Surgical neurology international最新文献

Background: Glioependymal cysts are rare lesions, especially in children.

Case description: The authors treated a well-developed 12-year-old male who presented with 1 week of acute-onset headache. Magnetic resonance imaging revealed a thin-walled third ventricular cyst obstructing the foramen of Monro. Endoscopic fenestration of the cyst with biopsy and endoscopic third ventriculostomy was performed. Histopathologic examination revealed a glioependymal cyst. At 13-month follow-up, the patient is asymptomatic without evidence of recurrence.

Conclusion: This case represents the first glioependymal cyst reported in an adolescent.

Background: While a variety of modalities are available for the treatment of hydrocephalus, ventriculoperitoneal shunting (VPS) remains the most utilized treatment. Although efficacious, VPS is susceptible to malfunction, with catheter obstruction as the primary cause of failure in pediatric patients. Prior studies have speculated that implanted catheters trigger an immune response from the central nervous system, resulting in cellular reactivity and subsequent obstruction of the device. These cells are derived from the choroid plexus (ChP), which plays an active role in immunological surveillance. Its cellular components contain some of the putative cells that contribute to ventricular catheter occlusion.

Case description: The case illustrated herein is a patient with a functionally obstructed polyvinylpyrrolidone (PVP)-coated catheter, with ChP occluding the catheter fenestrations. While silicone catheter obstruction typically presents with fibrosis and microglial reaction, the illustrated case demonstrates the absence of an immunological response. PVP-coated catheters appear to deter cellular attachment which may dampen the immune response to the catheter in the brain. However, the case discussed postulates that ChP can still obstruct PVP-coated catheters through growth and expansion into the catheter holes and lumen, even without an immune response.

Conclusion: This case report highlights the complexity of novel catheter designs constructed from nonimmunogenic materials while considering catheter hole configuration and size to deter ChP growth into the catheter holes and the lumen to prevent cellular catheter occlusion.

Background: Presigmoid approaches provide access to several structures anterior to the sigmoid sinus (SS) and may be intended for the treatment of lesions located in the middle and posterior fossa. We conducted a morphometric cadaveric study investigating the infratentorial presigmoid retrolabyrinthine suprameatal approach (PRSA) as a unique operative corridor. The typical anatomic-radiological characteristics and variations were evaluated and analyzed to predict surgical accessibility.

Methods: A total of 10 surgical dissections were performed on both sides of five adults, injected, and cadaveric heads. Fifteen morphometric parameters were measured, analyzed, and categorized into pre-procedural, intra-procedural, and additional parameters.

Results: Preoperative anatomic-radiological parameters provide valuable information to select patients with favorable anatomy that may offer appropriate surgical accessibility to the medial part of cerebellopontine angle cistern, lateral pons, and prepontine cistern through a PRSA corridor. An obtuse petroclival angle of ≥144° with a more horizontally oriented petrous bone, a posterior SS position, and a large mastoid cavity provided the greatest surgical accessibility through the PRSA corridor. The superior petrosal sinus drainage and the degree of petrous apex pneumatization were important factors affecting surgical fluency and speed. However, they were not determinant factors for selecting the most appropriate patients eligible for the PRSA.

Conclusion: The PRSA represents a minimally invasive modification of the trans-labyrinthine approach that may be offered in patients with lesions medial to the internal auditory canal or anterior/lateral to the brainstem, with the goal of preserving vestibulocochlear functions. Preoperative anatomic-radiological parameters are mandatory for a patient-tailored selection of the most effective surgical approach.

Background: Internal carotid artery (ICA) injury is a rare but severe complication of transsphenoidal surgery.

Case description: A 69-year-old woman presented with progressive visual disturbance secondary to pituitary adenoma. The patient underwent subtotal tumor resection through endoscopic transsphenoidal surgery. The residual tumor in the cavernous sinus gradually enlarged over the next 3 years. During a second surgical intervention, an inadvertent scratch, with the worn-out tip of the micro-suction device, on the partially calcified medial wall of the C4 segment resulted in ICA rupture, leading to uncontrollable hemorrhage. After provisional hemostasis, the patient was transported to the angiography suite, where an irregularly shaped leak of contrast on the medial aspect of C4. A stent-assisted coil embolization was successfully performed, resulting in complete aneurysm isolation. The patient underwent revisional surgery on postoperative day (POD) 14, in which the coils exposed from the ICA laceration were covered with fascia lata, muscle, and surgical glue. After a lumboperitoneal shunt placement for progressive hydrocephalus, the patient was discharged on POD 82 without focal neurological deficits.

