Journal of neurosurgery. Case lessons最新文献

Background: Ecchordosis physaliphora (EP) is a rare notochordal remnant and the benign counterpart to chordomas with the same cell of origin. They are most commonly located intracranially along the posterior clivus in the prepontine cistern. EPs are typically discovered incidentally, but a small subset can present with symptoms, including a CSF leak. There are very few reported cases of EP-related meningitis, which occur after a short course of CSF leakage.

Observations: A 48-year-old female with a history of clear rhinorrhea for several years presented with meningitis and a neurological decline. Neuroimaging identified a clival mass and associated bony defect between the sphenoid sinus and prepontine cistern. She was treated with antibiotics and CSF diversion via a lumbar drain. An endoscopic endonasal resection and skull base repair was performed after CSF sterilization. Neuropathological evaluation demonstrated an EP. She recovered to baseline and remains without a recurrent CSF leak or meningitis in outpatient follow-up.

Lessons: This is the first case of long-standing rhinorrhea and presentation of meningitis from a clival lesion, and it is one of the few cases of EP-related meningitis. Early recognition and workup of CSF rhinorrhea is critical to avoid progression to meningitis, and EPs are a rare cause of this presentation. https://thejns.org/doi/10.3171/CASE25540.

Background: Chronic subdural hematoma (cSDH) is a frequent neurosurgical condition, yet its preoperative natural history, particularly in patients receiving antiplatelet therapy, remains poorly defined. Although delaying surgery to allow aspirin washout is a common practice, the evidence supporting fixed discontinuation intervals is limited. Bilateral cSDH is associated with a higher risk of rapid deterioration, highlighting the need to consider emergency evacuation even in clinically stable patients.

Observations: A 71-year-old man with a history of ischemic stroke on aspirin presented with bilateral cSDH causing moderate mass effect but preserved consciousness with mild right-sided hemiparesis. Aspirin was withdrawn and surgery scheduled after a standard 5-day washout. On day 3 of interruption, he developed abrupt neurological deterioration. Emergency CT showed acute rebleeding within both hematomas and marked mass effect consistent with impending transtentorial herniation. Urgent bilateral burr hole evacuation achieved complete decompression. However, postoperative imaging revealed bilateral posterior cerebral artery (PCA) territory infarctions with thalamic involvement, consistent with herniation-related compromise of the basilar apex and proximal PCA segments. The patient never regained consciousness.

Lessons: This case highlights the hazards of delaying surgery for aspirin washout in bilateral cSDH. Individualized risk assessment and early evacuation may help prevent catastrophic herniation-related posterior circulation infarction. https://thejns.org/doi/10.3171/CASE25934.

Background: Even though head injury is one of the possible causes for oculomotor nerve palsy (ONP), it is uncommon to find an isolated ONP in a patient who sustained a traumatic brain injury (TBI). Both posttraumatic ONP and brainstem hemorrhage are more frequently seen in patients with severe TBI, and the overall outcome of ONP after head injury is poor.

Observations: A 53-year-old male patient presented after he was hit by a speeding car from behind while he crossing a road, and then he fell face first to the ground. His Glasgow Coma Scale score was 14 of 15. He had complete ONP of the left eye, but no other neurological abnormal findings. He had a midbrain hemorrhage on neuroimaging. On 6-month follow-up, the ptosis completely resolved, and the diplopia and eye movement showed partial recovery. However, the left pupil was still dilated and nonreactive to light.

Lessons: Even though very rare, mild TBI can be associated with midbrain bleeding and an isolated ONP. The pattern of improvement of ONP starts from ptosis and then progresses to the extraocular muscles. The chance of recovery of pupillary size and reactivity to light is poor. https://thejns.org/doi/10.3171/CASE25741.

Background: Subcortical cavernous malformations (CMs) that have bled pose increased risk of repeat hemorrhage and symptomatic progression. Open resection can be curative, but accessing CMs in certain subcortical locations poses significant risk of procedural morbidity. This study assesses the safety and feasibility of MRI-guided laser interstitial thermal therapy (MRgLITT) for hemorrhagic subcortical CMs.

