Journal of neurosurgery. Case lessons最新文献

Background: Parafalcine subdural hematomas (pSDHs) are a subtype of subdural hematoma (SDH) that occur most frequently in older patients after blunt trauma. The literature primarily describes two clinical courses for patients with pSDH: those who are neurologically intact with stable examinations and imaging and those with focal deficits, with or without hematoma progression. Surgical management is undoubtedly required for the latter group; however, there are no evidence-based guidelines specifically for pSDH. This report describes the cases of two patients with traumatic pSDH with neurological deficits who underwent surgical interventions with two different approaches and advocates for the use of stereotactic navigation to achieve adequate evacuation.

Observations: In the first case, a 55-year-old male with a parafalcine and convexity SDH underwent a hemicraniectomy, followed by a second surgery for evacuation of the residual pSDH due to a persistent neurological deficit. The second case involved an 84-year-old female with a parafalcine and convexity SDH, who underwent surgical evacuation of the pSDH with the aid of stereotactic navigation.

Lessons: Approaching the surgical evacuation of a pSDH as if it were a mass lesion led to the use of intraoperative navigation, which resulted in superior localization and complete evacuation, ultimately improving patient outcomes. https://thejns.org/doi/10.3171/CASE24541.

Background: Rupture of the lumbar catheter in lumboperitoneal (LP) shunts is rare and typically occurs due to long-term mechanical stress. The authors describe an unusual case of early postoperative lumbar catheter severing after a fall on the buttocks.

Observations: A 78-year-old woman underwent LP shunt placement for communicating hydrocephalus after aneurysmal subarachnoid hemorrhage. The lumbar catheter was inserted via a median approach, and the postoperative course was uneventful. However, 2 months after the LP shunt surgery, she accidentally fell on her buttocks in the hospital ward. Radiography showed a rupture of the lumbar catheter due to the shearing force caused by compression of the spinous processes from the impact of the fall.

Lessons: In patients who have undergone catheter placement via a median approach, even within a short period after LP shunt placement, the lumbar catheter that has deteriorated due to "pinch-off" can rupture due to "bite-off" by the spinous processes following a fall on the buttocks. https://thejns.org/doi/10.3171/CASE24509.

Background: Rotational vertebral artery occlusion, or bow hunter's syndrome (BHS), is a rare but clinically important cause of vertebrobasilar insufficiency. Extrinsic compression of the artery is usually caused by osteophytes, fibrous bands, or lateral disc herniation and typically occurs in the setting of anatomical variations, leading to dynamic compromise of the posterior circulation. Neoplastic causes of BHS are rare.

Observations: The authors present the case of a 72-year-old man with a left vertebral artery-dominant posterior circulation and isolated small right vertebral artery terminating in the posterior inferior cerebellar artery (PICA). He developed progressively worsening dynamic insufficiency of his right PICA circulation due to compression of the right vertebral artery at C2 from an intradural-extradural dumbbell-shaped lesion. This patient was successfully treated via surgical debulking of the lesion and cervical spine fixation and experienced no neurological deficits postoperatively.

Lessons: This neoplastic change represents an exceedingly rare presentation for BHS, which warrants further study on its etiology and treatment. https://thejns.org/doi/10.3171/CASE24415.

Background: Glossopharyngeal neuralgia (GPN) is a rare condition typically manifesting as paroxysms of sharp, lancinating pain localized to the middle ear and auditory canal, base of the tongue, tonsillar fossa, and region just inferior to the angle of the mandible. Vascular compression is a common etiology, and microvascular decompression (MVD) has been established as a safe and efficacious treatment in adults. With the exception of one report of an adult patient undergoing the procedure for symptomatology that began in adolescence, there are no published cases of MVD for GPN in pediatric patients to the author's knowledge.

