Surgical neurology international最新文献

Background: Thoracic ossification of the ligamentum flavum (OLF) and tuberculous infective spondylodiscitis rarely combine to cause paraplegia. Here, a 48-year-old female with both thoracic OLF and tuberculous spondylodiscitis experienced the acute onset of paraplegia successfully managed with a T8-L1 laminectomy with fusion.

Case description: A 48-year-old female presented with the acute onset of paraplegia attributed to magnetic resonance-documented thoracic OLF and infective spondylodiscitis. Imaging revealed spinal cord compression (i.e., occupying >50% of the spinal canal) from D8 to D10 level and infective spondylodiscitis at the D10-D11 level. Surgery included a D8-L1 laminectomy with instrumented fusion. Histology and cultures revealed the presence of tuberculosis, and anti-tubercular therapy was administered. Both surgery and continued antibiotic therapy contributed to neurological improvement.

Conclusion: Thoracic OLF combined with tuberculous spondylodiscitis may be effectively treated with decompression, fusion, and appropriate anti-tubercular therapy.

Keywords: Dorsal spine, Infective spondylodiscitis, Koch's, Neurological deficit, Ossified ligamentum flavum (OLF), Paraplegia, Tuberculosis spine instability score (TSIS).

Background: Meningiomas are benign, slow-growing tumors of the central nervous system (CNS) that arise from the arachnoid matter. It comprises one of the most common primary tumors of the CNS, occurring mostly in and after the fifth decade of life with a female gender predilection. Diagnosis is facilitated by imaging computed tomography (CT) or magnetic resonance imaging (MRI); however, atypical forms exist which augments the risk of missing the diagnosis. This is a case of a meningioma that mimics a hematoma on imaging, the diagnosis of which was only confirmed following histopathology.

Case description: A 36-year-old patient presented with a 9-month history of intermittent moderate-intensity headaches associated with photophobia, tinnitus, and dizziness. There was no previous history of trauma. There were no focal neurological deficits on examination. Both contrast-enhanced and noncontrast-enhanced brain CT scans showed features suggestive of an intraparenchymal hematoma. She had a control CT scan 2 months and 9 months later due to the persistence of symptoms despite remaining stationary, which revealed no changes in the lesion as seen in the previous CT scans. The patient did not benefit from an MRI scan due to the socioeconomic status of the country and the patient herself. A decision to operate was made, and the sample was sent for histopathology. Histopathology confirmed the lesion to be a psammomatous meningioma.

Conclusion: Although CT findings of meningiomas are quite often typical, it is important to note that atypical forms exist as well. Knowledge of the atypical forms, such as lesions that look like an intraparenchymal hemorrhage initially but remain unchanged over a period of time, would decrease the risk of missing the diagnosis in such instances.

Background: Cavernous sinus dural arteriovenous fistula (CSDAVF) is an abnormal arteriovenous connection involving the dura mater within or adjacent to the wall of the cavernous sinus. While cases with superior ophthalmic vein drainage and ocular symptoms are typical, we report a rare case of CSDAVF draining into the perimedullary vein of the medulla oblongata and spinal cord and causing cerebellar ataxia and myelopathy as the initial presentation.

Case description: A 73-year-old man presented with vertigo and rapidly progressing gait disturbance. Digital subtraction angiography revealed a left CSDAVF draining only into the spinal perimedullary veins, which was classified as Cognard type V. We performed a transvenous embolization through the occluded left inferior petrosal sinus and achieved a super-selective shunt occlusion using three platinum coils. The postoperative course was uneventful with immediate improvement of symptoms.

Conclusion: CSDAVF should be considered as a differential diagnosis in a patient with venous congestion in the brainstem.

Background: The intricate hemodynamic mechanisms of thrombosis in the bleb and/or dome of cerebral aneurysms remain unresolved. We encountered a unique case where the bleb of an unruptured internal carotid-posterior communicating artery (IC-PC) aneurysm underwent thrombosis over 7 years. Complete spontaneous thrombosis of a bleb in an unruptured cerebral aneurysm has not been previously reported. Therefore, a hemodynamic evaluation using computational fluid dynamics (CFD) analysis was conducted to examine the thrombotic development within the bleb of this aneurysm.

