Surgical neurology international最新文献

Background: Outcome measurement in skull base surgery lacks standardization, with substantial variability in definitions and reporting across pathologies. This heterogeneity prevents meaningful comparison of treatments, hinders quality improvement, and may compromise patient-centered care. While previous studies addressed pathology-specific challenges, it remains unclear whether these represent isolated issues or systemic problems requiring comprehensive solutions.

Methods: This narrative review synthesized 38 studies across diverse skull base pathologies (pituitary adenomas, meningiomas, chordomas, craniopharyngiomas, and sinonasal malignancies), employing thematic analysis to identify universal outcome measurement challenges transcending specific diagnoses.

Results: Five universal themes emerged, transcending specific diagnoses: (1) substantial heterogeneity in outcome definitions; (2) disconnect between clinician-centered and patient-centered priorities; (3) inadequate quality-of-life assessment integration; (4) methodological limitations in surgical approach comparisons; and (5) absence of standardized cross-pathology frameworks. These challenges persist despite pathology-specific guidelines, confirming systemic infrastructure deficits.

Conclusion: Outcome measurement controversies represent systemic infrastructure challenges requiring field-wide solutions. Essential interventions include: standardized consensus-based metrics applicable across pathologies, mandatory patient-reported outcome integration, improved comparative methodology, and establishment of international registries with unified protocols. Without addressing these fundamental issues, outcome assessment will remain fragmented regardless of pathology-specific advances.

Background: Marchiafava-Bignami disease (MBD) is a rare alcohol-related disorder that predominantly affects the corpus callosum. Because MBD frequently demonstrates diffusion restriction on magnetic resonance imaging (MRI), it can closely mimic acute ischemic stroke (AIS), posing a diagnostic challenge in image-driven acute stroke evaluation. Early recognition is crucial, as timely thiamine therapy may result in complete clinical and radiologic recovery.

Case description: A 38-year-old man with long-standing daily consumption of shochu, a Japanese distilled spirit, developed vertigo and vomiting on awakening, followed by mild right lower extremity weakness on day 5. MRI performed at a local clinic on day 6 revealed a diffusion-restricted lesion confined to the splenium of the corpus callosum, and corpus callosum infarction was initially suspected. On admission, the patient was fully conscious and exhibited horizontal gaze-evoked nystagmus with very mild right-sided weakness. MRI identified a splenial lesion of the corpus callosum exhibiting high signal intensity on diffusion-weighted imaging with corresponding low apparent diffusion coefficient values, accompanied by mild hyperintensity on T2-weighted and fluid-attenuated inversion recovery images. Given the patient's young age, absence of vascular risk factors, and the splenial distribution of the lesion, AIS was considered unlikely. Following consultation with a neurologist, MBD was suspected based on the patient's history of chronic alcohol consumption, and intravenous vitamin supplementation, including thiamine, was initiated. Neurological symptoms improved rapidly, and follow-up MRI on hospital day 8 demonstrated complete resolution of the splenial lesion. The patient was discharged without neurological sequelae on hospital day 10.

Conclusion: A diffusion-restricted splenial lesion in patients with a history of chronic alcohol consumption and without vascular risk factors should prompt consideration of MBD rather than a reflexive diagnosis of AIS. Careful integration of imaging findings with clinical context is essential for identifying reversible stroke mimics and ensuring timely, appropriate treatment.

Background: Pierre-Robin syndrome (PRS) is a disorder characterized by mandibular hypoplasia, leading to upper airway obstruction and feeding difficulties due to backward displacement of the tongue (glossoptosis). Cervical diastematomyelia is another rare congenital condition in which the spinal cord splits into two hemicords at the level of the cervical spine.

Case description: We report a unique case of a 6-month-old boy who has cervical diastematomyelia and PRS. At birth, our patient had mandibular hypoplasia, respiratory distress, a posterior parietal region swelling, and reduced tone in all four limbs. On current examination, he now also has left-sided torticollis along with the findings mentioned at birth. Imaging demonstrated features consistent with an atretic parietal cephalocele, enlarged cerebellum in comparison with age-matched group, and short segment type II diastematomyelia in the proximal cervical spinal cord.

