Journal of neurosurgery. Case lessons最新文献

Background: Dural hemangiomas are a relatively rare form of intracranial mass, as hemangiomas tend to present in bone or as intraparenchymal lesions and only around 5%-13% have been reported to originate from the dura mater. Here, the authors present the case of a 46-year-old female who underwent craniotomy for a suspected convexity meningioma resection, which was unexpectedly found to be a dural capillary hemangioma.

Observations: The patient was a 46-year-old female who presented with a left frontal intracranial mass found incidentally and showed significant growth over 4 years. The mass was suspected to be a meningioma as it was homogeneously enhancing, extra-axial, and exhibited findings of a broad base with a dural tail along the dura of the superior frontal lobe. This was excised en bloc and found to be a purplish-red mass firmly attached to the dura, which was diagnosed as a capillary hemangioma on histopathology.

Lessons: Dural hemangiomas, particularly at the convexity, are quite rare and can mimic meningiomas on imaging, sometimes even demonstrating homogeneous enhancement with a broad base and dural tail. These are an important part of the differential diagnosis when diagnosing dural-based masses and should be considered when planning operative or radiation treatment. https://thejns.org/doi/10.3171/CASE24476.

Background: Tuberous sclerosis complex (TSC) is a neurocutaneous disorder characterized by the multisystem development of benign tumors. Patients with TSC are also at an increased risk of developing intracranial aneurysms early in life. While aneurysms have historically been treated with open surgical clipping, endovascular approaches are increasingly being used in both pediatric and adult populations.

Observations: In this case series, the authors report the endovascular treatment of three young patients with TSC and fusiform intracranial aneurysms using the Pipeline embolization device (PED) for flow diversion of the affected artery. In all cases, complete aneurysm occlusion was observed, with good parent artery wall reconstruction and no parent artery stenosis or occlusion. All flow diverter stents were deployed successfully, and there were no device-related complications. All patients were maintained on dual antiplatelet therapy.

Lessons: The PED can serve as a safe and effective endovascular alternative to open surgery for the treatment of intracranial aneurysms in young patients with TSC. This could avoid an additional craniotomy in a population already likely to require surgical intervention for TSC-related tumors or epilepsy. Further studies investigating the use of the PED in the pediatric population must be undertaken to validate its long-term efficacy. https://thejns.org/doi/10.3171/CASE24452.

Background: The leading method of identifying critical functional regions during brain tumor resection is direct electrical stimulation (DES). In awake craniotomy patients, DES employs electric current to induce functional responses or task inhibition. In contrast, thermography uses infrared imaging to detect regions of increased blood flow from patient tasks, inferring the location of functional activity similarly to blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI). DES seldom produces no detectable response, but the case herein is an example featuring the subsequent use of thermography.

Observations: The authors present the case of a 40-year-old male in whom awake craniotomy DES for high-grade glioma re-resection produced no detectable response at the upper levels of tolerated current amplitude. Following inconclusive DES, infrared thermography was performed with a lip-pursing task, and face motor activation was thermally detected in regions corroborated by both preoperative BOLD fMRI and literature on BOLD fMRI face motor mapping.

Lessons: The lack of a detectable DES response was attributed to significant peritumoral edema, as evidenced by preoperative fluid-attenuated inversion recovery MRI. Findings indicate that infrared thermography overcomes the limitations of DES in an extensive edema setting and that thermography offers a useful complement to standard cortical mapping protocols for resection planning. https://thejns.org/doi/10.3171/CASE24549.

Background: Hypoglossal canal dural arteriovenous fistulas (HCDAVFs) are a relatively rare subtype of dural arteriovenous fistula (dAVF), representing 3%-5% of all dAVFs. The complex angio- and venous architecture predisposed to numerous anastomoses and nearby anatomical structures, including the posterior fossa sinuses and cranial nerves, can complicate both the diagnosis and treatment of these lesions.

Observations: The authors describe the case of HCDAVF in a 74-year-old male who presented with pulsatile tinnitus (PT) lasting 3 months and significant fatigue, headaches, and dizziness. Diagnostic cerebral angiography demonstrated a left-sided HCDAVF with bilateral supply from the ascending pharyngeal arteries and fistulous connection at the level of the left anterior condylar vein (ACV). This lesion was consistent with a Cognard and Borden type I dAVF.

