Atlanto-occipital assimilation: embryological basis and its clinical significance.

Atlanto-occipital assimilation is an osseous embryological anomaly of the craniovertebral junction in which the atlas (C1) is fused to the occiput of skull. Embryologically, this assimilation may happen due to failure of the segmentation and separation of the caudal occipital and the cranial cervical sclerotome. The segmentation clock is maintained by NOTCH and WNT signalling pathways along with Hox genes and retinoic acid. This condition is likely to be a consequence of mutation in above mentioned genes. The knowledge of this assimilation may be crucial for the clinicians as it may lead to various neurovascular symptoms. The present case report involves the analysis of atlanto-occipital assimilation with its clinical significance and embryological basis.

Is Asterion a Reliable Surgical Landmark for the Transverse and Sigmoid Sinus Junction in Indian Skulls?

Background: Asterion is the junction of lambdoid, parietomastoid, and occipitomastoid sutures. In traditional anatomy teaching, it is believed that asterion sits over the transverse-sigmoid sinus junction (TSSJ). It is a significant surgical landmark for the placement of a burr hole in the retrosigmoid approach. Objective: The purpose of this study was to evaluate the asterion's accuracy as a TSSJ-specific external surgical landmark in the Indian population. Materials and Methods: 16 human dried skulls were obtained from the Department of Anatomy, AIIMS, New Delhi. The point of TSSJ was taken between the two lips and just posterior to the entry of the superior petrosal sinus. Asterion internally was localized with the help of a geometrical divider. The x- horizontal/ anterior and y- vertically superior (+)/ inferior (-) distances were measured from asterion (internally) to the TSSJ by a digital vernier caliper. Results: The mean horizontal distance (x) of the left side asterion & TSSJ was 10.3±1.0mm whereas the vertical distance (y) ranged between +2 to -4.3 mm. The mean horizontal distance (x) of the right side asterion & TSSJ was 13.5±1.4mm whereas the vertical distance (y) ranged between +3 to -4.2 mm. Conclusion: Asterion is not a reliable landmark for TSSJ in Indian skulls. The TSSJ with respect to asterion was found on average 10mm and 13.5mm anterior on the left and right side respectively, and mostly inferior (average 4.2mm) in 75% of the skulls. The TSSJ was closer to the asterion on the left side in comparison with the right side. However, further studies with a larger sample size will be needed to evaluate the population-specific relation of asterion with the TSSJ.

Tadpole Sign in Filum Terminale Paragangliomas.

Two normotensive male patients came with complaints of low back pain. Contrast-enhanced magnetic resonance imaging of the lumbosacral spine revealed an enhancing intradural extramedullary lesion (at the L4-L5 vertebral level in the first patient and at the L2-L3 vertebral level in the second patient). The tumor resembled the head and caudal blood vessels the tail of a tadpole, thereby giving the "tadpole sign." This sign is an important radiologic and histopathologic correlate, which is helpful in preoperative diagnosis of spinal paraganglioma.

Complete resolution of syrinx after circumferential adhesiolysis without deformity correction in a case of 6 year old neglected cervical facet dislocation.

Neglected traumatic cervical dislocation can be difficult to treat as such and more so if they are accompanied by an associated post traumatic syringomyelia (PTS). We present the case of a 55 year old gentleman who had a traumatic C6-C7 grade 2 listhesis which was neglected and presented 6 year later with 6 months history of neck pain, spastic quadriparesis and bowel bladder involvement. The patient was diagnosed with a PTS extending from C4 to D5. The possible aetiology and management of such cases has been discussed. The patient was successfully treated with decompression, adhesiolysis of arachnoid bands and syringotomy without the correction of deformity. The patient improved neurologically and had complete resolution of syrinx at final followup.

A Reversible Cause of Cutaneous Rash in a Patient With Alcohol Consumption.

