Post-operative venous thromboembolism in patients after extracranial otologic surgery: A case series

Objective:This study aimed to report 9 venous thromboembolism(VTE)cases after extracranial otologic surgery and analyze the potential risk factors.Study design:Case series.Setting:Single tertiary-level academic center.Methods:Totally,9 cases of VTE were identified among adults who underwent extracranial otologic surgery at our hospital from January 2018 to December 2020.Caprini risk scores were calculated,and comprehensive preoperative,operative,and postoperative clinical data within 14 days were collected to assess the evidence of VTE.Results:The median age of 9 patients was 64 years old.Among them,7(77.8%)patients presented with intramuscular vein thrombosis,1(11.1%)patient had deep vein thrombosis,and 1(11.1%)patient experienced pulmonary embolism.Preoperatively,8(88.9%)patients had low or middle Caprini risk scores(≤4)with an average of 2.67±0.47 points.The average Caprini scores for all patients were 4.44±0.35 on postoperative day(POD)1 and 5.67±0.64 on POD14.D-dimer levels were collected,indicating an average of 0.55±0.17 mg/FEU preoperatively,8.53±3.94 mg/FEU at day 1,and 3.76±0.45 mg/FEU at POD14.In postoperative period,7(77.8%)patients experienced vertigo/dizziness and/or head immobility/bed rest.Conclusion:The present study highlighted that patients with low-and middle-risk of VTE undergoing otologic surgery should be also vigilant about postoperative VTE.Vertigo/dizziness and/or head immobility/bed rest in postoperative period should be considered as minor risk factors for developing VTE in patients undergoing extracranial otologic surgery.Conducting perioperative assessments,including Caprini risk score evaluation,Ddimer testing,and venous ultrasound of lower extremities,is recommended to ensure patients’safety.

Analysis of the Effect of the Comprehensive Nursing Model on Patients with Moyamoya Disease Undergoing Intracranial and Extracranial Revascularization Surgery

Objective:To explore the effect of a comprehensive nursing model on patients with Moyamoya disease who underwent intracranial and extracranial revascularization surgery.Methods:110 cases were divided into control and observation groups with 55 cases each.The control group received routine perioperative care,and the observation group received perioperative care along with comprehensive nursing care.The two groups’disease cognition levels,anxiety,symptoms,daily living ability scores,and postoperative complication rates were compared.Results:The anxiety score and total postoperative complications of the observation group upon discharge were lower than that of the control group,and the disease cognition level and daily living ability upon discharge were higher than that of the control group(P<0.05).Conclusion:Applying the comprehensive nursing model in conjunction with perioperative care for patients undergoing surgery can effectively improve their anxiety,strengthen activities of daily living,and reduce the risk of postoperative complications.

Extracranial metastasis of anaplastic oligoastrocytoma

Extracranial metastasis(ECM) of glioma is a rare condition that occurs in the internal nervous axis. A 23-year-old woman presented with anaplastic oligoastrocytoma(WHO III) in a left temporal tumor. The patient received chemoradiotherapy after surgery in our center. Three years after treatment, the patient experienced multiple ECMs in the right lung, left iliac bone, and multiple swollen subcutaneous nodules including the right clavicle, back of the neck, left forearm, right upper arm, and right clavicle. The patient died of cerebral herniation at the age of 27 due to recurrent intracranial glioma. Treatment of ECM of glioma remains very challenging, and further investigations are needed.

Association of bone turnover biomarkers with severe intracranial and extracranial artery stenosis in type 2 diabetes mellitus patients

