NMC case report journal最新文献

Giant thrombosed aneurysms of the posterior cerebral artery are rare and pose significant challenges in both diagnosis and management. We present a case of a 61-year-old woman who had been under observation for 5 years because of a partially thrombosed posterior cerebral artery aneurysm. The aneurysm gradually enlarged to 50 mm, resulting in left hemiparesis and homonymous hemianopsia. Magnetic resonance imaging revealed cerebral edema and contrast enhancement of the aneurysmal wall and intraluminal space. Digital subtraction angiography demonstrated a slowly perfused aneurysm located at the P1-P2 segment, with a medial posterior choroidal artery branching from the short P1 segment. Given the limited microsurgical exposure and the presence of critical perforators, a hybrid approach was selected. Endovascular parent artery occlusion was first performed using coils and n-butyl cyanoacrylate, targeting both the intraluminal space and the vasa vasorum. Seven days later, microsurgical proximal clipping and partial thrombectomy were carried out via a subtemporal approach. Although transient neurologic deterioration occurred postoperatively, significant improvement was observed with rehabilitation. Follow-up imaging showed marked reduction in aneurysmal size and localized infarction in the posterior cerebral artery territory. This case illustrates the effectiveness of a combined endovascular and microsurgical strategy for treating giant thrombosed posterior cerebral artery aneurysms. Individualized treatment planning based on anatomic complexity, collateral flow, and perforator preservation is essential for achieving successful outcomes in such challenging cases.

Postoperative brain collapse and subdural fluid collection are potential complications after craniotomy in pediatric and geriatric neurosurgery. We have been using underwater surgery for intraventricular tumors in pediatric patients since 2011 and have recently expanded its use for extra-axial brain tumors in older adult patients. Herein, we introduce our underwater surgical technique and present 3 cases: the first application of underwater surgery for a pediatric intraventricular tumor, and 2 recent cases of cisternal tumors in older adults treated with this technique. We have only used underwater surgery for non-highly-vascularized extra-axial tumors located in the ventricle or cistern, which are considered amenable to hemostasis in the underwater surgical setting. During underwater surgery, the patient is positioned such that the craniotomy site is at the highest position. The craniotomy is limited to 3 cm, and the surgical field is irrigated with artificial cerebrospinal fluid during intradural surgery. In the cases of patients with extra-axial tumors reported herein, underwater surgery was successfully performed without postoperative complications such as subdural fluid collection. Consequently, this surgical method shows promise for preventing postoperative cerebral subsidence and subdural fluid collection in both pediatric and geriatric patients, although its application is contraindicated for large and hemorrhagic tumors.

The efficacy of extracranial-intracranial bypass in treating acute cerebral infarction due to vertebrobasilar steno-occlusion remains controversial. Although endovascular therapy is often the first-line approach, certain anatomical and clinical situations may warrant surgical revascularization. We report a case involving a 74-year-old woman with progressive neurological deficits despite antiplatelet therapy, secondary to infarction in the left superior cerebellar artery territory caused by vertebrobasilar steno-occlusion. Imaging revealed poor collateral circulation and severe ischemia of the brainstem and cerebellum. Emergency right superficial temporal artery-superior cerebellar artery bypass was performed through a subtemporal transtentorial approach. The procedure was completed without complications, and postoperative imaging confirmed good patency. Although transient brainstem hyperperfusion was observed, the patient recovered gradually, achieving a modified Rankin Scale score of 1 at 4 months postoperatively. This case highlights the potential role of superficial temporal artery-superior cerebellar artery bypass as a rescue therapy in selected cases of acute vertebrobasilar steno-occlusion with poor collateral flow and progressive symptoms. With appropriate patient selection and surgical expertise, extracranial-intracranial bypass may offer a viable alternative to endovascular treatment in anatomically challenging cases.

