Surgical neurology international最新文献

Background: Impulsive aggression is the core symptom of intermittent explosive disorder, which can be a feature of several psychiatric disorders. There is a subset of individuals who do not respond adequately to medical treatment; they are treatment refractory. The objective of this report is to describe a case of a patient with a background of schizophrenia and concomitant refractory aggressiveness disorder, treated with two-stage bilateral hypothalamotomy and unilateral amygdalotomy with Gamma Knife radiosurgery (GKR).

Case description: A 36-year-old male presented with a background of paranoid schizophrenia. Episodes of self- and hetero-aggressiveness were present at the initial diagnosis. High dosages of psychotropic medication were taken, and 70 sessions of electroconvulsive therapy were performed; however, no adequate response was obtained. Bilateral hypothalamotomy plus left amygdalotomy through GKR was performed. After 25 months of follow-up, a marked decrease in the frequency, degree, severity of aggressiveness and the requirement for psychotropic medications was observed.

Conclusion: Hypothalamotomy plus amygdalotomy with Gamma Knife may be an effective ablative technique for the management of refractory aggressive disorder in patients with mental illness.

Background: One avenue to improve outcomes among brain tumor patients involves the mitigation of healthcare disparities. Investigating clinical differences among brain tumors across socioeconomic and demographic strata, such can aid in healthcare disparity identification and, by extension, outcome improvement.

Methods: Utilizing a racially diverse population from Hawaii, 323 cases of brain tumors (meningiomas, gliomas, schwannomas, pituitary adenomas, and metastases) were matched by age, sex, and race to 651 controls to investigate the associations between tumor type and various demographic, socioeconomic, and medical comorbidities. Tumor size at the time of diagnosis was also compared across demographic groups.

Results: At the time of diagnosis for benign meningiomas, Native Hawaiians and Pacific Islanders (NHPI; P < 0.05), Asians, and Hispanics exhibited nearly two-fold larger tumor volumes than Whites. For gliomas, NHPI similarly presented with larger tumor volumes relative to Whites (P = 0.04) and Asians (P = 0.02), while for vestibular schwannomas, NHPI had larger tumor sizes compared to Asians (P < 0.05). Benign meningiomas demonstrated greater odds of diagnosis (P < 0.05) among Native American or Alaskan Natives, patients comorbid with obesity class I, hypertension, or with a positive Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Malignant meningiomas demonstrated greater odds (P < 0.05) among patients from higher median household income and urban geography. Gliomas overall exhibited increased odds (P < 0.05) of diagnosis among Whites and reduced odds among Asians, with greater comorbidity with obesity class III; for glioblastoma specifically, there were reduced odds of asthma diagnosis. Patients with vestibular schwannomas were at increased odds (P < 0.05) of being from the highest income quartile and having a positive AUDIT-C, yet reduced odds of psychiatric disorders. Pituitary adenomas exhibited reduced odds of diagnosis among Whites, yet greater odds among NHPI, military personnel, obesity class I, and psychiatric disorders. Intracranial metastases were more common in patients with pre-obesity, asthma, a positive AUDIT-C, and living in more affluent regions. Benign meningiomas are most often presented with seizures, while malignant meningiomas have the addition of cognitive difficulty. Gliomas often present with seizures, cognitive difficulty, dizziness/nausea/vomiting (DNV), vestibular schwannomas with DNV, and metastases with seizures.

Conclusion: Brain tumors exhibit unique sociodemographic disparities and clinical comorbidities, which may have implications for diagnosis, treatment, and healthcare policy.

Background: Metastatic intramedullary spinal cord metastases (IMSCMs) constitute <2% of spinal cord tumors. IMSCM is a late-stage manifestation of cancer with a highly variable presentation and poor survival rate. Here, we present an operative video involving gross total resection of an IMSCM (i.e., non-small-cell lung cancer [NSCLC]) in a 74-year-old male.

Case description: A functionally independent 74-year-old male with a history of renal cell carcinoma (i.e., prior nephrectomy) and NSCLC presented with progressive right-sided hemiparesis/hemisensory loss. The patient's magnetic resonance imaging showed a right-eccentric metastatic lesion extending from the inferior of C3 to the superior of C5. The patient underwent a laminectomy with C2-C6 instrumentation for focal en bloc resection of the tumor (i.e., pathologically proven to be NSCLC). During surgery, dorsal column mapping defined the electrophysiological midline before proceeding with the midline myelotomy. Five months postoperatively, the patient's right-sided motor function continued to improve, and he was able to continue adjunctive therapies for his NSCLC.

