Journal of neurosurgery. Case lessons最新文献

Background: Intravenous sinus meningiomas are rare tumors that may mimic idiopathic intracranial hypertension when they obstruct venous outflow. Biopsy of such lesions is challenging due to their deep location and the risks associated with open surgical approaches.

Observations: A 40-year-old woman presented with worsening headaches, papilledema, and elevated intracranial pressure. Imaging revealed a homogeneously enhancing lesion within the right transverse-sigmoid sinus junction, causing venous occlusion. Despite medical therapy, symptoms persisted. An endovascular biopsy was performed using a NeVa NET stent retriever with aspiration. Three passes were made across the lesion, successfully yielding tissue for histopathological analysis. A diagnosis of benign meningioma was confirmed. The patient subsequently underwent ventriculoperitoneal shunt placement with significant clinical improvement.

Lessons: Endovascular biopsy using a stent retriever offers a safe, minimally invasive alternative to open surgical biopsy for intrasinus lesions. This technique is especially valuable in anatomically complex or high-risk locations where traditional approaches carry substantial morbidity. The use of newer-generation stent retrievers with integrated mesh structures may enhance tissue acquisition and diagnostic yield, guiding appropriate management in cases of isolated venous sinus lesions. https://thejns.org/doi/10.3171/CASE25456.

Background: Super-refractory status epilepticus (SRSE) is characterized by seizure activity that continues 24 hours or more despite the initiation of anesthetic therapy; it is a condition where epileptic activity may persist uninterrupted despite adequate anesthetic management, recur during ongoing anesthetics, or relapse after anesthesia withdrawal, requiring its readministration. In selected cases, surgical procedures such as lesionectomy may serve as a valuable treatment alternative.

Observations: A 25-year-old female with a known diagnosis of focal epilepsy secondary to a focal cortical dysplasia (FCD) was admitted to the emergency department; despite treatment with multiple antiseizure medications, seizure activity persisted, and she developed an SRSE. MRI showed right FCD at the level of the superior frontal sulcus, with cortical thickening, an abnormal gray-white matter interface, and a transmantle sign. Because of the SRSE, she underwent a lesionectomy guided by intraoperative electrocorticography. Histopathology confirmed FCD type IIb. Postoperatively, the patient's SRSE resolved, and she remains seizure free.

Lessons: This case highlights that lesionectomy, combined with intraoperative electrocorticography, should be considered a viable strategy for managing SRSE secondary to FCD. https://thejns.org/doi/10.3171/CASE25306.

Background: Olfactory groove meningiomas (OGMs) are rare intracranial tumors that arise from the anterior cranial fossa. Because of their slow-growing and insidious nature, OGMs often go undetected until they reach considerable size, making them among the largest CNS tumors at diagnosis. Common presenting symptoms include headache, anosmia, personality changes, and visual impairment; however, these can be subtle and easily overlooked.

Observations: The authors present the case of a female in her 70s who presented with a 5-week history of progressive visual deterioration, initially affecting the right eye. Notably, she exhibited no other common neurological symptoms. Imaging revealed a giant OGM measuring > 6 cm, with mass effect, midline shift, and encasement of both internal carotid arteries. The patient underwent a bifrontal craniotomy and subtotal tumor resection, achieving approximately 80%-90% removal.

Lessons: The patient's visual acuity and field improved over the following weeks. This case underscores the stealthy and potentially dangerous growth of OGMs, particularly when classical symptoms are absent. It highlights the importance of early imaging in unexplained visual loss and the role of a multidisciplinary approach in managing complex skull base tumors. Greater awareness of atypical presentations may aid in earlier diagnosis and improved outcomes. https://thejns.org/doi/10.3171/CASE25657.

Background: Carotid artery stent (CAS) placement and carotid endarterectomy can improve ocular ischemic syndrome (OIS). However, paradoxical visual deterioration due to neovascular glaucoma (NVG) may rarely occur after revascularization. The authors report a case of NVG developing after CAS placement, resulting in severe and irreversible vision loss.

