Interdisciplinary Neurosurgery: Advanced Techniques and Case Management最新文献

Background

Alkaptonuria (AKU) is a rare autosomal recessive disease characterized by a deficiency in an enzyme involved in the tyrosine and phenylalanine degradation. Patients suffering from this disorder develop a black coloration of cartilages known as ochronosis, leading to debilitating cartilage and arthritis at early ages. The spine is commonly involved but reports of lumbar disc disease are rare.

Methods

We present a case of a lumbar disc herniation secondary to ochronosis, and we also provide a comparative analysis with other cases documented in the literature. For the literature search we selected manuscripts published in PubMed, Embase, Scopus, Ovid, and Science Direct between 1963 and 2022.

Results

The mean age of the 25 included patients was 44.2 years (range: 22–69), and most of them were males (n = 19). The most common presentations were back pain and leg pain (n = 10), followed by lumbar radiculopathy (n = 9). Cauda equina syndrome (n = 2), thoracic myelopathy (n = 2), and cervical radiculopathy (n = 1) were less frequently observed. The lumbar region was the most affected area, with L4-L5 being the most affected level (n = 7), followed by L5-S1 (n = 4).

Conclusion

AKU can lead to ochronotic spondyloarthropathy and, rarely, disc herniation, particularly in the lower lumbar region. Surgeons should note that black cartilage during a discectomy indicates likely ochronotic disc involvement. Diagnosis requires histopathologic and biochemical analyses of blood and urine, usually done retrospectively. Genetic confirmation is crucial due to the multisystem nature of alkaptonuria. Our case contributes to the literature on this rare condition, emphasizing the need for comprehensive diagnostics.

Background

Re-resections is one of the treatment options for recurrence brain tumors, including both benign and malignant brain tumors, such as meningioma and glioblastoma. Re-resection for recurrent brain tumor sometimes needs extension of original craniotomy. However, extending original craniotomy is troublesome and can easily damage the adhered brain tissue and reconstruct of bone flap sometimes cause cosmetic problems, thus ideal way to re-resect recurrent brain tumor is to use the same original craniotomy.

However, when using an operative microscope, performing re-resections without extending craniotomy requires the surgeon to operate in an awkward position. A recently developed high-definition (4 K-HD) 3-D exoscope system, ORBEYE, can improve this problem. In this study, we analyzed the utility of 4 K-HD 3-D exoscope system, ORBEYE, for re-resecting recurrent brain tumor.

Methods

We report 32 cases managed by re-resecting recurrent brain tumor by ORBEYE. Perioperative clinical, surgical, and radiographic data were retrospectively examined.

Results

Re-resecting tumors for recurrent brain tumor by ORBEYE were successfully performed for all 32 resections, using ORBEYE, without any severe postoperative neurological deficit. In addition, we could avoid extending original craniotomy as much as possible by adjusting the ORBEYE camera angle.

Conclusion

Re-resecting tumors for recurrent brain tumors by ORBEYE are feasible and can avoid extending original craniotomy as much as possible.

Background

Epidural hematoma often develops in a single side in the skull box. However, even though this is quite rare, it may also arise from two sides: the so-called bilateral extradural hematoma (BEDH). Here, we report three cases of BEDH occurring in three young male patients following a head trauma.

Methods

We present three cases of BEDH and relate our experience with its management in general and discuss the relevant literature.

Cases description: The first case is a 15-year old male with no past history, referred to our emergency department for sustained headache, nausea/vomiting following a head trauma due to a wood blow with brief loss of consciousness. The head CT (Computed Tomography) scan performed showed a biparietal extradural hematoma. The 2nd case was a 41-year-old male, with no past history, referred to our emergency department for headache, nausea/vomiting following a head injury due to a wood blow with brief loss of consciousness. The head CT scan showed a double (frontal and parietal) bilateral extradural hematoma. The 3rd case was about a 20-year-old male patient referred to our casualty for sustained loss of consciousness with vomiting following head trauma caused by a machete blow. The head CT scan revealed a biparieto-frontal extradural hematoma. The three patients underwent hematomas evacuation through craniotomy. The post-operative follow-up was uneventful.

Conclusion

Post‑traumatic bilateral acute extradural hematoma remains uncommon. Its management requires careful planning, judicious surgical approach, and time management for good results.

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.