Central Lesions Research Articles

Central lymphatic surgery

In recent years, microsurgical reconstruction of the lymphatic system has opened new frontiers in the treatment of central lymphatic lesions. Central lymphatic lesions can be congenital or acquired. While the latter can result from any surgery or trauma in the area of the thoracic duct, congenital lymphatic lesions can show a plethora of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Regardless of the anatomical location of the thoracic duct lesion, these conditions cause recurrent chylous effusions and downstream lymphatic congestion and are associated with increased mortality due to the permanent loss of protein and fluid. In case of disruption of the lymphatic flow, microsurgical reconstructive surgery is indicated to treat downstream congestion leading to bronchitis plastica, protein-loosing enteropathy, chylothorax, and chylascites. Thoracic duct-vein anastomoses can reconstruct the physiological lymphatic flow.

Endobronchial Radiofrequency Ablation for pulmonary nodules with Radial-Ebus and Navigation: Pros and Cons.

Introduction: Pulmonary nodules are common in the everyday clinical practice. There is always a diagnostic issue with this imaging finding. Based on the size we can use a variety of imaging and diagnostic techniques. Moreover; in the case of primary lung cancer or metastasis we can use radiofrequency ablation endobronchially. Patients and Methods: We used the radial-endobronchial ultrasound with C-arm and Archemedes, Bronchus electromagnetic navigation in order to acquire biopsy sample and we also used rapid on-site evaluation as a rapid diagnosis for pulmonary nodules. After rapid diagnosis we used the radiofrequency ablation catheter in order to ablate central pulmonary nodules. Results: Both techniques provide efficient navigation, however, with the Bronchus system less time is needed. The new radiofrequency ablation catheter provides efficient results in central lesions with low watts ≤40. Conclusion: We provided in our research a protocol to diagnose and treat such lesions. Future larger studies will provide more data on this subject.

Longitudinally extensive transverse myelitis after epidural anaesthesia in childbirth

Introduction. Neurological complications related to epidural anesthesia are rare, but it is necessary to recognize and diagnose them as early as possible, in order to start appropriate therapy and prevent further neurological damage. One of the rare complications of regional anesthesia described in this paper is longitudinal extensive transversal myelitis (LETM). Case report. A 32-year-old patient, who gave birth by Caesarean section in due term, developed LETM the very same day. Considering the neuroradiological findings that indicated to the long central lesion in the thoracic and lumbar spine, and an expected reaction to the applied immunotherapy (immunosuppressive therapy and therapeutic plasma exchange), a diagnosis of LETM was made. Even with all the therapy and regression of the lesions, the patient could not stand up without support. During the subsequent treatment, according to the instructions of the physiatrist, physical therapy was carried out, to which the patient responded slowly but favorably, with a gradual return of the function of the lower extremities. Conclusion. Early diagnosis and timely treatment of LETM are crucial for the prognosis of the dis-ease and the early recovery of the patient.

An Automatic Image Processing Method Based on Artificial Intelligence for Locating the Key Boundary Points in the Central Serous Chorioretinopathy Lesion Area.

Accurately and rapidly measuring the diameter of central serous chorioretinopathy (CSCR) lesion area is the key to judge the severity of CSCR and evaluate the efficacy of the corresponding treatments. Currently, the manual measurement scheme based on a single or a small number of optical coherence tomography (OCT) B-scan images encounters the dilemma of incredibility. Although manually measuring the diameters of all OCT B-scan images of a single patient can alleviate the previous issue, the situation of inefficiency will thus arise. Additionally, manual operation is subject to subjective factors of ophthalmologists, resulting in unrepeatable measurement results. Therefore, an automatic image processing method (i.e., a joint framework) based on artificial intelligence (AI) is innovatively proposed for locating the key boundary points of CSCR lesion area to assist the diameter measurement. Firstly, the initial location module (ILM) benefiting from multitask learning is properly adjusted and tentatively achieves the preliminary location of key boundary points. Secondly, the location task is formulated as a Markov decision process, aiming at further improving the location accuracy by utilizing the single agent reinforcement learning module (SARLM). Finally, the joint framework based on the ILM and SARLM is skillfully established, in which ILM provides an initial starting point for SARLM to narrow the active region of agent, and SARLM makes up for the defect of low generalization of ILM by virtue of the independent exploration ability of agent. Experiments reveal the AI-based method which joins the multitask learning, and single agent reinforcement learning paradigms enable agents to work in local region, alleviating the time-consuming problem of SARLM, performing location task in a global scope, and improving the location accuracy of ILM, thus reflecting its effectiveness and clinical application value in the task of rapidly and accurately measuring the diameter of CSCR lesions.

