Iatrogenic Arterial Perforation During Endovascular Interventions.

The use of minimally invasive endovascular procedures has increased, and as such, the frequency of associated vascular complications has also increased. Regardless of the access site location, rarely, arterial perforation can occur, which can be fatal if not properly managed. Interventionalists should be aware of the risk factors for perforation, commonly perforated vessels, and how different sites of perforation are diagnosed and managed. Rapid recognition and endovascular management reduce the need for open surgical repair, and thus reduce the morbidity and mortality of these complications. This review outlines the presentation, diagnosis, and management of iatrogenic perforations of the subclavian artery, thyrocervical trunk (TT), common carotid artery, superficial femoral artery (SFA), and external iliac artery.

Intraoperative Anaphylaxis in Response to Hemostatic Agents With Protein Derivatives.

Topical hemostatic agents are commonly used in a wide variety of surgical procedures to assist in hemostasis. However, the use of these agents is not without risk as many contain biologically active agents derived from human and animal products that have the potential to cause adverse reactions. This case report covers a 44-year-old man with a history of alpha-gal syndrome who was scheduled for an open reduction and internal fixation of a left distal radius fracture. Alpha-gal syndrome is characterized by an IgE-mediated type 1 hypersensitivity reaction to a mammalian oligosaccharide epitope. Patients with this condition have a history of a past tick bite and subsequent development of an allergic reaction to mammalian protein products, most notably red meat. The patient had concerns about products used during surgery and potential reactions based on his allergy. The intent of this case report is to promote physician awareness of the widespread use of mammalian products in surgical hemostatic agents and potential immunogenic reactions. By increasing awareness of the alpha-gal syndrome, the goal is that medical device companies will actively disclose product components that could potentiate these adverse reactions and continue to develop alternative agents.

Multidisciplinary Management of Subclavian Artery Perforation and Complications.

The radial approach to cardiac catheterization and percutaneous coronary interventions has increased in popularity due to the favorable side effect profile relative to the femoral approach. Mediastinal hematoma after radial access cardiac catheterization has scarcely been reported in the literature and, if present, the exact location of the bleed was rarely identified. In this case presentation, we describe an elective transradial coronary angiography resulting in subclavian artery perforation in close proximity to the vertebral artery, with subsequent mediastinal and cervical hematoma formation. This scenario was managed by immediate imaging of the chest after sudden deterioration raised suspicion of an adverse event during wire navigation. Formation of a mediastinal hematoma is the equivalent of retroperitoneal bleed from the femoral approach and requires rapid recognition, interdisciplinary collaboration, and endovascular management.

Bupivacaine Field Block With Clonidine for Postoperative Pain Control in Posterior Spine Approaches: A Randomized Double-Blind Trial.

BACKGROUND: The synergistic effect of clonidine with bupivacaine, well established in peripheral nerve blocks, remains controversial in local field block for postoperative analgesia. OBJECTIVE: To investigate the potential analgesic benefit of adding clonidine to bupivacaine during preincisional field block in posterior approaches for spine surgeries. METHODS: Two hundred twenty-five patients were enrolled in this study and underwent lumbar spinal fusion (n = 80), lumbar laminectomy (n = 25), lumbar microdiscectomy (n = 94), or cervical laminectomy (n = 26). In each surgical subgroup, patients were randomly assigned in a double-blinded fashion to receive either 20 mL of 0.25% bupivacaine alone (control group, n = 109) or with 150 µg clonidine (clonidine group, n = 116) in the form of a preincisional field block. Outcome parameters included area under the curve of pain from postoperative day D0 to D8 and rescue morphine consumption from D0 to D3. RESULTS: The area under the curve was reduced in the clonidine group, particularly in the microdiscectomy subgroup, and without reaching statistical significance in the cervical laminectomy subgroup. Total rescue morphine consumption was reduced in the clonidine group, particularly at D1-D2, a benefit that was exclusive to the lumbar stenosis and lumbar fusion subgroups. Field block with clonidine, surgical subgroup, and the presence of preoperative spinal pain were factors independently influencing postoperative wound pain in multivariate analysis. CONCLUSION: The addition of clonidine to local preincisional field block with bupivacaine resulted in better and prolonged postoperative analgesia in posterior lumbar spine surgeries, an effect that was more pronounced in patients with no preoperative spinal pain.

