Involvement Of Internal Carotid Artery Research Articles

Transorbital Ultrasound in the Diagnosis of Giant Cell Arteritis.

The objective of this study was to prospectively evaluate the diagnostic efficacy of transorbital ultrasound (TOS) in patients newly diagnosed with giant cell arteritis (GCA), presenting with visual symptoms. Patients with newly diagnosed, untreated GCA were examined using TOS, assessing central retinal artery flow velocity [peak systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI)], and optic nerve diameter (OND). Vascular ultrasound was conducted to evaluate the superficial temporal arteries, their branches, facial, axillary, carotid, and vertebral arteries. We enrolled 54 GCA patients, 27 with visual symptoms, and 27 healthy controls. Eyes of GCA patients with visual symptoms demonstrated significantly lower PSV and EDV (PSV: β=-1.91; p=0.029; EDV: β=-0.57; p=0.032) and significantly elevated OND (β = 0.79; p=0.003) compared with controls. RI did not significantly differ from controls (β=-0.06, p=0.129). Vascular ultrasound identified an average of 8.7 (SD ± 2.8) pathological vessels per GCA patient. A significant negative association was observed between the number of affected vessels and both PSV (p=0.048) and EDV (p=0.040). No association was found with RI (p=0.249), while a positive significant association was noted with OND (p<0.001). This study pioneers the application of TOS to assess structural eye changes in newly diagnosed, untreated GCA patients with visual symptoms. Our findings suggest reduced central retinal artery flow and increased optic nerve diameter as potential biomarkers for serious ocular involvement in GCA. The detected association between internal and external carotid artery involvement indicates a common pathophysiological mechanism underlying systemic and ocular manifestations of GCA.

Magnetic resonance imaging in COVID-19-associated acute invasive fungal rhinosinusitis - Diagnosis and beyond.

The aim of the study was to evaluate the magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) at presentation and on follow-up imaging when patients receive treatment with systemic antifungal therapy and surgical debridement. This is a retrospective analysis of imaging data from a cohort of patients diagnosed with AIFRS during the second wave of COVID-19 in single tertiary referral hospital in South India between March 2021 and May 2021 (n = 68). Final diagnosis was made using a composite reference standard which included a combination of MRI findings, clinical presentation, nasal endoscopy and intraoperative findings, and laboratory proof of invasive fungal infection. Analysis included 62 patients with "Definite AIFRS" findings on MRI and another six patients with "Possible AIFRS" findings on MRI and laboratory proof of invasive fungal infection. Follow-up imaging was available in 41 patients. The most frequent MRI finding was T2 hypointensity in the sinonasal mucosa (94%) followed by mucosal necrosis/loss of contrast-enhancement (92.6%). Extrasinosal inflammation with or without necrosis in the pre-antral fat, retroantral fat, pterygopalatine fossa, and masticator space was seen in 91.1% of the cases. Extrasinosal spread was identified on MRI even when the computed tomography (CT) showed intact bone with normal extrasinosal density. Orbital involvement (72%) was in the form of contiguous spread from either the ethmoid or maxillary sinuses; the most frequent presentation being orbital cellulitis and necrosis, with some cases showing extension to the orbital apex (41%) and inflammation of the optic nerve (32%). A total of 22 patients showed involvement of the cavernous sinuses out of which 10 had sinus thrombosis and five patients had cavernous internal carotid artery involvement. Intracranial extension was seen both in the form of contiguous spread to the pachymeninges over the frontal and temporal lobes (25%) and intra-axial involvement in the form of cerebritis, abscesses, and infarcts (8.8%). Areas of blooming on SWI were noted within the areas of cerebritis and infarcts. Perineural spread of inflammation was seen along the mandibular nerves across foramen ovale in five patients and from the cisternal segment of trigeminal nerve to the root exit zone in pons in three patients. During follow-up, patients with disease progression showed involvement of the bones of skull base, osteomyelitis of the palate, alveolar process of maxilla, and zygoma. Persistent hyperenhancement in the post-operative bed after surgical debridement and resection was noted even in patients with stable disease. Contrast-enhanced MRI must be performed in all patients with suspected AIFRS as non-contrast MRI fails to demonstrate tissue necrosis and CT fails to demonstrate extrasinosal disease across intact bony walls. Orbital apex, pterygopalatine fossa, and the cavernous sinuses form important pathways for disease spread to the skull base and intracranial compartment. While cerebritis, intracranial abscesses, and infarcts can be seen early in the disease due to the angioinvasive nature, perineural spread and skull base infiltration are seen 3-4 weeks after disease onset. Exaggerated soft-tissue enhancement in the post-operative bed after debridement can be a normal finding and must not be interpreted as disease progression.

