Multiple Sinus Research Articles

Molecular identification of Actinomadura madurae isolated from a patient originally from Algeria; observations from a case report

BackgroundMycetoma is a chronic granulomatous subcutaneous infection caused by anaerobic pseudofilamentous bacteria or fungi. It is commonly prevalent in tropical and subtropical countries. Men are more susceptible to the disease due to greater participation in agricultural works. Mycetoma commonly involves lower extremities, wherein untreated cases lead to aggressive therapeutic choices, such as amputation of the affected body organs and consequently lifelong disability.Case presentationIn this report, we present the rare case of a 58-year-old man, originally from Algeria with a left foot chronic tumefaction of 5 years. In the initial clinical examination, mycetoma was diagnosed based on tumefaction and the presence of multiple sinuses with the emission of white grains. The latter was observed via direct examination. The histopathological analysis demonstrated an actinomycetoma caused by bacteria, as the etiological agent. Imaging showed a bone involvement with osteolysis at the levels of 2nd to 4th metatarsal diaphysis. The mycological and bacterial cultures were both negative. For an accurate diagnosis, the obtained grains were subjected to molecular analysis, targeting the 16S-rDNA gene. Molecular identification yielded Actinomadura madurae as the causal agent, and 800/160 mg of trimethoprim/sulfamethoxazole was prescribed twice a day for 1 year, as a treatment.ConclusionConsidering low information about this disease, especially in non-endemic areas, it is of high importance to enhance the knowledge and awareness of clinicians and healthcare providers, in particular in the countries with immigration issues.

Geological evolution of the Sinus Iridum basin

As a semi-enclosed crater basin on the northwest rim of Imbrium basin, Sinus Iridum is a key site to investigate the geological characteristics at the intersection of two basins. For this reason, we focused on model age determination in Sinus Iridum basin using Chang’E−2 high-resolution images coupled with compositional maps from the Clementine data sets, as well as with digital elevation models (DEMs) from the Lunar Orbiter Laser Altimeter (LOLA) onboard the Lunar Reconnaissance Orbiter (LRO). With these datasets we identified different geologic units onto which we performed model age determinations based on crater counting. This systematic analysis of the Sinus Iridum basin shows that the age of the oldest exposed basaltic unit is 3.37 ​Ga (Imbrian age), while the youngest, a mare basalt unit that enters the basin from Imbrium basin, is 1.24 ​Ga (late Eratosthenian). In general, the ages of the geologic units inside the Sinus Iridum basin gradually decrease from the northeast to the southwest, with the only exception of the young units being located in the north-eastern area. We conclude that the crater size-frequency distributions (CSFD) reflect a multi-layer sequence, suggesting multiple resurfacing events inside Sinus Iridum. The model age determinations identify several infilling events of basalts ranging from 3.37 ​Ga to 1.24 ​Ga, which are all derived mare basalt flows from the Imbrium basin.

Assessment of Patients with Intracerebral Hemorrhage or Hemorrhagic Transformation in the VENOST Study

Introduction: Cerebral venous and sinus thrombosis (CVST) may lead to cerebral edema and increased intracranial pressure; besides, ischemic or hemorrhagic lesions may develop. Intracerebral hemorrhages occur in approximately one-third of CVST patients. We assessed and compared the findings of the cerebral hemorrhage (CH) group and the CVST group. Materials and Methods: In the VENOST study, medical records of 1,193 patients with CVST, aged over 18 years, were obtained from 35 national stroke centers. Demographic characteristics, clinical symptoms, signs at the admission, radiological findings, etiologic factors, acute and maintenance treatment, and outcome results were reported. The number of involved sinuses or veins, localizations of thrombus, and lesions on CT and MRI scans were recorded. Results: CH was detected in the brain imaging of 241 (21.1%) patients, as hemorrhagic infarction in 198 patients and intracerebral hemorrhage in 43 patients. Gynecologic causes comprised the largest percentage (41.7%) of etiology and risk factors in the CVST group. In the CH group, headache associated with other neurological symptoms was more frequent. These neurological symptoms were epileptic seizures (46.9%), nausea and/or vomiting (36.5%), altered consciousness (36.5%), and focal neurological deficits (33.6%). mRS was ≥3 in 23.1% of the patients in the CH group. Discussion and Conclusion: CVST, an important cause of stroke in the young, should be monitored closely if the patients have additional symptoms of headache, multiple sinus involvement, and CH. Older age and parenchymal lesion, either hemorrhagic infarction or intracerebral hemorrhage, imply poor outcome.

