Epidermal growth factor receptor (EGFR) is a target of the tumor-suppressor E3 ligase FBXW7.

FBXW7 is an E3 ubiquitin ligase that targets proteins for proteasome-mediated degradation and is mutated in various cancer types. Here, we use CRISPR base editors to introduce different FBXW7 hotspot mutations in human colon organoids. Functionally, FBXW7 mutation reduces EGF dependency of organoid growth by ~10,000-fold. Combined transcriptomic and proteomic analyses revealed increased EGFR protein stability in FBXW7 mutants. Two distinct phosphodegron motifs reside in the cytoplasmic tail of EGFR. Mutations in these phosphodegron motifs occur in human cancer. CRISPR-mediated disruption of the phosphodegron motif at T693 reduced EGFR degradation and EGF growth factor dependency. FBXW7 mutant organoids showed reduced sensitivity to EGFR-MAPK inhibitors. These observations were further strengthened in CRC-derived organoid lines and validated in a cohort of patients treated with panitumumab. Our data imply that FBXW7 mutations reduce EGF dependency by disabling EGFR turnover.

Reliability of a Novel Classification System for Thoracic Disc Herniations.

STUDY DESIGN: This is a cross-sectional survey. OBJECTIVE: The aim was to assess the reliability of a proposed novel classification system for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA: TDHs are complex entities varying substantially in many factors, including size, location, and calcification. To date, no comprehensive system exists to categorize these lesions. METHODS: Our proposed system classifies 5 types of TDHs using anatomic and clinical characteristics, with subtypes for calcification. Type 0 herniations are small (≤40% of spinal canal) TDHs without significant spinal cord or nerve root effacement; type 1 are small and paracentral; type 2 are small and central; type 3 are giant (>40% of spinal canal) and paracentral; and type 4 are giant and central. Patients with types 1 to 4 TDHs have correlative clinical and radiographic evidence of spinal cord compression. Twenty-one US spine surgeons with substantial TDH experience rated 10 illustrative cases to determine the system's reliability. Interobserver and intraobserver reliability were determined using the Fleiss kappa coefficient. Surgeons were also surveyed to obtain consensus on surgical approaches for the various TDH types. RESULTS: High agreement was found for the classification system, with 80% (range 62% to 95%) overall agreement and high interrater and intrarater reliability (kappa 0.604 [moderate to substantial agreement] and kappa 0.630 [substantial agreement], respectively). All surgeons reported nonoperative management of type 0 TDHs. For type 1 TDHs, most respondents (71%) preferred posterior approaches. For type 2 TDHs, responses were roughly equivalent for anterolateral and posterior options. For types 3 and 4 TDHs, most respondents (72% and 68%, respectively) preferred anterolateral approaches. CONCLUSIONS: This novel classification system can be used to reliably categorize TDHs, standardize description, and potentially guide the selection of surgical approach. Validation of this system with regard to treatment and clinical outcomes represents a line of future study.

One-step generation of tumor models by base editor multiplexing in adult stem cell-derived organoids.

Optimization of CRISPR/Cas9-mediated genome engineering has resulted in base editors that hold promise for mutation repair and disease modeling. Here, we demonstrate the application of base editors for the generation of complex tumor models in human ASC-derived organoids. First we show efficacy of cytosine and adenine base editors in modeling CTNNB1 hot-spot mutations in hepatocyte organoids. Next, we use C > T base editors to insert nonsense mutations in PTEN in endometrial organoids and demonstrate tumorigenicity even in the heterozygous state. Moreover, drug sensitivity assays on organoids harboring either PTEN or PTEN and PIK3CA mutations reveal the mechanism underlying the initial stages of endometrial tumorigenesis. To further increase the scope of base editing we combine SpCas9 and SaCas9 for simultaneous C > T and A > G editing at individual target sites. Finally, we show that base editor multiplexing allow modeling of colorectal tumorigenesis in a single step by simultaneously transfecting sgRNAs targeting five cancer genes.

