Novel combination of GammaTile cesium-131 brachytherapy with 5-aminolevulinic acid fluorescence-guided resection in the re-irradiation of pediatric recurrent high-grade glioma: illustrative case.

BACKGROUND: Herein, the authors describe the successful utilization of 5-aminolevulinic acid (5-ALA) and the first case of GammaTile cesium-131 therapy in a pediatric patient with recurrent high-grade glioma. 5-ALA was utilized to optimize gross-total resection prior to GammaTile implantation. After conversion to an equivalent dose in 2-Gy fractions (EQD2), a composite was made of the GammaTile dose with the initial external beam radiotherapy. Two hypothetical plans consisting of a standard hypofractionated strategy for glioma reirradiation and a CyberKnife plan using GammaTile's planning target volume were developed and likewise underwent EQD2 conversion and composite plan generation with the initial radiotherapy. OBSERVATIONS: 5-ALA was useful in achieving gross-total resection with no acute toxicity from the surgery or GammaTile irradiation. When compared with the hypothetical composite doses, GammaTile's composite, axium point dose (D0.03cc) to the brainstem was 32.9 Gy less than the hypofractionated and the CyberKnife composite plans at 38.7 Gy and 40.2 Gy, respectively. The right hippocampus demonstrated a substantially reduced composite plan dose with GammaTile with a D0.03cc of 62.4 Gy versus 71.7 and 80.7 Gy for the hypofractionated and CyberKnife composite plans, respectively. LESSONS: Utilization of 5-ALA and GammaTile therapy yielded clinically superior tumor debulking and effective radiotherapy dose localization with sparing of organs at risk, respectively.

Delayed Traumatic Aortic Pseudoaneurysm Formation Causing Vertebral Body Erosion and Back Pain: Case Report and Literature Review.

BACKGROUND: Aortic pseudoaneurysms are a rare cause of chronic back pain, usually resulting from compression of the adjacent neurovasculature. It is uncommon for patients with pseudoaneurysms of the abdominal aorta to present in a delayed fashion after initial traumatic injury. CASE DESCRIPTION: We describe an unusual case of delayed pseudoaneurysm formation with subsequent erosion into the adjacent L1 vertebral body. This pseudoaneurysm was secondary to a gunshot wound with retained ballistic fragment that had occurred 27 years previously. Herein, we discuss the patient's presenting symptoms, imaging, and overall treatment. In this particular case, we used a combined surgical and endovascular (hybrid) approach after the patient experienced recurrent low back pain, weeks after a primary endovascular treatment was performed. We additionally review the current literature on the management of aortic pseudoaneurysms causing vertebral body erosion and back pain. CONCLUSIONS: In our patient, a combined surgical and endovascular (hybrid) approach led to the complete resolution of his back pain symptoms and to complete exclusion of the pseudoaneurysm on follow-up imaging. Endovascular management of aortic pseudoaneurysms may be a reasonable alternative to open surgery in high-risk patients; however, this approach may result in a higher recurrence of pseudoaneurysm and initial presenting symptoms. Further investigation is needed to elucidate the efficacy of endovascular treatment of these lesions.

Monteris AXiiiS Stereotactic Miniframe for Intracranial Biopsy: Precision, Feasibility, and Ease of Use.

BACKGROUND: Stereotactic biopsy is an important and minimally invasive technique used for a variety of indications in neurosurgery. Initially, this technique required a frame, but recently there have been a number of newer, less cumbersome approaches to biopsy including robotic arms, fixed arms, and, more recently, skull-mounted miniframes. Miniframes are attractive because they are disposable and low profile. However, the relatively limited degree of freedom offered by currently available devices necessitates a preplanned burr hole, which in turn limits flexibility and multiple trajectories. The AXiiiS device is a skull-mounted, magnetic resonance imaging-compatible miniframe that provides a similar degree of freedom with a frame while maintaining a low-profile, disposable platform. OBJECTIVE: To assess the image-guided trajectory alignment accuracy using AXiiiS stereotactic miniframe biopsy of intracranial lesions. The accuracy of the AXiiiS device is compared with the Navigus Trajectory Guide as platforms. METHODS: After approval by our institutional review board, medical records of 10 neurosurgical patients with intracranial pathologies were chosen for AXiiiS stereotactic miniframe biopsy, and histological correlation was obtained. RESULTS: Ten reported cases demonstrate the precision and ease of using the AXiiiS stereotactic miniframe for biopsy of intracranial lesions in conjunction with preoperative magnetic resonance imaging. Multiple trajectories and angles have been used with precision and safety. CONCLUSION: The AXiiiS stereotactic miniframe is a feasible, safe, and disposable platform for multitrajectory intracranial biopsies. Compared with existing platforms, this novel device provides a more stable base and wider limits of trajectory angles with comparable accuracy and precision.

