Journal of neurosurgery. Case lessons最新文献

Background: Cerebral venous sinus thrombosis (CVST) is a rare stroke subtype (0.5%-3%) that frequently presents with nonspecific symptoms, delaying diagnosis. Although hyperhomocysteinemia is a known risk factor, acquired cases resulting from severe vitamin B12 and folate deficiencies can be easily overlooked by clinicians in any setting, making this a critical yet preventable cause of life-threatening thrombosis.

Observations: A 44-year-old man with obesity, who adopted a carbohydrate-heavy diet and consumed excessive alcohol (70-140 g/day) following a major life event 3 years prior, presented with worsening headache, somnolence, and right-sided neurological deficits. Imaging confirmed CVST with bilateral parietal venous infarction and left-sided hemorrhage. Severe hyperhomocysteinemia (143.4 nmol/mL) secondary to critically low vitamin B12 and folate levels was identified, likely induced by these lifestyle changes. Anticoagulation therapy, vitamin supplementation, alcohol cessation, and nutritional counseling improved clinical symptoms, with normalization of homocysteine levels within 30 days, despite persistent evidence of brain tissue damage on imaging.

Lessons: This case highlights the serious consequences of severe vitamin deficiencies, triggered by lifestyle changes, in causing significant CVST, regardless of location. It emphasizes the importance of prioritizing detailed history-taking to identify modifiable lifestyle factors, facilitating timely intervention to manage symptoms, normalize homocysteine levels, and prevent recurrence. https://thejns.org/doi/10.3171/CASE25759.

Background: Aggressive vertebral hemangiomas are uncommon vascular spinal lesions that may enlarge during pregnancy due to hormonal and hemodynamic changes. Elevated estrogen and progesterone levels, increased blood volume, and venous congestion can lead to rapid lesion expansion and epidural extension, causing neurological deficits. Although rare, these lesions should be considered in pregnant or postpartum women presenting with back or radicular pain.

Observations: A 30-year-old woman with epilepsy controlled by lamotrigine developed progressive low back and right leg pain during late pregnancy, worsening postpartum. MRI revealed an aggressive L4 vertebral hemangioma with epidural extension compressing the thecal sac and right L4 nerve root. The patient underwent L4 laminectomy, excision of the epidural component, and vertebroplasty. Persistent bleeding after initial posterior cement injection required a second injection through the left pedicle to fill the superior vertebral body, followed by fibrin glue application. She was mobilized on the 1st postoperative day, and her symptoms resolved completely.

Lessons: Pregnancy-related aggressive vertebral hemangioma should be suspected in women with new-onset neurological symptoms during pregnancy or postpartum. Early diagnosis, multidisciplinary planning, and timely decompression with vertebroplasty yield excellent neurological recovery and functional outcomes. https://thejns.org/doi/10.3171/CASE25860.

Background: Posterior hypopharyngeal perforation is a rare yet serious complication of anterior cervical discectomy and fusion (ACDF), especially at upper cervical levels where anatomical relationships are critical. Prompt recognition and tailored management are key to minimizing morbidity and achieving favorable outcomes.

Observations: The authors report the case of a 54-year-old man who underwent ACDF at C3-5 for cervical disc prolapse. Within hours postoperatively, he developed a sore throat, hypersalivation, subcutaneous emphysema, and anterior neck swelling. Initial imaging showed emphysema without contrast leakage, prompting empiric conservative management with nothing by mouth, intravenous antibiotics, steroids, and proton pump inhibitor. A contrast-enhanced CT study on day 7 revealed a 5.3 × 4.7-mm (length × thickness) posterior hypopharyngeal fistulous tract with contrast leakage but no collection. The patient improved with nonoperative management and close outpatient follow-up, gaining 2 kg over 4 weeks. Follow-up imaging at week 4 confirmed tract resolution, and oral feeding was reintroduced with progressive dietary advancement.

Lessons: Early hypopharyngeal perforation following ACDF may present subtly. High clinical suspicion, even in the absence of early imaging findings, is essential. Contained injuries without systemic deterioration may be successfully treated with conservative therapy, including nutritional support and imaging-guided follow-up. This case underscores the importance of vigilance and individualized management. https://thejns.org/doi/10.3171/CASE25513.

