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Background: Management of pediatric skull defects after decompressive craniectomy (DC) poses unique problems, particularly in children younger than 24 months. These problems include complications such as resorption and infection as well as difficulties with plagiocephaly and reconstruction. The goal of this study was to evaluate bone resorption complications after cranioplasty in patients <24 months., Methods: A single-center retrospective case study was performed of all patients younger than 24 months who underwent cranioplasty after DC between 2011 and 2018. The following variables were assessed: injury cause, age at craniotomy, time to cranioplasty, craniectomy size, mode of fixation, drain use, shunt use, subdural fluid collection, resorption, need for synthetic graft revision, and plagiocephaly., Results: A total of 10 patients were identified who met inclusion criteria; 3 patients were excluded for insufficient follow-up. Ages ranged from <1 day to 19 months, with a mean of 10.7 months. Overall rate of cranioplasty resorption was 85.7%, 57.1% of which required revision with synthetic graft. There were univariate trends toward more frequent implant resorption with subdural fluid collection (P = 0.1071) and without shunt placement (P = 0.1429). These effects persisted through multivariable analysis and even reached statistical significance in the case of subdural collection when controlling for operative and demographic characteristics (P = 0.01138, P = 0.0694). In addition, univariate analysis showed a trend toward more frequent neurologic complications with greater craniotomy-to-cranioplasty intervals (P = 0.1043), which reached significance on multivariable analysis (P = 0.00518)., Conclusions: In patients younger than 24 months undergoing cranioplasty subdural collection, a lack of shunt placement and increased time to cranioplasty were associated with increased rates of resorption., (Published by Elsevier Inc.)

Background: De novo formation of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) is increasingly being reported in the neurosurgical literature, challenging the notion that AVMs are congenital in origin. Most of this literature centers around the pediatric population. After treatment of an AVM or AVF, recurrence, if any, appears to occur locally to the original insult. We present, to the best of our knowledge, the first case of a de novo direct AVF involving an anterior communicating artery aneurysm in a remote site from a prior ruptured AVM in a pediatric patient., Case Description: We present a case of a 14-year-old female who presented 2 years prior with an intraparenchymal hemorrhage secondary to a left parietal arteriovenous malformation. That AVM was successfully microsurgically resected and revealed complete angiographic obliteration on postoperative and surveillance angiograms. This patient now presents with a spontaneous intraventricular hemorrhage secondary to a ruptured anterior communicating artery complex aneurysm with a fistulous connection from this aneurysm to the inferior petrosal sinus. The aneurysm and direct AVF were not identified on prior surveillance imaging, indicating de novo formation in a remote site from her prior AVM., Conclusions: This case highlights the importance of long-term imaging surveillance in patients with AVMs. Further prospective studies are indicated to evaluate the long-term imaging surveillance necessary to detect early recurrence, thereby allowing doctors to institute earlier definitive treatment. The exact pathophysiology behind these lesions is not fully understood; however, this case lends support to an acquired etiology to vascular malformations., (Published by Elsevier Inc.)

Objectives: To assess the incidence of silent cerebral embolization when using the transradial approach for diagnostic coronary angiography (DCA)., Background: Compared to other vascular access sites, the right transradial approach (RTA) could reduce the amount of brain emboli by avoiding mechanical trauma to the aortic wall caused by catheters and wire, whereas it increases manipulation of catheters in the ascending aorta and has a higher risk of direct embolization into the right common carotid artery. A recent study showed an increased incidence of microembolic signals (MES) in RTA compared to femoral. However, left transradial approach (LTA) has never been assessed., Methods: 40 patients with suspected coronary artery disease were randomized to DCA via RTA (n=20) or LTA (n=20) with contemporaneous bilateral transcranial Doppler monitoring., Results: MES were detected in all patients, with a significantly higher rate in the RTA group (median 61, interquartile range (IQR) 47-105, vs 48, IQR 31-60, p=0.035). MES generated during procedures needing >2 catheters (n=8), are higher than those detected during procedures performed with 2 catheters (n=32, 102, IQR 70-108, vs 48, IQR 33-60, p=0.001). At multivariate analysis increasing number of catheters was the only independent predictor of high incidence of MES (OR 16.4, 95% CI 1.23-219.9, p=0.034, -2LL=26.7)., Conclusions: LTA has a lower risk of brain embolization because of the lower number of catheter exchange maneuvers. Since the degree of brain embolism depends on the magnitude of mechanical manipulation, catheter changes should be minimized to reduce the risk of cerebral embolization., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

A 69-year-old female was hospitalized for acute coronary syndrome and received full antiplatelet and anticoagulant therapy. The patient underwent angioplasty and stent implantation on right coronary and left circumflex arteries with good angiographic result. After the procedure, the patient developed hemorrhagic shock due to massive left renal hemorrhage. An emergent digital subtraction angiography showed bleeding from a left segmental renal artery. The hemorrhage was successfully managed with transcatheter superselective embolization. The patient was discharged after 22 days in good general condition with normal renal function. One-year follow-up was uneventful.

