Journal of neurosurgery. Case lessons最新文献

Background: Avascular necrosis (AVN) of the spine is a rare sequela of chronic sickle cell disease (SCD) in which the shape of the sickled red blood cells interfere with the normal vascular supply of vertebral bodies. In this report, the authors describe a case of progressive spinal AVN treated with radiofrequency ablation (RFA) and kyphoplasty for the patient's persistent lower back pain.

Observations: A 38-year-old male with long-standing spinal AVN due to SCD had been managed conservatively with hydroxyurea and oral opioid analgesics for several years until breakthrough episodes of low-back pain began to occur with an inability to perform activities of daily life. The patient's condition progressed to involve multiple vertebral bodies, leading to a refractory response. Bipedicular RFA directed at L3 and L4 with kyphoplasty was proposed as a novel, minimally invasive approach. The patient was found to have lasting postoperative relief.

Lessons: Patients with pain attributed to a sickle cell crisis can benefit from RFA and kyphoplasty to potentially eliminate or minimize symptoms from spinal AVN due to chronic SCD not responding to conservative management. https://thejns.org/doi/10.3171/CASE24343.

Background: Aneurysmal bone cysts (ABCs) are rare, benign, yet locally aggressive lesions that contain blood-filled channels that rarely occur in the thoracic spine of adults. The literature on the treatment of spinal ABCs is sparse, but the consensus is to achieve gross-total resection (GTR) due to these lesions being locally aggressive and to prevent recurrence.

Observations: This report describes a 35-year-old female admitted with back pain and right T5 dermatome radiculopathy without any inciting events. Magnetic resonance imaging revealed a 3.0 × 4.3 × 4.0-cm solid, enhancing, multicystic lesion with multiple fluid levels centered in the right posteromedial chest wall, involving the right fifth rib and costovertebral junction. Because of the high suspicion for an ABC, later found to be secondary to an osteoblastoma, surgical intervention was planned via preoperative embolization and T4-6 fusion with right T5 laminectomy and costotransversectomy to obtain GTR.

Lessons: This case of an ABC secondary to osteoblastoma of the spine showcases a strategy for unique surgical management, given the limited information on treatment considerations for secondary ABCs. https://thejns.org/doi/10.3171/CASE24471.

Background: Trigeminal neuralgia (TN) can arise from trigeminal nerve compression at the root entry zone due to neurovascular conflict, which most often presents in the 6th decade of life. The authors report the case of a young patient with TN with a petrous apex bony spur near the entrance of Meckel's cave, causing compression of the proximal trigeminal nerve.

Observations: A 21-year-old woman presented with a 5-year history of progressive right-sided TN. Axial T2 sampling perfection with application optimized contrast using different flip angle evolution magnetic resonance imaging (MRI) did not reveal vascular compression of the trigeminal nerve. However, sagittal reformats demonstrated a prominent bony ridge along the petrous apex, causing compression of the right trigeminal nerve at the porus trigeminus. Removal of the bony spur via a middle fossa approach completely resolved the patient's symptoms.

Lessons: Although TN is most frequently caused by neurovascular compression, it is vital to examine the entire course of the trigeminal nerve on MRI to identify alternative causes of nerve compression in the absence of neurovascular conflict. Bony compression is a rare cause of TN that should be considered, particularly in younger patients. The presence of prominent osseous structures along the course of the trigeminal nerve can be evaluated reliably on sagittal MRI. https://thejns.org/doi/10.3171/CASE24321.

Background: Fibrous dysplasia (FD) is a nonheritable genetic disorder characterized by abnormal osteogenesis, resulting in benign bone lesions in one or multiple bones. Despite their predominantly benign nature, these lesions can transform into malignant neoplasms, resulting in pain, swelling, disfigurement, and even death. The authors report a case of malignant sarcomatous transformation in an adult patient with a history of craniofacial FD.

