ANCA-associated vasculitis presenting with isolated neurological manifestations in a patient with cocaine abuse: a case report and literature review.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of rare conditions predominantly affecting small vessels of skin, musculoskeletal, pulmonary, renal, and rarely central and peripheral nervous systems. Isolated neurological manifestations of AAV are uncommon and challenging to diagnose. Cocaine has been reported as a potential trigger for the development of AAV. There are only a few case reports of isolated neurological involvement in cocaine-induced AAV with poorly characterized histopathological features. We present a unique case of AAV with isolated neurological manifestations presenting with multiple cranial neuropathies, leptomeningeal enhancement on imaging and histopathologic evidence of small-vessel vasculitis in the leptomeninges and brain and extensive dural fibrosis in a patient with cocaine abuse. The patient's progressive neurological deficits were controlled after starting immunosuppression with rituximab and prednisone. We also reviewed the literature to provide the diagnostic overview of AAV and evaluate intervention options. To our knowledge, this is the first case of AAV with isolated neurological manifestations and histopathologic evidence of small-vessel vasculitis in a patient with cocaine abuse. Patients with multiple cranial neuropathies and meningeal involvement should be screened for AAV, especially if they have a history of cocaine abuse.

Noninvasive Treatment of Venous Pulsatile Tinnitus with an Internal Jugular Vein Compression Collar.

OBJECTIVE: The study was conducted to evaluate the safety and efficacy of mild internal jugular (IJV) compression via an FDA approved compression collar for symptomatic treatment of venous pulsatile tinnitus. METHODS: This is a prospective study that recruited 20 adult patients with venous pulsatile tinnitus. Participants completed the Tinnitus Handicap Inventory (THI), were fitted with the collar, and rated symptom intensity on a 10-point tinnitus intensity scale before and during collar use. Once weekly for 4 weeks, they answered a survey quantifying days used, average tinnitus intensity before and after wearing the collar each day of use, and any safety concerns. Lastly, they completed an exit interview. The primary outcome was symptomatic relief, with secondary outcomes of safety, effect of treatment setting, effect of time, and quality of life assessed via nonparametric testing. RESULTS: 18 participants completed the study, and 276 paired daily before use/during use intensity scores were submitted. The median symptom intensity without the collar was 6 (IQR 4, 7), whereas with the collar it was 3 (IQR 2, 5), for a median symptomatic relief of 50%. The collar had a significant effect in reducing symptom intensity (p < 0.0001) and burden of illness via the THI (p < 0.0001). There was no effect of setting, frequency, or time on symptomatic relief with the collar. There were no adverse safety events reported aside from minor discomfort upon initial application. CONCLUSIONS: Venous compression collars offer acute symptom relief for patients with venous pulsatile tinnitus. Further study is needed to assess safety and efficacy of longitudinal use. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Synthetic interpolated DSA for radiation exposure reduction via gamma variate contrast flow modeling: a retrospective cohort study.

BACKGROUND: Digital subtraction angiography (DSA) yields high cumulative radiation dosages (RD) delivered to patients. We present a temporal interpolation of low frame rate angiograms as a method to reduce cumulative RDs. METHODS: Patients undergoing interventional evaluation and treatment of cerebrovascular vasospasm following subarachnoid hemorrhage were retrospectively identified. DSAs containing pre- and post-intervention runs capturing the full arterial, capillary, and venous phases with at least 16 frames each were selected. Frame rate reduction (FRR) of the original DSAs was performed to 50%, 66%, and 75% of the original frame rate. Missing frames were regenerated by sampling a gamma variate model (GVM) fit to the contrast response curves to the reduced data. A formal reader study was performed to assess the diagnostic accuracy of the "synthetic" studies (sDSA) compared to the original DSA. RESULTS: Thirty-eight studies met inclusion criteria (average RD 1,361.9 mGy). Seven were excluded for differing views, magnifications, or motion. GVMs fit to 50%, 66%, and 75% FRR studies demonstrated average voxel errors of 2.0 ± 2.5% (mean ± standard deviation), 6.5 ± 1.5%, and 27 ± 2%, respectively for anteroposterior projections, 2.0 ± 2.2%, 15.0 ± 3.1%, and 14.8 ± 13.0% for lateral projections, respectively. Reconstructions took 0.51 s/study. Reader studies demonstrated an average rating of 12.8 (95% CI 12.3-13.3) for 75% FRR, 12.7 (12.2-13.2) for 66% FRR and 12.0 (11.5-12.5) for 50% FRR using Subjective Image Grading Scale. Kendall's coefficient of concordance resulted in W = 0.506. CONCLUSION: FRR by 75% combined with GVM reconstruction does not compromise diagnostic quality for the assessment of cerebral vasculature. RELEVANCE STATEMENT: Using this novel algorithm, it is possible to reduce the frame rate of DSA by as much as 75%, with a proportional reduction in radiation exposure, without degrading imaging quality. KEY POINTS: • DSA delivers some of the highest doses of radiation to patients. • Frame rate reduction (FRR) was combined with bolus tracking to interpolate intermediate frames. • This technique provided a 75% FRR with preservation of diagnostic utility as graded by a formal reader study for cerebral angiography performed for the evaluation of cerebral vasospasm. • This approach can be applied to other types of angiography studies.

