Neurosurgery open最新文献

Background and importance: Spinal venous vascular ectasia associated with a low-flow fistula of paravertebral location is a very low-frequency entity. It usually manifests with myelopathy; however, in the present case, the symptomatology corresponded to thoracic radiculopathy, which can be difficult to diagnose and may be the cause of chronic pain refractory to analgesic management.

Clinical presentation: An adult patient who consulted about a 1 year and a half of flank pain refractory to analgesic management and hypoesthesia on palpation in the left T8 dermatome, therefore, pain of radicular origin was suspected. MRI of the thoracic spine was requested, showing an image suggestive of vascular malformation at the level of T8. After identification of the lesion, the patient was taken to spinal angiography to delimit the vascular malformation, finding an image suggestive of spinal venous vascular ectasia associated with a low-flow fistula of paravertebral location at T8. Subsequently, the case was discussed by a multidisciplinary team that established endovascular embolization as the best option for treatment. Thus, achieving complete occlusion of the lesion without complications and a slow improvement of the symptoms.

Conclusion: Spinal venous vascular ectasia associated with a low-flow fistula of paravertebral location is a very low-frequency entity that despite manifesting with myelopathy in some cases may generate radicular irritative symptoms and is differentiated from other lesions by its unusual location in spinal angiography.

Background and importance: The second stage of deep brain stimulation requires the placement of an implantable pulse generator (IPG). Although the current placement technique achieves acceptable outcomes, device erosion has been reported. We describe a simple surgical option aimed at increasing device longevity by placing the hardware under the superficial pectoralis fascia.

Clinical presentation: We describe and illustrate the technique of placing the IPG in the subfascial space in a patient undergoing deep brain stimulation. In addition, we provide pearls and pitfalls to be mindful of when implementing this method.

Conclusion: In this technical report, we have outlined a simple alternative approach to the traditional subcutaneous IPG placement by placing the IPG under the superficial pectoralis fascia. This subfascial approach can potentially reduce complications and preserve device longevity.

Background and importance: Patients with severe aphasia rarely become candidates for awake surgery because the intraoperative tasks of awake surgery for patients with aphasia have not been established.

Clinical presentation: A 50-year-old, right-handed woman presented with recurrent glioblastoma invading her left superior temporal gyrus and inferior parietal lobule. She had severe aphasia, as she could barely verbalize her own name. However, we noticed that she could sing nursery rhymes with simple melodies and applied her singing ability as an axis of awake surgery. During awake surgery, she continuously sang simple songs to detect language dysfunction. As a result, 90% of the tumor was resected, preserving her language function and allowing for improvement. She was discharged 9 days after surgery without further neurological deterioration.

Conclusion: Awake surgery is usually not indicated in patients with severe aphasia. However, for patients with aphasia who retain the ability to sing, intraoperative singing could be a possible alternative to maximize tumor resection while minimizing neurological dysfunction.

Background: In patients with brain tumors around the motor cortices, deterioration of motor performance may be observed even if the integrity of the cortical output is maintained. Especially, resection of medial premotor area (PM) can cause postoperative deterioration called supplementary motor area syndrome.

Objective: To clarify the neuronal mechanisms underlying postsurgical deterioration with a case-control study.

Methods: Twelve patients with brain tumors underwent preoperative and postoperative sessions consisting of motor performance evaluation and 3T-magnetic resonance imaging data acquisition. Based on additional postsurgical motor deficits, 6 patients were classified into "deficit group," and 6 others were into "no deficit group." Using resting-state functional magnetic resonance imaging (fMRI), the integrity of functional connectivity was evaluated by placing a seed in the ipsilesional primary motor area (M1). With motor task fMRI, hand and foot representations were identified in the M1 and lateral and medial PMs. Probabilistic tractography assessed anatomic connectivity in the cortico-cortical and corticofugal networks.

Results: Functional connectivity among M1 and lateral and medial PMs during resting-state fMRI was reduced postoperatively in the deficit group (P < .05, corrected) and preserved in the no deficit group. The deficit was unlikely to be attributable to surgical resection of specific anatomic connectivity. The amplitude of motor-evoked potential was maintained in available cases. These intraoperative observations agree with imaging findings suggesting preserved anatomic connectivity of the estimated corticofugal pathway.

Conclusion: The present findings suggest that supplementary motor area syndrome is caused by disorganization of functional connectivity among cortical motor networks rather than resection of anatomic connectivity of corticofugal pathway.

Background and importance: Pure aqueductal tumors are extremely rare and may lead to death, regardless of histopathology. We report the first case of pure aqueductal pilomyxoid astrocytoma in an adult woman with arrested hydrocephalus. Endoscopic tumor resection for securing aqueductal patency followed by chemotherapy allowed control of both the tumor and the hydrocephalus.

Clinical presentation: A 20-year-old woman presented with mild cognitive dysfunction and marked ventricular dilatation. She had no preoperative symptoms of intracranial hypertension, and her head circumference was more than 2 SDs above the 98th percentile. The aqueduct of Sylvius was entirely occupied by a neoplastic lesion with 2 periventricular nodules at the wall of the third ventricle and anterior horn of the right lateral ventricle. She was treated successfully with endoscopic tumor resection followed by chemotherapy, and the patency of the aqueduct of Sylvius was secured throughout the duration of treatment.

Conclusion: Pure aqueductal tumors may be an appropriate indication for endoscopic tumor resection to secure the aqueductal patency of cerebrospinal fluid. This case demonstrates the surgical technique of a combined rigid-flexible endoscopic transforaminal approach, which was a useful surgical intervention for the management of this patient.

Background: Previous series have demonstrated central nervous system activity for immune checkpoint inhibitors (ICIs) and shown improved local control between stereotactic radiosurgery (SRS) and ICI for lung cancer brain metastases.

Objective: To assess whether the addition of ICI to SRS for melanoma brain metastasis improves outcomes when compared with historical control group treated in the era before ICI availability.

Methods: In this single institution retrospective series, outcomes of 24 patients with melanoma receiving concurrent ICI and SRS were compared with 111 historical controls treated before ICI era. Overall survival (OS) was estimated using the Kaplan-Meier method. Cumulative incidence of local and distant failures was estimated using a competing risk model that accounted for baseline differences using propensity score adjustments.

Results: The median OS time was improved in patients receiving ICI compared with the historical control group (17.6 vs 6.6 months, hazard ratio [HR] = 0.056, P = .0005). Cumulative incidence at 1 year for local failure in the historical control and ICI groups was approximately 12.5% and 6.5%, respectively (HR = 0.25, P = .19), while cumulative incidence of distant brain failure in the historical control and ICI groups was approximately 48% and 28%, respectively (HR = 0.326, P = .015).

Conclusion: Distant brain failure and OS were improved in patients receiving concurrent ICI with SRS compared with historical controls. Local failure trended in the same direction; however, owing to small sample size, this did not reach statistical significance. While these data remain to be validated, they suggest that patients with brain metastasis may benefit from concurrent use of ICI with SRS.