Illustrative Case Series Research Articles

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

Ultrasonography is increasingly being discussed as an alternative to X-rays in emergency department settings. Systematic comparisons of the two modalities are often based on using computed tomography as a reference. In diagnosing patients with elbow trauma, the physicians at our emergency department experienced that ultrasonography can be more informative than cone beam computed tomography in identifying radial head fractures. Our purpose is to share this experience with the scientific community. All patients diagnosed with a radial head fracture in our emergency department between January 2021 and November 2022 were identified. The images of eighteen cases, in which both point-of-care ultrasonography and cone beam computed tomography had been used were reviewed by us. Eight examples were selected illustrating the variation in coincidence or discrepancy between ultrasonography and computed tomography. The eight examples illustrate that ultrasonography can be more informative than cone beam computed tomography or vice versa. The joint application of ultrasonography and computed tomography is advisable if a correct diagnosis of the extent and components of radial head fractures is of uttermost importance. Zusammenfassung Ziel: Sonographie wird zunehmend als Alternative zur Röntgenuntersuchung in der Notaufnahme diskutiert. Systematische Vergleiche der beiden Modalitäten basieren häufig auf der Verwendung der Computertomographie als Referenz. Bei der Diagnose von Patienten mit Ellenbogentrauma haben die Ärzte in unserer Notaufnahme die Erfahrung gemacht, dass der Ultraschall bei der Erkennung von Radiusköpfchenfrakturen informativer sein kann als die Kegelstrahl-Computertomographie. Unser Ziel ist es, diese Erfahrung mit der wissenschaftlichen Gemeinschaft zu teilen. Alle Patienten, bei denen in unserer Notaufnahme zwischen Januar 2021 und November 2022 eine Radiusköpfchenfraktur diagnostiziert wurde, wurden ermittelt. Die Bilder von achtzehn Fällen, bei denen sowohl Ultraschall als auch eine Kegelstrahl-Computertomographie angewandt worden waren, wurden von uns nachuntersucht. Acht Beispiele wurden ausgewählt, um die Variation in Übereinstimmung oder Diskrepanz zwischen Ultraschall und Computertomographie zu veranschaulichen. Ergebnisse: Die acht Beispiele zeigen, dass die Ultraschalluntersuchung informativer sein kann als die Kegelstrahl-Computertomographie oder umgekehrt. Schlussfolgerung: Die gemeinsame Anwendung von Ultraschall und Computertomographie ist ratsam, wenn eine korrekte Diagnose des Ausmaßes und der Komponenten von Radiusköpfchenfrakturen von größter Bedeutung ist.

Spectrum of Anti-GAD 65 Antibody Mediated Neurological Disease: Illustrative Case Series from East Africa

Spectrum of Anti-GAD 65 Antibody Mediated Neurological Disease: Illustrative Case Series from East Africa

The Art of Cerebral Revascularization: An Illustrative Case Series of Bypass Techniques for Complex Intracranial Aneurysms

Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs. The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru, during 2018-2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications. Seventeen patients (70.59% female; median age: 53years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first-, second-, and third-generation bypass. In 47.1% of cases, an anastomosis between the superficial temporal artery and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), a superficial temporal artery-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10-15). At the 6-month follow-up, 82.4% of patients had a modified Rankin Scale score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%. CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting.

The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series.

Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited. Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis andsupported by comprehensive angiographic and intraoperative images. One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk forendovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation. This illustrative case series highlights thetechnical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.

Intraoperative ultrasonography in microsurgical resection of vestibular schwannomas via retrosigmoid approach: surgical technique and proof-of-concept illustrative case series.

