Challenging Lesions Research Articles

Operative considerations and surgical treatment of sylvian fissure arteriovenous malformations: a 20-year experience.

Sylvian fissure (SF) arteriovenous malformations (AVMs) are among the most challenging vascular lesions amenable to neurosurgical treatment and account for 10% of all locations. As radiosurgery and endovascular techniques are increasingly involved in multimodal management protocols, the role of microsurgery needs to be reassessed as a stand-alone technique. The aim of this study was to show that total excision can be achieved with reasonable levels of morbidity and mortality in a real-world setting from a specialized high-volume center. Forty-three patients with SF AVMs were identified from a series of 577 AVM patients treated microsurgically over a 22-year period. The mean patient age was 33.07 years (range 15-60 years), and there were 22 male and 21 female patients. The mode of presentation was headache in 51.2%, hemorrhage in 34.9%, seizures in 30.2%, and steal phenomenon in 9.3%. The authors analyzed the anatomical basis and angiographic characteristics of such lesions. In the preoperative period, 83.7% of the patients had a modified Rankin Scale (mRS) score of 0-2, and 16.3% had an mRS score of 3-5. After a 12-month follow-up, 95.3% of patients had an mRS score of 0-2, and 4.7% had a score of 3-6. The difference between pre- and postoperative scores was not statistically significant. SF AVMs have several particular features: 1) They produce angiographic steal of the anterior cerebral artery. 2) The nidus is fed by only one of the main trunks of the middle cerebral artery (MCA). 3) Participation of deep perforators is uncommon. 4) They have two or more early draining veins showing their fistulous nature. 5) Preoperative embolization and radiosurgery have a low rate of permanent cure. These AVMs represent a surgical challenge due to their proximity to critical structures such as the MCA, insula, internal capsule, and speech and memory functions in the dominant hemisphere. Essential key points are the wide opening of the SF and proper differentiation between feeders and normal vessels. Although this location can seem daunting, SF AVMs carry no additional surgical risk if adequately managed.

Detection of Cavitated Proximal Carious Lesions in Permanent Teeth: A Visual and Radiographic Assessment

Detection of proximal carious lesions involves the combination of clinical and radiographic methods, both with inherent difficulties. The present cross-sectional study is aimed at estimating the prevalence of cavitation in proximal carious lesions, based on a direct clinical assessment of previously detected radiographic lesions, in permanent molars and premolars. Proximal dental surfaces were radiographically evaluated using the ADA coding system and cavitation was determined through clinical visual examination of the surfaces after separation with elastomeric bands. One-hundred and twenty-six patients attending the dental clinics at the University of Talca were examined, comprising 508 proximal surfaces with radiographic codes ranging from E1 to D3. Two examiners were trained and calibrated for radiographic and clinical detection of proximal lesions. Most participants were females (61.9%). The age mean of participants was 28.7 (0.8) years old. A total of 22.2% of the examined surfaces were cavitated. Only few lesions coded as E1 (n = 4; 2.1%) and E2 (n = 9; 9.8%) were cavitated. Fifty D1 (35.5%) and 22 D2 (41.5%) lesions were cavitated after separation. Most lesions coded as D3 (n = 28; 84.8%) were cavitated. The multilevel binary regression model (p = 0.003) demonstrated that sex, age, jaw, tooth type, surface, and side were not associated with the likelihood of having proximal cavitation. Challenging conventional wisdom, most D1 and D2 lesions were not cavitated. Combining detection methods seems desirable to increase the accuracy in assessing approximal posterior lesions. The low proportion of cavitated lesions reinforces the idea of cautiously indicating invasive approaches for managing proximal carious lesions.

Diagnostic Value of Nuclear Receptor Subfamily 4 Group A Member 3 in Salivary Gland Carcinomas