Analysis of the efficacy of endoscopic transnasal surgery for sinonasal and skull base adenoid cystic carcinoma

Objective: To evaluate the efficacy of endoscopic transnasal surgery for sinonasal and skull base adenoid cystic carcinoma (ACC), and to analyze the prognostic factors. Methods: Data of 82 patients (43 females and 39 males, at a median age of 49 years old) with sinonasal and skull base ACC who were admitted to XuanWu Hospital, Capital Medical University between June 2007 and June 2021 were analyzed retrospectively. The patients were staged according to American Joint Committee on Cancer (AJCC) 8th edition. The disease overall survival(OS) and disease-free survival(DFS) rates were calculated by Kaplan-Meier analysis. Cox regression model was used for multivariate prognostic analysis. Results: There were 4 patients with stage Ⅱ, 14 patients with stage Ⅲ, and 64 patients with stage Ⅳ. The treatment strategies included purely endoscopic surgery (n=42), endoscopic surgery plus radiotherapy (n=32) and endoscopic surgery plus radiochemotherapy (n=8). Followed up for 8 to 177 months, the 5-year OS and DFS rates was 63.0% and 51.6%, respectively. The 10-year OS and DFS rates was 51.2% and 31.8%, respectively. The multivariate Cox regression analysis showed that late T stage and internal carotid artery (ICA) involvement were the independent prognostic factors for survival in sinonasal and skull base ACC (all P<0.05). The OS of patients who received surgery or surgery plus radiotherapy was significantly higher than that of patients who received surgery plus radiochemotherapy (all P<0.05). Conclusions: Endoscopic transonasal surgery or combing with radiotherapy is an effective procedure for the treatment of sinonasal and skull base ACC. Late T stage and ICA involvement indicate poor prognosis.

Factors affecting the availability of hybrid cerebral and myocardial revascularization

Aim. To analyze factors affecting the availability of hybrid cerebral and myocardial revascularization by synchronous percutaneous coronary intervention (PCI) and carotid endarterectomy (CEA).Material and methods. This retrospective study included 263 patients with coronary and internal carotid artery involvement undergoing PCI and CEA during the period from 2011 to 2017.Results. The study revealed the following factors increasing the availability of revascularization: hybrid cerebral and myocardial revascularization, successful PCI using drug-eluting stents, postPCI TIMI flow grade 3, and radial access for PCI. The following factors reduced the availability: polyvascular disease &gt;50% in three beds, prior PCI, left ventricular ejection fraction &lt;50%, left coronary artery involvement, living without a family, staged revascularization, CEA before PCI, unsuccessful/complicated PCI with post-PCI TIMI flow grades of 0-1, residual SYNTAX score &gt;9, emergency hospitalization and multiple emergency PCI of the coronary arteries in the long-term follow-up period.Conclusion. Comprehensive analysis of clinical, demographic, anatomical, angiographic, and perioperative factors made it possible to identify predictors that affect the availability of hybrid revascularization.

Carotid endarterectomy in Russia. What if current guidelines do not answer difficult questions?