Frontal sinus inverted papilloma: Osteoplastic flap approach

Inverted papilloma of sinonasal system is a benign tumour comprising of 0.5% to 4% of all nasal tumours having locally aggressive features. Recurrence is common and can cause bone destruction. Clinically, the most common presentation is unilateral nasal obstruction. Isolated frontal sinus inverted papilloma maybe hidden for long time without any symptoms. A 55 yr old man with recurrent sinonasal polyposis who underwent endonasal surgery on multiple occasions presented to us with complaints of unilateral nasal obstruction, anosmia, fronto-temporal headache since 9 years which aggravated during past 6 months. Following admission CT – Para Nasal Sinuses showed sinonasal polyposis involving bilateral frontal , right maxillary sinuses with hyperdense lesions in frontal sinuses and multiple sinus wall erosions with exposure of dura. Patient was planned for Functional Endoscopic Sinus Surgery and osteoplastic flap without frontal sinus obliteration after adequate premedication. Intra-operatively frozen section revealed inverted papilloma histopathologically. Complete clearance of tumour was achieved via osteoplastic approach.In our case complete excision of the mass was very important because recurrence after surgery is between 25% -35% for inverted papillomas. There are difficulties in handling papillomas of the frontal sinus. Despite advances in endoscopic sinus surgery these may require open surgical approach to the frontal sinus. So, osteoplastic flap approach provides a safe and effective way to deal with these pathologies.

Acute lymphoblastic leukemia complicated with cerebral venous thrombosis in 14 children

Objective: To explore the clinical characteristics and management of childhood acute lymphoblastic leukemia (ALL) complicated with cerebral venous thrombosis (CVT). Methods: The clinical data of 14 ALL children complicated with CVT who were admitted to Department of Pediatrics of Sun Yat-sen Memorial Hospital and underwent chemotherapy from January 2011 to October 2019 were collected retrospectively. The clinical manifestations, coagulation function, imaging findings, treatment plan and prognosis of patients were analyzed. Results: CVT was diagnosed in 14 (2.8%, 14/505) cases, with a median age of 10 (3-14) years at onset, 11 cases occurred in the stage of induction remission, and the acute onsets were mainly characterized by convulsions (9 cases), consciousness disorders (6 cases) and headache (4 cases). Coagulation function test showed that, before the CVT, antithrombin Ⅲ activity was lower than 60% in 8 cases, D-dimer elevated on the day of onset in 8 cases. Arteriovenous angiography showed filling defects in single (9 cases) or multiple (5 cases) venous sinuses. The most common site of venous sinus enlargement was superior sagittal sinus (10 cases). Secondary cerebral hemorrhage was found in 5 cases. Anticoagulation therapy included combination of low-molecular-weight heparin (LMWH) and warfarin in 9 cases, sequential application of LMWH and warfarin in 2 cases, and LMWH alone in 3 cases. Patients accepted further asparaginase and no CVT recurrence or progression was found. Conclusions: The secondary coagulation dysfunction during induction remission chemotherapy is the major risk factor for CVT in ALL, which needs active monitoring and early prevention. Arteriovenous angiography can diagnose accurately, and the prognosis of anticoagulant therapy with LMWH and warfarin is optimistic.