Conclusion: In patients with these complex congenital anomalies, improving outcomes requires early detection and tailored management strategies.

Background: The objective of this study was to analyze whether the combined supra- and infraclavicular approach for neurogenic thoracic outlet syndrome (nTOS) increases postoperative complications and to determine whether its anatomical advantages translate into improved clinical outcomes without increasing morbidity when compared to isolated supraclavicular approaches.

Methods: A retrospective study of 69 procedures performed for nTOS between 2015 and 2024 by a single neurosurgeon. Surgical approaches, intraoperative findings, postoperative complications, and clinical outcomes were analyzed. Results were compared between the combined and isolated supraclavicular approaches using Chi-square testing and logistic regression models.

Results: The overall complication rate was 18.8% (13/69). Complications occurred in 22.5% of combined procedures (9/40) and 12.0% of isolated supraclavicular procedures (3/25), with no statistically significant difference (P = 0.545). All complications were transient, most commonly phrenic nerve palsy (7.2%) and superficial wound infection (5.8%). No permanent brachial plexus or vascular injuries occurred. The combined approach provided significantly better exposure of both proximal and distal compression zones, enabling more complete decompression, which was reflected in a higher rate of clinical improvement (82% vs. 69% in isolated approaches).

Conclusion: Although the combined approach presents a numerically higher complication rate, the difference is not statistically significant, and all complications were transient. Its superior anatomical exposure and higher rate of clinical improvement support the combined approach as a safe and advantageous surgical option for patients with suspected multilevel nTOS compression.

Background: Sacral chordomas are rare malignant bone tumors that are locally aggressive and difficult to treat due to proximity to pelvic viscera, neurovascular structures, and the high risk of surgical morbidity. En bloc resection with negative margins remains the gold standard, but it is often not feasible in large or adherent tumors. Rectal perforation is a rare yet potentially catastrophic intraoperative complication that remains sparsely reported.

Case description: We report the case of a 70-year-old man presenting with progressive back and gluteal pain, urinary difficulty, and bowel dysfunction. Magnetic resonance imaging revealed a giant sacrococcygeal chordoma (16.2 × 12.2 × 11.7 cm) compressing the rectum and sacral canal. Pre-operative arterial embolization of the bilateral internal iliac, median sacral, and feeding arteries was performed. During intralesional resection through a posterior approach, a rectal microperforation was detected, prompting intraoperative consultation with the general surgery team. The defect was repaired, and a trephine sigmoid colostomy was created. Tumor debulking was completed with an estimated blood loss of 300 mL. Histopathology confirmed chordoma. The patient recovered well, with a functional stoma and satisfactory wound healing.

Conclusion: Managing giant sacrococcygeal chordomas utilizing the "gold standard," en bloc resection, may risk rectal perforation due to visceral adherence. Prompt intraoperative recognition and management of this adverse event are critical, along with a multidisciplinary approach to maximize patient safety.

Background: Calcified nodules (CNs) are a distinct morphological subtype of calcified plaques that cause acute coronary events. However, their clinical relevance in carotid artery disease remains poorly understood.

Case description: We report two cases of symptomatic carotid artery stenosis caused by CNs, both successfully treated with carotid endarterectomy (CEA). In both cases, computed tomography angiography (CTA) revealed severely stenotic lesions with bulky calcified plaques protruding into the vascular lumen. Plaque imaging with magnetic resonance imaging and carotid ultrasonography suggested the presence of calcified components. Surgical excision confirmed the diagnosis of CNs through pathological evaluation. Both patients had favorable outcomes with no neurological deficits on discharge. Notably, CNs are rarely reported in the context of carotid artery disease, and preoperative diagnosis remains challenging due to the lack of established imaging criteria. CTA may be a useful non-invasive tool for identifying CNs, as shown in coronary artery studies.