Salivary gland carcinomas are diagnostically challenging lesions in heterogeneous groups. However, recently described genomic alterations may be helpful and have future therapeutic implications. The molecular investigation is becoming useful tool to help diagnosis and provide prognostic information. Diagnosis of acinic cell carcinoma (AcCC) is challenging due to its rarity and similarity with other SGCs or normal acinar cells.
 Herein, the diagnostic performance of transcription factor nuclear receptor subfamily 4 group A member3 (NR4A3) was analysed immunohistochemically. This study was done on 68 cases of SCCs, including 32 of AcCC, 14 of adenoid cystic carcinoma (AdCC), 8 of mucoepidermoid carcinoma (MEC), 7 of epithelial myoepithelial carcinoma (EMC), 4 of salivary duct carcinoma (SDC), and only one case from each of carcinoma ex pleomorphic adenoma (CXPA), polymorphous adenocarcinoma (PAC) and secretory carcinoma (SC) for detecting NR4A3.
 All stained samples of AcCC (100%) responded positively to the NR4A3 antibody. However, only one case of AdCC and MEC demonstrated NR4A3 immunostaining in less than 10% of cells. On the other hand, the different types of SGCs, including EMC, SDC, CXPA, PAC, and SC, revealed negative expressions. Therefore, we can conclude that NR4A3 can be used as a potential marker for AcCC rather than other SGCs.

B-25 | Two-Year Outcomes in Patients with Bifurcation Lesions treated with Resolute ONYX ZES: Final Results from the RESOLUTE ONYX Bifurcation Study

Bifurcations are a challenging lesion subset for percutaneous coronary intervention. In the RESOLUTE ONYX Bifurcation study, we evaluated the 2-year clinical outcomes of patients with bifurcation lesions treated with the Resolute Onyx zotarolimus-eluting stent (ZES).

A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms.

Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings. The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications. A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications. Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

Percutaneous Coronary Intervention of Bifurcation Lesion

Bifurcation lesion whether it is left main (LM) stem disease with left main to left anterior descending artery (LM-LAD) or left main to left circumflex (LM-LCX), LAD-Diagonal or LCX-Obtuse marginal or right coronary artery- posterior descending artery (RCA-PDA); are not uncommon lesion type that needs to be revascularized either by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) to establish the coronary flow and relieved patient anginal symptoms. Even though, many of the literature maintained non-inferiority of bifurcation lesion PCI over CABG and is Class IIb indication for PCI by coronary stent. In literature, bifurcation lesions commonly encountered in PCI and are regarded as most technically challenging lesions to treat, in up to 20% of PCI cases. With the advent of interventional procedures and the availability of cardiac catheterization laboratory facilities, skilled interventionist, many of the Bangladeshi patients are being treated for coronary artery diseases (CAD). With the advent of drug eluting stents, availability of IVUS (Intravascular Ultrasound), FFR (Fractional Flow Reserve) and individual expertise, treating bifurcation lesion may not be difficult task. Interventionist must be expert enough in doing PCI, before to proceed for bifurcation lesion PCI. We need to work together to develop common consensus in developing updated skill in treating bifurcation lesion which will prove bifurcation PCI in our population. Cardiovasc j 2022; 14(2): 168-175

Anterior petrosal (Kawase) approach to petroclival meningioma: 2-dimensional operative video.

Petroclival meningiomas are challenging lesions that can be treated with several surgical approaches. The authors present a 66-year-old woman with a 1.6-cm left petroclival meningioma that was initially observed and then radiated after it grew 8 years later. Despite radiation, the tumor continued to grow to 4 cm; therefore, the patient was referred to the authors’ institution. A left anterior petrosal (Kawase) approach was performed. Postoperatively, the patient had transient cranial nerve IV and VI palsy that improved. The case presentation, surgical anatomy, operative technique, postoperative course, and different surgical approaches are reviewed. The patient gave verbal consent for participating in the surgical video.The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21259

Combined transpetrosal approach for giant petroclival meningioma: 2-dimensional operative video.

Petroclival meningiomas are extremally challenging lesions due to their deep location and close relation to critical neurovascular structures. Several approaches have been described to achieve gross-total resection with low morbidity and mortality. In this 2-dimensional operative video, the authors show a simultaneous combined transpetrosal approach. The patient is a 44-year-old woman with an 8-month history of gait imbalance with evidence of a giant petroclival meningioma on neuroimaging. She underwent a combined middle fossa approach with anterior petrosectomy and retrosigmoid/retrolabyrinthine approach to achieve gross-total tumor resection. The postoperative course was characterized by trigeminal neuralgia, and neuroimaging showed gross-total resection of the tumor.The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21248

