Illustrative Case Research Articles

REtrieving thrombi and Separated Coils/catheters Unexpectedly detached during Endovascular therapy: RESCUE - the use of thrombectomy devices for rescue therapy in interventional neuroradiology.

Intraprocedural complications during intracranial embolisation include thromboembolic vessel occlusion, catheter tip detachment and coil migration. Stentrievers and aspiration catheters are valuable devices for the management of these complications. We present our experience with the use of these devices. We describe the devices and techniques used, case details and clinical outcomes. Currently there is no standardised approach for the management of the above intraprocedural complications. We performed a retrospective review of our interventional neuroradiology database of patients who underwent endovascular treatment in our institution from January 2012 to January 2019 and identified embolisation procedures during which either stentrievers or aspiration catheters were utilised. We present a case series of 24 cases in which these devices were utilised as rescue devices over a period of 7 years. We provide three illustrative cases. Stentrievers and aspiration catheters can be used safely and effectively as adjunctive or rescue devices during embolisation procedures.

Endoscopic Endonasal Approach to the Inferolateral Intraconal Orbit: An Anatomical Analysis of Exposure and Maneuverability.

Endoscopic endonasal techniques, initially developed for sinonasal tumor resection, have revolutionized the approach to orbital lesions. The emergence of endonasal orbital tumor surgery has prompted anatomical studies focusing on the medial orbit, yet there remains a lack of literature on maneuverability lateral to the optic nerve (ON), with current feasibility assessments relying primarily on the plane of resectability (POR). Bilateral anatomical dissections were conducted on four latex-injected human cadaveric heads using an endoscopic medial and inferior orbitotomy and superomedial displacement of the inferior rectus muscle (IRM) to access the inferolateral intraconal quadrant. Measurements of distances, areas, angles of attack, and volumetric exposure were obtained using stereotactic points from an imaging-based navigation system. Additionally, an illustrative case was presented to demonstrate the endoscopic management of laterally based intraconal lesions. The intraconal space was safely accessed through superomedial displacement of the IRM. The mean intraconal volumetric exposure attained through this maneuver was 2.78cm3 (1.18cm3). The most superolateral point reachable by the ipsilateral endoscopic endonasal approach was consistently lateral and superior to the ON at a mean absolute distance of 1.45cm (0.37cm). Maneuverability at this target point was superior in the sagittal plane, noted by a larger vertical angle of attack compared with the horizontal angle of attack. This study demonstrates that inferolateral intraconal dissection through an ipsilateral endoscopic endonasal approach is feasible via a medial orbitotomy and superomedial retraction of the IRM. Additionally, our findings reaffirm lesions below the POR are suitable for endoscopic endonasal resection.

Radial artery mechanical thrombectomy for transradial approach in neurointerventions: a step-by-step technical report.

Radial artery occlusion (RAO) is a relatively common but benign complication following transradial endovascular approaches. Radial artery thrombectomy offers a potential strategy for re-access. Transradial access in the occluded vessel has been described as safe and feasible in recent literature; however, the step-by-step technical details have not been defined. This illustrative case highlights the technique developed at this institution, which has been performed in 7 consecutive patients. A middle-aged woman underwent initial diagnostic cerebral angiogram and balloon-occlusion test for tumor resection planning. Subsequently, the patient returned to for tumor embolization and was found to have RAO. Radial artery mechanical thrombectomy was performed, and this access was safely used for the embolization procedure.This report provides a technical description with illustrations for this approach in the setting of an acute occlusion following prior radial artery catheterizations. Recanalization of an acutely occluded radial artery is feasible and safe in our institutional experience.

Green Pan-Africanism: Normative power and the making of a regional sustainability order

Abstract This article examines the role of normative power in shaping the global sustainability order. It challenges the prevailing focus on hegemonic leadership and norm diffusion from dominant states, arguing that less powerful states have contributed significantly to the global order by creating regional initiatives tailored to their unique contexts. The article adopts an alternative theoretical framework of norm-governed change, comprising norm-building, institutionalisation, and transformation. Using an illustrative case study of Africa’s regional economic institutions, it employs process-tracing and archival analysis of key policy documents. The study demonstrates how African states have proactively embedded environmental norms within their regional initiatives, while contributing to the global sustainability agenda, exemplifying a form of normative power referred to as ‘Green Pan-Africanism’. This approach broadens the understanding of global sustainability governance, positioning less economically powerful actors as active participants in world-making. The findings highlight the critical role of normative power in advancing global sustainability governance, particularly in addressing complex global challenges such as climate change.

