Journal of neurosurgery. Case lessons最新文献

Background: Dural sealants, widely used in neurosurgical practice, have been associated with few complications, mostly relating to the expansive nature of the hydrogel. Although generally well tolerated, DuraSeal expands up to 150% after application, and rare reports have described complications from mass effect.

Observations: This report presents the case of a 34-year-old female with a past surgical history of multiple operations for a Chiari type 1 malformation. After a thorough workup, intraoperative images and histological findings revealed a concealed hematoma-like mass at the patient's previous surgical site, likely due to the DuraSeal system. Imaging revealed that the DuraSeal was mostly hyperintense on T2-weighted MRI with focal spots of hypo-/isointensity, similar in appearance to an abscess or hematoma. Histological analysis showed exuberant fibrosis, granulation tissue, and a granulomatous response to the foreign material used for the dural patch and seal rather than the wall of an infectious abscess.

Lessons: This case adds to the growing body of literature on DuraSeal, highlighting the imaging and histological characteristics of "dural sealant-omas" and their expansile nature that can lead to the formation of a mass mimicking an abscess or a hematoma. In areas susceptible to compression, clinicians ought to be vigilant to identify findings consistent with the appearance of these dural sealant-omas. https://thejns.org/doi/10.3171/CASE25574.

Background: Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD). Concurrently, brain tumors are increasing in incidence, creating complex clinical scenarios when both conditions coexist. The safety of delivering radiation therapy to patients with active DBS devices remains poorly documented, with limited guidelines available.

Observations: This case report describes a 69-year-old male PD patient with bilateral DBS leads who developed metastatic melanoma with brain metastases. He underwent multiple radiation treatments, including stereotactic radiosurgery and hippocampal avoidance whole-brain radiation therapy, receiving a cumulative dose exceeding 47 Gy to the DBS device. Throughout treatment, the DBS device remained fully functional with no impedance changes or symptom deterioration. A review of similar cases indicates that radiation doses to DBS components, including leads and implantable pulse generators, are generally well tolerated, although no standardized safety protocols currently exist.

Lessons: This case reinforces the feasibility and safety of multiple radiation treatments in patients with implanted DBS devices when carefully planned and monitored. Cumulative high radiation doses may not impair DBS functionality, but attention to neutron contamination and dose distribution remains essential. Multidisciplinary collaboration and individualized planning are crucial to optimize tumor control while preserving device integrity in this emerging patient population. https://thejns.org/doi/10.3171/CASE25600.

Background: Radiation therapy is a common treatment for spinal metastases. However, its effects on extramedullary intrathecal structures are poorly understood. Arachnoid webs are rare structural abnormalities that can cause significant neurological symptoms due to spinal cord compression. While radiation-induced myelopathy is a rare known complication of radiation therapy, the potential relationship between radiation treatment and the formation or exacerbation of arachnoid webs has not been previously reported.

Observations: The authors present the case of a 64-year-old female with breast cancer and spinal osseous metastases who underwent palliative radiation therapy. Six months after radiation therapy, she developed progressive myelopathy refractory to conservative treatments. Imaging revealed dorsal cord indentation and edema with findings suggestive of a compressive arachnoid web. Surgical intervention confirmed an extensive complex arachnoid web spanning T5-8. Fenestration of the web resulted in immediate intraoperative improvement in somatosensory evoked potentials and significant postoperative neurological recovery over 8 months.

Lessons: This case highlights the importance of considering structural abnormalities, such as arachnoid webs, in patients with progressive myelopathy following spinal radiation therapy, even when doses are within safe limits. Myelography may be helpful for characterizing intrathecal changes in this context. Further research is needed to explore the relationship between radiation therapy and arachnoid pathology. https://thejns.org/doi/10.3171/CASE25733.

Background: Nail gun injuries are rare forms of penetrating brain injuries that can be associated with significant morbidity and mortality. Management strategies differ greatly in previously reported cases.

Observations: A male in his 40s presented with an accidental, work-related nail gun injury to the left parietal lobe with no focal neurological deficits. Noncontrast CT imaging of the head and vessel imaging including CT angiography and venography were performed that demonstrated the retained nail with trace surrounding intraparenchymal hemorrhage but no obvious vascular injury. The patient underwent a preoperative diagnostic cerebral angiography that confirmed no vascular injury. The patient was then taken to a hybrid operating room/angiography suite for a burr hole craniotomy for nail removal. Selective left internal carotid artery intraoperative angiography was performed to confirm there was no contrast extravasation after nail removal. The patient was discharged home on postoperative day 1 on prophylactic antibiotics. Follow-up angiography did not demonstrate pseudoaneurysm formation.