Technique for Validation of Intraoperative Navigation in Minimally Invasive Spine Surgery.

BACKGROUND: Intraoperative 3-dimensional navigation is an enabling technology that has quickly become a commonplace in minimally invasive spine surgery (MISS). It provides a useful adjunct for percutaneous pedicle screw fixation. Although navigation is associated with many benefits, including improvement in overall screw accuracy, navigation errors can lead to misplaced instrumentation and potential complications or revision surgery. It is difficult to confirm navigation accuracy without a distant reference point. OBJECTIVE: To describe a simple technique for validating navigation accuracy in the operating room during MISS. METHODS: The operating room is set up in a standard fashion for MISS with intraoperative cross-sectional imaging available. A 16-gauge needle is placed within the bone of the spinous process before intraoperative cross-sectional imaging. The entry level is chosen such that the space between the reference array and the needle encompasses the surgical construct. Before placing each pedicle screw, accuracy is verified by placing the navigation probe over the needle. RESULTS: This technique has identified navigation inaccuracy and led to repeat cross-sectional imaging. No screws have been misplaced in the senior author's cases since adopting this technique, and there have been no complications attributable to the technique. CONCLUSION: Navigation inaccuracy is an inherent risk in MISS, but the described technique may mitigate this risk by providing a stable reference point.

Does Advanced Imaging Aid in the Preoperative Evaluation of Patients With Moyamoya Disease?

Background Moyamoya disease is characterized by progressive nonatherosclerotic stenosis and eventual occlusion of the supraclinoid cerebral arteries with the associated development of abnormal collateral vessels. Treatment of moyamoya disease revolves around restoring cerebral blood flow (CBF) distal to the steno-occlusive disease. Numerous modalities can be used to assess hemodynamic parameters. We sought to determine the impact of preoperative imaging on surgical decision-making. Methods A retrospective review was performed of all patients seen with the diagnosis of moyamoya. Patients were grouped on presentation based on CT/MRI findings of infarction, hemorrhage, or normal. Patients who did not have all of the preoperative tests were excluded. Preoperative radiological results were dichotomized as either normal or abnormal. Results During a five-year period, 34 patients with moyamoya met the inclusion criteria. All patients had an abnormal magnetic resonance angiography (MRA) Non-invasive Optimal Vessel Analysis (NOVA; VasSol, Inc, River Forest, IL). Three patients had normal initial MRI. All symptomatic patients had abnormal preoperative workup and underwent revascularization, as all were found to have abnormal single photon emission computed tomography (SPECT). The only occasion where the decision for surgery or type of surgery was influenced by imaging findings was in patients with nonclassical or minimal symptoms. Conclusion Although hemodynamic imaging studies can aid in establishing a preoperative baseline of CBF and cerebral vascular reserve (CVR) for follow-up studies, the true implication of these tests in the preoperative evaluation of clearly symptomatic moyamoya patients is debatable. In asymptomatic/mildly symptomatic patients, hemodynamic studies are necessary to determine the need for treatment. For symptomatic patients, surgery can be performed without an exhaustive and costly preoperative hemodynamic evaluation.

RNA-binding protein Elavl1/HuR is required for maintenance of cranial neural crest specification.

While neural crest development is known to be transcriptionally controlled via sequential activation of gene regulatory networks (GRNs), recent evidence increasingly implicates a role for post-transcriptional regulation in modulating the output of these regulatory circuits. Using available single-cell RNA-sequencing datasets from avian embryos to identify potential post-transcriptional regulators, we found that Elavl1, which encodes for an RNA-binding protein with roles in transcript stability, was enriched in the premigratory cranial neural crest. Perturbation of Elavl1 resulted in premature neural crest delamination from the neural tube as well as significant reduction in transcripts associated with the neural crest specification GRN, phenotypes that are also observed with downregulation of the canonical Wnt inhibitor Draxin. That Draxin is the primary target for stabilization by Elavl1 during cranial neural crest specification was shown by RNA-sequencing, RNA immunoprecipitation, RNA decay measurement, and proximity ligation assays, further supporting the idea that the downregulation of neural crest specifier expression upon Elavl1 knockdown was largely due to loss of Draxin. Importantly, exogenous Draxin rescued cranial neural crest specification defects observed with Elavl1 knockdown. Thus, Elavl1 plays a critical a role in the maintenance of cranial neural crest specification via Draxin mRNA stabilization. Together, these data highlight an important intersection of post-transcriptional regulation with modulation of the neural crest specification GRN.

