Endoscopic Repair of Spontaneous Cerebrospinal Fluid Leaks in the Lateral Recess of the Sphenoid Sinus

Objective This study aimed to assess the effectiveness of 3 endoscopic endonasal approaches for the management of cerebrospinal fluid (CSF) leaks and meningoencephaloceles in the lateral recess of the sphenoid sinus (LRSS). Study Design Retrospective study. Setting University hospital. Methods This study retrospectively reviewed 49 patients with CSF leaks and meningoencephaloceles in the LRSS. Three endoscopic surgical repair approaches were indicated based on 5 different Rhoton’s types of the LRSS. The postoperative symptoms, complications, and follow-up outcomes were investigated and evaluated. Results The success rate of endoscopic surgical repair was 100% at a median follow-up of 75.06 (12-203.4) months. Endoscopic approaches to the LRSS included the prelacrimal recess (PLR) (18.37%), transsphenoidal (18.37%), and transpterygoid approaches (64.26%). All patients in the PLR approach (PLRA) group and most of the patients in the transpterygoid approach group had a full lateral type LRSS. Hypoesthesia and dry eyes were reported in 5 patients (55.56%) and 1 (11.12%) patient, respectively, from the PLRA group and in 6 (19.35%) and 5 (16.12%) patients, respectively, from the transpterygoid approach group. Conclusions Endoscopic closure is a safe and effective method for the treatment of CSF leaks and meningoencephaloceles in the LRSS. The transpterygoid approach and PLRA offer adequate exposure of the LRSS with extensive lateral pneumatization or a full LRSS. The endoscopic route of the PLRA is more direct than that of the transpterygoid approach. Careful preoperative imaging evaluation is crucial while selecting the optimal surgical approach for the repair of a skull base defect.

TMS Seeded Diffusion Tensor Imaging Tractography Predicts Permanent Neurological Deficits

Surgeons must optimize the onco-functional balance by maximizing the extent of resection and minimizing postoperative neurological morbidity. Optimal patient selection and surgical planning requires preoperative identification of nonresectable structures. Transcranial magnetic stimulation is a method of noninvasively mapping the cortical representations of the speech and motor systems. Despite recent promising data, its clinical relevance and appropriate role in a comprehensive mapping approach remains unknown. In this study, we aim to provide direct evidence regarding the clinical utility of transcranial magnetic stimulation by interrogating the eloquence of TMS points. Forty-two glioma patients were included in this retrospective study. We collected motor function outcomes 3 months postoperatively. We overlayed the postoperative MRI onto the preoperative MRI to visualize preoperative TMS points in the context of the surgical cavity. We then generated diffusion tensor imaging tractography to identify meaningful subsets of TMS points. We correlated the resection of preoperative imaging features with clinical outcomes. The resection of TMS-positive points was significantly predictive of permanent deficits (p = 0.05). However, four out of eight patients had TMS-positive points resected without a permanent deficit. DTI tractography at a 75% FA threshold identified which TMS points are essential and which are amenable to surgical resection. TMS combined with DTI tractography shows a significant prediction of postoperative neurological deficits with both a high positive predictive value and negative predictive value.

MRI-assessed tumor-free distance to serosa predicts deep myometrial invasion and poor outcome in endometrial cancer