Conclusion: During transsphenoidal surgery, ICA injury can result from inadvertent manipulation using a micro-suction device. Careful manipulation and conservative resection followed by stereotactic radiosurgery may be a valid strategy for managing pituitary adenomas invading the cavernous sinus.

Background: Rebleeding is a prognostic factor in hemorrhagic moyamoya disease (MMD). This report describes a case of cerebrospinal fluid over-drainage from a ventriculoperitoneal (VP) shunt after an intraventricular hemorrhage that may have contributed to a putaminal hemorrhage.

Case description: The patient was a 51-year-old woman with a prior intraventricular hemorrhage and moyamoya diagnosis who had not undergone revascularization surgery and was neurologically stable. She was readmitted in August 2023 with recurrent intraventricular hemorrhage and underwent shunt placement for hydrocephalus. Three weeks later, she developed a massive putaminal hemorrhage and required an emergency craniotomy. The narrowing of the ventricles before the hemorrhage suggested over-drainage. Rapid reduction in intraventricular pressure may have collapsed the fragile collateral vessels and led to the hemorrhage.

Conclusion: VP shunt placement for hydrocephalus in patients with MMD following intraventricular hemorrhage necessitates careful management of shunt pressure settings. Given the fragile condition of collateral vessels in MMD, aggressive reductions in shunt pressure should be avoided. Instead, gradual and controlled adjustments are recommended to minimize the risk of over-drainage and subsequent hemorrhagic complications. Regular imaging, such as frequent computed tomography scans, is essential to monitor ventricular size and guide cautious pressure modulation.

Background: Dural arteriovenous fistulas (DAVFs) of the anterior condylar confluence (ACC) are rare vascular lesions at the skull base, often characterized by complex venous anatomy and variable clinical presentations. Their symptoms may overlap with those of cavernous sinus (CS) DAVFs, leading to potential misdiagnosis. Advanced imaging techniques and individualized treatment approaches are essential for accurate diagnosis and effective management.

Case description: We present two cases of ACC DAVFs successfully treated with transvenous embolization (TVE). The first case involved a patient with hypoglossal nerve palsy and non-specific headache. The second case presented with cranial nerve III palsy, proptosis, and diplopia due to retrograde venous drainage into the CS, along with hypoglossal nerve symptoms, including tongue stiffness and difficulty speaking. Both patients experienced complete resolution of symptoms following treatment.

Conclusion: ACC DAVFs are challenging to diagnose and treat due to their anatomical complexity and diverse presentations. These cases highlight the efficacy and safety of TVE as the preferred treatment, underscoring the critical role of advanced imaging and individualized management in achieving favorable outcomes.

Background: Endoscopic transsphenoidal surgery (ETSS) is considered safe for the treatment of pituitary neuroendocrine tumors (PitNETs). Postoperative subarachnoid hemorrhage (SAH) is extremely rare in patients with PitNET, and information regarding the source of hemorrhage in such cases is limited.

Case description: Herein, we report the cases of a 59-year-old man and a 49-year-old woman who underwent ETSS for nonfunctioning PitNETs. Gentle subcapsular removal was performed, and no cerebrospinal fluid leakage was observed during the procedure. We routinely perform intraoperative magnetic resonance imaging (iMRI) to confirm the presence of residual tumors. In the former case, conservative treatment was selected because minimal bleeding was observed in iMRI. In the latter case, obvious arterial bleeding was observed beyond the diaphragmatic sellae before iMRI, prompting the selection of an extended transsphenoidal approach to identify the bleeding site. In both cases, iMRI revealed an SAH localized between the optic chiasm and diaphragmatic sellae adjacent to the pituitary stalk. Combined with intraoperative findings, the superior hypophyseal artery was considered the bleeding source in both cases. Hemostasis was achieved in both cases without the need for hemostatic procedures.

Conclusion: SAH associated with ETSS is rare, and the source of the hemorrhage is sometimes undetectable on postoperative imaging. Herein, iMRI was useful for identifying the source and extent of the hemorrhages, allowing observation of the patients without additional intervention.

Background: Glioblastoma multiforme (GBM) is a highly aggressive primary brain tumor with a poor prognosis. It commonly affects the brain and rarely spreads outside the central nervous system owing to barriers like the blood-brain barrier. We present a rare case of GBM with atypical features mimicking autoimmune meningitis, complicating the diagnosis.

