Journal of neurosurgery. Case lessons最新文献

Background: Type 1 spinal dural arteriovenous fistulas (SDAVFs) are vascular malformations that present with nonspecific neurological manifestations and imaging characteristics that can closely resemble high-grade intramedullary spinal cord tumors (IMSCTs).

Observations: The authors present the case of a 75-year-old male with 18 months of progressive thoracic myelopathy, who was referred for a spinal biopsy for a suspected IMSCT. The spine MRI study was notable for T2/short tau inversion recovery hyperintensity extending from T7 to L2 with no significant flow voids. MR angiography, digital subtraction angiography (DSA), and lumbar puncture studies were unremarkable. A corticosteroid trial did not delineate the underlying etiology, increasing diagnostic uncertainty between IMSCT and SDAVF. Therefore, a T11-12 laminectomy for a surgical exploration was indicated. Intraoperatively, an arterialized vein arising from the right T12 neural foramen was identified, confirmed with indocyanine green (ICG) angiography, and ligated. Postoperative clinical and radiographic improvement confirmed the diagnosis of SDAVF.

Lessons: This case illustrates how SDAVF can masquerade as infiltrative IMSCT, emphasizing the importance of maintaining a high index of clinical suspicion for arteriovenous shunting during the workup of suspected IMSCT. A repeat DSA study should be considered when the initial DSA is negative, and in the setting of surgical exploration, the early use of intraoperative ICG angiography can be valuable for identifying pathology successfully. https://thejns.org/doi/10.3171/CASE25787.

Background: Central sulcus identification using phase reversal on electrocorticography (ECoG) is a critical tool for neurosurgical intervention around the primary motor and somatosensory cortices. This mapping is typically performed using cortical arrays with a resolution of several millimeters.

Observations: A 30-year-old female underwent a right frontoparietal craniotomy for resection of a 4-cm contrast-enhancing lesion within the central sulcus. Central sulcus localization was performed using a standard ECoG array. High-resolution micro-ECoG (µECoG) arrays were then placed over the pre- and postcentral gyri, giving 2048-electrode recordings across the central sulcus. Combining this high-resolution µECoG with an augmented reality imaging overlay to identify the tumor, the central sulcus was split, revealing the underlying tumor. A safe, gross-total resection was obtained with no postoperative complications. Through the use of µECoG arrays spanning into the central sulcus, a high-resolution phase-reversal contour was identified across the central sulcus.

Lessons: The authors demonstrate the feasibility and utility of µECoG for sensorimotor mapping within the central sulcus, revealing a phase reversal at a resolution of approximately 400 microns. Compared to standard mapping, which records gyral surface electrophysiology, they further demonstrate phase-reversal electrophysiology within a dissected central sulcus. High-resolution cortical mapping from µECoG may foster several neurosurgical advancements, from tumor resection to brain-computer interfaces. https://thejns.org/doi/10.3171/CASE25534.

Background: Spontaneous CSF rhinorrhea is an uncommon but potentially serious condition. It may arise from skull base defects and anatomical variations, often combined with triggers such as idiopathic intracranial hypertension (IIH). The proximity of these defects to critical neurovascular structures and the complexity of endoscopic repair pose surgical challenges. Distinguishing congenital skull base defects, such as a persistent Sternberg canal (SC), from pressure-induced bony erosion is challenging, and both may coexist.

Observations: A 35-year-old woman presented with a 4-month history of spontaneous CSF rhinorrhea. Imaging revealed a lateral sphenoid meningoencephalocele, an SC defect, and superior sagittal sinus thrombosis. Lumbar puncture opening pressure and venous manometry were normal. Spontaneous sinus recanalization occurred without anticoagulation. The patient underwent successful endoscopic repair via an endonasal transmaxillary approach. Transient elevations in intracranial pressure (ICP) were observed twice: the first resolved spontaneously alongside concurrent management of iron deficiency, while the second was treated as IIH with acetazolamide.

Lessons: This case highlights the interplay between skull base defects and ICP, including subclinical IIH, in spontaneous CSF rhinorrhea. Surgical repair unmasked symptomatic IIH and dynamic venous sinus stenosis secondary to elevated ICP. Recognizing this pathophysiology enables accurate diagnosis, avoids unnecessary intervention, and guides appropriate management. https://thejns.org/doi/10.3171/CASE25775.