BACKGROUND Intracranial and extracranial artery stenosis is associated with cerebral infarction.Vascular calcification and atherosclerosis are the main causes of stenosis and major risk factors for cardiovascular and cerebrovascular events in patients with type 2 diabetes mellitus(T2DM).Bone turnover biomarkers(BTMs)are associated with vascular calcification,atherosclerosis,glucose,and lipid metabolism.AIM To investigate the association of circulating BTM levels with severe intracranial and extracranial artery stenosis in patients with T2DM.METHODS For this cross-sectional study including 257 T2DM patients,levels of the BTMs serum osteocalcin(OC),C-terminal cross-linked telopeptide of type I collagen(CTX),and procollagen type I N-peptide were measured by electrical chemiluminescent immunoassay,and artery stenosis was assessed by color Doppler and transcranial Doppler.Patients were grouped according to the existence and location(intracranial vs.extracranial)of artery stenosis.Correlations between BTM levels,previous stroke,stenosis location,and glucose and lipid metabolism were analyzed.RESULTS T2DM patients with severe artery stenosis had a higher frequency of previous stroke and levels of all three tested BTMs(all P<0.05)than patients without.Some differences in OC and CTX levels were observed according to the location of artery stenosis.Significant associations were also observed between BTM levels and some glucose and lipid homeostasis parameters.On multivariate logistic regression analysis,all BTMs were significant predictors of artery stenosis in T2DM patients with and without adjustment for confounding factors(all P<0.001),and receiver operating characteristic curve analysis demonstrated the ability of BTM levels to predict artery stenosis in T2DM patients.CONCLUSION BTM levels were found to be independent risk factors for severe intracranial and extracranial artery stenosis and were differentially associated with glucose and lipid metabolism in patients with T2DM.Therefore,BTMs may be promising biomarkers and potential therapeutic targets for artery stenosis.

Extracranial Carotid Atherosclerosis and Acute Ischemic Stroke in a Tertiary Hospital in Burkina Faso

Objective: To determine the prevalence and risk factors of carotid atherosclerosis among ischemic stroke patients in a tertiary hospital in Burkina Faso. Methodology: This was a descriptive and analytical retrospective study of patients admitted at neurology department of Yalgado Ouedraogo University Teaching Hospital with ischemic stroke and cerebral large vessel atherosclerosis in the period from January 1, 2012 to December 31, 2016. Results: The prevalence of extracranial carotid atherosclerosis was 23.9%. The mean age of patients was 63.5 years (Range 31 - 90 years). The study population included 65% of men and 35% of women. Hypertension was the most common vascular risk factor (75.6%). Stroke was mostly located in the anterior circulation in 23.9%. Low HDL-C was present in 52% of patients. The majority of plaque was homogeneous (85.2%). Plaque were located in carotid bulbar artery (38.5%) followed by common carotid artery (28.2%) and extracranial internal carotid artery (18.6%). According to cerebral lesion, plaque was bilateral in 45.5%, ipsilateral in 42.3% and contralateral in 12.1% of cases. Tight stenosis was found in 30.1% of patients. There was a significant link between male gender and tight stenosis (p = 0.004). Aspirin was the most antiplatelet therapy used (95.5%). Statin therapy was used in 91% of patients. The mean duration of hospitalization was 12.5 days with a mortality rate of 7.1%. Conclusions: Our study showed that extra carotid atherosclerosis was the most common cause of ischemic stroke in Burkina Faso. Man gender was most represented than women.

Spontaneous Extracranial Vertebral Artery Dissociation: A Case Report and Review of the Literature

We encountered a 36-year-old female who developed extracranial vertebral artery dissociation (EVAD), which is a rare condition in Japan. The disease developed with sudden severe right side neck pain and right upper arm pain. No abnormality was observed in the spinal canal, intervertebral discs, spinal cord, or nerve roots on MRI of the cervical spine, but dilation and double lumen were noted in the vertebral artery (VA) at the C4/5 level. The presence of aneurysm was confirmed by VA angiography, and EVAD was diagnosed. The symptoms were resolved by conservative treatment of pain, and the aneurysm shrank and disappeared with time on VA angiography. Even though neck and upper limb pain are the only clinical symptom and there is no brain dysfunction, such as disturbance of consciousness and vertigo, when symptoms develop acutely, this pathology should be included in differential diagnosis and orthopedists should carefully observe the vertebral artery, as well as the spinal canal, in evaluating cervical MRI.

Giant Intracranial and Extracranial Meningioma of the Falx Cerebri: Surgical Management and Case Report

Meningiomas are usually benign growths that rarely invade the substance of the brain, thus presenting the potential for curative surgery. Their sometimes difficult locations and propensity to recur if not completely excised represent formidable problems for the patient and the neurologic surgeon. This report describes a case of giant intracranial and extracranial meningioma of the falx cerebri. The tumor had displaced the anterior third of the superior sagittal sinusand a massive extracranial protrusion was eroding the calvarium, left supraorbital rim, frontal sinus and the left maxillary sinus. We present the surgical approach.