Case description: We observed a case in which thrombosis led to the disappearance of a bleb in the dome of an unruptured IC-PC aneurysm over 7 years. CFD analysis was employed to investigate the hemodynamics of bleb thrombosis and the thrombosed bleb-neck regions of the dome in this IC-PC aneurysm. The reduction and disappearance of the bleb were associated with a decreased flow rate within the bleb, reduced magnitude of wall shear stress (WSSm), a lower WSSm ratio between the bleb and dome, increased vector direction of wall shear stress (WSSv), and discrete streamlines entering the bleb-neck region, resulting in stasis and subsequent thrombosis within the bleb. Seven years later, the dome region corresponding to the thrombosed bleb-neck exhibited localized areas with low WSSm and high WSSv along the dome wall.

Conclusion: Hemodynamically, spontaneously thrombosed bleb and thrombosed post-bleb-neck dome walls were characterized by low WSSm and high WSSv. These findings underscore the importance of CFD analysis in predicting thrombotic events in cerebral aneurysms, which can inform better clinical management strategies.

Background: Intracranial aneurysms have a prevalence of 1-6% and significant rupture risks, leading to high morbidity and mortality. Endovascular therapy demands an understanding of its economic impacts. This study evaluates the costs and complications of unruptured intracranial aneurysm treatment in a private Latin American hospital.

Methods: A retrospective longitudinal observational study was carried out in a private hospital in Brazil from February 2015 to January 2021. Patients undergoing elective endovascular treatment for unruptured intracranial aneurysms (UIAs) were included in the study. Data collected included patient demographics, aneurysm characteristics, treatment modalities, costs, and clinical outcomes. Costs were adjusted to their present value in 2023 US dollars (USD). Descriptive statistics summarized the data.

Results: A total of 77 patients (68 females and nine males) with 111 aneurysms were included. The average total cost per patient was $31,831.08, with materials (65.9%) and hospital daily rates (11.3%) being the primary cost drivers. Device associations included flow diverter (51.9%), stent-assisted coiling (19.2%), and coiling (11.5%). Clinical outcomes were favorable, with an average inpatient stay of 6.5 ± 10.2 days, 6.5% of patients requiring readmission for complications, and no deaths within 90 days. The highest costs were associated with coiling and stent-assisted coiling.

Conclusion: The cost of endovascular treatment for UIAs at a private hospital in Brazil is substantial, primarily driven by materials and hospital daily rates. Despite high costs, clinical outcomes were favorable, with low complication rates. These findings underscore the need for continuous cost-effectiveness evaluation and treatment optimization to balance clinical benefits with financial considerations.

Background: The surgical management of aneurysms involving the proximal third of the anterior inferior cerebellar artery (AICA) usually necessitates complex and invasive approaches, thus posing major challenges. We aimed to investigate the infratentorial presigmoid retrolabyrinthine suprameatal approach (PRSA) as a surgical corridor for premeatal AICA aneurysms.

Methods: We performed 10 PRSA dissections in five cadaveric heads. Twelve morphometric parameters were measured, analyzed, and categorized into pre-procedural, intra-procedural, and additional parameters. The typical anatomic-radiological characteristics and variations were evaluated, and the related anatomical and radiological parameters were analyzed to predict surgical accessibility.

Results: Preoperative anatomic-radiological parameters provide valuable information to select patients with favorable anatomy that may offer appropriate surgical accessibility to the premeatal AICA through a PRSA corridor. The position of the basilar artery from the midline determines the degree of accessibility to the origin of AICA through the infratentorial PRSA. The PRSA for targeting proximal AICA aneurysms was also compared to other surgical approaches based on the available current literature.

Conclusion: Premeatal AICA aneurysms can be accessed and clipped through the infratentorial PRSA corridor. This would allow surgeons to avoid the sacrifice of hearing and balance as compared to other available invasive alternative approaches. The selection of the appropriate patients should be based on the individualized preoperative radiological characteristics for both the vascular and bony anatomy.

