Asian Journal of Neurosurgery最新文献

Paraspinal textilomas are dreaded complications of spinal surgery and rarely reported in view of the medico-legal problems they may create. As many of them are asymptomatic and most are unreported, their true incidence is unknown. They must be kept in mind when re-operating for any mass lesion seen on magnetic resonance imaging in the vicinity of a previously operated spine. We present the case of a 40-year-old man found to have a textiloma as a result of a previous surgery, describe his imaging and histological findings, discuss the causes that might lead to the same, and enumerate preventive strategies to avoid such a complication.

Objective  When small unruptured aneurysms (SUA) are embolized by coils, manipulation of the microcatheter and coil is limited because of their small size. Previous studies suggested that the morphology of the artery and aneurysm is important. In the present study, we clarified the morphological factors affecting coil-only embolization of SUA. Patients and Methods  We retrospectively identified 17 patients who underwent embolization for unruptured aneurysm with a maximum diameter less than 5 mm. We investigated the following: (1) the relationships among dome/neck ratio (D/N), height/neck ratio (H/N), height/dome ratio (H/D), projection of aneurysm-parent artery, and adverse events, (2) immediate and late occlusion, and (3) number of coils. Results  (1) Adverse events developed in three cases in which the H/D was smaller than 1 ( p  < 0.02). There was a significant difference in the rate of adverse events by projection of the aneurysm-parent artery ( p  < 0.03), (2) Occlusion rate: Immediately after coil embolization, 71% (12/17) were neck remnant; however, 88% (15/17) of SUA became complete occlusion in the follow-up term, and (3) 1.5 ± 0.6 coils were used. Conclusion  To achieve successful coil-only embolization in SUAs, it is important to select aneurysms for which the projection of the parent artery is suitable for embolizing and the H/D ratio is larger than 1. In SUAs, occlusion develops naturally after coil embolization.

Anatomical variations often occur in the anterior communicating artery (AComA) complex, and a careful preoperative evaluation is required before repair of this lesion. We report a case of a fenestrated AComA complex mimicking an unruptured cerebral aneurysm. A 49-year-old woman was referred to our hospital under suspicion of unruptured aneurysms of the AComA and the left middle cerebral artery on magnetic resonance angiography (MRA). Additional three-dimensional computed tomographic angiography (CTA) showed the lesion arising from the AComA complex with a maximum diameter of 4.2 mm. Intraoperative findings showed that the putative aneurysm was actually a fenestrated AComA complex as the blood vessels that formed the AComA complex were dilated and meandering. After the operation, MRA and CTA three-dimensional images were reviewed again but we could still not diagnose the lesion as a fenestrated AComA complex rather than an aneurysm. However, in the MRA source image, a secant line in the lesion was the only finding suggestive of a fenestration. The AComA complex is often associated with various vascular malformations, and it is essential to consider this association in the preoperative evaluation. The interpretation of source images may be helpful for accurate diagnosis and surgical planning.

Intracranial schwannomas (ISs) account for approximately 8% of intracranial tumors, while IS, a rare entity, is responsible for roughly 1% of IS. A 33-year-old man with a 3-month headache and sudden onset seizure was referred to our clinic. Preoperative magnetic resonance imaging revealed a contrast-enhancing mass accompanied by cystic components in the right temporal lobe. Ganglioglioma, metastasis, or glioblastoma multiforme was suspected, and surgery was advised. During surgery, gross total resection of a noninvasive tumor was conducted. Postoperative recovery was uneventful. Based on histopathological examination and confirmatory immunohistochemistry, the intraparenchymal temporal tumor was diagnosed as schwannoma. ISs are extremely scarce brain tumors mainly located on the surface of the brain or adjacent brain ventricles. The definite preoperative diagnosis of schwannoma cannot be readily established due to radiologically indistinguishable features from metastasis and gliomas; however, histopathology and immunohistochemistry are of great assistance. Complete surgical removal is the most preferred treatment alternative with a long-term favorable prognosis without adjuvant and neoadjuvant chemotherapy requirements.

Presentation of cervico-thoracic extradural hematoma in pediatric age is rare with stroke-like features. Its association with COVID-19 in the active stage of the disease had not been reported and its management presents a management dilemma as COVID-19 with stroke-like features. A 14-year-old boy was referred to our institute with complaints of sudden-onset upper and middle back pain, associated with loss of sensation below the middle of the back, sudden progressive weakness of both lower limbs (power 0/5) and upper limbs (power grade-2/5), and incontinence of urine, following bouts of vomiting 12 days back. There was no history of trauma, bleeding diathesis, etc. Blood investigation was suggestive of leukocytosis, and RT-PCR test for COVID-19 was positive with raised D-dimer, serum ferritin, and C-reactive protein. MRI spine was suggestive of cervicothoracic extradural hematoma extending from C5-D3 level and compressing the spinal cord. The patient refused surgical decompression and was managed conservatively, following which he improved with power grade in limbs to 4/5. Surgical decompression is the treatment of choice but the patient can sometimes improve on medical management. Association of COVID-19 with spontaneous cervicothoracic extradural hematoma had not been reported earlier in the active stage, but its role in inducing vasculopathy and increased chances of bleeding at the uncommon site had been reported in the literature, and it may precipitate such cervical epidural hematoma.

