Surgical neurology international最新文献

Background: Septic cerebral embolisms (SCE) are serious neurological complications of sepsis. An embolic occlusion due to infected thrombi can precipitate ischemic stroke and a spectrum of secondary pathologies, including intracerebral hemorrhages, mycotic aneurysms, meningitis, and brain abscesses, which are a major complication of SCE. However, delayed abscess formation following cerebral infarction is rarely encountered, and the underlying mechanisms remain poorly understood. Here, we present a rare case of SCE in a patient who underwent a mechanical thrombectomy (MT) for large-vessel occlusion and developed delayed abscess formation following cerebral infarction.

Case description: A 46-year-old man with a history of aortic stent graft implantation presented with sudden impairment of consciousness and right hemiparesis. Neuroradiological imaging revealed a left middle cerebral artery territory infarction due to occlusion of the left internal carotid artery. We performed emergency MT and achieved partial reperfusion. Histopathological evaluation of the retrieved thrombi revealed the presence of bacterial aggregates, confirming the diagnosis of SCE. Despite initial empiric antibiotic therapy, the patient developed a delayed brain abscess in the infarcted territory during the subacute phase. This unexpected course required further therapeutic intervention, including neurosurgical procedures and subsequent antibiotic therapy.

Conclusion: This case highlights both the diagnostic value of retrieved thrombi in SCE and the potential for delayed abscess formation after recanalization therapy using MT. In addition, this finding suggests the importance of ongoing vigilance for delayed brain abscess formation following SCE. In a severe clinical condition of sepsis, early diagnosis and tailored interventions are essential to improve outcomes.

Background: Craniofacial fibrous dysplasia (CFD) is a rare benign fibro-osseous disorder characterized by the replacement of normal bone with fibrous tissue, frequently resulting in craniofacial deformity, functional impairment, and neurological complications. Its pathogenesis is strongly associated with somatic GNAS gene mutations, which disrupt osteoprogenitor cell differentiation.

Case description: This study presents a 35-year retrospective review (1985-2019) of patients diagnosed with CFD at the National Cancer Institute of Mexico. Six adult patients (mean age 42.6 years, 66.7% females) met inclusion criteria. Polyostotic disease predominated (83.3%), with the sphenoid and ethmoid bones most frequently involved. Facial dysmorphism was the initial manifestation in 83.3% of cases, whereas headache was less common. Visual acuity was preserved in most patients, although cranial nerve involvement was identified in two cases. Using Chen's classification, multilocal disease affecting all three craniofacial zones was the most prevalent pattern (50%), correlating with greater surgical complexity. The mean Karnofsky Performance Status was 95, reflecting good functional status despite the disease burden. Two representative complex cases illustrate the challenges of surgical decision-making, highlighting the role of staged resections, craniofacial reconstruction, and the integration of advanced technologies such as virtual surgical planning and biomaterials.

Conclusion: Although surgery remains the cornerstone in symptomatic or deforming cases, recurrence and complications often require repeated interventions. Our findings emphasize the need for individualized, multidisciplinary management strategies, long-term follow-up, and the incorporation of evolving surgical and medical therapies to optimize outcomes and quality of life in patients with CFD.

Background: "Endovascular treatment (EVT)-first" strategies have been increasingly used to treat spinal dural arteriovenous fistulas (SDAVFs). Nevertheless, when EVT fails to penetrate the fistulous point and proximal draining vein, conversion to an open microsurgical approach is warranted.

Case description: A 52-year-old male presented with progressive myelopathy. The magnetic resonance imaging (MRI) showed spinal cord edema and dorsal flow voids at the T9 level; formal angiography demonstrated an SDAVF supplied by a radiculomeningeal artery and a single dorsal draining vein. Three-dimensional digital subtraction angiography (DSA) revealed a clear T-sign and caliber change suggesting a reachable shunt. However, when transarterial glue embolization was attempted, the embolic agent could not get past the nerve root sleeve, and, therefore, endovascularly, we could not reach the shunt. Further, we identified an additional new feeder originating from T8. Therefore, EVT was abandoned, and an open microsurgical approach was performed. Once the durotomy was completed, congested intradural "red vein" was identified; it was coagulated and ligated near its dural origin, resulting in complete fistula obliteration. Postoperatively, symptoms improved, and the MRI confirmed occlusion of the SDAVF with resolution of vascular congestion findings.

