Sternoclavicular joint arthropathy mimicking radiculopathy in a patient with concurrent C4-5 disc herniation

Background Patients with sternoclavicular joint arthropathy, which can result from septic arthritis, often present with localized sternoclavicular pain as well as shoulder pain. Such pain may be similar to the presenting symptoms of cervical intervertebral disc herniation. Clinical presentation A 47-year-old female presented with 1 month of significant pain in the neck as well as right anterior chest and deltoid. The patient was found to have reduced strength in the right deltoid muscle on physical examination. MRI revealed a C4-C5 herniated nucleus pulposus. The patient underwent successful C4-C5 anterior cervical discectomy, but subsequently developed painful swelling in the region of the right sternoclavicular joint with limited motor strength in the right shoulder and arm. A needle biopsy of the mass yielded negative results, but her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) numbers did respond to antibiotics, consistent with infection of the sternoclavicular joint. A follow-up CT scan (6.5 months postoperatively) revealed apparent resolution right sternoclavicular joint arthropathy, thought the patient continued to experience pain. 15 months postoperatively, the patient was prescribed methotrexate due to persistent pain and mild weakness arising from a possible rheumatologic inflammation. 19 months postoperatively, the patient had full strength of the right shoulder and arm and visible decrease in swelling at the sternoclavicular joint. More than three years postoperatively, the patient was diagnosed with multiple myeloma, which was appropriately treated. At follow-up four years postoperatively, the patient had an MRI showing new C6-C7 herniated nucleus pulposus, but no longer had any right shoulder or chest pain or associated weakness. Conclusion This case demonstrates that sternoclavicular joint arthropathy results in symptoms that can mimic the presenting symptoms of shoulder or cervical spine pathology, such as shoulder and neck pain, necessitating careful diagnosis and management

Abstract Number ‐ 35: Maximum Euclidean Deflection‐A Novel Metric For Safety Of Neurovascular Devices

Introduction Endovascular thrombectomy (EVT) devices are evolving rapidly to improve safety and efficacy of EVT‐mediated recanalization of large vessel occlusion strokes, and to access medium and distal vessel occlusions. To enable effective comparative analyses, there is a need to develop an objective in‐vitro safety metric for new EVT devices. Methods We utilized three FDA‐approved stent‐retrievers (4 mm diameter; variable lengths) currently available in the United States and deployed them in an in‐vitro ischemic stroke bench model (Sim Agility, Mentice Inc., Sweden). The stent‐retrievers were deployed in the M1 segment of the middle cerebral artery of the model using a system comprised of an 0.014 inch guide wire and 0.021 inch microcatheter. After unsheathing in the M1 segment, in the absence of a blood clot, the microcatheter was withdrawn back into the petrous internal carotid artery, and the whole system was withdrawn as a rate of 5 mm per second. Maximum deflection of the terminal internal carotid was measured in 3 axes using a specialized camera set‐up. Results A total of 3 passes were performed for each stent‐retriever (stent A, stent B, and stent C). Maximum deflection of the terminal internal carotid artery (from resting position to largest displacement during stent‐retrieval withdrawal) was measured in 3 planes and the values were as follows (Table).Maximum Euclidean Deflection (MED) ranged from 6.1 to 9.1 mm. Deflection varied based on 3 stent‐retriever designs and the plane of measurement. Figure demonstrates deflections as seen in Stent A. Conclusions Withdrawing an unsheathed stent‐retriever from the middle cerebral artery leads to significant deflection of the internal carotid artery terminus in an in‐vitro stroke model. The degree of deflection is variable in different planes and varies based on stent‐retriever design. Further studies are required to examine the predictors and impact of the deflection

Reaccessing an occluded radial artery for neuroendovascular procedures: techniques and complication avoidance

BACKGROUND: Radial artery occlusion (RAO) occurs in 1% to 10% of cases following transradial arterial access (TRA) for neuroendovascular procedures. When repeat access is required in patients discovered to have RAO, a transfemoral approach is often used. This study reports experience with repeat TRA procedures at a single center and techniques for reaccessing an occluded radial artery in select patients. METHODS: The electronic records of all patients who underwent multiple neuroendovascular procedures with an attempted TRA as the index procedure at a single center from July 2019 through February 2020 were reviewed. RESULTS: There were 656 TRA attempts for diagnostic angiography or intervention from July 2019 through February 2020. A total of 106 patients underwent a repeated attempt at TRA. Techniques for reaccessing an occluded radial artery were implemented halfway through the study period. One hundred patients (94.3%) had a successful second radial catheterization. Six patients required conversion to a transfemoral approach: five for RAO and one for radial branch perforation during the index procedure. After we implemented our techniques for reaccess, four additional patients with RAO successfully underwent TRA. There were no short-term complications, including pain, vessel perforation, forearm hematoma, or hand ischemia, following successful repeat catheterization of a previously occluded radial artery. CONCLUSION: RAO is not an absolute limitation for attempting TRA in patients undergoing repeat catheterization. Reaccessing the radial artery after occlusion is feasible for repeat neuroendovascular procedures