EVALUATION OF MORPHOLOGICAL CHANGES OF THE PARANASAL SINUS IN COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING MODALITIES

Objectives: The objective of the study was to evaluate the prevalence of pathological conditions and anatomical variations occurring within paranasal sinus among the patients undergoing computed tomography (CT) scan and magnetic resonance imaging (MRI) scan in Gurugram district.
 Methods: A prospective study was conducted among 20 patients in each modality, the patient undergoing the CT of paranasal sinus and patients undergoing routine MRI brain study. The clinical findings from CT and MRI were taken as primary data and later on compiled together under different variables to assess the occurrence of paranasal sinus disease and anatomical variations within.
 Results: The present study revealed that the most common pathology was mucosal thickening followed by polyp and the occurrence of air-fluid level; maxillary sinus being commonly affected. In patients undergoing CT, the most common anatomical variation was deviated nasal septum, that is, 16 out of 20 patients followed by the bone spur formation. In the patients undergoing routine MRI brain, most of the patient had mucosal thickening <5 mm. In the lining of maxillary sinus, moderate hyperintensity was reported.
 Conclusion: Based on the study, it is concluded that mucosal thickening is most commonly evident pathology with maximum occurrence seen in the maxillary sinus. The co-occurrence of more than 1 anatomical variation and involvement of multiple paranasal sinuses were seen positive. MRI was found more sensitive in assessing the early changes in sinus mucosal abnormalities.

Простые и окололоханочные кисты почек

The topic of renal cystic lesions is described in the article. The localization and structure of solitary, parapelvic and multiple sinus cysts are discussed. The Bosniak classification (1986) is presented, as well as the updated Bosniak classification, in which a number of modifications in 2019 were made. The contemporary diagnostic methods are mentioned, as well as factors that allow to select patient for active surveillance. Current surgical procedures are presented.

Trends in complications after functional endoscopic sinus surgery in Japan: A comparison with a previous study (2007–2013vs. 2013–2017)

ObjectiveFunctional endoscopic sinus surgery (FESS) for chronic rhinosinusitis is considered safe and is widely performed. Techniques and devices for this type of surgery have recently been updated. The purpose of this study was to describe the proportions of complications after FESS (2013–2017) and to compare the results with those from our previous study (2007–2013). MethodsWe obtained data on 70,288 patients who underwent FESS from April 2013 to March 2017 from a Japanese national inpatient database. We classified FESS into four types: single sinus surgery (ESS Type 2), multiple sinus surgery (ESS Type 3), whole sinus surgery (ESS Type 4), and extensive sinus surgery (ESS Type 5). We investigated the proportions of complications after FESS, including cerebrospinal fluid leakage, meningitis, orbital injury, severe hemorrhage, and toxic shock syndrome. We performed a multivariable logistic regression analysis with adjustment for within-hospital clustering to evaluate the association between the occurrence of overall complications and patient characteristics. ResultsThe proportion of overall complications was 0.50%. The proportions of patients with cranial complications, orbital complications, hemostasis operations, blood transfusion, and toxic shock syndrome were 0.11%, 0.04%, 0.05%, 0.30%, and 0.03%, respectively. The extent of FESS was not associated with the occurrence of overall complications. The occurrence of overall complications was associated with the severity of comorbidities and the academic hospital status. Asthma and use of a microdebrider were associated with a lower occurrence of overall complications. ConclusionThe proportion of overall complications after FESS in the present study was similar to that reported in our previous study. The extent of FESS and eosinophilic chronic rhinosinusitis were not associated with the occurrence of overall complications.