This literature review covers the publications of Russian vascular surgeons in recent years and deals with debatable issues of carotid surgery, including: 1. What is the best technique for carotid endarterectomy (CEA)? 2. Why does restenosis of the internal carotid artery (ICA) develop and how to eliminate it? 3. How to operate on bilateral ICA stenosis? 4. Should carotid glomus be preserved? 5. Is CEA safe in the acute phase of cerebrovascular accident (CVA)? 6. Is CEA safe in elderly patients? 7. How to operate on patients with combined internal carotid and coronary artery involvement? The evidence presented in this publication makes it possible to draw the following conclusions: 1. When choosing a CEA technique, the classical technique with patch angioplasty should be avoided due to the high risk of ICA restenosis. 2. To eliminate ICA restenosis, carotid angioplasty with stenting (CAS) should be used. When performing primary CEA with ICA transposition over the hypoglossal nerve, reCEA can be used 3. In the absence of contraindications, bilateral ICA stenosis can be operated at the same time using CEA. 4. CEA with carotid glomus preservation is the operation of choice in the treatment of patients with hemodynamically significant ICA stenosis due to the elimination of the risks of postoperative hypertension and the formation of hemorrhagic transformation. 5. If there are indications for cerebral revascularization in the most acute period of stroke, CEA should be abandoned in favor of CAS. 6. In old age, CAS is the safest treatment strategy. 7. In the presence of a combined ICA and coronary involvement, the choice of treatment tactics should be carried out only by a multidisciplinary commission, taking into account the risk stratification of adverse cardiovascular events.

Comparison of MRI Findings in Diabetic and Nondiabetic Patients with Rhino-Orbito-Cerebral Mucormycosis

Abstract Objective Rhino-orbito-cerebral mucormycosis (ROCM) has emerged as a key concern during the period of coronavirus disease 2019 (COVID-19) pandemic. Diabetes mellitus is a known risk factor for invasive fungal infection. The aim of this article was to study and compare the radiological features of COVID-19-associated ROCM between diabetic and nondiabetic patients using magnetic resonance imaging. Materials and Methods A retrospective observational study comprising 78 diabetics and 40 nondiabetics who developed ROCM after COVID-19 was conducted. The imaging data of both groups were analyzed, findings tabulated and compared using statistical methods. Results Maxillary and ethmoid sinuses were commonly involved in both groups. Periantral fat and orbits were the most common sites of disease extension. The spread of infection to periantral soft tissue was significantly higher in diabetics (p = 0.049). Diabetics were more likely to have bone, orbit, and brain involvement than nondiabetics, although the difference was not statistically significant. Diabetic patients were the only ones to experience complications such as fungal abscess and cavernous sinus and internal carotid artery involvement. However, a considerable number of nondiabetic patients (22.5%) also had an intracranial extension of disease. Conclusion The radiological appearances and common sites of invasion in ROCM are similar in diabetic and nondiabetic patients. The extensive spread of infection to extra-sinus regions can occur in nondiabetic patients with COVID-19 but is less frequent compared with diabetics.

Role of hybrid operating room in management of low-velocity penetrating brain injury

Penetrating brain injuries (PBIs) are a severe subtype of traumatic brain injuries (TBIs), where an object pierces the cranium and meninges. Based on the speed of penetration, it can be classified into high and low-velocity penetration. Low-velocity penetrating injury (LVPBI) cause lacerations to the scalp, depressed skull fractures as well as localized brain tissue and blood vessel damage along the object's path of travel. There have been many case reports and small case series published describing these events. However, there is no standardized guideline for general management to improve patient outcomes. In this report we discuss our experience of using the hybrid theatre to manage such cases. We present the clinical management of a 10-year-old boy who was shot in the head with a harpoon. Computed Tomography Angiography (CTA) demonstrated that the harpoon punctured through the jugular foramen and had a high probability of internal jugular vein (IJV) and internal carotid artery (ICA) involvement. The surgery was performed seven days after injury in a hybrid operating room (OR). We used intraoperative digital subtraction angiogram (DSA) to guide our decision to permanently occluded the IJV and ICA. The patient had a good postoperative recovery and was sent home after three weeks of observation in the hospital. Despite the high cost, intraoperative cerebral angiography in hybrid theatre for selected patients with penetrating brain injury where major blood vessel damage is anticipated might benefit overall patient outcome.