General acts passed by the General Court of Massachusetts

Imprint varies.Vols. for 1915-19 published in 2 v.: General acts; Special acts.Vols. for some years issued in parts.Separate vols. issued for extra session, 1916, and for extra session, 1933.Vol. 12 (May 1831-Mar. 1833) in Jan. session, 1833; Jan. 1834-Apr. 1836 in vol. for extra session 1835/Jan. session 1836; May 1824-Mar. 1828; June 1828-June 1831, Jan. 1832-Apr. 1834, Jan. 1835-Apr. 1838, each bound with corresponding vol.Resolves issued separately, 1780-1838

Multi-Modal Endovascular Management of Traumatic Pseudoaneurysm and Arteriovenous Fistula of the Ascending Cervical Artery: A Technical Report and Review of Literature

OBJECTIVE: The management of traumatic pseudoaneurysm (PA) with concomitant arteriovenous fistula (AVF) arising from the thyrocervical trunk is challenging and rarely reported. Here, the usefulness of a multi-modal endovascular strategy for management of traumatic PA and AVF arising from the thyrocervical trunk is presented. A literature review describing unique clinical features and management strategies of traumatic vascular lesions of the thyrocervical trunk is included. METHODS: A 58-year-old man presented with two PAs arising from the ascending cervical artery (AsCA) and a robust AVF between the AsCA and the left vertebral venous plexus which arose acutely after a stabbing incident. These lesions were managed with endovascular vessel sacrifice via coiling and controlled Onyx injection. Relevant literature was identified via a targeted search of the PubMed database. RESULTS: Post-management angiography demonstrated complete occlusion of the two traumatic PAs and successful disconnection of the concomitant AVF. Our literature review demonstrates a shift in preferred management approach from invasive surgery to endovascular treatment due to the lower risk and cosmetic preferability. CONCLUSION: Timely treatment of enlarging PA is necessary for reducing associated morbidity and mortality. While surgical resection has been the mainstay therapy, endovascular management has gained popularity in recent years. The choice of endovascular technique is variable and should be individualized based on patient\u27s clinical status, associated risk factors, and lesion morphology. We have shown that parent vessel sacrifice is safe and effective. Reconstruction with a combination of stents, coils, glue, or liquid embolics may be necessary when collateral flow is limited

Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms

Background: Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary: We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message: Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature

In Vivo Preclinical Quantitative Flow Analysis of Arterial Anastomosis Using a Microvascular Anastomotic Coupler and Clinical Application for Extracranial-to-Intracranial Bypass

OBJECTIVE: Although several commercially available sutureless anastomotic techniques are available, they are not routinely used in neurosurgery. We performed an in vivo flow analysis of end-to-end anastomosis using a microvascular coupler device in rats. We report our first clinical use of the microvascular anastomotic coupler. METHODS: Bilateral rat common carotid arteries (CCAs) were exposed, and a microvascular coupler was used to perform 8 anastomoses. A microflow probe provided quantitative measurement of blood-flow volume. Flow augmentation was assessed with end-to-side anastomoses connecting the distal CCA to the jugular vein (JV). A patient with chronic dominant hemisphere atherosclerotic ischemic disease and progressive symptoms refractory to medical management underwent end-to-end cerebral artery bypass using the microvascular coupler. RESULTS: Mean preanastomosis flow in the rat CCA was 3.95 ± 0.45 mL/min; this flow was maintained at 3.99 ± 0.24 mL/min on final measurements 54-96 minutes postanastomosis. Total occlusion time for each rat CCA was 12-19 minutes. After end-to-side anastomosis, with proximal and distal JV patent, CCA flow increased 477% to 22.8 ± 3.70 mL/min (P = 0.04, proximal; P = 0.01, distal). After in vivo testing, we successfully used the coupler clinically in a superficial temporal artery-to-middle cerebral artery bypass for dominant hemisphere flow augmentation. CONCLUSIONS: In vivo quantitative flow analysis demonstrated no flow difference between an unaltered artery and artery with end-to-end anastomosis using a microvascular coupler in rats. A 1-mm coupled anastomosis achieved a 4-fold flow increase with low-resistance venous outflow in rats, simulating increased arterial demand. The coupler was successfully used for extracranial-to-intracranial bypass in a patient