Technical Nuances of the Posterior Transpedicular Thoracic Diskectomy: 2-Dimensional Operative Video.

Thoracic disk herniations are relatively rare when compared with cervical and lumbar disk pathology accounting for less than 3% of spinal disk herniations.1 In addition to this, a larger proportion of thoracic disk herniations are calcified making them challenging to remove because of adherence to the dura and anatomy of the thoracic spinal canal.2,3 Owing to these unique features of thoracic disk herniations, typical posterior approaches are not always feasible to provide adequate decompression of the thecal sac.4 In this video, we present a 64-year-old male patient who presented with progressive paraplegia and a large ventral, eccentric, calcified thoracic disk herniation causing severe canal stenosis. Because of the size and location of the disk, a thoracic laminectomy with costotransversectomy and pediculectomies for resection of the disk was performed. Ventral decompression was achieved, and the patient made a full neurologic recovery. This video highlights the principles and technical nuances used during thoracic disk resection. The patient provided informed consent for surgery and video recording.

Does the clopidogrel CYP2C19 genotype assay predict postprocedure stenosis in cerebral aneurysms treated with a flow diverter?

OBJECTIVE: Flow diverters have emerged as a popular modality for treating cerebral aneurysms but require dual antiplatelet therapy (DAPT) after placement. Clopidogrel is a common choice but is a prodrug that some patients may not convert into an active metabolite. The CYP2C19 genotype assay is used to predict activation speed; however, limited data exist showcasing whether this genotype accurately predicts postprocedure complications after flow diversion treatment of cerebral aneurysms. Therefore, the authors sought to characterize whether CYP2C19 genotype correlated with the development of postprocedure intimal hyperplasia (stenosis) after flow diverter placement. METHODS: Medical records were reviewed for patients who underwent flow diverter treatment of cerebral aneurysm at a single academic institution between January 1, 2012, and May 31, 2020. Patient demographics and comorbidities were reviewed alongside CYP2C19 genotype assay, DAPT regimen, and postprocedure angiogram data. Stenosis was defined based on review of angiogram data by two independent physicians. RESULTS: In this review of 120 unique cerebral aneurysms, 102 received DAPT with clopidogrel and 18 received DAPT with an alternative agent. Stenosis was present on 3-month follow-up angiogram for 35/102 (34.3%) aneurysms receiving DAPT with clopidogrel and in 11/18 (61.1%) aneurysms receiving an alternative DAPT regimen (p = 0.031). The CYP2C19 genotype did not correlate with postprocedure stenosis (p = 0.35). CONCLUSIONS: Clopidogrel was a significantly more effective DAPT agent for preventing stenosis when compared to nonclopidogrel DAPT regimens. The clopidogrel CYP2C19 genotype did not predict postprocedure stenosis in this cohort of 120 cerebral aneurysms treated with a flow diverter.

Social Disparities in Helmet Usage in Bicycle Accidents Involving Children.

