When the bullet moves! Surgical caveats from a migrant intraspinal bullet

Rarely, spinal gunshot injuries result in migrating intraspinal bullets. Use of MRI is controversial and other radiographic imaging might mimic an extradural bullet, even though it is intradural and migratory. Here, we present a case of spinal missile injury resulting in an intraoperatively mobile intradural bullet. The challenges faced during diagnosis and surgical removal are described. We also show that intraoperative ultrasonography may be useful in clarifying whether the bullet is intradural. A 32-year-old male presented with weakness and paraesthesia in his right leg following an accidental gunshot injury to his spine. Facet joint destruction and an intraspinal bullet were detected. Immediate surgical removal and transpedicular instrumentation was performed. The surgical procedure was complicated by lack of an identifying dural perforation at the bullet entry point and a gliding bullet inside the spinal canal during surgery. Gliding of the bullet was caused by the pushing effect of the bone rongeur and further gliding was avoided by performing the next laminectomy with an electric drill. Where other modalities indicated for a possible extradural location, intraoperative USG clearly showed the intradural position of the bullet and provided clear images without major artifacts. Surgical treatment of a mobile intradural bullet is challenging and open to surprises. Location of the bullet may shift as result of surgical procedure itself. Laminectomy should be performed with a power drill. Where fluoroscopy was inadequate and MRI not available, intraoperative USG proved useful in ascertaining the intradural versus extradural position of the bullet and allowed for a tailored dural opening

UC-209 Remote Presence Robot

A motorized robot that has a screen, microphone, webcam, and speaker to perform video chat capabilities and the ability to move about the environment. The robot will have customization functionalities to add a personal flair for the remote user. A remote user can access a web dashboard to control the robot as if they were in person. This will be good for sick or handicapped people. In addition to the standard web dashboard, we can incorporate a customization aspect for the host user to add filters to their image or stream audio (background blur, soundboard playback, etc.) The robot will be controlled by a remote user via a keyboard or controller to control its movements and interact with its surroundings

Dural Arteriovenöz Fistül (DAVF) Tedavisinde Kombine Yaklaşım: Süperselektif Embolizasyon ve Gamma Knife Radyocerrahisi

Dural arteriovenöz fistüller (DAVF) dural arterler ve venler veya sinüsler arasındaki anormal vasküler bağlantılardan oluşan lezyonlardır. Çok sayıda fistül içerebilmeleri ve venöz drenaj paternlerindeki değişiklikler tedavi kararında güçlüklere neden olabilmektedir. Biz bu yazıda sol eksternal karotid arterin orta meningeal ve oksipital dallarından dolan, önce süperselektif olarak embolize edilen ve 3 ay sonraki kontrolde oksipital besleyicilerinin rekanalize olduğu gözlenen DAVF’ li olguya ikinci kez uyguladığımız kombine süperselektif embolizasyon artı Gamma Knife tedavisini sunmaktayı

Clinical Article A retrospective review of cervical corpectomy: indications, complications and outcome

Summary Background. Cervical corpectomy is a common spinal surgery procedure used to decompress the spinal cord in numerous degenerative, traumatic and neoplastic conditions. The aim of this study was to investigate the indications, complications and outcomes in past cervical corpectomy cases at one centre. Method. 72 patients who underwent cervical corpectomy between February 1992 and June 2001 were retrospectively investigated. Findings. The indications for this operation were degenerative spondylitic disease (26 cases; 36.1%), trauma (18 cases; 25%), tumour (11 cases; 15.3%), infection (10 cases; 13.9%), and ossification of the posterior longitudinal ligament (7 cases; 9.7%). Thirty-seven patients (51.4%) underwent one-level corpectomy, and 35 (48.6%) underwent two-level corpectomy. Autografts were used in 13 cases (18.1%) and allografts were used in 59 cases (81.9%). Anterior plate-screw fixation was performed in all cases. There were 31 postoperative complications in 15 (20.8%) patients. Twelve of the complications were surgical, 5 were graft-related, 7 were plating-related, and 7 were medical. Solid bony fusion was achieved in 65 (92.9%) of the 70 surviving patients. The mean follow-up time was 23.4 months. An overall favourable outcome was achieved in 88% of cases. Conclusion. The outcomes in this series indicate that cervical corpectomy is an effective method for treating traumatic lesions, degenerative disease, tumours and infectious processes involving the anterior and middle portions of the cervical spine