Neurectomies for treatment of stroke-related upper extremity spasticity.

Limb spasticity due to central nervous system lesions can lead to substantial functional impairment. This is particularly challenging when the patient retains control of limb movements. This intraoperative video demonstrates selective neurectomies to improve spasticity. The case of a patient with left spastic hemiplegia after stroke who requested peripheral neurectomies for durable treatment of left elbow flexion spasticity is shown. The patient had substantial improvement in resting tone and achieving a relaxed, near-full extension at rest. He retains elbow flexion, which has improved in subsequent clinical follow-up evaluation. Highly selective partial denervation surgery can successfully reduce spasticity. The video can be found here: https://stream.cadmore.media/r10.3171/2022.9.FOCVID22106.

Sixteen-Year Institutional Review of Magnetic Resonance Imaging-Guided Breast Biopsies: Trends in Histologic Diagnoses With Radiologic Correlation.

Breast magnetic resonance imaging (MRI) is an important imaging tool for the management of breast cancer patients and for screening women at high risk for breast cancer. To examine long-term trends in the distribution of histologic diagnoses obtained from MRI-guided breast biopsies. Retrospective analysis. We retrospectively reviewed the distribution of histologic diagnoses of MRI-guided breast biopsies from 2004 to 2019. All cases underwent central pathology review and lesions were classified based on the most prominent histologic finding present. Magnetic resonance imaging features were extracted from radiology reports when available and correlated with pathology diagnoses. Four hundred ninety-four MRI-guided biopsies were performed on 440 patients; overall, 73% of biopsies were benign and 27% were malignant. The annual percentages of benign and malignant diagnoses remained similar throughout the 16-year period. Of the benign entities commonly identified, the percentage of benign papillary and sclerosing lesions detected in the benign biopsies increased significantly (13% in 2004-2011 vs 31% in 2012-2019, P = .03). The mean size of malignant lesions was larger than benign lesions (30.1 mm compared with 14.2 mm, P = .045); otherwise, there were no distinguishing radiologic features between benign and malignant lesions. The specificity of breast MRI remained constant over a 16-year period; however, there was a shift in the distribution of benign diagnoses with increased detection and biopsy of benign papillary and sclerosing lesions. Monitoring the distribution of breast MRI biopsy diagnoses over time with radiology-pathology correlation might improve the suboptimal specificity of breast MRI.

A Clinical Approach to Diagnosis and Management of Vertigo in the Emergency Room Setting

Abstract Vertigo is a symptom of the illusory movement of spinning. Vertigo is a challenging diagnostic condition in the emergency room as it is a symptom-complex of a large number of benign to life-threatening conditions. Both peripheral vestibular and central nervous system can cause vertigo and it is often impossible to pinpoint the underlying etiology in the acute settings. Historical features such as recurrent vertigo, triggers, duration of vertigo, accompanying symptoms along with meticulous vestibular, and ocular and balance examination can be valuable in delineating peripheral from central vertigo. Currently, the emergency physicians approach majority of vestibular disorders with a mind-set of preventing any errors of omission, so they rely on unwarranted neuroimaging. In most instances, the timing and triggers of vertigo are ignored and characteristic maneuvers to diagnose benign peripheral vertigo are underused, thereby missing nonlife-threatening diagnosis. An urgent neuroimaging is usually indicated for patients with sustained vertigo and suspected central lesions associated with brainstem dysfunction.

