Anterior Lesions Research Articles

Diagnostic Dilemma of Chest Wall Tuberculosis Masquerading Breast Lump and Sarcoma

Chest wall tuberculosis (TB) is rare and can often masquerade as a tumour. Diagnostic confirmation is made by bacteriological findings of acid-fast bacilli and culture of Mycobacterium tuberculosis or histopathological findings. This is a 37-year-old immunocompetent lady who presented with a 3-month history of gradually increasing right breast lump with suspicious characteristics during clinical examinations. Ultrasound of the breast showed normal breast tissue with a well-defined hypoechoic lesion within the anterior inferior pectoralis muscle. CT scan of the thorax revealed a right anterior chest wall lesion with multiple lung nodules and consolidations. Thus, there was a high suspicion of chest wall tumour and an initial diagnosis of soft tissue sarcoma was made. Biopsy of the lesion showed necrotising granulomatous inflammation but no acid-fast bacilli. A revised diagnosis of chest wall tuberculosis was made. She attended follow-up complaining of shortness of breath and pleuritic chest pain with signs of right pleural effusion. Her symptoms improved after the initiation of anti-TB treatment. This case demonstrated the challenge in making an early diagnosis of chest wall TB and commencement of anti-TB treatment.

ANTERIOR THALAMIC ISCHAEMIC STROKE SECONDARY TO CARDIOPULMONARY ARREST.

Ischaemic anterior thalamic lesions are rare and can present with disturbances of behaviour and memory. We describe a patient with post-cardiac arrest thalamic stroke. A 63-year-old man presented with cardiac arrest, was resuscitated after receiving life support, and showed no lesions on computed tomography. Three days later, he presented with short-term memory disturbance and disorientation, with a de novo anterior thalamic lesion. The anterior thalamic nucleus, supplied by the posterior communicating artery, is part of the Papez circuit and has a role in modulating behaviour and memory. An anterior thalamic syndrome presents with no sensory-motor deficits. Anterior thalamic stroke is a rare condition and can present with disturbances of short-term memory and behaviour; it usually does not include any motor or sensory deficits.Thalamic stroke can occur due to global hypoxia, such as during cardiopulmonary arrest.

Nystagmus in Children - a Survey

Nystagmus describes an involuntary, periodic movement of one or both eyes. About 1/600 children and adolescents have nystagmus, most of them idiopathic infantile nystagmus (IIN), also called "congenital nystagmus", which can be caused by mutations in the FRMD7 gene. Other frequent forms of nystagmus are latent nystagmus, which is usually associated with infantile strabismus, and nystagmus associated with albinism. Sometimes difficult to distinguish in young infants is a sensory nystagmus, where a defect in the visual system reduces vision and causes nystagmus. Causes include retinal dystrophies, congenital stationary night blindness and structural ocular defects including optic nerve hypoplasia or dense bilateral congenital cataracts. Unilateral nystagmus can be the sign of an anterior visual pathway lesion. Seesaw nystagmus may be associated with suprasellar and mesodiencephalic lesions and - rarely - with retinal dystrophies.The ophthalmology plays a key role in identifying the form of nystagmus. Children with new onset nystagmus, with spasmus nutans, with vertical or unilateral nystagmus and those with seesaw nystagmus require neurologic evaluation including imaging of the brain.The treatment of nystagmus depends on the underlying cause. Even minor refractive errors should be corrected, contact lenses offer advantages over glasses.Gabapentin and memantine, possibly also carbonic anhydrase inhibitors, are effective in treating IIN, nystagmus in albinism and sensory nystagmus. Nevertheless, pharmacologic treatment of nystagmus is rarely used in children; the reasons are the limited effects on vision, the need for lifelong therapy, and potential side effects. Eye muscle surgery (Anderson procedure, Kestenbaum procedure) can correct a nystagmus-related anomalous head posture. The concept of "artifical divergence" of Cüppers may help to decrease nystagmus intensity in patients whose nystagmus dampens with convergence. The four-muscle-tenotomy, which involves disinsertion and reinsertion of the horizontal muscles at the original insertion of both eyes, has a proven but limited positive effect on visual acuity.