Lessons: The authors present a case in which transvenous embolization (TVE) with detachable coils via the ipsilateral internal jugular vein successfully occluded the previously visualized shunt to the left ACV and provided a clinical cure for the patient's PT and headaches without complication. Selecting the appropriate treatment strategy for the successful treatment of HCDAVFs is predicated on a comprehensive understanding of the anatomical features of the lesion, namely arterial feeders, venous drainage pattern, and location of the fistulous connection. TVE is a safe and efficacious treatment option for HCDAVFs. https://thejns.org/doi/10.3171/CASE24606.

Background: With the growing utilization of general endovascular techniques, iatrogenic endovascular foreign bodies have become more prevalent. Contact aspiration has proven to be a valuable technique in treating ischemic strokes by removing the intraluminal thrombus causing cerebral perfusion deficits and neurological symptoms. The authors present a case of the removal of a foreign body from the vasculature via contact aspiration, which had embolized in a delayed fashion after aortic valve replacement.

Observations: A 54-year-old male developed intermittent left-sided weakness 8 days after aortic valve replacement. A head computed tomography scan showed a metallic foreign body within the origin of the M2 superior division of the middle cerebral artery suspected to be a migrated Cor-Knot fastener. During angiography, the foreign body was repositioned and removed via contact aspiration. Postprocedurally, magnetic resonance imaging scans showed a small area of diffusion restriction in the right basal ganglia. The patient was neurologically intact and was discharged on postprocedure day 2 without further neurological sequelae.

Lessons: Contact aspiration is a safe and effective technique to remove foreign bodies from the intracranial circulation; however, it requires a quality interface between the aspiration catheter and the foreign body throughout the aspiration process. https://thejns.org/doi/10.3171/CASE24376.

Background: Snapping triceps is a dynamic condition in which a portion of the medial head of the triceps dislocates over the medial epicondyle during flexion or extension. Pushed by the triceps, the ulnar nerve typically also dislocates over the medial epicondyle, causing neuropathy. Posttraumatic cubitus varus deformities resulting from pediatric supracondylar fractures have been associated with snapping triceps. This is the first case of snapping triceps associated with cubitus varus due to distal humeral malunion, which occurred in an adult.

Observations: A 23-year-old man sustained a left distal humeral fracture from arm wrestling, which was treated nonoperatively, healing in a varus malunion. Within several months, he developed ulnar neuropathy and snapping at the medial elbow, which was diagnosed as a dislocating ulnar nerve and was treated with ulnar nerve transposition. He presented 8 years later with continued ulnar neuritis symptoms and snapping and was found to have snapping medial triceps. He chose nonoperative treatment.

Lessons: Snapping triceps, presenting as snapping at the elbow with ulnar nerve symptoms, can be incorrectly diagnosed as isolated ulnar nerve dislocation. Unrecognized snapping triceps leads to persistent symptoms after ulnar nerve transposition. The patient in this case demonstrated that an altered triceps line of pull can cause snapping triceps regardless of how the cubitus varus originated. https://thejns.org/doi/10.3171/CASE24596.

Background: Congenital external carotid-jugular arteriovenous fistulas (AVFs) are often diagnosed based on a pulsatile neck mass. Patients rarely complain of headaches or neck pain.

Observations: A 45-year-old woman with no history of trauma had been diagnosed with a congenital cervical external carotid AVF 10 years earlier. At that time, only a pulsatile neck mass in the right neck had been observed, and she had been managed conservatively. Over the next 10 years, the right neck mass had enlarged, and she started experiencing unbearable headaches and neck pain when she turned her head. Angiography images showed that the outflow veins, including the external and internal jugular veins, were more dilated and tortuous than they had been 10 years earlier. During neck rotation, the internal jugular vein constricted, causing intracranial venous reflux. Complete occlusion of the shunt was achieved with coils and n-butyl-2-cyanoacrylate. Immediately after surgery, the pulsation in the right neck, the unbearable headaches, and neck pain on neck rotation resolved.