A Hybrid Lesion of the Mandible with Three Co-existent Pathologies: Report of a Rare Case with Literature Review

Hybrid lesions are rare and microscopically composed of areas of distinct pathologic entities. The occurrence of dual lesions containing Central Giant Cell Lesion (CGCL) and fibro-osseous lesions has been recorded in the literature. Although many similar cases have been reported the pathophysiology of such lesions is yet not well understood. Furthermore, their clinical behaviour and treatment guidelines are also not clearly outlined. Presented here is a unique case of a 17-years old male with a hybrid lesion with a triad of pathological entities, Ossifying fibroma, CGCL and aneurysmal bone cyst. The clinical presentation, pathogenesis and behaviour of the reported lesion are comprehensively explained. The authors believe that greater knowledge of the hybrid variety of jaw lesions may aid in better understanding and management of these lesions by clinicians.

Connexin 30 Deficiency Ameliorates Disease Progression at the Early Phase in a Mouse Model of Amyotrophic Lateral Sclerosis by Suppressing Glial Inflammation.

Connexin 30 (Cx30), which forms gap junctions between astrocytes, regulates cell adhesion and migration, and modulates glutamate transport. Cx30 is upregulated on activated astroglia in central nervous system inflammatory lesions, including spinal cord lesions in mutant superoxide dismutase 1 (mSOD1) transgenic amyotrophic lateral sclerosis (ALS) model mice. Here, we investigated the role of Cx30 in mSOD1 mice. Cx30 was highly expressed in the pre-onset stage in mSOD1 mice. mSOD1 mice with knockout (KO) of the Cx30 gene (Cx30KO-mSOD1 mice) showed delayed disease onset and tended to have an extended survival period (log-rank, p = 0.09). At the progressive and end stages of the disease, anterior horn cells were significantly preserved in Cx30KO-mSOD1 mice. In lesions of these mice, glial fibrillary acidic protein/C3-positive inflammatory astroglia were decreased. Additionally, the activation of astrocytes in Cx30KO-mSOD1 mice was reduced compared with mSOD1 mice by gene expression microarray. Furthermore, expression of connexin 43 at the pre-onset stage was downregulated in Cx30KO-mSOD1 mice. These findings suggest that reduced expression of astroglial Cx30 at the early disease stage in ALS model mice protects neurons by attenuating astroglial inflammation.

Photoreceptor Function and Structure in Autosomal Dominant Vitelliform Macular Dystrophy Caused by BEST1 Mutations.

The purpose of this study was to evaluate rod and cone function and outer retinal structure within macular lesions, and surrounding extralesional areas of patients with autosomal dominant Best vitelliform macular dystrophy caused by BEST1 mutations. Seventeen patients from seven families were examined with dark- and light-adapted chromatic perimetry and optical coherence tomography. Subsets of patients had long-term follow-up (14-22 years, n = 6) and dark-adaptation kinetics measured (n = 5). Within central lesions with large serous retinal detachments, rod sensitivity was severely reduced but visual acuity and cone sensitivity were relatively retained. In surrounding extralesional areas, there was a mild but detectable widening of the subretinal space in some patients and some retinal areas. Available evidence was consistent with subretinal widening causing slower dark-adaptation kinetics. Over long-term follow-up, some eyes showed formation of de novo satellite lesions at retinal locations that years previously demonstrated subretinal widening. A subclinical abnormality consisting of a retina-wide mild thickening of the outer nuclear layer was evident in many patients and thickening increased in the subset of patients with long-term follow-up. Outcome measures for future clinical trials should include evaluations of rod sensitivity within central lesions and quantitative measures of outer retinal structure in normal-appearing regions surrounding the lesions.

Role of bedside video-oculography in selecting neuroimaging in patients with acute vertigo and ataxia posterior fossa mass lesions

The acute vestibular syndrome ((AVS) is the sudden onset of continuous vertigo, nausea, vomiting and head motion intolerance [1]. The most common peripheral cause is a vestibular neuritis [2], and the most frequent central lesion associated with an AVS is an ischemic stroke in about 10 to 15% of cases [3–5]; less frequently demyelinating plaques (multiple sclerosis (MS) and neuromyelitis optica (NMO)) [6], and inflammatory lesions associated with infectious and paraneoplastic disorders may be responsible.