Observations: The authors retrospectively reviewed the medical records of patients who underwent MRgLITT of a subcortical CM with prior symptomatic hemorrhage at their center. Seven patients underwent MRgLITT of subcortical CMs with at least 1 prior symptomatic hemorrhage. There were no symptomatic or radiographic hemorrhages perioperatively or in the follow-up period (mean 26.6 months, range 12-53 months). All patients were discharged home on postoperative day 1 (n = 5) or 2 (n = 2). Three patients had transient (< 30 days) neurological deficits. Compared to preoperative baseline, as of the last follow-up, 5 patients had improvement of neurological symptoms, 1 was stable 8 months after surgery, and 1 remained asymptomatic. There was a significant decrease in CM volumes on both T1-weighted (p = 0.016) and T2-weighted (p = 0.016) sequences.

Lessons: MRgLITT is a promising treatment for subcortical, hemorrhagic CMs, offering a minimally invasive approach with low morbidity and favorable clinical outcomes in this preliminary series. https://thejns.org/doi/10.3171/CASE25845.

Background: Craniopharyngiomas (CPs) usually manifest with symptoms of intracranial hypertension secondary to obstructive hydrocephalus, visual disturbances, or growth failure. Hypoglycemia as the sentinel presentation is exceptionally rare and reflects hypothalamic-pituitary dysfunction.

Observations: A previously healthy 4-year-old girl presented with progressive headache and vomiting for 4 days, followed by coma (Glasgow Coma Scale score 6). Emergency testing revealed profound hypoglycemia (capillary glucose 40 mg/dL [2.2 mmol/L]); consciousness returned rapidly after an intravenous dextrose bolus was administered. Because she had been vomiting, the hypoglycemia was initially attributed to malnutrition secondary to poor oral intake. However, recurrence of hypoglycemia within 24 hours prompted further evaluation. Abdominal CT excluded insulinoma and adrenal tumors. Endocrine testing revealed low morning cortisol and free thyroxine with inappropriately low thyroid-stimulating hormone, consistent with central adrenal insufficiency and hypothyroidism, while other hypothalamic-pituitary axes were preserved. Brain MRI showed a cystic sellar-suprasellar mass displacing the optic chiasm. Gross-total resection was achieved via a pterional approach. Histology confirmed an adamantinomatous CP. Postoperatively, hypoglycemia resolved, and the patient remained stable on hydrocortisone and levothyroxine replacement.

Lessons: CP, although relatively frequent, may exceptionally present with severe recurrent hypoglycemia and coma. Unexplained pediatric hypoglycemia warrants prompt endocrine evaluation and sellar imaging. Early recognition and multidisciplinary management (neurosurgery and endocrinology teams) are crucial for favorable outcomes. https://thejns.org/doi/10.3171/CASE25727.

Background: Arterial fenestration is a vascular anomaly resulting from failed embryonic fusion. Its association with arteriovenous malformations (AVMs) has been reported, but embolization of an AVM fed by an artery arising from a fenestration has not been described.

Observations: A 9-year-old girl presented with intracerebral hemorrhage. Imaging revealed a cerebellar AVM fed mainly by the posterior inferior cerebellar artery (PICA) originating from a vertebral artery (VA) fenestration. Associated anomalies included a type II persistent proatlantal artery and a VA entering the transverse foramen at the C4 level on the same side. Prior to resection, Onyx embolization was performed. A distal access catheter (DAC) was placed proximal to the VA fenestration, and a microcatheter was navigated through the VA fenestration to the distal PICA. Partial embolization was achieved using the simple push technique. The DAC was pulled backward during microcatheter withdrawal to prevent the former from moving forward and injuring the vessel. Complete AVM resection was then performed, and there has been no recurrence observed over the past 4 years.

Lessons: Because the vessel wall near the proximal end of a fenestration is fragile, careful manipulation is required during microcatheter insertion and withdrawal to avoid mechanical stress. https://thejns.org/doi/10.3171/CASE25790.

Background: Malresorptive hydrocephalus occurs when CSF is inadequately absorbed, often following surgery. Ventriculoperitoneal (VP) shunt implantation is a well-established intervention to manage hydrocephalus by diverting excess CSF to the peritoneal cavity.

Observations: This case report describes a rare complication following VP shunt implantation in a 62-year-old male patient with malresorptive hydrocephalus after prior aneurysm clipping. Despite laparoscopic intraoperative confirmation of correct intraperitoneal VP shunt catheter placement, postoperative imaging revealed migration of the shunt catheter into the right heart ventricle, having perforated the internal jugular vein during its insertion. The catheter formed a knot within the venous system, requiring a combined effort by surgeons of various specialties for safe removal and repositioning. After successful shunt repositioning, the patient's hydrocephalus resolved with marked improvement in clinical symptoms.

