Journal of neurosurgery. Case lessons最新文献

Background: Hemangioma is a rare vascular tumor characterized by endothelial cell proliferation that primarily occurs in soft tissues. While most cases in the paraspinal posterior mediastinum are clinically indolent, they can also exhibit aggressive growth, leading to severe clinical outcomes and necessitating urgent treatment.

Observations: A 61-year-old right-handed female presented with reduced lower-extremity mobility that had begun 4 days earlier. An examination revealed that both lower limbs had grade 4 muscle strength. Computed tomography and magnetic resonance imaging revealed a right T1-3 paravertebral dumbbell-shaped soft tissue mass invading the spinal canal, destroying the T2 vertebra, and compressing the spinal cord and nerve roots. Elective surgery was planned, but a rapid muscle strength decline prompted emergency surgery. Postoperative muscle strength improved to grade 4, and at the 3-month follow-up, muscle strength had fully recovered.

Lessons: Postoperative pathological examination revealed that the mediastinal dumbbell-shaped lesion was a hemangioma. While most hemangiomas progress slowly, acute symptoms of spinal cord compression are exceedingly rare. This case demonstrates the aggressive behavior of hemangioma, which invaded through the intervertebral foramen and compressed the spinal cord, resulting in acute symptoms. This case also shows that surgical removal of the tumor and restoration of spine stability via a posterior approach has proven beneficial. https://thejns.org/doi/10.3171/CASE24485.

Background: Iatrogenic vertebral artery injury during surgery can cause pseudoaneurysm, hemorrhage, thrombosis, ischemia, or death. Strategies to prevent cerebrovascular embolic complications include surgical ligation, endovascular stenting, and/or antiplatelet therapy.

Observations: A 73-year-old female with a known right vertebral artery occlusion underwent a C2-3 laminectomy, complicated by left vertebral artery injury and occlusion with subsequent posterior circulation ischemia. She underwent immediate angioplasty and stenting of the injured artery with undersized drug-eluting stents. Dual antiplatelet therapy of aspirin 81 mg daily and ticagrelor 90 mg twice daily was initiated. On two occasions, more than 6 months after stenting, holding a single ticagrelor dose led to in-stent thrombosis and embolic stroke within hours of the missed dose. Lifelong therapy with ticagrelor was favored over further procedural intervention.

Lessons: It is recommended to prioritize optimal wall stent apposition with oversized stents in patients without collateral circulation. The risk of thromboembolism due to poorly apposed stents is very high, even in delayed (> 6 months) settings. Stent construct revision or bypass grafting may not be feasible or desirable options. For patients without wall apposition, endothelialization may not occur, necessitating lifelong P2Y12 inhibitor therapy to prevent recurrent thromboembolic events. https://thejns.org/doi/10.3171/CASE24296.

Background: Pediatric intracranial aneurysms present unique diagnostic and therapeutic challenges due to their rarity and their distinct anatomical and physiological considerations compared with those of adult intracranial aneurysms. The authors present the case of a symptomatic pediatric patient who required emergency microsurgical treatment after a thrombosed dissecting aneurysm was identified in the right M1 segment of the middle cerebral artery.

Observations: The lesion completely occluded its parent vessel, although distal blood flow was reconstituted through leptomeningeal collaterals. However, aneurysm wall contrast enhancement and signs of early perfusion changes were noticed, which prompted emergency treatment consisting of microsurgical aneurysm trapping, decompression, and extracranial/intracranial revascularization to be successfully performed through a minipterional craniotomy. After 1 year, the bypass occluded, although the patient remained asymptomatic. A slight enlargement of the ipsilateral anterior cerebral artery suggested the possibility of a benign hemodynamic rearrangement.

Lessons: Emergency treatment may be necessary when signs of lesion instability or hemodynamic compromise are present; however, a comprehensive multidisciplinary evaluation is required. Treatment of complex vascular lesions using a minipterional approach is feasible even in pediatric patients, and delayed bypass occlusion may be a benign phenomenon reflecting gradual blood flow reorganization. https://thejns.org/doi/10.3171/CASE24484.

Background: Deep brain stimulation (DBS) is commonly used to treat Parkinson's disease (PD) and other movement disorders when other treatments fail. Although DBS can significantly improve motor symptoms, it carries risks such as infections, which can require multiple surgeries and prolonged antibiotic therapy. Research on the long-term neurological effects of DBS-related infections is limited.

Observations: A 58-year-old man with a 13-year history of PD, refractory to optimized clinical management, underwent subthalamic nucleus (STN) DBS after previous contralateral lesioning of the posterior subthalamic area. Postoperatively, the DBS lead migrated upward and was repositioned, but he developed perielectrode cerebritis 5 days later. The DBS system was completely removed, and he underwent a 28-day course of intravenous antibiotics. Initially, his motor symptoms remained unchanged, but 4 months later, he experienced a significant and sustained motor symptom improvement that continued until the last follow-up assessment (40 months). Magnetic resonance imaging performed 2 years after the explantation showed gliosis and hemosiderin deposition in the STN, suggesting that the infection-induced gliosis had a lesion-like effect, leading to the observed clinical improvement.

Lessons: This case suggests that infection-induced gliosis from DBS complications can unexpectedly result in long-term motor symptom improvements, potentially influencing future management strategies for similar cases. https://thejns.org/doi/10.3171/CASE24502.

Background: Neurocysticercosis is a parasitic infection of the central nervous system caused by the helminth Taenia solium. Racemose neurocysticercosis is a rare form of the disease that specifically involves cerebrospinal fluid-filled spaces in the brain and carries a high rate of complications and mortality.

