NMC case report journal最新文献

DuraGen, a collagen matrix-based artificial dura mater, is widely used in neurosurgery because of its biocompatibility and ease of use. Although generally considered safe, we present a rare case of a foreign body reaction to DuraGen presenting as a sterile inflammatory response. A 40-year-old woman underwent total resection of a right convexity meningioma, with dural repair using DuraGen. On postoperative day 31, she developed headache, nausea, and vomiting. Imaging revealed significant cerebral edema around the surgical cavity with midline shift but no signs of infection on diffusion-weighted imaging. To rule out infection, reoperation was performed. Intraoperatively, there was no purulence or necrosis, but DuraGen was found adherent to the cortical surface. The artificial dura was removed and replaced with Gore-Tex. Microbiological cultures were negative. Histopathology showed inflammatory granulation tissue with eosinophilic infiltration, indicating a foreign body reaction. The patient's symptoms resolved immediately after surgery, and follow-up imaging at 5 months confirmed complete radiological resolution. This case highlights a rare but significant complication of DuraGen, demonstrating that foreign body reactions can mimic infectious processes and lead to severe cerebral edema and intracranial hypertension. Awareness of this potential complication is important for neurosurgeons, especially when infection is suspected but not clearly supported by imaging or intraoperative findings. Timely recognition and removal of the offending material can lead to rapid clinical and radiological improvement. This case underscores the importance of considering foreign body reaction in the differential diagnosis of delayed deterioration after duraplasty, particularly when infection is not definitively confirmed.

Intrathecal baclofen therapy has become a widely adopted and effective surgical treatment for severe spasticity. However, it is known to carry a range of potential complications. We report a case of catheter kinking that occurred during long-term follow-up following initial intrathecal baclofen pump implantation using an Ascenda catheter. The patient was diagnosed with cerebral palsy in infancy, and spasticity in all 4 limbs gradually progressed. At 5 years of age, an intrathecal baclofen pump was implanted using an Ascenda catheter, which improved spasticity. However, at 14 years of age, she began to exhibit gradual worsening of spasticity. The percentage of drug delivery deviation was 65.50% at 9 years and 5 months after the initial surgery. Radiography showed that the tip of the Ascenda catheter had migrated caudally. In addition, scoliosis progression over the past 4 years was noted. Three-dimensional computed tomography revealed catheter kinking proximal to the anchor. Kinking of the Ascenda catheter was determined to be the cause of underdelivery of the drug and the subsequent worsening of spasticity. Catheter revision surgery was performed. The kinked segment of the previous catheter was removed and cut, and the newly inserted catheter was connected. Postoperatively, spasticity rapidly improved. Patients undergoing intrathecal baclofen therapy, especially those with cerebral palsy and scoliosis, should be clinically monitored for worsening spasticity and significant changes in drug delivery deviation, even when using Ascenda catheters. Rapid worsening of spasticity or marked drug delivery deviation changes should raise suspicion of catheter-related complications. Progression of scoliosis in patients with intrathecal baclofen may lead to catheter kinking, warranting ongoing close monitoring.

Internal neurolysis has been shown to be effective in treating trigeminal neuralgia without vascular compression. However, its use in glossopharyngeal neuralgia has been rarely reported, with only a single previous case described in the literature, despite the similarities in the underlying mechanisms of neurovascular compression. This study reports 2 cases of glossopharyngeal neuralgia without vascular compression that were successfully treated with internal neurolysis. Patient 1, a 57-year-old woman with 32 months of untreated episodic pain, underwent microvascular decompression, but no vascular compression was identified. Internal neurolysis was performed, generating immediate pain relief and resolution of transient dysphagia and hoarseness within days. The patient remained pain-free at 18-month follow-up. Patient 2, a 65-year-old man with recurrent pain after prior microvascular decompression and gamma knife radiosurgery, underwent a second microvascular decompression, which failed to resolve his symptoms. Internal neurolysis was performed 21 months later, leading to sustained pain relief and no recurrence at 12-month follow-up. These cases suggest that internal neurolysis is a feasible and potentially effective treatment for glossopharyngeal neuralgia without vascular compression. However, the procedure presents technical challenges due to the fragile and mobile nature of the glossopharyngeal nerve, necessitating meticulous handling and precise dissection to avoid nerve injury. Further studies are required to evaluate its long-term efficacy and safety.

