Low Consciousness in a Patient with Pancolitis.

Teaching point: Lentiform fork sign is a rare finding on MRI of the brain, found in patients with metabolic acidosis, in a critically ill patient with low consciousness and renal failure, this sign can correspond to uremic encephalopathy.

A rare presentation of a common carotid artery occlusion.

Background: A common carotid artery occlusion (CCAO) is very rare and the clinical features of CCAO have rarely been described. Since the blood supply of the eye and orbit is derived from the internal carotid artery, a CCAO may present with various ophthalmological symptoms, ranging from incidental findings to complete visual loss but also other neuro-ophthalmological abnormalities. Case report: A 61-year-old woman presented with acute monocular vision loss and an elevation deficit of the right eye. Fluorescein angiography showed delayed filling of both the retinal and choroidal vasculature, without occlusion/embolisms of the retinal arteries. Vascular imaging showed a right CCAO. Conclusion: CCAO has a variable presentation. In patients with acute unilateral visual loss a CCAO should be considered, especially when ocular motility deficits are present. Fluorescein angiography examination can aid in the localization and diagnosis of the vascular insult. Urgent referral for a systemic work-up is essential.

Immediate and 90-Day Clinical Outcome of Patients with Acute Stroke Treated with the NeVa-Vesalio Mechanical Thrombectomy Device: A Retrospective Case Series.

OBJECTIVE: The NeVa stent retriever is a newly designed mechanical thrombectomy device for the treatment of acute ischemic stroke caused by large vessel occlusion. We investigate the procedural characteristics and patients' clinical outcomes at discharge and at 90 days of follow-up. METHODS: We retrospectively reviewed a cohort of 75 patients (median age, 74 years) treated with the NeVa device for acute large vessel occlusion stroke. Per pass modified Treatment in Cerebral Infarction (mTICI) scores, procedural complications, and clinical outcome parameters including the National Institutes of Health Stroke Scale (NIHSS) score, modified Rankin Scale (mRS) score, and mortality were analyzed, based on patients' electronic medical records. RESULTS: Complete first pass effect was observed in 24 patients (32%). Vasospasm, repeated re-thrombosis, failure to advance the NeVa device through the microcatheter, and symptomatic intracranial hemorrhage were observed in 2, 1, 1, and 2 patient(s) respectively. The rate of complete (mTICI 2c-3) reperfusion was achieved in 61 patients (81.33%), with a median number of 2 passes (1-3). Median NIHSS score on admission, after 24 hours, and after 5-10 days or at discharge was 19 (15-23), 11 (4-19), and 3 (2-13.5), respectively. The number of patients with a functional mRS score (0-2) at 90 days follow-up was 29 (39%). CONCLUSIONS: Endovascular stroke management with use of the NeVa-Vesalio stent retriever may be associated with a 90-day functional mRS score in nearly 40% of treated patients.

NID1-related autosomal dominant Dandy-Walker malformation with occipital cephalocele in three generations.

The combination of Dandy-Walker malformation and occipital cephalocele is a rare autosomal dominant condition, known as ADDWOC, and caused by mutations in NID1 or LAMC1. We present a three-generation family with variable manifestations of Dandy-Walker malformation and occipital cephalocele. They all have normal psychomotor development and lack neurological manifestations. Mutation analysis revealed a likely pathogenic missense variant in NID1 (c.3336T > G, p.Asn1112Lys), affecting an amino acid residue crucial in the nidogen/laminin interaction.

Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients.

BACKGROUND: The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve. MATERIAL AND METHODS: All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records. RESULTS: Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015). CONCLUSION: The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.

All that glitters is not prostate cancer: incidental finding of PSMA-avid meningioma.

We present a case of a 79 year old patient with a medical history of unilateral nerve-sparing radical prostatectomy due to a pT3aN0 (Gleason score 7) prostate carcinoma. Because of slightly elevated prostate specific antigen (PSA) level (0.35ng/dL), a fluorine-18-prostate specific membrane antigen (18F-PSMA)-1007 positron emission tomography/computed tomography (PET/CT) scan was performed, showing no signs of malignant recurrence. However, a moderately PSMA-avid nodular lesion was observed in the left occipital region with homogeneous contrast enhancement, suggestive for a meningioma, which was confirmed on magnetic resonance imaging (MRI). One year later, the lesion was resected due to a small but significant growth. Histology confirmed the diagnosis of a transitional type meningioma (WHO grade 1).