As an embryo develops, different genetic programs become activated to give cell populations a specific biological identity that will shape their fate. For instance, when certain sets of genes get switched on, cells from the outermost layer of the embryo start to migrate to their final destination within the body. There, these 'neural crest cells' will contribute to bones and cartilage in the face, pigmented skin spots, and muscles or nerves in the gut. When genes responsible for the neural crest identity are active, their instructions are copied into an 'RNA molecule' which will then relay this information to protein-building structures. How well the RNA can pass on the message depends on how long it persists within the cell. Certain RNA-binding proteins can control this process, but it is unclear whether and how this regulation takes place in neural crest cells. In their work, Hutchins et al. therefore focused on identifying RNA-binding proteins involved in neural crest identity. Exploratory searches of genetic data from chick embryos revealed that, even before they started to migrate, neural crest cells which have recently acquired their identity produced large amounts of the RNA-binding protein Elavl1. In addition, these cells did not behave normally when embryos were deprived of the protein: they left the outer layer too soon and then switched off genes important for their identity. Genetic studies of neural crest cells lacking Elavl1 revealed that this effect was due to having lost the RNA molecule produced from the Draxin gene. Introducing an additional source of Draxin into mutant embryos missing Elavl1 was enough to restore normal neural crest behaviour. Further biochemical experiments then showed that the RNA for Draxin decayed quickly in the absence of Elavl1. This suggests that the protein normally allows Draxin's RNA to persist long enough to pass on its message. These results reveal a new mechanism controlling the identity and behaviour of the neural crest. Since many cancers in adulthood arise from the descendants of neural crest cells, Hutchins et al. hope that this knowledge could lead to improved therapies in the future.

Influence of Spinal Deformity Construct Design on Adjacent-Segment Biomechanics.

BACKGROUND: Adjacent level degeneration is a precursor to construct failure in adult spinal deformity surgery, but whether construct design affects adjacent level degeneration risk remains unclear. Here we present a biomechanical profile of common deformity correction constructs and assess adjacent level biomechanics. METHODS: Standard nondestructive flexibility tests (7.5 Nm) were performed on 21 cadaveric specimens: 14 pedicle subtraction osteotomies (PSOs) and 7 anterior column realignment (ACR) constructs. The ranges of motion (ROM) at the adjacent free level in flexion, extension, axial rotation, and lateral bending were measured and analyzed. RESULTS: ACR constructs had a lower ROM change on flexion at the proximal adjacent free level than constructs with PSO (1.02 vs. 1.32, normalized to the intact specimen, P < 0.01). Lateral lumbar interbody fusion adjacent to PSO and 4 rods limits ROM at the free level more effectively than transforaminal interbody fusion and 2 rods in correction constructs with PSO. Use of 2 screws to anchor the ACR interbody further decreased ROM at the proximal adjacent free level on flexion, but adding 4 rods in this setting added no further limitation to adjacent segment motion. CONCLUSIONS: ACR constructs have less ROM change at the adjacent level compared to PSO constructs. Among constructs with ACR, anchoring the ACR interbody with 2 screws reduces motion at the proximal adjacent free level. When PSOs are used, lateral lumbar interbody fusion adjacent to the PSO level has a greater reduction in adjacent-segment motion than transforaminal interbody fusion, suggesting that deformity construct configuration influences proximal adjacent-segment biomechanics.

Anatomical positional changes in the lateral lumbar interbody fusion.