Case of primary extracranial meningioma of the maxillary sinus presenting as buccal swelling associated with headache:A case report

BACKGROUND Meningiomas are benign tumors that originate from the meningothelial arachnoid cells,but they rarely develop extracranially.There is no specific surgical guideline for resecting them in the maxillary sinus,and little is known about their biological behavior and operative management.CASE SUMMARY We present a 54-year-old female patient referred to our department with a primary extracranial meningioma that presented as buccal swelling associated with headache.On clinical examination the mass was non-tender,fixed,sessile and non-pulsatile situating in the right maxillary sinus.Computed tomography scan showed a well-defined mass of 7 cm×6 cm×6 cm compressing the surrounding structures.Magnetic resonance imaging revealed a well circumscribed heterogenous lesion with necrotic center and relatively hypointense on T2-weighted imaging.Imaging studies revealed no evidence of intracranial extension and metastatic nests.Biopsy showed grade I primary extracranial with low mitotic activity.Total maxillectomy with excision of tumor and adjacent paranasal structures following reconstruction of the orbit and maxilla with tissue patch was done by the maxillofacial surgeon.The biopsy reported fibrous meningioma based on the hematoxylin and eosin section.On immunohistochemistry the tumor cells were positive for vimentin,focally positive for epithelial membrane antigen and CD99 and negative for signal transducer and activator of transcription 6.The mass was removed surgically with reconstruction,and the pathological studies confirmed the diagnosis to be an extracranial meningioma.The present study briefly reviews the current knowledge concerning the diagnosis and treatment of extracranial meningiomas in the head and neck area and offers suggestions for managing extracranial meningiomas in the paranasal sinuses.CONCLUSION To conclude,extracranial meningiomas in the paranasal sinuses may be successfully managed by surgical treatment without evident post-surgery complications.

Extracranial multiorgan metastasis from primary glioblastoma: A case report

BACKGROUND Glioblastoma has a high degree of malignancy and poor prognosis.It is common to have in situ recurrence and intracranial metastasis,while extracranial metastasis is rare,and extracranial multiorgan metastasis is extremely rare.We report a case of glioblastoma with extracranial multiorgan metastasis,which will strengthen clinicians’attention to the extracranial metastasis of glioblastoma and its treatment.CASE SUMMARY A male patient visited our hospital for treatment of dizziness and headache.Magnetic resonance imaging of the brain revealed a space-occupying lesion in the right temporoparietal occipital region.Chest computed tomography and abdominal ultrasound were normal,and no space-occupying lesions were observed in other organs of the body.The patient underwent surgery and diagnosed with glioblastoma.Postoperative concurrent radiotherapy and chemotherapy were completed.During the follow-up,the tumor was found to have metastasized to the scalp and neck,and a second tumor resection was performed.Postoperative follow-up revealed extracranial metastases to multiple extracranial organs including skull,scalp,ribs,spine,liver and lung.His family members refused further treatment,and requested only symptomatic treatment such as pain relief,and the patient died of systemic multiple organ failure.Survival time from diagnosis to death was 13 mo and from extracranial metastasis to death was 6 mo.CONCLUSION Glioblastoma extracranial metastasis is extremely rare,clinicians should always pay attention to its existence.The mechanism of glioblastoma extracranial metastasis is still unclear,and genetic and molecular studies are required.

Treatment of extracranial internal carotid artery dissecting aneurysm with SUPERA stent implantation:Two case reports

BACKGROUND There is no standard endovascular treatment for extracranial internal carotid artery dissecting aneurysms.In the past,stent-graft isolation and stent-assisted coil embolization were commonly used for wide-necked and fusiform aneurysms.Here,we present two cases of extracranial internal carotid artery dissecting aneurysms treated successfully using the SUPERA stent.CASE SUMMARY Case 1 was a 57-year-old male patient with sudden right limb weakness and vague speech and diagnosed with cerebral infarction in February 2019.Cervical computed tomographic angiography(CTA)revealed left internal carotid artery dissection with stenosis.CTA at 2 mo showed an eccentric wide-necked dissecting aneurysm(5 mm×5 mm×12 mm,10-mm neck)that was enlarged at 4 mo(7 mm×6 mm×12 mm,11-mm neck).The patient underwent SUPERA stent implantation.His condition was stable in July 2020.Case 2 was a 57-year-old man who suddenly felt dizzy and developed unsteady walking in November 2019.Cervical CTA suggested right internal carotid artery dissecting aneurysm(11 mm×9 mm×31 mm)complicated with severe lumen stenosis(95%).The patient underwent SUPERA stent implantation.The patient had no residual symptoms and was stable in December 2020.CONCLUSION SUPERA stent implantation might achieve good results in treating wide-necked or long fusiform internal carotid artery dissecting aneurysms.