The most common cutaneous manifestations of alcoholism include urticarial reaction, flushing, porphyria cutanea tarda, psoriasis, rosacea, seborrheic dermatitis, and pruritus. Here, we present a case of a young male with a history of alcohol abuse who presented with non-blanching, petechial, and perifollicular macular rash secondary to vitamin C deficiency in view of poor oral intake. The rash improved significantly with vitamin C supplementation. Although rare in developed countries, clinicians should keep vitamin C deficiency as a differential diagnosis for skin rash in alcohol consumers.

Transcranial Surgery for Pituitary Tumors: A "Community Neurosurgery Experience".

Background: Despite the evolution of endoscopic techniques, large pituitary adenomas with unfavorable characteristics and irregular anatomical configurations continue to pose a challenge for the dexterity, skills, and patience of endoscopic surgeons. Transcranial surgery retains a significant role in these situations where the tumor access, hemostasis, and dissection around adjoining neurovascular tissues can be controlled efficaciously. Objective: In this report, we describe our experience with transcranial surgery for pituitary adenomas highlighting its safety and versatility in peripheral centers. Methods: We accessed the case files and imaging records of pituitary tumors operated between 2001 and 2019 at a private hospital in a major Indian city. The records were analyzed with emphasis on postoperative clinical course, visual, and endocrinological outcomes. The data was analyzed with respect to differences between transcranial and transsphenoidal procedures. Categorical variables were compared with Chi-square test/Fischer's exact test and difference in means evaluated with Welch's t-test. Results: A total of 178 procedures were performed in 173 patients with pituitary adenoma, who were the subjects of this study. Ninety-eight (56.7%) patients were treated by transsphenoidal excision whereas 80 (46.2%) underwent transcranial procedures (75 primary and five secondary). In the patients operated transcranially, we observed three deaths and nine patients suffered from significant morbidity. Visual outcomes were similar to the group operated transsphenoidally. However, incidence of panhypopituitarism was significantly higher in transcranial procedures; the extent of resection was poorer than transsphenoidal surgeries owing to more extensive nature of tumors. Conclusions: In low-volume centers, the endoscopic skills required for transsphenoidal resection of large and complex pituitary adenomas may be scarce. Transcranial surgery, dependent on familiar microsurgical techniques and equipment, may still be viable, safe, and an effective option.

O-Arm Assisted Anterior Odontoid Screw Fixation in Type II and Rostral Type III Odontoid Fractures: Single Center Surgical Series of 50 Patients.

Background: Accuracy of screw placement is one of the important factors necessary for adequate union in odontoid fractures with malposition rates as high as 27.2% with standard techniques. Objective: To evaluate efficacy of intraoperative O-arm assistance in improving accuracy of anterior odontoid screw placement and clinco-radiological outcome in type II and III odontoid fractures. Material and Methods: In this retrospective study, surgery consisted of anterior odontoid screw fixation under intraoperative O-arm assistance over 5 years. Demographical, clinical, radiological, operative details and postoperative events were retrieved from hospital database and evaluated for fusion and surgical outcome. Results: 50 patients (Mean age 34.6 years, SD 14.10, range: 7-70 years; 44 males and 6 females) with Type II and Type III odontoid fracture underwent O-arm assisted anterior screw placement. The mean interval between injury and surgery was 12 days (range 1-65 days). Mean operating time was 132.2 min ± SD 33.56 with average blood loss of 93 ml. ±SD 61.46. With our technique, accurate screw placement was achieved in 100% patients. At the mean follow-up of 26.4 month (SD13.75), overall acceptable fusion rate was 97.8% with non-union in 2.2% patients. Morbidity occurred in two patients; one patient developed fixation failure while other patient had nonunion which was managed with posterior C1-C2 arthrodesis. We had surgical mortality in one patient due to SAH. So overall our procedure was successful in 94% patients and among patients whose follow-up was available, acceptable fusion rates of 97.8% were achieved. Conclusion: We conclude that use of intraoperative three-dimensional imaging using O-arm for anterior odontoid screw fixation improves accuracy and leads to improved radiological and clinical outcomes. It further enables us to extend the indications of odontoid screw fixation to selected complex Type II and rostral Type III odontoid fractures.

