Interdisciplinary Neurosurgery: Advanced Techniques and Case Management最新文献

Background and importance

The surgical approach to the medulla oblongata poses a significant challenge for neurosurgery, considering the clinical consequences and risks of this procedure. The authors describe a step-by-step technique to safely extirpate a cavernous malformation within the hypoglossal trigone with minimal risk of neurological deficits.

Clinical Presentation

In a young 33-year-old patient was identified a lesion in the center of the medulla oblongata. Complete resection of the cavernous malformation through the hypoglossal trigone was performed with an improvement of all symptoms. The key surgical tip is to dissect the lesion between the posterior median sulcus and the sulcus limitans avoiding the vagal trigone.

Conclusion

 Surgical approach through the hypoglossal trigone appears to be safe and effective for the treatment of medulla oblongata cavernomas. The entry zone through the dorsomedial sulcus of the hypoglossal trigone with a meticulous delicate microsurgical technique is the key to success with these kinds of lesions.

Background

Meningiomas are extra-axial tumors that arise from meningothelial cells, accounting for about one-third of primary central nervous system malignancies. While they are often classified by location and histology, the role of the molecular profile in their development and progression is significant. The topographic distribution of meningiomas has not been extensively studied, and it is unclear whether specific histological subtypes have predilection sites. Therefore, this study analyzes the preferred locations of meningiomas according to different biological characteristics and their association with different gradings.

Methods

This is a retrospective chart review of patients in tertiary institutes over 14 years. The data were retrieved from medical and pathological record archives. An association between the biological nature of tumors and the location of meningiomas was analyzed. SPSS version 25 was used to analyze the data.

Results

Out of 272 patients, the predominant location for meningioma distribution was convexity (33.5%), followed by parafalcine (12.5%). WHO Grade I meningiomas were the most common, accounting for 84.2% of all meningiomas. The transitional histological subtype is the common variant (34.6%). The distribution of the histological subtype of meningioma in relation to tentorium was statistically significant. However, that was not the case with the skull base.

Conclusion

The spatial distribution of meningiomas within the brain is not uniform. The most frequent locations for meningiomas were found to be convexity and parafalcine. Transitional and fibroblastic meningiomas were the predominant subtypes.

C-arm computed tomography (CT)-guided percutaneous balloon compression (PBC) achieves intraoperative visualization, which allows for an intuitive display of the morphology and positional relationship between the balloon and the cranial base osseous structures. By promptly diagnosing variations or abnormalities in the cranial base structures and adjusting surgical strategies in a timely manner during the operation, precision treatment can be achieved. We report a rare case of diagnosing dural calcification in the cranial base during C-arm CT-guided PBC for trigeminal neuralgia.

Background

Breast cancer is the more common tumor in women. The first description date 1789 by Mr. Hughes described a case of breast cancer of a 44-year-old married woman. The advances in the treatment of the pathology led to a higher life expectancy and increased the frequency of brain metastasis since 1970. The symptoms depend on the brain region committed. The cerebral lobes and cerebellum are more commonly affected, and the treatment is based on a triple basis: microsurgery, radiotherapy/radiosurgery, and the control of the extracerebral disease. The sellar region is a rare location. Only 38 cases were previously reported.

Case report

A 50-year-old woman presented progressive visual impairment, headache, and a past clinical history of breast cancer. Radiological exams showed an expansive lesion occupying the sella turcica, the suprasellar, and the pre-sellar spaces. An endoscopic endonasal biopsy was performed and confirmed Breast Cancer metastasis.

Conclusion

Despite the uncommon site, the sella turcica must be remembered as a possible site of breast cancer metastasis. The previous history of the oncological disease, the atypical radiologic aspect, and the fast and progressive onset of the symptoms are important aspects to be analyzed during medical management.

Background

The management of pituitary apoplexy (PA) is under debate. Therefore, we studied the clinical manifestations and neuroendocrine outcomes of PA after surgical management, as well as the efficacy and safety of the endoscopic endonasal transsphenoidal approach (EETA).

Methods

This retrospective study was conducted between January 2013 and May 2021, and included 62 cases of pituitary adenoma apoplexy that were managed with EETA.

Results

Data from 62 patients were analyzed with a mean age of 50.7 ± 10.9 years, 90.3 % of whom were female. On admission, most patients presented with abrupt onset severe headache and vomiting, associated with endocrine dysfunction in 43.5 % and deteriorated visual acuity in 92 %. Third nerve palsy was the most noted ocular nerve palsy. After using EETA, the adenoma was resected totally, subtotally, and partially in 59.7 %, 29 %, and 11.3 % of the cases, respectively. Postoperative improvement in visual acuity was achieved in 90.3 % of patients, unchanged in 6.5 % with vision defects, and deteriorated in 3.2 %. Endocrine dysfunction improved to 19.3 % after being 43.5 %. Six patients (9.6 %) experienced transient diabetes insipidus (DI) that responded completely to desmopressin therapy for a time, and three cases were complicated with CSF leakage after the operation, but it resolved completely. No intracranial infection, carotid artery injury, or death occurred.