Background Bicycle helmet use has a known protective health benefit; yet, pediatric populations have suboptimal helmet rates, which increases the risk of severe injuries. It is imperative to have an updated assessment of behavioral social disparities and for providers to be aware of them to better counsel patients. The study objective was to identify social determinants correlated with helmet use in children involved in bicycle accidents. Based on previous literature, we hypothesized that higher socioeconomic status, female sex, and Caucasian race were associated with increased helmet use. Methods A retrospective case series of 140 pediatric cases of bicycle-related traumas assessing helmet status. Participants presented to the emergency room with injuries due to a bicycle-related trauma and were subsequently admitted to the University of North Carolina (UNC) Hospital System in Chapel Hill, North Carolina (NC), from June 2006 to May 2020. The Institutional Review Board (IRB) approved study comprised a retrospective chart review of 140 cases from the pediatric (<18 years of age) trauma database with coding indicating bicycle-related injury. Zip codes were used to approximate the median household income utilizing the Proximity One government database. The primary exposure was helmet status, which was determined from the electronic record chart review. The hypothesis was formulated before the start of the study. The main outcomes measured in the study included age, sex, race, helmet status, zip code, insurance status, injury types, and mortality. Results There were a total of 140 study participants, of which 35 were female and 105 were male. Males comprised 79.6% of the non-helmeted group, while females were in the minority in both helmet status groups, with 65.7% still being non-helmeted. Additionally, 51.9% of patients who were helmeted used private insurance, and 59.3% of those non-helmeted used public insurance. Of the 71 head injuries, 88.7% were non-helmeted. Principally, this study found that 80.7% of children involved in a bicycle-related accident were not helmeted.  Conclusions Despite NC legislation mandating that children under 16 years of age wear helmets while operating bicycles, many children injured in bicycle-related trauma are not complying with this requirement. This study demonstrates that specific populations have decreased rates of helmet usage and emphasize the continued need to monitor helmet behaviors.

Minimally invasive modification of the Goel-Harms atlantoaxial fusion technique: a case series and illustrative guide.

OBJECTIVE: The Goel-Harms atlantoaxial screw fixation technique for the treatment of atlantoaxial instability and unstable odontoid fractures is reliable and reproducible for a variety of anatomies. The drawbacks of the technique are the potential for significant bleeding from the C2 nerve root venous plexus and the risks associated with posterior midline exposure and retraction, such as pain and wound complications. The authors developed a minimally invasive surgical (MIS) modification of the Goel-Harms technique using intra-articular grafting to facilitate placement of percutaneous lateral mass and pars screws with extended tabs for minimally invasive subfascial rod placement. The objective of this study was to present the authors' first series of 5 patients undergoing minimally invasive modification in comparison with 51 patients undergoing open atlantoaxial fusion. METHODS: A retrospectiveanalysis of patient comorbid conditions, blood loss, length of surgery, and length of stay was performed on patients undergoing Goel-Harms instrumented fusion (GHIF) for unstable odontoid fractures performed between 2016 and 2021. RESULTS: Patients undergoing the minimally invasive procedure showed significantly less blood loss than those undergoing the open atlantoaxial fusion procedure, with a median blood loss of 30 ml compared with 150 ml using the open technique (p < 0.01). The patients showed no significant differences in length of stay (2 days for MIS vs 4 days for open atlantoaxial fusion, p = 0.25). There were no significant differences in length of surgery for MIS, but a possible trend toward increased operative duration (234 vs 151 minutes, p = 0.112). CONCLUSIONS: In this small pilot study, it was shown that MIS-GHIF can be performed with decreased blood loss in atlantoaxial instability and odontoid fractures. This technique may allow for greater and safer application of the procedure in the elderly and infirm.

Disparities in Postoperative Endocrine Outcomes After Endoscopic-Assisted Transsphenoidal Pituitary Adenoma Resection.

