and a sensation of incomplete bladder emptying. Magnetic resonance imaging demonstrated a giant pelvic mass with sacral erosion and involvement of the nerve roots. Subsequently, he went on to have a 2-stage procedure in which complete resection of the schwannoma was achieved by both a posterior hemilaminectomy and laparotomy with the aid of neuromonitoring. The postoperative course was uneventful, with complete resolution of symptoms. CONCLUSIONS: We report one of the largest benign sacral schwannoma originating inside the spinal canal with pelvic extension to be resected without complications. We discuss our successful management and conduct a systematic review of the literature to provide the most up to date guidance on managing this tumor, including the application of neuromonitoring and a 360 approach in 2 stages.

Treatment by specialist surgical neurooncologists improves survival times for patients with malignant glioma.

OBJECT: Surgeries for CNS tumors are frequently performed by general neurosurgeons and by those who specialize in surgical neurooncology. Subspecialization in neurosurgical practice has become common and may improve patient morbidity and mortality rates. However, the potential benefits for patients of having their surgeries performed by surgical neurooncologists remain unclear. Recently, a shift in patient care to those who practice predominantly surgical neurooncology has been promoted. Evidence for this practice is lacking and therefore requires fundamental investigation. METHODS: The authors conducted a case-control study of neurooncology patients who underwent surgery for glioblastoma and anaplastic astrocytoma during 2006-2009. Outcomes were compared for patients whose surgery was performed by general neurosurgeons (generalists) or by specialist neurooncology neurosurgeons (specialists). An electronic record database and a picture archiving and communication system were used to collect data and assess the extent of tumor resection. Mortality rates and survival times were compared. Patient comorbidity and postoperative morbidity were assessed by using the Waterlow, patient handling, and falls risk assessment scores. Effects of case mix were adjusted for by using Cox regression and a hazards model. RESULTS: Outcomes for 135 patients (65 treated by generalists and 70 by specialists) were analyzed. Survival times were longer for patients whose surgery was performed by specialists (p=0.026) and after correction for case mix (p=0.019). Extent of tumor resection was greater when performed by specialists (p=0.005) and correlated with increased survival times (p=0.004). There was a trend toward reduced surgical deaths when surgery was performed by specialists (2.8%) versus generalists (7%) (p=0.102), and inpatient stays were significantly shorter when surgery was performed by specialists (p=0.008). CONCLUSIONS: The prognosis for glioblastoma multiforme remains dire, and improved treatments are urgently needed. This study provides evidence for a survival benefit when surgery is performed by specialist neurooncology neurosurgeons. The benefit might be attributable to increased tumor resection. Furthermore, specialist neurooncology surgical care may reduce the number of surgical patient deaths and length of inpatient stay. These findings support the recommendations for subspecialization within surgical neurooncology and advocate for care of these patients by specialists.

Microdialysis measurement of intratumoral temozolomide concentration after cediranib, a pan-VEGF receptor tyrosine kinase inhibitor, in a U87 glioma model.

BACKGROUND: Combining anti-angiogenesis agents with cytotoxic agents for the treatment of malignant gliomas may affect the cytotoxic drug distribution by normalizing the blood-brain barrier (BBB). This study examines the intratumoral concentration of temozolomide (TMZ) in the presence and absence of the pan-VEGF receptor tyrosine kinase inhibitor, cediranib. METHODS: Seven nude rats bearing U87 intracerebral gliomas had a microdialysis probe centered within the tumor. Ten-days after tumor implantation, TMZ (50 mg/kg) was given orally. The extracellular fluid (ECF) concentrations of TMZ within the tumor were assessed via microdialysis for 6 h following TMZ administration. Cediranib (6 mg/kg) was then given orally, and 12 h later, TMZ was re-administered with subsequent microdialysis collection. A subset of animals also underwent functional MRI to assess angiogenesis in vivo at post-inoculation days 12 and 21, before and after the cediranib treatment. RESULTS: After dosing of oral TMZ only, ECF-TMZ mean-C(max) and area under the concentration curve(AUC(0-∞)) within the tumor were 0.59 µg/mL and 1.82 µg h/mL, respectively. Post-cediranib, ECF-TMZ mean-C(max) and AUC(0-∞) were 0.83 µg/mL and 3.72 ± 0.61 µg h/mL within the tumor, respectively. This represented a 1.4-fold (p = 0.3) and 2.0-fold (p = 0.06) increase in the ECF-TMZ C(max) and AUC(0-∞), respectively, after cediranib administration. In vivo MRI measurements of the various vascular parameters were consistent with a BBB "normalization" profile following cediranib treatment. CONCLUSIONS: In the U87 intracerebral glioma model, within the first day of administration of cediranib, the intratumoral concentrations of TMZ in tumor ECF were slightly, but not statistically significantly, increased when compared to the treatment of TMZ alone with radiographic evidence of a normalized BBB.

A comparative analysis of saphenous vein conduit harvesting techniques for coronary artery bypass grafting--standard bridging versus the open technique.

