Background: Dermoid cysts (DCs) are rare congenital intracranial tumors. Among these tumors, extracranial and intracranial combined localization is extremely rare.
Case description: We present the case of a 49-year-old female patient with no prior medical history, diagnosed with an extradural and intradural extra-axial DC in the left temporo-parietal region, which manifested with signs of increased intracranial pressure. Cerebral magnetic resonance imaging showed an extra-axial lesional process with a cystic signal in the left temporo-parietal region. Surgical resection was successfully performed through a wide left temporo-parietal craniotomy. Histopathological findings were consistent with a DC. The postoperative recovery was uneventful, with improvement of increased intracranial pressure symptoms.
Conclusion: A rare case of combined extra- and intracranial DC of extradural and intradural localization in the temporoparietal region was reported. The tumor was completely removed by wide craniotomy. DCs can occur anywhere in the intracranial and extracranial space. Although they are benign tumors, serious complications can arise if they are not treated promptly and appropriately. Total radical resection is the best solution.
Background: Cirsoid aneurysms are rare, high-flow arteriovenous malformations (AVMs) of the scalp and neck, formed by direct arteriovenous shunts without an intervening capillary bed. They may present with pulsatile swelling, bruit, cosmetic disfigurement, pain, or hemorrhage. Giant, diffuse lesions with feeders from multiple vascular territories are uncommon and pose significant therapeutic challenges.
Case description: A 24-year-old male presented with a 10-12-year history of an enlarging occipital mass, which had rapidly increased in size over the preceding 2-3 years. Examination revealed a pulsatile, warm lesion extending anteriorly to the neck (right > left) with overlying skin thinning and discoloration; a loud bruit was audible. Computed tomography angiography demonstrated a 24 × 22 cm high-flow AVM supplied by multiple feeders from the external carotid and vertebral arteries, with venous drainage into the right internal jugular vein. Preoperative super-selective embolization was performed to reduce vascularity, followed by en bloc surgical resection along the pericranial plane with ligation of all feeders. Reconstruction was achieved using a split-thickness skin graft harvested from the thigh. The initial recovery was uneventful, with complete graft uptake. At 3 months, recurrence secondary to neoangiogenesis was treated with repeat embolization and adjuvant external beam radiotherapy. At the latest follow-up, the graft remained healthy, with no further bleeding or lesion progression.
Conclusion: Giant scalp and neck cirsoid aneurysms require meticulous preoperative imaging, staged endovascular flow reduction, complete surgical excision, and coordinated multidisciplinary management. Recurrence from collateral vessel formation may occur despite optimal therapy, underscoring the importance of long-term clinical and radiological surveillance.
Background: Pseudoaneurysm formation is a known but often underrecognized long-term complication following balloon embolization for traumatic carotid-cavernous fistula (TCCF). While many pseudoaneurysms remain asymptomatic, progressive enlargement and thrombosis may lead to mass effect and delayed neurological manifestations, including seizures and visual disturbances.
Case description: We report the case of a 33-year-old man who presented with new-onset generalized tonic-clonic seizure and binocular visual disturbances 14 years after undergoing transarterial detachable balloon embolization for TCCF. Brain magnetic resonance imaging revealed a large, partially thrombosed pseudoaneurysm arising from the cavernous segment of the internal carotid artery, extending into the suprasellar region with compression of the optic chiasm and adjacent frontal lobe. Humphrey visual field testing demonstrated bitemporal hemianopia. The patient underwent successful endovascular stent-assisted coiling. Post-treatment follow-up showed marked improvement in visual fields and complete seizure resolution, with no evidence of aneurysmal recurrence at 3 years.
Conclusion: This case highlights the importance of long-term surveillance following balloon embolization for TCCF. Delayed pseudoaneurysm growth may lead to significant neurological deficits years after initial treatment. Early recognition and appropriate endovascular intervention are essential to prevent irreversible complications and optimize patient outcomes.
Background: Tinnitus is a common otologic complaint, affecting 10-15% of the general population, with 5% of patients developing disabling symptoms refractory to pharmacological therapy. Neurovascular compression of the VIII cranial nerve has been proposed as a potential etiology, and microvascular decompression (MVD) may represent a therapeutic alternative.
Methods: We present a case series of seven patients with disabling tinnitus, vertigo, and, in some cases, hypoacusis, all of whom were refractory to at least 12 months of pharmacological treatment. Preoperative assessment included audiometry and high-resolution magnetic resonance imaging (fast imaging employing steady-state acquisition sequence), which confirmed a vascular loop contacting the VIII cranial nerve. Patients underwent retrosigmoid MVD, with follow-up ranging from 1 to 10 months.
Results: Five patients (72%) achieved complete resolution of tinnitus and vertigo, while two patients (28%) reported >80% improvement. One patient developed transient House-Brackmann III facial palsy that resolved with steroids. No cases of permanent hearing loss, cerebrospinal fluid leak, or vascular complications were observed. Quality of life scores improved significantly postoperatively. The most common offending vessel was the anterior inferior cerebellar artery.
Conclusion: MVD of the VIII cranial nerve is a safe and effective therapeutic option in selected patients with refractory tinnitus and vertigo, achieving substantial symptomatic improvement with a low complication rate. Larger prospective studies are warranted to validate these findings and establish long-term outcomes.
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 7th 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..
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