Learning Curve of Transperineal MRI/US Fusion Prostate Biopsy: 4-Year Experience

This study aimed to evaluate the learning curve of transperineal magnetic resonance imaging (MRI)/ultrasound (US) fusion biopsy in a team composed of a single surgeon, a single radiologist, and a single pathologist. We prospectively enrolled 206 patients undergoing MRI/US fusion prostate biopsy and divided them into four cohorts by the year of biopsy. We analyzed temporal changes in clinically significant prostate cancer (csPC) detection rate, percentage of positive cores on biopsy, and Gleason upgrading rate after radical prostatectomy. The csPC detection rate by MRI/US fusion targeted biopsy (TB) increased significantly (from 35.3% to 60.0%, p = 0.01). With increased experience, the csPC detection rates for small (≤1 cm) and anterior target lesions gradually increased (from 41.2% to 51.6%, p = 0.5; from 54.5% to 88.2%, p = 0.8, respectively). The percentage of positive cores on TB increased significantly (from 18.4% to 44.2%, p = 0.001). The Gleason upgrading rate gradually decreased (from 22.2% to 11.1%, p = 0.4). In conclusion, with accumulated experience and teamwork, the csPC detection rate by TB significantly increased. Multidisciplinary team meetings and a free-hand biopsy technique were the key factors for overcoming the learning curve.

Pediatric Ophthalmology Scope of Practice

ABSTRACT Purpose To determine practice patterns of pediatric ophthalmologists with respect to types of medical conditions cared for and age of patients treated due to limited data regarding pediatric ophthalmologists’ scope of practice. Methods A survey was sent to 1408 international and United States members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) membership through the group’s internet listserv. Responses were collated and analyzed. Results Ninety members (6.4%) responded. 89% of respondents confine their practices to pediatric ophthalmology and adult strabismus. The percentages of respondents who provide primary surgical and medical treatment of the following conditions include 68% for ptosis and anterior orbital lesions, 49% for cataracts, 38% for uveitis, 25% for retinopathy of prematurity, 19% for glaucoma, and 7% for retinoblastoma. For conditions other than strabismus, 59% restrict their practice to patients less than 21 years of age. Conclusion Pediatric ophthalmologists provide primary medical and surgical care for children with a wide variety of ocular conditions, including complex disorders. Awareness of this variety of practice might prove beneficial in encouraging residents to consider careers in pediatric ophthalmology. Consequently, fellowship education in pediatric ophthalmology should include exposure to these areas.

Feasibility and preliminary clinical tolerability of low-field MRI-guided prostate biopsy.

We evaluate the clinical feasibility of a portable, low-field magnetic resonance imaging (MRI) system for prostate cancer (PCa) biopsy. A retrospective analysis of men who underwent a 12-core systematic transrectal ultrasound-guided prostate biopsy (SB) and a low-field MRI guided transperineal targeted biopsy (MRI-TB). Comparison of the detection of clinically significant PCa (csPCa) (Gleason Grade [GG] ≥ 2) by SB and low field MRI-TB, stratified by Prostate Imaging Reporting & Data System (PI-RADS) score, prostate volume, and prostate serum antigen (PSA) was performed. A total of 39 men underwent both the MRI-TB and SB biopsy. Median (interquartile range [IQR]) age was 69.0 (61.5-73) years, body mass index (BMI) was 28.9 kg/m2 (25.3-34.3), prostate volume was 46.5 cc (32-72.7), and PSA was 9.5 ng/ml (5.5-13.2). The majority (64.4%) of patients had PI-RADS ≥ 4 lesions and 25% of lesions were anterior on pre-biopsy MRII. Cancer detection rate (CDR) was greatest when combining SB and MRI-TB (64.1%). MRI-TB detected 74.3% (29/39) cancers. Of which, 53.8% (21/39) were csPCa while SB detected 42.5% (17/39) csPCa (p = 0.21). In 32.5% (13/39) of cases, MRI-TB upstaged the final diagnosis, compared to 15% (6/39) of cases in which SB upstaged the final diagnosis (p = 0.11). Low-field MRI-TB is clinically feasible. Although future studies on the accuracy of MRI-TB system are needed, the initial CDR is comparable to those seen with fusion-based prostate biopsies. A transperineal and targeted approach may be beneficial in patients with higher BMI and anterior lesions.