Background: Hypoglossal neurinomas are rare tumors that pose management challenges, particularly when they contain cystic components. While total removal remains the standard treatment, resection can be excessively invasive for older adults. This report describes a case of cystic hypoglossal neurinoma successfully treated through a partial resection with cyst aspiration followed by Gamma Knife radiosurgery (GKRS).

Observations: A male aged 81 years presented with progressive dysarthria and dysphagia secondary to left hypoglossal nerve palsy. MRI revealed a cystic lesion compressing the medulla and a solid component within the left hypoglossal canal. Cyst aspiration was performed to alleviate potentially life-threatening lower cranial nerve palsy, followed by GKRS. At 21 months, marked cyst shrinkage was observed after a transient post-GKRS expansion, with no further interventions required.

Lessons: A treatment strategy combining cyst aspiration and GKRS was useful for managing cystic hypoglossal neurinoma in an older adult. Minimally invasive management should be considered for older adults with comorbidities who are at increased risk for postoperative complications. https://thejns.org/doi/10.3171/CASE25821.

Background: The anterior inferior cerebellar artery (AICA) is the second most common neurovascular etiology of trigeminal neuralgia.

Observations: Here the authors build on a prior reported technique for noncompressive decompression of a curious anatomical AICA variant, where a loop of the main artery nearly completely encircles the trigeminal nerve to circumferentially impact it.

Lessons: Circuitous anatomy of AICA may present particular challenges for microvascular decompression, but it is still possible to achieve a noncompressive configuration to best limit future irritation of the trigeminal nerve. An optimal and durable separation of the AICA loop and trigeminal nerve adhering to noncompressive principles was achieved using two aneurysm clips to fix a Teflon felt to the tentorium and petrous face of the temporal bone. https://thejns.org/doi/10.3171/CASE25388.

Background: Rare pediatric subdural tumors can mimic subdural hematomas and can be caused by lymphoma, sarcoma, and cancer metastases.

Observations: A 3-year-old boy with a history of chronic subdural hematoma, who had undergone multiple surgeries, was transferred to the authors' hospital with recurrent vomiting and lethargy. CT revealed a partially organized bilateral mass with heterogeneous intensities. Although the lesion was primarily located in the subdural space, a portion appeared to invade the brain. Gadolinium (Gd)-enhanced MRI revealed an enhanced nodule. Surgical findings revealed that the lesion bled easily, adhered to the arachnoid membrane, and invaded the brain parenchyma. Immunohistochemical and genetic analyses were performed, and the patient was diagnosed with an unclassifiable, malignant, intracranial tumor with epithelioid features and the HIST1H3B K37 mutation. Classification based on the methylation profile was conducted, but no definitive methylation class was identified. The tumor showed rapid regrowth after resection. The patient subsequently underwent chemoradiotherapy. Despite multimodal treatment, the patient died of the primary disease within 1 year of surgery.

Lessons: Primary subdural tumors in children are extremely rare; however, they should be considered as a differential diagnosis when Gd contrast MRI shows an enhanced nodule protruding into the brain. https://thejns.org/doi/10.3171/CASE25849.

Background: There is a paucity of literature to guide the surgical management of the simultaneous presentation of a diastematomyelia, two hemicords, and a unilateral bar unsegmented vertebra, a form of formation failure.

Observations: An 11-year-old female presented with acute-onset back pain, urinary incontinence, and lower extremity numbness. Evaluation revealed T7 diastematomyelia with a tethered cord and a right-sided T6-11 nonsegmented unilateral bar, resulting in thoracolumbar levoscoliosis (maximal Cobb angle of 49°). Initial surgical decompression and spinal cord detethering were performed, including a T7 laminectomy. A bony septation attached to the lamina and projecting through the dura mater and cord was removed and the cord was detethered. The patient subsequently regained neurological function. Eight months later, repeat scoliosis radiographic imaging showed progression to a maximal Cobb angle of 58.4°. The patient then underwent a second-stage T2-L3 posterior lateral fixation and fusion with a pedicle screw-rod construction. The postoperative curve magnitude was 25.2°. Five years following operation, she required no revision surgery and remained neurologically intact.

