Journal of neurosurgery. Case lessons最新文献

Background: Emphysematous osteomyelitis (EO) is a rare, rapidly progressing infection characterized by gas within bones, leading to severe morbidity if untreated. In the spine, EO can cause significant bone destruction and instability, requiring urgent surgical and medical intervention. Early diagnosis and a multidisciplinary approach are crucial for effective management and improved patient outcomes.

Observations: The authors present a unique case of EO involving the lumbar spine in a 40-year-old male patient with a medical history of diabetes mellitus, hyperlipidemia, and hypertension. Magnetic resonance imaging and computed tomography revealed the formation of gas within the L4 vertebral body and spinal canal, which led to the diagnosis of EO. Blood cultures grew Streptococcus dysgalactiae. The patient underwent laminectomy, discectomy, and vertebral body abscess washout to prevent further spread of the infection and successfully recovered.

Lessons: The authors report the first case of spinal EO caused by S. dysgalactiae, treated using laminectomy with debridement of the affected disc spaces. https://thejns.org/doi/10.3171/CASE24434.

Background: Carotid artery dissection is a common cause of ischemic stroke, predominantly affecting the internal carotid artery, with rare involvement of the common carotid artery (CCA). The limited literature makes diagnosis and management challenging, particularly in asymptomatic patients. In this report, the authors present a unique case of spontaneous, asymptomatic CCA dissection that resembled a carotid web, shedding light on its clinical spectrum and management.

Observations: A 70-year-old man was diagnosed with an intimal flap in the left CCA. Although the findings resembled those of a carotid web, cerebral angiography confirmed the presence of an intimal flap and arterial wall irregularities indicative of vascular dissection. Endarterectomy successfully prevented the stroke, and the postoperative recovery was uneventful. Pathological examination confirmed the diagnosis of CCA dissection.

Lessons: Spontaneous CCA dissection, though rare, presents significant diagnostic and therapeutic challenges. Because of morphological similarities, differentiating the diagnosis from a carotid web can be difficult. Available treatment strategies include antiplatelet therapy and surgical intervention. In this case, endarterectomy was chosen to avoid antithrombic treatment in anticipation of further invasive treatments for other conditions. The successful outcome highlights the potential as a treatment option, emphasizing the need for an individualized approach to each patient. https://thejns.org/doi/10.3171/CASE24344.

Background: Leiomyosarcoma (LMS) is a rare neoplasm that arises from tissues of embryonic mesodermal origin. Primary tissues of origin can include smooth muscle cells of the abdominopelvic viscera, blood vessels, or arrector pili muscles. LMS is known to metastasize to the lungs, with few reported cases of spread to the central nervous system.

Observations: A 66-year-old male with cutaneous LMS of the left forearm with metastases to the lungs and kidney that had been treated with chemoradiation presented with worsening headaches. Magnetic resonance imaging revealed a sellar lesion. An endocrine workup was unremarkable. Imaging over 6 months revealed rapid interval growth. Positron emission tomography demonstrated moderate uptake. Given the rapid growth, the patient was offered an endoscopic endonasal approach for resection. Pathology confirmed LMS.

Lessons: To the authors' knowledge, this is the first documented case of LMS metastasis to the sella. Pituitary carcinoma or metastases to the sellar region should be in the differential among patients with sellar region tumors with a rapid growth rate, bony erosion, or findings of lesions in the upper cervical lymph nodes or soft tissue. Tumors that show significant interval growth should raise suspicion for nonadenomatous lesions, and surgical intervention should be considered even in the absence of endocrinological dysfunction or cranial neuropathies. https://thejns.org/doi/10.3171/CASE2435.

Background: No universal protocol exists for treating cerebral abscesses in Down syndrome. An illustrative case supplemented with a systematic literature review on brain abscesses in Down syndrome is presented, comprising a total of 16 cases. Preoperative infectious disease workups, cardiac examinations including echocardiography, as well as reported surgical and antibiotic treatments were correlated in the reported cohorts.