Pulmonary atresia with intact ventricular septum: Intended strategies

ObjectiveNeonatal interventional strategies for pulmonary atresia with intact ventricular septum are based on tricuspid valve hypoplasia and right ventricle-dependent coronary circulation. We sought to evaluate long-term outcomes comparing biventricular (BiV) versus single-ventricle (SV) strategies. MethodsRetrospective review was performed of 119 patients diagnosed with pulmonary atresia with intact ventricular septum from 1995 to 2018. Descriptive statistics summarized patient characteristics and a multivariable Cox survival model was used to compare treatment strategies. ResultsOf 119 patients, 62 (52.1%) were male and 13 (10.9%) had a chromosomal abnormality. BiV was pursued in 53.8% (64 out of 119) and SV in 46.2% (55 out of 119) with median tricuspid valve z scores of −1.59 (interquartile range, −3.03 to 0.21) and −5.12 (interquartile range, −5.60 to −4.06), respectively. The median follow-up was 6 years (interquartile range, 2-15 years). Overall survival at 1, 3, and 10 years was 82.4% (98 out of 119), 80.6% (96 out of 119) and 79.8% (95 out of 119), respectively. End states include 36 (30.3%) BiV, 33 (27.7%) SV, 22 (18.5%) alive without definitive end state, 21 (17.6%) death before end state, 4 (3.4%) 1-and-a-half ventricle, and 3 (2.5%) transplants. No SV were converted to BiV, whereas 4 out of 64 (6.3%) BiV were converted to SV. After adjusting for gender, chromosomal abnormalities, gestational age, and birth weight, SV patients had a significantly higher hazard of mortality (hazard ratio, 9.0; 95% CI, 2.65-30.69; P < .001). Mortality was higher in those with right ventricle-dependent coronary circulation (41.9% [13 out of 31]) compared with those without right ventricle-dependent coronary circulation (7.3% [6 out of 82]) (P < .001). ConclusionsPulmonary atresia with intact ventricular septum remains a challenging lesion for those patients on the SV pathway, particularly with right ventricle-dependent coronary circulation.

Wnt3a but not CDX-2 expression is associated with differentiated thyroid cancer.

Thyroid neoplasm incidence has increased worldwide, mostly due to the advancements in medical imaging and screening rates. The aberrant Wnt/β-catenin pathway has been identified as a key mechanism, and it has also been related to the metastatic activity of differentiated thyroid cancer. We aimed to verify the difference in the expression of Wnt3a, a canonical activator of the β-catenin signaling, and CDX-2, a transcription factor upregulated by Wnt/β-catenin pathway, in multinodular goiter and differentiated thyroid cancer and to determine their prognostic value. We included 194 thyroid tissue surgical specimen and their clinicopathological data: study group (differentiated thyroid cancer, n=154) and control group (multinodular goiter, n=40). Immunohistochemistry (IHC) was performed on formalin-fixed, paraffin-embedded tissue by the primary antibodies Wnt3a and CDX-2. High Wnt3a expression was significantly associated with differentiated thyroid cancer (p=0.031). CDX-2 was negative in all differentiated thyroid cancer cases (100%) and also in multinodular goiter. Wnt3a expression was significantly associated with tumors ≤20 mm (p=0.044) and with the absence of capsule invasion (p=0.031). The multivariate analyses suggested that older age (≥55), independent of capsular invasion and tumor size, was an independent prognostic factor for Wnt3a expression (p=0.058). Wnt3a expression but not CDX-2 is correlated with differentiated thyroid cancer samples in comparison to multinodular goiter. Although its prognostic value was limited to tumor size and capsule invasion, a combined model in a panel of immune markers can add accuracy in the classification of challenging thyroid follicular-derived lesions.

Hotspot analysis by confocal microscopy can help to differentiate challenging melanocytic skin lesions.

Some melanocytic lesions do not present enough clinical and dermoscopic features to allow ruling out a possible melanoma diagnosis. These "doubtful melanocytic lesions" pose a very common and challenging scenario in clinical practice and were selected at this study for reflectance confocal microscopy evaluation and subsequent surgical excision for histopathological diagnosis. The study included 110 lesions and three confocal features were statistically able to distinguish benign melanocytic lesions from melanomas: "peripheral hotspot at dermo-epidermal junction", "nucleated roundish cells at the dermo-epidermal junction" and "sheet of cells". The finding of a peripheral hotspot (atypical cells in 1mm2) at the DEJ is highlighted because has not been previously reported in the literature as a confocal feature related to melanomas.

Hyper-fusion network for semi-automatic segmentation of skin lesions.

