Interdisciplinary Neurosurgery: Advanced Techniques and Case Management最新文献

Cerebral vasospasm, defined as the reversible constriction of cerebral arteries, is a deleterious complication, most related to aneurysmal subarachnoid hemorrhage. Although vasospasm can occur in the setting of traumatic subarachnoid hemorrhage, brain tumor resection, ruptured arteriovenous malformation with intraventricular extension, and other central nervous system insults, aneurysmal subarachnoid hemorrhage remains the most common cause. An association between vasospasm and anterior temporal lobectomy has been described in a few case reports. We report the case of a 32-year-old male patient, known to have refractory seizures developed left middle cerebral artery vasospasm after left anterior temporal lobectomy in the direct postoperative period. He underwent cerebral digital subtraction angiography and received intraarterial nicardipine as well as temporary stenting using a stent retriever, with swift restoration of arterial flow in the affected segments and remarkable improvement in his neurological examination. Therefore, symptomatic cerebral vasospasm remains a rare complication after temporal lobectomy, but its consequences can be catastrophic, and knowledge about this condition is fundamental to allow early diagnosis and prompt treatment.

Worldwide, the simultaneous occurrence of sellar gangliocytoma with pituitary adenoma is rarely reported. Herein, we describe a unique case of mixed gangliocytoma-pituitary adenoma of dual lineage. A 45-year-old male presented with transient ischemic attack, right sided numbness and decreased vision. Endocrinological examination found prolactin level to be elevated. Imaging studies revealed a 2.8 cm sellar/suprasellar lesion with superior displacement of optic chiasm. The patient underwent tumor resection via endoscopic endonasal transsphenoidal approach. Histologic sections show a biphasic tumor with two populations of cells, mature ganglion cells and prolactin secreting neuroendocrine cells. The tumor has unique dual lineage with one dominant expression of pituitary-specific transcription factor (PIT1) in all cell components which matched closely to prolactin positivity. By Immunohistochemistry, a less prominent but obvious component of scattered steroidogenic factor 1 (SF1) positive cells were identified, although follicle stimulating hormone (FSH) and luteinizing hormone (LH) were negative. T-box transcription factor (TPIT) stain was negative. Accordingly, the diagnosis of mixed gangliocytoma-pituitary adenoma of dual lineage was established.

Background

Cerebral vasospasm is a reversible vessel constriction following subarachnoid hemorrhage. Immunoreactive and inflammatory mechanisms induce long-term vasoconstriction and vessel dilatation inhibition. We hypothesized that D-penicillamine depresses this process given that it reduces the concentration of free oxygen (O₂) radicals. We evaluated the effects of D-penicillamine on cerebral vasospasm in rabbits induced with subarachnoid hemorrhage, achieved by autologous blood injection in the basal cistern.

Materials and methods

Four experimental groups were studied: Group 1: basilar angiography, Group 2: basilar angiography + D-penicillamine, Group 3: subarachnoid hemorrhage (SAH), and Group 4: SAH + D-penicillamine. Vessel diameter and cerebral vasospasm were evaluated angiographically in each group. Vascular degeneration was studied by electron microscopy of the basilar artery. Free O₂ radicals were investigated based on measurements of the levels of vascular superoxide dismutase and malondialdehyde. Myasthenia gravis–like side effects of D-penicillamine application were analyzed by electromyography and electron microscopy of the orbicularis oculi muscle.

Results

We detected a 9.03% decrease in basilar artery constriction in Group 4 compared with Group 3. In addition, levels of free O₂ radicals were reduced in Groups 2 and 4. Application of D-penicillamine resulted in the prevention of basilar artery wall degeneration, without myasthenia gravis–like side effects.

Conclusion

Our study indicated that D-penicillamine application induced vasodilatation and had anti-inflammatory effects.

Introduction

Dural arterio-venous fistulas /DAVF/ are rare vascular malformations that represent around 10-15% of all intracranial vascular malformations. The DAVF could be asymptomatic or produce a variety of symptoms – headache, pulsatile tinnitus, characteristic bruit over the site of the fistula, ocular symptoms – chemosis, proptosis, or other neurological symptoms due to intracerebral haemorrhage of the DAVF. We present a rare clinical case of a transverse sinus DAVF with ipsilateral ocular symptoms and maybe the first case to our knowledge occluded with Onyx.