Conclusion: Even when 3D-DSA indicates good access to a SDAVF shunt, in vivo penetration may be limited by root-sleeve anatomy and flow dynamics. When attempted embolization results in feeder occlusion without venous penetration, the procedure should be stopped, and early conversion to open microsurgical intervention should be considered as it is typically highly effective.

Background: Achieving watertight dural closure in posterior fossa surgery is often challenging due to the anatomical complexity of this region, particularly when suturing is not feasible near critical venous structures. These circumstances increase the risk of cerebrospinal fluid (CSF) leakage, a well-recognized complication. Traditional single-layer techniques may be insufficient to achieve a watertight seal. To address this limitation, we developed a novel multilayer duraplasty method, termed the "Sandwich Technique," which combines an absorbable collagen matrix with autologous fascia.

Methods: A 69-year-old woman with a large tentorial meningioma and obstructive hydrocephalus underwent tumor resection. Intraoperatively, a wide dural defect adjacent to the transverse sinus was identified, where primary closure was not feasible. Reconstruction was performed using the three-layer Sandwich Technique: Step 1, an inlay DuraGen^® sheet placed subdurally and sutured to the tentorium; Step 2, an overlay of autologous fascia lata; and Step 3, an onlay DuraGen^® sheet folded over the fascia and secured with the bone flap. Fibrin glue was applied between each layer to reinforce adhesion.

Results: Postoperative imaging confirmed a watertight closure with no evidence of CSF leakage. The patient experienced no complications, and follow-up imaging at 2 months demonstrated a stable reconstruction.

Conclusion: The Sandwich Technique provides a simple, reproducible option for dural repair in the posterior fossa when suturing is technically difficult. This multilayer approach, which integrates synthetic and autologous materials, allows tension-free watertight closure and may represent a valuable adjunct in neurosurgical dural reconstruction.

Background: Brucellosis is an endemic zoonotic infection in Saudi Arabia, with thousands of cases reported annually. Although musculoskeletal involvement is common, spinal complications - particularly cervical spondylodiscitis with epidural abscess - are rare and often difficult to diagnose due to nonspecific symptoms. Delayed recognition may lead to neurological compromise requiring urgent intervention.

Case description: A 55-year-old farmer with regular exposure to cattle and a history of brucellosis presented with progressive right-sided weakness and neck pain. Magnetic resonance imaging revealed cervical stenosis with cord compression. Serology on admission showed Brucella immunoglobulin G positive, immunoglobulin M negative. The patient underwent anterior cervical decompression, biopsy, and fixation. Intraoperative cultures confirmed Brucella infection; however, species-level identification was not performed. Targeted antibiotic therapy with ceftriaxone 2g intravenous daily, doxycycline 100 mg orally twice daily, and rifampicin 600 mg orally daily was initiated. The patient showed gradual neurological recovery with complete resolution at follow-up.

Conclusion: Spinal brucellosis, though rare, should be considered in endemic regions. Early diagnosis and combined surgical and medical management can prevent permanent neurological sequelae. The absence of Brucella species identification represents a limitation of this report.

Background: This systematic review and meta-analysis aimed to assess neurological outcomes at different thresholds and identify a cutoff associated with safer resections.

Methods: Following Preferred Reporting Items for Systematic Reviews Incorporating Network Meta-analyses guidelines, we included case series reporting the use of continuous dynamic mapping during tumor resection near the corticospinal tract. Outcomes included temporary and permanent post-operative motor deficits. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated; heterogeneity was assessed using the I² statistic.

Results: Seven studies involving 301 patients were included in this study. Patients with thresholds of 1-5 mA had a significantly higher risk of temporary motor deficits compared to those with thresholds >5 mA (43% vs. 11%; RR 3.14, 95% CI: 1.96-5.03; P < 0.00001). A post hoc analysis showed all permanent deficits occurred in patients with thresholds ≤3 mA, with a significantly higher risk than those with thresholds >3 mA (6% vs. 0%; RR: 16.40, 95% CI: 2.13-126.26; P = 0.007). No significant difference in permanent deficits was found between the 1-5 mA and >5 mA groups.