Coronary artery bypass graft (CABG) surgery involves harvesting the great saphenous vein (GSV) using the traditional open technique (TOT). This can be associated with significant leg morbidity and patient dissatisfaction. Alternatively, the standard bridging technique (SBT) is a minimally invasive procedure of vein retrieval that uses smaller frequent incisions along the length of the leg and may reduce postoperative complications. This study was designed to compare the success of SBT in reducing leg morbidity and increasing patient satisfaction. One hundred patients were recruited into the study and computer randomised into two groups of 50 undergoing SBT or TOT. Leg morbidity and patient satisfaction were analysed by assessment of pain scores, wound development and scar formation. Closure and harvesting time were also compared between the two groups. SBT was associated with better wound development (P<0.001) and a significantly higher patient satisfaction (P<0.001). Leg pain was significantly reduced amongst SBT group at rest and with movement (P<0.001). There was also a reduction in saphenous neuropathy with the use of SBT (P<0.001). No difference in closure or harvesting time was demonstrated (P=0.26 and P=0.23, respectively). This study demonstrates that harvesting the GSV by the minimally invasive SBT reduces postoperative leg morbidity and increases patient satisfaction without the need of costly equipment. SBT represents a safe, effective and financially viable technique for vein harvesting.

Ezetimibe and atorvastatin both immunoregulate CD4+ T cells from cardiac transplant recipients invitro.

BACKGROUND: Statins are LDL lowering agents that reduce cardiac allograft vasculopathy (CAV) incidence after cardiac transplantation. Furthermore, 'pleiotropic effects' including immunomodulation have been demonstrated by statins following transplantation. It has also been previously suggested that ezetimibe may exert specific effects on the innate immune system in vitro. We compared the effects of ezetimibe and atorvastatin on T lymphocytes in vitro on the justification that these cells are implicated in the pathogenesis of atherosclerosis, allograft rejection and CAV. METHODS: Peripheral blood mononuclear cells (PBMCs) were isolated from 30 cardiac transplant recipients and co-cultured with the study drug (or placebo) over 48 h. In total, 150 cultures were performed (5 per patient). Drug concentrations were calculated to simulate 10 mg or 100 mg daily in a 70 kg adult. Flow cytometry was performed to analyse T lymphocyte counts and functional characteristics. RESULTS: Ezetimibe reduced the standard CD3+CD4+ T cell count and CD3+CD4+CD45ro T memory count by dose linear effect (p < 0.001). Atorvastatin also reduced the CD3+CD4+ T cell count and CD3+CD4+CD45ro T memory count by dose linear effect (p = 0.005). Neither drug affected CD3+CD8+ cytotoxic T cells. DISCUSSION: Both atorvastatin and ezetimibe may have selective immunomodulatory properties independent of their mechanisms of LDL lowering, given that both drugs affect CD4 T helper cells but have no effect on CD8 cytotoxic lymphocytes in vitro. Although speculative, both of these agents could potentially offer benefits to the transplant patient by modulating important components of the adaptive immune system. CD4+ cells in particular are implicated in both CAV and rejection processes.

Randomized prospective study comparing conventional subcuticular skin closure with Dermabond skin glue after saphenous vein harvesting.

BACKGROUND: Dermabond (Ethicon UK, Edinburgh, United Kingdom) is a topical skin adhesive used for surgical wound closure, with purported advantages over conventional sutures on cosmetic outcomes, cost benefits, and operative times. This study compared results of skin closure using Dermabond and subcuticular sutures after coronary artery bypass grafting (CABG). METHODS: The study prospectively enrolled and randomized 106 patients who underwent CABG. The groups received closure with Dermabond skin glue or subcuticular sutures (n = 53 each) after saphenous vein harvesting using the bridging technique. Wound closure time for the two methods was recorded. Cosmetic appearance was assessed using the Hollander, the Vancouver, and the visual analog scale. Patient satisfaction was recorded before discharge and at week 6. RESULTS: There were no significant differences in the total operative time between the two groups (p = 0.43). Closure time was significantly shorter in the Dermabond group (p = 0.017). Patients in the Dermabond group also reported superior cosmetic outcome at weeks 1 (p < 0.001) and 6 (p = 0.001) and improved patient satisfaction (p < 0.001). CONCLUSIONS: Dermabond has demonstrated superiority over traditional subcuticular skin sutures in terms of closure time, cosmetic appearance, and patient satisfaction. This technique provides a novel method of wound closure after CABG.

Segmental mediolytic arteriopathy with post-transplant lymphoproliferative disorder of the lung: case report and review of the literature.

Segmental mediolytic arteriopathy (SMA) is an extremely rare condition of uncertain etiology causing degeneration of arterial media, intramural dissection or the rupture of aneurysms. It is recognized as a rare cause of fatal intra-abdominal bleeding. We report the first case of recurrent intra-abdominal bleeding secondary to SMA in a lung transplant patient, with a further complication of lymphoproliferative disease in the transplanted lung. We discuss the pathogenesis, clinical presentation, imaging characteristics and the complexities of management in this case.