Journal of neurosurgery. Case lessons最新文献

Background: Epidural arteriovenous fistulas (eAVFs) are rare vascular malformations often mistaken for their intradural counterparts due to similar angiographic features. Differentiation between epidural and intradural vascular lesions is crucial as it impacts surgical planning and prognosis. Despite advancements in diagnostic imaging, these entities can be misinterpreted and challenge management.

Observations: The authors report the case of a 68-year-old male suspected to have a type I dural arteriovenous fistula based on magnetic resonance angiography and angiographic evaluation. He presented with progressive myelopathy and multiple neurological symptoms exacerbated by recent trauma. A superselective angiogram of the right T10 segmental artery suggested an intradural arteriovenous fistula; however, intraoperatively, the lesion was epidural. The arterialized venous structures were obliterated, and the patient reported significant postoperative symptomatic improvement.

Lessons: This case highlights the critical importance of comprehensive imaging and cautious interpretation in the diagnosis of spinal vascular malformations. It also underscores the need for a multidisciplinary approach to ensure accurate diagnosis and effective treatment. Surgeons must be prepared for intraoperative findings that diverge from preoperative imaging to adapt surgical strategies accordingly. Furthermore, this case contributes to the evolving understanding of eAVFs, suggesting that revised imaging protocols may be required to better distinguish epidural from intradural vascular abnormalities. https://thejns.org/doi/10.3171/CASE24331.

Background: Microsurgical resection of drug-resistant epilepsy-associated perirolandic lesions can lead to postoperative motor impairment. Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (MRgLITT) has emerged as a less invasive alternative, offering reduced surgical risks and improved neurological outcomes. Electrophysiological tools routinely used for motor mapping in resective microsurgery are incompatible with intraoperative MRI. The utilization of advanced neuroimaging adjuncts for eloquent brain mapping during MRgLITT is imperative. The authors present the case of a 17-year-old athlete who underwent MRgLITT for a perirolandic long-term epilepsy-associated tumor (LEAT). They performed probabilistic multi-tissue constrained spherical deconvolution (MT-CSD) tractography to delineate the corticospinal tract (CST) for presurgical planning and intraoperative image guidance. The CST tractography was integrated into neuronavigation and MRgLITT workstation software to guide the ablation while monitoring the CST throughout the procedure.

Observations: The integration of CST tractography into neuronavigation workstation planning and laser ablation workstation thermoablation is feasible and practical, facilitating complete ablation of a deep-seated perirolandic LEAT while preserving motor function.

Lessons: Probabilistic MT-CSD tractography enhanced MRgLITT planning as well as intraprocedural CST visualization and preservation, leading to a favorable functional outcome. The limitations of tractography and the predictability of thermal output distribution compared to the gold standard of microsurgical resection merit further discussion. https://thejns.org/doi/10.3171/CASE24139.

Background: Spontaneous regression is relatively rare in meningiomas. Since meningiomas are known to have a relationship with sex-related hormones, spontaneous regression cases related to sex hormones have been reported.

Observations: A 66-year-old man with a petroclival meningioma was radiologically followed up for 13 years. The tumor initially measured 2.535 cm3 and 2.521 cm3 on gadolinium-enhanced magnetic resonance imaging (MRI) and fast imaging employing steady-state acquisition MRI, respectively. However, the measurements decreased in the follow-up period to 0.977 cm3 and 0.98 cm3, respectively, demonstrating spontaneous regression of an asymptomatic meningioma located in a petroclival area. Continuous meticulous long-term follow-up revealed this phenomenon.

Lessons: It is important to retain the option of conservative treatment for patients ineligible for surgery for reasons such as advanced age and coexisting diseases. https://thejns.org/doi/10.3171/CASE24416.

Background: Giant pituitary prolactinomas are rare entities that can present with pituitary apoplexy and acute neurological decline. Isolated acute hypoglossal nerve palsy is an extremely rare presentation that is not well described in the literature. The authors describe the case of a giant prolactin-secreting adenoma with apoplexy that presented with isolated bilateral hypoglossal palsy, followed by a brief review of the literature and management strategies.