Observations: Here, the authors report a case of GPN in a 5-year-old boy with a 7-month history of medically refractory headaches and progressively worsening paroxysms of stabbing, "shock-like" pain in his right ear. Magnetic resonance imaging demonstrated neurovascular compression of the right glossopharyngeal nerve. Following MVD, the patient experienced a near-complete resolution of symptoms and a dramatic improvement in quality of life.

Lessons: GPN must be included in the differential diagnosis of all children presenting with head, neck, or pharyngeal pain and can be difficult to distinguish from Eagle's syndrome. MVD represents a safe and efficacious treatment for pediatric patients with GPN due to neurovascular compression. https://thejns.org/doi/10.3171/CASE24578.

Background: The inability to localize pain generators often results in failed back surgery syndrome (FBSS). Structural imaging can identify multiple and/or noncausative abnormalities. Molecular imaging of glucose transporters offers the opportunity to localize metabolically active sites. Using the radiotracer [18F]fluorodeoxyglucose (FDG) with positron emission tomography/magnetic resonance imaging (PET/MRI) has enabled the localization of malignant lesions and pain generators via regions of high inflammation.

Observations: A 61-year-old woman was diagnosed with complex regional pain syndrome (CRPS) and experienced right greater than left upper-extremity pain. Following PET/MRI with the FDG radioligand for GLUT, increased radiotracer uptake was seen in the right C6 nerve root and dorsal root ganglion, providing additional information to the structural MRI findings of narrowing of the right C5-6 neural foramina. Together with pain relief following a transforaminal steroid injection to the area, these results prompted the authors to perform a C5-6 anterior cervical discectomy and fusion procedure, which resulted in significant symptom relief.

Lessons: The authors present a case of worsening upper-extremity CRPS with an occult radiculopathy that improved following surgery to address a pain generator identified by FDG PET/MRI. Localization of inflammatory sites can reduce FBSS and nonspecific management of pain believed to be resulting from spinal pain generators in a wide array of chronic pain syndromes. https://thejns.org/doi/10.3171/CASE24327.

Background: The authors describe the case of a 35-year-old male who presented with back pain and painful masses on his upper extremities. He had a known sacral lesion identified 1 year prior at an outside facility, suspected to be coccidioidomycosis on biopsy, but the workup was not completed because the patient left against medical advice and was lost to follow-up. Computed tomography (CT) and magnetic resonance imaging revealed lytic destructive lesions involving the calvaria, thoracolumbar spine, and sacrum, concerning for an active and disseminated infection. Sacrum and right-hand biopsies and culture results from both revealed the growth of Blastomyces dermatitidis. With the exception of limitations due to pain, the patient was neurologically afocal and ambulatory. His pain descriptions were biological in nature rather than mechanical. He was not placed on spinal precautions, and surgery was deferred; he was treated medically with inpatient intravenous antifungals and long-term oral therapy after discharge.

Observations: The patient's back pain was resolved at follow-up, and despite extensive lytic destruction demonstrated on CT imaging at initial assessment, he was found to have good bony remodeling at his affected levels, with no neurological deficits.

Lessons: This case illustrates the value of physical examination and symptomatology in surgical decision-making for disseminated fungal infections of the spine, even when imaging studies compellingly suggest instability. https://thejns.org/doi/10.3171/CASE24204.

Background: Adult spinal reconstructive surgery that requires multilevel spinal fusion is highly invasive and requires two-stage surgery using lateral lumbar interbody fusion (LLIF) and/or percutaneous pedicle screw (PPS) fixation to make it less invasive. However, it is still difficult to make spinal osteotomy less invasive, and the high complication rate is an issue.

Observations: The authors present the surgical techniques of a two-stage Schwab grade 4 spinal osteotomy using LLIF, which could reduce surgical invasiveness and enable good correction and anterior spinal column reconstruction for lumbar kyphosis, and also report a case treated with this procedure. The first surgery consisted of L2-5 LLIF and L6-S1 posterior lumbar interbody fusion with temporary PPS fixation. The second surgery, 2 weeks after the first surgery, was a grade 4 osteotomy performed in the L4 vertebral body at a 30° angle toward the center of the LLIF cage between L3 and L4, followed by PPS fixation from T10 to the pelvis and additional fixation with two collateral rods.