Cerebral infarction and risk factors in acute type A aortic dissection with arch branch extension.

Stanford type A aortic dissection (AAD) may affect the supra-aortic arteries, which are associated with acute ischemic stroke (AIS) or transient ischemic attack (TIA). This study aimed to investigate cerebral perfusion, the infarction incidence and risk factors in AAD patients. A total of 156 consecutive AAD patients were enrolled and divided into two groups according to whether the aortic arch branches were involved: the affected group (n = 90) and the unaffected group (n = 66). Clinical, echocardiographic/carotid Doppler data and cerebral infarction morbidity were compared between the groups. Independent predictors of 30-day AAD mortality were identified through multivariable Cox regression, and perioperative risk factors were analyzed. In total, 57.7% of AAD patients had aortic arch branch involvement. Abnormal Doppler waveforms were more common in the affected group (p <0.05). Regarding intracranial perfusion, the blood flow volumes (BFVs) of the bilateral internal carotid arteries (ICAs) and right vertebral artery (RVA) in the affected group were significantly reduced (p <0.05). The incidence of cerebral infarction in the affected group was significantly higher than that in the unaffected group (35.6% vs. 19.7%, p = 0.031). Multivariable analysis revealed that age >45 years old, right internal carotid artery (RICA) involvement and reduced left ventricular ejection fraction (LVEF) were significant predictors of perioperative death. Aortic arch branch involvement is common in patients with AAD and is associated with reduced cerebral blood flow (especially on the right side) and a higher incidence of cerebral infarction. Age, extension of the RICA dissection and LVEF impairment are independent risk factors for AAD-related death.

Giant Cell Arteritis - A Disease not to be Missed in Acute Ischemic Stroke

Giant cell arteritis is described classically as a medium and large vessel inflammatory disease. It generally affects the external carotid vascular system and causes its typical symptoms. However, relatively uncommon is its involvement of internal carotid artery to cause visual disturbances and ischemic strokes. Typically, ultrasonography of the superficial temporal artery shows classical feature of the disease i.e., halo sign with a high sensitivity. Biopsy of the affected vessel, even though less sensitive, is diagnostic. We are describing such a case of giant cell arteritis involving both external and internal carotid vascular system which is negative on biopsy and did not show typical ultrasonographic features but diagnosed based on clinical criteria. Additionally the patient also had a severe atherosclerotic carotid vascular disease. Both of which may be associated with ischemic stroke.

Carotid Artery Stenosis and Ischemic Strokes in Patients with Giant Cell Arteritis: A Characteristic Pattern-Literature Review and Case Report.

Purpose Ischemic stroke is a relatively rare complication of giant cell arteritis often accompanied by vessel stenosis. Our purpose was to compare the location of internal carotid artery stenosis in GCA patients by performing a literature review suggesting a specific and characteristic pattern. Methods We performed a PubMed research including all articles and cited articles reporting cases and case series about giant cell arteritis patients with internal carotid artery stenosis and ischemic strokes. Results In this case series 39 cases were included. We found a clear tendency of giant cell arteritis-related stenosis to be in the intracranial segments (35/39 (89.7%)). Only in 8/39 (20.5%) patients there was further involvement of extracranial segments. Many cases (27/39 [69.2%]) showed a bilateral involvement. Discussion This literature review reveals a specific pattern of internal carotid artery involvement in patients with giant cell arteritis and ischemic strokes. To our knowledge this pattern has not been reported as a sign strongly pointing toward giant cell arteritis before. We have not found case reports mentioning other common types of vasculitis reporting this involvement pattern. Conclusion Internal carotid artery stenosis and ischemic stroke is a rare complication in patients with giant cell arteritis. Considering the characteristic features of bilateral distal internal carotid artery stenosis giant cell arteritis should be suspected which potentially leads to an early diagnosis and immunotherapy.