Background: Chronic back pain stands as the most common musculoskeletal disorder and a primary cause of disability in people under 45 years old. Multidisciplinary consultation offers an efficient approach to chronic back pain management compared to traditional therapeutic-rehabilitative paths. This paper aims to show the benefit of a diagnostic-therapeutic multidisciplinary program pathway for patients with chronic back pain.

Methods: Twenty-six patients who underwent a second-level multidisciplinary consultation with a neurosurgeon and a pain therapist at our University Hospital were retrospectively identified from April 2023 to September 2023. The second-level multidisciplinary consultation is a second step consultation after a first consultation with a single specialist doctor (neurosurgeon, orthopedic, and pain therapist) who did not get the diagnosis and/or did not solve the painful symptom after medical or surgical treatment. Clinical outcomes, patient experience, and cost-effectiveness analysis were assessed using lean healthcare tools.

Results: With the introduction of second-level multidisciplinary consultation, patients were assessed by multiple physicians during a single visit, reducing the costs of individual visits, reducing the time to obtain the diagnosis, and facilitating early agreement on a diagnostic-therapeutic plan. The lean value-based healthcare approach showed an average of 45 working days lost per single patient and a total cost per single patient with chronic back pain of € 1069 for the national health system for an average Lead time of 18 months. Questionnaire analysis on service quality and utility, along with overall satisfaction, revealed excellent resolution of back pain in 53.8% of cases and partial resolution of back pain in 11.5% of cases after second-level multidisciplinary consultation.

Conclusion: Our multidisciplinary approach to chronic back pain has significantly improved healthcare efficiency. This new proposed clinical model reduces waiting times and costs and improves patient experience by improving clinical outcomes in the management of chronic back pain.

Background: Spinal arteriovenous fistulas (SAVFs) are direct communication between arteries and veins without intervening abnormal vessel nidus, which often results in venous congestion and spinal cord dysfunction. Ventrally located SAVF can be challenging to treat through traditional open or endovascular approaches.

Case description: We describe a hybrid (open/endovascular) procedure in a 72-year-old male with a Takai Type IVb SAVF presenting with paraparesis and sphincter dysfunction. Imaging revealed a conus medullaris SAVF in which the main fistulous connection was located ventrally. The conventional endovascular approach was deemed risky, and open surgery failed in the first attempt. The SAVF was resolved using a hybrid approach: under direct visualization, an engorged dorsal vein was punctured with an Angiocath, and a fluoroscopy-guided microcatheter was advanced through it to reach and embolize the ventral perimedullary fistulous connection. After surgery, his progressive neurological decline stabilized, radiographic spinal cord edema improved, and follow-up angiography confirmed obliteration of the fistula. Neurological function remained at the preoperative baseline.

Conclusion: This approach may be a treatment for selected cases of type IVb SAVF. Easily accessible feeding vessels are coagulated and cut; the inaccessible ones can be embolized endovascularly during the same procedure.

Background: Traumatic brain injury-related cerebral infarctions are well-documented in the literature. We want to report a case of malignant cerebral infarction that occurred at the contralateral location of evacuated epidural hematoma 3 days after surgery. The early-onset cerebral infarction's clinical presentation was already evident during the initial clinical examination, and it resembled "Kernohan's Notch Syndrome."

Case description: A 57-year-old male Indonesian was taken to our Academic General Hospital's emergency room following a motorcycle accident. His primary complaints were reduced consciousness and left-sided hemiparesis. A head computed tomography (CT) scan revealed an intracerebral hematoma beneath an epidural hematoma (EDH) at the left temporal area. The EDH was surgically removed promptly. The patient's Glasgow coma scale improved, and they were able to follow commands afterwards. The patient had a decreased consciousness 3 days after the surgery. A malignant infarction of the right middle cerebral artery region was identified from the head CT scan evaluation. He immediately had an emergency decompressive craniectomy and had an improvement of consciousness following the surgery.

Conclusion: It is imperative to reassess the initial clinical signs of Kernohan's notch phenomenon to determine whether the offending mass was able to generate this clinical phenomenon. Initial cerebral infarction, which occurs concomitantly with traumatic intracranial hematoma, is a possible cause of clinical deterioration following the surgery.