INTRODUCTION: ALIFs and LLIFs are now becoming more utilized for adult spinal disease. As technologies advance, so do surgical techniques, with surgeons now modifying traditional supine-ALIF and lateral-LLIF to lateral-ALIF and prone-LLIF approaches to allow for more efficient surgeries. The objective of this study is to characterize the anatomical changes in the surgical corridor that occur with changes in patient positioning. METHODS: MRIs of ten healthy volunteers were evaluated in five positions: supine, prone with hips flexed, prone with hips extended, lateral with hips flexed, and lateral with hips extended. All lateral scans were in the left lateral decubitus position. The anatomical changes of the psoas muscles, inferior vena cava, aorta, iliac vessels were assessed with relation to fixed landmarks on the disc spaces from L1 to S1. RESULTS: The most anteriorly elongated ipsilateral to approach psoas when compared to supine was seen in lateral-flexed position (- 5.82 mm, p < 0.001), followed by lateral-extended (- 2.23 mm, p < 0.001), then prone-flexed (- 1.40 mm, p = 0.014), and finally supine and prone-extended (- 0.21 mm, p = 0.643). The most laterally extending or "thickest" psoas was seen in prone-flexed (- 1.40 mm, p = 0.004) and prone-extended (- 1.17 mm, p = 0.002). The psoas was "thinnest" in lateral-extended (2.03 mm, p < 0.001) followed by lateral-flexed (1.11 mm, p = 0.239). The contralateral psoas did not move as anteriorly as the ipsilateral. 3D volumetric analysis showed that the greatest changes in the psoas occur at its proximal and distal poles near T12-L1 and L4-S1. In lateral-flexed compared to prone-extended, the IVC moves medially to the left (p < 0.001). The aorta moves laterally to the left (p = 0.005). The venous structures appeared more full and open in the lateral positions and flattened in the supine and prone positions. The arteries remain in full calibre. CONCLUSION: The MRI anatomical evaluation shows that the psoas, and therefore lumbar plexus, and vasculature move significantly with changes in positioning. This is important for preoperative planning for proper intraoperative execution from preoperative supine MRI. Understanding that the psoas and vessels move the most anteriorly in the lateral-flexed position and to a least degree in the prone-extended is essential for safe and efficient utilization of techniques such as the traditional LLIF, traditional ALIF, prone-LLIF.

Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction.

OBJECTIVE: The thoracolumbar (TL) junction spanning T11 to L2 is difficult to access because of the convergence of multiple anatomical structures and tissue planes. Earlier studies have described different approaches and anatomical structures relevant to the TL junction. This anatomical study aims to build a conceptual framework for selecting and executing a minimally invasive lateral approach to the spine for interbody fusion at any level of the TL junction with appropriate adjustments for local anatomical variations. METHODS: The authors reviewed anatomical dissections from 9 fresh-frozen cadaveric specimens as well as clinical case examples to denote key anatomical relationships and considerations for approach selection. RESULTS: The retroperitoneal and retropleural spaces reside within the same extracoelomic cavity and are separated from each other by the lateral attachments of the diaphragm to the rib and the L1 transverse process. If the lateral diaphragmatic attachments are dissected and the diaphragm is retracted anteriorly, the retroperitoneal and retropleural spaces will be in direct continuity, allowing full access to the TL junction. The T12-L2 disc spaces can be reached by a conventional lateral retroperitoneal exposure with the rostral displacement of the 11th and 12th ribs. With caudally displaced ribs, or to expose T12-L1 disc spaces, the diaphragm can be freed from its lateral attachments to perform a retrodiaphragmatic approach. The T11-12 disc space can be accessed purely through a retropleural approach without significant mobilization of the diaphragm. CONCLUSIONS: The entirety of the TL junction can be accessed through a minimally invasive extracoelomic approach, with or without manipulation of the diaphragm. Approach selection is determined by the region of interest, degree of diaphragmatic mobilization required, and rib anatomy.

Seq Your Destiny: Neural Crest Fate Determination in the Genomic Era.