Segmentation of skin lesions is an important step for imaging-based clinical decision support systems. Automatic skin lesion segmentation methods based on fully convolutional networks (FCNs) are regarded as the state-of-the-art for accuracy. When there are, however, insufficient training data to cover all the variations in skin lesions, where lesions from different patients may have major differences in size/shape/texture, these methods failed to segment the lesions that have image characteristics, which are less common in the training datasets. FCN-based semi-automatic segmentation methods, which fuse user-inputs with high-level semantic image features derived from FCNs offer an ideal complement to overcome limitations of automatic segmentation methods. These semi-automatic methods rely on the automated state-of-the-art FCNs coupled with user-inputs for refinements, and therefore being able to tackle challenging skin lesions. However, there are a limited number of FCN-based semi-automatic segmentation methods and all these methods focused on 'early-fusion', where the first few convolutional layers are used to fuse image features and user-inputs and then derive fused image features for segmentation. For early-fusion based methods, because the user-input information can be lost after the first few convolutional layers, consequently, the user-input information will have limited guidance and constraint in segmenting the challenging skin lesions with inhomogeneous textures and fuzzy boundaries. Hence, in this work, we introduce a hyper-fusion network (HFN) to fuse the extracted user-inputs and image features over multiple stages. We separately extract complementary features which then allows for an iterative use of user-inputs along all the fusion stages to refine the segmentation. We evaluated our HFN on three well-established public benchmark datasets - ISBI Skin Lesion Challenge 2017, 2016 and PH2 - and our results show that the HFN is more accurate and generalizable than the state-of-the-art methods, in particular with challenging skin lesions.

Prevention and treatment of CSF leaks in congenital complex spinal lipomas.

Congenital complex spinal lipomas (CSL) are challenging lesions to treat. Cerebrospinal fluid (CSF) leaks are feared complications due to the risk of infection, and subsequent scarring that may promote retethering. Much has been written in the literature on the surgical technique of CSL resection with less emphasis placed on the prevention and management of CSF leak. The authors describe the nuances in the prevention and management of CSF leaks in the context of CSL, including the operative approach, resection, closure and recommended postoperative care. CSF leaks are complications that can be minimized with deliberate steps and meticulous surgical technique.

Lesions in the parotidomasseteric domain: A plethora of diversity

Context: Swellings in parotidomasseteric region are one of the most intriguing and challenging lesions in the head and neck. Diverse array of diagnosis, striking clinical similarities between different pathologies and anatomical complexity of this region make parotidomasseteric lesions unique. Aims: This article aims to provide a detailed description of various pathologies associated, the diagnostic challenges posed, and the respective management strategies. Settings and Design: The study design involves retrospective observational. Subjects and Methods: Sixteen rare cases of various parotidomasseteric pathologies were reviewed to delineate clinical presentation and characteristic features in diagnostic investigations and subsequent treatment strategies. Statistical Analysis Used: Not applicable. Results: The analysis showed that lesions in the parotidomasseteric region can be categorized into specific entities with distinct but often overlapping clinical features. Given the location and anatomy of the parotidomasseteric region, these lesions can often remain indolent Investigations are fruitful to some extent in determining the expanse of these lesions, however, remain inconclusive in diagnosing the origin and their true nature. Conclusions: The authors conclude that a systematic approach to the diagnosis of a parotidomasseteric lesion is of utmost importance because the differential diagnosis is prodigious. These lesions can be considered very deceptive, demanding surgical intervention and their excision. With the exception of surgical exploration, physical examination remains the most indispensable tool. Hence, a better classification system which determines the treatment required for a particular parotidomasseteric lesion and which correlates the clinical findings with the preoperative investigations will be more beneficial for the operating surgeon.

Tips for difficult colorectal endoscopic submucosal dissection

Colorectal endoscopic submucosal dissection (ESD) is now widely performed and firmly established in the treatment of early-stage colorectal cancer. In particular, there have been many studies on difficult cases of colorectal ESD. Difficult cases can be divided into two groups: difficult dissection of the lesions and difficult approach to the lesion. In most cases, a combination of strategies can solve the problem. Challenging lesions such as those in the anal canal and ileum can also be treated from an anatomical perspective. In the rectum, there are no limits to size or circumference. In addition, the indications for ESD in patients without risk of metastasis other than deep invasion are being considered. Therefore, when ESD is performed on difficult lesions, it is necessary to ensure the quality of dissection.

