Endoscopic endonasal obliteration of the frontal recess and anterior skull base.

BACKGROUND: Although endoscopic techniques have become more widespread in repair of frontal sinus (FS) defects, certain pathologies still require open approach (extensive trauma or tumors). Under certain circumstances even multiple complex open reconstructive procedures might fail to resolve persistent pneumocephalus or CSF leak and subsequently surgeons tend to escalate the invasiveness and employ even more complex and aggressive approaches. We present our experience treating persistent pneumocephalus or CSF leak after previously failed transcranial reconstruction utilizing an endoscopic endonasal approach (EEA). METHODS: We retrospectively reviewed a prospectively maintained database of all patients undergoing an EEA for repair of persistent pneumocephalus or CSF leak following FS cranialization between 2016 and 2020. RESULTS: Six patients who underwent cranialization of the FS with subsequent persistent pneumocephalus or CSF leak were identified; two patients suffered a traumatic fracture of the FS, remaining four patients had undergone previous cranial surgery. Clear violation of the FS was not recognized in one patient. All patients underwent cranialization of the FS either directly following initial craniotomy or during open repair of a FS fracture. Two patients underwent multiple transcranial surgeries including using vascularized free tissue transfer. Complete cessation of pneumocephalus/CSF leak was achieved in 83.3% (5/6) after the first and 100% (6/6) after two endoscopic procedures. No morbidity or mortality resulted from the endoscopic procedure. CONCLUSIONS: Skull base defects following a failed cranialization of FS are usually located in or in close proximity to the frontal recess. These defects can be safely and effectively repaired via an EEA.

Epistaxis Risk Associated with Intranasal Corticosteroid Sprays: A Systematic Review and Meta-analysis.

OBJECTIVE: Intranasal corticosteroids (INCSs) are widely utilized for the treatment of allergic rhinitis. Epistaxis is a known adverse effect of INCSs, but it is not known if the risk of epistaxis differs among INCSs. DATA SOURCES: Systematic review of primary studies identified through Medline, Embase, Web of Science, PubMed Central, and Cochrane databases. REVIEW METHODS: Systematic review was conducted according to the PRISMA standard. English-language studies were queried through February 1, 2018. The search identified randomized controlled trials of INCSs for treatment of allergic rhinitis that reported incidence of epistaxis. An itemized assessment of the risk of bias was conducted for each included study, and meta-analysis was performed of the relative risk of epistaxis for each INCS. RESULTS: Of 949 identified studies, 72 met the criteria for analysis. Meta-analysis demonstrated an overall relative risk of epistaxis of 1.48 (95% CI, 1.32-1.67) for all INCSs. The INCSs associated with the highest risk of epistaxis were beclomethasone hydrofluoroalkane, fluticasone furoate, mometasone furoate, and fluticasone propionate. Beclomethasone aqueous, ciclesonide hydrofluoroalkane, and ciclesonide aqueous were associated with the lowest risk of epistaxis. Conclusions about epistaxis with use of budesonide, triamcinolone, and flunisolide are limited due to the low number of studies and high heterogeneity. CONCLUSIONS: While a differential effect on epistaxis among INCS agents is not clearly demonstrated, this meta-analysis does confirm an increased risk of epistaxis for patients using INCSs as compared with placebo for treatment of allergic rhinitis.

Stable Density and Dynamics of Dendritic Spines of Cortical Neurons Across the Estrous Cycle While Expressing Differential Levels of Sensory-Evoked Plasticity.