Lessons: This case highlights the need for early recognition of shunt complications via imaging and multispecialty management. https://thejns.org/doi/10.3171/CASE25607.

Background: Retro-odontoid pseudotumors are soft tissue lesions behind the odontoid process, commonly associated with chronic atlantoaxial instability from rheumatoid arthritis, Down syndrome, and untreated injuries. Surgical techniques have evolved to address these histologically benign lesions when their mass effect causes cervical myelopathy. Historically, these were treated by direct spinal cord decompression via a transoral odontoidectomy. It is now understood that most retro-odontoid pseudotumors will regress with atlantoaxial fixation and fusion. Although uncommon, cystic masses can be associated with retro-odontoid pseudotumors and can create a secondary space-occupying lesion contributing to further cord compromise. Such cysts have been described in the extradural compartment. More uncommonly, they can erode through the ventral dura mater.

Observations: A 63-year-old female with prior C4-7 anterior cervical discectomy and fusion presented with worsening gait instability and myelopathy. MRI confirmed a retro-odontoid pannus with an adjacent left-sided cyst causing severe spinal cord compression. Intraoperatively, the cyst was discovered to be extradural and adhered to the ventral dura, prompting a transdural approach for resection.

Lessons: A paucity of literature exists regarding the management of symptomatic retro-odontoid cysts. This report demonstrates key steps of a transdural approach for the resection of a large retro-odontoid cyst with strong adherence to the ventral dura, accompanied by an intraoperative video and graphical illustrations. https://thejns.org/doi/10.3171/CASE25757.

Background: Adjacent segment disease (ASD) is a known complication of spinal fusion surgery, resulting from altered spinal biomechanics. The Total Posterior Spine (TOPS) facet replacement system has emerged as a motion-preserving alternative to lumbar fusion for patients with lumbar spinal stenosis and symptomatic degenerative spondylolisthesis. By maintaining segmental mobility, the TOPS System aims to reduce the incidence of ASD and improve postoperative function.

Observations: A 43-year-old male with prior L4-5 discectomy, L4-5 transforaminal lumbar interbody fusion, and L5-S1 anterior lumbar interbody fusion developed progressive axial and radicular pain with lower limb paresthesia 12 months postoperatively. Imaging at 16 months revealed ASD at L3-4, demonstrating facet instability and stenosis. After multidisciplinary evaluation, the patient underwent TOPS facet arthroplasty, chosen over additional fusion given his surgical history and active lifestyle. Postoperatively, he experienced significant pain relief and full restoration of physical function.

Lessons: This case highlights ASD as a frequent complication of fusion procedures and illustrates the potential of motion-preserving technologies like the TOPS System to mitigate these effects. Further research is warranted to evaluate long-term outcomes and broader applicability of the TOPS System as a viable alternative to conventional spinal fusion. https://thejns.org/doi/10.3171/CASE25913.

Background: Flow diverter stent placement for unruptured intracranial aneurysms requires intensive antithrombotic therapy, which can lead to unexpected hemorrhagic complications. However, standard protocols for managing such conditions have not been established. A rare case of idiopathic esophageal submucosal hematoma after flow diverter stent placement, successfully managed with the continuation of antithrombotic therapy, is reported.

Observations: A 76-year-old woman had undergone coil embolization 12 years earlier for a ruptured right paraclinoid internal carotid artery aneurysm. Follow-up imaging showed recurrence of the aneurysm, and she was admitted for flow diverter stent placement. She received dual antiplatelet therapy (aspirin and prasugrel) for 2 weeks prior to treatment, along with appropriate systemic heparinization during the procedure. One hour after treatment, she developed severe chest pain. Contrast-enhanced CT imaging showed an esophageal submucosal hematoma without active bleeding. Conservative treatment was started without discontinuing antiplatelet therapy, resulting in the near-complete resolution of the hematoma on CT imaging by day 11, and she was discharged on day 21.

Lessons: Although rare, idiopathic esophageal submucosal hematoma should be considered a potential complication when a patient complains of chest pain after endovascular treatment. When antiplatelet therapy is required and no active bleeding is present, continuation of antiplatelet therapy can be a viable option under careful observation. https://thejns.org/doi/10.3171/CASE25495.