Observations: Overall, 18.8% of cases (n = 3) had no reported cardiac evaluation. The majority of cases were treated surgically (n = 8), with aspiration (n = 3), drainage (n = 2), or other operations (n = 3); 25% (n = 4) were treated with antibiotics only. Strikingly, 25% of cases (n = 4) reported neither surgical nor antibiotic therapy, a significantly higher rate compared to 0%-3% of patients with brain abscess in other reported cohorts. Half of the patients (n = 8) who died either lacked a cardiac evaluation or had existing heart conditions. This mortality rate was about 4 times higher than the rates observed in other studies.

Lessons: Down syndrome patients with cerebral abscess have a high morbidity rate, mainly due to cardiac disease. Therefore, early diagnostic workup, including echocardiography, allows proactive management with an improved outcome. https://thejns.org/doi/10.3171/CASE23394.

Background: A carotid-cavernous fistula (CCF) is a well-recognized entity resulting from an abnormal connection between the internal carotid artery (ICA) or external carotid artery and the cavernous sinus. Typical CCF symptomology includes proptosis, chemosis, orbital bruit, headache, facial pain, and cranial nerve (CN) palsies. While CCFs most often occur posttraumatically, they can also occur spontaneously, secondary to cavernous ICA aneurysm rupture. Very rarely, they can occur secondary to the rupture of an anomalous persistent trigeminal artery (PTA) aneurysm.

Observations: Herein, the authors describe the case of a 54-year-old woman who presented with a CN VI palsy and headache due to a CCF secondary to a PTA aneurysm rupture. The CCF was ultimately treated via coil embolization of the aneurysm and the parent PTA vessel.

Lessons: Though such occurrences are rare, clinicians should be vigilant in assessing for the presence of a PTA in patients with a CCF, as a PTA-associated CCF requires unique treatment considerations. In some cases where the PTA plays a crucial role in the posterior circulation supply, preservation of the parent vessel PTA is crucial. However, in cases in which an adequate posterior circulation collateral supply exists, embolization of the aneurysm and the parent vessel PTA is a reasonable treatment option for fistula closure. https://thejns.org/doi/10.3171/CASE24287.

Background: Parkinsonism has been reported in patients with obstructive hydrocephalus (OH) following ventriculoperitoneal shunting (VPS). While levodopa works well, some cases are drug resistant. A few case series have reported that endoscopic third ventriculostomy (ETV) is beneficial, though its mechanism remains unclear. The use of a pathophysiology-reflected marker can aid in the diagnosis and treatment strategy. The authors report a case of parkinsonism due to OH after VPS that improved after ETV in a patient taking levodopa, which was subsequently discontinued.

Observations: A 52-year-old man who had undergone VPS for OH caused by aqueductal stenosis with a tectal tumor presented with severe consciousness disturbance due to acute hydrocephalus and levodopa-refractory parkinsonism after multiple episodes of shunt malfunction. Magnetic resonance imaging showed an elevation of the floor of the third ventricle. ETV was performed to stabilize the pressure imbalance across the stenosis, and his parkinsonism symptoms improved after long-term rehabilitation, resulting in levodopa discontinuation. His pontomesencephalic angle, the angle between the anterior surface of the midbrain and upper surface of the pons in the midline of the sagittal plane, was significantly decreased.

Lessons: The focus in such cases should be on the essence of the pathophysiology for improving the symptoms rather than on easy-to-understand indicators such as ventricle size. https://thejns.org/doi/10.3171/CASE2429.

Background: Robot-assisted techniques are increasingly integrated into the field of spine surgery, with the potential benefits of increased accuracy and reduced radiation exposure. The objective of this study was to describe the technique of minimally invasive robot-assisted direct pars repair with 2 case illustrations.