Abstract 1122‐000193: Intracranial Bleeding in a Juvenile Nasopharyngeal Angiofibroma Stage IVb

Introduction : The trigeminocardiac reflex has been reported in craniofacial, neurosurgery, ophthalmological surgeries, and recently at endovascular procedures. Therefore, it has been called by other names also as trigeminal depressor reflex, reflex vagal trigeminal, or oculocardiac reflex. It is provoked by the stimulation of branches of the trigeminal nerve and presents cardiovascular alterations such as hypotension, bradycardia, cardiac arrhythmias, which can lead to asystole. This reflex originates at the brainstem and occurs as a rare autonomic dysfunction triggered by the stimulation of baroreceptors. Some factors predispose the appearance of this type of reflex, such as hypercapnia, hypoxemia, superficial anesthetic depth, and acidosis, among others. During these procedures is recommended continuous monitoring of the ECG and PAM. It is always essential to know the patient and modify the risk factors, or even stop the stimulus notifying the surgeon, if there is no adequate response, anticholinergic therapy, such as atropine, and the use of vasopressors should be applied. Methods : We report a clinical case of an 18‐year‐old male with a history of 3 years of recurrent epistaxis diagnosed with a Juvenilenasopharyngeal angiofibroma stage IVB, who underwent diagnostic cerebral angiography for surgical planning. Results : Angiography was performed under conscious sedation. When we placed the JB2 diagnostic catheter in the external carotid artery, the patient presented bradycardia of 40bpm. The catheter was removed, and the heart rate improved; we made a second attempt again with bradycardia, for which atropine was administered, and continued with the procedure without incident. We evaluated the vascular supply to the tumor and ruled out the involvement of the ipsilateral internal carotid artery. An occlusion test was also performed, which was positive. No aneurysms were found during angiography. At the end of the angiography, the patient presented anisocoria and left hemiparesis, so due to the suspicion of a thromboembolic event, a new femoral approach was performed to assess the intracranial circulation we found adequate patency. A non‐contrast head CT was performed, a subarachnoid hemorrhage in the prepontine and the interpeduncular cistern was observed. Medications used for sedation were discontinued to assess his neurological status at that time with GCS of 12. 48 hrs later, the patient was neurologically intact and without sequelae. In the literature review, we did not find reports of intracranial hemorrhage as complications in nasopharyngeal angiofibroma with intracranial extension or secondary to the presentation of the trigeminocardiac reflex. However, we suspected that it could result from a transient elevation of arterial hypertension due to the administration of anticholinergic therapy. Conclusions : Neuroanesthesiologists and endovascular surgeons must be aware of its manifestations and management to avoid complications due to the presentation of this reflex.

COVID-19 associated rhino-orbital-cerebral mucormycosis: An observational study from Eastern India, with special emphasis on neurological spectrum

Aims: 1Describe the epidemiology and determine risk factors for COVID-19 associated mucormycosis. 2Elaborate the clinical spectrum of Rhino-Orbital-Cerebral Mucormycosis (ROCM), pattern of neuroaxis involvement and it's radiological correlates. MethodsObservational study. Consecutive, confirmed cases of mucormycosis (N = 55) were included. A case of mucormycosis was defined as one who had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological examination (HPE). Data pertaining to epidemiology, risk factors, clinico-radiological features were analysed using percentage of total cases. ResultsMiddle aged, diabetic males with recent COVID-19 infection were most affected. New onset upper jaw toothache was a striking observation in several cases. Among neurological manifestations headache, proptosis, vision loss, extraocular movement restriction; cavernous sinus, meningeal and parenchymal involvement were common. Stroke in ROCM followed a definitive pattern with watershed infarction. ConclusionsNew onset upper jaw toothache and loosening of teeth should prompt an immediate search for mucormycosis in backdrop of diabetic patients with recent COVID-19 disease, aiding earlier diagnosis and treatment initiation. Neuroaxis involvement was characterized by a multitude of features pertaining to involvement of optic nerve, extraocular muscles, meninges, brain parenchyma and internal carotid artery.

