Laparoscopic nephroureterectomy/hemi-nephroureterectomy is well tolerated in children and should be the preferred option. Operative time is acceptable. There are few complications. Patients with MCDK should have an ultrasound before surgery to confirm ongoing presence of renal tissue. In patients with xanthogranulomatous disease, laparoscopy should be avoided.
ConclusionThe shorter and simpler PREDICT scale was found to be less preferable with EMS provider all-comers, which may be partially due to the mere-exposure cognitive bias effect though this difference persisted in providers who had no prior exposure to either scale. In providers who enrolled multiple patients, there was a statistically insignificant trend towards preference for RACE between their first and last screening.
Objectives The use of intrathecal fluorescein (ITF) has become an increasingly adopted practice for the identification of cerebrospinal fluid (CSF) leaks during endoscopic skull base surgery for pituitary adenomas. Administration through lumbar puncture can result in postoperative positional headaches, increasing morbidity, cost, and length of stay. We sought to identify the incidence of and variables associated with postoperative headaches to determine if there was a subgroup of patients in whom this procedure should be avoided. Methods We conducted a retrospective single-institution review of 148 patients who underwent endoscopic resection with ITF for pituitary adenoma between December 2003 and February 2016. We excluded patients who had lumbar drains and with intraoperative CSF leak, as these patients may have other headache etiologies. Patient demographics, comorbidities, tumor features, surgical approach, surgical closure, and histology were recorded. Primary outcomes included the presence of postoperative and positional headaches. Results We identified 62 patients with postoperative headaches (41.9%) and 10 with positional headaches (6.8%), of whom 6 underwent blood patch with complete resolution. Following univariate analysis, there was a significant positive association with prolactin-secreting tumors (p = 0.008). There was a negative association with a history of hypertension (p = 0.0001) and age (p = 0.01). Following multivariate modeling, the significance for hypertension (p = 0.01) was preserved. Conclusions Positional headaches in patients who receive ITF are uncommon and should not limit its use in the preparations for endoscopic resection of pituitary adenomas. Avoiding ITF in younger patients without hypertension with prolactinomas might decrease the risk of post-ITF positional headaches.
Pituitary adenomas are the most common intracranial neoplasms in adults, with a prevalence of 7% to 17%. Clinically, they can be divided into 2 categories based on whether they secrete pituitary hormones: functional (secretory) and nonfunctional (nonsecretory or endocrine silent) adenomas. The biologic latency of nonfunctional (endocrine silent) adenomas makes them usually diagnosed at the stage of macro (>1 cm) and giant (>4 cm) adenomas. Because these tumors are nonfunctioning, their primary symptoms are due to mass effect, particularly on the optic chiasm and normal pituitary gland and stalk superiorly, and the cavernous sinus laterally. Visual field disturbance is the most common presenting complaint, followed by pituitary dysfunction and headaches. Surgical outcomes, therefore, are aimed at determining visual outcome in addition to rates of gross total resection, recurrence, and postoperative pituitary dysfunction. Several recent case series have documented the increased success of the endonasal endoscopic transsphenoidal approach for resecting nonfunctioning pituitary adenomas, particularly in relation to the classic open cranial and microsurgical transsphenoidal techniques.
Introduction: The American Heart Association Stroke Guidelines recommend intra-arterial therapy (IAT) for acute ischemic stroke with large vessel occlusions involving the internal carotid and proximal middle cerebral artery, but the role of IAT for M2 occlusions is unclear. We sought to report the outcomes of acute ischemic stroke patients with M2 occlusions who received intravenous tissue plasminogen activator (IVtPA). Methods: Among 322 acute ischemic stroke patients who received IVtPA from July 1, 2016 to July 1, 2017, we identified 23 patients (7%) with imaging-confirmed M2 occlusions. Two patients with M2 occlusions who underwent IAT were excluded. Data was abstracted on demographics, time of Last Known Normal (LKN), National Institutes of Health Stroke Scale (NIHSS), neuroimaging, clinical presentation, and 90-day modified Rankin Scale (mRS). Good outcome was defined as 90-day mRS of < 2. Results: Among the 21 ischemic stroke patients who received IVtPA for M2 occlusions, the mean age was 64.3 years (range, 21 to 88) and 10 (48%) were male. IVtPA was administered from LKN at a mean 2.5 hours (range, 0.8 to 5.1). Most patients (90%) were transferred from outside facilities. Initial NIHSS prior to IVtPA was a mean of 11.2 (range, 3 to 29). All patients had CT angiogram which was done at a mean of 4.0 hours from LKN (range, 1.2 to 7) and showed 10 (48%) right-sided and 11 (52%) left-sided M2 occlusions. Most (20/21) had CT perfusion, which was done at a mean of 4.1 hours from LKN (range, 1.2 to 7.3) and all showed mismatch in the corresponding territory of the arterial occlusion. MRI brain was performed in 19/21 patients at a mean of 21 hours from LKN (range, 3 to 53) and restricted diffusion in the corresponding arterial territory was seen in 17 (89%). Discharge NIHSS was a mean of 8.1 (range, 0 to 24). Among 20 patients with 90-day mRS data available, good clinical outcome was seen in 7 (35%). Conclusions: Among acute ischemic stroke patients with M2 occlusions, good clinical outcome was seen in only 35%, despite receiving IVtPA. Further studies are warranted to investigate the potential role of IAT in improving the natural history of medically treated acute ischemic stroke with M2 occlusions.
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