Conclusion

Despite the availability of alternative treatment options, the surgical intervention by EETA remains the most effective and reliable method for managing patients with PA who present with sudden visual or endocrine symptoms. EETA has been shown to result in significant improvements in both visual and endocrine function, with an acceptable complication rate that can be managed effectively in many cases. As such, EETA continues to represent the cornerstone in the management of PA and should be considered the first-line treatment option for amenable patients.

Objective

This study explores safety, feasibility, and potential improvement in functional status after intravenous infusion of mesenchymal stem cells (MSCs) in chronic severe brain injury (BI) patients.

Methods

An intravenous infusion of autologous MSCs in autoserum cultured under Good Manufacturing Practice was delivered to four chronic patients with BI. In addition to assessing feasibility and safety, neurological function was evaluated using the National Institutes of Health Stroke Scale, Fugl-Meyer Assessment, Barthel Index, and cognitive-related behavioral assessment. Imaging studies with 18F-FDG-PETCT and 11C-methionine-PETCT (METPET) were carried out to evaluate brain metabolic activity.

Results

No serious adverse events were recorded. None of the patients developed CNS tumors, abnormal cell growth, or neurological deterioration. While this initial case series was not blinded, gradual functional improvement was observed after MSC infusion. Serial 11C-METPETs displayed a statistically significant increase in methionine uptake, primarily in the thalamus and pons.

Conclusion

We emphasize that this study was unblinded and did not exclude placebo effects, the contribution of endogenous recovery, or observer bias; however, our observations support feasibility and safety. No adverse events were observed. The data suggests improved quality of life after infused MSCs; however, a blinded, larger-scale study will be necessary to fully address this possibility.

Parkinson's disease is a neurodegenerative pathology of the central nervous system that affects thousands of individuals worldwide. There are several treatment methods, from drugs to emerging surgical methods. Many studies in this field are carried out annually, in view of this, this study aims to bibliometrically analyze the 50 most cited articles regarding this topic. In February 2022, a search was performed in the PubMed, SCOPUS and Embase databases using the search terms “parkinson's disease”, “deep brain stimulation” and “pallidotomy”. A total of 960 articles were found and, after their selection, the analysis of the 50 most cited was performed and then the metrics analyzed were the H index of the first author, year of publication, institution, country of origin, journal and its impact factor, total number of citations and the article methodology. This analysis brought the characteristics of the articles with the greatest impact in the scientific community on the use of pallidotomy and deep brain stimulation (DBS), and some insights on studies in this area.

Cavernomas are vascular malformations that occur commonly in cerebrum, cerebellum, and brainstem, being rare in occurrence within the hypothalamus having only 29 cases known in the literature. They may be clinically asymptomatic or present with symptoms of headache, seizures, hemorrhage, or focal neurologic deficits. The gold standard for diagnosing a cavernoma is magnetic resonance imaging (MRI). The management strategies for hypothalamic cavernoma are expectant, medical, and surgical, along with laser ablation and radiosurgery. Our case is of a 17-years old female who presented with headache and reduced vision secondary to hypothalamic cavernoma on diagnostic imaging. She is on expectant management till date, without worsening of her symptoms. As per the literature, there has been no data on conservatively-managed hypothalamic hamartomas.

Background

Retroclival hematomas and clival fractures are not common, and retroclival hematoma is one of the types of posterior fossa extra-axial hematomas. The exact incidence is not known. They can be categorized into epidural or subdural hematomas based on their relationship to the tectorial membrane. In the literature, most cases occur in the pediatric population, and a few cases have been reported in the adult population as well. The etiology is related to accidental trauma in most cases. Others occur generally spontaneously due to coagulopathy, pituitary apoplexy, and ruptured aneurysms. Still, some remain idiopathic without an identifiable cause.

Case presentation

This is a 28-year-old male patient who presented after sustaining a motor vehicle accident. He was a pedestrian walking by the side of a road when he was suddenly hit by a minibus. He lost consciousness immediately and was non-communicating after the trauma with right ear bleeding. GCS is 9/15, right pupil has cataract, and left pupil is midsized and reactive. A brain CT scan demonstrated retroclival hematoma extending from midclivus to the lower level of C2, right mastoid fracture, multiple post-traumatic subarachnoid hemorrhage, pneumocephalus, and transverse upper third clival fracture. This patient's GCS on the second day improved to 14/15. All cranial nerves are intact. Discharged on the 7th day with GCS 15/15.

Conclusion

Retroclival hematomas and clival fractures are very rare in adults, most often reported in pediatric age groups, and mostly occur due to accidental trauma. Associated cranial nerve palsy is common and the management is non-surgical in most of the cases.