Curēus
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Inadvertent occlusion of the anterior choroidal artery during aneurysm clipping can cause a disabling stroke in minutes. We evaluate the clinical utility of direct cortical motor evoked potential (MEP) monitoring during aneurysm clipping, as a real-time assessment of arterial patency, prior to performing indocyanine green videoangiography. Direct cortical MEPs were recorded in seven patients undergoing surgery for aneurysms that involved or abutted the anterior choroidal artery. ⋯ In one patient, a profound decrease in MEP amplitude occurred 220 seconds after placement of a permanent clip on a large posterior communicating aneurysm. An inspection revealed that the anterior choroidal artery was kinked. The clip was immediately removed, and the MEP signals returned to baseline shortly thereafter. A clip was then optimally placed, and the patient awoke without neurologic deficit. Direct cortical MEPs are a useful adjunct to standard electrophysiologic monitoring in aneurysm surgery, particularly when the anterior choroidal artery or lenticulostriate arteries are at risk. When these arteries are occluded, infarction may occur before the occlusion is detected by indocyanine green videoangiography or intraoperative angiography. The use of MEPs allows real-time detection of ischemia to subcortical motor pathways.
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Atrial myxomatous embolization into the coronary arteries is a rare event. Management of large myxomas is usually via surgical resection involving a median sternotomy. ⋯ Transthoracic echocardiogram and transesophageal echocardiogram revealed a large and highly mobile atrial mass, traversing through the mitral valve orifice during diastole. Coronary angiography revealed a focal 60% lesion in the right coronary artery and no other significant obstructive coronary artery disease, suggesting that the cause of his presentation was tumor embolization into the coronary circulation. The patient underwent robot-assisted endoscopic resection of his atrial mass and was discharged in stable condition on postoperative day 2. Pathology revealed atrial myxoma. To our knowledge, this is the first reported case of an atrial myxoma presenting with an NSTEMI and managed with a robot-assisted endoscopic approach. This case also highlights the importance of routine early echocardiography in patients presenting with NSTEMI.
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Introduction Kambin's Triangle is a right triangle over the dorsolateral disc. The area of this right triangle currently serves as a strategic site of posterolateral, minimally invasive access to the nerve root for delivery of epidural steroid injections. This posterolateral approach has also been considered a safe area of access to the intervertebral disc space and, thus, an effective approach in reducing complications, such as violation of the thecal sac, the nerve root, or the bony elements of the spine during minimally invasive spinal surgery. No published studies have been performed to characterize the dimensions of the Kambin's Triangle. ⋯ All dissected levels demonstrated adequate anchoring of the Kirschner wire into the disc space with no evidence of nerve injury. Following this, a retractor was placed and complete discectomies were performed. All exiting nerves were protected in this safe zone and the thecal sac remained inviolate. Conclusion Understanding the Kambin's Triangle will assist surgeons in the minimally invasive approach to spinal surgeries, with potentially safe placement of interbody cages through this strategic space.