Observations: This report describes the case of a 37-year-old man who developed headaches and nausea, which were found to be secondary to racemose neurocysticercosis. He ultimately required an endoscopic third ventriculostomy, which provided transient symptom relief. In the weeks following the procedure, his symptoms returned, at which point a recommendation to proceed with a ventriculoperitoneal shunt was made.

Lessons: The presentation of racemose neurocysticercosis is wide-ranging and often nonspecific. Patients who respond well to initial surgical management with endoscopic third ventriculostomy can still require more durable measures, such as a ventriculoperitoneal shunt, in the following months. https://thejns.org/doi/10.3171/CASE24489.

Background: An 80-year-old male was found to have a metastatic lesion in his cerebrum. He underwent uncomplicated resection with prolonged inhalational anesthesia due to issues with intravenous access prior to surgery. Postoperatively, the patient had persistent altered mental status. Immediate postoperative head computed tomography and continuous electroencephalography were negative for possible causes.

Observations: Standard brain magnetic resonance imaging (MRI) after metastatic resection demonstrated the development of edema in his pons and thalami, concerning for posterior reversible encephalopathy syndrome (PRES). Tight blood pressure control was initiated. His neurological examination returned to baseline. Follow-up MRI showed the resolution of edema.

Lessons: This is a report of PRES hypothesized to be attributable to prolonged inhalational anesthetic. PRES is a disorder in which patients present with altered mentation, seizures, visual impairment, or headache. PRES often occurs due to acute uncontrolled hypertension; however, other conditions, including autoimmune disease and cancer chemotherapy, have been linked. In severe cases, permanent brain damage and death have been reported. The authors present a case of PRES as the cause of severe neurological decline following craniotomy without severe or sustained hypertension. The authors hypothesize that PRES could be caused by blood pressure variability in the perioperative period and prolonged anesthesia. https://thejns.org/doi/10.3171/CASE24245.

Background: Obsessive-compulsive disorder (OCD) is a psychiatric condition characterized by recurrent, unwanted thoughts (obsessions) and repetitive behaviors (compulsions) performed to relieve distress related to the obsessions. For patients with severe illness refractory to first-line pharmacotherapy and psychotherapy, neurosurgical treatments such as deep brain stimulation (DBS) and stereotactic lesioning are an option. The choice between DBS and lesioning is often driven by patient preference, but these options are not mutually exclusive. Here, the authors highlight the success of one surgical therapy (DBS) after the failure of another (lesioning).

Observations: Two patients with severe, treatment-refractory OCD underwent DBS lead implantation targeting the ventral capsule/ventral striatum after they did not attain any worthwhile benefit from a previous anterior capsulotomy. Both patients showed significant improvement (≥ 35% reduction in Yale-Brown Obsessive-Compulsive Scale [YBOCS] score) of their OCD symptoms at the long-term follow-up after DBS. One patient experienced a 37% reduction in symptom severity as measured by the YBOCS, and the other patient experienced a 47% reduction.

Lessons: DBS and lesioning procedures are both effective surgical options for patients with intractable OCD. In these cases, the authors demonstrate that DBS can be utilized even after a lesioning procedure in nominally the same target (ventral portion of the anterior limb of the internal capsule). https://thejns.org/doi/10.3171/CASE24289.

Background: Spinal hemangiopericytoma (sHPC) is a rare vascular tumor that presents significant challenges in diagnosis and management due to its potential for recurrence and metastasis.

Observations: This report documents the 7-year clinical course of a 68-year-old female diagnosed with multifocal sHPC. The patient initially presented with myelopathy due to a spinal mass, which was managed with resection, followed by several years of stability. Subsequent magnetic resonance imaging (MRI) revealed new growths, necessitating further interventions, including stereotactic radiosurgery. Despite the recurrence and progression of the disease, the strategic use of surgical and radiosurgical interventions demonstrated significant efficacy in managing tumor growth and alleviating symptoms.

Lessons: This case emphasizes the critical importance of continual surveillance and a multidisciplinary approach in the treatment of sHPC. Continuous monitoring through regular MRI is essential for early detection of recurrences. Adaptable treatment strategies, including resection and radiosurgery, are necessary to manage the complex dynamics of tumor behavior. This report also highlights the need for patient-centered care and flexible, individualized treatment plans to ensure optimal patient outcomes in the face of recurrent and multifocal disease manifestations. https://thejns.org/doi/10.3171/CASE24368.

Background: Hemodynamic disturbances during lumbar spine surgeries have proven to be exceptionally rare, with only seven published cases demonstrating instances where intraoperative dural manipulation coincided with bradycardia, hypotension, and/or asystole.

Observations: The authors present the case of a 39-year-old male with a history of chronic low-back pain and leg weakness. Imaging demonstrated a disc herniation at L5-S1, resulting in impingement of the left S1 traversing nerve root. The patient agreed to surgery. The preoperative workup was unremarkable. While retracting the S1 nerve root, transient asystole occurred when the S1 nerve root was manipulated, causing the patient's heart rate to drop from 51 to 0 bpm. Manipulating the nerve root once again triggered a similar event, and upon cessation of the surgical stimulus, the patient's heart rate spontaneously returned to baseline. Other potential causes of these hemodynamic perturbations were excluded.

Lessons: As in other reported cases, each cardiovascular disturbance corresponded with either direct or indirect dural manipulation. Given the limited number of lumbar spinal cases reported to have undergone hemodynamic perturbances via dural manipulation, this case report provides evidence for the likelihood of a spinal-cardiac reflex between the cardiovascular system and the spinal dura mater. https://thejns.org/doi/10.3171/CASE24158.