Radiofrequency ablation of spinal osteoid osteoma: a prospective study.

OBJECTIVE Surgery has been considered the standard treatment for spinal osteoid osteomas that are refractory to analgesic agents. Radiofrequency ablation (RFA) is a less invasive technique with established efficiency for the treatment of peripheral osteoid osteomas. The main objectives of this study are to evaluate the safety of RFA based on the results of a previous experimental study in rats conducted in the authors' laboratory and to identify its short- and long-term efficiency in the treatment of spinal osteoid osteomas. METHODS Between March 2009 and July 2016, 8 consecutive patients with spinal osteoid osteomas were enrolled in the study and underwent 9 CT-guided RFA procedures. All patients presented with spinal pain (median preoperative visual analog scale [VAS] score 7.55, range 6-8.8) predominantly during the night, and they all had normal neurological examination results before the procedure. Pain (according to the VAS score) and neurological status were reassessed immediately before discharge, with further follow-up at 1, 6, and 12 months after the procedure. At the final follow-up, VAS score, neurological examination, patient satisfaction, and a radiological control (CT scan) were documented (median 48 months, range 12-84 months). VAS scores before and after the procedure were compared during the 3 days before surgery (D0), on the day of the surgery, Day 1 (D1), and at the final follow-up. RESULTS No neurological deficit was documented following the procedure or at the final follow-up. A statistically significant reduction in the VAS score was observed on Day 1 (mean 2.56 ± 0.68, p = 0.005) compared with D0. At the final follow-up, all patients reported a VAS score of 0 and a satisfaction rate of 100%. Only 1 patient had recurrent symptoms (pain, VAS score 8.1) 6 months after the initial RFA. A second procedure was performed, and the patient was subsequently symptom free at the final follow-up. CT scanning performed in all patients (12-84 months post-RFA) showed residual sclerosis in 4 patients and complete resolution of the radiological lesion in the remaining 4 patients. CONCLUSIONS CT-guided RFA appears to be a safe and effective method for the management of spinal osteoid osteoma and can be safely performed for lesions close to the dura or exiting nerve root based on the motor response threshold testing performed during the procedure. It should be considered the treatment of choice for spinal osteoid osteomas refractory to conservative treatment, thus avoiding more aggressive spinal approaches with subsequent potential morbidity.

Antithrombotic Medication Use and Misuse Among Patients with Intracranial Hemorrhage: A 16-Year, Lebanese, Single-Center Experience.

OBJECTIVE/BACKGROUND: The use of antithrombotic medication (ATM) frequently is reported in patients with intracranial hemorrhage (ICH) and is associated with increased mortality. Unfortunately, ATMs sometimes are prescribed and/or used inappropriately. We sought to determine the rate of ATM misprescription/misuse among patients with ICH in a single-center retrospective study. METHODS: All patients admitted with ATM-related ICH in 1998-2014 were included. Charts were reviewed and demographic, clinical, and radiologic variables were recorded. The type of ATM, dose, and duration of treatment were analyzed critically. The adequacy of ATM prescription/use was assessed in light of the recommendations and guidelines of the American Heart Association, American Stroke Association, and French National Authority for Health, in effect at the time of admission. RESULTS: A total of 106 patients with mean age 68 years were identified. Aspirin (53.8%) was the most commonly used drug, followed by oral anticoagulants (31.1%) and clopidogrel (22.6%). In only 80 patients (75.5%), the use of ATM was in line with contemporary guidelines. In the remaining 26 (24.5%), the use of ATMs was inappropriate, including bad drug combination, wrong dose, poor indication, wrong drug class, and/or incorrect treatment duration. CONCLUSIONS: In this Lebanese cohort of patients with ICH, the 24.5% rate of ATM misprescription and/or misuse is highly alarming and the origin of this problem is likely multifactorial. Immediate measures should be undertaken, and efforts should be focused on regaining tight control of ATM prescription and fulfillment, ensuring good patient education, and offering more vigilant oversight on physician licensure.