Lessons: Even in adults with congenital cervical external carotid AVFs that have been managed as simple neck masses, progressive dilatation and tortuosity of the outflow veins can, over time, lead to venous reflux during neck rotation and can cause unbearable headaches and neck pain. https://thejns.org/doi/10.3171/CASE24407.

Background: Cerebral radiation necrosis (RN) is an uncommon sequela that occurs in up to 25% of irradiated patients. This can occur 6 months to several years after therapy and create symptoms of headaches, focal neurological deficits, seizures, or behavioral changes. Management can involve corticosteroids, antiplatelet drugs, surgery, and hyperbaric oxygen therapy (HBOT). Currently, there is a paucity of literature investigating these therapies for routine use in the pediatric population.

Observations: A 5-year-old male with a right frontal atypical teratoid rhabdoid tumor previously underwent craniotomy for tumor resection, followed by chemotherapy, radiation, and autologous stem cell transplant therapy. Progressive radiographic changes surrounding the resection cavity were noted on routine surveillance imaging 20 months after the initial craniotomy and 11 months after the completion of radiation therapy. A biopsy ultimately confirmed RN. Due to the patient's previous complications with steroid use, the patient underwent HBOT. This achieved a significant improvement in clinical and radiographic sequelae of RN.

Lessons: HBOT was utilized successfully for the management of this patient's RN. HBOT should be considered for pediatric patients with cerebral RN as a potential treatment strategy. https://thejns.org/doi/10.3171/CASE24460.

Background: Undiagnosed pheochromocytoma can present with hemodynamic instability during surgical procedures. Here, the authors discuss a 69-year-old male with isocitrate dehydrogenase (IDH)-wildtype glioblastoma copresenting with undiagnosed pheochromocytoma, which, to the authors' knowledge, is the second reported case in the literature.

Observations: The patient presented to the emergency department with a 1-month history of coordination difficulties, progressive morning headache, and mild left-side weakness. Imaging showed a 5-cm peripherally enhancing intra-axial right parietal mass with surrounding vasogenic edema. Intraoperatively, the patient had significant uncontrollable hypertension up to 240/120 mm Hg, and the operation was promptly aborted. Contrast-enhanced computed tomography imaging of the chest, abdomen, and pelvis identified a 4.9-cm left adrenal mass of indeterminant etiology. Endocrinology diagnosed the incidentaloma as a pheochromocytoma, initiating alpha blockade followed by beta blockade, and the urology service performed a laparoscopic adrenalectomy after patient stabilization. The neurosurgery service removed the intra-axial brain lesion 2 days after adrenalectomy, which was diagnosed as IDH-wildtype glioblastoma. The patient was discharged home after 6 days in stable condition.

Lessons: This case highlights the importance of preoperative screening for pheochromocytoma in neurosurgical patients with adrenal incidentalomas, especially in incidentalomas > 4 cm, even without high clinical suspicion. https://thejns.org/doi/10.3171/CASE24374.

Background: Because of ischemic symptoms, intracranial internal carotid artery (IICA) dissection has no established treatment guidelines. The authors report a case of IICA dissection in which an emergency superficial temporal artery-middle cerebral artery (STA-MCA) bypass was performed.

Observations: A 46-year-old woman presented with a headache and left hemiplegia. Her cortical symptoms appeared on day 10, and an STA-MCA bypass was performed because of cerebral hypoperfusion. Her postoperative patency was good, and cortical symptoms improved. Contrast-enhanced magnetic resonance imaging (MRI) was performed in the acute phase with wall contrast. From day 18, the internal carotid artery delineation improved, and the patient was transferred for rehabilitation without worsening symptoms. A literature review of spontaneous IICA dissection with revascularization procedures was conducted to discuss the indications, timing, treatment modalities, and surgical outcomes.

Lessons: The STA-MCA bypass provides supplemental cerebral blood flow and can prevent critical complications. Contrast-enhanced MRI in the acute phase of dissection can show a wall contrast effect and assist in predicting disease progression. https://thejns.org/doi/10.3171/CASE24332.