Lessons: The authors present a successful surgical correction of concomitant diastematomyelia and a unilateral bar and unsegmented butterfly vertebra in a pediatric patient. While the curve magnitude at presentation warranted surgical correction, neurological deficits necessitated urgent decompression before stabilization. https://thejns.org/doi/10.3171/CASE25315.

Background: Lumbosacral dermoid cysts are rare pathological entities, particularly among adults, and can be challenging to diagnose because of nonspecific clinical symptoms and variable MRI characteristics. In this patient, the importance of including dermoid cysts in the differential diagnosis of lumbosacral intradural lesions, even in older patients, is highlighted.

Observations: A 65-year-old woman presented with a 3-year history of progressive low back pain radiating to the left buttock and gait disturbance. She underwent mediastinal schwannoma resection under general anesthesia 22 years ago. Lumbar spinal MRI revealed an intradural mass lesion extending from the L2 to L5 levels with high and iso-hyperintense signals on T1- and T2-weighted images, respectively. The lesion was heterogeneously enhanced with gadolinium contrast. CT demonstrated calcifications at the L5 level. Without establishing a preoperative diagnosis, surgery was performed. Intraoperatively, a brownish capsule containing hair follicles and sebaceous material was dissected and removed from the lumbar enlargement and surrounding nerve roots. A small portion of the tumor remained inside of the conus medullaris. Postoperative MRI confirmed near-complete tumor resection, and the patient experienced symptomatic improvement. Histological analysis confirmed the diagnosis of dermoid cyst.

Lessons: Dermoid cysts typically contain hair, sebaceous material, and calcifications. Their capsule may adhere firmly to the spinal cord or nerve roots. Careful surgical manipulation is essential to prevent injury and subsequent chemical meningitis. Preoperative recognition of this pathology is crucial for surgical planning, patient counseling, and minimizing intraoperative risks. Awareness of this rare condition in older patients can lead to more accurate preoperative diagnosis and improved clinical outcomes. https://thejns.org/doi/10.3171/CASE25883.

Background: Cerebral venous thrombosis (CVT) is a rare cerebrovascular disorder that predominantly affects younger individuals. Its development is influenced by multiple factors, including hypercoagulability, hemodynamic abnormalities, and venous vessel wall injury. Thyrotoxicosis is an uncommon but increasingly recognized predisposing factor for CVT.

Observations: The authors present the case of a young female with thyrotoxicosis-induced CVT who achieved successful recovery following endovascular intervention and therapeutic plasma exchange (TPE).

Lessons: This report emphasizes the clinical importance of recognizing thyrotoxicosis as a risk factor for CVT, underscores the therapeutic potential of TPE in thyroid storm complicated by thrombosis, and provides clinical reference for endovascular intervention in the treatment of CVT. https://thejns.org/doi/10.3171/CASE25820.

Background: Esthesioneuroblastoma (ENB) is a rare malignant tumor originating from the olfactory epithelium, often involving the anterior skull base with intracranial extension. Surgical management options include the transcranial approach combined with the endoscopic endonasal approach (EEA) or purely EEA. However, conventional indications for EEA are limited to tumors with lateral extension not exceeding the midorbital line, due to restricted lateral exposure. Logically, extending the resection of the orbital roof bone can enhance lateral access, potentially expanding the surgical indications for EEA in selected cases.

Observations: A young male patient presented with epistaxis and was diagnosed with a giant ENB involving the nasal cavity and anterior skull base. Through an EEA, extended resection of the orbital roof was performed to achieve gross-total tumor removal. The patient recovered uneventfully, with no neurological deficits, and follow-up at 6 months showed no evidence of tumor recurrence.

Lessons: The EEA offers inherent advantages, such as avoiding brain retraction and minimizing invasiveness. With improved understanding of skull base anatomy, the indications for EEA can be expanded beyond traditional limits, including tumors extending lateral to the midorbital line. In appropriate cases, this approach may obviate the need for craniotomy, reducing surgical morbidity. https://thejns.org/doi/10.3171/CASE25914.