Periodic oscillations of gonadal hormone levels during the estrous cycle exert effects on the female brain, impacting cognition and behavior. While previous research suggests that changes in hormone levels across the cycle affect dendritic spine dynamics in the hippocampus, little is known about the effects on cortical dendritic spines and previous studies showed contradictory results. In this in vivo imaging study, we investigated the impact of the estrous cycle on the density and dynamics of dendritic spines of pyramidal neurons in the primary somatosensory cortex of mice. We also examined if the induction of synaptic plasticity during proestrus, estrus, and metestrus/diestrus had differential effects on the degree of remodeling of synapses in this brain area. We used chronic two-photon excitation (2PE) microscopy during steady-state conditions and after evoking synaptic plasticity by whisker stimulation at the different stages of the cycle. We imaged apical dendritic tufts of layer 5 pyramidal neurons of naturally cycling virgin young female mice. Spine density, turnover rate (TOR), survival fraction, morphology, and volume of mushroom spines remained unaltered across the estrous cycle, and the values of these parameters were comparable with those of young male mice. However, while whisker stimulation of female mice during proestrus and estrus resulted in increases in the TOR of spines (74.2 ± 14.9% and 75.1 ± 12.7% vs. baseline, respectively), sensory-evoked plasticity was significantly lower during metestrus/diestrus (32.3 ± 12.8%). In males, whisker stimulation produced 46.5 ± 20% increase in TOR compared with baseline-not significantly different from female mice at any stage of the cycle. These results indicate that, while steady-state density and dynamics of dendritic spines of layer 5 pyramidal neurons in the primary somatosensory cortex of female mice are constant during the estrous cycle, the susceptibility of these neurons to sensory-evoked structural plasticity may be dependent on the stage of the cycle. Since dendritic spines are more plastic during proestrus and estrus than during metestrus/diestrus, certain stages of the cycle could be more suitable for forms of memory requiring de novo formation and elimination of spines and other stages for forms of memory where retention and/or repurposing of already existing synaptic connections is more pertinent.

Bilateral inferior petrosal sinus sampling using desmopressin or corticotropic-releasing hormone: a single-center experience.

BACKGROUND: Bilateral inferior petrosal sinus sampling (BIPSS) following corticotropic-releasing hormone (CRH) stimulation is the current gold standard technique in the diagnosis of Cushing disease. However, as a result of CRH shortage, desmopressin (DDAVP) has been used instead for BIPSS. We present the experience of a single tertiary care center using the modified BIPSS protocol and compare the results obtained with DDAVP with those obtained with CRH. METHODS: Using the radiology department's electronic database, BIPSS procedures performed at our institution using DDAVP and CRH were identified. Electronic medical records and imaging studies were reviewed and the clinical history, demographic data, endocrine test results, complications of BIPSS, and patient outcomes were recorded. BIPSS data were analyzed for centralization and lateralization of pituitary adrenocorticotropic hormone (ACTH) source. We identified 20 BIPSS cases (16 women, mean age 38 years) performed using DDAVP between 2012 and 2013. RESULTS: The 20 cases demonstrated conventional inferior petrosal sinus anatomy and were successfully cannulated bilaterally. Of these, 18 met the criteria for both centralization and lateralization. A total of 18 patients underwent trans-sphenoidal tumor resection; one patient was lost to follow-up and one is still being followed. There were no complications resulting from the use of DDAVP, specifically no thromboembolic events. Calculated sensitivity for BIPSS with DDAVP was 94.5%. There was also no significant difference in the biochemical results produced by BIPSS using either DDAVP or CRH. All 18 patients demonstrated an ACTH-secreting adenoma on pathology review. CONCLUSIONS: DDAVP is a safe alternative to CRH, producing comparable diagnostic results.

Novel lead-free drape applied to the X-ray detector protects against scatter radiation in the angiography suite.

PURPOSE: To evaluate a sterile, disposable lead-free drape for reducing scatter radiation exposure during fluoroscopy-guided procedures. MATERIALS AND METHODS: Computer-aided design software was used to model a procedure room with a thoracic anthropomorphic phantom on the angiography table. Using this model, measurements of scatter radiation were made from the phantom before and after the application of the drape using a collimated and full field of view in low-output conditions (70 kVp, 48 mA) and high-output conditions (125 kVp, 156 mA). Transmission of x-rays through the drape and entrance exposure rates were also measured. Statistical significance was measured using a Student t test. RESULTS: Scatter radiation was attenuated throughout the procedure room when the drape was applied. The highest level of scatter radiation was detected in the expected position of the operator, adjacent to the phantom. Radioprotection by the drape was the greatest in this position: 71.5% attenuation at waist level and 89% at neck level (P < .0001). The use of the drape did not result in an increase of backscatter radiation to the phantom. CONCLUSIONS: The use of this drape significantly reduces scatter radiation in the procedure room; this effect is maximal in close proximity to the phantom.