Surgical neurology international最新文献

Background: Ventriculo-gallbladder (VGB) shunt represents an uncommon yet well-documented surgical intervention for the treatment of hydrocephalus through cerebrospinal fluid (CSF) diversion into the gastrointestinal tract through the gallbladder. When other ventricular shunt types have failed or are contraindicated, VGB shunts are effective. In exceptionally rare circumstances, biliary reflux can occur and cause accumulation of bile in the ventricular system. The authors report a case of bile reflux through a ventricular gallbladder shunt with eventual patient recovery after surgical intervention. Prior reports of VGB shunt complications are discussed.

Case description: The authors present the case of a 3-year-old girl with a history of craniopharyngioma causing obstructive hydrocephalus. At an outside facility, she underwent ventriculo-peritoneal (VP) shunt placement, which failed due to abdominal pseudocyst after 6 months. The patient then underwent a subtotal resection of her tumor and placement of a right VGB shunt system with a subdural and ventricular catheter connected distally to a Certas valve. Her postoperative course was complicated by the left-sided tonic-clonic seizures and hyponatremia. Three months later, the patient presented to our emergency department with persistent hyponatremia, encephalopathy, and seizure activity in the setting of COVID-19. Imaging demonstrated a right hypodense subdural fluid collection. Right frontal craniotomy demonstrated accumulation of bile in the subdural space secondary to retrograde flow from the gallbladder, which was evacuated. After externalized subdural drainage evolved from biliary fluid to normal CSF, the externalized ventricular shunt and subdural drain were replaced with a ventriculo-atrial shunt. The patient gradually improved with each follow-up visit over the course of several years.

Conclusion: This case demonstrates a potentially life-threatening complication of VGB shunt in the form of biliary reflux into the subdural space. Valveless VGB shunts should be avoided to prevent this rare but potentially fatal complication.

Background: Papillary glioneuronal tumor (PGNT) is a rare, World Health Organization (WHO) Grade I mixed glioneuronal neoplasm characterized by the presence of both neuronal and glial elements. It commonly presents with seizures or headaches and has a generally favorable prognosis after gross total resection. Here, we present an unusual case of PGNT with deep hemispheric extension involving the centrum semiovale, temporal lobe, and mesencephalon in a pediatric patient.

Case description: A 6-year-old male patient presented with a history of two partial epileptic seizures over the past 3 months. On admission, neurological examination was unremarkable. Personal and family histories were non-contributory. Initial cranial magnetic resonance imaging (MRI) revealed a heterogeneous T2-hyperintense, T1-hypointense, noncontrast-enhancing lobulated lesion extending from the left centrum semiovale to the temporal lobe and mesencephalon with minimal rightward midline shift. The patient underwent left frontoparietal craniotomy and microsurgical excision under neuronavigation. Given the tumor's eloquent location, a safe subtotal resection was performed. Histopathological evaluation revealed a WHO Grade I PGNT with glial fibrillary acidic protein, Olig2, and synaptophysin positivity and a low Ki-67 proliferation index (2-3%). Postoperatively, the patient had no neurological deficits and was discharged on the 7^th day. A follow-up MRI is planned at 6 months.

Conclusion: This case underscores the need to include PGNT in the differential diagnosis of pediatric patients presenting with new-onset focal seizures and MRI findings suggestive of a low-grade glioma. Surgical management is typically curative, resulting in excellent seizure control and long-term outcomes.

Background: Craniotomy involves creating multiple burr holes followed by the opening of a bone flap. After the intracranial procedure, the bone flap is replaced (osteoplasty), but burr hole defects remain and may lead to scalp depressions over time. This study evaluates the effectiveness of using a graft combination of bovine scaffold material and autologous calvarial bone dust for burr hole defect closure in calvarial osteoplasty.

Methods: The scaffold was derived from the epiphysis of bovine cancellous femur bone, prepared by the tissue bank of Dr. Soetomo General Hospital, and adjusted to fit burr hole defects. Four patients underwent grafting with this combination during osteoplasty. All patients were followed up and evaluated at least 1 year after graft placement. Clinical assessment focused on scalp depressions, while head computed tomography (CT) scans were used to evaluate bone integration between the calvarial bone and the graft.

Results: Among four patients, one showed scalp depression at the graft site, while the other three had no visible indentations. CT scans demonstrated that the three cases without scalp depression have intact grafts with cortical thickening in some areas. The single case with depression exhibited graft resorption and lytic bone changes. Importantly, no signs of graft rejection or allergic reactions were observed in any patient.