Clinical, surgical and postoperative outcome analysis of tumors occupying both posterior and middle cranial fossa

Objectives: To analyse clinical, surgical and postoperative outcome perspectives of tumors occupying both middle and posterior cranial fossa.&#x0D; Materials and Methods: This retrospective cohort study includes 23 patients operated for tumors involving both middle and posterior cranial fossa in our department between August 2016 and August 2020. Each patient was evaluated for age, sex, co morbidities, tumour histopathology, clinical presentation, radiological characteristics, surgical and outcome characteristics. Unpaired t- test and chi-square test was used for statistical analysis. P &lt; 0.05 was considered statistically significant.&#x0D; Results: The mean age was 46 years (range 40–57 years), with the majority of patients being female (56.5%). Most tumors (65.3%) were trigeminal schwannoma, with the remaining being vestibular schwannoma (21.7%), facial schwannoma (8.7%) and epidermoid (4.3%). The most commonly used surgical approach was the retrosigmoid approach (30.4%) and combined approach (30.4%). Gross total resection (GTR) was done in 14 patients while subtotal resection (STR) was done in 9 patients. STR was significantly associated (p&lt;0.05) with persisting cranial nerve deficit and tumour progression. Midbrain compression, internal carotid artery and cavernous sinus involvement were significantly (p&lt;0.05) associated with STR.&#x0D; Conclusions: Trigeminal schwannoma is the most common tumour involving both middle and posterior cranial fossa. Combined approach for such tumours is required in tumours having significant size in both middle cranial fossa and posterior cranial fossa. The intent of surgery is to achieve a gross total resection (GTR) but adhesions and involvement of critical brain structures results in STR.

Skull base aneurysms: a retrospective review of fifteen cases focusing on the involvement of internal carotid artery

Objective: To explore the diagnosis and clinical features of internal carotid artery aneurysm in the skull base. Methods: The data of 15 patients with internal carotid aneurysms in the skull base diagnosed and treated by digital subtraction angiography (DSA) or CT angiography (CTA) in the Provincial Hospital Affiliated to Shandong First Medical University from 1995 to 2017 were collected and analyzed. Among the 15 patients, 12 were males, and 3 were females, aging from 17 to 67 years old, with a median age of 44 years. Thirteen patients were diagnosed by DSA; the other two patients were diagnosed by CTA. Thirteen patients were diagnosed with pseudoaneurysm with the first symptom of epistaxis, in which eight patients underwent head trauma and 5 underwent radiotherapy of skull base tumor. The other two patients were diagnosed with true aneurysm presented headache and cranial nerve disorder. All patients were followed up for 2 to 12 years after treatment to see whether they were cured and survived. Results: Among the eight patients with a history of trauma, five patients were cured by embolization, two patients without embolization died of massive epistaxis, one patient died of progressive cerebral infarction after embolization. Among the five patients with radiotherapy of skull base tumor, one patient died of cerebral infarction after embolization, two patients died out of the hospital due to the recurrence of the primary tumor and intracranial invasion, one patient recovered well after embolization and surgical operation, one patient gave up treatment and died of massive hemorrhage out of hospital. In the other two patients with symptom of headache, one received embolization treatment outside the hospital after receiving mistake operation, and another one gave up treatment and died due to personal reasons. In total, four patients died in hospital, four died out of the hospital, and seven patients survived. Conclusions: Internal carotid artery aneurysm is a high-risk disease of anterior and middle skull base. For patients with epistaxis with a history of trauma and radiotherapy or patients with headaches and cranial nerve disorders, the possibility of the internal carotid artery aneurysm should be considered, in which DSA or CTA examination is essentially required for ensured diagnosis and disease evaluation.. The correct diagnosis and treatment by the otolaryngologist are crucial to the prognosis of the patient.