Postoperative glioma extracranial metastasis:A case report

A case with intracranial glioma after the surgery metastasizing to the spine was described. A 28-year-old female patient who underwent surgery and radiation therapy for glioma in the left frontal lobe and was diagnosed as having extracranial metastasis to L2–L4 vertebral body by MRI, PET-CT and pathological examination. The clinical, imaging and pathologic features of the case are described and discussed.

Protective and Indicating Effect of Indirect Bilirubin in Intracranial or Extracranial Artery Atherosclerotic Stenosis Progresses

Background: Bilirubin is the metabolic end-product of heme degradation by heme oxy-genase (HO), which has recently been shown to act as an antioxidant which can protect against atherosclerosis. This study explored the relationship between serum bilirubin levels and different degrees of atherosclerotic stenosis in intracranial or extracranial arteries. Methods: The study included 189 patients undergoing digital subtraction angiography (DSA) diagnosed as being normal or having been confirmed as atherosc lerotic stenosis in the intracranial or extracranial arteries. The patients were allocated to normal, mild (Results: Indirect bilirubin (Ibil) concentrations increased in parallel with the increasing severity of atherosclerotic stenosis in the intracranial or extracranial arteries, but decreased in patients with occluded cranial vessels. Multivariate analysis showed that Ibil levels were significantly higher in patients with severe stenosis group than in those with mild stenosis (OR, 1.464;95% CI, 1.050 - 2.042;P = 0.024). However, Ibil levels were significantly lower in patients with occlusion than in those with severe stenosis (OR, 0.790;95% CI, 0.684 - 0.913;P = 0.001). Conclusions: Ibil appears to have a protective effect against the development of atherosclerotic stenosis in intracranial or extracranial arteries. The biosynthesis of Ibil increases with stenosis progresses but decreases once occlusion occurs.

Extracranial Metastasis of an Anaplastic Ependymoma, RELA Fusion-Positive: A Rare Occurrence

Primary intracranial ependymomas originate from ependymal cells. They may migrate mainly in the spinal cord but rarely metastasize outside the central nervous system. Metastases outside the central nervous system are rare. Metastatic diffusion from the central nervous system is low due to the unique interaction of the brain and the tumor with the blood-brain barrier. Nevertheless, three main hypotheses have been mentioned in the literature, the tumor growth, the surgical manipulation (which may be considered to be the case in our patient), and the aggressiveness of the tumor according to the Ki67 index. We report the case of a 16-year-old female, who underwent complete surgical removal of a left occipital 2007 WHO grade II ependymoma. 3 years later, the patient presented multiple cervical and occipital indurated masses. MRI showed a left hemispheric meningeal infiltration, with multiple nodules located on the neck, occiput and mastoid. Histopathological study of a left temporal surgical biopsy and resection of an occipital subcutaneous nodule turned to be metastases of an anaplastic ependymoma. The ependymoma considered as a benign tumor could very quickly turn into malignancy by its metastatic potential. Early diagnosis and longer follow-up of patients would be recommended for a rapid management.

Bleomycin inhibits CLEC14A to attenuate the progression of extracranial arteriovenous malformations

Background:We previously reported that interstitial injection of bleomycin(BLM)reduces the size of early-stage extracranial arteriovenous malformation(AVM).Here,we sought to investigate the potential mechanism of BLM in treating extracranial AVM.Methods:Samples of human extracranial AVM(n=3)with no pharmacological treatment were harvested.AVM endothelial cells were isolated and cultured in primary cell culture.The transcriptome was examined using RNAsequencing,and differentially expressed C-type lectin domain family 14 member A(CLEC14A)was validated at the transcriptomic and protein levels.Immunocytochemical staining of CLEC14A was performed in samples of human extracranial AVM,with and without BLM treatment.Results:Through second-generation sequencing,we found that the expression of 5689 genes were differentially increased or decreased following 24-h BLM stimulation.We found that CLEC14A may play an important role in the progression of AVM and can be inhibited by BLM treatment.Conclusion:BLM inhibited CLEC14A expression to attenuate the progression of AVM.

