Tension pneumosella (TP) is a rare entity reported as the invagination of the sphenoid sinus mucosa into the skull base after endonasal transsphenoidal surgery. Few studies have reported on TP, and in these studies, invagination is confined to either the intrasellar or suprasellar area. We encountered a case of unexpected prominent TP toward the intracranial space 5 years after endoscopic endonasal transsphenoidal surgery (EETS) for a nonfunctioning pituitary adenoma. In addition, we present a hypothesis of the underlying mechanism by a pressure gradient change between the extracranial and intracranial space in TP formation. For repair, a pedicled nasal septal flap was fabricated from the remaining part of the septal mucosa, and a pedicled inferior turbinate flap was created. Moreover, the nasal septal cartilage was used as a rigid support for reconstruction, which was useful for preventing TP recurrence. This is the first report of an unexpected prominent TP after EETS. It is important for otorhinolaryngologists and neurosurgeons to be aware of the possibility of TP following EETS. Laryngoscope, 1798-1801, 2018.
Objective: To assess the efficacy and safety of botulinum toxin treatment (onabotulinumtoxinA 200 units) for Japanese patients with neurogenic detrusor overactivity caused by spinal cord injury or multiple sclerosis. Methods: Patients with urinary incontinence refractory to pharmacological treatment were enrolled and randomized in a phase III trial. A single dose of onabotulinumtoxinA (n = 11) or placebo (n = 10) was given in the double-blind phase, and repeat injections of onabotulinumtoxinA were given in the subsequent open-label phase. Outcomes included urinary incontinence episodes, urodynamics, patient-reported outcomes and adverse events. Results: The onabotulinumtoxinA group showed a numerically greater reduction in the number of urinary incontinence episodes per day than the placebo group, with the difference between the groups at week 6 of À3.02 (95% confidence interval À5.85 to À0.19). The onabotulinumtoxinA group also showed greater improvements in urodynamic assessments. Adverse events related to onabotulinumtoxinA injections were hematuria, urinary retention, urinary bladder hemorrhage, autonomic dysreflexia and epididymitis. Most events were deemed mild or moderate. Conclusions: Intradetrusor injections of onabotulinumtoxinA are efficacious and tolerable for Japanese patients with neurogenic detrusor overactivity-related symptoms that are difficult to manage with anticholinergics and/or b 3 -adrenergic receptor agonists.
BACKGROUND AND IMPORTANCE: Cholesterol granuloma (CG) is the most common petrous apex (PA) cystic lesion. Posterolateral expansion of a PA CG (PACG) compresses the internal auditory canal (IAC), leading to vestibulocochlear (VC) and facial nerve dysfunction. Even small, symptomatic PACGs are managed surgically. The preferred strategy is not complete removal, but drainage and aeration. PACG with anteromedial expansion using an endoscopic endonasal approach provides natural drainage into the nasal sinus without risking VC and facial dysfunction. Endoscopic endonasal approach is inappropriate for small PACGs without anteromedial expansion because of potential damage to the petrous internal carotid artery. Small PACGs without anteromedial expansion are managed using extradural middle fossa (EMF) approach, which lacks a natural drainage pathway, thus necessitating an artificial drainage pathway for PACG aeration to prevent recurrence. We introduced EMF approach for CG decompression and cyst-tomastoid antrum (MA) diversion for managing small, symptomatic PACGs without anteromedial expansion. CLINICAL PRESENTATION: A 48-year-old woman presented with headache, vertigo, tinnitus, and left hemifacial spasm with preserved hearing because of IAC compression caused by a small PACG without anteromedial expansion. Using the EMF approach, the CG and IAC were safely decompressed. Effective and long-standing artificial drainage for CG aeration was established by anterior petrosectomy and silicone tubing from the CG into the MA. Surgery resolved the symptoms, which have not recurred in 3 years. CONCLUSION: Granuloma decompression and cyst-to-MA diversion using silicone tubing using the EMF approach is a safe and effective surgical management for small, symptomatic PACG without anteromedial expansion.
guidelines recommend that patients should receive mechanical thrombectomy if the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is ≧6. However, its benefits are uncertain if the ASPECTS is <6. This study aimed to identify the outcomes of mechanical thrombectomy in patients with ASPECTS <6. Methods: Thirty-nine patients with acute ischemic stroke with diffusion weighted imaging (DWI)-ASPECTS ≦5, with internal carotid artery or middle cerebral artery segment 1 (M1) occlusion were treated with mechanical thrombectomy between May 2014 and April 2018. We retrospectively compared patients with a good outcome [modified Rankin Scale (mRS): 0-2] and those with a poor outcome (mRS 3-6) at 3 months. Results: The good-outcome group comprised 16 patients (41%) and the poor outcome group comprised 23 patients (59%) at 3 months. There were no significant differences in the baseline characteristics [age, sex, occluded artery, National Institutes of Health Stroke Scale score and DWI-ASPECTS] between the two groups. The onset to recanalization time was shorter in the good-outcome group (192 versus 210 minutes, p=0.0083). The mean DWI-ASPECTS of the good-outcome group did not change between arrival and post thrombectomy (5 versus 4, p=0.24), but the mean DWI-ASPECTS of the pooroutcome group worsened (5 versus 2, p=0.0014) between hospitalization and after thrombectomy. Conclusions: The outcome of mechanical thrombectomy could be good even in patients with low DWI-ASPECTS and a magnetic resonance angiography-DWI mismatch.
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