Management of advanced cholesteatoma: Madras ENT Research Foundation experience

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Cholesteatoma is a common condition encountered by the otolaryngologist in the Indian subcontinent. Due to absence of pain in most patients, they may have advanced disease at presentation. Lack of awareness, long distance between the patient’s home and the treatment centre are also reasons for late presentation. Surgical management is the mainstay of treatment. The aim of this study was to retrospectively analyze the number of patients with advanced cholesteatoma, the extent of disease, and associated complications.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Fifty one patients out of a total of 1132 patients with cholesteatoma presented with advanced disease in a tertiary referral centre between January 2010 to January 2020. The surgical issues in the management of the disease and the outcomes were studied. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Fifty one patients presented with extensive cholesteatoma in a tertiary referral centre. There were 33 males and 18 females in the study. Of fifty one patients, pediatric cholesteatoma was seen in 6 patients. Hearing loss was the most common presentation. Facial palsy, labyrinthine fistula, dural involvement, internal auditory meatus involvement was noted in some patients. All patients underwent surgical management with good outcomes.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Advanced cholesteatoma is a dreaded disease that can result in various complications. Involvement of the facial canal, labyrinth, cochlea, dura, internal auditory meatus, internal carotid artery, jugular bulb, and sigmoid sinus involvement in the presence of extensive disease should be identified before surgery. Appropriate treatment with complete disease clearance can result in good outcomes.&lt;/p&gt;

Rapidly progressive fatal orbito-cerebral mucormycosis in an immunocompetent patient following entry of an insect into his eye; a case report and literature review

Mucormycosis, an uncommon and rapidly progressive fungal infection, is mainly seen in immunocompromised patients. However, immunocompetent individuals can also be infected. Here, we present a rapidly progressive orbito-cerebral mucormycosis in an immunocompetent patient, who had a history of entry of an insect into his eye. We report an immunocompetent patient, who had a history of entry of an insect into his eye, presented with left eye panophthalmitis, cellulitis and loss of vision. He underwent orbital exenteration. Then, mucormycosis was diagnosed and amphotericin B was initiated. Left cavernous sinus and internal carotid artery involvement were found in brain magnetic resonance imaging (MRI) and cerebrovascular accident (CVA) was diagnosed. Surgical debridement of necrotic tissue was performed, and postoperatively, our patient died following CVA. Mucormycosis, as a fatal fungal infection, requires early diagnosis, appropriate early surgical and rapid antifungal management so that successful outcome can be achieved.

Predictors of Good Outcomes in Patients with Failed Endovascular Thrombectomy.

ObjectiveEndovascular thrombectomy (EVT) fails in approximately 20% of anterior circulation large vessel occlusion (AC-LVO). Nonetheless, the factors that affect clinical outcomes of non-recanalized AC-LVO despite EVT are less studied. The purpose of this study was to identify the factors affecting clinical outcomes in non-recanalized AC-LVO patients despite EVT.Materials and MethodsThis was a retrospective analysis of clinical and imaging data from 136 consecutive patients who demonstrated recanalization failure (modified thrombolysis in cerebral ischemia [mTICI], 0–2a) despite EVT for AC-LVO. Data were collected in prospectively maintained registries at 16 stroke centers. Collateral status was categorized into good or poor based on the CT angiogram, and the mTICI was categorized as 0–1 or 2a on the final angiogram. Patients with good (modified Rankin Scale [mRS], 0–2) and poor outcomes (mRS, 3–6) were compared in multivariate analysis to evaluate the factors associated with a good outcome.ResultsThirty-five patients (25.7%) had good outcomes. The good outcome group was younger (odds ratio [OR], 0.962; 95% confidence interval [CI], 0.932–0.992; p = 0.015), had a lower incidence of hypertension (OR, 0.380; 95% CI, 0.173–0.839; p = 0.017) and distal internal carotid artery involvement (OR, 0.149; 95% CI, 0.043–0.520; p = 0.003), lower initial National Institute of Health Stroke Scale (NIHSS) (OR, 0.789; 95% CI, 0.713–0.873; p < 0.001) and good collateral status (OR, 13.818; 95% CI, 3.971–48.090; p < 0.001). In multivariate analysis, the initial NIHSS (OR, 0.760; 95% CI, 0.638–0.905; p = 0.002), good collateral status (OR, 14.130; 95% CI, 2.264–88.212; p = 0.005) and mTICI 2a recanalization (OR, 5.636; 95% CI, 1.216–26.119; p = 0.027) remained as independent factors with good outcome in non-recanalized patients.ConclusionBaseline NIHSS score, good collateral status, and mTICI 2a recanalization remained independently associated with clinical outcome in non-recanalized patients. mTICI 2a recanalization would benefit patients with good collaterals in non-recanalized AC-LVO patients despite EVT.

