Journal of neurosurgery. Case lessons最新文献

Background: Human herpesvirus 6 (HHV-6) is a neurotropic virus known to induce encephalitis in immunocompromised patients as well as a subset of pediatric patients. However, ventriculitis secondary to HHV-6 is a rare occurrence among immunocompetent adults. Although acquired hydrocephalus has been described to infrequently co-occur with HHV-6 encephalitis in pediatric and immunocompromised adult patients, it has not been described in an immunocompetent adult.

Observations: The authors present a rare case of HHV-6 encephalitis and obstructive hydrocephalus in an immunocompetent adult patient. Despite CSF diversion, the emergence and proliferation of multiple septations throughout the ventricular system resulted in the progression of severe hydrocephalus.

Lessons: Previous studies have linked HHV-6 to inflammatory states, occurring predominantly among children and immunocompromised adults, that manifest primarily as meningitis and encephalitis. This case highlights the fact that HHV-6 can cause life-threatening ventriculitis and hydrocephalus in immunocompetent adults. Pathophysiological mechanisms of virus-induced neuroinflammation yielding intraventricular septation formation are reviewed. https://thejns.org/doi/10.3171/CASE25273.

Background: Early intracerebral hematoma (ICH) expansion without aneurysm rerupture is extremely rare in patients with a ruptured basilar artery perforator aneurysm (BAPA), and the treatment strategy has not been established.

Observations: A 47-year-old male was rushed to the authors' hospital due to loss of consciousness. CT imaging showed diffuse subarachnoid hemorrhage (SAH) and ventriculomegaly, and 3D CT angiography (CTA) showed a BAPA. Ventricular drainage was performed, and conservative treatment for the BAPA was started. However, CT imaging on SAH day 1 showed an enlarged ICH in the right temporal lobe with no increase of SAH. Subsequent CTA showed no contrast extravasation from the right middle cerebral artery and no detection of BAPA. Since the BAPA was not considered to have reruptured and there was no mass effect due to the ICH, conservative treatment was continued with close imaging studies. There was no rerupture of the BAPA, and ventriculoperitoneal shunt insertion was performed on SAH day 36. The patient was transferred to a rehabilitation hospital on SAH day 62 with a modified Rankin Scale score of 1 (mild attention disorder).

Lessons: Conservative management for a ruptured BAPA can be performed even in a case of early ICH enlargement without aneurysm rerupture. https://thejns.org/doi/10.3171/CASE25760.

Background: Intraoperative shunt use during carotid endarterectomy (CEA), although critical for cerebral protection, may cause internal carotid artery (ICA) dissection in approximately 0.5% of cases. Shunt-induced dissections represent a distinct pathophysiological mechanism, differing from surgical technique-related dissection, and typically occur distal to the arteriotomy site due to trauma from shunt tips or balloon inflation.

Observations: The authors present 2 cases of ICA dissection occurring during CEA with shunt use, both successfully managed with emergency endovascular stent insertion. In both case, complete resolution was achieved, with modified Rankin Scale scores of 0. Case 1 involved a 70-year-old male with 95% right carotid stenosis who developed dissection extending 6 cm distal to the arteriotomy. Dual-stent carotid artery stent placement resulted in complete resolution. Case 2 involved an 80-year-old female who developed extensive 55-mm left internal carotid dissection, immediately treated with overlapping dual-stent placement. A literature review of 13 cases demonstrated favorable outcomes with recent endovascular management approaches.

Lessons: Shunt-related dissection is a preventable complication requiring specific technical precautions, including ensuring symmetric balloon expansion, using a gentle insertion technique, and minimizing longitudinal movement. When dissection occurs, immediate endovascular stent placement may provide superior outcomes compared with conservative management, effectively preventing thromboembolic complications while achieving excellent functional recovery. https://thejns.org/doi/10.3171/CASE25697.

Background: Basilar artery occlusion (BAO) is a threatening condition requiring rapid reperfusion to preserve brainstem function. Although endovascular thrombectomy is considered standard treatment, underlying pathology or limited resources may require surgical intervention. The authors performed an emergency superficial temporal artery-superior cerebellar artery (STA-SCA) bypass in the hyperacute setting of BAO following elective aneurysm surgery. The bypass prevented stroke progression and dramatically improved consciousness.