Fundus autofluorescence pattern in different cases of cone inherited macular dystrophies

AbstractPurpose: To study fundus autofluorescence (FAF) with blue light excitation (488 nm) in different cases of cone inherited macular dystrophies an to assess differential characteristics.Methods: We studied different cone inherited retinal dystrophies due primary to ABCA4 mutation with blue FAF and correlate the findings with the clinical impairment. We compared with the findings in other mutations.Results: We presented 9 cases of Stargardt diseases with ABCA4 mutation with different blue FAF characteristics, from single macular impairment with an hypofluorescence, pattern, hyperreflective flecks around the central lesion or flecks extended outside the vascular branches. The extension of the flecks was no correlate with the degree of functional impairment. We compared with other cone dystrophies such as CRX mutation, with similar findings than the ones with only central impairment. Asymptomatic CRX mutation showed a hyperreflective central lesion.Conclusions: FAF is an essential tool to diagnose and follow‐up inherited retinal dystrophies with primary macular manifestation. Same mutation and clinical stage could present different patterns.

STATE OF COCHLEOVESTIBULAR DISORDERS IN PATIENTS WITH ARTERIAL HYPERTENSION

The article presents the otoneurological characteristics of pre-stroke cerebrovascular disorders in patients with essential hypertension. Among the problems of modern otorhinolaryngology, one of the leading places belongs to cochleovestibular disorders in some cardiovascular diseases, in particular, hypertension. The state of vestibular function in arterial hypertension was studied by many authors who noted a decrease in resistance in such patients. It has been established that one of the reasons for the formation of secondary cochleovestibular disorders is chronic hypertensive encephalopathy, which develops in patients with arterial hypertension, often already in the early stages of the disease. In the study of the peculiarities of the pathogenesis of cochleovestibular disorders, certain results have made it possible to study the nature of the vestibulo-vascular interaction. It is shown, in particular, the difference in vestibulo-vascular reactions in the case of central and peripheral lesions of the vestibular analyzer, which is important for the differential diagnosis of these pathological conditions.

Non-immune system comorbidity in neuromyelitis optica spectrum disorders

Comorbidities may influence the clinical features, prognosis, and treatment outcomes of neuromyelitis optica spectrum disorders (NMOSD). The aim of this study was to determine the status of non-immune system comorbidities in patients with NMOSD and the effect on treatment response and prognosis.We retrospectively collected data from all patients who met the 2015 NMOSD diagnostic criteria from the NMOSD database established by our center. Patients were divided into positive and negative groups based on the presence of non-immune disease comorbidities. Patient data, clinical characteristics, treatment response, prognosis, and mortality were compared between the two groups.A total of 138 patients with NMOSD plus comorbidities were included, and 404 patients without comorbidities were selected as controls. The average age at onset was older (45 years vs 38 years, P < 0.001), the mean body mass index was higher (23.12 vs 22.04, P = 0.042) and more patients experienced relapse after immunotherapy (68.5 % vs 54.5 %, P = 0.020) in the comorbidity group than in the non-comorbidity group. Multifocal central nervous system lesions as an initial symptom was more common in the comorbidity group than in the non-comorbidity group (30.4 % vs 18.32 %, P = 0.003). Further, more patients experienced severe vision attacks (28.3 % vs 15.8 %, P = 0.003) and severe motor attacks (30.4 % vs 11.9 %, P < 0.001) in the comorbidity group than in the non-comorbidity group.In conclusion, patients with NMOSD with comorbidities tended to be older, less responsive to treatment, and at a higher risk of vision loss and paralysis.

The use of stereotactic MRI-guided laser interstitial thermal therapy for the treatment of pediatric cavernous malformations: the SUNYUpstate Golisano Children's Hospital experience.