Neural crest stem/progenitor cells arise early during vertebrate embryogenesis at the border of the forming central nervous system. They subsequently migrate throughout the body, eventually differentiating into diverse cell types ranging from neurons and glia of the peripheral nervous system to bones of the face, portions of the heart, and pigmentation of the skin. Along the body axis, the neural crest is heterogeneous, with different subpopulations arising in the head, neck, trunk, and tail regions, each characterized by distinct migratory patterns and developmental potential. Modern genomic approaches like single-cell RNA- and ATAC-sequencing (seq) have greatly enhanced our understanding of cell lineage trajectories and gene regulatory circuitry underlying the developmental progression of neural crest cells. Here, we discuss how genomic approaches have provided new insights into old questions in neural crest biology by elucidating transcriptional and posttranscriptional mechanisms that govern neural crest formation and the establishment of axial level identity.

Single-Position Prone Lateral Interbody Fusion Improves Segmental Lordosis in Lumbar Spondylolisthesis.

OBJECTIVE: Single-position surgery in prone position is a novel technique for lateral interbody fusion with pedicle screw fixation. We performed a radiographic comparison of patients treated for spondylolisthesis using the prone lateral (PL) transpsoas approach versus the traditional dual position (DP) approach (lateral decubitus then prone). METHODS: Thirty consecutive patients with spondylolisthesis were treated using the PL approach (n = 15) versus the dual position approach (n = 15). Radiographic factors in the groups were retrospectively compared. RESULTS: The groups were similar for age, sex, body mass index, and implant size, but there were more 15° (vs. 10°) cages inserted in the dual position group. Radiographically the groups had similar baseline spinopelvic parameters, lumbar lordosis (LL), segmental lordosis, anterolisthesis, and disc height (P > 0.05). Postoperatively the PL group demonstrated a larger improvement in segmental lordosis (5.1° vs. 2.5°, P = 0.02), but not overall LL (6.3° vs. 3.1°, P = 0.14). Both groups had similar improvements in pelvic tilt, disc height, and spondylolisthesis reduction (P > 0.05). The mean relative distance of the implant from the posterior edge of the vertebral body was greater in the PL group (26% vs. 17%, P < 0.001) indicating a tendency for more anterior cage placement. However, there was no significant correlation between the relative cage position and the increase in segmental lordosis (P = 0.35), so this result alone did not explain the relative increase in lordosis seen. CONCLUSIONS: This is the first study to our knowledge to demonstrate an improvement in segmental lordosis for patients with single-level spondylolisthesis using the PL approach.

A single-plasmid approach for genome editing coupled with long-term lineage analysis in chick embryos.

An important strategy for establishing mechanisms of gene function during development is through mutation of individual genes and analysis of subsequent effects on cell behavior. Here, we present a single-plasmid approach for genome editing in chick embryos to study experimentally perturbed cells in an otherwise normal embryonic environment. To achieve this, we have engineered a plasmid that encodes Cas9 protein, gene-specific guide RNA (gRNA), and a fluorescent marker within the same construct. Using transfection- and electroporation-based approaches, we show that this construct can be used to perturb gene function in early embryos as well as human cell lines. Importantly, insertion of this cistronic construct into replication-incompetent avian retroviruses allowed us to couple gene knockouts with long-term lineage analysis. We demonstrate the application of our newly engineered constructs and viruses by perturbing ß-catenin in vitro and Sox10, Pax6 and Pax7 in the neural crest, retina, and neural tube and segmental plate in vivo, respectively. Together, this approach enables genes of interest to be knocked out in identifiable cells in living embryos and can be broadly applied to numerous genes in different embryonic tissues.

Risk Factors for Proximal Junctional Kyphosis Following Surgical Deformity Correction in Pediatric Neuromuscular Scoliosis.