Lessons: This case demonstrates that with early recognition, protocolized monitoring, and microsurgical capability, STA-SCA bypass is a viable effective strategy for revascularization in acute posterior circulation stroke and can prevent progression of the ischemic core.

Observations: A 69-year-old man with a recent history of bilateral cerebellar infarction underwent elective microsurgical clipping of a left M1 middle cerebral artery aneurysm. The authors confirmed complete aneurysm exclusion with postoperative CTA. Eight hours later, the patient developed aphasia and deep state coma. CTA perfusion revealed BAO, with extensive cerebellar penumbra and a small core. Due to severe preexisting right vertebral and basilar intracranial atherosclerotic disease, urgent STA-SCA bypass was performed with a right subtemporal approach. Intraoperative studies confirmed graft patency reperfusion. The patient recovered consciousness and was discharged with a modified Rankin Scale score of 3. https://thejns.org/doi/10.3171/CASE25710.

Background: Dural sealants, widely used in neurosurgical practice, have been associated with few complications, mostly relating to the expansive nature of the hydrogel. Although generally well tolerated, DuraSeal expands up to 150% after application, and rare reports have described complications from mass effect.

Observations: This report presents the case of a 34-year-old female with a past surgical history of multiple operations for a Chiari type 1 malformation. After a thorough workup, intraoperative images and histological findings revealed a concealed hematoma-like mass at the patient's previous surgical site, likely due to the DuraSeal system. Imaging revealed that the DuraSeal was mostly hyperintense on T2-weighted MRI with focal spots of hypo-/isointensity, similar in appearance to an abscess or hematoma. Histological analysis showed exuberant fibrosis, granulation tissue, and a granulomatous response to the foreign material used for the dural patch and seal rather than the wall of an infectious abscess.

Lessons: This case adds to the growing body of literature on DuraSeal, highlighting the imaging and histological characteristics of "dural sealant-omas" and their expansile nature that can lead to the formation of a mass mimicking an abscess or a hematoma. In areas susceptible to compression, clinicians ought to be vigilant to identify findings consistent with the appearance of these dural sealant-omas. https://thejns.org/doi/10.3171/CASE25574.

Background: Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD). Concurrently, brain tumors are increasing in incidence, creating complex clinical scenarios when both conditions coexist. The safety of delivering radiation therapy to patients with active DBS devices remains poorly documented, with limited guidelines available.

Observations: This case report describes a 69-year-old male PD patient with bilateral DBS leads who developed metastatic melanoma with brain metastases. He underwent multiple radiation treatments, including stereotactic radiosurgery and hippocampal avoidance whole-brain radiation therapy, receiving a cumulative dose exceeding 47 Gy to the DBS device. Throughout treatment, the DBS device remained fully functional with no impedance changes or symptom deterioration. A review of similar cases indicates that radiation doses to DBS components, including leads and implantable pulse generators, are generally well tolerated, although no standardized safety protocols currently exist.

Lessons: This case reinforces the feasibility and safety of multiple radiation treatments in patients with implanted DBS devices when carefully planned and monitored. Cumulative high radiation doses may not impair DBS functionality, but attention to neutron contamination and dose distribution remains essential. Multidisciplinary collaboration and individualized planning are crucial to optimize tumor control while preserving device integrity in this emerging patient population. https://thejns.org/doi/10.3171/CASE25600.

Background: Radiation therapy is a common treatment for spinal metastases. However, its effects on extramedullary intrathecal structures are poorly understood. Arachnoid webs are rare structural abnormalities that can cause significant neurological symptoms due to spinal cord compression. While radiation-induced myelopathy is a rare known complication of radiation therapy, the potential relationship between radiation treatment and the formation or exacerbation of arachnoid webs has not been previously reported.

Observations: The authors present the case of a 64-year-old female with breast cancer and spinal osseous metastases who underwent palliative radiation therapy. Six months after radiation therapy, she developed progressive myelopathy refractory to conservative treatments. Imaging revealed dorsal cord indentation and edema with findings suggestive of a compressive arachnoid web. Surgical intervention confirmed an extensive complex arachnoid web spanning T5-8. Fenestration of the web resulted in immediate intraoperative improvement in somatosensory evoked potentials and significant postoperative neurological recovery over 8 months.

