Interdisciplinary Neurosurgery: Advanced Techniques and Case Management最新文献

Aneurysms arising from fenestrated proximal anterior cerebral arteries are rare. Previous studies primarily reported performing clipping. In contrast, endovascular treatment is rarely selected. In this report, we present a case of coil embolization for a ruptured aneurysm arising from a fenestrated proximal anterior cerebral artery.

A sixty-five-year-old woman was transferred to the emergency department of our hospital owing to sudden onset of severe headache and vomiting. A head computed tomography scan showed a diffuse subarachnoid hemorrhage. A cerebral angiogram revealed an aneurysm at the fenestration of the A1 segment. Coil embolization of the aneurysm was performed, and the aneurysm was completely occluded. Both fenestration channels were preserved.

The patient’s clinical course was good, and she was discharged from the hospital twenty-six days after admission. Coil embolization of a ruptured aneurysm in the fenestration of the A1 segment was possible without sacrificing the parent arteries forming the fenestration. However, securing a working projection proved difficult due to the aneurysm being surrounded by two parent arteries forming the fenestration.

Background

Adult-onset tethered cord syndrome (ATCS) is occasionally reported, but older adult onset is very rare. We treated a patient who was asymptomatic until older adulthood and then developed subacute exacerbation of neurological symptoms.

Case description

A 76-year-old woman presented with bilateral leg pain, numbness, and weakness plus low back pain and dysuria for 1 month. Imaging showed a retained medullary cord with a syrinx and an enhanced mass lesion. She was diagnosed with symptomatic ATCS and underwent surgery. Intraoperative findings were an intramedullary syrinx and inflammatory granulation due to adhesive arachnoiditis.

Conclusion

We experienced a very rare case in which an older adult developed ATCS. Caution is required because idiopathic adhesive arachnoiditis can exacerbate the neurological symptoms.

Introduction

Choosing a promising specialty for medical students is not an easy decision, particularly in a field like neurosurgery known for its high levels of stress. However, in recent years, there has been a decrease in interest, especially among female students, in choosing surgical specialties. Therefore, the present study aimed to identify influential factors in the selection of neurosurgery as a specialty from the perspective of medical students.

Methods

This descriptive-analytical study was conducted in 2023 at the Shahr-e Kord University of Medical Sciences. we estimated a sample size of 425 individuals from the study population. We collected the data using a questionnaire, which was administered through an online questionnaire system.

Results

Male and female perceptions of neurosurgery was similar across many of the surveyed factors, except for: “Male dominated”,“ Tolerant of criticism”, “Duration of residency” and “Must be an athlete”. The factor analysis reduced the 28-variable dimensionality to six latent factors that accounted for 60.72% of the variance found. The factor analysis recognized that, although male and female medical students do have some similar Survey Variable, the influence or weighing of those preferences is different for male and female students. The first latent factor for females consisted of: “Diverse patient population,” and “Procedural based.” The first latent factor for males consisted of: “Male dominated,” and “Prestige.”

Conclusion

The factor analysis indicated that male and female students weight differently when selecting a specialty; this difference may account for the large differences in proportion between males and females in Neurosurgery residency.

Introduction

Due to less than favorable conditions in low and low-middle-income countries, surgeons have had to carefully craft improvised devices to try and mimic the functionality and level of innovation in the developed countries. In this review, we sought to examine the existing literature to review the alternative ways by which intracranial pressure is measured when standard devices are inaccessible. Furthermore, we aimed to see how these devices are made and how much they cost.

Methodology

The PRISMA extension for scoping reviews was utilized. Databases and Grey Literature (PubMed, Google Scholar, and AJOL) were searched extensively, and papers reporting on the use of improvised intracranial pressure monitoring were included. The devices were grouped into two setups and described extensively. The cost of the devices was also estimated. We extracted the relevant information after identifying the papers that would be used in our review study.

Results

3 papers satisfied our eligibility criteria and were used in the review. Two setups were discussed. The first setup involved the use of a makeshift device made up of a size 6 feeding tube/soft silicon catheter, a central venous pressure manometer and sterile 0.9% saline as the coupling agent, while the second setup involved the use of a size 8 feeding tube, a pressure line extension, dome, transducer, and monitor. Both devices cost less than USD 20, a price far cheaper than the standard ICP devices quoted at about USD 800.

Conclusion

Our review posits that these makeshift devices have certain advantages and may be useful in the rural and less developed parts of the world. It also serves as an area for intervention, especially in the context of global neurosurgery.

Prolactinomas are the most common pituitary tumors and are treated with surgery with or without dopamine agonists. Amyloid in prolactinoma is known to occur, but spherical type of amyloid deposition is extremely rare and can pose a diagnostic challenge during intraoperative consultation. They do not respond to medical treatment with dopamine agonists and enlarge in size or undergo fibrosis, causing a failure of medical therapy. Hence, it needs to be identified preoperatively by imaging to institute appropriate management. Here we report a case of a 50 year male with symptoms of burning sensations in the left upper limb and temporal seizures for 4 months. Magnetic resonance imaging showed a well-defined lobulated lesion measuring 4x3.5x3cm eroding the floor of sella. Histology showed spherical, eosinophilic amyloid material with focal cellular areas. Immunohistochemistry and serum levels were high for prolactin. 11 months later, the patient was readmitted with CSF rhinorrhea. The biopsy revealed abundant spherical amyloid with scant cellularity suggesting a recurrence.