Lessons: Nail gun injuries require a comprehensive, multidisciplinary approach to minimize the risk of complications, particularly related to vascular injury. Judicious use of preoperative and intraoperative catheter-based angiography can facilitate safe, efficient nail removal and is imperative in assessing immediate and delayed sequelae of penetrating trauma. https://thejns.org/doi/10.3171/CASE25476.

Background: Pial arteriovenous fistulas (pAVFs) are rare vascular abnormalities in the subpial space, characterized by high-flow connections between pial arteries and draining veins, without an intervening nidus. This case report describes a left parietal pAVF feeding from the angular branch (M4) of the left middle cerebral artery, which presented as an acute subdural hematoma (SDH).

Observations: The authors present the case of a 68-year-old neurologically intact male with 1-week history of progressive holocranial headache. Initial noncontrast CT imaging of the head revealed a left-sided SDH. Subsequent CTA confirmed the SDH with a spot sign in the posterior part of the SDH. Digital subtraction angiography identified a left parietal pAVF with an associated saccular aneurysm. The patient underwent successful microsurgical ligation and hematoma evacuation, with no residual fistula or vascular abnormality on follow-up angiography.

Lessons: This case highlights the importance of a lower threshold for advanced imaging in acute SDH with no known predisposing factors. It also focuses on the complexity of managing pAVFs with associated aneurysms, along with the importance of individualized treatment strategies integrating advanced imaging and microsurgical techniques. https://thejns.org/doi/10.3171/CASE25605.

Background: Paddle electrode stimulation of the trigeminal nucleus caudalis (TNC) for refractory craniofacial pain syndromes provides improved coverage and has lower migration rates than cylindrical leads; however, paddle implantation requires open surgery, which can cause significant pain and limit use in high-risk patients. Herein, the authors present a minimally invasive (MIS) approach, adapting the use of tubular retractors for MIS spine surgery and therefore minimizing the surgical morbidity of paddle electrode implantation at the craniocervical junction.

Observations: An 81-year-old man with postherpetic trigeminal neuropathy in the left V1 and V2 distribution underwent paddle lead implantation via a 2.5-cm occipitocervical incision and a tubular retractor system. The patient experienced a reduction in pain (from a visual analog scale score of 9/10 to 2/10), without any postoperative complications.

Lessons: This technical report demonstrates the feasibility of implanting paddle electrodes via an MIS tubular retractor system for stimulating the TNC. The approach minimizes soft tissue disruption, reduces postoperative pain, and offers a viable alternative to open surgery, which is especially useful for medically complex patients requiring neuromodulation for craniofacial pain. https://thejns.org/doi/10.3171/CASE25721.

Background: Lymphocytic panhypophysitis (LPH) is a rare inflammatory disorder that primarily affects the pituitary gland. Extension into the cavernous sinus has been described, but clival involvement is exceedingly rare. To date, no cases of isolated clival extension have been documented. Anti-rabphilin-3A antibodies have been identified as diagnostic markers that may facilitate the diagnosis of this challenging condition.

Observations: An 81-year-old man presented with headache, anorexia, and fatigue. Evaluation demonstrated panhypopituitarism followed by central diabetes insipidus. MRI revealed homogeneous pituitary enlargement with isolated clival extension. Endoscopic evaluation during transsphenoidal biopsy demonstrated thickened dura mater extending from the pituitary gland to the clivus. Histopathological analysis revealed lymphoplasmacytic infiltration with a predominance of CD20-positive B cells over CD3-positive T cells and inflammatory infiltration between the clival bone trabeculae, confirming direct invasion. The serum anti-rabphilin-3A antibody test was positive. Hormone replacement therapy resulted in clinical improvement, and follow-up MRI at 3 and 6 months showed marked resolution.

Lessons: This appears to be the first reported case of LPH with isolated clival extension. Intraoperative dural thickening and histological evidence of trabecular bone infiltration suggest a potential pathway for extrapituitary extension. Anti-rabphilin-3A antibody testing can support diagnosis, particularly in such atypical presentations. https://thejns.org/doi/10.3171/CASE25737.