Objectives Socioeconomic factors can influence morbidity in patients with pituitary adenoma. This study aims to identify associations between socioeconomic factors and postoperative outcomes in patients with pituitary adenomas. Methods A retrospective medical chart review was conducted on adult patients who underwent resection of purely sellar nonfunctional and functional pituitary adenomas between May 1, 2014, and May 31, 2020, at the University of North Carolina Medical Center. The main outcome measures included the incidence of postoperative diabetes insipidus (PDI), postoperative hyponatremia (PHN), and postoperative hypopituitarism (PHP). Outcome measures were analyzed using univariate and multivariate analyses against preoperative tumor volume as well as socioeconomic and demographic factors (self-identified race/ethnicity, age, gender, address assessed by the Area Deprivation Index (ADI), and insurance status). Results On univariate analysis, patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods had an increased incidence of postoperative diabetes insipidus. Patients who experienced PDI were significantly younger on average in both univariate and multivariate analyses. When analyzed further, patients of Hispanic race/ethnicity were significantly younger and more likely to be uninsured compared to their respective racial/ethnic counterparts. No significant correlations were found for PHN or PHP. Conclusions Patients of Hispanic race/ethnicity and patients living in more disadvantaged neighborhoods were more likely to experience PDI. This finding, when combined with findings regarding age and insurance status, suggests complex disparities in medical care that are confirmed or corroborated by prior literature. These results may enhance clinicians' management of patients from disadvantaged socioeconomic backgrounds through increased awareness of disparities and the provision of resources for assistance.

Case report: Minimally invasive modification of the Goel-Harms atlantoaxial fusion utilizing percutaneous screws and intra-articular cage is feasible and results in decreased blood loss.

Treatment of atlantoaxial pathology is often associated with significant morbidity and mortality. While surgical techniques for fixation are well established, approaches that minimize blood loss and muscle dissection are advantageous for expediting recovering and minimizing surgical risk. We present a 34-year-old female who presented with a Type III odontoid fracture requiring surgical fixation. She underwent a C1-2 fusion employing a novel minimally invasive modification of the Goel-Harms atlantoaxial fusion using percutaneous screws and intra-articular cage.

Characterization of a paradoxical post-operative increase in serum cortisol in Cushing disease.

PURPOSE: In Cushing disease, early post-operative serum cortisol fluctuations have not been adequately characterized, and their association with initial remission and recurrence is unclear. METHODS: A retrospective cohort study of patients with Cushing disease was conducted at two institutions. A "riser" was defined a priori as a paradoxical increase in serum cortisol with an immediate incremental increase in serum cortisol over three consecutive cortisol draws separated by roughly 6-h (definition 1). Post hoc analyses used a definition of two consecutive increases (definition 2). Risers were compared to non-risers for initial remission and time-to-recurrence. RESULTS: A total of 505 patients with Cushing disease were screened, and 469 had adequate data for group assignment. Analysis of post-operative cortisol showed a subgroup of "risers" with a frequency of 3.6% for definition 1 and 42.6% for definition 2. In these patients, cortisol levels were significantly higher until approximately 36 h post-operatively, and cortisol had a significantly longer mean serum half-life. In the post hoc analysis, definition 2 risers had a lower remission rate compared to non-risers (162/196, 82.7%, versus 243/264, 92.0%) with an odds ratio of 0.41 (0.23-0.73; p = 0.003). For both definitions, recurrence was similar between groups. CONCLUSIONS: We found that almost half of Cushing disease patients experienced a temporary increase in serum cortisol level during the early post-operative period. Serum cortisol half-life was longer, and the remission rates were lower, however, recurrence rates were similar to non-risers.

Novel use of percutaneous cervical pedicle inlet screws for supplemental posterior fixation after anterior cervical deformity correction.

INTRODUCTION: Correction of cervical deformity can be achieved using anterior cervical fixation and fusion techniques. However, supplemental posterior fixation is a critical component for ensuring biomechanical longevity and favorable patient outcomes. We present a novel percutaneous technique for posterior cervical fixation in patients where cervical pedicle (CP) screws may not be feasible and midline muscle dissection is not needed. METHODS: Three patients presented to our hospital with cervical pathology amendable to circumferential cervical fusion. After adequate deformity correction was performed through an anterior cervical decompression and fusion, staged posterior supplemental fixation was achieved using percutaneous CP inlet (CPI) screws using a percutaneous muscle-sparing approach. RESULTS: All three patients underwent CPI screw placement without postoperative neurovascular complications. Postoperative radiographic follow-up showed the desired, proper screw placement, with continued maintained cervical alignment. CONCLUSIONS: CPI screw placement may be alternative hybrid screw that achieves a advantageous safety profile while also avoiding an open midline exposure.