SAT-519 Armour Thyroid and Liothyronine Combination Potentiated Thrombosis

Objective To describe a case presentation of multiple sinus thrombosis while on combination therapy of liothyronine and Armour Thyroid for Hashimoto’s thyroiditis with other risk factors of thrombosis. Methods A case report with medical history, diagnostic and treatment course is presented with discussion. Results A 47-year-old female with a history of Hashimoto’s thyroiditis on liothyronine and Armour Thyroid, on oral contraceptive use and cigarette smoking presented to Emergency Room with complaints of severe headache, neck pain and dizziness later developing confusion, word-finding difficulty and various left-sided neurological deficit. She was found to have superior sagittal sinus and right transverse sinus thrombosis, both with partial to complete occlusion and involved hematoma. Patient went through endovascular intervention for successful thrombectomy with recanalization, and neurosurgical intervention for decompressive evacuation of hematoma. Patient was found to have undetectably low thyroid stimulating hormone level, and her base-line level from one year ago was 0.147 milli-international units per liter while having been on liothyronine and Armour Thyroid for years. Patient was started on daily oral levothyroxine and recovered eventually from neurological deficits. Repeated thyroid function test showed improving results. Evaluation for other causes of thrombosis included positive results for prothrombin gene mutation, confirming her inherited thrombophilia condition that has been undiagnosed until this event. Discussion Primary hypothyroidism is one of the most prevalent endocrine disorders, occurring in up to 5% of the population. While synthetic thyroxine has been standard therapy for the primary hypothyroidism for many years, many alternative thyroid therapies have resurfaced recently. For instance, there has been increasing trend of using liothyronine in addition to levothyroxine with symptomatic benefit despite insufficient evidence. Armour Thyroid, which is a natural porcine derivative thyroid supplement often used as a weight loss supplement without proper monitor by physician, has repeatedly been controversial. Many studies have raised concerns for cardiovascular disease including arrhythmia with high thyroid hormone level. Also a number of case reports have shown association with hyperthyroidism and pro-thrombotic state. Although there are scarce publications associating liothyronine or Armour Thyroid and hypercoagulable thrombotic event, significant drug interactions may exist with patient who are more vulnerable with inherited condition or other risk factors.

Incidence and extent of sinus procedures in treatment of pediatric orbital cellulitis

IntroductionIt is unknown the optimal extent of sinus surgery in pediatric patients with orbital cellulitis. Our aim was to determine the nationwide incidence of sinus procedures used to treat pediatric orbital cellulitis. Additionally, we sought to identify patient-factors that influence a multi-procedural approach. MethodsCross-sectional analysis of 15,260 cases of primary pediatric orbital cellulitis identified in the Kids’ Inpatient Database (KID) from January 1, 2003 to December 31, 2012. Cases were included if they contained a primary diagnosis code of orbital cellulitis. Frequency of sinus procedures in relation to pediatric age cohort were noted (≤8 years versus 9–20 years). Comorbidities, cost, and length-of-stay were compared between age cohorts. Multivariate models investigated patient-factors associated with multiple sinus procedures and patient-factors that affected hospital costs and length-of-stay. ResultsChildren ≤8 years of age constituted 67% of cases (n = 10,290). 1103 cases (7.2%) were treated with at least one defined sinus procedure; and, 712 of these cases documented more than one sinus procedure. The younger cohort (≤8 years) exhibited fewer sinus procedures and a lower rate of reoperation (4.6% vs 12.8%, p < .001; 5.1% vs 7.7%, p < .001, respectively). Presence of cellulitis/abscess of the face was the strongest predictor of multiple sinus procedures (OR = 1.982, p = .033). Patients with acute sinusitis and those >8 years had similarly increased odds of a multi-procedural approach (OR = 1.333, p = .049; OR = 1.367, p = .032, respectively). Multivariate analysis of cost and length-of-stay found that patients >8 years incurred 14% longer hospital stays and an increase in costs of 9% compared to younger patients (p = .001, p = .039; respectively). The secondary diagnosis with the largest effect on length-of-stay and cost was an intracranical abscess (OR = 2.352, p < .001; OR = 2.752, p < .001; respectively). ConclusionIn a nationwide population of pediatric patients with primary orbital cellulitis there was an incidence of sinus surgery in 7.2% of cases - with patients over 8 years having a 2.8-fold increase compared to younger patients. Additionally, nearly two-thirds of patients treated with sinus surgery had multiple sinus procedures. The high incidence of multiple sinus procedures suggests that further prospective studies are needed to elucidate the extent of drainage associated with the best patient outcomes.

Host genetic susceptibility to mycetoma.