Association of Lhermitte-Duclos disease and split cord malformation in a child.

Lhermitte-Duclos disease (LDD) or cerebellar gangliocytoma is a rare pathological entity, the etiology of which remains controversial. Numerous developmental anomalies are known to be associated with LDD, but the association between LDD and split cord malformation (SCM) has not been reported to our knowledge. We report LDD in a 3-year-old girl in whom repetitive urinary tract infections led to the diagnosis of a neurogenic bladder. Thorough screening revealed a SCM at the thoracic level which was surgically repaired. The pathogenesis of this entity and management strategies are discussed in this paper.

Solitary fibrous tumor of the scalp in a child.

Solitary fibrous tumors (SFTs) are rare mesenchymal neoplasms that arise most commonly in the pleura but have been increasingly reported in extrapleural sites. The authors report the case of an SFT of the scalp that manifested as an enlarging scalp mass in a 2-year-old boy. The mass was surgically excised. Histological examination showed it to be composed of fusiform cells of variable cellularity with a central hyalinization zone. Immunohistochemical staining was positive for CD34 and negative for smooth muscle actin, S100 protein, desmin, and h-caldesmon. On 1-year follow-up, there was no recurrence of the mass. This case presented some diagnostic difficulty because of the wide range of possible diagnoses for a pediatric scalp mass; however, the distinct immunohistochemical profile helped to eliminate other more frequent fibrous tumors of the scalp. The behavior of scalp SFTs is usually benign, but their course can be unpredictable, and recognition of these lesions is essential.

Lumbar microdiscectomy: a clinicoradiological analysis of outcome.

BACKGROUND: The long-term outcome after lumbar microdiscectomy (LMD) may be affected by low back pain (LBP) and segmental instability, the determinants of which remain unclear. We sought to analyze the interaction between clinical, functional, and radiological variables and their impact on patient outcome. METHODS: All patients who underwent LMD in 2004-2005 were invited to participate in this retrospective cohort study. Patients were re-evaluated clinically and radiologically after a three to five year follow-up. RESULTS: Forty-one of 97 eligible patients were enrolled. Twelve patients (29.3%) reported moderate-to-severe sciatica, 12 (29.3%) had moderate LBP, and 13 (31.7%) exhibited clinical evidence of segmental instability. Thirty-eight patients (92.7%) had minimal disability and 3 (7.3%) had moderate disability. Twenty-three patients (56.1%) were fully satisfied, while 18 (43.9%) had only partial satisfaction, having expected a better outcome. Thirty-three patients (80.5%) returned to full-time work. Median disc space collapse (DSC) was 20% (range 5-66%) and L4-L5 was particularly affected. Prevalence of Modic changes increased from 46.3% to 78% with type 2 predominance. Multivariate logistic regression analysis identified the following negative prognostic factors: female sex, young age, lack of regular exercise, and chronic preoperative LBP. There was no correlation between the course of Modic changes, DSC, and patient outcome. CONCLUSION: Although many patients may be symptomatic following LMD, significant disability and dissatisfaction are uncommon. Female sex, young age, lack of exercise, and chronic preoperative LBP may predict a worse outcome. Disc collapse is a universal finding, particularly at L4-L5. Neither DSC nor Modic changes seem to affect patient outcome.

What happens to Modic changes following lumbar discectomy? Analysis of a cohort of 41 patients with a 3- to 5-year follow-up period.

