Intramedullary Thoracic Spine Astrocytoma Presenting as Hydrocephalus in an Infant: A Case Report.

We present the case of an intramedullary spinal cord tumor from C7 to T4, classified as a WHO grade I pilocytic astrocytoma, manifesting solely with isolated, acute hydrocephalus and a normal neurological exam in a 5-month-old infant. We discuss the common presenting symptoms of spinal cord tumors in the pediatric population and possible anatomical explanations for this unique presentation and offer recommendations for the management of isolated hydrocephalus in an infant.

Quantitative assessment of changes in cerebral arteriovenous malformation hemodynamics after embolization.

BACKGROUND AND PURPOSE: Embolization reduces flow in arteriovenous malformations (AVMs) before surgical resection, but achievement of this goal is determined subjectively from angiograms. Here, we quantify effects of embolization on AVM flow. METHODS: Records of patients who underwent AVM embolization at our institution between 2007 and 2013 and had flow rates obtained pre- and postembolization using quantitative magnetic resonance angiography were retrospectively reviewed. Total flow was estimated as aggregate flow within primary arterial feeders or flow in single draining veins. RESULTS: Twenty-one patients were included (mean age 35 years, 24% hemorrhagic presentation) with Spetzler-Martin grades 1 to 4. Fifty-four total embolization sessions were performed. The mean AVM flow was 403.4±262.4 mL/min at baseline, 285.3±246.4 mL/min after single session (29% drop, P<0.001), and 102.0±103.3 mL/min after all sessions of embolization (75% drop, P<0.001). Total number of pedicles embolized (P<0.001) and embolization of an intranidal fistula during any session (P=0.002) were significantly associated with total decreased flow postembolization. On multivariate analysis, total pedicles embolized was predictive of total flow drop (P<0.001). However, pedicles embolized per session did not correlate with flow drop related to that session (P=0.44). CONCLUSIONS: AVM flow changes after embolization can be measured using quantitative magnetic resonance angiography. The total number of pedicles embolized after multiple embolization sessions was predictive of final flow, indicating this parameter is the best angiographic marker of a hemodynamically successful intervention. The number of pedicles embolized per session, however, did not correlate with flow drop in that session, likely because of flow redistribution after partial embolization.

Axial and oblique C2 pedicle diameters and feasibility of C2 pedicle screw placement: Technical note.

BACKGROUND: For C2 pedicle screw placement/instrumentation, it is critical to adequately measure the axial and oblique C2 pedicle diameters utilizing the intraoperative O-arm. METHODS: Thirty-three patients who underwent C2 pedicle screw placement (2013-2016) utilizing the O-arm with tri-planar reconstruction. As O-arm software does not allow calibrated measurements with the application's measurement tool, we directly measured axial and oblique widths of the C2 pedicles on the screen with a regular ruler (e.g., "screen width of C2 pedicle"). RESULTS: The axial width of the C2 pedicles ranged from 6 to 15 mm on the right (mean 10.44 ± 2.15 mm) to 7 to 14 mm (10.29 ± 1.72 mm) on the left. The oblique width of C2 pedicles ranged from 10 to 19 mm on the right (mean, 14.73 ± 1.85 mm) and from 12 to 19 mm on the left (mean, of 15.33 ± 1.67 mm). These measurements indicated that oblique screen widths of the C2 pedicles were 1.4 and 1.5 times higher than their axial screen widths on the right and left sides, respectively. CONCLUSIONS: The oblique screen widths of the C2 pedicles better predict the feasibility of C2 pedicle screw placement vs. their axial screen width as measured with a regular ruler.

Surgical Repair of Iatrogenic Transverse-Sigmoid Sinus Laceration with a Dural Flap During Skull Base Tumor Surgery: A Technical Case Report.

BACKGROUND: Injury to cerebral venous sinuses during craniotomy procedures can cause significant blood loss or venous air embolism, potentially leading to serious morbidity or mortality. When iatrogenic sinus injuries occur, it is essential to promptly obtain hemostasis and repair the sinus defect. CASE DESCRIPTION: We report on a 43-year-old woman that sustained a transverse-sigmoid sinus injury during a retrosigmoid craniotomy for resection of a cerebellopontine angle meningioma. Sinus repair was performed using a reflected dural flap with excellent outcome. CONCLUSIONS: The use of a reflected dural flap for closure of a widely torn sinus proved to be an effective and straightforward sinus repair strategy, with postoperative imaging demonstrating persistent patency of the sinus. The described technique may be a useful addition to any neurosurgeon's armamentarium and should be considered during cases of complex sinus injuries.

