Surgical neurology international最新文献

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.

Background: Prediction rules for computed tomography (CT) use in mild traumatic brain injury (MTBI) often have limited generalizability due to restrictive inclusion criteria and development in high-income countries. A clinical-based prediction score was recently developed for a broader MTBI population in a low- to middle-income country. This study aims to externally validate this score in a new patient dataset.

Methods: We prospectively collected data from adult patients with MTBI (Glasgow Coma Scale score 13-15) presenting to a hospital in Thailand between 2014 and 2016. The performance of the 13-predictor clinical-based score was evaluated for two outcomes: traumatic intracranial findings on CT and need for neurosurgical intervention. We assessed discrimination using the area under the receiver operating characteristic curve (AuROC) and diagnostic accuracy at predetermined cut-points.

Results: The study included 565 patients. Seventy-two patients (12.7%) had a positive CT scan, and 8 (1.4%) required neurosurgical intervention. The AuROC was 0.70 for predicting a positive CT scan and 0.78 for predicting neurosurgical intervention. At a cut-point score of ≥2, the sensitivity for a positive CT was 97.2% with a specificity of 12.6%. At a cut-point score of ≥3, the sensitivity for neurosurgical intervention was 100% with a specificity of 21.0%.

Conclusion: The clinical prediction score demonstrated acceptable and safe diagnostic performance in an external validation cohort, maintaining high sensitivity for critical outcomes. The score may be a useful tool to help guide management policy for MTBI patients, particularly in low- to middle-income countries.

Background: Tourette syndrome is a condition characterized by involuntary motor tics that are often managed with a combination of medication and behavioral therapy. This condition has also been associated with cervical spinal injuries and has been documented as causing multiple cases of progressive myelopathy. In these patients, surgical stabilization may be effective.

Case description: We present a case of a patient with progressive cervical myelopathy with a chronic type II odontoid fracture and Tourette syndrome who had significant hardware failure within 1 month postoperatively due to uncontrolled tics.

Conclusion: A failure to sufficiently control the Tourette syndrome led to a failure of the surgical stabilization hardware. Patient education may lead to increased treatment compliance. Treatment guidelines are needed to help practitioners and patients develop individualized and effective treatment programs that not only address the myelopathy but also the tics that contribute to their development.

Background: In the complex management of hydrocephalus, ventriculoperitoneal (VP) shunt insertion is the mainstay for cerebrospinal fluid (CSF) diversion. However, when traditional routes fail or are contraindicated - due to congenital abnormalities, infections, extensive adhesions, or previous abdominal surgeries - surgeons must consider less conventional alternatives. The second line is the ventriculo-atrial shunt then the ventriculo-pleural. The ventriculo-gallbladder (VG) shunt, although rarely used, presents a fascinating option with unique physiological advantages. Here, we present an interesting case of VG shunt insertion in King Faisal specialist hospital, Jeddah.

Case description: We present the case of a 12-year-old female with a complex history, including myelomeningocele repair at birth, hydrocephalus managed through multiple VP shunt revisions, and end-stage renal disease. Admitted under general pediatrics with peritonitis, she was treated with a temporary external ventricular drain and VP shunt. However, rapid abdominal distention ensued, and imaging revealed adhesions and collections, ruling out the peritoneum as a feasible shunt site. Given her complex anatomy and limited options, a VG shunt was chosen. Remarkably, at a 3-month follow-up, the patient demonstrated full stability with excellent VG shunt function, highlighting the gallbladder's potential as a reliable CSF reservoir.

Conclusion: The VG shunts have a promising results in terms of absorption and complication rate as documented in the literature. In patients who failed the other commonly used cavities, the gallbladder is a safe and effective organ for absorption.

Background: Rosai-Dorfman disease (RDD) is an uncommon histiocytic proliferative disorder that typically involves the lymph nodes but can also present with extranodal involvement. Central nervous system involvement is rare, and the spine-restricted RDD is an extremely rare variant that poses significant diagnostic challenges, often resulting in delays in diagnosis and management.

Case description: We report a case of a 32-year-old gentleman with a history of back pain for 1-year, initially being managed as ankylosing spondylitis, which subsequently developed spastic paraparesis and was ultimately diagnosed with spine-restricted RDD.

Conclusion: Recognizing this rare entity and its potential associations with immune-mediated conditions, such as human leukocyte antigen B27-related spondyloarthropathies and possibly inflammatory bowel disease, is essential to avoid misdiagnosis and guide individualized, multidisciplinary treatment strategies.