Impact of Surgical and Medical Treatment on Survival of Patients with Cerebral Aspergillosis: Systematic Review of the Literature.

OBJECTIVE: Cerebral aspergillosis carries a high mortality. Rapid diagnosis and treatment can increase survival, but symptoms and imaging findings are nonspecific. The literature on cerebral aspergillosis consists mostly of case reports and case series and lacks large-scale review of data. METHODS: We performed a review of the literature using PubMed in March 2019. We recorded the year of publication, age and sex of patients, neurosurgical involvement, the antifungals administered, use of intrathecal antifungals, and the outcome of patients. The relationships among variables were tested using bivariant statics and linear regression. RESULTS: A total of 324 studies met the eligibility criteria, and 198 studies including 248 patients were included. Surgical resection (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.25-0.80; P < 0.01) and administration of voriconazole (OR, 0.32; 95% CI, 0.18-0.55; P < 0.001) or itraconazole (OR, 0.36; 95% CI, 0.16-0.72; P < 0.001) were shown to be significantly associated with survival. CONCLUSIONS: Given the significant survival benefits for patients who received voriconazole and surgical intervention, we suggest early antifungal medical treatment and resection.

Gender diversity in United States neurosurgery training programs.

OBJECTIVE: Neurosurgery continues to be one of the medical specialties with the lowest representation of females in both the resident and faculty workforce. Currently, there are limited available data on the gender distribution of faculty and residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery training programs. This information is critical to accurately measure the results of any effort to improve both the recruitment and retention of women in neurosurgery. The objective of the current study was to define the current gender distribution of faculty and residents in ACGME-accredited neurosurgery training programs. METHODS: Data publicly available through institutional and supplemental websites for neurosurgical faculty and residents at ACGME-accredited programs were analyzed for the 2017-2018 academic year. Data collected for faculty included gender, age, year of residency graduation, academic rank, h-index, American Board of Neurological Surgery certification status, and leadership positions. Resident data included gender and postgraduate year of training. RESULTS: Among the 109 ACGME-accredited neurosurgical residency programs included in this study, there were 1350 residents in training, of whom 18.2% were female and 81.8% were male. There are 1320 faculty, of whom 8.7% were female and 91.3% were male. Fifty-eight programs (53.2%) had both female faculty and residents, 35 programs (32.1%) had female residents and no female faculty, 4 programs (3.7%) had female faculty and no female residents, and 6 programs (5.5%) lacked both female residents and faculty. Six programs (5.5%) had incomplete data. Female faculty were younger, had lower h-indices, and were less likely to be board certified and attain positions of higher academic rank and leadership. CONCLUSIONS: This study serves to provide a current snapshot of gender diversity in ACGME-accredited neurosurgery training programs. While there are still fewer female neurosurgeons achieving positions of higher academic rank and serving in leadership positions than male neurosurgeons, the authors' findings suggest that this is likely due to the small number of women in the neurosurgical field who are the farthest away from residency graduation and serves to highlight the significant progress that has been made toward achieving greater gender diversity in the neurosurgical workforce.

Pediatric neurosurgery training during residency in the United States: a program director survey.

