Journal of neurosurgery. Case lessons最新文献

Background: Traumatic dural lacerations can be caused by thoracolumbar burst fractures and, infrequently, can be associated with the entrapment of neural elements within a laminar fracture. The diagnosis of both is difficult to make on preoperative imaging, as the conditions are typically appreciated during surgical exploration. The authors present a case of traumatic durotomy with entrapment of neural elements in a laminar fracture that they believed could be appreciated on preoperative magnetic resonance imaging (MRI).

Observations: A young male involved in a motor vehicle collision presented to the authors' trauma center with a lumbar burst and laminar fracture. Preoperative MRI demonstrated epidural hemorrhage and entrapment of neural elements within the laminar fracture, which was confirmed intraoperatively. The patient underwent a successful decompression, release of nerve roots, fusion, and recovery.

Lessons: Traumatic durotomy and entrapment of neural elements can occur after a traumatic spinal fracture, and a diagnosis made upon preoperative MRI can allow for effective preoperative planning. Clinicians should have a high index of suspicion for these pathologies when encountering certain fracture patterns and could therefore tailor the surgical approach to avoid further neurological injury during surgery. https://thejns.org/doi/10.3171/CASE24455.

Background: Fibrous dysplasia (FD) is typically asymptomatic but is known to occasionally cause neurological symptoms such as visual disturbances. However, FD-associated abducens nerve palsy is extremely rare.

Observations: A 76-year-old woman had a left abducens nerve palsy due to mass effect on the abducens nerve at Dorello's canal caused by FD and its associated cyst, which was resolved by resection of the cyst through an endoscopic transnasal route.

Lessons: Although FD is generally an asymptomatic lesion occurring in younger patients, it can occasionally cause abducens nerve palsy even in older patients. In particular, cystic degeneration within FD tends to trigger a mass effect and thus can require surgical decompression. https://thejns.org/doi/10.3171/CASE24424.

Background: Fibrous dysplasia of the bone is a disease caused by a somatic GNAS mutation that affects craniofacial bones and can have a mass effect on different neurovascular structures. The authors present the first case of primary jugular foramen fibrous dysplasia with occlusion of the transverse and sigmoid sinuses.

Objective: A 33-year-old man presented with a history of dizziness and occasional dysphagia over the past year. Magnetic resonance imaging showed a uniform enhanced mass in the left jugular foramen, with complete blockage of the adjacent transverse and sigmoid sinuses. The computed tomography scan revealed a cystic bone lesion of the jugular foramen. The patient underwent a gross-total removal of the tumor through an infratemporal transjugular approach with complete preservation of the lower cranial nerves.

Lessons: This first reported case of primary jugular foramen fibrous dysplasia highlights the importance of considering this diagnosis when evaluating jugular fossa lesions. Understanding the anatomy of the infratemporal and jugular fossae, along with proficiency in microsurgical techniques, is essential for removing such tumors while preserving cranial nerve functions and the patient's quality of life. https://thejns.org/doi/10.3171/CASE24396.

Background: Paraclinoid aneurysms can pose an operative challenge during clip reconstruction, given the complex surrounding anatomy and the aneurysmal tendency to maintain turgor despite standard approaches to proximal control. This report demonstrates the use of intraoperative retrograde arteriovenous shunting with the transcarotid artery revascularization (TCAR) system to assist in the safe clip reconstruction of an irregular paraclinoid aneurysm.

Observations: A 33-year-old woman presented with perimesencephalic subarachnoid hemorrhage and was found to have an incidental 9-mm ophthalmic aneurysm. Coil embolization was not successful. During microsurgical clip reconstruction, the left common carotid artery was exposed to allow for proximal control as well as transcarotid arterial sheath placement. Flow reversal was instituted throughout the aneurysm dissection and clipping, with a visible softening of the aneurysm. Intraoperative angiography confirming successful clip reconstruction was performed utilizing the TCAR sheath. The case was complicated by the development of cerebrospinal fluid rhinorrhea postoperatively, requiring surgical repair. The patient has since made a complete recovery.