Clinical case:

A 46-year-old male patient presented with headache, redness of the left eye and left-sided proptosis. The symptoms started after a heavy physical exertion two months ago. MRI scan and DSA confirmed the presence of a DAVF located around the left transverse sinus with venous ectasia and retrograde flow up to the left cavernous sinus. Transarterial endovascular embolization of the DAVF with Onyx was performed with complete resolution of the symptoms of the patient.

Discussion

The more posteriorly located the DAVF the less likely is to present with ocular symptoms. Sometimes these are the first signs of the presence of a DAVF and especially of higher grade DAVF that could lead to intracerebral haemorrhage. The Borden Grade 2 and 3 DAVF risk of intracerebral haemorrhage is 17% and 46%, respectively. Cognard Grade IIa+b around 40% and all grades III-V - 80-100%. The high risk of intracranial haemorrhage and the ocular symptoms are indication for treatment.

Conclusion

Transarterial embolization of DAVF with Onyx is safe, with high initial occlusion rate (55-85%). Ocular symptoms of DAVF have a benign course after successful embolization.

Objective

Low grade gliomas (LGGs) account for 15 % of primary brain tumors. The paper has the aim to identifying prognostic factors affecting overall survival (OS) and progression-free survival (PFS), and to evaluate the outcome of patients.

Methods

A total of 40 patients undergoing surgery for cerebral LGG (WHO grades I and II) at Our Institute were enrolled in the retrospective study. Inclusion criteria were: histological diagnosis of LGG, availability of complete clinical-instrumental documentation and follow-up data. For each patient, the following were analyzed: the clinical parameters in the preoperative and postoperative phases, the histological variant of the tumor, the extent of surgical resection (EOR) and any use of intraoperative methods, the Mib-1/Ki-67 proliferation index, the administration of adjuvant chemotherapy and/or radiotherapy and the occurrence of any complications.

Results

The cohort included 14 males and 26 females. The independent predictors of OS at multivariate analysis were: age, pre-operative KPS, Ki67/Mib-1, EOR and adjuvant chemotherapy. With regard to PFS, statistical significance on multivariate analysis was observed for pre-operative KPS, Ki67/Mib-1, EOR, post-operative tumor volume and radiotherapy. An EOR < 80 % was confirmed as negative prognostic factor for both OS and PFS. Lastly, the pre-operative tumor volume and the use of Intra-operative Electrophysiological Monitoring were significantly associated with EOR.

Conclusion

In this study, according to the literature, several prognostic factors determining the outcome of LGG patients, both in terms of OS and PFS, were confirmed. Knowing the impact of these parameters in terms of prognosis would guide the choice of treatment, which will necessarily be multidisciplinary and tailored.

Introduction

Endoscopic endonasal transsphenoidal surgery is currently the gold-standard therapeutic approach for pituitary adenomas. Although being spread worldwide, the endoscopic endonasal approach for pituitary adenomas is recently implemented in Senegal.

This study aimed to report our results and the complications observed in the context of an under-equipped facility.

Materials and methods

We conducted a retrospective study including all patients with a pituitary adenoma treated who underwent endonasal transsphenoidal resection under a single endoscopic approach from January 2014 to May 2022, in the Neurosurgery Department of Fann National Hospital Centre, Dakar. All patients were assessed according to clinical, radiological, and endocrinological criteria. They all were operated by the same team with an average follow-up of 24 months.

Results

In this series of 180 patients, including 57.7 % women and 42.3% men with a mean age of 44.8 years (extremes of 18 and 76 years), the visual deficit was the most frequent onset symptom (69.4 %), followed by clinical forms of hormone hypersecretion (30.5 %). Twelve cases of pituitary apoplexy and 1 case of incidentaloma were reported. The most frequent tumors were non-functional tumors (61.6 %). Among the functional adenomas, the most frequent was prolactinoma (15.5 %). Regarding tumor size, 75 % were macroadenomas, 15.5 % were microadenomas, and 9.5 % were giants. Cavernous sinus invasion (Knosp grade ≥ 3) and suprasellar extension were noted in 14.4 % and 53.3 %, respectively. The resection was total in 80 % of cases, subtotal in 18.8 %, and partial in 1.2 %. Partial improvement of sight was observed in 91.1% and endocrine hypersecretion remission in 76.6 %. As for complications, the most frequent was transient diabetes insipidus (32.7 %).

Conclusion

Despite the scanty resources, our results are similar to the best-reported series and strengthen scientific evidence on the efficacy and safety of performing this technique in an under-equipped setting context.