Observations: A 61-year-old male with a history of systemic FD presented with a rapidly enlarging cranial mass that had recently started becoming painful to touch. Magnetic resonance imaging of the brain displayed extensive FD changes throughout the calvarium and a large dysplastic mass in the right parietal bone with extension into the underlying epidural space, resulting in severe mass effect. The patient subsequently underwent radical resection and complex soft tissue reconstruction. The pathology confirmed high-grade undifferentiated pleomorphic sarcoma, for which the patient subsequently underwent an adjuvant chemotherapy regimen.

Lessons: Malignant sarcomatous transformation of craniofacial FD most often results in the formation of an osteosarcoma in the maxilla, with the temporal and sphenoid bones also being common sites of such transformations. Although treatment begins with radical resection, the efficacy of adjuvant chemotherapy and radiation remains controversial. https://thejns.org/doi/10.3171/CASE24537.

Background: Idiopathic intracranial hypertension is caused by an elevation of intracranial pressure and can present with slowly progressive visual deterioration from bilateral papilledema. Unilateral papilledema is an exceedingly rare phenomenon, and the mechanisms underlying asymmetric optic nerve involvement remain unknown.

Observations: A 42-year-old woman presented with acute left-eye blurred vision and extraocular pain. Examination revealed unilateral left optic disc edema with an enlarged blind spot, while the right optic disc appeared flat. Neuroimaging examination was suggestive of intracranial hypertension, characterized by flattening of the posterior globes and narrowing of bilateral distal transverse sinuses. Increased intracranial pressure was confirmed by lumbar puncture. Acetazolamide and weight loss yielded initial improvement, but recurrence prompted cerebral arteriography, revealing a transstenotic gradient in the right distal transverse sinus and hypoplastic left sigmoid and transverse sinuses with extensive collateralization to the left cavernous sinus. Stenting of the right transverse sinus successfully alleviated the optic disc swelling.

Lessons: This case highlights the intricate interplay between venous sinus dynamics and unilateral papilledema, underscoring the importance of tailored interventions. https://thejns.org/doi/10.3171/CASE24385.

Background: Depressed skull fractures in infants often present as "ping-pong ball" fractures with inward buckling of the calvarium, secondary to trauma. Management varies widely, and few concrete guidelines exist in the literature to guide decision-making when choosing a methodology for fracture elevation. The authors present two cases of attempted depressed skull fracture elevation with traction on a percutaneously placed bone fiducial screw, followed by a review of the literature, in order to further investigate the factors considered when selecting an intervention.

Observations: An 8-month-old female and a 10-month-old male presented with a right parietal depressed skull fracture. Both underwent attempted fracture elevation with a self-tapping screw anchored into the skull. The authors directly elevated the fracture with the screw technique in the 8-month-old female patient. The 10-month-old male had persistent depressed skull deformity; thus, the authors extended the incision for a standard craniotomy for depressed skull fracture elevation.

Lessons: Percutaneous screw placement may be considered an option in the spectrum of treatment strategies for select patients with depressed skull fractures. Consideration of patient age, skull thickness, and depth of skull fracture can assist with the choice of treatment strategy and the preoperative prediction of the likelihood of fracture elevation success with this technique. https://thejns.org/doi/10.3171/CASE23742.

Background: Clazosentan, a selective endothelin A receptor antagonist, effectively prevents cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Although various adverse effects have been reported, there have been no specific case reports of clazosentan-associated focal brain edema. This report highlights a rare complication associated with clazosentan treatment.

Observations: A female in her 70s with a subarachnoid hemorrhage underwent surgical clipping of a ruptured middle cerebral artery aneurysm and received clazosentan postoperatively. Six days after surgery, magnetic resonance imaging revealed high-intensity signals in the left basal ganglia on fluid-attenuated inversion recovery and apparent diffusion coefficient sequences without changes on diffusion-weighted imaging. The patient's right-sided hemiparesis and disturbance of consciousness gradually progressed. On day 9, clazosentan was discontinued because of suspected adverse effects. Within approximately 2 weeks of discontinuation, both imaging findings and neurological symptoms improved. The temporal relationship between clazosentan administration, symptom onset, and improvement after discontinuation strongly suggested clazosentan-induced vasogenic edema.