Background: Normal pressure hydrocephalus (NPH) is a condition characterized by enlarged intracerebral ventricles with normal intracranial pressure. The typical clinical presentation includes cognitive decline, gait disturbances, and urinary incontinence. While the classic triad of symptoms is well documented, atypical presentations, including focal deficits and aphasia, pose significant diagnostic challenges.

Observations: This is the case of a previously healthy 70-year-old patient presenting with rapidly progressive gait disturbances, right hemiplegia, cognitive decline, and mutism. The focal presentation suggested a left hemispheric cerebrovascular insufficiency. A comprehensive diagnostic workup, including serial imaging, lumbar punctures, and electroencephalography, was undertaken given diagnostic uncertainty. Initial evaluations suggested a left hemispheric stroke or neurodegenerative process, ultimately delaying the definitive diagnosis and treatment of NPH. MRI revealed progressive ventriculomegaly and white matter changes prompting a lumbar drain trial. This yielded clinical improvement and ventriculoperitoneal shunt placement. Postoperatively, the patient had complete resolution of symptoms and returned to a normal functional status within 6 weeks.

Lessons: This case demonstrates the diagnostic challenges in differentiating NPH from stroke or neurodegenerative disorders. Recognizing its varied presentations and distinguishing them from other diseases is crucial for initiating appropriate treatment. Early intervention improved this patient's outcome and prevented unnecessary morbidity, demonstrating the significant impact of accurate and timely diagnosis. https://thejns.org/doi/10.3171/CASE25620.

Background: Syringomyelia is most often associated with Chiari malformation, for which posterior fossa decompression is the standard treatment. Treatment failure should raise suspicion for alternative mechanisms, particularly in patients with a history of supratentorial craniectomy. In such cases, sinking skin flap syndrome (SSFS) may alter intracranial-extracranial pressure gradients, impair CSF dynamics, and result in an acquired Chiari malformation with secondary syrinx formation.

Observations: A 64-year-old man with a remote supratentorial decompressive craniectomy for intracerebral hemorrhage presented with progressive headache, neck pain, and bilateral arm paresthesia. MRI revealed tonsillar herniation with syringomyelia. Posterior fossa decompression led to initial symptom relief and reduction of the syrinx. Three months later, he developed new bilateral leg sensory deficits, and follow-up MRI showed syrinx recurrence despite adequate decompression and no arachnoid adhesions. Because of prior cranioplasty-related infection, he hesitated to undergo further surgery, but ultimately cranioplasty was performed. Postoperatively, symptoms improved, with sustained clinical recovery and syrinx regression confirmed on serial MRI at 12 and 24 months.

Lessons: Persistent or recurrent syringomyelia after Chiari decompression should prompt evaluation for acquired causes. SSFS may mimic primary Chiari malformation; in such cases, cranioplasty can restore CSF dynamics and achieve durable syrinx resolution. https://thejns.org/doi/10.3171/CASE25763.

Background: Carbon fiber (CF) instrumentation is a useful tool for the treatment of spinal oncological disease. CF produces less instrumentation artifact on imaging, facilitating radiation planning and oncological monitoring. CF screws have different physical properties than traditional titanium, leading to decreased manual feedback during placement. Electromyography (EMG) monitoring is an intraoperative adjunct to assist in safe screw placement. While titanium and CF have different electrical properties, there is no literature comparing their responses to intraoperative stimulation.

Observations: The authors present a case of mobile spine chordoma at L1 previously stabilized at an outside hospital. During en bloc resection, asymptomatic titanium screws at L2 were replaced with CF-reinforced PEEK (CFR-PEEK) (Icotec). Stimulation of the CFR-PEEK screws at 2 mA resulted in quadriceps EMG firing. Titanium screws at L3 required 10 mA of stimulation to produce an EMG signal (DePuy Synthes). Intraoperative CT demonstrated optimal screw placement. Postoperatively, the patient was neurologically intact. In ex vivo analysis, the CFR-PEEK screw exhibited increased resistivity and decreased conductivity compared to an analogous titanium screw.

Lessons: Surgeons and intraoperative monitoring teams should be aware of lower EMG stimulation thresholds for CF screws than titanium. Additional adjuncts, such as intraoperative imaging, may be helpful in these cases. https://thejns.org/doi/10.3171/CASE25786.

