Journal of Neurological Surgery Reports最新文献

Background: Intracerebral hemorrhage (ICH) disproportionately affects low- and middle-income countries (LMICs), where prevalence and outcomes are poor. Surgical intervention is often necessary in life-threatening cases. This study explored the feasibility of using a low-cost, in-house tubular retractor for ICH evacuation in a resource-limited setting.

Methods: We retrospectively reviewed adults with spontaneous supratentorial ICH who underwent evacuation with an International Organization for Standardization (ISO)-compliant, in-house tubular retractor (production cost approximately $60) between January 2023 and June 2024. Outcomes included hematoma volume reduction, correction of midline shift, perioperative complications, reoperation, hospital stay, and Glasgow Coma Scale (GCS) scores at discharge and 6 months.

Results: A total of 18 patients (13 males, 5 females; mean age 60.6 ± 13.8 years) underwent surgery. Median hematoma volume was 65.3 cm ³ (IQR, 48.5-93.8), with a mean reduction of 81.2% ± 11.7 (median 83.9% [IQR 73.4-88.3]). Midline shift correction averaged 58.5% ± 28.0 (median 55.9% [IQR 43.7-69.6]). Hematoma evacuation was similar whether surgery occurred within 6 hours or later (79.8% vs. 83.5%, p  = 0.49). Putaminal and frontal hematomas ( n  = 14) showed greater reduction than non-putaminal ( n  = 4), though not statistically significant. Median hospital stay was 23.5 days (IQR, 14.5-50.5). At 6 months, median GCS improved from 13 (IQR, 9-14) at discharge to 15 (IQR, 12-15). Two patients died of non-neurological causes.

Conclusion: Use of an in-house, ISO-compliant tubular retractor is feasible and cost-effective for intracerebral hematoma evacuation in resource-limited settings. These preliminary findings support further investigation to refine the technique and assess its clinical impact.

Introduction: Tetraventricular hydrocephalus happens due to the fourth ventricle outlet obstruction. Idiopathic fourth ventricle outlet obstruction (IFVOO) is a condition where no clear-cut etiology for fourth ventricle outlet obstruction can be found. The etiopathogenesis of IFVOO is unclear. There is no clear-cut consensus regarding the treatment practices for its management. These cases present a diagnostic dilemma to the treating neurosurgeon and are thus often managed inappropriately. This study aims to review the existing literature regarding this condition, illustrating with a case from our hospital.

Case details: We present a case of a 50-year-old female who presented to us with the chief complaints of headache, difficulty in walking, with an inability to balance while standing and walking, diplopia, and three episodes of loss of consciousness for 6 months. A brain MRI was done, which was suggestive of dilatation of all ventricles with obstruction at the foramina of Luschka and Magendie. She underwent a right-sided, medium-pressure ventriculoperitoneal shunt at our hospital. Postsurgery, there was immediate improvement in her symptoms.

Conclusion: IFVOO is a rare cause of tetraventricular hydrocephalus with an unknown cause. Endoscopic third ventriculostomy (ETV) appears to have a higher risk of failure in such cases. Fenestration procedures after craniotomy and shunt procedures are still effective in their management. ETV is still an alternative to the above-mentioned procedures. To confirm these conclusions, larger studies involving multiple hospitals and institutes are required.

Postoperative (or postprocedural) pneumocephalus is unique from those associated with head injury, spontaneous cerebrospinal fluid leaks, and intracranial infection. Postoperative cranial imaging usually demonstrates a small volume of air that remains in the surgical bed, which is essentially self-limited and resolves over several weeks or less. However, occasionally, surgical defects lead to symptomatic postoperative air entrapment, and severe cases are generally due to one-way valves created by tissue, a mechanism shared with severe traumatic pneumocephalus. In the case where this causes progressive pressurization, this is termed tension pneumocephalus, analogous to its pulmonary counterpart. In the closed adult cranium, the Monroe-Kellie doctrine can be extended to include pneumocephalus if the compressible nature of gas is accounted for. Three illustrative cases are used to highlight common etiologies of postoperative tension pneumocephalus, management strategies, and imaging findings of these collections.

Introduction: Female patient, age 50, allergic to acetylsalicylic acid (ASA) presented to the emergency department of our institution with spontaneous and severe headache.

Case report: Emergent brain MSCT and CTA scan showed subarachnoid hemorrhage with aneurysm in the C7 segment of left internal carotid artery (ICA). Prasugrel monotherapy was started and she underwent endovascular aneurysm occlusio. Small, atypically shaped aneurysm was found at the origin of anterior choroidal artery (AChA). Flow diverter stent was placed in the left C7 segment. One single coil was deployed in the sac. She was discharged without any neurological sequelae with prasugrel monotherapy. Two years after the procedure, aneurysm was completely occluded with normal flow in left ICA and its branches.