In patients with bilateral internal carotid artery (ICA) obstruction, the basilar and ophthalmic arteries become the most critical arteries for brain perfusion, and the location of aneurysm formation may be associated with increased wall shear stress induced by compromised carotid circulation. Consideration of collateral routes may have an impact on therapeutic decisions for patients undergoing extracranial to intracranial (EC-IC) bypass and aneurysm surgery. We report a rare case of a young woman with bilateral ICA occlusion simultaneous with dissecting aneurysm of the obstructed ICA reconstituted via collaterals, emphasizing the functional value of collaterals and therapeutic strategy. We present a young woman with angiographic evidence of cerebrovascular early atherosclerotic disease. A young patient was found to have bilateral ICA occlusion and dissecting aneurysm of the obstructed ICA. A large fusiform aneurysm was clipped. Then, an anastomosis was performed from the left superficial temporal to the M3 segment of the middle cerebral artery. The patient's postoperative course was uneventful, and she was discharged to rehabilitation with no residual sequelae. This case illustrates a rare case of bilateral ICA occlusions, presented with robust collaterals, and dissecting aneurysm of the obstructed ICA reconstituted via collaterals. We also demonstrate excellent surgical clipping of a challenging ICA aneurysm and cerebral bypass surgery.

Aim  Primary central nervous system lymphoma (PCNSL) is a rare extra nodal non-Hodgkin's lymphoma. The optimal treatment for PCNSL is still unclear. In this study, we present our experience with management of PCNSL in a tertiary care center in Iran. Methods  In this retrospective study, 58 patients with tissue diagnosis of PCNSL were studied. All patients were treated with chemotherapy including intravenous high-dose methotrexate, rituximab and temozolomide and radiotherapy by the same oncologist. Statistical analysis was performed using SPSS. Results  The mean overall survival (OS) in this study was 37.4 ± 13.6 months and the mean progression free survival (PFS) was 35.1 ± 9.8 months. The mean time to progression was 15.2 ± 8.79 months among 8 patients who experienced progression in this series. Finding of a positive CSF cytology was not linked with disease progression, while HIV infection and multifocal involvement at initial presentation were strongly linked to a lower PFS. The single most important factor affecting the OS was the histopathologic type of the PCNSL; two of the three patients who died from their disease in this series had non-B cell PCNSL, whereas only one patient with DLBCL died because of brainstem involvement. Conclusion  The results of this study show a lower rate of HIV-infection in patients with PCNSL as compared to the series from the western countries. Non-B cell histopathology and HIV-infection were found to be associated with the dismal prognosis.

Fronto-temporal lobectomy for refractory intracranial hypertension following an acute arterial ischemic stroke in a child is rarely performed following failed conventional measures including decompressive craniectomy. We present a case of a 10-year-old child who presented with acute ischemic stroke with intractable cerebral edema and failed conventional measures including decompressive craniectomy and had significant neurological recovery following frontotemporal lobectomy.

Malignant peripheral nerve sheath tumor (MPNST) of the scalp is rare. These lesions are associated with neurofibromatosis type 1 (NF1), but patients had been reported without NF1 also. We tried to analyze the difference between the clinical course and outcome of the patient with MPNST having stigmata of NF1 and without it. We included five patients treated over 3 years between July 2018 and July 2021 with diffuse scalp MPNST. Two of these five patients with MPNST of the scalp had neurocutaneous stigmata of NF1. Three were female and two males with an average age of 38.40 ± 18.48 years-the youngest with NF1 being a 19-year-old female. We found dull aching pain as the most typical complaint in all patients and a repeated episode of generalized seizure in one patient. In these cases, two patients with NF1 have highly vascular tumors and attained large sizes greater than 30 cm. These two cases required preoperative digital subtraction angiography (DSA) and embolization with n-butyl acrylate. Total excision of the tumor was done in all patients with radiotherapy. Metastases within 1 year were noted in two patients with NF1, and one of these two succumbed to her illness. The rest of the three patients without NF1 are under follow-up with no evidence of disease with a maximum follow-up of 2 years. Large MPNST (size > 20 cm) are rare and reported to have been associated with and without NF1. Patients with scalp MPNST with NF1 can achieve larger size with fast progression of tumor size and higher chances of recurrence and metastases.

Background  There is an increasing incidence of chronic subdural hematoma due to extended life expectancy and associated trauma and fall risk. This retrospective study evaluates the efficacy of two burr-hole craniotomy over mini-craniotomy. Methods  Sixty-five patients were recruited over 2 years, of which 56 were male and 9 were females. A patient with a chronic subdural hematoma either underwent burr-hole craniostomy or mini-craniotomy for hematoma evacuation. Glasgow coma scale (GCS) and modified Rankin score were used to assess the neurological status and interventional outcome at discharge and follow-up, respectively. A head CT scan was performed at 3 week and 3 month follow-up. Statistical Analysis  Categorical data are presented as frequency and percentage, while non-categorical data are represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using the chi-square test and p -value less than 0.05 was considered statistically significant. Results  The mean age of patients was 55.6 years. Headache (35 cases), hemiparesis, and altered sensorium were seen in 20 patients, each with the main presenting symptoms. Trauma history was noted in 69.2% of patients. One (3.7%) hematoma recurrence in the burr-hole group and four (8.3%) in the mini-craniotomy group was recorded. The mean operative time was longer in the minicraniotomy group (124.2 min vs. 75.4 min; p  < 0.001). A higher incidence of recurrence was noted in the craniotomy group (8.3%) than the burr-hole group (3.7%). No statistical difference in the recurrence rate, duration of hospital stay, GCS at discharge, modified Rankin score between the two study groups at discharge was noted. Conclusion  Two burr-hole craniostomy is a safe and effective surgical option to treat chronic subdural hematoma. It is also validated in patients on anticoagulants and antiplatelet medications with adequate pre-surgical correction of coagulation parameters.