Conclusion: This study documents the efficacy/utility of gross total en bloc resection in preserving/improving the neurological function of IMSCM lesions in elderly patients.

Background: Pituitary apoplexy (PA) is a rare, life-threatening clinical syndrome that occurs in response to acute ischemic infarction or hemorrhage of a pituitary adenoma. We report two cases of sudden neurologic and visual decline in patients with pituitary region masses in coronavirus disease (COVID)-positive patients with a focus on potential pathophysiological mechanisms and a safe approach to treatment.

Case description: Case one is a 58-year-old male presenting with sudden-onset headache and visual disturbance. He was febrile and tested positive for COVID-19. Magnetic resonance imaging (MRI) revealed a large sellarsuprasellar mass with intratumoral hemorrhagic components. He underwent endoscopic endonasal resection with subsequent improvement in vision and oculomotor function. Pathology was consistent with hemorrhagic pituitary adenoma. Case two is a 15-year-old male presenting with sudden-onset severe headache and acute visual loss. He also tested positive for COVID-19. MRI revealed a sellar-suprasellar mass with a regional mass effect. He underwent endoscopic endonasal resection with improvement in vision over time. Pathology was consistent with craniopharyngioma. There was no evidence of intraoperative COVID-19 transmission among members of the surgical team, who were monitored for 2 weeks after surgery.

Conclusion: PA in the setting of severe acute respiratory syndrome coronavirus 2 infection should be considered in the differential diagnosis of a COVID-positive patient presenting with acute severe headache, visual loss, and/or ophthalmoplegia; we discuss proposed mechanisms related to inflammation, coagulability, and hypoxia. The absence of intraoperative COVID-19 transmission during transsphenoidal resection performed in an emergency setting suggests that the risk of exposure may be attenuated with safety precautions.

Background: Meningioma is the most common primary intracranial tumor. This single-center study aimed to analyze the clinicopathological, radiological profile, and outcomes of patients with intracranial meningiomas in terms of functional status, morbidity, mortality, and recurrence-free survival (RFS).

Methods: Patients of intracranial meningioma treated between January 01, 2010, and December 31, 2019, at the Department of Neurosurgery, King George's Medical University, India, were included in this study. Retrospective data analysis of 172 patients with intracranial meningioma was done.

Results: The majority of the patients, that is, 94 (54.65%), presented in the 4^th and 5^th decade. The mean size of the meningioma was 36.4 ± 4 mm (range: 26-68 mm). Of the 172 patients, 128 (74.41%) were diagnosed as non-skull base meningiomas, and in 44 patients (25.59%), meningioma originated from the skull base. Recurrence was observed on follow-up imaging in 11 patients after a mean postoperative interval of 55.2 ± 5.8 months. Radiological meningioma recurrence paralleled with clinical deterioration in seven patients. Three of these patients were subjected to the second surgery, followed by radiotherapy, and in the remaining four patients, Gamma knife or fractionated radiotherapy was given.

Conclusion: The majority of patients had good functional outcomes (KPS >70) at discharge. Morbidity and mortality was 18.60% and 3.49%, respectively. Meningioma size ≥4 cm, age >45 years, World Health Organization Grade (II, III), non-skull base location, and Simpson grade III, IV of resection showed significantly shorter RFS.

Background: Propofol is one of the most used intravenous anesthetic agents in traumatic brain injury (TBI) patients undergoing emergency neurosurgical procedures. Despite being efficacious, its administration is associated with dose-related adverse effects. The use of adjuvants along with propofol aids in limiting its consumption, thereby mitigating the side effects related to propofol usage. This study aims to compare the safety and efficacy of dexmedetomidine-propofol versus fentanyl-propofol-based total intravenous anesthesia (TIVA) in adult TBI patients.

Methods: A hundred patients posted for emergency evacuation of acute subdural hematoma were enrolled, and they were randomized into two groups of 50 each. Propofol-based TIVA with a Schneider target-controlled infusion model was used for induction and maintenance. Patients in Group F received fentanyl, and those in Group D received dexmedetomidine infusions as adjuvants. Advanced hemodynamic parameters were monitored. Intracranial pressure (ICP) and brain relaxation were measured after dural opening. The mean propofol consumption, number of additional fentanyl boluses, and blood samples for S100b (a biomarker of neuronal injury) were also collected.