Mycetoma is one of the badly neglected tropical diseases, characterised by subcutaneous painless swelling, multiple sinuses, and discharge containing aggregates of the infecting organism known as grains. Risk factors conferring susceptibility to mycetoma include environmental factors and pathogen factors such as virulence and the infecting dose, in addition to host factors such as immunological and genetic predisposition. Epidemiological evidence suggests that host genetic factors may regulate susceptibility to mycetoma and other fungal infections, but they are likely to be complex genetic traits in which multiple genes interact with each other and environmental factors, as well as the pathogen, to cause disease. This paper reviews what is known about genetic predisposition to fungal infections that might be relevant to mycetoma, as well as all studies carried out to explore host genetic susceptibility to mycetoma. Most studies were investigating polymorphisms in candidate genes related to the host immune response. A total of 13 genes had allelic variants found to be associated with mycetoma, and these genes lie in different pathways and systems such as innate and adaptive immune systems, sex hormone biosynthesis, and some genes coding for host enzymes. None of these studies have been replicated. Advances in genomic science and the supporting technology have paved the way for large-scale genome-wide association and next generation sequencing (NGS) studies, underpinning a new strategy to systematically interrogate the genome for variants associated with mycetoma. Dissecting the contribution of host genetic variation to susceptibility to mycetoma will enable the identification of pathways that are potential targets for new treatments for mycetoma and will also enhance the ability to stratify ‘at-risk’ individuals, allowing the possibility of developing preventive and personalised clinical care strategies in the future.

What Is the Role of the Endoscope in the Sinus Preservation Management of Frontal Sinus Fractures?

The management of frontal sinus fractures has remained controversial. The present study investigated the role of minimally invasive endoscopic surgery in a sinus preservation treatment protocol and described the ideal approach for each frontal sinus fracture type. We performed a prospective cohort study of patients with multiple frontal sinus fracture types. Patient demographic data, including age, gender, and cause of the fracture, were recorded. Four main management methods were proposed. Group A underwent observation only, group B underwent reduction and fixation of the anterior table, group C underwent endoscopic management of the frontal sinus outflow tract (FSOT), and group D underwent cranialization with an assessment of FSOT. The outcome measurements were the correction of the clinical deformity, which was determined by comparison of the preoperative and postoperative images, and the patent frontal sinus drainage, which was measured on the postoperative radiologic sagittal and coronal views of the frontal recess. The long-term outcomes were confirmed by the absence of long-term complications on postoperative follow-up examinations. Statistical analysis and comparisons were performed using SPSS software (IBM Corp, Armonk, NY). A total of 60 patients (52 men, 8 women; mean age, 29.5±8years) were included in the present study. Of the 60 patients, 20 were in group A, 20 in group B, 16 in group C, and 4 in group D. All 60 patients had undergone correction of the deformity and had a patent FSOT postoperatively. No long-term complications were encountered in the follow-up period (median, 24months; range, 12 to 36months). Endoscopic evaluation of the FSOT is of great importance in the surgical management of frontal fractures, because it allows for sinus preservation. The outcomes achieved in the present study were the result of selecting the right management plan for each fracture type.

Angio-architecture of complex cranial dural arteriovenous fistulas: A single centre retrospective review of treatment modalities and outcomes

IntroductionCranial dural arteriovenous fistulas (DAVFs) are rare vascular lesions that often harbour complex angio-architectural features. This subtype of DAVF may require multiple, multimodality, or hybrid treatments. In this paper we aim to identify specific angio-architectural features that are present in complex cranial DAVFs and we report our series with respect to treatment modalities and outcomes. MethodsTwenty-five cranial Borden type II and III cranial DAVFs were treated at our Institution from 2013 to 2017. We classified nine (36%) as complex based on specific angio-architectural features. Treatment strategies were based on fistula location, angiographic features and patient's presenting condition. Phone interviews were used to confirm outcome at 6 and 12 months. ResultsFour patients (45%) presented with acute hydrocephalus, and 3 (33%) with intracranial hemorrhage. Multiple and combined treatment sessions were needed for all complex DAVFs. Five patients required 2 endovascular procedures each. One patient had 2 surgeries. The first line of treatment was endovascular in 6 cases (67%) and surgery in 3 (33%). Two treatment-related (22%) complications occurred. Complete disconnection was achieved in 5 out of 9 patients (55%). Two patients with an incomplete disconnection refused further treatment and were well at last follow up, with a partially treated fistula and persistent CVR. The other 3 patients concluded treatment after the end of our data collection period. At 1 year, 7/9 patients had stable or improved clinical symptoms, and 8/9 patients had GOS of 4 or 5. ConclusionsComplex cranial DAVF often require a multidisciplinary approach and multiple treatment sessions should be expected. Specific angio-architectural features that increase DAVF complexity include multiple arterial feeders, especially transosseous or pial, reflux into multiple cortical veins, sinus occlusion/entrapment, venous aneurysms, segmental stenosis, medial or deep location, and association with the deep venous system.