Unique Proteomic Signatures Distinguish Macrophages and Dendritic Cells

Monocytes differentiate into heterogeneous populations of tissue macrophages and dendritic cells (DCs) that regulate inflammation and immunity. Identifying specific populations of myeloid cells in vivo is problematic, however, because only a limited number of proteins have been used to assign cellular phenotype. Using mass spectrometry and bone marrow-derived cells, we provided a global view of the proteomes of M-CSF-derived macrophages, classically and alternatively activated macrophages, and GM-CSF-derived DCs. Remarkably, the expression levels of half the plasma membrane proteins differed significantly in the various populations of cells derived in vitro. Moreover, the membrane proteomes of macrophages and DCs were more distinct than those of classically and alternatively activated macrophages. Hierarchical cluster and dual statistical analyses demonstrated that each cell type exhibited a robust proteomic signature that was unique. To interrogate the phenotype of myeloid cells in vivo, we subjected elicited peritoneal macrophages harvested from wild-type and GM-CSF-deficient mice to mass spectrometric and functional analysis. Unexpectedly, we found that peritoneal macrophages exhibited many features of the DCs generated in vitro. These findings demonstrate that global analysis of the membrane proteome can help define immune cell phenotypes in vivo

The reliability and interobserver reproducibility of T2/FLAIR mismatch in the diagnosis of IDH-mutant astrocytomas

PURPOSE:The reliability and reproducibility of T2-weighted imaging/ fluid-attenuated inversion recovery (T2/FLAIR) mismatch were investigated in the diagnosis of isocitrate dehydrogenase (IDH) mutant astrocytoma between WHO grade II and III diffuse hemispheric gliomas.METHODS:WHO grade II and grade III diffuse hemispheric gliomas (n=133) treated in our institute were included in the study. Pathological findings and molecular markers of the cases were reviewed with the criteria of WHO 2016. The finding of mismatch between T2-weighted and FLAIR images in preoperative magnetic resonance imaging (MRI) of the cases was evaluated by two different radiologists. The readers reviewed MRIs independently, blinded to the histopathologic diagnosis or molecular subset of tumors. The cases were classified as IDH-mutant astrocytoma, oligodendroglioma and IDH-wildtype (IDH-wt) astrocytoma according to molecular and genetic features.RESULTS:T2/FLAIR mismatch positivity was observed in 46 patients (34.6%). T2/FLAIR mismatch positivity was observed in 42 of 75 IDH-mutant astrocytomas (56%) and 4 of 43 oligodendrogliomas (9.30%), while it was not seen among IDH-wt astrocytomas (0/15, 0%). The T2/FLAIR mismatch ratio was significantly different between IDH-mutant astrocytomas (WHO grade II and grade III) and oligodendrogliomas (chi-square, p <0.05). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of T2/FLAIR mismatch in predicting IDH-mutant astrocytomas were 58.7%, 90.7%, 91.7%, 61.4%, and 70.3% respectively. Radiologist 1 diagnosed T2/FLAIR mismatch in 48 of 133 cases (36.1%) and Radiologist 2 in 66 of 133 cases (49.6%). The interrater agreement for the T2/FLAIR mismatch sign was 0.61 (p <0.05), 95% CI (0.55, 0.67).CONCLUSION:T2/FLAIR mismatch appears to be an important MRI finding in distinguishing IDH-mutant astrocytomas from other diffuse hemispheric gliomas. However, it should be kept in mind that T2/FLAIR mismatch sign can be seen in a minority of oligodendrogliomas besides IDH-mutant astrocytomas

IDH-mutant glioma specific association of rs55705857 located at 8q24.21 involves MYC deregulation

The single nucleotide polymorphism rs55705857, located in a non-coding but evolutionarily conserved region at 8q24.21, is strongly associated with IDH-mutant glioma development and was suggested to be a causal variant. However, the molecular mechanism underlying this association has remained unknown. With a case control study in 285 gliomas, 316 healthy controls, 380 systemic cancers, 31 other CNS-tumors, and 120 IDH-mutant cartilaginous tumors, we identified that the association was specific to IDH-mutant gliomas. Odds-ratios were 9.25 (5.17–16.52; 95% CI) for IDH-mutated gliomas and 12.85 (5.94–27.83; 95% CI) for IDH-mutated, 1p/19q co-deleted gliomas. Decreasing strength with increasing anaplasia implied a modulatory effect. No somatic mutations were noted at this locus in 114 blood-tumor pairs, nor was there a copy number difference between risk-allele and only-ancestral allele carriers. CCDC26 RNA-expression was rare and not different between the two groups. There were only minor subtype-specific differences in common glioma driver genes. RNA sequencing and LC-MS/MS comparisons pointed to significantly altered MYC-signaling. Baseline enhancer activity of the conserved region specifically on the MYC promoter and its further positive modulation by the SNP risk-allele was shown in vitro. Our findings implicate MYC deregulation as the underlying cause of the observed association