Lessons: This case highlights the importance of considering structural abnormalities, such as arachnoid webs, in patients with progressive myelopathy following spinal radiation therapy, even when doses are within safe limits. Myelography may be helpful for characterizing intrathecal changes in this context. Further research is needed to explore the relationship between radiation therapy and arachnoid pathology. https://thejns.org/doi/10.3171/CASE25733.

Background: Nail gun injuries are rare forms of penetrating brain injuries that can be associated with significant morbidity and mortality. Management strategies differ greatly in previously reported cases.

Observations: A male in his 40s presented with an accidental, work-related nail gun injury to the left parietal lobe with no focal neurological deficits. Noncontrast CT imaging of the head and vessel imaging including CT angiography and venography were performed that demonstrated the retained nail with trace surrounding intraparenchymal hemorrhage but no obvious vascular injury. The patient underwent a preoperative diagnostic cerebral angiography that confirmed no vascular injury. The patient was then taken to a hybrid operating room/angiography suite for a burr hole craniotomy for nail removal. Selective left internal carotid artery intraoperative angiography was performed to confirm there was no contrast extravasation after nail removal. The patient was discharged home on postoperative day 1 on prophylactic antibiotics. Follow-up angiography did not demonstrate pseudoaneurysm formation.

Lessons: Nail gun injuries require a comprehensive, multidisciplinary approach to minimize the risk of complications, particularly related to vascular injury. Judicious use of preoperative and intraoperative catheter-based angiography can facilitate safe, efficient nail removal and is imperative in assessing immediate and delayed sequelae of penetrating trauma. https://thejns.org/doi/10.3171/CASE25476.

Background: Pial arteriovenous fistulas (pAVFs) are rare vascular abnormalities in the subpial space, characterized by high-flow connections between pial arteries and draining veins, without an intervening nidus. This case report describes a left parietal pAVF feeding from the angular branch (M4) of the left middle cerebral artery, which presented as an acute subdural hematoma (SDH).

Observations: The authors present the case of a 68-year-old neurologically intact male with 1-week history of progressive holocranial headache. Initial noncontrast CT imaging of the head revealed a left-sided SDH. Subsequent CTA confirmed the SDH with a spot sign in the posterior part of the SDH. Digital subtraction angiography identified a left parietal pAVF with an associated saccular aneurysm. The patient underwent successful microsurgical ligation and hematoma evacuation, with no residual fistula or vascular abnormality on follow-up angiography.

Lessons: This case highlights the importance of a lower threshold for advanced imaging in acute SDH with no known predisposing factors. It also focuses on the complexity of managing pAVFs with associated aneurysms, along with the importance of individualized treatment strategies integrating advanced imaging and microsurgical techniques. https://thejns.org/doi/10.3171/CASE25605.

Background: Paddle electrode stimulation of the trigeminal nucleus caudalis (TNC) for refractory craniofacial pain syndromes provides improved coverage and has lower migration rates than cylindrical leads; however, paddle implantation requires open surgery, which can cause significant pain and limit use in high-risk patients. Herein, the authors present a minimally invasive (MIS) approach, adapting the use of tubular retractors for MIS spine surgery and therefore minimizing the surgical morbidity of paddle electrode implantation at the craniocervical junction.

Observations: An 81-year-old man with postherpetic trigeminal neuropathy in the left V1 and V2 distribution underwent paddle lead implantation via a 2.5-cm occipitocervical incision and a tubular retractor system. The patient experienced a reduction in pain (from a visual analog scale score of 9/10 to 2/10), without any postoperative complications.

Lessons: This technical report demonstrates the feasibility of implanting paddle electrodes via an MIS tubular retractor system for stimulating the TNC. The approach minimizes soft tissue disruption, reduces postoperative pain, and offers a viable alternative to open surgery, which is especially useful for medically complex patients requiring neuromodulation for craniofacial pain. https://thejns.org/doi/10.3171/CASE25721.