Recent Advances of Strategies and Applications in Aptamer-Combined Metal Nanocluster Biosensing Systems

Metal nanoclusters (NCs) are promising alternatives to organic dyes and quantum dots. These NCs exhibit unique physical and chemical properties, such as fluorescence, chirality, magnetism and catalysis, which contribute to significant advancements in biosensing, biomedical diagnostics and therapy. Through adjustments in composition, size, chemical environments and surface ligands, it is possible to create NCs with tunable optoelectronic and catalytic activity. This review focuses on the integration of aptamers with metal NCs, detailing molecular detection strategies that utilise the effect of aptamers on optical signal emission of metal NC-based biosensing systems. This review also highlights recent advancements in biosensing and biomedical applications, as well as illustrative case studies. To conclude, the strengths, limitations, current challenges and prospects for metal NC-based systems were examined.

Ultrasonography can be more informative than computed tomography for diagnosing radial head fractures: An illustrative case series.

Ultrasonography is increasingly being discussed as an alternative to X-rays in emergency department settings. Systematic comparisons of the 2 modalities are often based on the use of computed tomography as a reference. When diagnosing patients with elbow trauma, the physicians at our emergency department experienced that ultrasonography can be more informative than cone beam computed tomography for identifying radial head fractures. Our goal is to share this experience with the scientific community.All patients diagnosed with a radial head fracture in our emergency department between January 2021 and November 2022 were identified. The images of 18 cases in which both point-of-care ultrasonography and cone beam computed tomography had been used were reviewed by us. Eight examples were selected illustrating the variation in coincidence or discrepancy between ultrasonography and computed tomography.The 8 examples illustrate that ultrasonography can be more informative than cone beam computed tomography or vice versa.The joint application of ultrasonography and computed tomography is advisable if a correct diagnosis of the extent and components of radial head fractures is of uttermost importance.

Approach to the Diagnosis and Management of Complex Fascicular Ventricular Tachycardias.

Complex ventricular tachycardias involving the fascicular system (fascicular ventricular tachycardias [FVTs]) can be challenging. In this review, we describe our approach to the diagnosis and ablation of these arrhythmias with 10 illustrative cases that involve (1) differentiation from supraventricular tachycardia; (2) assessment for atypical bundle branch reentry and other interfascicular FVTs; (3) examination of P1/P2 activation sequences in sinus rhythm, pacing, and tachycardia; and (4) entrainment techniques to establish the tachycardia mechanism and aid circuit localization. To summarize, 5 cases had prior ablation with 2 previously misdiagnosed as supraventricular tachycardia. A short His-ventricular interval supported ventricular tachycardia. Atrial stimulation could initiate and entrain 4 FVTs. P1 potentials were recorded in all cases of left posterior FVT. Entrainment at P1 and P1 to P2 connection sites at the mid-septal region, and the postablation emergence of a late P1 with decremental properties, is consistent with the left septal fascicle being the slowly conducting, retrograde limb of the left posterior FVT circuit. Ablation targeting the mid-septal left septal fascicle and P1 to P2 connection sites successfully eliminated left posterior FVT. Right ventricular apical pacing was useful in differentiating bundle branch reentry and focal FVTs from reentrant FVTs. Two cases exhibited bundle branch reentry and other interfascicular FVTs. Three cases were postinfarct FVTs involving the LPF, where pacing and entrainment at sites of conduction system potentials were able to localize sites critical for ablation, in contrast to previously unsuccessful substrate modification. In conclusion, several ventricular tachycardia mechanisms involving the fascicular system can occur in both structurally normal and abnormal hearts. A high index of suspicion is required given their rarity and potential for misdiagnosis. Once identified, we emphasize a structured approach to the diagnosis and management of FVTs to confirm the mechanism and localize suitable ablation targets involving careful recording of conduction system potentials and pacing/entrainment maneuvers.