Levers of change: a review of contemporary interventions to enhance diversity in medical schools in the USA.

A growing body of research illustrates the importance of aligning efforts across the operational continuum to achieve diversity goals. This alignment begins with the institutional mission and the message it conveys about the priorities of the institution to potential applicants, community, staff, and faculty. The traditional themes of education, research, and service dominate most medical school mission statements. The emerging themes of physician maldistribution, overall primary-care physician shortage, diversity, and cost control are cited less frequently. The importance and salience of having administrative leaders with an explicit commitment to workforce and student diversity is a prominent and pivotal factor in the medical literature on the subject. Organizational leadership shapes the general work climate and expectations concerning diversity, recruitment, and retention. Following the Bakke decision, individual medical schools, supported by the Association of American Medical Colleges, worked to expand the frame of reference for evaluating applicants for medical school. These efforts have come together under the rubric of "holistic review", permitted by the US Supreme Court in 2003. A large diverse-applicant pool is needed to ensure the appropriate candidates can be chosen for the incoming medical school class. Understanding the optimal rationale and components for a successful recruitment program is important. Benchmarking with other schools regionally and nationally will identify what should be the relative size of a pool. Diversity is of compelling interest to us all, and should pervade all aspects of higher education, including admissions, the curriculum, student services and activities, and our faculties. The aim of medical education is to cultivate a workforce with the perspectives, aptitudes, and skills needed to fuel community-responsive health-care institutions. A commitment toward diversity needs to be made.

The dentato-rubro-olivary pathway revisited: New MR imaging observations regarding hypertrophic olivary degeneration.

Hypertrophic olivary degeneration (HOD) following a lesion of the dentato-rubro-olivary pathway (DROP) is a well-known imaging finding and has extensively been described in the recent literature. We reviewed our patients with HOD as a result of a lesion of the DROP in order to analyze the disruption of the DROP and the resulting HOD in comparison with the literature. We observed unusual imaging findings in four patients. In two patients it concerned new observations related to the timing and imaging appearances of HOD. HOD became only visible 6 years after a lesion in the red nucleus in one patient and a cystic degeneration of the olivary nucleus was seen 3 years after the HOD in a second patient. In two patients we found HOD that could only be explained by the existence of an afferent feedback loop between the dentate nucleus and the inferior olivary nucleus and by the knowledge that these fibers run through the ipsilateral olivary nucleus before ending in the contralateral olivary nucleus. In one of these patients the lesion was located in the inferior cerebellar peduncle. In the other patient the lesion was located on the midline in the medulla oblongata. The imaging findings in these patients reveal new observations in the stages of imaging appearances in HOD and shed light on the forgotten dentato-olivary afferent feedback loop of the DROP. Clin. Anat. 30:543-549, 2017. © 2017 Wiley Periodicals, Inc.

Chondroblastoma: An Unusual Cause Of Shoulder Pain In Adolescence.

Chondroblastoma is a rare benign bone tumor, most often localized in the epiphysis of long bones. We report a case of atraumatic shoulder pain in a 17-year old soccer player. This chondroblastoma case demonstrates the difficult differentiation of chondroblastoma from giant cell tumor and clear cell chondrosarcoma and highlights possible pitfalls and clinical importance.

Acute Exertional Compartment Syndrome in a Young Amateur Soccer Player: A Case Report.

We present a case of acute compartment syndrome of the lateral compartment of the lower leg, caused by strenuous eccentric exercise. The diagnosis can be made based on clinical findings, but ultrasound and MRI can be useful in recognizing this rare form of compartment syndrome.

Primary Angiosarcoma of the Central Nervous System: Case Report and Review of the Imaging Features.