OBJECTIVE: Pediatric neurosurgery is a core component of neurosurgical residency training. Pediatric case minimums are established by the Neurosurgery Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). Case minimums, by themselves, allow for great variability in training between programs. There are no prior data on how the residency programs meet these requirements. The authors' objective was to gather information on pediatric neurosurgical education among the ACGME-accredited neurosurgery training programs in order to shape further pediatric neurosurgical educational efforts. METHODS: A 25-question survey about pediatric neurosurgical education was created by the Education Committee of the Section on Pediatric Neurological Surgery of the American Association of Neurological Surgeons/Congress of Neurological Surgeons and distributed to program directors of all 111 ACGME-accredited neurosurgery training programs. RESULTS: The response rate was 77% (86/111). In 55% of programs the residents are rotated to a responder-designated "freestanding" children's hospital, and 39% of programs rotate residents to a children's hospital within a larger adult hospital or a general hospital. There are 4 or fewer pediatric neurosurgical faculty in 91% of programs. In 12% of programs less than 100 cases are performed per year, and in 45% more than 500 are performed. In 31% of responding neurosurgery residency programs there is also a pediatric neurosurgery fellowship program supported by the same sponsoring institution. Seventy-seven percent of programs have at least one specific pediatric neurosurgery rotation, with 71% of those rotations occurring during postgraduate year 3 and 50% occurring during postgraduate year 4. The duration of pediatric rotation varies from no specific rotation to more than 1 year, with 48% of residents spending 4-6 months on a pediatric rotation and 12% spending 7-11 months. Last, 17% of programs send their residents to external sites sponsoring other residency programs for their pediatric rotation. CONCLUSIONS: There is great variety between neurosurgery training programs with regard to resident education in pediatric neurosurgery. This study's data will serve as a baseline for future studies, and the authors hope the findings will guide further efforts in pediatric neurosurgical education in residency training programs.

Differential Patterns of Referral to Neurosurgery: A Comparison of Allopathic Physicians, Osteopathic Physicians, Nurse Practitioners, Physician Assistants, and Chiropractors.

BACKGROUND: Rising cost and limited resources remain major challenges to U.S. health care and neurosurgery in particular. To ensure an efficient and cost-effective health care system, it is important that referrals to neurosurgery clinics are appropriate, and that referred patients have a reasonably high probability of requiring surgical intervention or, at a minimum, ongoing neurosurgical follow-up. This retrospective study tests the null hypothesis that the probability of a referred patient requiring surgery is independent of referring provider credentials and referring service specialty. METHODS: A database of all patients referred to the neurosurgery clinic from 2015 through 2018 (n = 5677) was reviewed; the database included referring provider, referring provider specialty, number of subsequent clinic visits, and outcome of surgery or no surgery. Associations between categorical variables were tested using a χ2 analysis with post hoc relative risk (RR) calculations and binary logistical regression. RESULTS: Compared with patients referred by allopathic physicians, patients referred by osteopathic physicians (RR, 0.63; 95% confidence interval [CI], 0.48-0.84) and those referred by nurse practitioners (RR, 0.66; 95% CI, 0.51-0.86) were significantly less likely to require surgery. Probability of surgical intervention also varied by referrer specialty. Patients referred by neurologists required surgery 35% of the time, whereas patients referred by family practitioners required surgery 19% of the time, and patients referred by pediatricians required surgery only 7% of the time (P < 0.01). Binary logistic regression revealed that referrals from nurse practitioners and osteopathic physicians were independently associated with a decreased probability of surgical intervention. CONCLUSIONS: Our data strengthen the concept of having interdisciplinary teams led by physicians at the primary care level to ensure appropriate referrals. Training and adherence to guidelines must continually be reinforced to ensure proper referrals.

United States Medical Licensing Exam Step I Score as a Predictor of Neurosurgical Career Beyond Residency.

BACKGROUND: United States Medical Licensing Exam (USMLE) Step I score is cited as one of the most important factors when for applying to neurosurgery residencies. No studies have documented a correlation between USMLE Step I score and metrics of neurosurgical career trajectory beyond residency. OBJECTIVE: To determine whether USMLE Step I exam scores are predictive of neurosurgical career beyond residency, as defined by American Board of Neurological Surgery (ABNS) certification status, practice type, academic rank, and research productivity. METHODS: A database of neurosurgery residency applicants who matched into neurosurgery from 1997 to 2007 was utilized that included USMLE Step I score. Online databases were used to determine h-index, National Institutes of Health (NIH) grant funding, academic rank, practice type, and ABNS certification status of each applicant. Linear regression and nonparametric testing determined associations between USMLE Step I scores and these variables. RESULTS: USMLE Step I scores were higher for neurosurgeons in academic positions (237) when compared to community practice (234) and non-neurosurgeons (233, P < .01). USMLE Step I score was not different between neurosurgeons of different academic rank (P = .21) or ABNS certification status (P = .78). USMLE Step I score was not correlated with h-index for academic neurosurgeons (R2 = 0.002, P = .36). CONCLUSION: USMLE Step I score has little utility in predicting the future careers of neurosurgery resident applicants. A career in academic neurosurgery is associated with a slightly higher USMLE Step I score. However, USMLE Step I score does not predict academic rank or productivity (h-index or NIH funding) nor does USMLE Step I score predict ABNS certification status.