Lesions of the prevascular mediastinum

Mediastinal masses are agroup of heterogenous lesions which may be acoincidental finding or present with symptoms. More than half of mediastinal lesions are located in the prevascular mediastinum. As these tumors are not often encountered in clinical routine, making adiagnosis with ahigh degree of confidence may seem challenging. The latest computed tomography (CT)-based classification of the mediastinal compartments by the International Thymic Malignancy Interest Group (ITMIG) moves away from earlier radiograph-based classification systems and helps to reliably classify tumors based on location, although in some cases the lesion can occupy more than one compartment. Radiology plays an important role in the evaluation of anterior mediastinal lesions. Although in some cases imaging features alone allow adiagnosis to be made; in other cases knowledge of important radiological features and their analysis in the context of patient factors like age and duration of symptoms can help to narrow down the differential diagnosis, avoid unnecessary workup, and guide further steps. Computed tomography (CT) is central for the characterization of mediastinal masses in clinical routine. In some situations, like in the case of thymic cysts or thymic hyperplasia, magnetic resonance imaging (MRI) can be used as anoninvasive problem-solving tool.

Effects of Different Etiologies of Anterior Circulation Tandem Lesions on Short-term Prognosis of Acute Ischemic Stroke.

The prognosis of anterior circulation tandem lesions caused by carotid artery dissection (CAD) and large artery atherosclerosis (LAA) after mechanical thrombectomy is controversial. By analyzing the clinical data of different etiologies, we explored the best treatment plan. Clinical data of patients with anterior circulation tandem lesions admitted to the Second Affiliated Hospital of Soochow University from April 2018 to October 2021 were retrospectively collected. The Modified Rankin Scale was used as the standard to evaluate the functional prognosis of patients at 3 months. Safety assessment included symptomatic intracranial hemorrhage (sICH) and mortality. The technical evaluation of interventional procedures included operation time, successful recanalization, and times of pass. 74 patients were enrolled, 59 in the LAA group and 15 in the CAD group. The two groups were similar regarding the proportion of successful recanalization, the bridge treatment and the choice of surgical instruments. The puncture to recanalization time and the onset of symptoms to successful recanalization time had no significant difference (p > 0.05). There were no significant differences in hemorrhage transformation (p = 0.26), sICH (p > 0.999), good functional prognosis (p = 0.054), and mortality (p = 0.181) between the two groups. We found a trend toward a better functional outcome at 3 months in the CAD group (p = 0.054). The tandem lesions of anterior circulation caused by CAD tend to have a good functional prognosis in 3 months. The proportion of successful recanalization and surgical safety was similar between the two groups.

Abstract WP116: Clinical And Diagnostic Features On Cerebrospinal Fluid And Vessel Wall MRI Can Differentiate Primary From Secondary CNS Vasculitis

Introduction: Differentiating primary CNS vasculitis (PCNSV) from secondary CNS vasculitis (SCNSV) can be challenging based on brain imaging and cerebrospinal fluid (CSF) profile alone. Little is known about the diagnostic nuances of differentiating these 2 entities with CSF and vessel wall magnetic resonance imaging (VWMRI) as overlapping features may exist. We aimed to look at clinical features, serum & CSF biomarkers, and VWMRI differences between PCNSV & SCNSV. Methods: Patients presenting to our tertiary care center with a diagnosis of PCNSV or SCNSV between January 2015 and January 2021 were extracted from electronic medical record data. We included patients older than 18 years of age with active disease who had CSF studies and VWMRI data available. Demographic, clinical and diagnostic characteristics were reviewed and descriptive statistics were reported for comparison. Results: A total of 42 patients (24 with PCNSV and 18 with SCNSV) met study inclusion criteria. The SCNSV group was older (median age 43 years vs 41.5 years), had a higher proportion of male gender (78% vs 54%) and black race (22% vs 4%) compared to PCNSV. Patients with PCNSV more commonly had headache (63% vs 50%) and seizures (21% vs 11%) but less commonly had encephalopathy (42% vs 50%), focal neurological deficits (79% vs 83%) and constitutional symptoms (17% vs 33%). Patients with PCNSV more likely had positive antinuclear antigen levels (25% vs 11%) and elevated sedimentation rate (33% vs 25%) but less likely had elevated C-reactive protein (25% vs 33%) in blood. Comparison of CSF studies showed that the PSCNV group had a lower median CSF white blood cell count (10 cells/mm3 vs 43.5 cells/mm3 , both lymphocytic), lower median CSF protein count (62 mg/dl vs 82 mg/dl) and lower IgG index (33% vs 56%) in comparison to the SCNSV group. On VWMRI, PCNSV group had less diffuse (40 vs 54%) involvement and more anterior multifocal lesions (40 vs 15%) compared to SCNSV group with more large or medium-vessel involvement (70 vs 54%). Conclusion: Clinical and diagnostic differences with regards to CSF and VWMRI exist between PCNSV and SCNSV that can aid in differentiating these two entities. This can prove useful especially in undiagnosed systemic vasculitides presenting with CNS vasculitis.