Lessons: Two-stage grade 4 osteotomy using LLIF could reduce invasiveness and blood loss while providing good anterior support. This surgical method is expected to make spinal reconstruction surgeries requiring osteotomy less invasive. https://thejns.org/doi/10.3171/CASE24515.

Background: A bipartite atlas is a rare congenital anomaly characterized by incomplete fusion of the anterior and posterior arches of the first cervical vertebra (C1). While typically asymptomatic, this condition can result in cervical myelopathy when accompanied by degenerative changes. This report presents a rare case of cervical myelopathy caused by a bipartite atlas in an older patient that required surgical intervention.

Observations: A 63-year-old male presented with progressive neurological symptoms, including impaired fine motor skills, pain, and paresthesias in both the upper and lower extremities. Imaging revealed a bipartite atlas accompanied by degenerative changes, resulting in significant spinal cord compression. The patient underwent a posterior decompression via C1 laminectomy and duraplasty, resulting in significant clinical improvement and a resolution of symptoms.

Lessons: This case highlights the importance of recognizing a bipartite atlas as a potential cause of cervical myelopathy, particularly in older patients with degenerative changes. This is a rare case in which congenital and degenerative factors are intertwined, underscoring the importance of a comprehensive pathological analysis and the development of a personalized treatment strategy. Prompt diagnosis and appropriate surgical intervention are essential for favorable outcomes. https://thejns.org/doi/10.3171/CASE24688.

Background: Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare central nervous system tumor, especially in adult females. Typically, it presents with leptomeningeal enhancements in the basal cisterns and spinal cord. However, varied radiological and pathological features can complicate the diagnosis, as the present case illustrates.

Observations: An adult female presented with severe headache, blurred vision, and cognitive impairment. Elevated intracranial pressure (ICP) was detected via lumbar puncture. Brain magnetic resonance imaging (MRI) revealed atypical unilateral basal cistern enhancement, differing from the usual symmetrical DLGNT presentation. Despite high ICP, only mild ventricular enlargement was observed. Noncontrast spine MRI failed to demonstrate spinal leptomeningeal enhancement. A stereotactic biopsy of an occipital lesion was inconclusive. These atypical findings led to misdiagnoses of viral encephalitis or inflammation at two hospitals. Significant symptom relief occurred only after ventriculoperitoneal (VP) shunt surgery. Over 2.5 years, intraparenchymal lesions in the parahippocampal gyrus grew, necessitating surgical intervention. Pathological examination finally confirmed DLGNT. Postsurgery, the patient underwent chemotherapy with temozolomide and remains symptom free.

Lessons: This case underscores the critical importance of comprehensive initial imaging, strategic biopsy planning, and timely placement of a VP shunt in patients with DLGNT. It contributes to the literature by revealing atypical imaging features and long-term progression patterns of DLGNT. https://thejns.org/doi/10.3171/CASE24701.

Background: Colloid cysts (CCs) are benign lesions commonly located in the third ventricle, near the foramen of Monro. They constitute about 0.5%-1% of all intracranial tumors. As benign lesions, CCs can be found incidentally, but they can also present with neurological deterioration and are even associated with sudden death, which might be explained as a result of obstructive hydrocephalus. Thus, larger and symptomatic CCs are often considered for surgery.

Observations: The following case presents a rare and curious instance of a spontaneously regressing CC. This represents the 11th case ever reported about an extremely rare occurrence: the spontaneous regression of a previously diagnosed CC in the third ventricle.

Lessons: Carefully selected asymptomatic CCs can be monitored through regular imaging studies and neurological examinations. If regression of the cyst is observed, physicians should not be surprised, as this event, although rare, has been documented and published in 11 cases, including this one. https://thejns.org/doi/10.3171/CASE24498.