Cavernous malformations (CM) are central nervous system lesions characterized by interlaced vascular sinusoids coated with endothelial cells without intervening parenchyma. Magnetic resonance imaging-guided laser interstitial thermal therapy (MRIgLITT) is a minimally invasive treatment modality that can precisely treat pathologic cerebral tissue, making it an effective alternative for the management of cavernomas. We describe the outcomes of a series of pediatric patients with cavernous brain malformations treated with MRIgLITT between 2014 and 2018 at our institution. We retrospectively analyzed 11 cavernomas in 6 pediatric patients treated with MRIgLITT. Both the Visualase System® and/or Neuroblate® systems were used. A variation of the surgical technique on the application of the laser was developed. Post-ablation MRIs were obtained to assess ablated areas. A total of 11 cavernomas in 6 patients were treated with MRIgLITT. Median age was 15years (12 to 17years); 75% were males. Presenting symptoms were headache (75%) and seizures (25%). Two patients presented with multiple CMs. All lesions in this study were supratentorial (cerebral hemispheres 81.8%, corpus callosum 9.1%, basal ganglia 9.1%). Our surgical technique was well-tolerated, with no significant adverse events observed. Hospital stay for all patients was less than 48hours. MRIgLITT is an effective minimally invasive technique for the treatment of pediatric CMs. It represents a useful and safe tool, when other therapeutic alternatives may represent a greater risk of surgical morbidity.

Clinical Comparison of Fusarium Keratitis according to the Initial Potassium Hydroxide (KOH) Smear: A Retrospective Study in South Korea.

This study aimed to compare predisposing factors, clinical characteristics, treatment, and prognosis of Fusarium keratitis according to the result of the initial potassium hydroxide (KOH) smear. This is a retrospective study of cases with Fusarium keratitis between January 2000 and December 2019 at two tertiary hospitals in South Korea. Patients were divided into two groups depending on the KOH smear result (KOH-positive and KOH-negative group), and its clinical factors were analyzed. Among 319 fungal keratitis, seventy-nine cases were identified with Fusarium keratitis. Forty-seven cases (59.5%) were negative in the initial KOH smear prior to their diagnosis. The most common predisposing factor for Fusarium keratitis was ocular trauma (55.7%). There were no significant differences in sex, occupation, ulcer size or shape, hypopyon, and initial visual acuity between the two groups. Differences were observed between the KOH-positive group and the KOH-negative group in terms of deep corneal infiltration (50.0% vs. 78.7%, p=0.008) and evisceration treatment (3.1% vs. 25.5%, p=0.008). The delayed time to initiate antifungal eye drops was longer in the KOH-negative group (1.13 ± 0.49 vs. 3.93 ± 4.89, p=0.002). Only the KOH-negative group combined bacterial infection. The significant risk factors for poor clinical outcomes were the central corneal lesion (odds ratio (OR) 3.50, p=0.047), a large ulcer size (size ≥ 7.5 mm2) (OR 4.98, p=0.009), and endothelial plaque (OR 7.00, p=0.031). Initial KOH-negative patients often needed evisceration and had worse final visual outcomes. The delay of prompt initiation of antifungal treatment and combined bacterial infection result in a poor prognosis. This study highlights the initial KOH effect on early diagnosis and early treatment of Fusarium keratitis.

Surgical Management of Peripheral Nerve Pathology in Patients With Neurofibromatosis Type 2.

Neurofibromatosis type 2 (NF2) is rare genetic disorder mainly characterized by the development of central nervous system lesions, but peripheral nerve pathology may also cause high morbidity including pain, motor, and sensory loss. To describe the tumor burden of patients with peripheral nerve pathology in NF2 including peripheral neuropathies and schwannomas and the results of surgery in the latter group. We conducted a retrospective chart review of all patients with NF2 followed up at our NF2 Reference Center to include all patients suffering from peripheral nerve pathology. Tumor detection relied on focal MRIs based on symptoms. Thirty-four patients harboring 105 peripheral nerve schwannomas and 1 perineurioma were included. Schwannomas were mainly located in major nerves (n = 74, 71%) compared with subcutaneous (n = 23, 22%) and intramuscular (n = 8, 7%) cases. Most schwannomas (81/90-90%) were classical discrete tumors while multinodular cases represented only 9 cases (10%). During follow-up, 63 (60%) tumors were operated in 24 patients, including 39 schwannomas of major nerves. A complete resection was achieved in most of the cases (52/63, 83%) with a complete relief of preoperative pain in most patients (57/60, 95%). Persistent motor deficits (5/39, 13%) were mostly encountered in patients operated from multinodular schwannomas (4/5, 80%). Six patients had an associated peripheral neuropathy with 5 cases of pseudo-Charcot-Marie-Tooth-associated amyotrophy. Surgery remains a safe and effective method of treating peripheral nerve schwannoma-associated pain in NF2, with the exception of rare multinodular tumors. Special attention should be drawn to patients harboring severely debilitating neuropathies and perineuriomas.