Results: The mean propofol consumption in Group D (88.7 ± 31.8 μg/kg/min) was lower when compared to Group F (107.9 ± 34.6 μg/kg/min), (P = 0.005). The mean intraoperative fentanyl requirement and postoperative S100b were significantly reduced in Group D. Subdural ICPs and brain relaxation scores were comparable. Hemodynamic parameters were well maintained in both groups.

Conclusion: In TBI, dexmedetomidine as an adjunct to propofol-based TIVA results in a greater reduction in total propofol consumption and intraoperative opioid requirements while maintaining hemodynamic stability when compared to fentanyl.

Background: Causes of cerebrospinal fluid (CSF) rhinorrhea could be divided into primary (spontaneous) and secondary (head trauma and iatrogenic). Idiopathic intracranial hypertension (IIH) has emerged as a cause for spontaneous CSF rhinorrhea but is still underestimated, may be overlooked and needs special consideration in management. The objective of this study is to demonstrate spontaneous CSF rhinorrhea as the primary presentation of IIH and explore the algorithm of management.

Methods: All patients with spontaneous (primary) CSF rhinorrhea were included with complete clinical and radiological assessment. We performed lumbar puncture and CSF pressure measurements in the lateral decubitus position for all included patients to detect those with intracranial hypertension. A pressure of 20 cmH2O in cases of CSF rhinorrhea is considered a cutoff for diagnosing raised intracranial pressure. When intracranial hypertension was diagnosed, patients were subjected immediately to lumboperitoneal shunt. If CSF leakage stopped after shunt insertion, we would not perform skull base repair, and the patient was sent for follow-up. However, if CSF leakage did not stop after shunt insertion despite normalization of intracranial tension or recurrence of CSF rhinorrhea despite shunt patency or there was intracranial pneumocephalus, skull base repair would be performed.

Results: During the period of the study, 293 cases of CSF rhinorrhea were seen. Only 42 (14.3%) patients were diagnosed with spontaneous CSF rhinorrhea, and the remaining were posttraumatic. Thirty-seven patients (88.1%) of 42 patients revealed high CSF pressure readings. All 37 patients received lumboperitoneal shunt followed by CSF rhinorrhea stoppage. Later, during follow-up, 7 patients developed recurrence of leakage; 3 of them revealed shunt obstruction, and rhinorrhea improved after shunt revision. The other 4 patients revealed patent shunt and needed skull base repair.

Conclusion: Spontaneous CSF rhinorrhea is considered secondary to IIH until proven otherwise. Initial placement of lumboperitoneal shunt may provide an effective alternative to skull base repair for the treatment of patients with IIH presenting with CSF rhinorrhea.

Background: Intracranial arteriovenous malformations (AVMs) are extremely rare in the pediatric population, with an estimated prevalence of 0.014-0.028%. About 75-80% of pediatric AVMs present with intracranial hemorrhage, a source of significant morbidity and mortality. Awake craniotomy (AC) has become the standard approach for resecting eloquent area intracranial lesions in the adult population. Its use, however remains limited in the pediatric population and has very rarely been reported for an AVM of the motor cortex in this age group.

Case description: We report the case of a 17-year-old, right-handed boy who presented to our setup with a 2-month history of left-sided hemiparesis and left facial hypoesthesia following an episode of acute loss of consciousness (ALOC) while playing football. A computed tomography scan done after ALOC revealed an AVM in the right frontoparietal cortex with associated acute hemorrhage. Digital subtraction angiography (DSA) was done which revealed a right-sided grade II AVM with arterial supply from the right middle cerebral artery and venous drainage into the superior sagittal and cavernous sinuses. The patient underwent elective neuronavigation-guided right frontoparietal AC and resection of AVM. Postoperative DSA revealed no residual disease. The patient's neurologic deficits showed improvement in the first few days following surgery. He was discharged with advice to follow up in a neurosurgery clinic to monitor his postoperative recovery and ensure compliance with physiotherapy.

Conclusion: This case represents only the second pediatric patient in the available medical literature to have ever undergone AC for intracranial AVM resection. Pediatric AVMs are a rare entity and pose the risk of significant morbidity and mortality. Awake surgery has the potential to reduce iatrogenic neurological deficits in the pediatric population significantly. More work must be done to increase pediatric patient compliance with awake surgery.