The AHEAD leadership development program: an illustrative case example in a unique healthcare context

Purpose Leadership development programs (LDPs) have emerged relatively recently in the healthcare context as a mechanism not only to develop capable and competent leaders but also to retain them. The purpose of this paper is to describe a perspective on practice by illustrating a case example that showcases a pilot LDP for newly promoted healthcare leaders. The details about how it was developed and implemented collaboratively by a healthcare consortium and higher education institution (HEI) to address shared healthcare leadership talent pipeline and retention challenges are provided. Design/methodology/approach This perspective on practice describes how a consortium of competitive healthcare organizations, a type of branded Inter-organizational Relationship referred to as “Coopetition,” contracted with a HEI to design, develop and launch a pilot LDP, referred to as the Academy for Healthcare Education and Development program, using the analyze, design, develop, implement and evaluate model. Findings The significance of this illustrative case example is discussed along with some initial lessons learned based upon this pilot LDP that 24 program participants completed. Implications for research, theory and practice are presented, followed by limitations and a conclusion. Originality/value Inter-organizational relationships, particularly coopetition, are relatively new in the healthcare sector, along with collaboration with HEIs to develop interventions to solve compelling industry problems. This illustrative case example offers insights that address scholars’ calls and practitioners’ needs to explicate different approaches for LDPs to build the healthcare leadership talent pipeline.

Management of cerebrospinal fluid leak after a minimally invasive lumbar decompression procedure: illustrative case.

Neurogenic claudication caused by lumbar stenosis is a prevalent disorder of the spinal canal for which many treatment options exist. The mild (minimally invasive lumbar decompression) procedure has recently been introduced as a safe and effective alternative to medical management in the treatment of lumbar stenosis. However, data on complications are rarely reported, and the incidence of complications, when reported, is frequently assessed at 0% in the literature. The case of a patient with a cerebrospinal fluid leak following a mild procedure performed at an outpatient facility who presented to an inpatient emergency department is discussed. After lumbar drainage failed, the patient required 2 operative procedures to rectify the leak. A seemingly innocuous procedure may have highly morbid complications requiring a lengthy inpatient stay and return trips to the operating room. The physicians and surgeons who manage these complications are frequently not those who performed the index procedure; they should be educated on the risks of the procedure and best practices for definitive management. https://thejns.org/doi/10.3171/CASE24497.

High intracranial pressure following endoscopic third ventriculostomy: illustrative case.

Endoscopic third ventriculostomy (ETV) is an effective procedure for the treatment of triventriculomegaly associated with aqueductal stenosis. However, some patients can develop severe and symptomatic intracranial pressure (ICP) elevations in the immediate postoperative period that can be monitored and treated with external ventricular drain (EVD) placement and controlled cerebrospinal fluid (CSF) diversion until the ICP normalizes and symptoms resolve. The authors describe the case of a 39-year-old male who underwent ETV and intraoperative EVD placement for obstructive hydrocephalus associated with aqueductal stenosis. The patient was noted to have sustained ICP elevations in the immediate perioperative period but ultimately experienced a successful clinical outcome without requiring a ventriculoperitoneal shunt. Significant sustained ICP elevations in the immediate postoperative period following ETV can occur and may indicate a prolonged adjustment period. These elevations can be tolerated if the patient's symptoms and ICP are well controlled, with temporary external CSF diversion if the patient becomes symptomatic, as the ICP will likely normalize with a reassuring clinical outcome. https://thejns.org/doi/10.3171/CASE24478.

Fiducial-marked laminectomy window for intrathecal medication administration after spinal fusion: illustrative case.