Traumatic extracranial internal carotid-jugular fistula leading to serious injury: a case report in forensic assessment

Extracranial carotid artery injuries may produce severe haemorrhage,cerebral damage or arteriovenous fistula.Examples of traumatic extracranial carotid-jugular fistula are not frequently reported,especially in forensic medicine.We report a controversial case of an extracranial internal carotid-jugular fistula resulting from a stab wound to the neck.The degree of the injury was classified under“The Standard of Human Body Injury Assessment(2014)”(SIA)in China by forensic examiners.We believe this case report will provide information for the forensic assessment of similar cases.

Primary gliosarcoma with widespread extracranial metastases--spatiotemporal morphological variation

Background:We summarize 5 cases of primary gliosarcoma with widespread extracranial metastases including our case.The glial components are eliminated due to the needs of the living environment in the process of parasitism and survival of brain glioma-sarcoma cells in lung metastasis.Methods:A PubMed search using the keywords"gliosarcoma"and"extracranial metastases"was performed followed by a review of cited literature.Our case was a 50-year-old female presented with headache and dizziness.MRI examination showed that there was a cystic solid tumor in the right temporal lobe.The tumor was removed totally.Seven months after the operation,the patient suffered recurrent intermittent headache.The resection for the recurrent tumor was performed.Postoperative pathology confirmed the recurrent gliosarcoma.A needle biopsy was performed for the nodular on the right lung.The lung tumor pathology suggested a sarcoma structure.Results:There was a female patient in five cases.The age range is 47 to 69 years old.The tumor recurred within a year.A combination of treatment modalities may extend survival;however,the prognosis remains poor.Conclusion:Primary gliosarcoma with extracranial metastases is extremely rare.Some findings uncovered an unexpected spatiotemporal morphological variation in the different foci of the same malignancy.

Operative managements of extracranial carotid artery aneurysms: a report of three cases and literature review

Background:The purpose of this study is to report the treatment approaches and postoperative outcomes of extracranial carotid artery aneurysms (ECAAs) and discuss the symptoms,related risk factors,etiology,diagnostic methods,treatments,and follow-up period complications.Case presentation:We describe three patients with symptomatic extracranial carotid artery aneurysms;one of them was treated with end-to-end anastomosis of the extracranial internal carotid artery (EICA) after the resection of the aneurysm,while the other two patients were deployed with Willis covered stents in the extracranial internal carotid artery.All of the patients were in good condition when discharged home.After a mean follow-up period of 8 months,all the patients were alive and only one of them had the neurologic deficit.Additionally,we reviewed the relative literatures.Conclusion:Both of the surgical and endovascular treatments have relatively satisfactory outcomes in ECAA patients.However,it is necessary to provide individualized treatments to different patients according to the characteristics of the aneurysms.

Clinical usefulness of ankle brachial index and brachial-ankle pulse wave velocity in patients with ischemic stroke

Ankle brachial index （ABI） and brachial-ankle pulse wave velocity （baPWV） are widely used noninvasive modalities to evaluate atherosclerosis. Recently, evidence has increased supporting the use of ABI and baPWV as markers of cerebrovascular disease. This study sought to examine the relationship between ABI and baPWV with ischemic stroke. This study also aimed to determine which pathogenic mechanism, large artery disease （LAD） or small vessel disease （SVD）, is related to ABI or baPWV. Retrospectively, 121 patients with ischemic stroke and 38 subjects with no obvious ischemic stroke history were recruited. First, ABI and baPWV were compared between the groups. Then, within the stroke group, the relevance of ABI and baPWV with regard to SVD and LAD, which were classified by brain magnetic resonance image （MRI） and magnetic resonance angiography （MRA） or computed tomography angiography （CTA） findings, was assessed. The baPWV was higher in the stroke group than non-stroke group （1,944.18±416.6 cm/s vs. 1,749.76±669.6 crn/s, P 〈 0.01）. Regarding LAD, we found that mean ABI value was lower in the group with extracranial large artery stenosis （P 〈 0.01）, and there was an inverse linear correlation between ABI and the grade of extracranial large artery stenosis （P〈 0.01）. For SVD, there was a significant correlation between SVD and baPWV （2,057.6±456.57 cm/s in the SVD （＋） group vs. 1,491±271.62 cm/s in the SVD （-） group; P 〈 0.01）. However, the grade of abnormalities detected in SVD did not correlate linearly with baPWV. These findings show that baPWV is a reliable surrogate marker ofischemic stroke. Furthermore, baPWVand ABI can be used to indicate the presence of small vessel disease and large arterial disease, respectively.