Primary angiosarcoma of the central nervous system is a rare malignant tumor with only 28 reported cases so far. Imaging findings have only been reported in a few cases. We report a case of intracranial angiosarcoma in a Caucasian male and present a review of the imaging features in the recent literature. The tumor mostly presents as a well-demarcated, heterogeneous, moderately to strongly enhancing lesion with signs of intratumoral bleeding and surrounding vasogenic edema. The differential imaging features of common hemorrhagic intracranial tumors are discussed.

Visuo-motor coordination in 8-year-old children born pre-term before and after 28 weeks of gestation.

PURPOSE: This study compared the visuo-motor abilities between pre-term and full-term children. METHODS: Twenty-three 8-year-old children participated, five being born under 28 weeks gestational age (wGA) referred to as Preterms1 (mean=8 years 5 months [SD 0.3]), nine Preterms2 of 28-35 wGA (mean=7 years 9 months [SD 0.7]) and nine typically developing full-term controls (mean=8 years 6 months [SD 0.7]). All children were studied in an interhemispheric transfer time and in a visuo-manual pointing-task to test motor programming time in three conditions: unimanual pointing (dominant, non-dominant hands), mirror bimanual pointing (same direction for both hands) and opposite bimanual pointing. RESULTS: Significant differences were detected between Preterms 1 and 2, the latter being similar to controls. Preterms1 presented increases in interhemispheric time, suggesting an alteration in the transcallosal pathways. Programming time was significantly lengthened (p50.01) for dominant hand unilateral pointing and opposite bilateral pointing and it was the shortest for mirror pointing. CONCLUSIONS: A faulty programming of visuo-manual tasks is suspected in Preterms1 with potential difficulty inhibiting the non-dominant limb mirror movement. This may result from an impaired interhemispheric inhibition owing to potential corpus callosum thinning. Such measures may be used to help follow-up subtle changes in fine motor control and detect pre-terms at risk of developing long-term deficits.

Development of a computerized intervertebral motion analysis of the cervical spine for clinical application.

OBJECTIVE: The objective of this study was to develop a measurement method that could be implemented in chiropractic for the evaluation of angular and translational intervertebral motion of the cervical spine. METHODS: Flexion-extension radiographs were digitized with a scanner at a ratio of 1:1 and imported into a software, allowing segmental motion measurements. The measurements were obtained by selecting the most anteroinferior point and the most posteroinferior point of a vertebral body (anterior and posterior arch, respectively, for C1), with the origin of the reference frame set at the most posteroinferior point of the vertebral body below. The same procedure was performed for both the flexion and extension radiographs, and the coordinates of the 2 points were used to calculate the angular movement and the translation between the 2 vertebrae. RESULTS: This method provides a measure of intervertebral angular and translational movement. It uses a different reference frame for each joint instead of the same reference frame for all joints and thus provides a measure of motion in the plane of each articulation. The calculated values obtained are comparable to other studies on intervertebral motion and support further development to validate the method. CONCLUSION: The present study proposes a computerized procedure to evaluate intervertebral motion of the cervical spine. This procedure needs to be validated with a reliability study but could provide a valuable tool for doctors of chiropractic and further spinal research.

ETO2 coordinates cellular proliferation and differentiation during erythropoiesis.

The passage from proliferation to terminal differentiation is critical for normal development and is often perturbed in malignancies. To define the molecular mechanisms that govern this process during erythropoiesis, we have used tagging/proteomics approaches and characterized protein complexes nucleated by TAL-1/SCL, a basic helix-loop-helix transcription factor that specifies the erythrocytic lineage. In addition to known TAL-1 partners, GATA-1, E2A, HEB, LMO2 and Ldb1, we identify the ETO2 repressor as a novel component recruited to TAL-1 complexes through interaction with E2A/HEB. Ectopic expression and siRNA knockdown experiments in hematopoietic progenitor cells show that ETO2 actively represses erythroid TAL-1 target genes and governs the expansion of erythroid progenitors. At the onset of erythroid differentiation, a change in the stoichiometry of ETO2 within the TAL-1 complex activates the expression of known erythroid-specific TAL-1 target genes and of Gfi-1b and p21(Cip), encoding two essential regulators of erythroid cell proliferation. These results suggest that the dynamics of ETO2 recruitment within nuclear complexes couple cell proliferation to cell differentiation and determine the onset of terminal erythroid maturation.