Lessons: Clazosentan can cause reversible localized vasogenic brain edema in the basal ganglia following subarachnoid hemorrhage treatment. This rare but significant complication underscores the importance of careful neurological monitoring and timely imaging in patients receiving clazosentan. Further research is required to understand the risk factors and mechanisms underlying this phenomenon. https://thejns.org/doi/10.3171/CASE24567.

Background: The articular origin of intraneural ganglion cysts has been previously described and well supported, except for the median nerve at the level of the elbow.

Observations: The authors present a patient with a median intraneural ganglion cyst at the elbow region and magnetic resonance imaging (MRI) evidence of a joint connection to the proximal radioulnar joint. A 63-year-old man presented with thumb flexion weakness and dysesthesias in the thumb, index, and middle fingers. Electromyography confirmed a median nerve lesion at the elbow. MRI demonstrated a median intraneural cyst as well as an extraneural cyst, both arising from the proximal radioulnar joint. The articular branch between the cyst and the proximal radioulnar joint was identified preoperatively on MRI and intraoperatively using indocyanine green. Following disconnection of the articular branch and pedicle and decompression of the intra- and extraneural cysts, the patient recovered grade M4 motor function after 6 months, with resolution of neuropathic pain immediately after surgery.

Lessons: The authors present the first case of a median intraneural cyst with a joint connection to the proximal radioulnar joint. The authors believe that this report along with other historical data strengthens the articular theory for intraneural ganglion cysts not only at this site but at all sites. https://thejns.org/doi/10.3171/CASE24564.

Background: Endovascular treatment of internal carotid artery (ICA) pathology includes reconstructive or deconstructive options. One reconstructive option is covered stent placement, although this is limited by a lack of devices designed specifically for neurointervention. The PK Papyrus is a balloon-mounted covered coronary stent that has a lower profile and is more flexible than other stent grafts, which makes it more suitable for treating ICA lesions.

Observations: The PK Papyrus was used to treat patients with iatrogenic cavernous ICA injury and symptomatic cervical ICA pseudoaneurysms. In both cases, the stent could be easily delivered without the use of an intermediate catheter or stiff microwire. Stent deployment resulted in immediate angiographic resolution of the pathology, and there were no peri- or postoperative complications.

Lessons: The PK Papyrus covered coronary stent is a good option for treating cervical and cavernous carotid pathology. Its single-layer design makes it more flexible and deliverable than other stent grafts, but additional case series are needed. https://thejns.org/doi/10.3171/CASE24517.

Background: Vestibular schwannomas are common posterior fossa tumors, often managed with stereotactic radiosurgery (SRS) due to its low invasiveness and high tumor control rates. However, malignant transformation of vestibular schwannoma (MTVS) is a rare but serious complication with a poor prognosis.

Observations: The authors present a case of MTVS occurring 29 years after initial SRS, the longest latency reported. A 68-year-old woman developed sudden facial nerve paralysis, with magnetic resonance imaging revealing tumor regrowth. Surgical removal and histopathological analysis confirmed malignant transformation, characterized by spindle-shaped atypical cells and significant p53 positivity. Despite multiple surgeries and radiation therapy, the tumor exhibited rapid regrowth and cerebrospinal dissemination, leading to a poor prognosis.

Lessons: This case underscores the critical importance of long-term monitoring after SRS, as malignant transformation can occur decades later. Additionally, it highlights the potential necessity for early intervention during malignant transformation to improve patient outcomes, despite the challenges in identifying effective treatments for MTVS. https://thejns.org/doi/10.3171/CASE24526.