Giant anterior triangle neck lipoma with unusual extension: a case report

BackgroundLipomas are considered to be the most common benign mesenchymal neoplasm which can originate from any fatty tissue. Only 13% of lipomas are present in the head and neck region where the posterior triangle of the neck is the most common site.Case presentationGiant lipomas > 10 cm involving the anterior triangle of the neck with para- and retropharyngeal extension are rarely seen. We report a 59-year-old male patient with giant anterior neck space lipoma 13 × 7.5 × 3.5 cm with medial extension to the retropharyngeal space which was surgically excised.ConclusionsGiant anterior neck lipomas are very challenging in excision compared to posterior neck ones. ENT surgeons should keep lipomas in mind when dealing with anterior neck lesions. Complete surgical excision is the best treatment modality.Level of evidence4

Thymus and lung mucosa-associated lymphoid tissue lymphoma with adenocarcinoma of the lung: a case report and literature review

BackgroundMucosa-associated lymphoid tissue (MALT) lymphoma is a common, low-grade, malignant B-cell lymphoma. However, simultaneous MALT lymphoma in the thymus and lung is extremely rare, and concomitant adenocarcinoma of the lung is even rarer. Herein, we report a rare case of a collision tumor in which MALT lymphoma was found in both the thymus and lung with Sjögren’s syndrome (SS) and adenocarcinoma in the lung.Case presentationA physical examination of a 32-year-old woman revealed an anterior superior mediastinal space-occupying lesion, and chest computed tomography (CT) indicated a nodular ground-glass opacity and irregular mixed-density focus in the right lung. All lung cancer-related tumor biomarkers were within normal ranges. The thymus and part of the lung tissue were surgically resected. The histopathology and molecular examinations confirmed MALT lymphoma of the thymus and lung with lung adenocarcinoma. SS was also diagnosed. No special postoperative treatment was performed for the MALT lymphoma, and the patient underwent immunosuppressive therapy for SS after 4 months of follow-up observation.ConclusionsMALT lymphoma of the thymus and lung tissues has no specific presentation on imaging and is difficult to differentiate from common malignant tumors, and the definite diagnoses of these tumors are highly dependent on histopathological examination in combination with molecular testing and cytogenetics. SS may be an important potential condition for the occurrence of MALT lymphoma in the thymus and lung. Additional similar cases are needed to clarify the biological pathways and potential molecular mechanisms of rare lymphomas and collision tumors.

Clinical Outcome of Intravascular Ultrasound Guided Percutaneous Coronary Intervention of Isolated Ostial Left Anterior Descending Artery Lesions

