Surgical neurology international最新文献

Background: Multiple trials have recently been published evaluating middle meningeal artery embolization (MMAE) for the treatment of chronic subdural hematomas (SDHs). All trials, however, have assessed distal embolization with liquid embolic while many retrospective reviews have evaluated distal embolization with polyvinyl alcohol (PVA) particles. The present study sought to compare the efficacy and safety of proximal coil MMAE with the efficacy and safety of distal embolization.

Methods: A prospectively collected, retrospectively analyzed database was queried for patients undergoing MMAE. Patients were subdivided into cohorts based on treatment modality: distal embolization with PVA particles or proximal coil embolization. The electronic medical record was reviewed to obtain demographic, surgical, and outcome data, and these data were compared. Additional subgroups were created to separately compare patients undergoing only embolization as well as patients undergoing surgical decompression with embolization.

Results: Ninety-five patients with 122 SDH were identified. No significant difference was identified between groups demographically; however, there was a significant decrease in fluoroscopy with unilateral proximal embolization (14.0 min vs. 17.2 min, P = 0.037) and a nonstatistical reduction in the number of embolic complications (0 vs. 4, P = not significant). In addition, there was no difference in the rate of SDH improvement at 3-month postprocedure or last follow-up. These findings were also true for patients treated with only embolization but not for the group treated with surgical decompression and embolization (likely due to small sample size).

Conclusion: Proximal MMAE is noninferior to distal embolization with a decrease in fluoroscopy time and a potential reduction in embolic complications.

Background: Intracranial aneurysms affect 3% of the population, with advancements in radiology enabling more diagnoses of unruptured aneurysms. The black blood magnetic resonance imaging (bbMRI) is a valuable noninvasive method to study of the inflammatory process in the wall of intracranial arteries. This study aimed to correlate wall enhancement of aneurysms through bbMRI with known risk factors.

Methods: A retrospective analysis was conducted on patients who had microsurgery for ruptured and unruptured intracranial aneurysms from June 2020 to March 2023. Patient demographics and radiological findings were reviewed with qualitative variables analyzed using Fisher's exact test and quantitative variables using the Mann‒ Whitney.

Results: We analyzed 120 patients and 139 aneurysms. All patients underwent microsurgery for clipping at least one aneurysm. Female was more prone to exhibit ruptured aneurysms than males (28% vs. 8%, P + 0.03, odds ratio [OR] = 0.2, 95% confidence interval [CI] 95% = 0.04-0.9). Ruptured aneurysms were more likely to have a diameter ≥7 mm (50% ruptured vc. 23.8% unruptured, P = 0.05, OR = 0.3, 95% CI = 0.1-0.6). bbMRI was positive in 76.5% of ruptured aneurysms and 23.5% were negative (P < 0.0001). In the unruptured aneurysm group, the larger the aneurysm was, the greater the chance of positive bbMRI (OR = 0.1, 95% CI = 0.05-0.3). In this subgroup, either size or positive bbMRI was associated with rupture.

Conclusion: Our analysis demonstrated that ruptured aneurysms are more prone to be positive on bbMRI, that is, aneurysm wall enhancement after the administration of contrast. This reinforces the association between positive bbMRI and aneurysm instability.

Background: Sparganosis is a rare parasitic infection caused by the plerocercoid larvae (spargana) of Spirometra species. Central nervous system (CNS) involvement is uncommon; cerebral sparganosis can be particularly challenging to diagnose because its clinical presentation and imaging features often mimic those of more common parasitic infections (e.g., neurocysticercosis) or neoplastic lesions.

Case description: A 74-year-old woman with slowly progressive Alzheimer's disease, who had undergone regular brain magnetic resonance imaging (MRI) examinations over the past three years, was incidentally found to have a slowly enlarging lesion with surrounding edema in the left frontal lobe on MRI of the brain. The lesion demonstrated calcification and radiological features atypical for a neoplastic process, thus prompting a left frontal craniotomy for diagnostic purposes. Intraoperatively, a whitish, linear structure was removed. Frozen section revealed granulomatous inflammation with parasitic structures. Molecular biological analysis identified the specimen as a Spirometra larva (Type I), confirming the diagnosis of cerebral sparganosis. Postoperatively, her baseline cognitive impairment persisted; however, follow-up MRI at 1 month demonstrated resolution of the enhancing lesion, and no new neurological deficits occurred.

Conclusion: Cerebral sparganosis should be considered in the differential diagnosis of intracranial mass lesions with a tumor-like appearance. Although the diagnosis remains challenging, molecular techniques permit definitive confirmation. Surgical resection serves a dual role, facilitating both accurate diagnosis and treatment.

Background: Dural arteriovenous fistula (DAVF) has been reported as a rare cause of chronic subdural hematoma (CSDH); however, CSDH associated with a Cognard type IIa+b DAVF has not been reported.

Case description: A 56-year-old woman without traumatic history presented with headache and was diagnosed with right-sided CSDH and a transverse-sigmoid sinus DAVF. She underwent transvenous and transarterial embolization along with burr-hole drainage. Although residual shunting persisted after the first session, complete resolution was achieved after the third. Over 4 years of follow-up, there was no recurrence of CSDH or DAVF.

Conclusion: This case highlights that DAVFs can cause CSDH regardless of the Cognard type, and that combined curative DAVF treatment and drainage may be effective.

Background: The lateral transorbital neuroendoscopic approach (TONES) is progressively gaining popularity. Recent studies have emphasized its feasibility and potential applications. A thorough understanding of the anatomy and the phases of this approach is essential for developing confidence in its execution.

Methods: A step-by-step description of the transpalpebral TONES approach, accompanied by detailed, illustrative images, was provided using recent and most relevant publications. High-definition images of the orbit were created using the photo stacking technique. Digital drawings of the approach steps were optimized and simplified, eliminating distractions, using Procreate. Brainlab 3D Elements and SmartBrush 5.0 were used for patient images.

