Surgical neurology international最新文献

Background: Here, we report a thoracolumbar (TL) junction synovial cyst (SC) causing a cauda equina syndrome (CES)/epiconus syndrome (ECS).

Case description: A 69-year-old male presented with a progressive parparesis/CES. When the magnetic resonance imaging revealed a T12-L1 epiconus/TL SC, a decompression was performed, resulting in symptomatic improvement (i.e., right-sided foot drop still resolving).

Conclusion: ECS attributed to TL SC warrants immediate magnetic resonance evaluations and surgical decompression.

Background: Slack or kinking of the spinal cord due to compression lesions is rare.

Case description: A 73-year-old woman sustained a vertebral compression fracture at L1 following a fall. Progressive vertebral collapse caused upward displacement of the conus medullaris and slackening of the spinal cord, leading to bilateral thigh pain and myelopathic symptoms. Decompression and fixation surgery were performed. Due to osteoporosis, screws were inserted through the endplates and augmented with bone cement to prevent implant failure. Postoperatively, the patient's symptoms resolved, and her neurological function improved.

Conclusion: When the spinal cord becomes slack due to compression at the thoracolumbar junction, symptoms of both cauda equina tension and myelopathy may develop. Surgical decompression and fixation can restore the spinal cord morphology and improve neurological function.

Background: Spontaneous regression of nonfunctioning pituitary macroadenomas is rare, typically linked to pituitary apoplexy caused by infarction or hemorrhage. Regression without apoplexy is exceptional and challenges the standard surgical approach.

Case description: We present a 24-year-old woman, 15 months postpartum, with progressive headaches and bitemporal hemianopsia due to a 17 × 17 × 20 mm nonfunctioning pituitary macroadenoma compressing the optic chiasm. Endocrine testing revealed corticotropic and thyrotropic insufficiencies, for which hydrocortisone and levothyroxine were initiated. Surgery was initially declined, but later reconsidered due to persistent symptoms. Preoperative imaging unexpectedly showed complete spontaneous resolution of the lesion, with normalization of visual function and no new endocrine deficits. The patient remained stable at 12-month follow-up.

Conclusion: This case highlights complete spontaneous regression of a symptomatic macroadenoma without apoplexy, possibly influenced by postpartum hormonal factors. Although surgical decompression remains the standard treatment for lesions causing chiasmal compression, this exceptional case demonstrates that, in rare situations where surgery is declined, repeat imaging and close monitoring may reveal unexpected regression. Careful multidisciplinary evaluation is essential to balance the risks of waiting against the potential for spontaneous resolution.

Background: Central nervous system (CNS) high-grade neuroepithelial tumors with BCL-6 co-repressor (BCOR) exon 15 internal tandem-duplication (ITD) are rare, aggressive pediatric neoplasms characterized by poor prognosis and unclear treatment protocols. The diagnosis requires molecular confirmation, and early neurosurgical intervention is critical.

Case description: A 2-year-old male presented with progressive fatigue, ataxia, and signs of increased intracranial pressure. Imaging revealed a large left frontal mass with midline shift. Emergent bifrontal craniotomy was performed, achieving gross total resection (GTR) without preoperative MRI due to hemodynamic instability. Subsequent deoxyribonucleic acid methylation profiling confirmed the diagnosis of a CNS BCOR-ITD. The patient was treated with intensive chemotherapy following the ACNS0334 protocol, followed by autologous hematopoietic stem cell transplantation. He remains neurologically intact at the past follow-up 9 months after surgery.

Conclusion: This case highlights the diagnostic and therapeutic challenges of pediatric CNS BCOR-ITD, emphasizing the need to attempt early GTR and multimodal chemotherapy in providing a meaningful functional recovery for this patient.

Background: Patient participation affected management decision-making trends over the past two decades. This study aimed to survey trends in vestibular schwannoma (VS) management using a large national database.

Methods: This analysis collated demographic and clinical data for 23,488 VS cases from 2004 to 2021 using the national surveillance, epidemiology, and end result database. Relationships between tumor size and age were analyzed with Chi-square and logistic regression and trends over time were assessed.