Purpose: Despite recent advances in interventional cardiology procedures, isolated ostial left anterior descending (LAD) lesions remain a challenge in cardiology. Due to the probability of left main (LM) affection, an LM bifurcation stenting technique may be required in certain individuals. So we evaluated result of Intravascular Ultrasound (IVUS) guided percutaneous coronary intervention (PCI) in isolated LAD coronary artery lesions, either by crossing over the ostium or not, with a focus on major adverse cardiovascular events (MACE).
 Methodology: Our prospective study from January2021 to November 2022 included 79 isolated ostial LAD patients with Ostial LAD stenting (OS) or LM to LAD cross-over (CO) stenting at the National Heart Institute. As per the recommended guidelines, the participants were divided into two groups: the first one had IVUS guided PCI and Group (2) had Angiography guided PCI. The data was collected and statistically analyzed with SPSS 23.0 program.
 Findings: No statistically significant difference was present between the groups regarding socio-demographic or clinical data (P-value > 0.05). It was discovered that an increase in Rotablator use, a decrease in Fluoroscopy time (min), a decrease in Contrast volume (ml), and a decrease in PCI duration (min) in patients who had IVUS guided PCI, with statistically significant difference when compared to other group who had Angiography guided PCI (P-value < 0.05). In addition, it was discovered that an increase in the necessity for a cross-over stenting method in group (1), with no statistically significant difference (P-value > 0.05). High prevalence of mortality and morbidity among IVUS guided PCI patients was present with statistical significance regarding TVR (P-value < 0.05).
 Recommendations: IVUS can offer valuable information on vascular lumen, plaque features, stent deployment, & device failure causes. As a result, IVUS-guided PCI may enhance clinical impact among participants, particularly those with complicated coronary lesions & those at high risk. Further reduction in IVUS’s cost, cardiologists’ education and enhancing IVUS use at PCI should be adapted next.

The transition from transrectal to transperineal prostate biopsy without antibiotic prophylaxis: Cancer detection rates and complication rates.

Currently, transperineal prostate biopsy (TPB) is preferred over transrectal biopsy (TRB) because of less infectious complications and improved clinically significant prostate cancer (csPCa) detection. However, literature on omitting antibiotic prophylaxis (AP) is limited. Furthermore, previous studies did not include invasive cribriform growth/intraductal carcinoma (CR/IDC) in the definition of csPCa. Therefore, we compared the infectious complication rates between TPB without AP and TRB with AP, and we compared the csPCa detection rates between TPB and TRB including CR/IDC in the definition of csPCa. We included 729 men who were referred to Erasmus MCCancer Institute between 2013-2019 for MRI/TRUS fusion-guided prostate biopsy. Up to 2019, TRB was performed with AP, thereafter TPB was performed without AP. Data on complications were collected prospectively. We compared csPCa detection rates between the biopsy routes using multivariable logistic regressions for men without previous PCa diagnosis and mixed logistic regression for men on active surveillance. To compare the csPCa detection rates in anterior and apical lesions, and the complications rates between the biopsy routes, we used the chi-square test. Overall, we found no difference in csPCa detection between TPB and TRB (odds ratio 1.0, 95%-confidence interval (CI) 0.62-1.76, p = 0.9; for men on active surveillance: odds ratio 1.05, 95%-CI 0.58-1.88, p = 0.9). This was confirmed in anterior and apical lesions although absolute numbers were low. TPB reduced infectious complications with fever compared to TRB (1.1% vs 5.1%, difference = 4.0%, 95%-CI 1.0-7.9, p = 0.010). TPB has no different csPCa detection rate from TRB taking CR/IDC into account. TPB is, however, preferable because of less infectious complications, even if AP is omitted.

Mandibular Fossa Approach to Petroclival and Anterior Pontine Lesions.

Objective To describe the anatomy related to a novel approach to the petroclival region through the mandibular fossa for the treatment of petroclival and anterior pontine lesions. Design Five dry skulls were examined for surgical approach. Three adult cadaveric heads underwent bilateral dissection. One cadaveric head was evaluated with computed tomography after dissection. Setting This study was performed in an academic medical center. Participants Neurosurgical anatomy researchers performed this study using dry skulls and cadaveric heads. Main Outcome Measurements This was a proof-of-concept anatomical study. Results The mandibular fossa approach uses a vertical preauricular incision above the facial nerve branches. Removal of the temporomandibular joint exposes the mandibular fossa. The anterior boundary is the mandibular nerve at the foramen ovale, and the posterior boundary is the jugular foramen. The chorda tympani, eustachian tube, and tensor tympani muscle are sectioned. The carotid artery is transposed out of the petrous canal, and a petrosectomy is performed from Meckel's cave to the foramen magnum and anterior occipital condyle. Dural opening exposes the anterior pons, vertebrobasilar junction, bilateral vertebral arteries, and the ipsilateral anterior and posterior inferior cerebellar arteries. At completion, the temporomandibular joint is reconstructed with a prosthetic joint utilizing a second incision along the mandible. Conclusions The mandibular fossa approach is a new trajectory to the petroclival region and the anterior pons. It combines the more anterior angle of endoscopic approaches along with the enhanced control of open approaches. Further study is necessary before this approach is used clinically.