Outcomes of Monoclonal Antibody Infusion Treatment During Delta (B.1.617.2) and Omicron (B.1.1.529) COVID 19 Variant Surges among Vaccinated and Unvaccinated Patients.

Background: Coronavirus infection of 2019 (COVID-19) is associated with significant morbidity and mortality. Vaccines supplement public health and social measures in preventing severe illness and mortality from COVID-19; however, vaccination rates remain inadequate in many regions. It is important to continuously explore the effective treatment due to the insufficient vaccination rate and increasing number of patients infected with virus. The emergence of new variants has led to multiple surges throughout the world requiring changes to treatment protocols. Method: We conducted a single-center observational study on all adult patients who received monoclonal antibody (mAb) infusion as a treatment for COVID-19 infection. Based on the predominant variant, patients were either offered Casirivimab (600 mg)/imdevimab (600 mg) or Sotrovimab (500 mg). Forty-six patients were given mAbs; 24 were vaccinated, and the remaining unvaccinated. Result: The mean age was 56 years, and the majority (63.04%) of the patients were female. Clinical symptoms of COVID-19 improved within 3 days of infusion in the majority of the patients (70%). None of the patients who received mAb showed progression of disease or required hospitalization at 30 days follow-up. There were no deaths at 30 days follow-up. Monoclonal antibodies are highly effective in reducing hospitalizations and mortality when given within 7 days of symptoms onset in patients with high-risk factors for progression to severe COVID-19 infection. The mean number of days after the onset at which the mAbs were administered to the patient was 4. Conclusion: Monoclonal antibodies should be considered in both vaccinated and unvaccinated patients with COVID-19 infection if newer antiviral agents are contraindicated. Our study highlights the effectiveness of monoclonal antibody infusions when given early in the course of COVID-19 infection regardless of vaccination status.

Intraventricular Pilocytic Astrocytoma: A Single Centre Experience.

Background: Intraventricular pilocytic astrocytomas are a rare occurrence, accounting for approximately 4% -15.6% of all pilocytic astrocytomas .The aim of the study was to describe the radiology, surgical management and outcome in 15 patients with histopathologically proven intraventricular pilocytic astrocytoma(IVPA). Objective: To study the clinical presentation radiology and operative challenges in rare intra ventricular pilocytic astrocytomas. Materials and Methods: Between January 2010 and August 2018, 15 patients with histopathologically proven IVPA were identified. The radiological images were obtained from PACS. Patient and surgical details were obtained from the computerized discharge summary, OT records and operative notes, whereas follow up was obtained from the record section. Results: Headache with progressive loss of vision was the most common presentation. Duration of symptoms varied from 4 months to 2 years (mean 9. 88 months). Except one patient, all patients with preoperative CT scan revealed calcifications in the lesion, with extensive calcification in 3 patients. All the tumors were predominantly hypointense on T1WI and iso to hyperintense on T2WI. Lesion in all patients showed heterogenous contrast enhancement on post gadolinium images. Mean blood loss in the series was 1969 ml (range 250 ml- 4500 ml).There was one death in this series due to meningitis and septic shock. Conclusion: IVPAs are rare tumors and are difficult to diagnose in the preoperative period based on the radiologic profile alone. These tumors can be extremely vascular with potential for massive blood loss. These tumors can be associated with extensive calcification and the calcified tumors have less bleeding as expected.

Necrotizing Fasciitis In A Patient with Metastatic Clear Cell Ovarian Carcinoma Treated with Bevacizumab.

