OBJECTIVE: This study describes the surgical outcome of pediatric primary spinal arachnoid cysts (SACs) presenting with compressive myelopathy and gives an update on the classification and management of these rare lesions.
METHODS: We performed a single-center retrospective analysis of pediatric patients operated for primary spinal arachnoid cysts. The clinical and radiologic profiles and surgical outcomes of these children were analyzed. Subgroup analysis was done in the laminoplasty vs laminectomy groups to see for the development of spinal deformity.
RESULTS: There were 10 males and seven females with a mean age of 10.4 years (range:6-14 years). The cysts extended to an average of 5.2 levels (range:2-8). They were extradural in seven (41%) and intradural in 10 (59%). Six intradural and four extradural cysts underwent laminectomy (n = 10) while four intradural and three extradural cysts underwent laminoplasty (n = 7). Although three out of 10 cases in the laminectomy group and none in the laminoplasty group had post-operative spinal deformity, this result was not statistically significant (p = 0.110). There was a moderate negative correlation between post-operative cord occupancy ratio (COR) and post-operative McCormick grade (Pearson correlation coefficient = -0.453, p = 0.068), suggesting that higher CORs are associated with lower McCormick grades.
CONCLUSIONS: Symptomatic pediatric primary spinal arachnoid cysts are safely and effectively managed by marsupialization or microsurgical excision. Considering the growing age group, laminoplasty rather than laminectomy should be the standard surgical procedure to prevent late postoperative spinal deformity. Clinically significant recurrences are rare in the setting of adequate cord expansion and restored subarachnoid CSF flow following surgery.

OBJECTIVE: The optimal bridging stent for fenestrations during complex endovascular aortic aneurysm repair (EVAR) has not been defined. At our institution, the Viabahn VBX® is frequently used given its availability and mechanical and heparin-bonding characteristics. This study aims to assess the performance of the Viabahn VBX® versus the iCast® balloon-expandable covered stents as bridging stents for fenestrations during complex EVAR.
METHODS: A retrospective study of consecutive patients undergoing complex EVAR between 2015 and 2021 was performed. Celiac arteries (CAs), superior mesenteric arteries (SMAs), left renal arteries (LRAs), and right renal arteries (RRAs) stented with fenestrations were grouped according to the type of bridging stent, VBX® versus iCast®. Target vessels (TV) stented with a branch or scallop were excluded. The primary endpoints included primary patency and freedom from target vessel instability (TVI).
RESULTS: A total of 292 patients undergoing complex EVAR were treated using VBX® or iCast® with a mean follow-up of 190 days (interquartile range [IQR], 36-384) for the VBX® cohort and 804 days (IQR, 384-1507) for the iCast® cohort. A total of 677 TVs were stented, including 134 (20%) CAs, 175 (26%) SMAs, 182 (27%) LRAs, 186 (27%) RRAs, and 12 (2%) additional vessels. Proximal reinforcement was more frequent with VBX than with iCast® stent (23% vs. 2.4%, P <.0001). There was no difference in primary patency rates at 2-year between VBX® and iCast® stent for CA (100% vs. 96.4%; P=.32), SMA (97.8% vs. 100%; P=.14) and renal arteries (96.7% vs. 99.4%; P=.11). There was no difference between VBX® and iCast® in the cumulative incidence of type Ic and type IIIc endoleaks (3.2% vs. 5.6%; P=.69) or freedom from TVI at 2 years.
CONCLUSIONS: Viabahn VBX® stents are a safe and effective option as bridging stents in fenestrations during complex EVAR with comparable mid-term outcomes to iCast® stents. However, proximal stent reinforcement may be required with VBX stent to ensure adequate sealing at the fenestrations. Longer follow-ups and larger series are required to assess long-term outcomes and durability.

UNASSIGNED: Tendinopathy is a disease state characterized by tendon disorder with pain or decreased function that can cause significant disability. Multiple treatment modalities exist; however, no single treatment is superior. Ultrasound-guided percutaneous needle tenotomy (PNT) and TENEX are emerging as promising treatment options for tendinopathy.
UNASSIGNED: To review the current literature of reported outcomes for PNT, TENEX, and TENJET, for the treatment of tendinopathy, including pain relief, change in function, and patient-reported outcomes.
UNASSIGNED: A comprehensive search was conducted from database inception to September 2023 in Ovid Medline, Ovid Embase, and Cochrane Library.
UNASSIGNED: Keywords and index terms related to tendon injury, ultrasound, and tenotomy were used in combination to identify relevant literature that included ultrasound-guidance, treatment of tendinopathy, and treatment with PNT, TENEX, or TENJET. Covidence Systematic Review Software used to screen for relevant studies. Only English-language studies were included.
UNASSIGNED: Systematic Review using PICO framework as defined and registered with the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42022321307).
UNASSIGNED: Level 4 (evidence from a systematic review graded to the lowest level of study included).
UNASSIGNED: Articles meeting the inclusion criteria were reviewed. Type and region of tendinopathy studied, outcome measures, and complications were recorded. Clinical and self-reported outcomes data were compared across studies.
UNASSIGNED: A total of 10 studies, representing 11 tendon sites, were included. The studies overall report improvements in pain, function, and quality of life after undergoing PNT or TENEX, with minimal adverse effects. Mean risk of bias assessment scores were 8.35 out of 10 assessing internal and external validity for included studies.
UNASSIGNED: PNT and TENEX are safe, beneficial, and minimally invasive treatment option for patients, especially for conditions refractory to more conservative treatments options.