Spinal epidural abscess in a patient with piriformis pyomyositis.

BACKGROUND: Spinal epidural abscess resulting from piriformis pyomyositis is extremely rare. Such condition can result in serious morbidity and mortality if not addressed in a timely manner. CASE DESCRIPTION: The authors describe the case of a 19-year-old male presenting with a 2-week history of fever, low back pain, and nuchal rigidity. When found to have radiographic evidence of a right piriformis pyomyositis, he was transferred to our institution for further evaluation. Because he demonstrated rapid deterioration, cervical, thoracic, and lumbar magnetic resonance imaging scans were emergently performed. They revealed an extensive posterior spinal epidural abscess causing symptomatic spinal cord compression extending from C2 to the sacrum. He underwent emergent decompression and abscess evacuation through a dorsal midline approach. Postoperatively, he markedly improved. Upon discharge, the patient regained 5/5 strength in both upper and lower extremities. Cultures from the epidural abscess grew methicillin-sensitive Staphylococcus aureus warranting a 6-week course of intravenous nafcillin. CONCLUSION: A 19-year-old male presented with a holospinal epidural abscess (C2 to sacrum) originating from piriformis pyomyositis. The multilevel cord abscess was emergently decompressed, leading to a marked restoration of neurological function.

The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms.

OBJECT: Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain. METHODS: This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy. RESULTS: For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p < 0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p < 0.01). CONCLUSIONS: For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.

Publication rates of presentations made at annual meetings of the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America.

The purpose of this study was to determine the publication rates of presentations made at the annual meetings of 2 sports medicine specialty societies--the American Orthopaedic Society for Sports Medicine (AOSSM) and the Arthroscopy Association of North America (AANA). We created a database covering annual AOSSM meetings from 1990 to 1993 (4 years) and annual AANA meetings from 1991 to 1993 (3 years) and searched the Melvyl Medline Plus database for abstracts from 1990 through 1998 to determine which had been published in peer-reviewed journals. Of the 333 abstracts listed for the 1990 to 1993 meetings, 198 (59.5%) were published in peer-reviewed journals. Publication rates of the AOSSM and AANA meetings were 68.1% and 50.9%, respectively. The majority of articles were published in American Journal of Sports Medicine (40.1%) and Arthroscopy (30.3%). Publication rates of presentations made at meetings of these sports medicine specialty societies are high and exceed the publication rates associated with meetings of other medicine specialty societies.

Blind endovascular catheterization and direct access of an occluded superior ophthalmic vein for treatment of carotid cavernous fistula.

We describe a case of an elderly patient who presented with right-sided ophthalmoplegia, proptosis, chemosis, and increased intraocular pressure. An angiogram showed feeding vessels from the bilateral internal and external carotid arteries. Our initial attempt to blindly probe the inferior petrosal sinus was unsuccessful. This was followed by a right anterior orbitotomy exposing the superior ophthalmic vein which was directly cannulated with an 18 gauge angiocatheter. However, a proximal third of the superior ophthalmic vein within the orbit which was thrombosed was probed blindly. The thrombosed vein was cannulated with a microcatheter to obtain coil embolization of the carotid cavernous fistula. The implications of the procedure are discussed, given that, to our knowledge, such an endeavor has never been performed.

Blind endovascular catheterization and direct access of an occluded superior ophthalmic vein for treatment of carotid cavernous fistula.

We describe a case of an elderly patient who presented with right-sided ophthalmoplegia, proptosis, chemosis, and increased intraocular pressure. An angiogram showed feeding vessels from the bilateral internal and external carotid arteries. Our initial attempt to blindly probe the inferior petrosal sinus was unsuccessful. This was followed by a right anterior orbitotomy exposing the superior ophthalmic vein which was directly cannulated with an 18 gauge angiocatheter. However, a proximal third of the superior ophthalmic vein within the orbit which was thrombosed was probed blindly. The thrombosed vein was cannulated with a microcatheter to obtain coil embolization of the carotid cavernous fistula. The implications of the procedure are discussed, given that, to our knowledge, such an endeavor has never been performed.