Observations: A 74-year-old man with severe right internal carotid artery stenosis and preoperative retinal ischemia underwent CAS placement. The stenosis was successfully resolved. On the day after the procedure, he developed a headache and was diagnosed with cerebral hyperperfusion syndrome, which stabilized with strict blood pressure control. Despite this, his headache persisted, accompanied by progressive visual deterioration. On postoperative day 10, ophthalmological evaluation confirmed NVG, and topical treatment was initiated. Nevertheless, the visual impairment remained irreversible.

Lessons: NVG following carotid revascularization has no established preventive strategies and often leads to profound vision loss. Neurosurgeons and neurointerventionalists should recognize this potential complication. The authors recommend conducting preoperative and postoperative ophthalmological assessments for high-risk patients, including those with OIS or a history of cataract surgery. https://thejns.org/doi/10.3171/CASE25746.

Background: Spinal dural arteriovenous fistulas (dAVFs) are rare vascular malformations that typically cause progressive congestive myelopathy. Hemorrhagic presentations of dAVFs, such as subdural hematomas (SDHs), are exceedingly rare and can lead to acute neurological deterioration.

Observations: The authors present a case of spinal SDH secondary to a ruptured spinal dAVF. A 46-year-old woman presented with rapidly progressing paraparesis to complete paralysis within hours, without a history of trauma, anticoagulation, or infection. Thoracic spine MRI revealed an intradural, ventral extramedullary lesion from T4 to T7, consistent with a compressive hematoma. The patient underwent a thoracic laminectomy for evacuation. Intraoperative indocyanine green angiography identified a spinal dAVF near the left T7 nerve root sleeve, which was successfully clipped. At the 9-month follow-up, the patient had significantly recovered with 4/5 strength in her lower extremities.

Lessons: This is the fourth documented instance of a spinal dAVF presenting as a spinal SDH. Clinicians should consider this diagnosis in patients with acute paraplegia, back pain, and sphincter dysfunction, especially without trauma or coagulopathy. Diagnosis may be complicated by angiographically occult lesions due to a hematoma mass effect, making intraoperative imaging essential. Prompt surgical decompression and fistula disconnection can yield significant neurological recovery, as demonstrated in this case and limited literature. https://thejns.org/doi/10.3171/CASE25510.

Background: Pott's puffy tumor (PPT) is a subperiosteal abscess formation of the frontal bone with associated osteomyelitis. Few studies have described the range of neurosurgical techniques used or compared patient outcomes across different management strategies. These illustrative cases aim to compare the clinical course, surgical approaches, and outcomes in 4 pediatric patients and 1 adult patient with PPT.

Observations: The authors report 5 illustrative cases of PPT in Tasmania. There were 3 males and 2 females with a mean age of 11 years. All patients presented with frontal headache, fever, and forehead edema after a trial of oral antibiotics in the community. One case resolved with medical therapy alone, while the remaining 4 required neurosurgical intervention. Among the operative cases, 1 patient underwent multiple procedures including a bifrontal craniectomy. Two patients underwent a frontal surgical incision and drainage, and 1 patient underwent needle aspiration. Fortunately, there were no long-term sequelae for any of the patients.

Lessons: The failure of medical management underscores the need for prompt neurosurgical referral with various surgical techniques available. Serious intracranial infection can result in significant surgical morbidity and mortality. This neurosurgical perspective advocates for early minimally invasive surgical intervention to prevent significant surgical morbidity and mortality. https://thejns.org/doi/10.3171/CASE25690.

Background: CSF leaks are common complications after cerebellopontine angle tumor surgeries, often through the eustachian tube (ET). Repair techniques, including endoscopic endonasal ET obliteration, have failure rates up to 20%.