BACKGROUND Necrotizing fasciitis is a life-threatening infection of the deep soft tissues that leads to progressive destruction of the fascia and subcutaneous fat. It typically spreads along the muscle fascia planes because of the relatively poor blood supply. Muscle tissue is usually spared because of its better blood supply. The usual risk factors for necrotizing fasciitis include trauma, malnutrition, obesity, uncontrolled diabetes mellitus, alcoholism, cirrhosis, neutropenia, and recent surgery. CASE REPORT We present a case of a middle-aged female who presented with necrotizing fasciitis of the right gluteal region. Her medical history was significant for well-controlled diabetes mellitus (hemoglobin A1c: 6.6), and clear cell carcinoma of ovaries (stage IV). She was on active chemotherapy with bevacizumab, paclitaxel, and carboplatin. She underwent incision and debridement of right gluteal abscess with drainage of 200 ml of foul-smelling pus and was started on intravenous antibiotics. Her blood cultures were negative, but the cultures taken from the right gluteal abscess showed moderate growth of Escherichia coli. The antibiotics were de-escalated and the patient was discharged with outpatient follow-up. CONCLUSIONS Bevacizumab, a humanized monoclonal IgG antibody, is a novel treatment for metastatic ovarian cancer. It is associated with necrotizing fasciitis due to anti-angiogenic, pro-thrombotic, and poor wound healing properties. It should be stopped in the patients presenting with necrotizing fasciitis.

Impact of COVID-19 on the Gastrointestinal Tract: A Clinical Review.

Coronavirus disease 2019 (COVID-19) has spread rapidly throughout the world, causing a pandemic that has resulted in more than 5 million deaths globally. The gastrointestinal (GI) tract is known to have high expression of angiotensin-converting enzyme 2 (ACE2) receptors in the human body, making it prone to direct damage from the cellular invasion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Numerous GI symptoms have been reported among patients with COVID-19. This systemic review details the mechanism and effects of COVID-19 on the GI tract along with the hepatobiliary and pancreatic systems.

Reversible Systolic Heart Failure in a Patient on Ibrutinib Chemotherapy.

Ibrutinib is an irreversible Bruton tyrosine kinase inhibitor that is approved for the treatment of mantle cell lymphoma, chronic lymphocytic leukemia, small lymphocytic lymphoma, Waldenström macroglobulinemia, marginal zone lymphoma, and mantle cell lymphoma. However, it is associated with significant cardiotoxic effects, with hypertension and atrial fibrillation being the most common. We present the case of a 42-year-old female with a medical history significant for lymphoplasmacytic lymphoma who presented with non-arrhythmic, non-ischemic cardiomyopathy after four months of chemotherapy with ibrutinib. In addition, her left ventricular ejection fraction improved markedly within a few days of stopping ibrutinib. We propose that the use of ibrutinib may be associated with reversible non-ischemic cardiomyopathy even in the absence of cardiac arrhythmias. Therefore, clinicians should be cognizant of the signs and symptoms of cardiomyopathy in patients on ibrutinib chemotherapy.

A High-Risk Patient With COVID-19 Vaccine Hesitancy Successfully Treated With Monoclonal Antibodies Through Two Major Surges.

Vaccine hesitancy remains a significant challenge in managing the current pandemic despite highly effective vaccines in the United States. Monoclonal antibodies (mAb) are an essential addition to coronavirus disease 2019 (COVID-19) treatment, along with oral antiviral agents (OAA), for non-hospitalized patients having risk factors for progression to severe COVID-19, especially in unvaccinated people. We present a case of a 74-year-old unvaccinated Hispanic woman with a history of diabetes mellitus, hypertension, coronary artery disease, obesity, and asthma who survived two episodes of severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2) infections in January 2021 and December 2021 with exclusive use of mAb. Our case highlights the importance of using mAbs for treating high-risk patients with SARS-CoV-2 infection, especially in patients with vaccine hesitancy.

Safety and feasibility of intramedullary injected bone marrow-derived mesenchymal stem cells in acute complete spinal cord injury: phase 1 trial.