Ethnic Variation in Diabetic Retinopathy Lesion Distribution on Ultra-widefield Imaging

To evaluate whether the distribution of diabetic retinopathy (DR) lesions differs among various ethnicities. Multi-center, retrospective cohort study. We accrued a cohort of 226 eyes with DR consisting of 51 East Asian eyes, 102 South Asian eyes, 30 Caucasian eyes, and 43 Latino eyes, all evaluated with ultrawide field pseudocolor images. Images were manually annotated for DR lesions and were classified as having predominantly peripheral lesions (PPL) or predominantly central lesions (PCL) using 4 quantitative methods. The percent distribution of PCL to PPL was compared among different ethnicities. Using a single-field lesion frequency-based method, East Asian eyes more frequently demonstrated a PPL distribution (86.3%), whereas South Asian eyes more frequently demonstrated a PCL distribution (64.7%). These findings were also observed when considering only the subset of treatment-naïve eyes. Furthermore, in treatment-naïve eyes without proliferative DR, the percent distribution of PPL to PCL in East Asian eyes was significantly different when compared to other ethnicities (P < .0001 South Asian, P=.035 Caucasian, P=.0003 Latino). The majority of patients (60%-78%) in all ethnic groups had moderate nonproliferative diabetic retinopathy(NPDR), and the same difference between East Asian and South Asian eyes was observed in this subgroup. The distribution of DR lesions appears to vary among different ethnicities. DR lesions tend to be distributed more peripherally in East Asian eyes compared to other ethnic groups, particularly South Asian eyes, which tend to have more central disease. The prognostic implications of these ethnic differences in DR lesion distribution require further investigation.

Reconceptualize tall-cell variant papillary thyroid microcarcinoma: From a “sonographic histology” perspective

This study aimed to examine the relationship between sonographic features and histological manifestations in the tall-cell variant of papillary thyroid microcarcinoma (TCV-PTMC), thus proposing the concept of "sonographic histology" and examine its value in the clinical management of the aggressive tall-cell variant. This study retrospectively included 104 participants who were admitted to Peking University Third Hospital from 2015 to 2022 and were histopathologically confirmed as having TCV-PTMC or classical PTMC. We mainly compared the general characteristics, sonographic characteristics, and pathological specimens between the two cohorts. Hypoechoic nodules with a localized central isoechoic lesion and hypoechoic halo around nodules were most often observed in TCV-PTMC, which correlated with circumferentially distributed tumor epithelium and densely distributed tumor stroma histopathologically. Additionally, TCV-PTMC showed nodules with a more regular margin and less microcalcification than classical PTMC, which led to an underestimation of the risk of TCV-PTMC. The good association between the ultrasound echo pattern and tissue cell arrangement was defined as sonographic histology in this study and can be applied in the preoperative identification of TCV-PTMC. This concept may provide novel insight for the identification of special subtypes of thyroid tumors and may modify pitfalls of the Thyroid Imaging Reporting and Data System in aggressive variants of microcarcinoma.

Clinical and Serological Characteristics of Ocular Toxoplasmosis in the Democratic Republic of Congo

ABSTRACT Purpose To describe demographic data, clinical features, and serological profiles in a cohort of Congolese patients with ocular toxoplasmosis (OT). Method Cross-sectional study, carried out between March 2020 and July 2021 in two ophthalmic clinics in Kinshasa. Results The study comprised 95 participants with OT. Fifty-three patients were male (55.8%). The mean age at presentation was 35.6 ± 14.1 years (range 8–69 years); 71 had active OT (74.7%), among them, 33 had primary OT (46.5%), and 38 had recurrences (53.5%). At presentation, 51 patients (53.7%) had visual impairment (VA < 6/18). Retinochoroidal lesions were located in the central retina in 60 patients (63.1%). Patients with primary OT tend to have higher IgG levels than those with recurrent OT (P = .01). Conclusion We report the largest cohort of patients with OT in sub-Saharan Africa. In our setting, most patients had recurrent OT with multiple, extensive, and central retinochoroidal lesions.