Journal of neurosurgery. Case lessons最新文献

Background: Brown-Séquard syndrome (BSS) is a rare neurological condition characterized by injury to one-half of the spinal cord. In the context of trauma, BSS is typically seen with penetrating injuries. Here, the authors present the unique case of a patient presenting with BSS after blunt trauma.

Observations: A 70-year-old male with a history of right cervical hemilaminectomies from C4 to C6 and ossification of the posterior longitudinal ligament (OPLL) presented after a motor vehicle collision. He had left-sided weakness (American Spinal Injury Association [ASIA] grade C with a motor score of 45 and a neurological level of C4), left-sided sensory loss, and right-sided loss of sensation to painful stimulation. Magnetic resonance imaging revealed significant spinal cord compression from C2 to C6, with intramedullary signal from C2 to C5. The patient underwent urgent C2-6 laminectomies with C2-5 instrumented fusion. Intraoperative ultrasound confirmed complete decompression as well as visualized a hyperechoic signal, particularly in the left C3-4 hemicord, evident of spinal cord injury. Postoperatively, his ASIA motor score improved to 56 at the 6-week follow-up.

Lessons: This case highlights a unique scenario in which prior decompressive surgeries could have provided a protective effect on the spinal cord at the levels with concomitant OPLL and hemilaminectomies, potentially preventing complete tetraplegia. https://thejns.org/doi/10.3171/CASE24637.

Background: Postoperative subdural hematoma (SDH) typically presents with headache, impaired consciousness, hemiplegia, gait disturbance, and aphasia but can also present with visual impairment.

Observations: A 52-year-old woman diagnosed with Chiari malformation type I and syringomyelia underwent foramen magnum decompression. Cerebrospinal fluid was lost due to arachnoid injury during the procedure. Postoperatively, a small acute SDH was apparent in the posterior convexity on head computed tomography but was managed conservatively because no neurological deficits were present. Visual impairment developed 2 weeks postoperatively. Ophthalmological examination showed right lower quadrantanopia with normal anterior ocular segment and fundoscopic findings. Magnetic resonance imaging demonstrated SDH in the left posterior convexity with direct compression of the visual cortex. Conservative treatment reduced the hematoma and improved visual impairment.

Lessons: SDH in the posterior convexity can cause visual impairment via direct compression of the visual cortex. SDH should be included in the differential diagnosis for patients presenting with visual impairment following craniotomy. https://thejns.org/doi/10.3171/CASE24525.

Background: Transorbital penetrating brain injury (PBI) accompanied by electrical injury is an extremely rare presentation. This type of traumatic injury has a unique set of diagnostic and therapeutic challenges due to the potential multiple organ system involvement and severe neurological complications.

Observations: A 50-year-old male experienced a high-impact injury from a welding spike that penetrated the orbit just above the eyeball with a concurrent electrical injury; the electricity exited through the great toe. Initial assessments revealed extensive subarachnoid pneumocephalus and a linear hemorrhage extending from the left medial orbital wall through the ethmoid air cells to the right thalamic nucleus. Remarkably, the eye itself was not injured given the superior trajectory of the spike within the orbit.

Lessons: PBIs and electrical injuries usually cause serious sequelae, but the welding spike and electrical current managed to avoid major neuroanatomical structures and visceral organs, allowing the patient to recover with minimal deficits. https://thejns.org/doi/10.3171/CASE24418.

Background: Metastatic follicular thyroid carcinoma to the central nervous system (CNS), including the skull and dura, is exceedingly rare.

Observations: The authors present the case of a gigantic, intraosseous, dural-based follicular thyroid carcinoma, highlighting the operative strategy for this mass. They also provide a literature review of CNS metastases of differentiated thyroid carcinoma.

Lessons: Although follicular thyroid carcinoma rarely metastasizes to the CNS, it should be included in the differential diagnosis of hypervascular intraosseous skull lesions, even in the absence of disseminated metastatic disease. The authors illustrate key operative steps in managing the tumor's hypervascularity, extracranial extension, and posterior sagittal sinus invasion, as well as unintended sequelae from ligating the seemingly occluded anterior and middle third of the superior sagittal sinus in large tumors. https://thejns.org/doi/10.3171/CASE24550.

Background: A ventriculoatrial (VA) shunt is an alternative to a ventriculoperitoneal (VP) shunt for managing hydrocephalus, especially when VP shunt insertion is not feasible. Despite its decline in use, the VA shunt remains vital for certain patients. This report highlights a rare complication of bilateral vocal cord paralysis following VA shunt insertion for hydrocephalus secondary to subarachnoid hemorrhage.

Observations: A woman in her 60s with a history of hypertension and giant liver cysts developed hydrocephalus after a subarachnoid hemorrhage. Because of her abdominal anatomical problems, VA shunt insertion assisted by transesophageal echocardiography (TEE) was chosen. Postoperatively, she experienced sudden dyspnea and upper airway stridor, diagnosed as bilateral vocal cord paralysis, necessitating an emergency tracheostomy. Gradual improvement was noted over the following month.

Lessons: Bilateral vocal cord paralysis can be a potential complication of TEE-assisted VA shunt procedures. To mitigate this risk, preoperative assessments of vocal cord function and swallowing are recommended. Alternatives to TEE, such as fluoroscopy or smaller probes, can be considered for patients with risk factors, including severe subarachnoid hemorrhage and prolonged intubation. https://thejns.org/doi/10.3171/CASE24518.