Preservation of facial nerve function while achieving sufficient tumor removal is a key objective in vestibular schwannoma surgery, and continuous facial nerve monitoring provides real-time, quantitative, and functional assessment of facial nerve during resection. In our experiences of more than 1,900 vestibular schwannoma surgeries, we have occasionally observed an abrupt and marked decrease in monitoring amplitude without any high-risk manipulation such as direct nerve dissection. This rare phenomenon, illustrated by 2 recent cases in this study, was transient or unrelated to postoperative facial nerve dysfunction, suggesting a mechanism distinct from structural nerve injury. One plausible explanation is a temporary conduction block caused by factors such as local ischemia, torsional stress, or changes in the microenvironment of the nerve. Recognition of this event is clinically important because a decrease in amplitude may prompt unnecessary discontinuation of resection or consideration of nerve reconstruction if misinterpreted as irreversible facial nerve injury. Differentiating conduction block from true injury requires careful correlation with surgical context, nerve anatomy, and subsequent amplitude recovery. Awareness of this pattern can help maintain appropriate surgical progress while minimizing the risk of facial nerve injury. Continuous facial nerve monitoring, by detecting such sudden changes in real time, not only supports safe tumor removal but also enhances intraoperative decision-making in complex vestibular schwannoma surgery.

Postoperative pneumocephalus is a common complication following burr hole surgery, particularly in older adults with cerebral atrophy. Although often self-limiting, its management may be challenging in patients with complex comorbidities. We report a 74-year-old woman with Parkinson's disease, ischemic stroke, and dementia who underwent bilateral burr hole drainage for subdural effusion and hematoma. Postoperatively, she developed bilateral pneumocephalus with persistent impaired consciousness. High-flow nasal cannula oxygen therapy was initiated, resulting in a marked reduction of intracranial air and considerable neurological improvement. This case highlights that high-flow nasal cannula oxygen therapy is a safe and effective strategy for managing postoperative pneumocephalus in older adults with multiple neurological comorbidities and underscores the importance of individualized treatment planning in complex neurosurgical cases.

Chiari malformation type I poses significant challenges during pregnancy, particularly among patients who present with severe or progressive neurological symptoms. Due to the rarity of the condition, clear management guidelines during pregnancy are lacking. Surgical intervention is generally deferred until the postpartum period. We report the case of a woman in her early 30s who presented with a 6-month history of severe downbeat nystagmus and cough-induced headaches. Magnetic resonance imaging revealed the presence of a 27-mm descent of the cerebellar tonsils and a small syrinx, with features consistent with Chiari malformation type I. She was found to be pregnant shortly after the diagnosis. Considering the severity of her symptoms and the surgical risks during the third trimester, posterior fossa decompression with duraplasty was performed at 15 weeks' gestation. The procedure was uneventful, and her headaches improved postoperatively. No neurological deterioration was observed during labor, and she delivered a healthy infant via spontaneous vaginal delivery. This case represents a rare instance of posterior fossa decompression for Chiari malformation type I performed during pregnancy. The favorable outcome highlights the potential safety and efficacy of second-trimester surgical intervention in select cases. We hope that this report will aid clinicians in making informed decisions regarding treatment timing for pregnant patients with symptomatic Chiari malformation type I.

Compression neuropathy of the common peroneal nerve commonly occurs around the fibular head, typically caused by fibrous bands or muscle fascia. We report a unique case of a 54-year-old woman with common peroneal nerve entrapment caused by a vein. She suffered from a 6-year history of numbness and weakness in the left lower leg. Conservative treatments were ineffective, and we performed surgical treatment. Surgical neurolysis revealed a vein penetrating and compressing the common peroneal nerve; the common peroneal nerve was decompressed by coagulation and transection. The patient's symptoms resolved after the surgery. Surgeons should be aware of venous structures as potential causes of common peroneal nerve entrapment.