Conclusion: This study suggests that the combination of bovine scaffold material and autologous calvarial bone dust in burr hole defect closure during calvarial osteoplasty can prevent scalp depression in the defect area.

Background: Cervical diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is an uncommon but potentially reversible cause of dysphagia due to mechanical compression of the hypopharynx or upper esophagus.

Case description: Two male patients presented with progressive dysphagia caused by anterior cervical DISH. Radiological evaluation demonstrated extensive anterior osteophyte formation resulting in significant hypopharyngeal and esophageal compression. Both patients underwent anterior cervical osteophytectomy, which led to immediate and complete resolution of dysphagia without perioperative complications, with normalization of postoperative eating assessment tool-10 (EAT-10) and functional oral intake scale (FOIS) scores. In addition, a focused review of the literature (2015-2024) identified 41 clinical studies involving 200 patients treated surgically for cervical DISH-related dysphagia, demonstrating approximately 90% symptomatic improvement with minimal morbidity.

Conclusion: Cervical DISH is a rare but surgically treatable cause of dysphagia. Early recognition and timely anterior cervical osteophytectomy result in excellent clinical outcomes and rapid symptom resolution..

Background: Surgery in the dorsal root entry zone (DREZ) was introduced in 1972 to treat pain and spasticity. Originally, Sindou's technique involved performing the DREZ surgical lesion utilizing a scalpel and bipolar cautery. Here, we introduce a variation of the original technique, avoiding cautery for 14 consecutive patients (Group 2), and compared them with a previous series of 22 patients, operated on with the original Sindou's technique (Group 1).

Methods: We performed the modified DREZ technique in 14 consecutive patients with lower limb spasticity. After sharply opening the lateral sulcus (i.e., lateral to the dorsal root), we interspersed fragments of absorbable gelatin sponge to prevent heat from cautery spreading to the surrounding neural tissues.

Results: In the 1^st group, two of the 22 patients developed worsening unilateral paresis postoperatively. In the 2^nd group, after "cold MDT," no patients, 0 of 14 total patients, were worse. Further, spasticity improved in approximately 82% of patients from both groups.

Conclusion: In this short series of 14 patients (Group 2), we observed benefits similar to those described for patients undergoing classical DREZ lesions utilizing Sindou's technique (Group 1), but none sustained any new postoperative motor deficits.

Background: Vascular compression of the medulla oblongata is a rare but serious condition most commonly caused by dolichoectatic vertebrobasilar arteries. This syndrome, sometimes referred to as vertebral artery compression syndrome, can result in severe and progressive neurological symptoms. Optimal diagnostic and therapeutic approaches remain challenging in complex cases of medullary compression caused by ectatic vertebral arteries.

Case description: We report a 55-year-old man with progressive neurological deficits secondary to bilateral vertebral artery compression of the medulla oblongata. He presented with tetraparesis, lower cranial nerve palsies, and significant gait disturbance. Preoperative magnetic resonance imaging confirmed bilateral dolichoectatic vertebral artery compression. Three-dimensional reconstructed images facilitated both diagnosis and surgical planning. Surgical macrovascular decompression was performed using sling transposition for the left vertebral artery and an interposition technique for the right vertebral artery. Postoperatively, the patient demonstrated significant neurological recovery, including complete resolution of cranial nerve deficits and marked improvement in motor function.

Conclusion: This case demonstrates the effectiveness of combining vascular sling and interposition techniques for the treatment of complex vertebral artery compression of the medulla oblongata. Three-dimensional reconstructed images proved valuable for both diagnosis and treatment planning of this challenging condition.

Background: The anterior Sylvian point (ASP) is defined as the most anterior portion of the Sylvian fissure (SF) and is three-dimensionally located between the pars triangularis of the frontal lobe and the pars opercularis of the temporal lobe. Despite the importance given to the ASP in numerous anatomical studies, little has been devoted to objectively describe and generate a correlation between this measurement and its microsurgical approach.

Methods: This study was carried out at the laboratory of microsurgical neuroanatomy, second chair of anatomy of the University of Buenos Aires, and entails the morphometric analysis of 40 cerebral hemispheres, their digital registration and subsequent measurement of the ASP utilizing the international system of units, expressed in millimeters (mm). Our results were classified into three types (A, B, and C), defining type A as hemispheres with an ASP < 5 mm, type B as those between 5.1 mm and 10 mm, and type C as those with distances >10 mm.