Background: Low-velocity penetrating brain injury (PBI) is an uncommon variant of traumatic brain injury (TBI). Patients affected by PBI can present with highly variable injury patterns, which, along with guideline-directed TBI care, may require the employment of unique operative management strategies. There are no strict guidelines for the management of low-velocity penetrating injuries. Characterizing approaches and outcomes for various injury patterns may be of use in guiding surgical decision-making. The authors report their experience with two cases of PBI by mechanism of a nail gun with a retained intracranial foreign body requiring surgical removal.

Observations: The two patients were managed using different operative approaches with directly visualized nail removal, and both cases were managed with different empiric antibiotic regimens. Both patients were neurologically intact at follow-up and had no perioperative complications.

Lessons: These cases illustrate two methods of foreign body removal and the perioperative management protocol utilized at the authors' institution. https://thejns.org/doi/10.3171/CASE24522.

Background: Camurati-Engelmann disease (CED) is an extremely rare autosomal dominant genetic disorder that can cause increased intracranial pressure (ICP) secondary to cranial hyperostosis, which decreases intracranial volume. Surgical procedures to reduce ICP in medically refractory cases include intracranial volume expansion and ventriculoperitoneal shunting.

Observations: The authors present the case of a pediatric patient with CED and medically refractory increased ICP who underwent unilateral hemicraniectomy with titanium cranioplasty, resulting in a complete long-term resolution of symptoms.

Lessons: Unilateral hemicraniectomy with titanium cranioplasty is a feasible surgical treatment for CED in pediatric patients with medically refractory increased ICP and papilledema. https://thejns.org/doi/10.3171/CASE24590.

Background: Treatment of pediatric craniopharyngioma requires a multidisciplinary approach to counsel patients and families on the spectrum of treatment options, including biopsy, radiation, and/or resection. Gross-total resection can avoid radiation and its long-term comorbidities. In very young patients, this is of particular importance but is especially challenging because of anatomical considerations.

Observations: A 23-month-old boy was found to have a partially calcified and cystic sellar and suprasellar mass. A fully endoscopic endonasal transtuberculum and transsellar approach was performed for gross-total resection of a subdiaphragmatic adamantinomatous craniopharyngioma. Postoperatively, the patient was diagnosed with panhypopituitarism with diabetes insipidus, though without other hypothalamic dysfunction or new visual deficits. To date, there is no evidence of tumor recurrence.

Lessons: In a high-volume center with an experienced multidisciplinary skull base team, endoscopic endonasal approaches to sellar and suprasellar pathology in children younger than 2 years can be safely performed. A smaller nasal cavity and lack of sinus aeration necessitate wide exposure via bone removal and complete opening of the sinuses to enable an adequate working corridor to perform not only tumor resection but also reconstruction. Safe gross-total resection can avoid, or at least delay, radiation and its long-term morbidity when performed in a developing child. https://thejns.org/doi/10.3171/CASE24209.

Background: Chiari malformation type I (CM-I) is a common pediatric neurosurgical condition that is often associated with syringomyelia (SM) and spine deformity. The association of these three conditions is well recognized, but the pathophysiology linking them has yet to be fully elucidated.

Observations: This case report describes the unusual course of a 13-year-old male with CM-I, a large holocord syrinx, and progressive scoliosis who developed an angiography-negative subarachnoid hemorrhage (SAH) 4 months after successful posterior fossa decompression with duraplasty (PFDD). Notably, his cervical spinal canal diameter was increased relative to normative data. After presenting with SAH, he was treated with a course of lumbar cerebrospinal fluid drainage, which relieved his symptoms, and he had no further incidents. His syrinx responded to PFDD with a dramatic decrease in spinal cord diameter, in contradistinction to his dilated bony spinal canal. He is presently 4 years out from his SAH and doing well clinically.

Lessons: This report describes the first case of nonaneurysmal SAH following PFDD for CM-I and SM and explores a possible link between SM and bony spinal canal diameter. https://thejns.org/doi/10.3171/CASE24272.

Background: The insula is a central node in network models of compassion and empathy. Because of this, resection of the insula for the treatment of drug-resistant epilepsy can change an individual's level of compassion.

Observations: Here, the authors present the clinical case of a woman with drug-resistant epilepsy localized to the nondominant insula. Because of the widespread literature implicating insular function in empathy and compassion, including lesion studies, her primary concern was changes in her compassion level after insular resection. In this case, the authors performed a novel compassion mapping paradigm before resection, using 30-second video clips to elicit compassion. This showed no changes in compassion with electrical stimulation of sites spanning the anterior insula, providing some reassurance that resection would not affect her compassion. Consistent with this, pre- and postresection testing, along with informal subjective reports by the patient, demonstrated no change in compassion or subcomponents of compassion (sadness and empathy) after right insular resection.

Lessons: While resection of the nondominant insular cortex warrants caution, this case illustrates a compassion mapping paradigm that reassured the clinical team and the patient that her compassion would not be affected and formal postoperative testing that was consistent with this. https://thejns.org/doi/10.3171/CASE24339.