Identification of brain tumors border and determination of their possible pathology in MR images is an important step in pre-operation analyzing of this serious medical condition. Manual segmentation and classification of brain tumors could be challenge full in neurosurgical practice because of vast differences between brain tumors characteristic such as shape, border irregularity, consistency and etc. as well as interobserver variations. To solve this problem, some automatic methods have been proposed for brain tumors segmentation or classification during recent years, but an intelligence-based method for simultaneous identification of tumor type and tumor border in MR images has not proposed till now. Here, we have planned a unique automatic model includes a common encoder for feature representation, one decoder for segmentation and a multi-layer perceptron for classification of three common primary brain tumors (meningiomas, gliomas and pituitary adenomas) in brain MR images. The proposed model was examined on a brain tumor images dataset and the output were evaluated in both multi-task and single-task learning model. The multi-task learning model gains significant improvement in simultaneous classification and segmentation of brain tumors with promising accuracy of 97% for each task. So, this model could serve as a primary screening tool for early diagnosis of common primary brain tumors in general practice with a high success rate.

Background

An instrument that penetrates the dura mater and the thickness of the skull bone is considered to have produced a penetrating craniocerebral injury. Nonmissile penetrants and missiles are two types of penetrating agents. Nonmissile penetrants can travel at low speeds or at high speeds (>100 m/s). It might stay inside the skull or come out of another place. One item that can inflict piercing injuries on civilians is a knife. Although the precise frequency of penetrating head injuries in the general population is unknown, current estimates suggest that bullets account for 4.6 % of these injuries, while puncture wounds from stabs, nails, and other trauma account for 0.4 %. Unlike European reports, Reportedly, male assailants in South Africa are much more likely to have suffered a single head-stab wound. The frontal bone is the most frontal, thickest, and most accessible section of the skull for assailants; nevertheless, the orbit and squamous portion of the temporal bone are thinner, more fragile, and more appealing to skilled attackers.

Case presentation

This is a 29-year-old male patient referred to our hospital after being referred from the primary hospital. He sustained a stab injury to the left temporal area of the head, bleeding from the scalp, and loss of consciousness. The stab is retained in the brain, with its tip visible in the left temporal area (Fig. 1). GCS is 10/15; the pupils are midsized and non-reactive bilaterally, and he had a left-side preference. On a brain CT scan, there is a left temporal area foreign body seen penetrating through the scalp, skull temporal bone, temporal lobe, and occipital lobe of the brain with a stab tip at the edge of the left tentorium cerebelli, and there is an associated left massive acute subdural hematoma and intraventricular hemorrhage extending from the lateral ventricle to the fourth ventricle (Fig. 2). We did left-side decompressive craniectomy, expansile duraplasty, and removed a foreign body (stab) safely (Fig. 3), and postoperatively, the patient was discharged with stable vital signs and no neurologic deficit with improved GCS 15/15.

Conclusion

The main idea is to wait to remove the knife until after a thorough investigation has been completed and the interdisciplinary team is ready to remove the instrument using suitable techniques. Removing the penetrating object should allow the knife to follow its original path. It’s important to avoid making any rocking motions during the extraction process that could endanger vital neurovascular structures at risk at the knife's tip.

Background

Up now, several model were proposed for predicting the outcome of treating brain aneurysm. This study aims to investigate the performance of Machine learning (ML) in predicting the outcome of intracranial aneurysm after endovascular or microsurgical management.

Method

This systematic review and meta-analysis was prepared with adhering to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline. The electronic databases of PubMed/Medline, Embase, Scopus, and Web of Science were systematically reviewed up to 5th June 2023. All statistical analysis was done by STATA/mp V.20.

Results

Recent studies have utilized ML models to forecast the results of cerebral aneurysm treatment. The models exhibit a sensitivity of 0.88 and a specificity of 0.80, with the latter revealing substantial variability across the various studies. Meanwhile, the sensitivity remained consistent. The models displayed a positive DLR (PLR) of 4.5 and a negative DLR (NLR) of 0.15. The aggregate diagnostic score determined that heterogeneity was negligible, with a value of 3.41. However, the diagnostic odds ratio 30.29 indicated noteworthy heterogeneity among the studies. The pooled AUC of 0.90 showcased the ML's ability to predict cerebral aneurysm treatment outcomes accurately.

Conclusion

Predicting treatment outcomes in patients with intracranial aneurysms non-invasively is a promising approach with good diagnostic performance. However, further studies are required to improve the accuracy of ML algorithms, as the pooled metrics had a wide confidence interval. This will not only enhance the reliability of the predictions but also facilitate the integration of these algorithms into daily clinical practice.