Interdisciplinary Neurosurgery: Advanced Techniques and Case Management最新文献

Background

Deep brain stimulation (DBS) has been shown to be an effective treatment for essential tremor and other movement disorders. However, hardware-related complications have limited its efficacy. Lead fracture in DBS typically occurs in the cervical area in high-risk patients. Surgical revision is needed to relieve worsened tremor symptoms in these cases.

Case Report

An 89-year-old woman with a history of bilateral DBS to the ventralis intermedius nucleus for essential tremor presented with worsened tremor in the right upper limb. Examination revealed normal impedance. Increased stimulation did not improve her tremor symptoms. Radiographic examination revealed lead fracture. Given the patient’s high surgical risk we performed thalamotomy followed by extraction of the electrode lead from the left ventralis intermedius nucleus.

Conclusion

Lead fracture is a hardware-related complication of DBS and should be suspected if a patient complains of sudden-onset rebound tremor, even when electrical impedance values are within the normal range. Imaging studies should be performed, and thalamotomy may be an option for patients in whom the risks of general anaesthesia preclude surgery.

Background

Decompressive craniectomy (DC) is performed for the management of the patients with acutely elevated intracranial pressure (ICP). Considering the paucity of the evidence regarding the outcome predictors in patients with non-traumatic raised ICP, we aimed to assess short- and long-term outcome related factors in DC subjects.

Methods

In this cross-sectional study, health records of the patients who underwent DC for non-traumatic etiologies over the five years were interrogated and demographic data, clinical features, operative findings, and follow-up notes were collected. The primary short- and long-term outcomes were in-hospital mortality and functional status, respectively. Functional status was evaluated using Glasgow Outcome Scale (GOS) at 6-month follow-up.

Results

Of the 223 eligible patients, 113 (50.7 %) were male and the mean age was 48.68 ± 13.97 years. In-hospital mortality rate was 48.4 % (n = 108). Of the survivors, 28 (30.4 %) had favorable outcomes (GOS 4–5). The most common post-operative complications were infection with respiratory source (n = 52, 23 %) and external cerebral herniation (n = 61, 27.4 %). Presence of diabetes mellitus (DM) (OR = 6.09; 95 % CI = 2.0–18.51; P = 0.001), subarachnoid hemorrhage (SAH) (OR = 5.61; 95 % CI = 1.47––21.3; P = 0.01), and prolonged duration of ICU-stay (OR = 1.37; 95 % CI: 1.03, 1.24; P = 0.006) were associated with in-hospital mortality. Also, preexisting DM was two times more prevalent among the subjects deceased in the hospital than those who survived.

Conclusions

Concomitant SAH, DM, and prolonged ICU stay were associated with increased in-hospital mortality. In addition, preexisting DM may increase mortality rates, likely irrespective of age factor.

Post-traumatic headache is a common secondary headache disorder caused by head or neck trauma. However, the etiology and management have not been established. Here, we present a unique case of steroid-responsive acute post-traumatic headache with neuroinflammation following a mild head injury.

A 19-year-old female soccer player experienced persistent headache, vomiting, and low-grade fever after sustaining a mild sports-related head injury. Subsequent cerebrospinal fluid (CSF) examination and contrast-enhanced magnetic resonance imaging (MRI) revealed leptomeningeal contrast enhancement, elevated intracranial pressure, and an increased CSF cell count. Notably, the patient tested negative for viral, fungal, tumor, and autoimmune markers, thus a diagnosis of acute post-traumatic headache with neuroinflammation was determined. Treatment with dexamethasone (8 mg/day) resulted in rapid symptom relief, enabling the patient to return to sports without symptom recurrence.

This case highlights the importance of considering post-traumatic headache with neuroinflammation in patients with atypical post-head injury symptoms. Although her condition shared clinical similarities with concussions, the presence of fever accompanied with specific MRI and CSF findings offered critical diagnostic differentiators. Additionally, our report highlights the potential underdiagnosis of steroid-responsive neuroinflammation following head injury and the necessity for active differential diagnosis.