Isthmic spondylolisthesis at the L5-S1 level frequently leads to foraminal stenosis, while degenerative changes often cause lumbar spinal canal stenosis at L4-5. When both conditions coexist, accurate identification of the symptomatic lesion is challenging. Conventional surgical strategies typically involve combined decompression and interbody fusion under general anesthesia, which may not be suitable for elderly or high-risk patients. Recent advances in full-endoscopic spine surgery performed under local anesthesia provide a minimally invasive alternative. In this report, we present the case of a 75-year-old man with L5 radiculopathy in whom magnetic resonance imaging demonstrated right-sided lateral recess stenosis at L4-5 and right-sided foraminal stenosis at L5-S1 due to stable isthmic spondylolisthesis. Two-stage full-endoscopic spine surgery was performed under local anesthesia. The first procedure involved transforaminal pars crisscross decompression at L5-S1. Although foraminal decompression was achieved, symptoms persisted. A second-stage full-endoscopic ventral facetectomy at L4-5 resulted in immediate resolution of his symptoms. The patient remained asymptomatic at the 3-month follow-up. This case highlights the feasibility and efficacy of sequential full-endoscopic decompression under local anesthesia for multilevel lumbar stenosis associated with L5 radiculopathy. This approach may serve as a safe, less invasive alternative to fusion surgery in elderly patients and those with significant comorbidities.

Congenital protein S deficiency, caused by PROS1 gene variants, is a hereditary thrombophilia associated with venous thrombosis. Cerebral venous sinus thrombosis can lead to dural arteriovenous fistula; however, the optimal management of dural arteriovenous fistula in this setting remains unclear. We present a 50-year-old man with multiple intracranial dural arteriovenous fistulas and an arteriovenous malformation associated with confirmed protein S deficiency. The patient had a prior history of thrombosis at the superior sagittal sinus and left transverse sinus treated with anticoagulation at age 41. Digital subtraction angiography at age 49 revealed a de novo left temporal arteriovenous malformation (Spetzler-Martin grade II), left parietal dural arteriovenous fistula (Cognard type III), and anterior skull base dural arteriovenous fistula (Cognard type III) while the superior sagittal sinus and left transverse sinus remained patent. The patient was referred to our hospital due to a residual nidus following arteriovenous malformation resection at a previous institution. Transarterial embolization using Onyx and n-butyl-2-cyanoacrylate achieved complete occlusion of the dural arteriovenous fistulas, and stereotactic radiosurgery using Gamma Knife was subsequently performed for the residual arteriovenous malformation. A thrombophilia workup revealed markedly reduced protein S activity and a homozygous PROS1 p.Lys196Glu variant. Long-term oral anticoagulation was initiated, and no recurrence or new thrombotic events were observed during the 6-month follow-up period. This case highlights the importance of considering congenital thrombophilia in patients with multiple arteriovenous fistulas/arteriovenous malformations. Genetic testing combined with a multidisciplinary treatment strategy tailored to the underlying prothrombotic state can contribute to favorable clinical outcomes.

Saccular limited dorsal myeloschisis is a condition in which the spinal cord is tethered by a fibroneural stalk that links the cord to a saccular skin lesion, probably due to a small segmental failure of the disjunction between the neural and cutaneous ectoderm during primary neurulation. We previously reported that the dorsally bent cord deviated from the canal into the sac when the tethering effect of the limited dorsal myeloschisis stalk was strong. These cases of saccular limited dorsal myeloschisis should be prenatally differentiated from myelomeningoceles; however, this is complicated by the limited resolution of prenatal magnetic resonance imaging. Nevertheless, postnatal magnetic resonance imaging, including three-dimensional heavily T2-weighted imaging, to demonstrate the stalk linking the top of the bent cord to the sac dome is essential. We recently treated a patient who presented with a cord deviation to the sac due to a short stalk linking the rostral part of the bent cord to the base of the sac. While the sagittal and axial views of three-dimensional heavily T2-weighted imaging alone were insufficient to visualize the short stalk, the coronal view clearly demonstrated that the stalk ran almost parallel to it. During surgery, untethering the cord and completely returning it to the canal is important.