Results: The text was divided into two main headings: anatomy and surgery. Both main portions involved detailed descriptions of the most critical and influential characteristics of the TONES. Straightforward anatomical illustrations were used to simplify the learning of the endoscopic transorbital perspective and steps of the TONES approach.

Conclusion: A stepwise, comprehensive, and straightforward review of this emerging approach is essential for the learning community in endoscopic skull base surgery. TONES is estimated to increase from a feasibility perspective, guiding the development of lateral skull base access options. We believe it will be similar to the evolution of the endonasal endoscopic approach.

Background: Paragangliomas of the cauda equina are rare neuroendocrine tumors that can mimic ependymomas on imaging and histology, creating diagnostic challenges and influencing surgical planning.

Case description: A 41-year-old man presented with progressive low back pain and bilateral leg numbness. MRI showed a well-circumscribed, enhancing intradural extramedullary mass at L3. He underwent L3-L4 laminectomy with gross-total microsurgical excision. Histopathology revealed pseudorosettes and uniform tumor cells, initially suggesting ependymoma; however, immunohistochemistry demonstrated strong synaptophysin and S100 positivity with negative GFAP and EMA, confirming a cauda equina paraganglioma. Postoperatively, the patient recovered fully and remained asymptomatic at 1-year follow-up.

Conclusion: Paragangliomas can closely resemble ependymomas, and accurate diagnosis requires immunohistochemistry. Complete surgical excision yields excellent outcomes, and individualized long-term imaging follow-up is recommended because recurrence, although uncommon, can occur.

Background: Brain abscesses are recognized complications of penetrating craniocerebral trauma, typically developing within 6-8 weeks following the initial injury. Delayed onset abscesses have been occasionally reported, with extremely few cases occurring decades after the trauma. The pathophysiological mechanisms behind such scenarios remain poorly understood, highlighting the need for heightened clinical suspicion in patients with a history of head injury who present with new neurological symptoms, regardless of the time elapsed.

Case description: We present the case of a 68-year-old male with gait instability, dizziness, and dysmetria. Past medical history was notable for a craniocerebral gunshot wound sustained 38 years earlier. Imaging revealed a cerebellar mass consistent with a brain abscess and neurosurgical intervention confirmed the diagnosis. The unusual latency between the initial injury and the development of the abscess raises significant questions about the long-term behavior of dormant infectious foci and the potential triggers for reactivation.

Conclusion: This case emphasizes the importance of considering remote trauma as the cause of new symptoms, even decades after the event. The possibility of a latent infection becoming active after a prolonged period remains a speculative yet critical issue. For survivors of penetrating brain injuries, clinicians must maintain a high index of suspicion when atypical symptoms arise. Delayed diagnosis due to unfamiliarity with such rare presentations can lead to suboptimal outcomes. This case also underscores the diagnostic challenge these scenarios pose, particularly for clinicians without specialized training. Awareness of this possibility may lead to earlier recognition and management, potentially improving patient outcomes.

Background: Intracranial epidermoid cysts are congenital lesions with a predilection for midline or paramedian spaces including the cerebellopontine cistern, fourth ventricle, or the interhemispheric fissure. The only effective treatment is resection. Conventionally, epidermoid cysts are resected with open transcranial approaches. The advent of neuroendoscopy has allowed for less invasive options and can assist open microneurosurgery in better visualization of the lesion around corners. As rigid neuroendoscopes are limited in accessing tight corners, flexible endoscopy has been proposed to assist neurosurgery, with the additional angles of view and the advantage of tip-steerability. We present a case of flexible endoscopy assistance in epidermoid cyst resection.

Case description: A 41-year-old woman presents with a posterior fossa epidermoid cyst, where suboccipital craniotomy and flexible endoscopy-assisted resection allowed for visualization of the remaining cranial portion of the tumor in the 4^th ventricle without excessive brain retraction, guide microsurgical instruments into the cavity, and confirm clearance of clots and debris in the cerebral aqueduct. A 62-year-old man presents with an interhemispheric epidermoid cyst, where bifrontal craniotomy, pure left hemispheric approach, and flexible endoscopy assistance allowed resection of cystic components in difficult areas with an acute angulation.

Conclusion: We illustrate the novel use of flexible endoscopy to assist with the resection of a recurrent posterior fossa epidermoid cyst and an interhemispheric epidermoid cyst.

Background: Chronic subdural hematoma is one of the most common pathologies in neurosurgery and represents one of the first surgical challenges for residents and surgeons in their early years of experience, particularly when the hematoma lacks a typical hemispheric distribution. Our study presents an innovative and low-cost smartphone-based augmented reality (AR) technique designed to facilitate the preoperative planning of chronic subdural hematomas.

Methods: Twenty patients with non-fully hemispheric subdural hematomas operated using a smartphone-based AR platform (AR-based planning, AR-b) were included in our study. Before the skin incision, the site and extent of the surgical access were verified by a second surgeon, whose planning was based solely on 2D computed tomography images (2D-b). Data regarding spatial discrepancies and length differences between the two planning were collected and analyzed with a paired t-test with a significance level of 0.05.

Results: No discrepancies >1 cm were found between the two methods. We found a significant difference between the length of the two planning phases (AR-b: 8' ± 1,9 vs. 2D-b: 4,1' ± 1,4). Nevertheless, concerning the overall surgical duration, no marked difference was found between the total length of the procedures performed with AR-b and similar procedures planned with 2D-b.

Conclusion: Due to its lack of additional costs and effective precision, our technique represents a valuable aid for surgeons in training or in their early years of experience in the presurgical planning of chronic subdural hematoma.