Intraoperative ultrasonography (ioUS) is an established tool for the real-time intraoperative orientation and resection control in intra-axial oncological neurosurgery. Conversely, reports about its implementation in the resection of vestibular schwannomas (VS) are scarce. The aim of this study is to describe the role of ioUS in microsurgical resection of VS. ioUS (Craniotomy Transducer N13C5, BK5000, B Freq 8MHz, BK Medical, Burlington, MA, USA) is integrated into the surgical workflow according to a 4-step protocol (transdural preresection, intradural debulking control, intradural resection control, transdural postclosure). Illustrative cases of patients undergoing VS resection through a retrosigmoid approach with the use of ioUS are showed to illustrate advantages and pitfalls of the technique. ioUS allows clear transdural identification of the VS and its relationships with surgically relevant structures of the posterior fossa and of the cerebellopontine cistern prior to dural opening. Intradural ioUS reliably estimates the extent of tumor debulking, thereby helping in the choice of the right moment to start peripheral preparation and in the optimization of the extent of resection in those cases where subtotal resection is the ultimate goal of surgery. Transdural postclosure ioUS accurately depicts surgical situs. ioUS is a cost-effective, safe, and easy-to-use intraoperative adjunctive tool that can provide a significant assistance during VS surgery. It can potentially improve patient safety and reduce complication rates. Its efficacy on clinical outcomes, operative time, and complication rate should be validated in further studies.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

Objective Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks. Methods This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure. Results Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection. Conclusions Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Kiosk 9Q-TA-06 - CMR of Cardiac Hydatidosis- an Illustrative Case Series

Kiosk 9Q-TA-06 - CMR of Cardiac Hydatidosis- an Illustrative Case Series

Giant Lumbosacral Neural Tumours with Extraspinal Extension: An Illustrative Case Series and Review of Surgical Approaches

Giant Lumbosacral Neural Tumours with Extraspinal Extension: An Illustrative Case Series and Review of Surgical Approaches

Black blood MRI sequences in the acute management of ruptured and unruptured intracranial aneurysms

We present an illustrative case series in which high spatial resolution black blood (BB) MRI sequences were used as an adjunct in the acute management of intracranial aneurysms with diagnostic uncertainty regarding rupture status. Several acute management dilemmas are discussed including the surveillance of previously treated ruptured intracranial aneurysms, identifying culprit lesion(s) amongst multiple ruptured intracranial aneurysms, and risk stratifying incidental unruptured intracranial aneurysms. We present our experience which supports the evaluation of this vessel wall imaging technique in larger multi-centre observational studies. MR imaging was performed on a 3.0 Tesla Siemens Somatom Vida system and sequences used included: Susceptibility Weighted Imaging, Diffusion Weighted Imaging & 3D T1 pre- and post-contrast-enhanced BB sequences.

Patients with rare neurogenetic diseases experience decades of diagnostic delay and enacted stigma: An illustrative case series from Kenya

Patients with rare neurogenetic diseases experience decades of diagnostic delay and enacted stigma: An illustrative case series from Kenya

SAT205 99Technitiumm Sestamibi Negative Sporadic Metastatic Parathyroid Carcinoma In A Young Female-A Diagnostic Conundrum

Abstract Disclosure: D.V. Reddy: None. S. Paidipally: None. V. kyatham: None. S. Palle: None. C. Bhandiwad: None. Background: Parathyroid carcinoma (PC) is a very rare and indolent endocrine malignancy occurring a decade earlier than parathyroid adenoma. It can present as recurrent pancreatitis, anemia, and peptic ulcers. Serum calcium >14mg/dl, 3-10 times ULN of PTH, and concomitant renal and bone involvement should arise suspicion for PC. PC is diagnosed only through histopathology in the majority. It can also present during a prolonged follow-up, either by local recurrences or distant metastases. Clinical Case: A 27 year old female presented with hypercalcemic crises (as pancreatitis). At admission serum calcium and PTH were grossly elevated; 15.1 mg/dl (8.5-10 mg/dl) and 363 pg/ml (10-55 pg/ml) respectively. Abdominal CT revealed acute pancreatitis with medullary nephrocalcinosis. Ultrasonography of the neck revealed a colloid cyst in the right lobe of thyroid.99Tc m-sestamibi /SPECT-CT revealed no uptake. CT neck and chest showed a 13 mm X 13 mm well-defined round nodular lesion in the left apico-posterior segments of the lung. 18F-FDG PET/CT revealed uptake in the lesion with an SUV max of 10, suggestive of a metabolically active solitary pulmonary nodule. She had a similar presentation 8 years back and was diagnosed to have parathyroid adenoma for which she underwent resection. Serum PTH and calcium levels normalized postoperatively and also on follow-up till 3 years. Differentials include-recurrent ectopic parathyroid adenoma, parathyromatosis, and metastatic parathyroid carcinoma. After managing hypercalcemia medically, the patient underwent video-assisted thoracoscopic surgery with left lung wedge resection. Postoperatively serum calcium and PTH normalized. Histopathology revealed a grey-white nodule of 1.4X1.5X1.2 cm with sections, showing a well-defined lesion composed of lobules and nests of tumor cells separated by thin-walled vascular sinusoids. Tumor cells were polygonal with well-defined margins, moderate granular cytoplasm, and vesicular nuclei showing prominent nucleoli with a mitotic activity of 9/hpf. Immunohistochemistry revealed staining with PanCK, GATA3, and S100 with focal PAX 8 activity in the periphery. MIB index was 18%.IHC was suggestive of a neuroendocrine tumor consistent with metastatic parathyroid carcinoma. Whole exome sequencing did not reveal any pathogenic variants. Conclusion: Though 99Tc MIBI is useful in localizing PC, there are reports of false negative MIBI in documented cases of PC, which has been ascribed to the defective transport to the interior of the malignant cells. This demonstrates the importance of a multimodality imaging approach in such cases. 99Tc MIBI may miss certain cases of PC substantiating the importance of 18F-FDG PET/CT in diagnosis as well as follow-up. Reference: Evangelista L et al. FDG-PET/CT and parathyroid carcinoma: Review of literature and illustrative case series. World J Clin Oncol 2011; 2(10): 348-354. Presentation: Saturday, June 17, 2023