Objectives To explore the diagnostic accuracy of preoperative magnetic resonance imaging (MRI)-derived tumor measurements for the prediction of histopathological deep (≥ 50%) myometrial invasion (pDMI) and prognostication in endometrial cancer (EC). Methods Preoperative pelvic MRI of 357 included patients with histologically confirmed EC were read independently by three radiologists blinded to clinical information. The radiologists recorded imaging findings (T1 post-contrast sequence) suggesting deep (≥ 50%) myometrial invasion (iDMI) and measured anteroposterior tumor diameter (APD), depth of myometrial tumor invasion (DOI) and tumor-free distance to serosa (iTFD). Receiver operating characteristic (ROC) curves for the prediction of pDMI were plotted for the different MRI measurements. The predictive and prognostic value of the MRI measurements was analyzed using logistic regression and Cox proportional hazard model. Results iTFD yielded highest area under the ROC curve (AUC) for the prediction of pDMI with an AUC of 0.82, whereas DOI, APD and iDMI yielded AUCs of 0.74, 0.81 and 0.74, respectively. Multivariate analysis for predicting pDMI yielded highest predictive value of iTFD < 6 mm with OR of 5.8 (p < 0.001) and lower figures for DOI ≥ 5 mm (OR = 2.8, p = 0.01), APD ≥ 17 mm (OR = 2.8, p < 0.001) and iDMI (OR = 1.1, p = 0.82). Patients with iTFD < 6 mm also had significantly reduced progression-free survival with hazard ratio of 2.4 (p < 0.001). Conclusion For predicting pDMI, iTFD yielded best diagnostic performance and iTFD < 6 mm outperformed other cutoff-based imaging markers and conventional subjective assessment of deep myometrial invasion (iDMI) for diagnosing pDMI. Thus, iTFD at MRI represents a promising preoperative imaging biomarker that may aid in predicting pDMI and high-risk disease in EC.

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post–Caldwell-Luc Surgery: A Case Report

Background: The Caldwell-Luc (CL) procedure, an outdated operative procedure that is used to treat inflammatory sinus diseases, is rarely performed presently. However, physicians may encounter patients with a history of CL surgery who develop considerable postoperative changes that may lead to diagnostic confusion in imaging evaluation; increase the difficulty of future surgery, such as sinonasal surgery; and increase the incidence of future intraoperative complications. Case summary: A 67-year-old man with a surgical history of chronic sinusitis reported epiphora of the left eye for five years. Balloon dacryocystoplasty was attempted but failed. Endo-DCR (Endoscopic dacryocystorhinostomy) was indicated; however, preoperative CT (computed tomography) imaging and nasal endoscopic examination showed sinonasal anomalies and the loss of internal landmarks for localizing the lacrimal sac. Preoperative CT results indicated previous CL surgery. Endo-DCR was performed with the aid of nasal forceps and a 20-gauge vitreoretinal fiberoptic endoilluminator. A six-month follow-up revealed the complete resolution of symptoms and no signs of recurrence. Conclusions: Epiphora might be a delayed complication of the CL procedure. Before performing endo-DCR, ophthalmologists should be familiar with the sinonasal anatomy and carefully assess preoperative imaging to identify anatomical variations. Nasal forceps and transcanalicular illumination can assist in determining the precise location of the lacrimal sac during endo-DCR.

Non-Invasive Preoperative Imaging Differential Diagnosis of Intracranial Hemangiopericytoma and Angiomatous Meningioma: A Novel Developed and Validated Multiparametric MRI-Based Clini-Radiomic Model

BackgroundAccurate preoperative differentiation of intracranial hemangiopericytoma and angiomatous meningioma can greatly assist operation plan making and prognosis prediction. In this study, a clini-radiomic model combining radiomic and clinical features was used to distinguish intracranial hemangiopericytoma and hemangioma meningioma preoperatively.MethodsA total of 147 patients with intracranial hemangiopericytoma and 73 patients with angiomatous meningioma from the Tiantan Hospital were retrospectively reviewed and randomly assigned to training and validation sets. Radiomic features were extracted from MR images, the elastic net and recursive feature elimination algorithms were applied to select radiomic features for constructing a fusion radiomic model. Subsequently, multivariable logistic regression analysis was used to construct a clinical model, then a clini-radiomic model incorporating the fusion radiomic model and clinical features was constructed for individual predictions. The calibration, discriminating capacity, and clinical usefulness were also evaluated.ResultsSix significant radiomic features were selected to construct a fusion radiomic model that achieved an area under the curve (AUC) value of 0.900 and 0.900 in the training and validation sets, respectively. A clini-radiomic model that incorporated the radiomic model and clinical features was constructed and showed good discrimination and calibration, with an AUC of 0.920 in the training set and 0.910 in the validation set. The analysis of the decision curve showed that the fusion radiomic model and clini-radiomic model were clinically useful.ConclusionsOur clini-radiomic model showed great performance and high sensitivity in the differential diagnosis of intracranial hemangiopericytoma and angiomatous meningioma, and could contribute to non-invasive development of individualized diagnosis and treatment for these patients.