Pregnancy-Induced Physiologic Adaptation of the Abdominal Aorta Is Associated with Changes in Gene Expression and Genomic Methylation.

BACKGROUND/AIMS: Ten-eleven translocation 2 (Tet2), a DNA demethylase enzyme, has been identified as a master epigenetic regulator of vascular smooth muscle cell plasticity. We hypothesized that pregnancy will induce significant adaptive changes in aortic biomechanics that correlate with the Tet family gene expression. METHODS: Abdominal aortas from pregnant and nonpregnant mice were dissected and cannulated. Intraluminal pressure was adjusted using a pressure-servo system while using a video dimension analyzer to measure the lumen diameter. Quantitative polymerase chain reaction and immunoblot was used to analyze the expression of Tet genes. Global genomic methylation was assessed with the luminometric methylation assay. RESULTS: Compared to the nonpregnant (NP, 706 ± 8 µm) control group, the aortic luminal diameter was significantly increased in both E18.5 (836 ± 14 µm) and PP30 (889 ± 16 µm) mice. Distensibility was reduced in E18.5 (90 ± 4%) mice and returned to NP values (108 ± 2%) in PP30 (108 ± 3%) mice. Tet2 transcription decreased at the beginning of pregnancy and subsequently increased in late gestation, inversely corresponding to changes in global methylation. CONCLUSION: Physiologic changes in the aorta were accompanied by changes in gene expression and genomic methylation, suggesting an epigenetic component to maternal vascular remodeling during pregnancy.

Tenosynovial Giant Cell Tumor of the Clinoid: Rare Condition.

BACKGROUND: A tenosynovial giant cell tumor (TGCT) is a rare type of tumor that primarily arises from the tendon sheath, synovium, and bursae. In rare cases, these tumors can affect joints of the head and neck such as the temporomandibular joint. This is the only case to our knowledge of an intracranial TGCT tumor of the clinoid. CASE DESCRIPTION: We present the case of a 25-year-old female with a 2-year history of progressively blurred vision in her left eye without visual field defects. She denied any headaches or symptoms referable to the left eye region. Past medical history was significant for meningitis at 10 months of age. Family history was noncontributory with no history of brain tumors. CONCLUSIONS: A tumor originating from the left anterior clinoid was found intraoperatively and confirmed by histology to be a TGCT.

Venoarterial communication mediates arterial wall shear stress-induced maternal uterine vascular remodeling during pregnancy.

Although expansive remodeling of the maternal uterine circulation during pregnancy is essential for maintaining uteroplacental perfusion and normal fetal growth, the underlying physiological mechanisms are not well understood. Using a rat model, surgical approaches were used to alter uterine hemodynamics and wall shear stress (WSS) to evaluate the effects of WSS and venoarterial communication (e.g., transfer of placentally derived growth signals from postplacental veins to preplacental arteries) on gestational uterine vascular remodeling. Changes in WSS secondary to ligation of the cervical but not the ovarian end of the main uterine artery and vein provoked significant expansive remodeling at the opposite end of both vessels, but only in pregnant animals. The ≈50% increase in lumen diameter (relative to the contralateral horn) was associated with an upregulation of total endothelial nitric oxide (NO) synthase expression and was abolished by in vivo NO synthase inhibition with N-nitro-l-arginine methyl ester. Complete removal of a venous segment adjacent to the uterine artery to eliminate local venous influences significantly attenuated the WSS-induced remodeling by about one-half ( P < 0.05). These findings indicate that, during pregnancy, 1) increased WSS stimulates uterine artery growth via NO signaling and 2) the presence of an adjacent vein is required for arterial remodeling to fully occur. NEW & NOTEWORTHY This study provides the first in vivo evidence for the importance of venous influences on arterial growth within the uteroplacental circulation.