Results: Across the study period, a statistically significant portion of older patients was managed with observation compared to younger patients. The relationship of age to initial management persisted across tumor sizes. From 2004 to 2021, observation was increasingly popular. The strongest relationship between time and treatment modality was observed in young patients (<65), for which there was a 16.6% point increase in observation and a 10.9% point decrease in surgery between the extremes of the study period. This trend is contrasted with the trend in radiation therapy over this time in the elderly population, in whom the rate of radiation nearly halved (39.9-22.7%) from 2004 to 2018.

Conclusion: This large database study demonstrates the impact that the dawn of the century had on trends in the management of VS. Over the past 20 years, treatment options have not changed greatly, but the way the options are utilized evolved with time.

Background: Traumatic brain injury (TBI) remains a leading cause of death and disability, particularly in younger populations, with significant clinical and socioeconomic burdens in both developed and developing countries. Despite extensive research, outcomes for TBI patients, especially those with subarachnoid hemorrhage (SAH), remain poor. Oxidative stress and ischemia, both typical sequelae of TBI, contribute to secondary brain injury, which worsens clinical outcomes. SAH exacerbates brain damage by degrading hemoglobin, forming oxyhemoglobin, and increasing oxidative stress. This cascade ultimately leads to lipid peroxidation, with malondialdehyde (MDA) as a key product. This study aims to evaluate the potential of elevated MDA levels as a prognostic biomarker for predicting poor clinical outcomes in patients with moderate-to-severe TBI complicated by SAH.

Methods: This prospective cohort study included patients with moderate to severe TBI and SAH who were evaluated at RSUP Prof. Dr. I.G.N.G. Ngoerah Denpasar, Bali, Indonesia from January to June 2024. Serum MDA levels were tested at admission and classed as high or low using receiver operating characteristic (ROC) curve analysis. Additional clinical characteristics, such as demographic information and clinical condition, were also collected. Fifty-eight patients were followed for 3 months to determine clinical results, which were divided into two categories: good and poor. ROC curve analysis, descriptive statistics, proportion comparisons, and Cox regression were all performed using IBM Statistical Package for the Social Sciences version 26.

Results: Patients with high MDA levels had a significantly higher mean age compared to those with low MDA levels (42.36 vs. 38.13 years). ROC analysis revealed that high MDA levels were a significant predictor of poor clinical outcomes in TBI patients with SAH, with an area under the curve of 0.714 (P = 0.0006). The relative risk for poor outcomes in patients with high MDA was 2.6 compared to those with low MDA (P = 0.004). Cox regression analysis confirmed that elevated MDA is an independent predictor of poor clinical outcomes in this patient population.

Conclusion: Elevated serum MDA levels are a reliable biomarker for predicting poor clinical outcomes in patients with moderate to severe TBI complicated by SAH.

Background: A thorough understanding of third ventricle anatomy is essential for safe and effective surgical planning, particularly for lesions in this deep and complex brain region. The ventricle is surrounded by critical neurovascular structures, whose variability can significantly influence the choice of surgical approach and the risk of complications. Anatomical knowledge, supported by cadaveric dissection and imaging, enables surgeons to anticipate challenges, minimize risks, and improve outcomes. This is especially important for third ventricular tumors, where errors may lead to neurological deficits due to injury of hypothalamic or vascular structures.

Case description: We present the case of a 19-year-old male presenting with clinical signs of hydrocephalus. Imaging revealed a tumor within the third ventricle. This video illustrates its surgical management, highlighting the importance of anatomical familiarity and proper approach selection. The approach was based on detailed anatomical insights, reinforced by cadaveric dissections. Anterior and inferior approaches to the subcallosal region carry a risk of damaging branches of the anterior cerebral artery (ACA), particularly the hypothalamic and subcallosal branches. Injury in these areas can result in memory deficits, amnestic-confabulatory syndrome, or hypothalamic dysfunction. To minimize these risks, we employed a bimanual interhemispheric transrostral approach. This technique provides controlled access to the floor of the third ventricle and hypothalamus through three anatomical windows. The integration of anatomical expertise, surgical strategy, and laboratory training is essential to achieve safe and effective outcomes in third ventricular surgery. The patient experienced no complications and showed progressive neurological recovery.