OBJECTIVE: The intramedullary route holds the potential to provide the most concentration of stem cells in cases of spinal cord injury (SCI). However, the safety and feasibility of this route need to be studied in human subjects. The aim of this study was to evaluate the safety and feasibility of intramedullary injected bone marrow-derived mesenchymal stem cells (BM-MSCs) in acute complete SCI. METHODS: In this prospective study conducted over a 2-year period, 27 patients with acute (defined as within 1 week of injury) and complete SCI were randomized to receive BM-MSC or placebo through an intramedullary route intraoperatively at the time of spinal decompression and fusion. Institutional ethics approval was obtained, and informed consent was obtained from all patients. Safety was assessed using laboratory and clinicoradiological parameters preoperatively and 3 and 6 months after surgery. RESULTS: A total of 180 patients were screened during the study period. Of these, 27 were enrolled in the study. Three patients withdrew, 3 patients were lost to follow-up, and 8 patients died, leaving a total of 13 patients for final analysis. Seven of these patients were in the stem cell group, and 6 were in the control group. Both groups were well matched in terms of sex, age, and weight. No adverse events related to stem cell injection were noted for laboratory and radiological parameters. Five patients in the control group and 3 patients in the stem cell group died during the follow-up period. CONCLUSIONS: Intramedullary injection of BM-MSCs was found to be safe and feasible for use in patients with acute complete SCI.

Post myocardial infarction left ventricular intramural dissecting hematoma: a case report describing a very rare complication.

BACKGROUND: Dissecting intramural hematoma is a rare complication of acute myocardial infarction (AMI) and has been associated with increased mortality. There has been paucity of literature to establish protocols and guidelines for management in such cases. CASE PRESENTATION: We hereby report the case of a 45-year-old male patient with left ventricular intramural dissecting hematoma (LV-IDH) who presented with chest pain and breathlessness and diagnosed as non-ST-elevation myocardial infarction (NSTEMI). Transthoracic echocardiography (TTE) was performed showing LV-IDH, confirmed with cardiac magnetic resonant imaging (cMRI). Selective coronary arteriography (CAG) was performed showing significant obstructive coronary artery disease (CAD). Further management with conservative approach involved discussion with patient, cardiothoracic surgeon and cardiology team including heart failure specialist and interventional cardiology. CONCLUSIONS: This case describes a rare complication of AMI and also focuses on utility of TTE and cMRI in the diagnosis of this rare complication. Both diagnosis and management are challenging and have to be individualized in similar cases. Multidisciplinary care coordination is important in management of patients with this diagnosis.

Submassive Pulmonary Embolism Treated With Catheter-Directed Thrombolysis in Resource-Limited Setting: A Case Report and Review of Literature.

We describe a case of a young male who presented with acute onset progressively worsening shortness of breath for four days duration. He used to smoke cigarettes, and his profession required prolonged periods of standing. He underwent a two-dimensional echocardiogram showing right ventricular (RV) strain and computed tomography (CT) showing thrombus in the left major pulmonary artery. His pulmonary embolism severity index (PESI) score was high, predicting higher short-term mortality. Treatment options including risks and benefits were discussed with the patient, and he underwent catheter-directed thrombolysis (CDT) with rapid resolution of symptoms, oxygen saturation, and pulmonary artery pressures (PAP). He was discharged home safely after successful treatment of his condition.

A Rare Case of Coronavirus Disease 2019 Vaccine-Associated Cerebral Venous Sinus Thrombosis Treated with Mechanical Thrombectomy.