Virtual undergraduate chemical engineering labs based on density functional theory calculations

Abstract Offering virtual laboratories to chemical engineering students is likely to extend beyond the COVID-19 era. Thus, there is a need to develop more simulation-based tasks in a wide blend of subjects, spanning thermodynamics, chemical reactions, and unit operations. Molecular and material modeling based on density functional theory (DFT) calculations provides limitless opportunities to train students on how to obtain thermokinetic values that are typically measured experimentally. Through a series of illustrative cases, this contribution provides detailed procedures pertinent to calculating reaction rate constants, standard enthalpies of reactions, redox potentials, equilibrium reaction constants, and surface-assisted mechanisms. We hope that DFT-operated virtual labs will assist students in attaining learning outcomes and promote their self-learning in the above-mentioned subjects. From a broader prospective, the presented case studies are expected to encourage students to appreciate the practical applications of DFT, not only in the academic but also in the industrial domains.

A sneak peek into the diagnostic conundrum of neuroendocrine neoplasms of the breast: An updated review with a brief illustrative case series

Abstract Neuroendocrine neoplasms (NENs) of the breast are uncommon tumours that have been a hitherto poorly and variably defined entity. In the recent fifth Edition World Health Organisation (WHO) classification of breast tumour, NENs are dichotomously classified into neuroendocrine tumours (NETs) and neuroendocrine carcinomas (NECs), mirroring the classification of NENs in other organ systems. Both NETs and NECs are invasive tumours in the breast. However, the clinical significance of neuroendocrine differentiation (NED) in breast cancers, especially in NETs of the breast, is not yet fully understood, and a large overlap appears to exist between breast cancers showing NED and invasive breast carcinoma of no special type (IBC-NST). Although breast NECs show distinct clinical and morphological features and show overlapping molecular features with their counterpart in other organs, especially the high-grade component. Diagnosis of NETs based on the morphological characteristics alone can be challenging; one reason is that breast NETs do not necessarily have the same morphological characteristics as those of NENs arising in other organs and are genetically heterogeneous and harbour molecular alterations that differ from IBC, NST. The keynote changes in the current WHO are the exclusion of other histological subtypes that is, solid papillary carcinoma and a hypercellular variant of mucinous carcinoma which are strong immunohistochemical mimickers of NED and the inclusion of large cell neuroendocrine carcinoma (LCNEC). Thus, the heterogeneity of breast tumours with NED and the changes in their classifications over the years have left many open issues that still need to be resolved. Data regarding the prognostic significance of NED is conflicting and histologic grade and tumour stage remain the main prognostic parameters. Current management of NENs is similar to that of IBC of NST. In this review article, we will summarise the journey of NENs of the breast with an update on the recent WHO classification and discuss their differences from NENs arising in other organs by highlighting an interesting case series depicting their clinical, radiological, histological and molecular features.