Treatment of Pilonidal Sinus by Limberg Flap-Only Hope of Cure (Study of 50 Cases)

Background : Pilonidal sinus was first described by Dr. A.W. Anderson in 1847 and is often seen in the intergluteal region. It is a disease of mainly younger male and rarely affects after 40. Main causes for the formation of this sinus are hirsutism, sweating in the area, repeated maceration due to trauma, leading to breakage of the skin barrier, attracting hair inside which initiates a foreign body reaction leading to infection with abscess or sinus formation. Most common embarrassing situation is discharging sinus. The diagnosis is mainly on clinical ground. Though there are a lot of modalities of treatment but recurrence is still a challenge. We have adopted Limberg flap technique since 2012 with a least recurrent chance.&#x0D; Objectives : To prove that this procedure will be end up with lower morbidity &amp; least chance of recurrence&#x0D; Methods : This prospective study was done jointly by the Department of Surgery of Central Medical College and Comilla Medical College Hospital. In this series 50 patients were selected from July 2012 to June 2017.&#x0D; Results : Out of 50 patients operated by Limberg flap technique 42(84%) were males and 8(16%) were females. Mean age was 27.3 years (range 18–37years). Of them,12(24%) were driver, 6(12%) police, 6(12%) teacher, 6(12%) student, 5(10%) worker, 4(8%) millitary army, 4(8%) housewife, 4 (8%)service holder, 2(4%) computer operator, 1(2%) doctor and 1(2%) were barber. In our study most common mode of presentation were chronic discharging sinuses 15(30%), beside this 12(24%) had multiple sinuses, 10(20%) had multiple pits,7(14%) had acute abscess and 6(12%) had unpleasant smell. Associated hirsutism were present in 30(60%) and absent in 20(40%) patients. One (2%) male patient had wound gap &amp; discharge and six(12%) patients had flap edema. We have found no recurrence in follow up period.&#x0D; Conclusion : Pilonidal sinus is a notoriously recurrent disease, so treatment by this flap technique is the only hope of cure with lower morbidity.&#x0D; Journal of Surgical Sciences (2018) Vol. 22 (2) : 89-94

Bacterial Flora of the Nose and Paranasal Sinuses Among Patients Over 65 Years Old with Chronic Rhinosinusitis Who Underwent Endoscopic Sinus Surgery.

PurposeChronic rhinosinusitis (CRS) is one of the most common chronic diseases in the geriatric population. However, CRS inflammatory mechanisms in older people have not been thoroughly investigated. Our work aimed to analyze the bacterial flora of the nose and paranasal sinuses in patients with CRS over 65 years of age, including comorbidities, previously performed endoscopic sinus surgery (ESS), presence or absence of polyps and the extent of the inflammatory process.Patients and MethodsThe study involved 529 patients between 18 and 84 years of age with chronic rhinosinusitis who underwent endoscopic sinus surgery. There were 101 patients separated over 65 years of age (M = 52, K = 49, mean age 69 ± 0.7 years). The control group consisted of 168 patients aged 18–40 years with CRS. The bacterial culture of material collected from the patients during ESS was analyzed.ResultsIn the group of patients over 65 years of age, more frequent occurrence of Proteus spp. and Pseudomonas aeruginosa was found in comparison to younger patients. In older patients with bronchial asthma, the occurrence of S. aureus, Escherichia coli, and Citrobacter spp. was more frequent than in control group. Multiple sinus surgical procedures in older patients were associated with the dominance of Staphylococcus aureus and Escherichia coli, which was not demonstrated in the control group. There were no statistically significant differences between the occurrence of bacterial strain and the presence of polyps, both in the group of patients over 65 years of age as well as in the control group.ConclusionThe bacterial flora of patients with CRS is different in older and younger patients. A different therapeutic approach should be considered in older patients with CRS, but this problem requires further studies.