Discussion: Here, we describe case of blood-blister like aneurysm (BBA) at the origin of left AChA. There is still no consesus regarding optimal treatment strategy for BBAs. Our experience shows it is possible to treat BBA with flow diversion even in the acute setting and near origins of ICA branches. Flow diversion needs to be reinforced with aneurysm coiling in the case of ruptured aneurysm. Due to patient's ASA allergy, we opted for prasugrel monotherapy which proved to be both safe and effective antiplatelet therapy after flow diverter placement.

Conclusion: To the best of our knowledge this is first published case in which coiling with flow diversion was used to treat BBA at the branching point of supraclinoid ICA in a patient allergic to ASA.

Background: Deep-brain stimulation (DBS) is used to treat movement disorders and drug-resistant focal epilepsy. However, electrode placement accuracy is affected by brain shift caused by pneumocephalus and cerebrospinal fluid (CSF) leakage during surgery. We present the novel half burr-hole method for improved DBS electrode placement accuracy.

Case description: This approach was used to treat a 28-year-old man with drug-resistant epilepsy in whom stereo-electroencephalography revealed bilateral seizure onset in the temporal lobes, precluding focal resection. The patient, under general anesthesia, was placed in the supine position. Using a ROSA robot-assisted surgical system, approximately 8-mm-deep "partial burr-holes" were created, with the deeper portion perforated using a 2.4-mm twist drill. Stimulation electrodes were placed bilaterally in the anterior thalamic nucleus. Directional leads were secured using standard burr-hole caps. Postoperative computed tomography confirmed a 0.46-cm ³ pneumocephalus and electrode positioning with 0.47 mm (range: 0-1.62 mm) vector and 0.12 mm (range: 0.08-0.16 mm) axial errors relative to the target coordinates. Postoperative electrode impedance values were within the normal range.

Conclusion: The half burr-hole method effectively minimizes CSF leakage and pneumocephalus during DBS surgery, reducing brain shift and enhancing electrode placement accuracy, and is compatible with standard burr-hole caps for electrode fixation, minimally affecting impedance values.

Introduction: Atypical teratoid/rhabdoid tumors (AT/RT) are malignant central nervous system (CNS) tumors that represent 3% of all pediatric CNS tumors. Majority of cases have SMARCB1 gene mutations and historically carried a poor prognosis.

Case presentation: A 9-year-old boy was diagnosed with a third ventricle AT/RT and initially underwent endoscopic surgical biopsy. Subsequent tumor resection was completed using an interhemispheric-transcortical approach.

Lessons: Surgical approaches to ventricular system must be tailored to the tumor characteristics on a case-by-case basis. We present a case using a transcortical approach for understanding of the microsurgical anatomy for safe resection of a third ventricle AT/RT.

We report a patient with an arachnoid cyst in the velum interpositum (VI) and discuss the mechanism of the symptoms based on functional neuroanatomy. A 68-year-old woman presented with difficulty in doing housekeeping and with route-finding disorientation in known locations. Her performance intelligence quotient (PIQ) score was 68, significantly lower than her verbal intelligence quotient (IQ) of 103. Significantly low scores were obtained for the picture arrangement, picture completion, and symbol search tasks (4, 1, and 5, respectively) in the PIQ subtests. Her copies of the interlocking pentagons and cube designs were distorted, indicating visual-spatial construction apraxia. However, verbal IQ, working memory, urination control, ideational and ideomotor function, and dressing were intact. Magnetic resonance imaging revealed a cystic enlargement of the VI. Neuroendoscopic cyst fenestration to the lateral ventricles contributed to a decrease in the volume of the cyst. Postoperatively, her PIQ improved to 94. Her scores on the picture arrangement, picture completion, and symbol search tests increased to 7, 7, and 11 points, respectively. The pentagons and cube designs were copied correctly. An arachnoid cyst in VI is known to present with cognitive dysfunction. In our patient, symptoms were limited to the constructional apraxia and route-finding disorientation owing to the disturbance in the biparietal connections and posterior cingulate gyrus, respectively. The intramantle pressure gradient created by the characteristic cone-shaped cyst may have caused the selective dysfunctions. Namely, the impairment in the deep parietal region was more severe than on the frontal lobes or superficial parietal lobes.

[This corrects the article DOI: 10.1055/a-2642-8152.].

Bilateral paragangliomas are rare neuroendocrine tumors stemming from the paraganglia along the autonomic nervous system. This case report presents a case of a 49-year-old woman with a year history of bilateral neck masses and recurrent syncopal episodes. Diagnostic imaging revealed bilateral, hypervascular carotid body tumors. This case underlines the importance of recognizing paragangliomas as a differential diagnosis in patients with neck masses and highlights the role of advanced imaging techniques in diagnosis and management.