Background: Colloid cysts (CCs) are rare benign lesions, typically found in the third ventricle. While most CCs remain asymptomatic, they can occasionally cause significant symptoms such as headaches, visual disturbances, seizures, and, in rare cases, sudden death.

Observations: This article reports a rare case of spontaneous regression of a CC located in the lateral ventricle. After remaining stable for more than 4 years, the cyst underwent spontaneous regression.

Lessons: This case challenges existing ideas regarding the origin and regression mechanisms of CCs. It demonstrates that lateral ventricle CCs can spontaneously regress, highlighting the need to reconsider their embryological origin, their natural history, and the role of surgery. However, the diagnosis of CC has been solely radiological, and other forms of tumor-like cystic lesions, such as neuroepithelial or ependymal cysts, should be taken into consideration. https://thejns.org/doi/10.3171/CASE25319.

Background: The incidence of cerebral aneurysms in polyarteritis nodosa (PN) is low, and reports of subarachnoid hemorrhage (SAH) in patients with PN are even rarer. The necessity of head imaging may be underestimated, particularly when the patient is in remission.

Observations: A 20-year-old female with PN, who had been in remission following anti-interleukin-6 receptor antibody therapy, developed SAH and was admitted to the authors' department. Cerebral angiography revealed multiple beaded changes in both carotid and vertebral arterial systems, along with several small aneurysms. These findings posed substantial difficulty in identifying the bleeding source and proceeding with surgical intervention. Therefore, the authors intensified the immunosuppressive therapy targeting the underlying PN. The patient remained free from rebleeding, her headaches and other symptoms resolved, and she was discharged in ambulatory condition. Follow-up MR angiography 3 months after discharge confirmed resolution of the small aneurysms.

Lessons: This case suggests that enhanced immunosuppressive therapy may be effective in treating both extracranial and intracranial vascular lesions in PN. In patients with PN, early and serial head imaging may be beneficial. The appearance of de novo aneurysms in the context of disease progression may indicate the need for more aggressive treatment. https://thejns.org/doi/10.3171/CASE25617.

Background: The authors successfully removed a type B intradural lumbar disc herniation (IDH) using unilateral biportal endoscopic (UBE) technology, without CSF leakage, even though the nerve root sheath was not sutured. This emphasizes the diagnostic and therapeutic role of UBE technology in managing type B IDH.

Observations: An 82-year-old male patient with multilevel lumbar disc herniation underwent endoscopic discectomy and lumbar laminoplasty at the symptomatic level using UBE technology. During surgery, under endoscopic visualization, a white, mass-like protrusion was observed on the surface of the responsible nerve root, consistent with type B IDH. The nerve root sheath was incised, and the herniated nucleus pulposus was successfully removed without CSF leakage. The nerve root sheath was left open without repair.

Lessons: Using UBE technology to treat lumbar disc herniation, if an abnormal bulge or white, mass-like protrusion is observed on the nerve root under endoscopic visualization, clinicians should highly suspect the presence of type B IDH. In such cases, the nerve root sheath can be incised along the direction of the nerve root to safely remove the herniated disc material. Notably, repair of the nerve root sheath is not required, and no CSF leakage occurred in this case. https://thejns.org/doi/10.3171/CASE25795.

Background: Spinal epidural lipomatosis (SEL) is a rare disorder characterized by pathological accumulation of adipose tissue in the spinal epidural space, leading to signs and symptoms of lumbar stenosis. SEL is increasingly linked to obesity, and treatment requires surgical decompression if conservative measures fail. The role of modern pharmacological weight-loss agents in reversing SEL has not been previously described.

Observations: A 35-year-old man with severe, symptomatic lumbar SEL and class II obesity (BMI 37.8 kg/m) presented with progressive neurogenic claudication and functional decline. MRI revealed multilevel lumbar SEL with severe spinal stenosis. After counseling, the patient initiated tirzepatide therapy and achieved approximately 60 pounds of weight loss within 1 year. This was accompanied by marked symptom resolution and near-complete regression of epidural fat on repeat MRI, negating the need for surgical intervention.

Lessons: This case demonstrates that pharmacological weight loss with agents such as tirzepatide may offer a viable, nonoperative alternative for patients with obesity-related SEL, particularly those who are not ideal surgical candidates. Validation in larger studies is needed to assess long-term efficacy and help guide patient selection for pharmacological versus surgical approaches. https://thejns.org/doi/10.3171/CASE25886.