Concomitant percutaneous coronary intervention and transcatheter aortic valve replacement: safe and feasible replacement alternative approaches in high-risk patients with severe aortic stenosis and coronary artery disease.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) is performed as a stand-alone procedure in patients that are not suitable for surgical aortic valve replacement. However, a significant proportion of patients with severe aortic stenosis have coexisting coronary artery disease (CAD). We report concomitant TAVR and percutaneous coronary intervention (PCI) as a single procedure in such patients. METHODS: Three patients with severe aortic stenosis and CAD that were high risk for conventional surgery had concomitant alternative approach TAVR and PCI performed. Two patients had PCI and stent placement immediately after the deployment of the transapical transcatheter aortic valve, and one patient had a coronary artery stent placed just prior to the deployment of the transaortic transcatheter aortic valve. RESULTS: Two male patients and one female (age range 68-91 years) had 100% procedural success with resolution of symptoms and zero residual stenosis. There were no complications related to neurologic events, worsening renal function, or myocardial infarction. In-hospital and 30-day mortality was zero. All three patients were discharged home with a median hospital stay of eight days. CONCLUSIONS: In our small series of patients presented we demonstrate that PCI and TAVR performed concurrently in the hybrid operating room is a feasible option in patients undergoing TAVR with coexisting CAD. Furthermore, we propose this single-stage approach in such high-risk patients as it decreases the number of procedures performed and may theoretically lower cost and hospital stay.

Unusual presentation of congenital dermal sinus: tethered spinal cord with intradural epidermoid and dual paramedian cutaneous ostia.

The authors present the first report of spinal congenital dermal sinus with paramedian dual ostia leading to 2 intradural epidermoid cysts. This 7-year-old girl had a history of recurrent left paramedian lumbosacral subcutaneous abscesses, with no chemical or pyogenic meningitis. Admission MRI studies demonstrated bilateral lumbar dermal sinus tracts and a tethered spinal cord. At surgery to release the tethered spinal cord the authors encountered paramedian dermal sinus tracts with dual ostia, as well as 2 intradural epidermoid cysts that were not readily apparent on MRI studies. Congenital dermal sinus should be considered in the differential diagnosis of lumbar subcutaneous abscesses, even if the neurocutaneous signatures are located off the midline.

Synthesis and structural characterization of the peptide epitope of the ovarian cancer biomarker CA125 (MUC16).

A highly conserved region of 21 amino acids flanked by cysteine residues, contained within a larger repeated domain, has been proposed to be the antibody-binding site in the ovarian cancer biomarker CA125 (MUC16). In this study solid-phase peptide synthesis with Fmoc protection chemistry was used to assemble a 21-mer peptide corresponding to the most frequently occurring antibody binding sequence in CA125. Potentially significant sequence variants were also synthesized. Peptide secondary structure was investigated using Fourier transform infrared spectroscopy, revealing the consensus sequence peptide to be largely unstructured at physiological pH whether the cysteine residues were reduced or were oxidized to form an intramolecular disulfide bond. Substitution of serine for proline at position 8 (P8S) results in ß-sheet formation in peptides involved in intramolecular disulfide bonds. This ß-sheet structure does not persist in peptides incapable of intramolecular disulfide bonding because of sequence nor in peptides treated with the reducing agent dithiothreitol. In CA125, P8S is predicted to occur in ∼25% of repeat domains, suggesting that this structural motif is a non-negligible contributor to overall structure and function. These findings suggest that future structural characterization efforts of CA125 should be especially mindful of the amino acid sequence and oxidation state of the protein.