The purpose of this case report is to familiarize the sinus surgeon with the possibility of the rapid development of internal carotid artery aneuryams from fungal infections of the sphenoid sinuses. A renal dialysis patient with progressive loss of vision was treated with high doses of steroids for the presumed diagnosis of temporal arteritis. Subsequent work-up included a magnetic resonance arteriogram (MRA) and computed tomography (CT) with contrast that failed to demonstrate aneurysmal changes of the carotid arteries but suggested the presence of a mycotic infection of the sphenoid sinuses. During a sphenoidotomy two days later, in addition to the anticipated aspergillus infection of the sinuses, an aneurysm extending from the left internal carotid artery into the sphenoid sinus was encountered. An emergency arteriogram immediately following the surgery revealed a second newly developed large mycotic aneurysm of the right internal carotid artery filling the right sphenoid sinus as well. This case report documents the rapidity with which mycotic aneurysms can develop from a sphenoid sinus infection secondary to aspergillosis in an immunocompromised host.

T he ability to localize an intraoperative spinal level and correlate that level with the pathology observed on preoperative imaging is of paramount importance. In certain patients it is difficult to precisely define the level with existing imaging technology. C-arm fluoroscopy and conventional radiography have a limited field of view. These technologies are accurate for the rostral and caudal ends of the spine, but defining the intervening levels requires moving the frame of reference while counting. This has an inherent potential for error and often requires extended surgical time and increased radiation exposure to the patient and to the operating room personnel.Wrong-level spine surgery remains a prevalent problem, with nearly 50% of surgeons having performed a wrong-level surgery at least once during their career, according to a recent survey by the American Association of Neurological Surgeons. 4 Such an error fails to resolve the pathological condition and alleviate the patient's symptoms.Identifying the correct spinal level intraoperatively is critical to optimizing the patient's surgical outcome, thereby eliminating any adverse consequences associated with wrong-level spine surgery. Multiple factors can increase the difficulty of spinal localization, including osteoporosis, obesity, scapular/humeral shadow, anatomical variations in the number of vertebrae, and ribs. 11Although various techniques have been proposed to facilitate intraoperative localization of the vertebral level, none has achieved widespread use.In this paper a new technique to localize pathology within the thoracic spine is presented. We propose the placement of a radiopaque marker, in a separate preoperative stage, with postplacement confirmation of the level with either CT or MRI, depending on the spinal pathology. This approach ensures confident localization of the defined pathology while causing minimal discomfort to the patient, minimizes the intraoperative radiation exposure to the patient and to the operating room personnel, and provides a safe, effective method of preventing a wrong-level surgery. Methods A patient presented with symptoms of progressive myelopathy referable to an MRI-documented thoracicNovel technique for preoperative pedicle localization in spinal surgery with challenging anatomy Department of Neurological Surgery, George Washington University Medical Center, Washington, DCAccurately localizing a spine level in the thoracic spine is often not easily achieved with the existing imaging modalities available in the operating room. The coordination of the preoperative imaging pathology with intraoperative imaging is even more difficult in patients with challenging anatomy. Using standard percutaneous techniques, the authors placed a radiopaque embolization coil into the pedicle of interest under biplanar fluoroscopy in 1 patient. Thoracic spine MRI along with scout MRI was then performed to confirm coil marker placement in relation to the actual spine pathology prior to surgical intervention. No complications were ...