MRI-Based Stepwise Approach to Anterior Mediastinal Cystic Lesions for Diagnosis and Further Management

As the majority of incidentally detected lesions in the anterior mediastinum is small nodules with soft tissue appearance, the differential diagnosis has typically included thymic neoplasm and prevascular lymph node, with benign cyst. Overestimation or misinterpretation of these lesions can lead to unnecessary surgery for ultimately benign conditions. nonsurgical anterior mediastinal lesions. The pitfalls of MRI evaluation for anterior mediastinal cystic lesions are as follows: first, we acknowledge the limitation of T2-weighted images for evaluating benign cystic lesions. Due to variable contents within benign cystic lesions, such as hemorrhage, T2 signal intensity may be variable. Second, owing to extensive necrosis and cystic changes, the T2 shine-through effect may be seen on diffusion-weighted images (DWI), and small solid portions might be missed on enhanced images. Therefore, both enhancement and DWI with apparent diffusion coefficient values should be considered. An algorithm will be suggested for the diagnostic evaluation of anterior mediastinal cystic lesions, and finally, a management strategy based on MRI features will be suggested.

Gesture meaning modulates the neural correlates of effector-specific imitation deficits in left hemisphere stroke

BackgroundPrevious studies on left hemisphere (LH) stroke patients reported effector-specific (hand, fingers, bucco-facial) differences in imitation performance. Furthermore, imitation performance differed between meaningless (ML) and meaningful (MF) gestures. Recent work suggests that a gesture’s meaning impacts the body-part specificity of gesture imitation. MethodsWe tested the hypothesis that the gesture’s meaning (ML vs MF) affects the lesion correlates of effector-specific imitation deficits (here: bucco-facial vs arm/hand gestures) using behavioural data and support vector regression-based lesion-symptom mapping (SVR-LSM) in a large sample of 194 sub-acute LH stroke patients. ResultsBehavioural data revealed a significant interaction between the effector used for imitation and the meaning of the imitated gesture. SVR-LSM analyses revealed shared lesion correlates for impaired imitation independent of effector or gesture meaning in the left supramarginal (SMG) and superior temporal gyri (STG). Besides, within the territory of the left middle cerebral artery, impaired imitation of bucco-facial gestures was associated with more anterior lesions, while arm/hand imitation deficits were associated with more posterior lesions. MF gestures were specifically associated with lesions in the left inferior frontal gyrus and the left insular region. Notably, an interaction of effector-specificity and gesture meaning was also present at the lesion level: A more pronounced difference in imitation performance between the effectors for ML (versus MF) gestures was associated with left-hemispheric lesions in the STG, SMG, putamen, precentral gyrus and white matter tracts. ConclusionThe current behavioural data show that ML gestures are particularly sensitive in assessing effector-specific imitation deficits in LH stroke patients. Moreover, a gesture’s meaning modulated the effector-specific lesion correlates of bucco-facial and arm/hand gesture imitation. Hence, it is crucial to consider gesture meaning in apraxia assessments.

Anterior segment and ocular adnexal lesions in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome at a tertiary hospital in Southwestern Nigeria

Anterior segment and ocular adnexal lesions in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome at a tertiary hospital in Southwestern Nigeria

Transcervical, retropharyngeal odontoidectomy - Anatomical considerations.