Spinal muscular atrophy (SMA) is an inherited disease that leads to weakness, loss of ambulation, and progressive scoliosis in many patients, frequently requiring early spinal fusion. Nusinersen is a disease-modifying agent that improves symptoms and slows the progression of SMA but requires serial lumbar punctures for intrathecal drug delivery. Spinal fusion for scoliosis has historically been a contraindication for nusinersen therapy, as the fused spinal laminae block access to the thecal sac. Here, the authors report a case wherein a patient with SMA and prior scoliosis surgery underwent a one-level lumbar laminectomy with the placement of four titanium microscrews at the corners of the bone window thatfunction as fiducial targets for radiography-guided lumbar punctures. This procedure allowed the patient to receive nusinersen injections easily and successfully on an ongoing basis. Nusinersen is an important novel treatment for children with SMA. Thus, it is imperative to discover new ways to administer intrathecal injections to increase the number of patients able to undergo this therapy. The described one-level laminectomy with microscrew placement for serial lumbar punctures can increase the number of patients able to receive nusinersen and other intrathecal therapies. https://thejns.org/doi/10.3171/CASE24411.

Spinal cord-spinal canal disproportion following treatment for syringomyelia associated with Chiari malformation type I: illustrative case.

Chiari malformation type I (CM-I) is a common pediatric neurosurgical condition that is often associated with syringomyelia (SM) and spine deformity. The association of these three conditions is well recognized, but the pathophysiology linking them has yet to be fully elucidated. This case report describes the unusual course of a 13-year-old male with CM-I, a large holocord syrinx, and progressive scoliosis who developed an angiography-negative subarachnoid hemorrhage (SAH) 4 months after successful posterior fossa decompression with duraplasty (PFDD). Notably, his cervical spinal canal diameter was increased relative to normative data. After presenting with SAH, he was treated with a course of lumbar cerebrospinal fluid drainage, which relieved his symptoms, and he had no further incidents. His syrinx responded to PFDD with a dramatic decrease in spinal cord diameter, in contradistinction to his dilated bony spinal canal. He is presently 4 years out from his SAH and doing well clinically. This report describes the first case of nonaneurysmal SAH following PFDD for CM-I and SM and explores a possible link between SM and bony spinal canal diameter. https://thejns.org/doi/10.3171/CASE24272.

Stimulation-based compassion mapping to assess risk of insular resection for surgical epilepsy management: illustrative case.

The insula is a central node in network models of compassion and empathy. Because of this, resection of the insula for the treatment of drug-resistant epilepsy can change an individual's level of compassion. Here, the authors present the clinical case of a woman with drug-resistant epilepsy localized to the nondominant insula. Because of the widespread literature implicating insular function in empathy and compassion, including lesion studies, her primary concern was changes in her compassion level after insular resection. In this case, the authors performed a novel compassion mapping paradigm before resection, using 30-second video clips to elicit compassion. This showed no changes in compassion with electrical stimulation of sites spanning the anterior insula, providing some reassurance that resection would not affect her compassion. Consistent with this, pre- and postresection testing, along with informal subjective reports by the patient, demonstrated no change in compassion or subcomponents of compassion (sadness and empathy) after right insular resection. While resection of the nondominant insular cortex warrants caution, this case illustrates a compassion mapping paradigm that reassured the clinical team and the patient that her compassion would not be affected and formal postoperative testing that was consistent with this. https://thejns.org/doi/10.3171/CASE24339.

Endoscopic endonasal resection of a craniopharyngioma in a 23-month-old patient: illustrative case.

Treatment of pediatric craniopharyngioma requires a multidisciplinary approach to counsel patients and families on the spectrum of treatment options, including biopsy, radiation, and/or resection. Gross-total resection can avoid radiation and its long-term comorbidities. In very young patients, this is of particular importance but is especially challenging because of anatomical considerations. A 23-month-old boy was found to have a partially calcified and cystic sellar and suprasellar mass. A fully endoscopic endonasal transtuberculum and transsellar approach was performed for gross-total resection of a subdiaphragmatic adamantinomatous craniopharyngioma. Postoperatively, the patient was diagnosed with panhypopituitarism with diabetes insipidus, though without other hypothalamic dysfunction or new visual deficits. To date, there is no evidence of tumor recurrence. In a high-volume center with an experienced multidisciplinary skull base team, endoscopic endonasal approaches to sellar and suprasellar pathology in children younger than 2 years can be safely performed. A smaller nasal cavity and lack of sinus aeration necessitate wide exposure via bone removal and complete opening of the sinuses to enable an adequate working corridor to perform not only tumor resection but also reconstruction. Safe gross-total resection can avoid, or at least delay, radiation and its long-term morbidity when performed in a developing child. https://thejns.org/doi/10.3171/CASE24209.