Chordoid glioma is a rare, slow-growing neoplasm of the central nervous system. To select an appropriate surgical approach, chordoid glioma should be differentiated from other third ventricle/suprasellar tumors, such as craniopharyngiomas. In this report, we present 3 cases of chordoid glioma. Magnetic resonance images of all cases showed a round or ovoid-shaped tumor with significant enhancement with contrast medium on T1-weighted images. Moreover, preoperative T2-weighted coronal images revealed high intensity along the bilateral hypothalamus. The tumor was removed using the trans-lamina terminalis approach. Gross total resection and partial resection were achieved in 2 cases and 1 case, respectively. Immunohistochemical staining showed strong positivity for glial fibrillary acidic protein and thyroid transcription factor-1, indicating a chordoid glioma. Tumor cells also showed diffuse immunoreactivity for matrix metalloproteinase 9, indicating that the high intensity was caused by vasogenic edema. High-intensity bilateral hypothalamus on T2-weighted images is a unique feature of chordoid glioma and plays an important role in improving clinical outcomes through local tumor control and functional preservation.

Pediatric vertebro-vertebral arteriovenous fistulas are exceptionally uncommon. Most of those patients have undergone digital subtraction angiography for making a diagnosis and transarterial embolization as the treatment. Here, we report a 4-month-old boy with congenital heart disease brought to our department after developing an iatrogenic vertebro-vertebral arteriovenous fistula as a result of a central venous catheter. Magnetic resonance angiography revealed the exact location of the shunt point. Furthermore, three-dimensional computed tomography angiography accurately described the vascular configuration, including the venous drainage route, which was chosen as a potential approach route for endovascular therapy. The shunt was completely occluded by transvenous embolization of the vertebral venous plexus around the shunt point. Magnetic resonance angiography and three-dimensional computed tomography angiography provide useful information for planning treatment strategies for vertebro-vertebral arteriovenous fistulas, particularly in pediatric patients who are at a higher risk of undergoing digital subtraction angiography. Additionally, transvenous embolization can be the first line of treatment for pediatric patients with vertebro-vertebral arteriovenous fistulas due to its safety and effectiveness.

As the name implies, new-onset refractory status epilepticus is a condition wherein a pediatric or a young adult patient with no previous history of epilepsy suddenly develops idiopathic, uninterrupted, and difficult-to-control seizure episodes. While different neurosurgical interventions in new-onset refractory status epilepticus have already been reported, they are primarily used for palliation and diagnostic purposes. Here we report a young comatose patient who significantly improved after being subjected to intensive intracranial pressure management. Our patient was a 20-year-old male construction worker who was transferred to our institution after he was managed for 13 days (X day [day of ictus] to X+12 days) at a local hospital as a case of refractory status epilepticus. Since the patient has non-convulsive status epilepticus induced by minor stimuli, despite continuous midazolam administration, a central venous catheter-based percutaneous thermoregulation system was inserted on the day of the transfer (X+13 days), which depressed the temperature to 37°C, effectively suppressing the electrographic seizure to some extent. Moreover, on X+15 days, an intracranial pressure sensor was implanted, and a ventriculostomy was done to control the increased intracranial pressure induced by uncontrolled seizures. Because the seizure episodes ceased on X+22 days, intracranial pressure monitoring was eventually terminated. Four days later (X+26 days), the patient's wakefulness improved from Glasgow Coma Scale score of 3 (E1V1M1) to8 (E4VTM4) and was transferred to a rehabilitation facility with a modified Rankin Score of 1. Aside from medical management, neurosurgical interventions should be considered if indicated to improve the survival of a condition with a grave prognosis, such as new-onset refractory status epilepticus.

Extracorporeal membrane oxygenation is utilized in the treatment of severe acute cardiac failure and respiratory failure. While it provides the advantage of oxygenating blood through extracorporeal circulation, it also carries risks of intracranial ischemic and hemorrhagic complications due to the continuous presence of artificial materials within the body. We encountered a case in which venoarterial extracorporeal membrane oxygenation was initiated for fulminant myocarditis, and the patient subsequently developed a large vessel occlusion. The diagnosis was confirmed using perfusion computed tomography. A visible thrombus was observed on the arterial cannula of the extracorporeal membrane oxygenation circuit, and the large vessel occlusion was determined to have been caused by thromboembolism. An immediate extracorporeal membrane oxygenation circuit exchange was performed, followed by endovascular thrombectomy. The patient experienced no perioperative complications and achieved a favorable neurological outcome. Endovascular thrombectomy in extracorporeal membrane oxygenation patients requires careful perioperative management and should be promptly performed in eligible cases of thromboembolic events. Furthermore, because patients on extracorporeal membrane oxygenation are often sedated and under intensive systemic management, regular neurological assessments and intracranial monitoring are essential for the early detection of intracranial pathologies.