A Warm Welcome to The First Issue of JSCAI

A Warm Welcome to The First Issue of JSCAI

Intravascular lithotripsy for the treatment of severely calcified carotid lesion: An early single center experience

Although endovascular carotid treatment became more efficient and prevalent, severely calcified carotid lesions remain one of the most challenging lesions and a strong predictor of complications for both endovascular and surgical treatment. We sought to evaluate the effectiveness and safety of intravascular lithotripsy (IVL) using Shockwave balloon device to treat severely calcified carotid lesions. We enrolled five patients with symptomatic severely calcified carotid lesions who were selected for endovascular treatment using IVL. Final stent expansion and calcium load plaque were evaluated using angiographic, ultrasound and intravascular imaging. A total of 5 patients were included in our study. The mean age was 79.6 years, all patients had at least one cardiovascular risk factor. Two patients had bilateral carotid lesions and three had concomitant coronary lesions. All procedures were done through a femoral access and cerebral protection device was used in all cases. Balloon pre-dilatation was performed in all cases with a small coronary balloon before crossing the lesion with the 5 × 60 mm Shockwave balloon. Four cycles of 30 pulses were used in 4 patients and five cycles in one patient. Post dilatation was performed with good balloon expansion in all cases. Good stent expansion was obtained in all cases. Angiographic and vascular ultrasound results showed successful debulking and calcified plaque disrupt. Intravascular imaging (2/5 patients) confirmed calcium disrupt and good stent apposition. There were no procedural complications. Post-procedural cerebral CT showed no stroke for all patients. Our early experience showed that IVL for the treatment of heavily calcified carotid lesions is feasible and safe following a rigorous technique and a good patient selection.

Microsurgical management of complex middle cerebral artery aneurysms

Introduction Management of complex aneurysms of the middle cerebral artery (MCA) is very challenging and require individualized treatment strategies. The aim of our review was to analyze experience with the treatment of complex MCA aneurysms using revascularization and artery sacrifice techniques. Methods We have reviewed 9 original articles on patients' treatment with complex MCA aneurysms. Depending on localization of complex aneurysm of MCA various methods of parent artery sacrifice, revascularization strategies, surgical results, outcomes and complications were reviewed. Results We have analyzed treatment of 244 patients with 246 complex MCA aneurysms in 9 different groups. From 67 to 100% of cases the aneurysms were occluded successfully. Bypass patency being a result of the performed revascularization methods was from 83.3 to 100%. The main complications included ischemic disorders related to occlusion of the bypass graft or perforators injury. Morbidity in some reviews varied from 2.4 to 6.9%. The majority of patients in late follow-up showed good outcomes 0-2 on modified Rankin scale and 4-5 on Glasgow Outcome Scale. Illustrative clinical cases of the patients with complex MCA aneurysms treated at the Federal Neurosurgical Center were presented. Conclusion Complex aneurysms of the MCA are very challenging lesions. The surgical strategy for treating complex MCA aneurysm should take into account vascular anatomy, complex aneurysm morphology, its localization and rupture status of each case

The last resort during complex retrograde percutaneous coronary chronic total occlusion intervention: Extraplaque intracoronary lithotripsy to externally crush a heavy calcified occluded stent

Chronic total occlusions (CTO) due to in-stent restenosis represent a challenging lesion subset for percutaneous coronary intervention in particular when associated with coronary calcification. Sometimes CTO lesions require antegrade or retrograde dissection-re-entry techniques with extraplaque dilation. Recently intravascular lithotripsy (IVL) emerged as a therapeutic option for the treatment of severely calcified coronary lesions but its role in extraplaque dilation is not described. In this report, we present a case of retrograde complex percutaneous coronary chronic total occlusion revascularization accomplished by the use of extraplaque IVL necessary to externally crush a heavy calcified previous implanted stent.

Surgical management of benign tumors at the foramen magnum region

Tumors in the foramen magnum region are among the most challenging neurosurgical lesions to operate. They may be divided into intradural and extradural tumors, which have differing pathologies. Meningiomas represent the most common intradural tumor in this region. Anatomical constraints caused by adjacent critical areas of the brainstem, proximity to the lower cranial nerves (CNs), and vertebral arteries add to the complexity and make total tumor resection difficult without damaging the brain stem, CNs, or the vertebral artery and branches. This review article summarizes the surgical approaches and relevant anatomical landmarks with illustrations at each step. We also illustrate with example cases, the decision-making process and highlight key strategies for the safe resection of these tumors.