Association between Serum Alkaline Phosphatase and Carotid Atherosclerosis in a Chinese Population: A Community-based Cross-sectional Study

Objective This study aimed to investigate the relationship between alkaline phosphatase(ALP) and common carotid intima media thickness(IMT), carotid plaque, and extracranial carotid artery stenosis(ECAS). Methods A total of 3,237 participants aged ≥ 40 years were recruited from Jidong community in 2013-2014. Participants were divided into five quintile groups based on their serum ALP levels. Carotid atherosclerosis was assessed using ultrasound. Abnormal IMT, carotid plaque, and ECAS were defined as IMT > 0.9 mm, IMT > 1.5 mm, and ≥ 50% stenosis in at least one extracranial carotid artery, respectively. Results Common carotid IMT values and the prevalence of carotid plaque increased across serum ALP quintiles. Higher ALP quintiles were correlated with an increased risk of abnormal IMT [fourth quintile: odds ratio(OR) 1.78, 95% confidence interval(CI) 1.13-2.82, P = 0.0135;fifth quintile: OR = 1.82, 95% CI: 1.15-2.87, P = 0.0110] and ECAS compared to the lowest quintile(fifth quintile: OR = 1.47, 95% CI: 1.09-1.97, P = 0.0106). The association between ALP and prevalence of carotid plaque became insignificant after adjustment for confounders. Conclusion Serum ALP levels were independently associated with abnormal common carotid IMT and ECAS. These conclusions need to be further corroborated in future prospective cohort studies.

Diffusion-weighted magnetic resonance imaging in cancer: Reported apparent diffusion coefficients,in-vitro and invivo reproducibility

There is considerable disparity in the published apparent diffusion coefficient(ADC) values across different anatomies. Institutions are increasingly assessing repeatability and reproducibility of the derived ADC to determine its variation,which could potentially be used as an indicator in determining tumour aggressiveness or assessing tumour response. In this manuscript,a review of selected articles published to date in healthy extracranial body diffusion-weighted magnetic resonance imaging is presented,detailing reported ADC values and discussing their variation across different studies. In total 115 studies were selected including 28 for liver parenchyma,15 for kidney(renal parenchyma),14 for spleen,13 for pancreatic body,6 for gallbladder,13 for prostate,13 for uterus(endometrium,myometrium,cervix) and 13 for fibroglandular breast tissue. Median ADC values in selected studies were found to be 1.28 × 10-3 mm2/s in liver,1.94 × 10-3 mm2/s in kidney,1.60 × 10-3 mm2/s in pancreatic body,0.85 × 10-3 mm2/s in spleen,2.73 × 10-3 mm2/s in gallbladder,1.64 × 10-3 mm2/s and 1.31 × 10-3 mm2/s in prostate peripheral zone and central gland respectively(combined median value of 1.54×10-3 mm2/s),1.44 × 10-3 mm2/s in endometrium,1.53 × 10-3 mm2/s in myometrium,1.71 × 10-3 mm2/s in cervix and 1.92 × 10-3 mm2/s in breast. In addition,six phantom studies and thirteen in vivo studies were summarized to compare repeatability and reproducibility of the measured ADC. All selected phantom studies demonstrated lower intra-scanner and inter-scanner variation compared to in vivo studies. Based on the findings of this manuscript,it is recommended that protocols need to be optimised for the body part studied and that system-induced variability must be established using a standardized phantom in any clinical study. Reproducibility of the measured ADC must also be assessed in a volunteer population,as variations are far more significant in vivo compared with phantom studies.