A 54-year-old man developed unstable angina pectoris and was found to have both an anomalous left coronary artery, which arose from the right sinus of Valsalva and followed an intramyocardial (septal) course, and severe atherosclerotic stenosis of the mid-right coronary artery. Stress perfusion imaging showed ischemia in the distribution of the right coronary artery, leading to successful percutaneous transluminal balloon angioplasty of the right coronary artery rather than surgical correction of the congenital anomaly.

A technique for a separate sidearm graft ("cobrahead") to facilitate reattachment of intercostal arteries in descending aortic replacement is described. The technique allows for very prompt restoration of spinal cord blood flow (via a Y attachment from the arterial perfusion circuit). The technique permits a simple, quick, and fully accessible anastomosis, technically more facile than the traditional side-to-side anastomosis. None of 7 patients treated with this technique had early or late paraplegia. Preliminary computed tomographic follow-up scans confirm patency of the cobrahead graft.

Background: Topical hypothermia, an early method developed for myocardial protection by virtue of its reduction of cardiac metabolic rate, is not without sequelae such as phrenic nerve paralysis and pulmonary complications., Methods: The hospital records of 505 nonrandomized consecutive patients undergoing coronary artery bypass grafting between 1991 and 1995 at the University of South Alabama were reviewed to evaluate the effectiveness of topical hypothermia and its relationship to pulmonary complications. Group A included 191 patients between 1991 and 1992 who received systemic hypothermia and topical hypothermia with iced slush in addition to cold blood cardioplegia. Group B included 314 patients between 1993 and 1995 who received systemic hypothermia and intermittent cold blood cardioplegia without iced slush., Results: Myocardial temperature mapping did not reveal any difference between the two groups. Postoperative cardiac morbidity, manifested as intraaortic balloon use, low cardiac output, inotrope use, and perioperative myocardial infarction, was decreased in group B, but the difference failed to achieve statistical significance. Mortality (group A, 3.14%; group B, 3.82%) and rates of significant morbidity such as sternal infection, stroke, reoperation for bleeding, renal failure, and prolonged ventilation were comparable between the two groups. However, there was a statistically significant difference in the incidence of diaphragmatic paralysis between group A and group B. Group A had a 25% incidence of diaphragmatic paralysis on the first postoperative day, 18% on the 15th postoperative day, and 8% at 6 months, as opposed to group B, which had incidences of 2% on the first postoperative day, 1% on the 15th postoperative day, and 1% at 6 months (p < 0.001). Also, there was a significant difference in incidence of pleural effusions (60% versus 25%) and rate of thoracentesis (25% versus 8%) between groups A and B (p < 0.0001)., Conclusions: We conclude that topical hypothermia did not offer any additional cardioprotective benefit above systemic hypothermia and cold blood cardioplegia alone in coronary bypass patients, but significantly increased the incidence of diaphragmatic paralysis and associated pulmonary complications.

We correlated the in vivo 1H Magnetic Resonance Spectroscopy (MRS) concentration of the choline peak (CHO) with in vitro chemical measures of choline-containing compounds and a histological grade of cellularity in 18 patients with neoplastic and infectious brain lesions. Gas-chromatography-mass-spectrometry (GCMS) was used to measure the concentrations of free choline (Cho), glycerophosphocholine (GPCho), phosphocholine (PCho) and phosphatidylcholine (PtdCho) from biopsies in the same area where MRS was performed. Cellular density, free Cho, PCho and GPCho were the strongest determinants of 1H MRS CHO while PtdCho was not. Just as the 1H MRS 2.0 peak reflects both the concentration of n-acetyl-l-aspartate and neuronal density, the 1H MRS 3.2 peak reflects the concentration of water-soluble choline-containing compounds and cellular density.

Patients with aortic regurgitation and severe left ventricular dysfunction remain candidates for aortic valve replacement, as long as the risks of late left ventricular dysfunction and congestive heart failure have been fully discussed with the patient, the patient's family, and the referring physician. In contrast, patients with mitral regurgitation and severe systolic dysfunction are at considerable risk of more severe left ventricular dysfunction after operation, especially if mitral valve repair or chordal-sparing procedure cannot be performed. In patients who are candidates for such procedures that preserve the integrity of the subvalvular mitral apparatus, operation may be successful in selected patients despite moderate-to-severe depression of systolic function. Prognosis is guarded to poor in patients with regurgitant valvular lesions and advanced left ventricular dysfunction, and the emerging alternative treatments discussed in other articles in this Cardiology Clinics deserve consideration in these patients.