Durotomy- and Irrigation-Related Serious Adverse Events During Spinal Endoscopy: Illustrative Case Series and International Surgeon Survey.

Durotomy during endoscopic spine surgery can cause a patient's neurological or cardiovascular status to deteriorate unexpectedly intra- or postoperatively. There is currently limited literature regarding appropriate fluid management strategies, irrigation-related risk factors, and clinical consequences of incidental durotomy during spinal endoscopy, and no validated irrigation protocol exists for endoscopic spine surgery. Thus, the present article sought to (1) describe 3 cases of durotomy, (2) investigate standard epidural pressure measurements, and (3) survey endoscopic spine surgeons on the incidence of adverse effects believed to result from durotomy. The authors first reviewed clinical outcomes and analyzed complications in 3 patients with intraoperatively recognized incidental durotomy. Second, the authors conducted a small case series with intraoperative epidural pressure measurements during gravity-assisted irrigated video endoscopy of the lumbar spine. Measurements were conducted on 12 patients with a transducer assembly that was introduced through the endoscopic working channel of the RIWOSpine Panoview Plus and Vertebris endoscope to the decompression site in the spine. Third, the authors conducted a retrospective, multiple-choice survey of endoscopic spine surgeons to better understand the frequency and seriousness of problems they attributed to irrigation fluid escaping from the surgical decompression site into the spinal canal and neural axis. Descriptive and correlative statistical analyses were performed on the surgeons' responses. In the first part of this study, durotomy-related complications during irrigated spinal endoscopy were observed in 3 patients. Postoperative head computed tomographic (CT) images revealed massive blood in the intracranial subarachnoid space, the basal cisterns, the III and IV ventricle, and the lateral ventricles characteristic of an arterial fisher grade IV subarachnoid hemorrhage, and hydrocephalus without evidence of aneurysms or angiomas. Two additional patients developed intraoperative seizures, cardiac arrhythmia, and hypotension. The head CT image in 1 of these 2 patients had intracranial air entrapment.In the second part, epidural pressure measurements in 12 patients who underwent uneventful routine lumbar interlaminar decompression for L4-L5 and L5-S1 disc herniation showed an average epidural pressure of 24.5 mm Hg.In the third part, the online survey was accessed by 766 spine surgeons worldwide and had a response rate of 43.6%. Irrigation-related problems were reported by 38% of responding surgeons. Only 11.8% used irrigation pumps, with 90% running the pump above 40 mm Hg. Headaches (4.5%) and neck pain (4.9%) were observed by nearly a 10th (9.4%) of surgeons. Seizures in combination with headaches, neck and abdominal pain, soft tissue edema, and nerve root injury were reported by another 5 surgeons. One surgeon reported a delirious patient. Another 14 surgeons thought that they had patients with neurological deficits ranging from nerve root injury to cauda equina syndrome related to irrigation fluid. Autonomic dysreflexia associated with hypertension was attributed by 19 of the 244 responding surgeons to the noxious stimulus of escaped irrigation fluid that migrated from the decompression site in the spinal canal. Two of these 19 surgeons reported 1 case associated with a recognized incidental durotomy and another with postoperative paralysis. Patients should be educated preoperatively about the risk of irrigated spinal endoscopy. Although rare, intracranial blood, hydrocephalus, headaches, neck pain, seizures, and more severe complications, including life-threatening autonomic dysreflexia with hypertension, may arise if irrigation fluid enters the spinal canal or the dural sac and migrates from the endoscopic site along the neural axis rostrally. Experienced endoscopic spine surgeons suspect a correlation between durotomy and irrigation-related extra- and intradural pressure equalization that could be problematic if associated with high volumes of irrigation fluid LEVEL OF EVIDENCE: 3.