Conclusion: Extending resection beyond the minimal stimulation threshold of 5mA increases the risk of transient neurological deficits. Going beyond ≤3 mA will additionally increase the risk of permanent motor deficits. These exponential risks should be carefully counterweighted with the potential oncological benefit of higher EOR in each patient. These findings emphasize the need for prospective multicenter studies with standardized stimulation parameters to establish evidence-based guidelines for safe resection near eloquent motor pathways.

Background: Migrated lumbar foraminal disc herniation (FDH) poses a great challenge, requiring the facet joint resection and stabilization procedure. We used a contralateral sublaminar unilateral biportal endoscopic (UBE) approach utilizing O-arm navigation to preserve the facet and effectively resect a FDH.

Methods: Through the sublaminar window, resecting the ligamentum flavum, performing a limited medial facetectomy using O-arm navigation, safely exposed the foraminal zone, allowing for the safe FDH resection.

Results: Fourteen patients underwent this procedure between 2022 and 2023. Mean operative time was 75 min with minimal blood loss and no perioperative complications. Visual analog scale scores improved markedly: back pain decreased from 8.6 preoperatively to 0.8 at 12 months, and leg pain from 9.2 to 0.4. Radiological analysis showed an average 5.1% reduction in facet joint area without new instability or spondylolisthesis.

Conclusion: Utilizing O-arm navigation, the contralateral sublaminar UBE approach enables safe, precise, and facet-preserving decompression for FDH.

Background: Parasagittal vertical hemispherotomy (PSVH) is a surgical technique increasingly adopted in epilepsy centers worldwide, providing excellent seizure control in children with drug-resistant epilepsy (DRE) due to unilateral hemispheric abnormalities.

Case description: We report a case of a 5-year-old girl with DRE secondary to hemimegalencephaly and treated with PSVH. At 11 months postoperatively, the patient achieved complete seizure freedom without major complications. This successful case supports the effectiveness and safety of PSVH in managing DRE caused by unilateral hemispheric lesions and highlights the importance of early surgical intervention in this pediatric population.

Conclusion: PSVH achieves reliable seizure control with reduced surgical morbidity and favorable functional outcomes in children with hemispheric epileptogenic disorders.

Background: Intracranial hemorrhage is a leading cause of secondary brain injury following traumatic brain injury (TBI). Tranexamic acid (TXA), an antifibrinolytic agent, is recommended by Advanced Trauma Life Support for hemorrhagic trauma, but its role in TBI remains debated. Recent meta-analyses and randomized controlled trials (RCTs) have demonstrated conflicting results regarding TXA's mortality benefits, while beta-blockers (BBs) show potential in mitigating hyperadrenergic states post-TBI. This study aims to update the evidence on TXA and BB administration in TBI by incorporating newer RCTs and systematic reviews published post-February 2023.

Methods: A systematic search of PubMed, ScienceDirect, and clinicaltrials.gov was conducted using keywords: "tranexamic acid," "beta blockers," and "traumatic brain injury." Studies published up to December 2024 were included to address gaps in the literature. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and data were analyzed using RevMan 5. Primary outcomes were the safety and efficacy of TXA and BB.

Results: Thirteen RCTs (n = 16,452) were included, expanding on prior meta-analyses. TXA did not significantly reduce mortality (relative risk 0.93, 95% confidence intervals [CI] 0.86-1.01) but reduced hematoma progression (mean difference -3.67 cm³,*P* = 0.007). BB showed a non-significant mortality reduction (13.65% vs. 18.34%; Odds ratio [OR] 0.55 [95% CI 0.27-1.13]). Adverse events were comparable between groups.

Conclusion: TXA and BB are safe but do not significantly improve mortality in TBI. Our updated analysis aligns with recent literature, underscoring the need for further RCTs to clarify subgroups (e.g., mild-moderate TBI) that may benefit.