OBJECT: The natural history of Modic changes (MCs) in the lumbar spine is often marked by conversion from one type to another, but their course following lumbar discectomy remains unknown. The authors sought to study the impact of surgery on the natural history of these lesions. METHODS: Forty-one patients treated with lumbar microdiscectomy between 2004 and 2005 were enrolled in this study and underwent clinical evaluation and repeat MR imaging after a median follow-up of 41 months (range 32-59 months). Preoperative and follow-up MR images were reviewed and the type, location, and extent of MCs at the operated level were recorded and compared. RESULTS: The study population consisted of 27 men and 14 women with a mean age of 54 years (range 24-78 years). During the follow-up period, the prevalence of MCs increased from 46.3% to 78%, and 26 patients (63.4%) had Type 2 lesions at the operated level. Of the 22 patients without MCs, 4 (18.2%) converted to Type 1 and 9 (40.9%) to Type 2. Of the 5 Type 1 lesions, 3 (60%) converted to Type 2, and 2 (40%) remained Type 1 but increased in size. In contrast, none of the 14 Type 2 changes converted to another type, although 10 (71.4%) increased in extent. There were no reverse conversions to Type 0. CONCLUSIONS: Following lumbar discectomy, most patients develop Type 2 changes at the operated level, possibly as a result of accelerated degeneration in the operated disc. Neither the preoperative presence of MCs nor their postoperative course appears to affect the clinical outcome.

Endoscopic third ventriculostomy: the Lebanese experience.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has gained wide popularity as a first-line treatment for obstructive hydrocephalus (OHC). We have been performing ETV since 1998. We report our experience with this technique in the management of OHC. METHODS: Between 1998 and 2007, we performed 49 ETV procedures in 46 patients suffering from OHC. Medical records were retrospectively reviewed. Success was defined as shunt-free survival. RESULTS: There were 29 males and 17 females with a mean age of 23 years (6 months-65 years). Aqueductal stenosis and tectal tumor were the most common etiologies (63%). Seven patients (15.6%) had early ETV failure. Of 38 patients with initial success and available follow-up, shunt independence was achieved in 29 patients (76.3%) after a mean follow-up of 37 months. Kaplan-Meier analysis yielded a 70% 5-year shunt-free survival rate. On multivariate analysis, no variables could predict early or late ETV failure. Transient complications occurred in 6 patients (13%), but there were no ETV-related deaths or permanent morbidity. CONCLUSION: ETV is a safe and effective treatment for OHC, resulting in a high rate of long-term shunt independence with a low risk of complications. ETV should be considered the treatment of choice for patients with OHC and its development as a substitute to shunt placement should be encouraged in neurosurgically developing countries.

Impact of the lunar cycle on the incidence of intracranial aneurysm rupture: myth or reality?

OBJECTIVE: To analyze the impact of the lunar cycle and season on the incidence of aneurysmal subarachnoid hemorrhage (SAH). PATIENTS AND METHODS: The medical records of 111 patients who were admitted over a 5-year period to our department because of aneurysmal SAH were retrospectively reviewed. The date of aneurysm rupture was matched with the corresponding season and moon phase. RESULTS: An incidence peak for aneurysm rupture (28 patients) was seen during the phase of new moon, which was statistically significant (p < 0.001). In contrast, no seasonal variation in the incidence of SAH was observed. CONCLUSION: The lunar cycle seems to affect the incidence of intracranial aneurysm rupture, with the new moon being associated with an increased risk of aneurysmal SAH.

Hydrocephalus following bilateral jugular venous thrombosis in a child: case report and review of the literature.

Hydrocephalus resulting from bilateral thrombosis of the jugular veins has been rarely described in the literature. We report the case of an 18-month-old girl who was diagnosed with this condition following total parenteral nutrition. We also review the literature relevant to this subject and discuss the pathophysiology of hydrocephalus in the setting of bilateral jugular venous thrombosis.

[Multiple sclerosis mimicking brain tumor: an unusual presentation]. / Forme rare d'une sclérose en plaques révélée par une pseudotumeur cérébrale.