A case report of duodenal arteriovenous malformation: usefulness of intraoperative indocyanine green angiography for precise identification of the lesion

Background Arteriovenous malformation (AVM) of the gastrointestinal (GI) tract can cause bleeding. The treatment choice for GI tract AVM is surgical resection of the involved bowel segment with complete resection of the nidus. The AVM formed in the duodenum or pancreatic head could also cause gastrointestinal bleeding, and there are several reports of pancreaticoduodenectomy as its treatment. However, if the area of AVM can be accurately identified during surgery, it may be possible to completely resect the AVM while preserving the organ. We report a case of duodenal AVM in a patient successfully treated with a subtotal stomach-preserving duodenal bulb resection using intraoperative indocyanine green (ICG) angiography technique. Case presentation An 18-year-old man was diagnosed with duodenal AVM after several examinations for anemia and was referred to our hospital for further treatment. Preoperative imaging studies showed that the inflow vessels of this duodenal AVM were the inferior pyloric artery and the superior duodenal artery, and the AVM was localized to the duodenal bulb. Thereafter, stomach-preserving duodenal bulb resection preceded by ligation of the inflow vessels was performed. During the surgery, ICG angiography clearly demonstrated the area, where the nidus was distributed, and a duodenal bulb resection with complete resection of the AVM was successfully performed. There was no recurrence at the 6-month follow-up. Conclusions Intraoperative ICG angiography was a useful procedure for precise identification of the AVM of the GI tract.

Vertebral Artery Variations at the Craniovertebral Junction in “Sandwich” Atlantoaxial Dislocation Patients

Objective: To summarize the vertebral artery (VA) pattern of 96 “sandwich” atlantoaxial dislocation (AAD) patients and to describe the strategies of reducing the injury of VA during surgery.Methods: From 2009 to 2020, we retrospectively reviewed the 3-dimensional computed tomography angiography data of 96 AAD patients combined with atlas occipitalization and C2–3 fusion, which were diagnosed as “sandwich” AAD and 96 patients as control group patients who were without atlas occipitalization, C2–3 fusion and any other cervical bone deformity at our institution. The variations of each side of VA were described in 3 different parts (C0–1, C1–2, and C2–3) according to the characteristics of the 3-part pathological structures in “sandwich” subgroup.Results: One hundred ninety-two sides of VAs in every group of patients were analyzed and every VA was described separately at 3 different level regions. There were different variations in these 3 different regions: 4 variations in the upper fusion region, 5 variations in the sandwiched region, and 6 variations in the lower fusion region in sandwich AAD patients. And the rate of VA deformity in sandwich AAD patients was much higher and more types of VA variations existed.Conclusion: In “sandwich” AAD patients, deformities of vertebral arteries in craniovertebral junction are more common, and the same VA may have deformities at different levels that severely affect surgical procedures. Therefore, preoperative imaging examination of VA for “sandwich” AAD patients is vital of guiding surgeons to avoid injury of VA during surgery.

INSULINOMA AND METABOLIC URGENCY CASE REPORT

Insulinoma is a rare neuroendocrine tumor, occurring almost exclusively in the pancreas. Most often unique and benign in 90% of cases. Usually sporadic, 10% of lesions become part of type 1 multiple endocrine neoplasia. The main manifestation of insulinoma is hypoglycemia, which is a life-threatening metabolic emergency. The hypoglycemia occurring in this context are particularly serious and frequent with sometimes harmful cerebral consequences. Topographic diagnosis remains difficult due to the small size of the lesions justifying the importance of the preoperative imaging required for the location of the tumor. Enucleation is the surgical indication of choice in the presence of a sporadic insulinoma that is presumably benign. Pathological and immunohistochemical examination confirms the diagnosis of neuroendocrine tumor. Our observation is particular by the circumstances of discovery of the insulinoma, the severe nature of the symptoms.