Successful treatment of Aspergillus ventriculitis through voriconazole adaptive pharmacotherapy, immunomodulation, and therapeutic monitoring of cerebrospinal fluid (1→3)-ß-D-glucan.

Aspergillus ventriculitis is an uncommon but often fatal form of invasive aspergillosis of the central nervous system (CNS). As little is known about the diagnosis, treatment, and outcome of this potentially lethal infection, we report the strategies used to successfully treat Aspergillus ventriculitis complicating a pineal and pituitary germinoma with emphasis on the critical role of adaptive pharmacotherapy of voriconazole and serial monitoring of (1→3)-ß-D-glucan in cerebrospinal fluid. We describe several rationally based therapeutic modalities, including adaptive pharmacotherapy, combination therapy, sargramostim-based immunomodulation, and biomarker-based therapeutic monitoring of the CNS compartment. Through these strategies, our patient remains in remission from both his germinoma and Aspergillus ventriculitis making him one of the few survivors of Aspergillus ventriculitis.

Endovascular biopsy of a sigmoid sinus lesion using a stent retriever and aspiration catheter.

A teenager with a history of acute myeloid leukemia presented with headache, nausea and blurry vision over a 2 week period. The MRI of the brain was concerning for the presence of a myeloid sarcoma within the right sigmoid sinus. For evaluation of venous obstruction and the underlying lesion the patient underwent a cerebral angiogram and transvenous biopsy of the sigmoid sinus lesion using a stent retriever and aspiration catheter. The tissue extracted was consistent with myeloid sarcoma. This pathologic finding was consistent with the recurrence of leukemia and guided the targeted oncologic treatment.

Aggressive variant of a papillary glioneuronal tumor. Report of 2 cases.

Papillary glioneuronal tumors are a newly recognized type of brain neoplasm characterized by prominent pseudopapillary structures and glioneuronal elements. All prior cases have shown that these tumors have an indolent course. The authors present 2 patients with an aggressive variant of the tumor. The first patient had dissemination of her tumor and the second had local spreading. Therefore, the authors conclude that papillary glioneuronal tumors do not always behave in a strictly benign fashion.

The role of the sternocleidomastoid muscle flap for esophageal fistula repair in anterior cervical spine surgery.

STUDY DESIGN: A retrospective study was undertaken which evaluated the medical records and imaging studies of a subset of patients managed by the spine service at Jackson Memorial Hospital who were diagnosed with an esophageal perforation in the setting of spinal surgery. OBJECTIVE: To assess the safety and efficacy of a sternocleidomastoid muscle flap in the repair of esophageal perforation in the setting of anterior cervical spine surgery. SUMMARY OF BACKGROUND DATA: The management of an esophageal fistula in the setting of spine surgery is challenging and starts with a prompt and accurate diagnosis. In addition to broad spectrum intravenous antibiotics, several methods have been described to repair the fistula, which range from enteral tube feeding, direct repair, and/or repair with a local or free muscle flap. METHODS: The review encompassed medical records, discharge summaries, operative reports, and imaging studies. Data were gathered with specific attention to demographics, primary pathology, mechanism of esophageal injury, method of spinal stabilization, method of esophageal repair, and time to initiation of oral intake. Follow-up interviews were conducted either in-person or by telephone. RESULTS: Six patients were treated over the study period. There were 3 men and 3 women. The mean age was 52.8 years. Primary pathologies were penetrating trauma, blunt trauma (2 cases), degenerative disease (2 cases), and tumor. Mechanisms of esophageal injury were penetrating trauma, acute iatrogenic, chronic iatrogenic (3 cases), and intubation trauma. The time to diagnosis ranged from immediate to 10 months. The method of spinal stabilization was anterior autograft followed by posterior instrumentation in 4 of 6 patients. The method of esophageal repair was an inferiorly based sternocleidomastoid (SCM) flap in 4 cases, primary repair in 1 case, and esophageal diversion alone in 1 case. The time to oral intake averaged 59.2 days (range, 23-113 days) in those with a SCM flap versus 153.5 days (range, 119-188 days) in those treated without a flap. CONCLUSION: The use of an SCM flap for the repair of esophageal injury, in the setting of anterior cervical spine surgery, is a safe and effective tool. An SCM flap appeared to improve the time in initiating oral intake without any significant morbidity.