STUDY DESIGN: Single-center retrospective cohort analysis. OBJECTIVE: The aim of this study was to evaluate risk factors associated with the development of proximal junctional kyphosis (PJK) in pediatric neuromuscular scoliosis (NMS). SUMMARY OF BACKGROUND DATA: PJK is a common cause of reoperation in adult deformity but has been less well reported in pediatric NMS. METHODS: Sixty consecutive pediatric patients underwent spinal fusion for NMS with a minimum 2-year follow-up. PJK was defined as >10° increase between the inferior end plate of the upper instrumented vertebra (UIV) and the superior end plate of the vertebra two segments above. Regression analyses as well as binary correlational models and Student t tests were employed for further statistical analysis assessing variables of primary and compensatory curve magnitudes, thoracic kyphosis, proximal kyphosis, lumbar lordosis, pelvic obliquity, shoulder imbalance, Risser classification, and sagittal profile. RESULTS: The present cohort consisted of 29 boys and 31 girls with a mean age at surgery of 14 ±â€Š2.7 years. The most prevalent diagnoses were spinal cord injury (23%) and cerebral palsy (20%). Analysis reflected an overall radiographic PJK rate of 27% (n = 16) and a proximal junctional failure rate of 7% (n = 4). No significant association was identified with previously suggested risk factors such as extent of rostral fixation (P = 0.750), rod metal type (P = 0.776), laminar hooks (P = 0.654), implant density (P = 0.386), nonambulatory functional status (P = 0.254), or pelvic fixation (P = 0.746). Significant risk factors for development of PJK included perioperative use of halo gravity traction (38%, P = 0.029), greater postoperative C2 sagittal translation (P = 0.030), decreased proximal kyphosis preoperatively (P = 0.002), and loss of correction of primary curve magnitude at follow-up (P = 0.047). Increase in lumbar lordosis from post-op to last follow-up trended toward significance (P = 0.055). CONCLUSION: Twenty-seven percent of patients with NMS developed PJK, and 7% had revision surgery. Those treated with halo gravity traction or with greater postoperative C2 sagittal translation, loss of primary curve correction, and smaller preoperative proximal kyphosis had the greatest risk of developing PJK.Level of Evidence: 4.

Macropinocytosis-mediated membrane recycling drives neural crest migration by delivering F-actin to the lamellipodium.

Individual cell migration requires front-to-back polarity manifested by lamellipodial extension. At present, it remains debated whether and how membrane motility mediates this cell morphological change. To gain insights into these processes, we perform live imaging and molecular perturbation of migrating chick neural crest cells in vivo. Our results reveal an endocytic loop formed by circular membrane flow and anterograde movement of lipid vesicles, resulting in cell polarization and locomotion. Rather than clathrin-mediated endocytosis, macropinosomes encapsulate F-actin in the cell body, forming vesicles that translocate via microtubules to deliver actin to the anterior. In addition to previously proposed local conversion of actin monomers to polymers, we demonstrate a surprising role for shuttling of F-actin across cells for lamellipodial expansion. Thus, the membrane and cytoskeleton act in concert in distinct subcellular compartments to drive forward cell migration.

Bimodal function of chromatin remodeler Hmga1 in neural crest induction and Wnt-dependent emigration.

During gastrulation, neural crest cells are specified at the neural plate border, as characterized by Pax7 expression. Using single-cell RNA sequencing coupled with high-resolution in situ hybridization to identify novel transcriptional regulators, we show that chromatin remodeler Hmga1 is highly expressed prior to specification and maintained in migrating chick neural crest cells. Temporally controlled CRISPR-Cas9-mediated knockouts uncovered two distinct functions of Hmga1 in neural crest development. At the neural plate border, Hmga1 regulates Pax7-dependent neural crest lineage specification. At premigratory stages, a second role manifests where Hmga1 loss reduces cranial crest emigration from the dorsal neural tube independent of Pax7. Interestingly, this is rescued by stabilized ß-catenin, thus implicating Hmga1 as a canonical Wnt activator. Together, our results show that Hmga1 functions in a bimodal manner during neural crest development to regulate specification at the neural plate border, and subsequent emigration from the neural tube via canonical Wnt signaling.