The sign of the cross

Acute, painful, transient, right-sided, monocular visual loss lasting 4 hours developed in a 46-year-old man. This was followed by headache and left-sided transient hemiparesis. The association of ipsilateral transient vision loss with transient contralateral hemiparesis implicates involvement of the ipsilateral internal carotid artery (i.e., a crossed symptom).

A Simple Scoring System to Predict the Resectability of Skull Base Meningiomas via an Endoscopic Endonasal Approach

To identify clinico-radiologic factors associated with incomplete anterior cranial fossa (ACF) meningioma resection via an endoscopic endonasal approach. Patients undergoing endoscopic endonasal resection of an ACF meningioma were retrospectively accrued from two university-affiliated centers. Demographic profiles and radiologic findings, including tumor dimensions and morphology, anatomic location, and vascular involvement, were stratified according to the extent of resection. Twenty-five patients were included in this study. Factors associated with incomplete surgical resection via an endonasal route were: presence of hyperostosis (P= 0.04), cavernous internal carotid artery involvement (P= 0.001), maximal dural tail length in the transverse plane (P= 0.006), and its ratio to the inter-fovea ethmoidalis distance (P= 0.01). Using a multiple regression analysis, only cavernous internal carotid artery involvement (P= 0.002) and a large dural tail length to inter-foveal distance ratio (P= 0.04) were significant predictors of incomplete resection (multiple correlation coefficient= 0.71). The combination of predictive factors to determine the likelihood of complete endoscopic resection produced a scoring system with a sensitivity and specificity of85.7% (95% confidence interval [CI], 42.1-99.6] and 100% (95% CI, 81.5-100), respectively. The use of a simple scoring system outlined in our study can facilitate proper patient selection for endoscopic endonasal resection of ACF meningiomas.

Spontaneous Middle Cerebral Artery Dissection with Distal Internal Carotid Artery Involvement Confirmed by High-Resolution MRI

허혈성 뇌졸중의 원인 중 동맥박리는 흔히 발견되지는 않지 만, 비교적 청장년층에 발생하는 뇌졸중의 주요 원인으로 알 려져 있다. 주로 경추부 내경동맥이나 척추동맥에 발생하며, 두개내 동맥에 국한된 동맥박리는 매우 드물게 관찰된다. 특 히 두개내 동맥박리 중 전순환영역 동맥박리는 후순환영역에 비해 더욱 드물게 관찰되며, 이전 문헌들에 의하면 상상돌기 분절(supraclinoid segment) 내경동맥과 중대뇌동맥의 시작 부 위에 주로 발생하는 것으로 알려져 있다. 또한 전순환영역 두 개내 동맥박리 중 중대뇌동맥박리는 단독으로 발생하기도 하 지만, 내경동맥박리와 동반되어 관찰되기도 한다. 두개내 동 맥박리는 컴퓨터단층혈관조영술, 자기공명영상 및 자기공명 혈관조영술로 진단할 수 있으나, 고식적인 뇌영상기법을 통한 진단은 동맥박리의 위치와 침범 범위를 정확하게 파악하는데 제한적이다. 저자들은 중대뇌동맥박리가 의심되는 환자에서 고해상도 자기공명영상(high-resolution MRI)을 통한 내경동맥 박리의 동반을 확인하였기에 보고하는 바이다.