Abstract IA011: Strategies to close the translational gap for nanoscale drug delivery systems

Abstract Nanoscale drug delivery systems have enormous potential to leverage innovative chemistry and encapsulate a wide range of cargo. However, compared to the large number and diverse scope of nanoscale systems described in preclinical manuscripts, there are relatively few approved drug products representing a narrow range of chemistries. There are many reasons for this translational gap, ranging from manufacturing and regulatory challenges to clinical relevance and safety. This presentation outlines key strategies to address the multifaceted challenges that hinder the clinical adoption of nanoscale drug delivery systems. One of the first barriers is the difficulty of scaling up the production of nanoscale systems while maintaining quality and consistency. An illustrative case study will be shared of an approved nanotherapeutic becoming unavailable due to manufacturing concerns, and the resultant change in clinical practice. For a new investigational agent, the work required to optimize a promising nanoformulation is time-consuming and may not result in immediate, publishable findings, creating tension between essential translational work and projects more likely to yield high-profile publications and contribute to academic promotion. In the industry setting, successfully navigating this hurdle is likely to require significant capital, again without a guarantee of success. Without a stable and robust formulation that can be scaled for good manufacturing practice, the benefits of an innovative formulation cannot be fully realized. Another key principle underlying successful translation is identifying a clear clinical indication, which will guide clinical trial design and improve the likelihood of regulatory approval. Recent data suggest that national research funding trends heavily influence the focus of nanotechnology studies, resulting in a misalignment between clinical needs and the investigational agents being developed. In the future, a funding re-alignment may open additional opportunities for basket trials in patient populations lacking a standard of care, or in diseases where the current treatment options are highly toxic. Expanding the clinical indications for nanotherapeutics will likely require academic-industry partnerships to bring together a robust drug product and a strong clinical rationale. The regulatory process for nanoscale therapeutics is evolving, making early communication between investigators and regulators crucial for successfully transitioning nanoscale drug delivery systems from the lab to clinical use for cancer patients. Citation Format: Joelle P. Straehla. Strategies to close the translational gap for nanoscale drug delivery systems [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Optimizing Therapeutic Efficacy and Tolerability through Cancer Chemistry; 2024 Dec 9-11; Toronto, Ontario, Canada. Philadelphia (PA): AACR; Mol Cancer Ther 2024;23(12_Suppl):Abstract nr IA011.

MODELING APPROACH TO URBAN VULNERABILITY TO FLOODING IN THE METROPOLITAN AREA OF ANNABA

Historically, natural hazards have been a constant presence in Mediterranean regions. Earthquakes, eruptions, and floods frequently impact various territories, underscoring this reality. Consequently, governments have prioritized the establishment of prevention, management, and alert systems, making fundamental applied research essential for the ongoing development of these nations. Algeria has experienced numerous natural disasters in the past, particularly those associated with major earthquakes, such as the El Asnam earthquake on October 10, 1980, the Boumerdes earthquake on May 21, 2003, the Bab El Oued floods on November 10, 2001, and more recently, the Ghardaia floods on October 1, 2008.The general living conditions in Algeria, especially in urban areas, are characterized by insufficient management of various issues, largely due to rapid growth. This has at times led to unregulated and uncontrolled urban expansion, with developments on riverbeds, unstable slopes, and other high-risk areas. Such urbanization fails to consider the persistent presence of natural hazards, which are further intensified by climate change.Our objective is to identify the primary causes of natural risks and disasters in urban areas. This study includes an illustrative case in the intermunicipal area of Annaba, located in northeastern Algeria, where flood risk remains significant. The study aims to assess the impact of climate change and the support provided for crisis prevention and management within a sustainable framework.

The history of lobotomy as a neuropsychiatric intervention in Brazil - a case report of a geriatric patient

ABSTRACT Lobotomy was a widespread neurosurgical procedure in the first half of the 20th century. It was used as a treatment for various mental disorders. The development of psychosurgeries in Brazil, their indications, effects, consequences, advancements, as well as the social context of the population subjected to it are revised herein. Also, an illustrative case report of an elderly Brazilian bipolar disorder patient who underwent this procedure in the 1940’s is described in this paper. The article promotes a critical debate around the ethical and social implications of this practice, contributing to the understanding and reflection on the history of psychiatry, neuroscience, and research ethics.