Observations: A 62-year-old female with a history of neck pain presented after a syncopal episode with dysarthria and dysphagia attributed to bilateral hypoglossal nerve palsies. Magnetic resonance imaging revealed a giant apoplectic pituitary tumor with extensive suprasellar and clival extension, including clear invasion of bilateral occipital condyles on computed tomography. The patient underwent urgent endoscopic transsphenoidal decompression and debulking of her tumor and was started on medical therapy with immediate, significant improvement in the bilateral hypoglossal nerve palsies.

Lessons: Prolactinomas presenting with acute neurological decline, including bilateral hypoglossal nerve palsy, can benefit from urgent endoscopic transsphenoidal surgical decompression and safe debulking. Bilateral condylar tumor invasion may not always require craniocervical surgical fixation in the acute setting. Patients should be followed up and monitored clinically and radiographically for any signs of craniocervical instability after the initiation of medical therapy. https://thejns.org/doi/10.3171/CASE24326.

Background: The prone transpsoas (PTP) technique involves the performance of a lateral lumbar interbody fusion with the patient prone. One challenge encountered in the early experience with the PTP technique is that with the patient in the prone position rather than the lateral decubitus position, the surgeon is often forced to raise the bed significantly and perform the interbody work in a hunched and seated position with their neck extended and shoulders abducted. The authors report on the use of a sterile retractor-mounted camera during PTP that allows for the surgery to be performed with surgical anatomy visualized on a heads-up display.

Observations: The PTP procedure is performed without significant modification from standard practice. After the self-retaining retractor is inserted, a sterile retractor-mounted camera can be introduced down one of the blades of the self-retaining retractor, preferably the dorsally situated blade to avoid camera line-of-sight issues with dependent irrigation or bleeding. The surgical field can now be visualized on a high-definition monitor, allowing the surgeon to stand at the patient's side instead of sitting.

Lessons: A sterile retractor-mounted camera with a heads-up display is a novel way to address ergonomic challenges as well as improve educational opportunities in the operating room. https://thejns.org/doi/10.3171/CASE24318.

Background: The management of recurrent Rathke's cleft cysts (RCCs) remains challenging. The off-label application of steroid-eluting bioabsorbable or nonabsorbable intracystic stents has been recently described. Early outcomes and complications of this treatment have been described as well, but long-term data are lacking.

Observations: A 31-year-old woman who had undergone 3 prior transsphenoidal surgeries for recurrent RCC at other institutions was admitted for methicillin-susceptible Staphylococcus aureus meningitis. Five years earlier, a nonabsorbable stent had been placed in the cyst using a microsurgical transsphenoidal approach. RCC recurrence had been radiologically evident after 2 years but was clinically asymptomatic. Acute cerebrospinal fluid leakage and other causes of meningitis were ruled out; the stent was occluded. After antibiotic therapy and resolution of the meningitis, the patient underwent endoscopic removal of the catheter, excision of the cyst, and reconstruction with a nasoseptal flap. At the 18-month follow-up, she remained neurologically intact, under replacement therapy, and with no signs of recurrence.

Lessons: The authors report the first case of late meningitis due to a nonabsorbable stent positioned for the treatment of a recurrent RCC. Currently, data on the long-term outcomes, failure rates, and complications of stents for RCC are limited. https://thejns.org/doi/10.3171/CASE2477.

Background: Approximately 15% of Lyme disease cases involve the nervous system and are termed "neuroborreliosis." A rare complication of neuroborreliosis is idiopathic intracranial hypertension with resulting neurological deterioration. There are very few reports of this in the literature, most of which consist of case reports and small case series. Neurosurgical intervention is exceedingly rare but may be needed in select cases.

Observations: The authors present the case of a 13-year-old male with Lyme disease and concurrent babesiosis with progressive headache, meningismus, emesis, and visual loss over several weeks. Serum and cerebrospinal fluid (CSF) testing confirmed a diagnosis of neuroborreliosis. Despite antimicrobial therapy and acetazolamide, visual loss worsened. An external ventricular drain (EVD) was urgently placed for CSF diversion. The use of CSF diversion, antimicrobial therapy, and acetazolamide led to significant improvement in the patient's symptoms with nearly complete resolution. The EVD could be weaned, and permanent CSF diversion was not needed.