Background

Dermal sinus tract is a rare type of spinal dysraphism. It is usually associated with other types of spinal congenital anomalies. This work shows the rare co-occurrence of primary and secondary neurulation defect in a single patient.

Case presentation

We introduce a 2 year old boy who presented with a sacral dimple. He had a complex underlying spinal neural tube defect, dermal sinus tract, dermoid cyst, filum terminale lipoma, tethered spinal cord and syringomyelia. He was managed with excision of the dermal sinus tract, dermoid cyst and filum terminale lipoma with untethering of the spinal cord. He had a good post operative outcome without any neurologic deficit.

Conclusion

This case shows how a simple skin dimple can be an indicator of underlying complex spinal dysraphism. It also shows the co-occurrence of primary and secondary neurulation defect which suggests the complex nature of the neurulation process.

Background

Amidst progressive improvement of microsurgical techniques, facial nerve (FN) dysfunction is one of the most common complications after vestibular schwannoma (VS) resection. The current study discusses the risk factors associated with FN dysfunction, preservation of FN, and the patient’s quality of life (QoL). In addition, the use of exoscope and FN outcomes was discussed.

Method

We searched PubMed and Scopus using the search terms vestibular schwannoma, acoustic neuroma, risk factors, facial nerve dysfunction, and microsurgery. Linkage or association studies available in full text were analyzed regarding risk factors of FN dysfunction after sporadic VS resection.

Results

We categorized risk factors for FN dysfunction into three groups: non-tumoral, tumoral, and surgical. Tumoral factors were identified as the most significant predictors of FN dysfunction, including large tumor size, tumor extension, FN adhesion, the presence of cystic lesions, and advanced tumor stage. Data regarding non-tumoral factors, such as age and sex, showed heterogeneity and inconsistency. While the middle cranial fossa (MCF) approach may lead to increased FN injury, it was not deemed a significant predictor of FN dysfunction. Furthermore, employing intraoperative monitoring of the FN was linked with improved FN outcomes.

Conclusions

Our review indicates that mounting evidence supports the association of cystic lesions, large tumors, and tumor adhesion to the FN as critical predictors of adverse FN outcomes. When these risk factors necessitate partial resection, radiological follow-up is imperative to monitor for tumor recurrence and to determine the necessity of further surgical intervention.

Introduction

 The preparation of the pedicle and the insertion of a transpedicular screw is a high-risk procedure during spine surgeries. To avoid pedicle screw misplacement in posterior spinal deformity surgery, patient specific 3D‐printed guides can be used but technical issues reported in 17% of screw fixations. To address this concern, our team has developed single-level guide templates and a locking screw mechanism. We share our experience using a surgical planning and support system with 3D printed patient-specific guides that utilize a locking screw, highlighting the advantages of incorporating it into complex spine surgeries.

Materials and Methods

The surgical planning and support system is composed of six phases: (1) spine digitization, (2) segmental analysis and vertebral characterization, (3) planning of angulation, depth, and diameter of transpedicular screws, (4) 3D printing of the spine model, and the locking single level drill guides, (5) selection of surgical instruments, and (6) surgery.

Illustrative cases

High resolution tomographic images of two 15-year-old females and one 16-year-old male were processed through software analysis for segmental analysis and vertebral characterization. This process aimed to propose the most suitable plan in a multidisciplinary meeting. Sterilized 3D-printed patient-specific locking spine drill guide models were utilized for the spinal instrumentation.

Conclusions

 Multiple countries are now developing 3D printed drill guides for screw fixation in severe scoliosis. Our guide represents the first one using a transitory locking mechanism to improve accuracy of fixation. The 3D printed locking drill guides enabled accurate insertion and direction of the transpedicular screw, resulting in improvements in sagittal and coronal balance, and all screws classified as accurately placed and with minimal difference with the planned trajectory. Additional outcomes such as surgical time, intraoperative bleeding, radiation exposure, hospital stay, and postoperative complications should also be considered for further studies in this area.

A 68-year-old man suffered from slowly progressive proximal upper extremity weakness for 17 years. Examination revealed bilateral C5–C6 muscle weakness. Upon spinal magnetic resonance imaging (MRI), the T2-weighted images showed high-intensity signals in the anterior horns at the C3–C5 spinal levels, with ventral epidural fluid collection at the C6–T6 spinal levels. Brain MRI also revealed hemosiderin deposition in the cerebellum. The patient was ultimately diagnosed with brachial multisegmental amyotrophy caused by spontaneous spinal cerebrospinal fluid leak with superficial siderosis. During surgery, a dural defect was identified at the T2–T3 spinal level, which was subsequently repaired. At the 60-month follow-up, no signs of disease progression were noted. This disease could potentially be treated through surgery and should be included in the differential diagnosis of slowly progressive segmental amyotrophy.

Malignant deep brain stimulation (DBS) withdrawal syndrome constitutes a rare neurological emergency among advanced Parkinson's disease (PD) patients treated with the subthalamic nucleus (STN) Deep Brain Stimulation. Its clinical course mimics Neuroleptic Malignant Syndrome and when left untreated might lead to death.

We present a case of a 61 year old woman treated with STN DBS because of PD, who underwent under local anesthesia implantable pulse generator (IPG) replacement. The IPG stopped functioning several days before the replacement. Due to increased motor symptoms the patient was unable to intake medications several days prior to surgical intervention. Within immediate post-operative period she developed malignant DBS withdrawal syndrome. The successful treatment consisted of supportive care, dopaminergic medication and immediate restoration of the IPG.