Abstract Number ‐ 89: Left M1 occlusion rescued by the Recurrent artery of Huebner: a spectrum of MCA collaterals

Introduction Proximal MCA occlusion has variable presentation and clinical course, ranging from MCA syndrome with completed infarct at presentation to asymptomatic, discovered incidentally on imaging. This variability is likely dictated by variable collateral circulation that ultimately fails on variable time courses. For discussion we can divide these into (1) rapid progressors, (2) standard, (3) slow progressors, (4) situationally symptomatic, and (5) asymptomatic. There is clear evidence for the role of endovascular therapy for those who are significantly symptomatic and progress along an acute timeline when combined with imaging criteria (1 and 2), but there is no clear guidance for those patients who progress slowly or are minimally symptomatic (3‐5). Methods We present selected cases of patients with left MCA occlusion from groups 3–5 along with their presentation and collateral flow as assessed by non‐invasive imaging and DSA. Results Case 1. Slow Progressor. A 63‐year‐old woman with past occipital lobe strokes presented with progressive aphasia of insidious onset that began at some point the previous day. NIHSS 4 for aphasia and LOC questions. Initial CTA revealed a left M1 occlusion with ASPECTS 9. Despite low NIHSS and extended time to LKW, she was brought to the angiography suite. Initial angiogram confirmed M1 occlusion with extensive collateralization via the left ACA and anterior temporal artery, but no reconstitution of the MCA proper. Thrombectomy was completed with TICI2B recanalization. Followup MRI revealed minimal infarct in the left insula. The patient was discharged with an NIHSS of 1 for a baseline hemianopia not appreciated on initial exam. Case 2. Situationally Symptomatic. A 55‐year‐old man with symptomatic epilepsy from bilateral subdural hygromas was admitted for video EEG monitoring of episodic dizziness and word‐finding difficulty. Initial exam revealed only orthostatic light‐headedness. Further history revealed these events often happed at night upon standing. No epileptiform events were captured. MRA revealed a complete occlusion of the proximal M1 with reconstitution at the M2 bifurcation in the sylvian fissure. Given lack of persistent clinical deficit and absence of infarct on MRI, DSA was deferred. The patient is followed outpatient without further symptom progression. Case 3. Asymptomatic. A 38 year‐old‐man with TBI presented to the emergency department with thunderclap headache. Initial exam was without deficits. CTA and MRA revealed complete occlusion of the left MCA. We proceeded to the angiography suite where DSA revealed complete left M1 occlusion with distal reconstitution at the M2 bifurcation primarily via the Recurrent Artery of Huebner in addition to ACA collaterals. Lumbar puncture was benign and his headache responded completely to typical migraine treatment. The patient was discharged to outpatient follow up without further sequalae. Conclusions We present a series of illustrative cases of patients with MCA occlusion of variable collateral supply and clinical course, none of whom met conventional criteria for endovascular intervention. More research is needed to establish clinical and imaging criteria to separate patients who would benefit from endovascular intervention from those who are best managed medically in these scenarios.

Extramedullary Hematopoiesis: A Forgotten Diagnosis and a Great Mimicker of Malignancy.

Radiology errors have been reported in up to 30% of cases when patients have abnormal imaging findings. Although more than half of errors are failures to detect critical findings, over 40% of errors are when findings are recognized but the correct diagnosis or interpretation is not made. One common source of error is when imaging findings from one process simulate imaging findings from another process but the correct diagnosis is not made. This can result in additional imaging studies, unnecessary biopsies, or surgery. Extramedullary hematopoiesis is one of those uncommon disease processes that can produce many imaging findings that may lead to misdiagnosis. The objective of this article is to review the common and uncommon imaging features of extramedullary hematopoiesis while presenting a series of interesting relevant illustrative cases with emphasis on CT.

Surgical management of anterior sacral meningoceles: an illustrated case series and review of the literature

Background Anterior sacral meningocele (ASM) is an uncommon variant of spinal dysraphism. Surgical correction for this condition is challenging and optimal corrective approaches are uncertain. Objective To share our experience of managing this rare condition using the posterior trans-sacral approach and provide a contemporary review of the literature. Methods Retrospective review of case notes, operative records, and imaging of eligible patients treated via the posterior trans-sacral approach between 2006 and 2020 at our regional neurosciences centre. Results Three patients, two females and one male with a mean age of 30 years (range 16–38), were treated. Presenting symptoms included lower abdominal pain and recurrent miscarriages. Patients underwent corrective surgery using the posterior approach involving a sacral laminectomy, durotomy and closure of the communicating fistula. A single patient required reoperation due to early recurrence. Another patient proved challenging because of a very large sacral fistula and required two procedures due to the development of high-pressure headaches secondary to a recurrence. All patients improved symptomatically postoperatively and remained symptom free at the last clinic follow-up and have been discharged. Following review of the literature, only two other non-syndromic cases have been described. Conclusions ASM is an uncommon congenital abnormality, typically presenting with mass effect symptoms secondary to a presacral cystic mass. Surgical management using a posterior approach to close the meningeal sac is feasible and less invasive than an anterior approach. Long term clinical outcomes in our series were satisfactory.