OBJECTIVE: The aim of our study is to report a case of a large fenestrated vertebral artery (FVA) and bilateral duplication of the superior cerebellar artery (SCA) incidentally diagnosed using Computed Tomography Angiography (CTA) and Digital Subtraction Angiography (DSA).
METHODS: A 63-year-old female patient presenting to the neurology clinic with complaints of dizziness and balance disorder. CTA and DSA revealed a large FVA involving the V3 and V4 segments. Additionally, we observed bilateral duplicated SCAs originating from the distal basilar artery.
CONCLUSIONS: FVA is a rare anomaly resulting from fusion failure during the embryological period, with a reported incidence of 0.1%. FVA is often (70%) detected in the extracranial region, but it can also occur intracranially at a frequency of approximately 30%. Although various nomenclatures are used in the literature, we identified only two reports of a single fenestration encompassing the V3 and V4 segments, i.e., involving both the extracranial and intracranial regions. While duplication of the SCA is relatively common, bilateral duplication of SCA occurs at a rate of 0.9-5%.
CONCLUSIONS: This case report describes an unusual case of VA fenestration involving both extracranial and intracranial segments, along with bilateral duplication of the SCAs. While rare, these findings highlight the importance of recognizing such vascular anomalies, which could be relevant for planning surgical or endovascular procedures in the posterior circulation.

OBJECTIVE: This report presents a rare anatomical variation, double fenestration of the External jugular vein on the right side.
METHODS: During the routine dissection of a male cadaver aged 60 years, we observed a unilateral large double fenestration of the External jugular vein on the right side.
RESULTS: After its formation from the posterior division of the retromandibular and posterior auricular veins, External jugular vein descended in the posterior triangle of neck. Here, it divided into medial, intermediate, and lateral veins that united again before draining into the subclavian vein. Lateral vein was the largest (7.2 cm) and intermediate and medial veins were measuring 6.4 cm each. Two large fenestrations, measuring 5.8 cm each, arranged like a \"double bubble\" were seen in the External jugular vein extending from fourth to sixth cervical (C4 to C6) vertebrae. The medial branch of supraclavicular nerve was seen passing superficial to the distal part of External jugular vein. On the left side, the course of External jugular vein showed a standard pattern.
CONCLUSIONS: Surgeons must be acquainted with the varied anatomy of the superficial neck veins to prevent major bleeding during operative procedures, including carotid endarterectomy, flap operations, & central venous catheterisation.

To compare the clinical efficacy of interlaminar endoscopic surgical system delta (iLESSYS-Delta) discectomy with that of classical fenestration discectomy for treating lumbar disc herniation. Patients who underwent iLESSYS-Delta or fenestration discectomy were enrolled in this study. Baseline information and clinical indicators were collected. The baseline data were matched using propensity score matching. Fifty-two patients were in each group. In the iLESSYS-Delta cohort, the volume of intraoperative bleeding was 18.17 ± 4.20 ml, the length of postoperative hospital stay was 4.16 ± 2.29 days, and the length of postoperative off-bed activity was 1.58 ± 0.88 days. In contrast, in the fenestration group, the volume of intraoperative bleeding was 32.50 ± 17.13 ml, the length of postoperative hospital stay was 6.66 ± 2.44 days, and the length of postoperative off-bed activity was 3.18 ± 1.28 days. The difference between the two groups was statistically significant (P < 0.05). The operation time was 88.90 ± 19.14 min in the iLESSYS-Delta group and 67.63 ± 19.32 min in the fenestration group, and the difference between the two groups was statistically significant (P < 0.05). Regarding the pain visual analogue scale scores at 24, 48, and 72 h after surgery, patients in the iLESSYS-Delta group had less pain than did those in the fenestration group (P < 0.05). The Oswestry disability indices of postoperative patients in both groups significantly improved at 3 months after surgery and at the last follow-up (P < 0.05); however, there was no statistically significant difference in the postoperative ODI scores between the two surgery groups (P > 0.05). The two groups showed no significant differences in clinical effects, postoperative recurrence rates, or perioperative complications. iLESSYS-Delta can cause less intraoperative bleeding and faster recovery than fenestration discectomy.