Verbal Abuse, Depersonalization, and the Innate Alarm and Defensive Systems: A Single Case Illustration of Treatment with Deep Brain Reorienting

AbstractThis study aimed to a) discuss the neurobiological mechanisms of depersonalization as arising from activation at the brainstem level and b) assess the effectiveness of deep brain reorienting psychotherapy (DBR) with a patient presenting with depersonalization-derealization disorder (DDD). In the first part of the paper, we discuss verbal abuse as a severe form of relational trauma and how it can be connected to depersonalization. It is argued that suddenly aversive experiences engage the brainstem locus coeruleus in widespread noradrenergic activation of the thalamus and cortex such that the balance of functioning within the cortex becomes disturbed and a subjective experience of chronic depersonalization results. In the second part, the single-case study aims to provide initial evidence of how the patient experienced and responded to DBR therapy. Pre- and post-treatment measures consisted of instruments to measure depersonalization, social anxiety symptoms and quality of life. After 43 DBR sessions, the participant's depersonalization and comorbid symptoms decreased significantly. Patients with DDD may benefit from DBR. Future research is required to address generalizability to a larger population.

From Complementarity to Mutual Recognition and Thirdness in Child–Parent Psychotherapy

AbstractThis article explores the integration of Jessica Benjamin’s concepts of ‘mutual recognition’ and ‘the third’ into child-parent psychotherapy (CPP), a relationship-based trauma-informed dyadic intervention model rooted in attachment theory. Despite the significance of caregiver-child relationships in trauma response, Benjamin’s work remains underutilized in the CPP literature. This article uses a case illustration to demonstrate how incorporating Benjamin’s concepts enriches CPP interventions that address the relational impact of trauma on young children. Three strategies are outlined to cultivate thirdness within CPP, drawing from clinical material: exploring trauma and complementarity, distinguishing play from reality, and working with the clinician’s subjectivity. The article illustrates how the utilization of Benjamin’s concepts can complement CPP and how emphasizing the intersubjective dynamic between parent and child, enhancing parental subjectivity, and prioritizing the repair of recognition breakdowns can support clinicians in advancing the therapeutic goals of CPP.

Development of a Virtual Telehandler Model Using a Bond Graph

Recent technological advancements and evolving regulatory frameworks are catalysing the integration of renewable energy sources in construction equipment, with the objective of significantly reducing greenhouse gas emissions. The electrification of non-road mobile machinery (NRMM), particularly self-propelled Rough-Terrain Variable Reach Trucks (RTVRT) equipped with telescopic booms, presents notable stability challenges. The transition from diesel to electric propulsion systems alters, among other factors, the centre of gravity and the inertial matrix, necessitating precise load capacity determinations through detailed load charts to ensure operational safety. This paper introduces a virtual model constructed through multiphysics modelling utilising the bond graph methodology, incorporating both scalar and vector bonds to facilitate detailed interconnections between mechanical and hydraulic domains. The model encompasses critical components, including the chassis, rear axle, telescopic boom, attachment fork, and wheels, each requiring a comprehensive three-dimensional treatment to accurately resolve spatial dynamics. An illustrative case study, supported by empirical data, demonstrates the model’s capabilities, particularly in calculating ground wheel reaction forces and analysing the hydraulic self-levelling behaviour of the attachment fork. Notably, discrepancies within a 10% range are deemed acceptable, reflecting the inherent variability of field operating conditions. Experimental analyses validate the BG-3D simulation model of the telehandler implemented in 20-SIM establishing it as an effective tool for estimating stability limits with satisfactory precision and for predicting dynamic behaviour across diverse operating conditions. Additionally, the paper discusses prospective enhancements to the model, such as the integration of the virtual vehicle model with a variable inclination platform in future research phases, aimed at evaluating both longitudinal and lateral stability in accordance with ISO 22915 standards, promoting operator safety.