BACKGROUND Vaccine-related thrombosis and thrombocytopenia syndrome (TTS) is a rare life-threatening syndrome reported after vaccination against COVID-19. CASE REPORT We describe a case of 56-year-old postmenopausal, obese woman with hypothyroidism and hyperlipidemia, who presented to the Emergency Department (ED) with fluctuating mental status and left-side weakness for 5 days. She received her first and second dose of mRNA-1273 vaccine (Moderna) at 12 and 8 weeks, respectively, prior to presentation. She was found to have multiple hemorrhages and infarcts on a computed tomography (CT) scan of the head. She was intubated in the ED for airway protection and mechanically ventilated. Magnetic resonance angiogram and venogram showed multiple infarcts in right frontal, parietal, and left parietal lobes, along with occlusion of left-side transverse sinus, sagittal sinuses, and left internal jugular vein, suggesting cerebral venous sinus thrombosis (CVST). Despite anticoagulation, her clinical condition continued to worsen, and she was referred for emergent endovascular thrombectomy. Her clinical condition improved after thrombectomy, and she was discharged on warfarin. At 4-month follow-up, she was able to walk with an assistive device and able to carry out activities of daily living with assistance. She is planned for further work-up for hypercoagulable state at follow-up. CONCLUSIONS This case highlights the occurrence of vaccine-related thrombosis 3 months after vaccine administration. Only 2 cases of TTS have been reported so far after mRNA-1273 vaccination (Moderna). To the best of our knowledge, this is the first reported case of CVST presenting 3 months after the first dose of COVID-19 mRNA-1273 vaccine (Moderna).

Efficacy of antimicrobial medicated ventricular catheters: a network meta-analysis with trial sequential analysis.

There is paucity of evidence regarding relative performance of antibiotic-medicated (AM), silver-medicated (SM) and non-medicated (NM) ventricular catheters in controlling infection rate. We aim to quantitatively synthesize the current evidence after addition of the three-armed British Antibiotic and Silver Impregnated Catheters for ventriculoperitoneal Shunts (BASICS) trial, understand the need for further evidence using trial sequential analysis (TSA) and incorporate the indirect evidence using network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing AM, SM and NM ventriculoperitoneal shunt (VPS) or external ventricular drain (EVD) were included. Antibiotic-medicated VPS show a significantly lower infection rate as compared to non-medicated VPS (RR 0.44; 95% CI: 0.27-0.73; p = 0.001), however, TSA reveals need for further evidence. SM including both EVD as well as VPS were found to be inferior to AM while no significant difference was found in comparison to the NM catheters. In NMA for VPS, the AM were found to be significantly better than SM (RR 0.41, 95% CI: 0.22-0.75) as well as NM (RR 0.42; 95% CI: 0.25-0.71) with a SUCRA of 99.8% and a mean rank of 1. However, antibiotic medicated shunts did not show a statistically significant association with reoperation rate (RR 0.99; 95% CI:0.81-1.20; p = 0.9) with no further need for evidence as per TSA.

Implementation and outcomes of monoclonal antibody infusion for COVID-19 in an inner-city safety net hospital: A South-Bronx experience.

BACKGROUND: Monoclonal antibody therapy (MAT) is recommended in mild to moderate Coronavirus disease 2019 (COVID-19) patients who are at risk of progressing to severe disease. Due to limited data on its outcomes and the logistic challenges in administering the drug, MAT has not been widely used in the United States (US) despite of emergency use authorization (EUA) approval by the Food and Drug Administration (FDA). AIM: We aim to study the outcomes of MAT in patients predominantly from ethnic minority groups and the challenges we experienced in implementing the infusion therapy protocol in an inner-city safety-net-hospital in the South Bronx. METHODS AND RESULTS: We conducted a retrospective observational study of 49 patients who were offered MAT as per EUA protocol of FDA. Patient who met the criteria for MAT and received therapy were included in treatment group (n = 38) and the remaining (n = 11) who declined treatment were included in the control group. A majority of patients (76%) in the study group reported symptomatic improvement, the day after infusion. There was statistically significant reduction in COVID-19 related hospitalizations (7.8 vs 54.5%, P = < 0.001) mortality (0 vs 18.1%, P value = 0.008) in the treatment group. CONCLUSION: MAT reduced both hospitalization and mortality in this predominantly Hispanic patient population with mild to moderate COVID-19 with high risk factors for disease progression.