BACKGROUND: Arachnoid cysts are commonly encountered benign cystic structures and often come to attention as incidental findings following cranial imaging. Surgical intervention rates vary in different studies; however, rupture of cyst and subdural collection with mass effect are some of the indications for surgical intervention. In this study, we aimed to evaluate our operated cohort of middle fossa arachnoid cysts to determine the rate of traumatic subdural collection in this cohort and further assess outcomes.
METHODS: A retrospective review of all consecutive operated middle cranial fossa arachnoid cysts was carried out for the period 2010 to 2024. Demographics including age, sex, Galassi type, surgical technique for fenestration, preceding history of trauma, presence of papilloedema, and complications following surgery were extracted. Indication for surgery included papilloedema and headaches or increasing head circumference or rupture and subdural collections. Arachnoid cysts managed with CSF diversion as primary surgery were excluded.
RESULTS: Over the study period, 21 fenestrations of the arachnoid cysts were carried out in 19 patients with mean age of 7 years and M:F ratio of 2.2:1 (laterality: 9 right-sided and 10 left-sided). These included seven Galassi 2 and twelve Galassi 3 arachnoid cysts. At presentation, 10 had papilloedema, 5 with no papilloedema, and 4 with no available ophthalmological assessment. Fenestration of cyst included 12 microscopic, 6 endoscopic, and 3 combined approaches. Of the operated cohort, 8 were due to rupture of arachnoid cyst and subdural collections causing mass effect. Of 8 cases of ruptured arachnoid cyst with subdural collections, 75% had clear history of preceding head injury in the context of accidental or sports-related injuries. Two patients required redo-fenestration (10.5%), 1 patient required temporary lumbar drain (5.2%), and 2 patients required cysto-peritoneal shunts (10.5%).
CONCLUSIONS: Rupture of arachnoid cysts and subdural collections although rare can be associated with head injury in majority of cases. All operated cases belonged to grade 2 and 3 Galassi.

We report the case of a 65-year-old male patient who was deemed unfit for open surgery and underwent zone 0 endovascular repair with a physician-modified fenestrated endograft for a symptomatic penetrating ulcer. A thoracic stent graft was modified creating a large fenestration for the innominate artery and the left common carotid artery, and a second small fenestration for the left subclavian artery and the left vertebral artery, which had a common origin. No bridging stent was used for the left subclavian artery to avoid coverage of the left vertebral artery. The postoperative course was uneventful, and no leaks nor other complications were detected on postoperative computed tomography angiography. Although long-term durability needs to be better assessed, our experience suggests that physician-modified fenestrated endografts are a feasible option for the emergent treatment of aortic arch lesions in unfit patients and provide satisfactory results in the short term.

An 82-year-old man with a secundum atrial septal defect (ASD) underwent transcatheter closure. The patient had a wide area of aortic and superior rim deficiency, with left ventricular diastolic dysfunction and moderate mitral regurgitation. These findings suggested the risk of both cardiac erosion and increased left atrial pressure after closure. To avoid cardiac erosion, a GORE® CARDIOFORM ASD (GCA) occluder (W.L. Gore & Associates, Flagstaff, AZ, USA) was considered an appropriate device in this patient. However, the possibility of excessively high left atrial pressure due to complete defect closure was a concern. Thus, we created a 4.5-mm fenestration using a surgical punch in the fabric membrane of a 44-mm GCA. The device was deployed in an appropriate position, and no significant elevation of pulmonary capillary wedge pressure was observed. One month after the closure, marked improvement in clinical symptoms and continuous flow through the fenestration were observed. This novel fenestration technique may contribute to expansion of the indications for transcatheter ASD closure in patients who require a GCA owing to an anatomically high risk of erosion accompanied by left ventricular diastolic dysfunction.
UNASSIGNED: In elderly patients with left ventricular diastolic dysfunction, transcatheter atrial septal defect (ASD) closure is difficult because rapid resolution of an ASD shunt can cause an increase in left atrial pressure. Previous reports described the creation of a fenestration in the closure device. The use of a GORE® CARDIOFORM ASD (GCA) occluder can reduce the erosion risk; however, creating a stable fenestration is difficult. We developed a novel technique to create a stable fenestration in a GCA.

The presence of facial jewelry and medical devices within a radiographic field of view may promote the formation of artifacts that challenge diagnostic interpretation. The objective of this article is to describe a previously unreported radiographic anomaly produced by an oral piercing site below the lower lip. This unusual artifact masqueraded as a severe resorptive defect, dental caries, or cervical abfraction and occurred following removal of an extremely large labret below the lower lip and subsequent acquisition of a radiographic image. The radiolucency was ultimately attributed to an extensive aperture below the lower lip created by a series of sequentially larger soft tissue expanders. Clinicians should seek correlation of atypical radiographic presentations with soft tissue defects secondary to injury or intentional oral piercing.