Multiple sclerosis (MS) is almost always diagnosed in current medical practice on the basis of clinical, biologic and imaging criteria without need for tissue diagnosis. There are, however, rare pseudo tumoral cases of MS with atypical clinical and imaging features that suggest initially a neoplastic or an infectious processes and in which a stereotactic brain biopsy becomes needed for the diagnosis. We report the case of a 28-year-old man who presented with a right hemiparesis of rapid onset. Magnetic resonance imaging (MRI) of the brain showed a left contrast enhancing fronto-parietal mass lesion with important peripheral edema and displacement of the lateral ventricle. The patient underwent stereotactic biopsy of the mass. The pathologic examination revealed gross architectural disorganization of the white matter with massive infiltration by numerous foamy macrophages and a few lymphocytes consistent with a demyelinating disease. Despite a standard corticoid therapy regimen with initial clinical improvement, the patient was readmitted to the hospital three weeks later for relapse of right hemiparesis. Two months later, he recovered almost entirely except for a slight residual weakness in his right arm and a mild dysarthria. The MRI at that time showed a marked decrease in size of the brain lesion. The stereotactic brain biopsy remains to date the most dependable means for diagnosing the rare pseudotumoral forms of MS and differentiating them from their neoplastic and infectious mimickers.

Hemicerebellitis mimicking a tumour on MRI.

CASE REPORT: We report a case of hemicerebellitis in a 13-year-old girl presenting with symptoms of intracranial hypertension with acute onset. RESULTS: MRI of the brain revealed a unilateral cerebellar swelling with foliaform enhancement. The patient was still symptomatic even with high doses of intravenous steroids, so we decided to operate on her for diagnosis and decompression. The pathology showed leptomeningitis. She had a good postoperative outcome and a normal brain MRI 2 months later. DISCUSSION: It is unusual to have a unilateral cerebellitis; only two cases have been published so far. CONCLUSION: Although cerebellitis is considered to be benign and self limited, surgical intervention is sometimes mandatory.

Prenatal growth deficiency with narrowness of the cervical spine, subglottic stenosis, hip dislocation, and severe delayed bone ossification: a new skeletal dysplasia.

A boy with a severe prenatal onset dysplasia, prominent occiput, hypertelorism, epicanthus inversus, low-set ears, flat nasal bridge, small nares, cleft palate, subglottic stenosis, narrow cervical canal, undermodeled bones, cortical thinning of the diaphyses, hip dislocation, severely delayed bone ossification, and apparently normal intellectual development is described. Osseous histopathological studies were unremarkable. The boy's parents are first cousins, suggesting recessive inheritance. To the best of our knowledge, this association has not been reported before, and may be considered a novel syndrome.

Schwannoma of the tentorium cerebelli in a child. Case report.

Intracranial schwannomas not arising from a cranial nerve are very rare. Schwannomas of the dura are even rarer; in the literature, we found only two cases: a schwannoma of the falx and one of the torcula. We report a third case of a 9-year-old girl with a schwannoma of the tentorium cerebelli. The different theories concerning the origin of this tumor in this particular location are discussed.

[Adjustable shunt system for the treatment of intracranial cerebrospinal fluid collections. Analysis of a series of 50 cases]. / Intérêt de la valve à pression d'ouverture réglable dans le traitement de l'hydrocephalie et des kystes arachnoïdiens. Analyse d'une série de 50 cas.

OBJECTIVE: The objective of this work is to evaluate the results of a draining valve of the cerebrospinal fluid, whose opening pressure is transcutaneously adjustable, in the treatment of intracranial collections. MATERIAL AND METHODS: A series of 50 operated patients is retrospectively reviewed. Forty-four patients are treated for hydrocephalus of variable causes and six patients for arachnoidal cysts. Offering eight opening pressures, the adjustable valve Sophy was used in all these patients. The mean follow-up is of 48 months. RESULTS: Nineteen patients (38%) needed an adjustment of their valve's opening pressure. This adjustment was achieved to higher levels in seven patients presenting with overdrainage and to lower levels in twelve patients presenting with underdrainage. In 4 patients a subdural collection was observed and treated. Six patients underwent a second surgery for infection or obstruction. Taking all etiologies into consideration, and after the adjustment of the valve's opening pressure, 40 patients had a positive clinical result (obvious amelioration of the symptomatology), ten patients did not improve. CONCLUSION: The valve Sophy provides a simple solution for the patients in whom it is difficult to choose an adapted opening pressure, it particularly allows to avoid a reintervention when this is rendered necessary by a hypo or a hyper drainage programmable valve.