Observations: An 18-year-old male and a 42-year-old male, both with bilateral L5 spondylolysis, underwent successful minimally invasive L5 direct pars repairs with robotic assistance after conservative measures failed, and their cases are presented herein.

Lessons: A robot-assisted direct pars repair is a safe and effective technique for treating bilateral lumbar spondylolysis. The integration of robot-assisted techniques in spine surgery has the potential to improve outcomes, decrease surgical time, and reduce the amount of radiation exposure to operating room staff. https://thejns.org/doi/10.3171/CASE2415.

Background: Vestibular paroxysmia is defined by spontaneous, recurrent, short, paroxysmal episodes of vertigo. The authors present a case of vestibular paroxysmia caused by neurovascular compression of the vestibulocochlear nerve due to the subarcuate artery, which was successfully treated with microvascular decompression.

Observations: A 46-year-old man first experienced vertigo attacks 5 years earlier. The attacks became more frequent, and left-sided tinnitus developed over the past 4 months, prompting a referral to our hospital. Carbamazepine treatment alleviated symptoms but had to be discontinued due to rash. Brain magnetic resonance imaging and angiography revealed that the left anterior inferior cerebellar artery was pressing on the cisternal segment of the left vestibulocochlear nerve. The authors diagnosed vestibular paroxysmia caused by neurovascular compression and performed microvascular decompression. During the operation, a subarcuate artery was identified as the offending vessel, with a prominent indentation on the vestibulocochlear nerve. The vertigo was completely relieved following surgery.

Lessons: Neurovascular compression of the vestibulocochlear nerve by the subarcuate artery can result in vestibular paroxysmia. https://thejns.org/doi/abs/10.3171/CASE24239.

Background: Computed tomography (CT)-guided cordotomy has been shown to be a safe and effective method for treating cancer pain in adults in a palliative care setting. Its effectiveness has been rarely reported in children. During cordotomy, patient feedback is considered essential. Unfortunately, in this report, the featured patient's age and demeanor precluded an awake cordotomy. The authors report the first case, to their knowledge, of percutaneous cordotomy with the patient under general anesthesia.

Observations: An 11-year-old boy with osteosarcoma of the right pelvis presented with medically refractory unilateral nociceptive pain. The pain prevented ambulation, interfered with sleep, was the focus of his concern, and could not be relieved without sedation. A left percutaneous CT-guided cervical cordotomy while he was under general anesthesia was performed without complication and provided sufficient pain relief to allow ambulation and restorative sleep. Pain was no longer an issue for the patient and his family.

Lessons: CT-guided percutaneous cervical cordotomy can be accomplished in a pediatric patient under general anesthesia. The risks of cordotomy under general anesthesia without patient feedback must be weighed against the opportunity to improve palliative care. https://thejns.org/doi/abs/10.3171/CASE2427.

Background: Cerebral cavernous hemangiomas (CHs) are the most common vascular malformations and can be found in many locations in the brain. The most common extra-axial locations are the intrasellar and parasellar regions. Both locations are rare for CH.

Observations: A 41-year-old female who had experienced headaches for about a year presented to the authors' institution because of a mass located in the left cavernous sinus (CS). It was confirmed that it was not causing any loss in the visual field and that there was no pituitary irregularity. Surgery was planned with a preliminary diagnosis of CH. An endoscopic endonasal approach (EEA) was undertaken with the otorhinolaryngology team. The dura mater was opened following excision of the back wall of the sphenoid sinus. A blue-purple vascular lesion was observed, filling the left CS. Gross-total resection (GTR) was achieved. In the literature, there were 10 cases in which GTR had been performed using the EEA.

Lessons: Patients with CHs located in the sellar region present with various complaints. The preference for endoscopic surgery over cranial surgery for such lesions requires more comprehensive studies, but it is thought that this approach can reduce surgical complications and the time to discharge for the patient. https://thejns.org/doi/abs/10.3171/CASE24227.