Lessons: Transcarotid flow reversal utilizing the TCAR system has potential for use in the surgical treatment of paraclinoid aneurysms, as it may aid in softening the aneurysm for safer dissection and clip reconstruction, protect against aneurysm-associated emboli, and provide an avenue for intraoperative angiography. https://thejns.org/doi/10.3171/CASE24330.

Background: Spinal subdural empyemas are a rare presentation of rapid neurological decline, progressing from radiculopathy to complete paralysis and sensory loss. Although pathogenic mechanisms have been hypothesized, their occurrence in this population of patients remains unclear.

Observations: The authors present the third documented case of an isolated spinal subdural empyema of unclear etiology in an immunocompetent patient with no established risk factors.

Lessons: Successful treatment requires prompt clinical suspicion, radiological diagnosis, and surgical evacuation along with empirical antibiotic treatment. Radiological clarification of the subdural versus the epidural location of the empyema is difficult, while intraoperative durotomy for exploration risks subdural dissemination. In these cases, intraoperative ultrasonography would be a useful adjunct and decision aid. https://thejns.org/doi/10.3171/CASE24464.

Background: Spinal arachnoid cysts are cerebrospinal fluid-filled sacs that are frequently located within the thoracic spine and can lead to symptoms due to direct compression of the thoracic spinal cord. These lesions are typically treated with laminectomy and fenestration of the cyst, with or without shunting. However, with recurrence, treatment is often more complex and sometimes requires re-exposure and fenestration or shunting.

Observations: Here, the authors describe a 57-year-old female with a thoracic intradural arachnoid cyst that recurred despite extensive and initially successful fenestration. Given the failure of fenestration, the authors instead attempted to place a cystoperitoneal shunt. Given how extensive her laminectomy was, the authors elected to perform the procedure under ultrasonic guidance to avoid the large incision required for open shunt placement. The procedure was successful, with gradual improvement in the size of the arachnoid cyst as well as symptomatic improvement.

Lessons: Here, the authors present a unique minimally invasive technique to treat recurrent spinal arachnoid cysts. They successfully demonstrated the feasibility and safety of this approach in shunting the cyst while avoiding the extensive re-exposure often required in such complex cases. https://thejns.org/doi/10.3171/CASE24461.

Background: Children with cerebral palsy often have neurogenic bladders. Bladder function is further affected by complex medical management and multifactorial disease processes, leading to worsened function and poorer quality of life. Intrathecal baclofen (ITB) therapy has been used to treat hypertonia and spasticity, but implications in neurogenic bladder management have not been well described.

Observations: A 20-year-old female with a history of cerebral palsy and neurogenic bladder treated with sacral neuromodulation underwent ITB therapy and subsequently experienced improvement in bladder control, obviating the need for bladder stimulator use.

Lessons: ITB improves hypertonia and can effectively obviate the need for neurostimulation to treat neurogenic bladder in patients with cerebral palsy. Further research is necessary to discern mechanisms. https://thejns.org/doi/10.3171/CASE24364.

Background: Cystic formation due to radiation necrosis in metastatic brain tumors is a rare condition. Surgical intervention is necessary if symptoms develop. Additionally, excising radiation necrosis lesions within the cyst is essential to prevent recurrence. Neuroendoscopic surgery is a minimally invasive method suitable for treating cystic diseases and accessing deep lesions in the brain. The authors herein present a method for removing radiation necrotic tissue from deep lesions of cystic radiation necrosis using neuroendoscopy.

Observations: Endoscopic surgery was performed in two patients with symptomatic cystic radiation necrosis. Both cases involved multilocular cysts, with radiation necrosis located deep within the cyst. The authors performed a small craniotomy of approximately 3 cm and opened the cyst. After removing its contents, an endoscope was used to closely observe the interior of the cyst. Removal of the septum within the cyst allowed the endoscope to be inserted deeply. The authors identified and excised the nodular lesion diagnosed as radiation necrosis in the deep tissue. Following the surgery, the cyst shrank rapidly, and symptoms disappeared. Both patients showed no recurrence of the lesions.

Lessons: The authors performed minimally invasive surgery and achieved good outcomes. Endoscopic surgery was considered beneficial for treating cystic radiation necrosis. https://thejns.org/doi/10.3171/CASE24250.