The neural plate is a structure that serves as the basis for the brain and central nervous system during the development of animals with a backbone. In particular, the tissues at the border of the neural plate become the neural crest, a group of highly mobile cells that can specialize to form nerves and parts of the face. The exact molecular mechanisms that allow the crest to emerge are still unknown. The protein Hmga1 alters how genes are packaged and organized inside cells, which in turn influences how genes are switched on and off. Here, Gandhi et al. studied how Hmga1 helps to shape the neural crest in developing chicken embryos. To do so, they harnessed a genetic tool called CRISPR-Cas9, and deleted the gene that encodes Hmga1 at specific developmental stages. This manipulation highlighted two periods where Hmga1 is active. First, Hmga1 helped to define neural crest cells at the neural plate border by activating a gene called pax7. Then, at a later stage, Hmga1 allowed these cells to move to other parts of the body by triggering the Wnt communication system. Failure for the neural crest to develop properly causes birth defects and cancers such as melanoma and childhood neuroblastoma, highlighting the need to better understand how this structure is formed. In addition, a better grasp of the roles of Hmga1 in healthy development could help to appreciate how it participates in a range of adult cancers.

Reprogramming Axial Level Identity to Rescue Neural-Crest-Related Congenital Heart Defects.

The cardiac neural crest arises in the hindbrain, then migrates to the heart and contributes to critical structures, including the outflow tract septum. Chick cardiac crest ablation results in failure of this septation, phenocopying the human heart defect persistent truncus arteriosus (PTA), which trunk neural crest fails to rescue. Here, we probe the molecular mechanisms underlying the cardiac crest's unique potential. Transcriptional profiling identified cardiac-crest-specific transcription factors, with single-cell RNA sequencing revealing surprising heterogeneity, including an ectomesenchymal subpopulation within the early migrating population. Loss-of-function analyses uncovered a transcriptional subcircuit, comprised of Tgif1, Ets1, and Sox8, critical for cardiac neural crest and heart development. Importantly, ectopic expression of this subcircuit was sufficient to imbue trunk crest with the ability to rescue PTA after cardiac crest ablation. Together, our results reveal a transcriptional program sufficient to confer cardiac potential onto trunk neural crest cells, thus implicating new genes in cardiovascular birth defects.

Internal Maxillary to Middle Cerebral Artery Bypass Using an Anterior Tibial Artery Graft, Performed Using a 3-Dimensional Exoscope: 2-Dimensional Operative Video.

Fusiform aneurysms remain challenging entities to treat, as maintenance of flow and prevention of branch occlusion are concerns. Use of endovascular stents may risk nearby branch occlusion. We present a 31-yr-old male with a prior subarachnoid hemorrhage from a left middle cerebral artery (MCA) M1 aneurysm. Informed consent for use of the operative video and information was obtained from the patient. Initially, open clipping was performed with noted residual because of risk of nearby branches. On angiography, a growing fusiform segment distal to the initial aneurysm was noted. The patient was referred to our institution for this finding, and a multidisciplinary team reviewed the case. Endovascular treatment was felt to be risky, as stenting could jail nearby MCA branches. Clipping would also risk occlusion because of scaring from previous hemorrhage. Sufficient flow would be needed, and because the ipsilateral superficial temporal artery was sacrificed in the initial craniotomy, the internal maxillary artery (IMAX) was chosen as the bypass source. A cerebrovascular neurosurgeon, skull base otolaryngologist, and vascular surgeon worked together to perform a left-side IMAX to MCA bypass using an anterior tibial artery graft under 3-dimensional exoscopic visualization. Specifically, a 9-0 nylon suture on a BV-130 needle along with straight and tying forceps were used along with heparinized saline. The bypass was noted to be of robust flow, and the patient did very well on postoperative follow-up. The utilization of an anterior tibial artery graft, IMAX exposure, and corresponding bypass provides educational value, as there are only a limited number of videos on this topic.