Lessons: This case highlights a rare but significant complication of neuroborreliosis. Intracranial hypertension with resulting neurological deterioration, while uncommon, can occur in patients with Lyme disease. Management is most often medical, consisting of intravenous antibiotics and acetazolamide to reduce CSF production. In rare cases, temporary CSF diversion is necessary and can provide significant benefits to select patients. https://thejns.org/doi/10.3171/CASE2451.

Background: Neurocysticercosis (NCC) is a public health problem in most of the world. Approximately 50 million people worldwide experience this disease, and it remains one of the most important causes of neurological morbidity. Extraparenchymal NCC (basal cisterns) is associated with high rates of morbidity and mortality. Currently, minimally invasive approaches, including the endoscopic endonasal approach, are used with good functional results.

Observations: A 25-year-old patient presented with headache and pain in the left hemiface. Magnetic resonance imaging (MRI) showed cystic lesions in the prepontine basal cisterns compressing and displacing the left trigeminal nerve. The cysticercal lesions were excised using a transclival endoscopic approach. There were no complications during surgery, and pathology confirmed the diagnosis of NCC. The pain subsided after surgery. No residual cysts were observed on control MRI.

Lessons: Minimally invasive approaches can be used to treat tumor and infectious problems of the skull base, as in this case, with good functional results. https://thejns.org/doi/10.3171/CASE24223.

Background: A silicone allergy can significantly impact the efficacy of ventriculoperitoneal shunt devices used in hydrocephalus treatment. Its clinical presentation often resembles infectious ventriculitis, characterized by altered cerebrospinal fluid (CSF) parameters, including low glucose levels, elevated protein concentrations, and increased white blood cell counts predominantly comprising eosinophils.

Observations: The authors report the case of an 18-month-old male who experienced recurrent shunt malfunction linked to CSF changes indicative of infectious ventriculitis. The patient underwent surgeries for suspected infection management. Notably, he exhibited increased eosinophil counts in both blood and CSF, as well as the development of neoformation tissue. This, along with the absence of microbial infection, indicated silicone hypersensitivity. While navigating medical device scarcity, innovative methods were employed to secure a silicone-free valve, markedly improving the patient's clinical outcome.

Lessons: Clinicians must be vigilant for silicone allergy in patients with ventriculoperitoneal shunts, particularly when elevated serum eosinophil counts and negative microbiological tests are present. This rare condition demands a multidisciplinary approach for timely diagnosis and management to reduce morbidity, unnecessary surgeries, and healthcare costs. The limited availability of non-silicone-based shunts further complicates management. This case emphasizes the need for considering silicone allergy in differential diagnoses, especially in pediatric patients. https://thejns.org/doi/10.3171/CASE2474.

Background: Rathke's cleft cysts (RCCs) are benign fluid-filled cysts that develop in the pituitary gland because of the abnormal embryological development of Rathke's pouch. Most RCCs are small and asymptomatic; however, they can present with symptoms or documented growth, sometimes prompting surgical treatment. For smaller asymptomatic lesions, an unknown proportion demonstrates regression over time. This study describes 3 cases of spontaneous RCC regression.

Observations: Three patients with a diagnosis of RCC demonstrated an average decrease of 78% in cyst volume over a mean interval of 3.7 months. One patient experienced the resolution of chronic headaches, whereas the other 2 patients had persistent headaches and endocrinopathies at follow-up. A systematic review included 9 studies that reported results from observational cohorts of patients with RCC, totaling 619 observed patients, with 158 (25.5%) patients demonstrating spontaneous cyst regression. In the patients with cyst regression, the majority had a resolution of symptoms.

Lessons: A substantial proportion of RCC patients managed nonsurgically demonstrated spontaneous regression. There is a role for the conservative management of RCCs in patients without significant symptoms, and surveillance should continue for a minimum of 5 years to confirm cyst stability. For patients undergoing planned surgery, same-day or recent imaging is recommended to prevent operating on involuted RCCs. https://thejns.org/doi/10.3171/CASE24268.