A unique presentation of subretinal fluid in a type III torpedo maculopathy phenotype.

Purpose: To report a rare type III torpedo maculopathy lesion with a unique manifestation of subretinal fluid. Observations: A nine-year-old patient was referred to retina for an evaluation of a hypopigmented oval-shaped lesion in the temporal macula with an area of inferior subretinal fluid in the right eye. The lesion demonstrated inner and outer retinal and retinal pigment epithelial attenuation, intraretinal and subretinal fluid, a serous neurosensory retinal detachment, and inner choroidal excavation on optical coherence tomography. Fundus autofluorescence showed a lane of downward-tracking fluid. Intravenously administered fluorescein angiography revealed a window defect in the area of the torpedo lesion suggesting choroidal flush. Conclusions and Importance: The case is the third documented case of torpedo maculopathy with subretinal fluid in the literature with a unique combination of intraretinal cystic changes and dependent descending subretinal fluid, somewhat akin to a Best disease outside of the fovea with choroidal excavation. The morphology of torpedo maculopathy continues to expand as more cases are revealed.

Selective posterior cerebral artery amobarbital test: a predictor of memory following subtemporal selective amygdalohippocampectomy.

BACKGROUND: The selective posterior cerebral artery (PCA) amobarbital test, or PCA Wada test, is used to predict memory impairment after epilepsy surgery in patients who have previously had a failed internal carotid artery (ICA) amobarbital test. METHODS: Medical records from 2012 to 2018 were retrospectively reviewed for all patients with seizures who underwent a selective PCA Wada test at our institution following a failed or inconclusive ICA Wada test. Standardized neuropsychological testing was performed before and during the Wada procedure and postoperatively in patients who underwent resection. RESULTS: Thirty-three patients underwent a selective PCA Wada test, with no complications. Twenty-six patients with medically refractory epilepsy had a seizure focus amenable to selective amygdalohippocampectomy (AHE). Six patients (23%, n=26) had a failed PCA Wada test and did not undergo selective AHE, seven (27%) declined surgical resection, leaving 13 patients who underwent subtemporal selective AHE. Hippocampal sclerosis was found in all 13 patients (100%). Twelve patients (92%) subsequently underwent formal neuropsychological testing and all were found to have stable memory. Ten patients (77%) were seizure-free (Engel Class I), with average follow-up of 13 months. CONCLUSION: The selective PCA Wada test is predictive of memory outcomes after subtemporal selective AHE in patients with a failed or inconclusive ICA Wada test. Furthermore, given the low risk of complications and potential benefit of seizure freedom, a selective PCA Wada test may be warranted in patients with medically intractable epilepsy who are candidates for a selective AHE and who have a prior failed or inconclusive ICA Wada test.

Digital subtraction cerebral angiography after negative computed tomography angiography findings in non-traumatic subarachnoid hemorrhage.

BACKGROUND: CT angiography (CTA) is widely used for the detection of vascular lesions in patients with non-traumatic subarachnoid hemorrhage (ntSAH); however, digital subtraction angiography (DSA) remains the gold standard for diagnosis. Our aim was to analyze the diagnostic yield of DSA after negative high-resolution CTA findings. METHODS: Records of patients with a CTA-negative ntSAH at a single institution from 2014 to 2018 were retrospectively analyzed. ntSAH patterns were categorized as cortical, perimesencephalic, or diffuse. Subsequent DSA findings were compared across the three cohorts. RESULTS: A total of 186 patients had CTA-negative ntSAH. The ntSAH pattern was identified as cortical (n=77, 41.4%), diffuse (n=60, 32.3%), or perimesencephalic (n=49, 26.3%). In eight patients (4%), DSA revealed a vascular lesion (one cervical arteriovenous fistula and seven atypical aneurysms) after negative CTA findings. All eight patients with positive DSA findings had diffuse SAH (13% of patients with a diffuse pattern). The seven aneurysms included four blister or dissecting (two basilar artery, one superior cerebellar artery, and one dorsal wall internal carotid artery), two fusiform (one posterior communicating artery and one anterior spinal artery), and one saccular aneurysm (middle cerebral artery). CONCLUSION: DSA identified a causative lesion in 4% of patients with CTA-negative ntSAH, but only in patients with diffuse ntSAH. Most of the lesions detected were atypical aneurysms and were found on delayed angiograms. These results suggest that DSA can help to diagnose CTA-negative ntSAH caused by unusual aneurysms, and repeat DSA may be needed only for patients with diffuse ntSAH.

Laparoscopic-Assisted Ventriculoperitoneal Shunt Placement and Reduction in Operative Time and Total Hospital Charges.

OBJECTIVE: In ventriculoperitoneal shunt (VPS) placement, distal placement of the peritoneal catheter will typically be performed by a neurosurgeon. More recently, laparoscopic-assisted (LA) placement of the distal peritoneal catheter by general surgeons has become common. The present study examined whether LA placement of a VPS (LAVPS) is associated with a reduced operative time, lower hospital costs, and fewer distal revisions. METHODS: A retrospective review was performed of the data from all patients who had received a new VPS at our institution from 2013 to 2016. Age, sex, diagnosis, previous abdominal surgery, operative time, anesthesia grade, incidence of 30-day shunt failure, and total hospital charges were analyzed. RESULTS: A total of 680 patients had undergone first-time VPS placement, including 199 with LAVPS and 481 with non-LAVPS placement (non-LAVPS). The mean age of the LAVPS patients was significantly older than that of the non-LAVPS patients (64.1 vs. 59.3 years; P = 0.002). The mean operative time was shorter in the LAVPS group than in the non-LAVPS group (55 vs. 75 minutes; P < 0.001). Distal shunt revision within 30 days occurred more often for the non-LAVPS patients (6 of 481 [1.2%]) than for the LAVPS patients (0 of 199 [0%]). A subset analysis of patients with normal-pressure hydrocephalus found decreased total hospital charges in the LAVPS group ($67,124 vs. $80,890; P = 0.009). CONCLUSIONS: Compared with non-LAVPS, LAVPS was associated with significantly shorter operative times and fewer distal shunt revisions within 30 days. The findings from a subset analysis supported a decrease in total hospital charges. Additional studies are needed; however, these data suggest that LAVPS is a safer, less-expensive alternative to non-LAVPS.