Introduction

Road Traffic accidents (RTA) in India are the sixth among the leading cause of death. The cranial nerves serve several essential functions. Loss of these functions can adversely affect the quality of life. This study was conducted to assess the incidence of Cranial Nerve Injury (CNI), radiological and clinical patterns and to ascertain the significant and often debilitating effect of CNI in otherwise non-life threatening Traumatic Brain Injuries.

Methodology

This prospective study was conducted in the Department of Neurosurgery, SRIHER between April 2019 and September 2021. A total of 62 patients among the 402 patients with TBI had CNI. Patients with GCS <9 were excluded from the study.

Results

Three fourth of the patients belonged to the 21–50 age group (n = 301) and 78 % of the study population were men (n = 313). Patients with cranial nerve injuries, ear bleed and nasal bleed occurred in a higher proportion compared to patients without CNI −58 %(n = 36) vs 15 %(n = 60). Forty Two of the 62 patients with CNI had an associated skull base fracture, the incidence of which was considerably high compared to those without CNI (68 % vs 23 %). The average GOS for patients with TBI and CNI was worse than for those with TBI without CNI in our study group (2.64 vs 1.43).

Conclusion

Patients with TBI with CNI often tend to be younger and have a poor outcome. Early identification with aggressive neuro-rehabilitation may improve the outcome.

Spindle cell oncocytomas (SCOs) are rare, benign, non-functioning tumours of the pituitary gland that were included in the World Health Organisation’s (WHO) classification of central nervous system tumours in 2007. Due to their radiological appearance, they often are mistaken for pituitary adenomas prior to histopathological confirmation. Due to their rarity, there are no known risk factors or correlations in the literature between SCOs and other primary central nervous system tumours.

This is a case report of a 71 year old gentleman who underwent transsphenoidal resection of a symptomatic and histologically-confirmed growth-hormone secreting pituitary adenoma. Due to persistently elevated IGF-1 levels, he underwent repeat surgery which led to biochemical remission. The histology from the second surgery returned a diagnosis of SCO. We hypothesise that our patient had concomitant pathologies of a GH-secreting adenoma and a SCO. This is the first described case of a synchronous functional pituitary macroadenoma and a spindle cell oncocytoma.

A Diffuse Leptomeningeal Glioneuronal Tumor (DLGNT), a rare entity as classified in the World Health Organization’s Fifth Edition of the Classification of Tumors of the Central Nervous System (WHO CNS5), is characterized by oligodendrocyte-like cells with MAPK pathway alterations. This report details the case of a 29-year-old female presenting with unique radiological features: extensive spinal cord dissemination involving both parenchyma and leptomeninges, without intracranial involvement. Near-total resection (NTR) was performed, revealing H3K27me3 positivity, a molecular characteristic not previously reported in DLGNTs. We also review recent studies to expand the understanding of DLGNT’s clinical, imaging, and molecular profiles, aiming to assist radiologists and clinicians in accurate diagnosis and timely management.

Purpose

To present the successful outcome of a patient with 2 extra vertebrae having spinal deformity.

Participant and methods

A 29-year-old female presented with chronic low back pain. Uniquely, the patient demonstrated 2 extra vertebrae, 13 rib bearing vertebrae and 6 non-rib bearing lumbar vertebrae. Radiography assessment demonstrated an exaggerated thoracolumbar kyphosis. Treatment was given to reduce the deformity using spinal rehabilitation and postural rehabilitation methods. Extension traction for the deformity was given as well as corrective exercises and spinal manipulative therapy.

Results

After 31 treatments there was dramatic reduction in pain, disability, quality of life and improved X-ray parameters. Following another 24 treatments, the patient reported to be well demonstrated a 14° reduction in thoracolumbar kyphosis and a 50 mm reduction in posterior thoracic translation. A 5-year follow-up showed only slight regression of both deformity and symptoms.

Conclusion

This case has demonstrated that patients with an atypical number of vertebrae can benefit from structural spinal rehabilitation and experience improved spinal alignment and reported outcomes. The improved sagittal spine alignment corresponded with the dramatic reduction in chronic pain, disability and improved quality of life. Routine radiographic screening is necessary to diagnose atypical anatomical variants which can and should alter treatment approaches.