Observations: A 31-year-old male developed CSF rhinorrhea after resection of a left cerebellopontine angle acoustic neuroma. Multiple interventions, including lumbar drainage, craniotomy with fat grafting, and intranasal ET obliteration with N-butyl-2 cyanoacrylate-Lipiodol, failed. The patient later developed recurrent CSF rhinorrhea and pneumocephalus. He underwent endoscopic nasopharyngectomy and pedicled nasoseptal flap (NSF) closure, which successfully resolved the symptoms. At the 1-year follow-up, the patient remained asymptomatic with no recurrence of CSF rhinorrhea or pneumocephalus, and complete mucosal healing was observed.

Lessons: Endoscopic nasopharyngectomy with pedicled NSF closure may be an effective salvage technique for refractory CSF rhinorrhea after multiple failed interventions, including in cases complicated by pneumocephalus. https://thejns.org/doi/10.3171/CASE25269.

Background: Endometriosis is a chronic gynecological disorder characterized by ectopic endometrial tissue, commonly affecting pelvic structures. Rarely, it occurs in extrapelvic locations, mimicking other pathologies and posing diagnostic challenges.

Observations: The authors describe the case of a 44-year-old female with a slowly growing, uncomfortable suprapubic mass, with an MRI study demonstrating a 1.1-cm enhancing soft tissue lesion overlying the right pubic symphysis. Fine-needle biopsy was inconclusive. Peripheral nerve involvement was suspected due to its radiographic features, associated allodynia, and painful nature of the biopsy. Excision was performed due to suspicion of a peripheral nerve sheath tumor. Histopathological examination confirmed ectopic endometrial tissue. Prior cases and the pathogenesis and characteristics of extrapelvic endometriosis are reviewed.

Lessons: This case highlights the importance of considering endometriosis in the differential diagnosis of nerve-adjacent soft tissue masses in women of reproductive age. https://thejns.org/doi/10.3171/CASE25642.

Background: Glioblastoma, isocitrate dehydrogenase-wildtype CNS WHO grade 4 (formerly primary glioblastoma multiforme), is the most common and most malignant primary brain tumor. High-grade gliomas most commonly present as unifocal lesions; however, they invade the brain parenchyma in a diffuse manner, an attribute that renders successful resection difficult. Resection, wherein resection of more than 90% of the tumor mass must be achieved to improve outcomes, represents the first step in optimal treatment; therefore, surgical planning, approach, and technique are of utmost importance for successful treatment.

Observations: In this paper, the authors present a rare case of a glioblastoma presenting as an atypical bilateral lesion with erosion through the falx cerebri. Morphologically, it was overtly distinct from a typical butterfly glioma. Initially, the authors believed this tumor to be a meningioma, or even a sarcoma, based on radiological morphology. Intraoperatively, destruction of the falx cerebri by the tumor, with spread to the contralateral hemisphere, was seen.

Lessons: To the best of the authors' knowledge, the erosion of the falx cerebri has not been previously described in glioblastoma in the literature, and this case highlights the importance of a thorough differential diagnosis and understanding its impact on surgical planning. https://thejns.org/doi/10.3171/CASE25410.

Background: Visual field defects are key determinants for surgical intervention in Rathke's cleft cysts (RCCs). While hemianopia and quadrantanopia are typical, atypical visual field defects without cyst enlargement may complicate treatment decision-making.

Observations: A 55-year-old woman developed headaches and bilateral paracentral scotoma 1 month after being referred to our hospital for an incidentally detected RCC in the sella, despite no radiographic evidence of cyst growth. Gadolinium-enhanced MRI demonstrated enhancement extending from the cyst wall to the optic chiasm, suggesting inflammatory spread. Endoscopic endonasal surgery to drain the cyst resulted in complete resolution of symptoms. Histological examination confirmed inflammatory cell infiltration of the cyst wall. Follow-up MRI at 2 years postoperatively showed no evidence of cyst recurrence.

Lessons: RCCs can impair vision not only through compression but also, in some cases, via inflammatory involvement of the optic pathways. Even radiographically stable cysts can produce atypical visual field defects, indicative of inflammation. Early recognition of this mechanism is essential for timely surgical intervention and favorable visual outcomes. https://thejns.org/doi/10.3171/CASE25836.