Case description: A 45-year-old previously healthy man presented with persistent headaches, dizziness, vomiting, neck pain, diplopia from bilateral abducens nerve palsy, and cognitive dysfunction. The cerebrospinal fluid analysis did not confirm meningitis, although initial clinical and radiological findings suggested autoimmune meningitis. Head magnetic resonance imaging (MRI) showed postcontrast leptomeningeal enhancement and meningeal thickening. A spinal MRI revealed a contrast-enhancing lesion at the L1 level with leptomeningeal enhancement of the spinal cord. Despite empirical steroid therapy, his condition worsened, resulting in severe neurological deficits and impaired consciousness. A biopsy confirmed GBM through L1-2 laminectomy. Although adjuvant therapy was scheduled, his health rapidly declined, and he passed away on the 24^th day of admission before receiving chemotherapy or radiotherapy.

Conclusion: GBM can rarely present with noticeable symptoms and radiological features resembling autoimmune meningitis, posing diagnostic challenges. GBM cases involving spinal dissemination typically have a poorer prognosis, emphasizing the necessity of thorough diagnostic strategies. These should encompass histopathological biopsy and advanced imaging for optimal management, as delayed intervention significantly impacts survival. This report highlights the importance of maintaining a high level of suspicion for GBM and prompt intervention, including biopsy, in the presence of atypical clinical, radiological, and laboratory signs suggestive of meningitis.

Background: Internal carotid artery dissection (ICD) is a common cause of cerebral ischemia in adults. Medical management has been the standard of care; however, endovascular internal carotid artery (ICA) reconstruction has certain indications. The pipeline^™ embolization device (PED) is a flow-diverting (low porosity), self-expanding, braided platinum and nickel-cobalt chromium alloy stent and is indicated for wide neck or large aneurysms of the ICA from the petrous to the superior hypophyseal segments. The flexible nature of PED stents, with their high wall coverage, makes them amenable as stents for reconstructing arterial dissections diagnosed in the tortuous segments of the extracranial ICA. We present our experience using PEDs for ICA reconstruction in cases of distal cervical or petrous segment dissection or dissecting aneurysms and review the literature on this contemporary indication of flow diverter devices.

Methods: This study was a retrospective review of patients with ICD or dissecting aneurysms who underwent endovascular reconstruction at our center using PED stent implants. Patients were selected based on pre-morbid modified Rankin Scores ≤1a and National Institutes of Health Stroke Scale (NIHSS) ≥3 and radiologic data consistent with ICA dissection.

Results: Eight patients with a mean age of 55.6 years (range: 31-82 years) and median NIHSS score of 8 (Interquartile range IQR: 2.75-16) who underwent off-label PED surgery were analyzed and are illustrated in this short series. The technical success rate was 100%, with all cases achieving reperfusions of thrombolysis in cerebral infarction grades ≥2b.

Conclusion: In our series of patients with distal cervical or petrous segment ICD or dissecting aneurysms, we found the PED to be feasible, safe, and effective in achieving arterial recanalization. Further studies will clarify the role of this technique.

Background: Adult spinal deformity (ASD) surgeries often face complications, such as pseudoarthrosis and rod fractures (RFs), particularly at the lumbosacral junction. While transforaminal lumbosacral interbody fusion (TLIF) at L5-S1 is thought to improve outcomes, its efficacy in major ASD surgeries remains unclear. This study aims to compare clinical and radiological outcomes and implant complications in patients undergoing spinopelvic fixation with or without L5-S1 TLIF.

Methods: A retrospective cohort study was conducted, including 157 ASD patients who underwent high-grade osteotomies and spinopelvic fixation from 2021 to 2024. Patients were divided into two groups: those with L5-S1 TLIF (C group, n = 71) and those without (NC group, n = 86). Outcomes included rod fracture (RF) rate, sagittal alignment, and patient-reported measures such as the Visual Analog Scale (VAS), Oswestry disability index (ODI), and 36-Item Short Form Survey (SF-36), assessed at baseline, 1, 6, and 12 months postoperatively.

Results: RFs were significantly lower in the C group (4% vs. 13%, P = 0.03). Improved postoperative sagittal vertical axis and pelvic tilt were noted in the C group (P < 0.01). Both VAS and ODI scores were significantly better at 6 and 12 months in the C group (P < 0.01), along with higher SF-36 scores. No significant differences in baseline characteristics, estimated blood loss, or operation time were observed.

Conclusion: The use of L5-S1 TLIF reduces RF rates, improves sagittal alignment, and clinical outcomes in ASD surgery. Incorporating TLIF at L5-S1 may optimize outcomes without increasing perioperative risks.