Results: ASP type B was the most frequent type in our sample, representing 45% of the right and 40% of the left hemispheres. This was followed by type A with 35% and 40%, respectively, and type C was found in a lower percentage.

Conclusion: A considerable morphometric variation of the ASP was identified and classified into three types according to its distance (A, B, and C). Validation of this measurement is warranted for its subsequent microsurgical application regarding SF openings, suggesting that ASP type B and C could require less time and technical difficulty than type A.

Background: Concomitant odontoid fractures associated with subaxial cervical lesions are extremely rare and present both diagnostic and therapeutic challenges.

Case description: A 70-year-old man presented after a high-energy car accident with severe posterior neck pain but no neurological deficit. Computed tomography imaging revealed a type II odontoid fracture and a C7-T1 fracture-dislocation. He underwent anterior odontoid screw fixation followed by anterior cervical discectomy and fusion at the same session. Postoperative recovery was uneventful, and follow-up imaging confirmed solid fusion at 6 months.

Conclusion: This case highlights the feasibility and safety of single-session, all-anterior stabilization for concomitant upper and lower cervical fractures in a selected elderly patient, achieving solid fusion with minimal morbidity.

Background: Awake craniotomy with intraoperative mapping remains the gold standard for resection of gliomas in eloquent brain regions, enabling functional preservation while maximizing tumor removal. Recent advances in brain connectomics provide a connectivity-based approach, complementing traditional localization strategies by visualizing patient-specific structural and functional networks. We report the first Latin American case of diffuse glioma resection in the motor cortex using connectome-guided neuronavigation combined with awake functional monitoring.

Case description: A 43-year-old male presented with focal motor seizures affecting the left upper limb. Preoperative magnetic resonance imaging revealed a motor-eloquent lesion. Patient-specific connectome parcellation identified intratumoral motor parcels, guiding surgical approach planning. During awake craniotomy, intraoperative mapping confirmed motor activation sites, enabling selective resection. Surgery was halted upon detecting transient monoparesis (3/5, Daniels scale) to preserve function. Postoperative recovery was complete within 2 weeks. Pathology confirmed the World Health Organization grade 2 diffuse astrocytoma.

Conclusion: This case illustrates the synergistic potential of connectome-guided neuronavigation and awake surgery in achieving a balance between oncologic and functional goals. Connectomics enhances preoperative planning by delineating individualized cortical-subcortical networks, even in anatomically distorted brains. Awake mapping provides real-time functional verification, mitigating limitations such as brain shift and resolution constraints inherent to navigation alone. While evidence is still limited to small series, this integrated approach offers a promising avenue for safe maximal resection in eloquent gliomas. Further studies are needed to validate its impact on long-term functional and oncologic outcomes.

Background: Moderate-to-severe traumatic brain injury (TBI) is a major public health burden in middle-income countries, yet local prognostic data are scarce. This study aims to define the epidemiological profile, management, and predictors of outcomes in TBI patients surviving the initial phase in a Moroccan university hospital.

Methods: A retrospective observational study was conducted on 133 consecutive patients admitted for moderate-to-severe TBI at the Hassan II University Hospital in Fes between 2022 and 2023. Demographic, clinical, radiological, and therapeutic data were collected. Multivariate logistic regression was used to identify independent predictors of an unfavorable outcome (defined as death or major disability, with a Glasgow Outcome Scale score of 1-3) at 28 days.

Results: The cohort was predominantly composed of young men (78.2%), with a median age of 28 years. Road traffic accidents were the leading cause of injury (47.4%). The overall mortality rate at 28 days was 13.5%. Five independent predictors of an unfavorable outcome were identified: age over 65 years (odds ratio [OR] = 4.2), an initial Glasgow Coma Scale (GCS) score ≤8 (OR = 3.8), the presence of bilateral brain lesions (OR = 2.9), persistent arterial hypotension (OR = 2.4), and a time-to-management exceeding 4 h (OR = 1.9). The predictive model demonstrated excellent discrimination (area under the curve = 0.91).

Conclusion: In our setting, moderate-to-severe TBI primarily affects a young population, mainly as a result of road accidents. Age, initial GCS score, the extent of lesions, hemodynamic instability, and treatment delays are major determinants of prognosis. These findings highlight the critical importance of early diagnosis and rapid intervention to improve patient outcomes.