Unusual presentation of an extraoral and multiple intraoral sinus tracts in a 6-year-old pediatric patient

Unusual presentation of an extraoral and multiple intraoral sinus tracts in a 6-year-old pediatric patient

Cerebral Venous Sinus Thrombosis in Children: A Study from a Tertiary Care Hospital of Eastern India.

ABSTRACTContext:Cerebral venous sinus (sinovenous) thrombosis (CVST) in childhood is a rare, but under recognized, disorder, typically of multifactorial etiology, with neurologic sequelae apparent in up to 40% of survivors and mortality approaching 10%.Aim:The aim of this study was to enlist the patients diagnosed as CVST younger than 14 years of age and to diagnose the etiology along with radiological correlation.Settings and Design:This prospective clinical study was conducted for 2 years in the Department of Neurology, Srirama Chandra Bhanja Medical College & Hospital (SCBMCH), Cuttack, Odisha, India.Materials and Methods:All the patients were enlisted in a prestructured format with detailed clinico-radiological evaluation. Treatment was performed according to recent guidelines. Outcome after 3 months was analyzed. Ethical clearance was obtained from institutional ethics committee.Statistical Analysis:Data were statistically analyzed using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA).Results:The total number of patients included in the study was 30. Of them, six were neonates. The most common provocative factor was tuberculous meningitis. Phototherapy after neonatal hyperbilirubinemia was prominent cause in neonatal age group. Multiple sinus involvement was seen in most of the patients. Transverse sinus was the most common sinus to be involved.Conclusion:CVST is an underdiagnosed but important cause of stroke in childhood, occurring most often in the neonatal period. Mortality and morbidity are significant. Infections hyper coagulative disorders are the two primary associations. Magnetic resonance venography is the investigation of choice. Early diagnosis with management along with plan for secondary prevention can save from catastrophic consequences.

Cardiogenic dementia improved after permanent pacemaker implantation: a case report

Background: Heart diseases are the most common diseases worldwide which cause significant morbidity and mortality. Bradycardia comes under the category of heart diseases and is more common in the elderly. Bradycardia is defined as “heart rate of less than 60 beats per minute (bpm)”. There is a wide range of causes of bradycardia and the road to diagnosis includes extensive investigations. Case Presentation: Here we present the case of a 71-year-old male who presented with a history of dizzy spells, easy fatigueability, syncopal attacks, and memory impairment for 3 months prior to admission. On investigation, his complete blood counts, liver function tests, renal function tests, serum electrolytes, and urine routine examination were normal. His thyroid function tests were also normal. Electrocardiogram showed sinus bradycardia with pauses. Echocardiography was also normal. Holter monitoring showed multiple sinus pauses of 3.15 seconds average. Conclusion: We made a diagnosis of cardiogenic dementia due to sinus node dysfunction. The patient underwent permanent pacemaker implantation therapy and his symptoms improved. Our case highlights the importance of early diagnosis of the culprit disease and early intervention to prevent further complications.

Catheter Directed Thrombolytic Therapy for Pediatric Cerebral Sinus Vein Thrombosis