Conclusion: This case highlights the essential role of thorough third ventricle anatomical knowledge in planning safe and effective surgery. Laboratory-based training, including cadaveric dissections, allows surgeons to practice complex maneuvers, refine technical skills, and anticipate challenges before operating on patients. Combining deep anatomical understanding with hands-on practice is key to minimizing complications and achieving optimal outcomes in these high-risk procedures.

Background: Specialized pediatric neurosurgical care is often limited or absent in resource-limited countries. This study aims to characterize the unmet need for pediatric neurosurgery by characterizing the burden and outcomes of pediatric neurosurgical disease in children at a high-volume surgical center in Pakistan.

Methods: We conducted a retrospective chart review of all pediatric patients admitted for any indication requiring a neurosurgical consultation between 2010 and 2021 at a tertiary care hospital in Karachi, Pakistan. We described the scope and volume of neurosurgical procedures performed, key surgical quality metrics, and the overall outcomes of select pediatric neurosurgical cases.

Results: A total of 3,100 patients met criteria, with a male preponderance (n = 2,070, 66.8%). Patients were broadly classified as having neurotrauma (n = 1377, 44%), congenital anomalies (n = 1256, 41%), or central nervous system (CNS) tumors (n = 467, 15%). The most common procedures performed were craniotomies (n = 97, 64.7%), tumor removal (n = 62, 41.3%), ventriculoperitoneal shunt placement (n = 21, 14%), and laminectomies (n = 5, 0.03%). Importantly, there were no cases of kyphoscoliosis, craniosynostosis, or epilepsy surgery in our patient cohort. The outcomes of 268 (19.5%) surgical cases of neurotrauma and 424 (90.8%) congenital anomalies were evaluated further, with high 30-day mortality observed (4.8% and 4.3%, respectively).

Conclusion: The scope of pediatric neurosurgical care is limited at our urban healthcare setting in Pakistan, with a limited variety of procedures and poor key quality indicators such as length of stay and operative blood loss. These findings may suggest that training and capacity building to develop specialized pediatric neurosurgical care may address these critical gaps in care provision.

Background: Findings and statistical data showed that stereotactic biopsy has an effective role in histopathological diagnosis of brain tumors and lesions and accordingly in creating a treatment protocol.

Methods: In our clinic, 143 biopsy procedures were performed on 142 patients between 2014 and 2022. Consistency rates were evaluated by comparing preoperative diagnoses with postoperative diagnoses.

Results: Postoperative complications occurred in 7 patients. Complications were observed in 2 patients due to surgery. 4 patients died, not related to our surgical procedures. In 8.4% of the patients, a pathological diagnosis was not performed. The correct diagnosis rate is 91.6% in our group. In this study, a magnetic resonance-compatible Leksell frame was used.

Conclusion: Because of its high diagnostic value and low morbidity and mortality rates, stereotactic biopsy is a reliable and indisputable neurosurgical technique which is used worldwide.

Background: Brain arteriovenous malformations (AVMs) present significant surgical challenges due to their complex angioarchitecture. This study evaluates the clinical application of augmented reality (AR) and 3D modeling for preoperative planning in AVM microsurgery.

Methods: A prospective series of 20 patients with Spetzler-Martin grade II-IV AVMs underwent preoperative 3D planning using computed tomography/magnetic resonance imaging segmentation (Inobitec DICOM Viewer Pro), AR navigation (Microsoft HoloLens 2 with Medgital software), and QR-code registration. Technical parameters including target registration error (TRE), preoperative preparation time, and intraoperative outcomes were analyzed.

Results: Complete AVM resection was achieved in all cases (100%). The AR system demonstrated submillimeter accuracy (TRE: 0.5 ± 0.3 cm with QR-code vs. 1.2 ± 0.5 cm with craniometric points). Preoperative modeling required 15.3 ± 5.1 min, while AR navigation averaged 12.7 ± 3.2 min.

Conclusion: Our findings support the feasibility of AR-assisted 3D planning as an adjunctive tool for AVM microsurgery. This proof-of-concept study suggests that AR technology may improve spatial orientation and facilitate surgical workflow, especially for complex lesions near eloquent areas. While the clinical benefit in terms of outcomes remains to be confirmed in larger prospective studies, the presented experience demonstrates technical reliability and practical applicability. Future integration with automated segmentation and cloud-based platforms may further enhance its clinical utility.