Objective

Limited data on the treatment and outcomes of patients with intracranial aneurysms (ICAs) in the (coronavirus disease 2019) COVID-19 era is available. Our objective was hence to investigate the impact of the pandemic on the overall complication rate and postprocedural ischemic strokes specifically, in patients treated for ICAs.

Methods

The National Inpatient sample database was used. The main outcomes were the occurrence of postprocedural ischemic strokes, as well as death, non-routine discharge, total charges (US dollars), and length of stay (days). Propensity score matching was applied to compare the pre- and COVID-19 periods. Trends were assessed using piecewise joinpoint regression with the Mann-Kendall test.

Results

A total of 57,715 patients were included in the study. The mean age was 65 years, with most of the patients (69.9 %) being females. After matching, no differences in length of stay (p = 0.266), non-home discharge (p = 0.475), and in-hospital mortality rates (p = 0.305) between the two periods were found. However, the overall complication rate was significantly higher during the pandemic (31.1 % vs. 28.3 %; p < 0.001). Patients hospitalized after treatment of ICAs during the COVID-19 pandemic had significantly higher odds of ischemic strokes (OR 1.13; 95 % CI 1.05 to 1.22; p = 0.03), even when adjusting for other factors.

Conclusions

There is no denying that the COVID-19 pandemic has significantly impacted the healthcare system in several aspects. One aspect highlighted in this study, patient outcomes, was especially notable among patients’ receiving treatment for ICAs. Our results suggest a correlation between the COVID-19 pandemic and postprocedural complications, of which ischemic strokes were the most notable.

Background

Traumatic brain injury (TBI) is a global concern, and many people suffer from TBI annually. Determining the outcome of patients with brain injury has a valuable clinical impact and results in better management of patients. In this study, we aimed to investigate the predictive value of magnetic resonance spectrometry (MRS) in patients with diffuse axonal injury (DAI).

Method

This is a prospective cohort study on patients with DAI in 6 months at a tertiary medical center. According to the eligibility criteria, the patients were enrolled in the study. The MRS scan was conducted on days 3 and 30, and the correlation of metabolites of MRS according to the GCS score of patients on days 3 and 30 was investigated to determine the prognostic impact of MRS in patients with DAI.

Results

A total of 50 patients with DAI, including 39 males and 11 females, were recruited. MRS of patients on day 3 and 30 was conducted and showed that the level phosphocreatine (r = -0.56, P < 0.001), NAA/choline ratio (r = 0.86, P < 0.001), and hunter angle (r = 0.59, P < 0.001) on day 3 are significantly correlated with the GCS score of patients on day 30. Phosphocreatine (r = -0.84, P < 0.001), phosphocholine (r = -0.86, P < 0.001), NAA/choline (r = 0.89, P < 0.001), myoinositol (r = -0.75, P < 0.001), and hunter angle (r = 0.89, P < 0.001) on day 30 are substantially associated with day 30 GCS score.

Conclusion

Among different investigated metabolites, the level of phosphocreatine, NAA/choline ratio, and hunter angle on day three significantly correlated with patients' GCS on day 30.

Background

Central Neurocytoma (CNCy) is an exceedingly rare brain tumor occurring within the ventricles in young adults. Anecdotal cases of CNCy occurring simultaneously with other brain lesions have been reported but to the best of our knowledge, no one was accompanied by brain AVM.

Case presentation: A 12-year-old girl presented with signs of increased intracranial pressure. A multi-bleb CNCy originated from the septum in the midline, expanding to the lateral and third ventricles, back to the incisura and infratentorial- supra-cerebellar cistern concomitant with a left frontal parafalx AVM. The tumor excised successfully, and hydrocephalus controlled by ventriculoperitoneal shunting. The AVM bled after 7 years and was removed surgically. She is tumor free after 10 years.

Conclusion

We present the first case of CNCy concomitant with brain AVM in a 12-year-old girl with more than 10 years follow up.