A Unique Approach to Neurosurgical Wound Closure With Porcine Urinary Bladder Matrix: An Illustrative Case Series

Introduction. PUBM is a non-synthetic, completely resorbable xenograft product with a myriad of uses, including management of burns, acute and chronic wounds, soft tissue reinforcement, and hernia repair. The material is available in both powder and sheet forms which allows for excellent coverage of irregularly shaped wounds. Case Report. The authors present 2 challenging neurosurgical wound cases. The first case is a large thoracolumbar wound secondary to a laminectomy complicated by a high output CSF fistula and dermal dehiscence. The second case is a deep postoperative surgical site infection in the setting of a large amount of surgical hardware. Both cases were successfully managed to complete wound healing with PUBM. Conclusion. Neurosurgical wounds can be technically challenging and difficult to manage. CSF fistulas lack evidence for standard treatment strategy, making complications and chronic wounds more likely. The application of PUBM in the closure of neurosurgical wounds has not been thoroughly studied and may lead to improved wound closure.

Ekstrakraniyal uzanımı olan menengiomların tedavisinin zorlukları: Klinik çalışma

Objective: Surgical treatment of extracranial meningiomas is challenging. In this study, we present an illustrated case series to share our experience in the treatment of meningiomas with extracranial extension.
 
 Method: We retrospectively reviewed the data of 11 patients with meningiomas who underwent surgical treatment between 2008 and 2020. The intracranial and extracranial components were radiologically and intraoperatively confirmed for all patients.
 
 Results: The patients included seven men and four women with a mean age of 55.4 years. Most patients presented with facial disfigurement or asymmetrical skull growth. The most common symptom at presentation was headache. The most common location of the meningiomas was the frontal region and those of extracranial growth were the paranasal sinuses and parietal bone invasion. We recognized two distinct modalities of bone destruction: hyperostosis (n=3) and osteolysis (n=8). Pathological investigation revealed atypical features in six patients. Preoperative embolization was attempted in four patients but it proved to be difficult; proper embolization could be achieved only in one patient. The most commonly encountered challenges during surgery were large calvarial and cranial base defects due to bone erosion, dural defects, and managing the superior sagittal sinus with parietal tumors. Excessive blood loss was also of particular concern, which was managed using simple scalp clips, intraoperative transfusion, and other conservative approaches of tumor extensions into paranasal sinuses. No perioperative mortality occurred. Calvarial reconstruction was performed with polymethyl methacrylate cement where needed.
 
 Conclusion: Meningiomas with extracranial extension are surgically challenging but treatable. It contains fine neurosurgical trics in its treatment and follow-up.

Acute Subdural Hematoma Associated with Aneurysmal Rupture: A Case Series and Review of Literature

Ruptured cerebral aneurysms represent a neurosurgical emergency with characteristic clinical presentation and imaging findings. However, atypical presentations may occur in association with acute subdural hematomas (SDHs). A retrospective review was conducted at our institution between 2013 and 2021 to identify patients with aneurysmal rupture presenting with SDH. Cases were reviewed for clinical presentation, imaging findings, management, and outcome. A total of 8 patients were included in this review with an average age of 48.5years. Six patients were women. The average Glasgow coma scale upon arrival was 6.3, and the Hunt-Hess average grade was 4.6. Aneurysm locations included posterior communicating artery (n= 3), anterior communicating artery (n= 2), middle cerebral artery (n= 2), and internal carotid artery terminus (n= 1). The size of aneurysm varied between 3 and 11mm. Seven patients required surgical intervention, either craniotomy or craniectomy for hematoma evacuation, and aneurysms were treated by coiling (n= 2) or clipping (n= 6). Ruptured aneurysms may present with SDH with or without significant subarachnoid hemorrhage. This illustrative case series highlights this challenging presentation and the importance of early recognition and appropriate management.