Anterior craniocervical junction lesions have always been a challenge for neurosurgeons. Presenting with lower cranial nerve dysfunction and symptoms of brainstem compression, decompression is often required. While posterior approaches offer indirect ventral brainstem decompression, direct decompression via odontoidectomy is necessary when they fail. The transoral and endoscopic endonasal approaches have been explored but come with their own limitations and risks. A novel retropharyngeal approach to the cervical spine has shown promising results with reduced complications. This study aims to explore the feasibility and potential advantages of the anterior retropharyngeal approach for accessing the odontoid process. To investigate the anatomical aspects of the anterior retropharyngeal approach, a paramedian skin incision was performed below the submandibular gland on two cadaveric specimens. The subcutaneous tissue followed by the platysma is dissected, and the superficial fascial layer is opened. The plane between the vascular sheath laterally and the pharyngeal structures medially is entered below the branching point of the facial vein and internal jugular vein. After reaching the prevertebral plane, further dissection cranially is done in a blunt fashion below the superior pharyngeal nerve and artery. Various anatomical aspects were highlighted during this approach. The anterior, submandibular retropharyngeal approach to the cervical spine was performed successfully on two cadavers highlighting relevant anatomical structures, including the carotid artery and the glossopharyngeal, hypoglossal, and vagus nerves. This approach offered wide exposure, avoidance of oropharyngeal contamination, and potential benefit in repairing cerebrospinal fluid fistulas. For accessing the craniocervical junction, the anterior retropharyngeal approach is a viable technique that offers many advantages. However, when employing this approach, surgeons must have adequate anatomical knowledge and technical proficiency to ensure better outcomes. Further studies are needed to enhance our anatomical variations understanding and reduce intraoperative risks.

Phototherapeutic keratectomy: current approaches and changing trends in a tertiary eye clinic.

To examine the efficacy of phototherapeutic keratectomy as a treatment for variable pathologies with anterior corneal opacities and evaluate the distribution of phototherapeutic keratectomy indications over the past 10 years. The records of 334 eyes from 276 patients who underwent phototherapeutic keratectomy between March 2010 and 2020 were retrospectively reviewed. Etiologies of the patients who underwent phototherapeutic keratectomy were noted, and their changes were examined. Refractive and visual acuity results before and after the operation were recorded and analyzed according to etiology. The mean age of the patients was 40.7 ± 16.2 years (range: 19-84). The mean follow-up was 25.5 ± 19.1 months (range: 3-96). Phototherapeutic keratectomy was most frequently applied for corneal stromal dystrophies (44%, 151 eyes from 111 patients), and granular dystrophy was the most common phototherapeutic keratectomy indication among corneal dystrophies. Unlike other indications, there has been an increase in the application of phototherapeutic keratectomy for persistent subepithelial opacities due to adenoviral conjunctivitis in the past 10 years. There was a significant increase in visual acuity in all groups except for the recurrent epithelial defect group (p<0.05). The greatest improvement in visual acuity was detected for stromal dystrophies in the granular dystrophy subgroup. Despite changing indication trends, phototherapeutic keratectomy remains an effective and reliable treatment for anterior corneal lesions.

Etiology and Factors Related Outcomes of Longitudinally Extensive Transverse Myelitis in Thailand

Objective This study aimed to evaluate the clinical features, etiology, and prognosis of longitudinally extensive transverse myelitis (LETM) patients in Thailand. Background LETM has various etiology and is different in each region. Proper investigations are essential to reduce misdiagnosis and delay in treatments, which affect clinical recovery and prognosis. In Thailand, there is no clinical study on the etiology of LETM. Therefore, our study aimed to evaluate the clinical features, etiology, and prognosis of LETM patients in Thailand. Design/Methods Patients diagnosed with LETM at University Hospital between January 2015 and October 2021 were included. Patient demographics, clinical presentations, Expanded Disability Status Scale (EDSS), imagings, laboratory testing, cerebrospinal fluid profiles, final diagnosis, and treatments were recorded. Factors related to outcomes of LETM were analyzed. Results A total of 40 patients, there were 21 females (52.5%), the mean age of onset was 48.4 years (SD = 15.8). NMOSD was the most common etiology of LETM (n = 15), followed by infection (n = 5), SLE (n = 5), idiopathic causes (n = 4), CIS (n = 3), MS (n = 1), spinal dural AVF (n = 2), ADEM (n = 2), either 1 had spinal cord infarction, schwannoma, and vitamin B12 deficiency. Most patients in this study had severe LETM (n = 31). Complete cord had significantly poorer outcome (p-value = 0.003), while dorsolateral and anterior cord had better outcome (p-value = 0.046, 0.046). Conclusions NMOSD was the most common etiology of LETM, and a history of prior attacks led to the diagnosis of NMOSD. Complete cord lesion on axial spinal cord MRI was sensitive to NMOSD but not specifically. Factors related to the prognosis of LETM included completed cord lesions on MRI axial view trended to have a poor outcome, and dorsolateral and anterior cord lesions had a better prognosis.