Background: Cerebral sinus vein thrombosis (CSVT) involves the thrombosis of the dural sinus and/or cerebral veins and it is considered a form of stroke. The estimated incidence of CSVT in children is 0.6 per 100,000 children per year. Poor outcomes, including death, happen in 9 to 29% of patients affected by CSVT. In addition, neurologic deficits, affecting primarily cognition and behavior, are seen in 50% of affected children. No randomized clinical trials have been conducted on pediatric CSVT so current guidelines for treatment have been extrapolated primarily from adult studies. Published guidelines by the American College of Chest Physicians, American Heart Association and American Society of Hematology, support the use of anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH). These same guidelines also suggest that catheter directed thrombolysis (CDT) with tissue plasminogen activator (tPA) and mechanical thrombectomy (MT) could be used when there has been clinical deterioration or no improvement (clot progression) despite anticoagulation. In all cases, these are based on uncontrolled case series and expert opinion. There is very little data on the safety and efficacy of CDT and/or MT for pediatric CSVT. Method: Pediatric patients with CSVT seen at Cook Children's Medical Center from January 1, 2008 to December 31, 2018 were identified by searching EMR using ICD-9 and ICD-10 codes. From this group, patients treated with MT and CDT in addition to anticoagulation were selected and reviewed. Results: Five children (4 to 14 y/o) were treated with MT and CDT after failing anticoagulation with UFH or LMWH. Diagnosis was made by MRI/MRV and all had CSVT of multiple sinuses. Four patients had more than one underlying disorders/factors that increased their risk for thrombosis including: Ulcerative Colitis in 2, severe anemia in 2, Systemic Lupus Erythematosus (SLE) in 1, use of oral contraceptives together with obesity and bacterial sepsis in 1. Two patients did have a thrombophilia: Protein S deficiency in 1 and Protein S and C deficiency in another. One patient with SLE had a positive hexagonal phase neutralization test but rest of evaluation was negative. Three patients had systemic bleeding prior initiation of UFH and MT/CDT. All children were treated with UFH, and due to clinical neurologic deterioration and/or worsening of imaging findings (4 comatose and 1 with persistent increased ICP), all underwent thromboaspiration and catheter directed infusion of tPA for 17 to 48 hours at a dose of 1 to 2 mg/hr. All patients continued anticoagulation with UFH during catheter directed tPA infusion and after the catheter was removed. All cases had partial resolution of the sinus vein thrombosis, although 1 had quick reocclusion. Post procedure bleeding happened in 1 patient who had also had an external ventricular drainage placed and developed parenchymal and intraventricular hemorrhage that led to discontinuation of tPA infusion, and 2 patients developed petechial brain hemorrhages. Four patients had great neurologic recovery and minimal deficits, but 1 had significant neurologic deficits. One patient died from lupus complications. (Table) Conclusion: Endovascular therapy including MT and CDT with tPA in conjunction with systemic UFH, may have a role in pediatric patients with CSVT who have deterioration despite initial anticoagulation. In our series, after procedures, all patients had partial resolution of their CSVT (but 1 had quick reocclusion) and 4 out of 5 patients had good neurologic outcomes despite bad predictor signs (coma, extensive CSVT). Further studies are needed to identify which patients would benefit from early endovascular treatment. Table Disclosures No relevant conflicts of interest to declare.

Complete natal cleft removal with kite incision in the treatment of extensive sacrococcygeal pilonidal sinus.

Pilonidal sinus (PS) is a benign disease for which different treatment modalities are used, varying from non-surgical treatments to surgical treatments with flap use for big defects. High recurrence is the main problem in complicated cases. We presented complete natal cleft excision with kite incision and fasciocutaneous flap (CNCEF with kite incision) in extensive sacrococcygeal PS. Seventy-six patients who underwent CNCEF with kite incision because of extensive PS extending through intergluteal sulcus to the anus, with multiple sinus tracts and recurrent PS were retrospectively analysed. A special incision involving natal cleft and all sinus tracts completely and fasciocutaneous flap, lateralizing median line, was used in all cases. Post-operative complications and recurrence was recorded. Sixteen (21.1%) patients were operated because of recurrence. The mean age and body mass index were 33.04 ± 6.78 and 29.86 ± 5.46, respectively. The mean hospital stay period and mean operation time was 2.95 ± 0.76 days and 64.33 ± 8.64 min, respectively. The mean drain removal time was 2.78 ± 0.7 days and mean follow-up was 13.46 ± 4.31 months. There were flap oedema and seroma in one (1.3%) and four (5.3%) of the patients, respectively. Surgical site infection necessitating antibiotic treatment developed in three (3.9%) patients. The overall post-operative complication rate was 10.5% and there was recurrence in one patient on follow-up period (1.3%). CNCEF with kite incision method, which shifts midline, is a safe and reliable method with acceptable post-operative complication and recurrence rates in extensive sacrococcygeal PS patients.