We report a concurrent case of aneurysmal subarachnoid hemorrhage and acute aortic dissection. A 47-year-old woman presented to our hospital unconscious. Subarachnoid hemorrhage was diagnosed by brain computed tomography on arrival. Computed tomography angiography revealed 2 aneurysms in the right internal carotid artery. Computed tomography angiography from the cervical to thoracic regions, which was initially performed to inspect the access route for interventional radiology, demonstrated the presence of Stanford type A acute aortic dissection. Neck clipping and total aortic arch replacement were performed for the 2 aneurysms and the acute aortic dissection, respectively. Only a few reports have described the coexistence of acute aortic dissection and subarachnoid hemorrhage. Managing these 2 pathologies requires a thorough evaluation of each therapeutic strategy and careful management of the patient's systemic and neurological conditions. We believe our case report enhances the understanding of this specific pathological condition and will provide valuable insights for treating future patients with similar conditions.

Flow diverter stents are used for the treatment of intracranial aneurysms and require long-term antiplatelet therapy, which has been associated with complications such as intracranial hemorrhage. We encountered a case in which rapid increases in the size and number of cerebral microbleeds were observed shortly after flow diverter stent placement. It is known that microthrombosis within a stent can occur after flow diverter stent placement, and this microthrombosis is thought to cause cerebral microbleeds. The patient was a 77-year-old man who underwent flow diverter stent placement for an unruptured intracranial aneurysm. Postoperatively, he developed disorientation and limb paralysis, with magnetic resonance imaging showing diffuse cerebral infarction but no hemorrhagic lesions. Subsequent imaging revealed numerous cerebral microbleeds that were not present earlier and progressively worsened despite dual antiplatelet therapy and blood pressure management. Adjustments to medications, including delaying aspirin and adding antihypertensives, were made. Sodium ozagrel was introduced but later discontinued due to further increases in cerebral microbleeds. At 30 days post-surgery, imaging showed stabilization. By 3 months, residual cerebral microbleeds remained without further progression, and the patient had a modified Rankin scale score of 1. By adjusting antiplatelet medication and controlling blood pressure, it was possible to somewhat manage cerebral hemorrhage. Even when antiplatelet medications are maintained within the optimal therapeutic range, there remains a risk of cerebral hemorrhage. This risk must be carefully considered, and appropriate adjustments to antiplatelet therapy are essential during the perioperative period.

We present an extremely rare case of lung cancer that metastasized to a gonadotroph pituitary neuroendocrine tumor, along with other organs. A 73-year-old man presented with dysarthria and bitemporal hemianopia. Head magnetic resonance imaging revealed cerebellar infarction and a pituitary tumor. Endoscopic transnasal pituitary tumor resection was performed. Pathologically, the tumor consisted of a well-differentiated neuroendocrine component, suggestive of a pituitary neuroendocrine tumor, alongside a poorly differentiated, highly malignant tumor with invasive growth. One month postoperatively, gadolinium-enhanced head magnetic resonance imaging revealed rapid growth of the residual tumor. Whole-body computed tomography and positron emission tomography revealed a 10-mm lung tumor and multiple muscle and bone metastases. Pathological examination of the pituitary tumor revealed poorly differentiated malignant cells. It was initially hypothesized that the pituitary neuroendocrine tumor had undergone malignant transformation with systemic metastases. However, further pathological examinations revealed steroidogenic factor 1-positive differentiated cells and steroidogenic factor 1-negative, synaptophysin-negative, cytokeratin-7-positive, and thyroid transcription factor-1-positive poorly differentiated malignant cells. The final diagnosis classified the tumor as a poorly differentiated lung adenocarcinoma that had metastasized to a gonadotroph pituitary neuroendocrine tumor, which showed rapid growth. Radiation and chemotherapy were administered; however, the patient died 6 months after surgery. Tumor metastasis to a pituitary neuroendocrine tumor is typically seen in older adults with non-functioning pituitary neuroendocrine tumors and no diabetes insipidus. Hence, clinicians should consider both metastatic pituitary neuroendocrine tumors and tumor metastasis to a pituitary neuroendocrine tumor when diagnosing a rapidly growing pituitary tumor in patients with signs of systemic metastasis.