Background: H3 K27-altered diffuse midline gliomas (DMGs) are a rare form of primary CNS tumors. In this retrospective single-center case study, DMGs were reviewed for clinical and imaging findings, surgical approaches and challenges, and molecular diagnosis.

Observations: Four cases of adult DMG, H3 K27-altered, located among midline structures of the thalamus, brainstem, and spinal cord are presented here. All tumors exhibited heterogeneous presentations on imaging. Symptoms ranged from unspecific back pain and vertigo to focal neurological deficits. Surgery was complicated by high vascularization, infiltrative growth, and proximity to eloquent areas. Diagnostic accuracy was increased by epigenetic DNA methylation-based classification. Three cases were rapidly progressive and resulted in death within 1 year of diagnosis. One case had an exceptionally long overall survival of > 5 years, which was associated with a FGFR1 p.N546K hotspot mutation.

Lessons: DMGs are rare but imitate other pathologies due to variable clinical and radiological characteristics. Surgery is complicated by location and high vascularization. Although DMGs are rare, they should be considered as a differential diagnosis in intracranial and spinal masses in adults. As the FGFR1 p.N546K hotspot mutation is associated with prolonged survival, it may justify more radical surgery in eloquent regions. https://thejns.org/doi/10.3171/CASE25357.

Background: Common carotid artery (CCA)-subclavian artery bypass is performed for CCA occlusive disease. Reported complications include infection, occlusion, anastomotic leakage, and nerve injury. A pseudoaneurysm at the anastomotic site is rare, and most develop within 1-2 years after the procedure. The authors present a case of an anastomotic pseudoaneurysm occurring 50 years after bypass surgery.

Observations: A 76-year-old woman presented with progressive neck swelling. She had undergone left CCA-subclavian artery bypass 50 years earlier. Imaging revealed a pseudoaneurysm, with occlusion of both the left CCA and the graft. The distal CCA was opacified via retrograde flow through an extracranial-intracranial anastomosis from the right internal carotid artery (ICA). The aneurysm was thought to be supplied solely by this. Ligation of the ICA-external carotid artery bifurcation was planned. Intraoperatively, however, several microvessels resembling the vasa vasorum were found entering and supplying the pseudoaneurysm. Trapping and excision were achieved by dividing them. Pathological analysis showed a fibrous aneurysm wall containing remnants of the vascular prosthesis, with immune cell infiltration, phagocytosis, and surrounding microvessels.

Lessons: Anastomotic pseudoaneurysm may occur decades after CCA-subclavian artery bypass. This case underscores that prosthetic grafts require lifelong surveillance, as delayed complications may result from long-term graft degeneration, chronic inflammation, or occult infection. https://thejns.org/doi/10.3171/CASE25704.

Background: Extraosseous epidural cavernous hemangiomas are rare spinal lesions. While often asymptomatic, they can present in patients with myelopathy-/radiculopathy-like symptoms. These lesions can be caused by venous pooling secondary to negative pressure within the intrathoracic cavity. Diagnosis is often challenging and largely relies on radiographic imaging, where lesions are commonly found in the thoracic spine region and present as a homogeneous contrast-enhancing signal intensity on MRI T1-weighted sequences and appear as hyperintense on T2-weighted sequences. Although usually indolent, these lesions can cause compression or can rupture, causing hyperacute neurological decline.

Observations: The authors describe the case of a 77-year-old woman with a history of breast cancer and melanoma presenting with progressive low back pain and new urinary incontinence. Initial lumbar MRI was unremarkable, but thoracic MRI revealed a 2-cm dorsal epidural lesion at the T7 level. Minimally invasive laminectomy achieved gross-total resection and pathological analysis confirmed a cavernous hemangioma. On the 1-month follow-up, the patient reported complete remediation of symptoms.

Lessons: This case highlights the importance of including extraosseous epidural cavernous hemangioma in the differential diagnosis for spinal lesions, even in patients with nonspecific symptoms. Early recognition requires considering spinal imaging beyond the symptomatic region. Prompt resection is recommended to prevent worsening symptomatology and acute neurological decline. https://thejns.org/doi/10.3171/CASE25637.