Conclusion: These cases demonstrate that CNs can cause severe carotid stenosis requiring CEA. CTA may aid in the preoperative identification of CNs, and when CNs are identified on CTA, CEA should be the preferred treatment over carotid artery stenting. Further studies are warranted to clarify the diagnostic criteria and treatment strategies for CNs in carotid disease.

Background: Severe traumatic brain injury (STBI) is associated with high mortality and significant management challenges, particularly due to elevated intracranial pressure (ICP) and its role in triggering secondary injury through inflammatory pathways. This study investigates the predictive value of initial ICP, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP), and D-dimer for 14-day mortality in patients with isolated STBI.

Methods: A prospective cohort study was conducted at Ngoerah Hospital, Denpasar, including patients with isolated STBI requiring ICP monitoring. Initial ICP, NLR, PLR, CRP, and D-dimer levels (measured on day 3 of admission) were analyzed. The primary endpoint was 14-day mortality.

Results: Among participants, 64.7% were male and 62.5% were aged 25-40 years. An initial ICP >20 cm H₂O was significantly associated with increased 14-day mortality (relative risk [RR]: 6.43; P < 0.05; 95% confidence interval [CI]: 0.966-43.25). PLR <90.63 was also linked to higher mortality (P = 0.036). No significant associations were found for NLR, CRP, or D-dimer.

Conclusion: An initial ICP exceeding 20 cmH2O (14.71 mmHg) may serve as a new predictive threshold for 14-day mortality in isolated STBI patients. In addition, low PLR (<90.63) may serve as an early mortality predictor. Further studies are needed to clarify the role of other biomarkers.

Background: Only 1-5% of all spinal meningiomas (SMs) are calcified. These tumors typically grow slowly and remain asymptomatic for prolonged periods of time. They are only rarely acute and present with neurological deterioration precipitated by trauma. Here, an 81-year-old female with a calcified upper cervical meningioma presented with acute paralysis following just minor head trauma.

Case description: An 81-year-old female developed the rapid onset of quadriparesis following minor head trauma. The brain cervical magnetic resonance imaging demonstrated a calcified intradural extramedullary lesion at the C2-C3 level, causing significant spinal cord compression, accompanied by a subtle intramedullary high-intensity signal at C2-likely reflecting a spinal cord injury. The computed tomography confirmed a hyperdense mass with circumferential calcification at the C2-C3 level. Surgery, performed 6 days later, consisted of a C2- C3 hemilaminectomy. Intraoperatively, the firm/grayish tumor was completely removed. The histopathological examination confirmed a psammomatous meningioma. Postoperatively, motor function improved immediately, and the patient achieved independent ambulation by postoperative day 14.

Conclusion: Calcified SMs present diagnostic and surgical challenges due to firm adhesion to surrounding neural and dural structures. This case highlights that even minor trauma can precipitate neurological deterioration due to calcified upper cervical meningiomas.

Background: Adult primary spinal tumors (PST) are under-reported, particularly in low- and middle-income countries, including Pakistan. Notably, despite the limited availability of Intraoperative neurophysiological monitoring (IONM), we safely managed 137 patients with spinal cord tumors at a tertiary center over 10 years.

Methods: We retrospectively reviewed demographic, neurological status (i.e., evaluation using Modified McCormick Scale preoperatively/postoperatively), surgical outcomes, and progression-free survival (PFS) for 137 patients operated for primary spinal cord tumors over 10 years.

Results: These 137 patients with mean age 40.8 ± 15.1 years were followed up for an average of 8.7 months after surgery. Pre-operative common symptoms included lower extremity weakness (61, 44.5%) and back pain (50, 36.5%). Tumors were located mainly in the cervical (49, 36.6%) and thoracic spine (43, 32.1%). With IONM use in 29 (21.5%) patients, gross total resection (GTR; 25 [86.2%]) was achieved for the majority of tumors. IONM was not available for 106 patients. Of the latter, 90 (85.0%) had GTR. Notably, GTR was the only significant predictor of PFS (P = 0.03). At last follow-up, MMS improved in 97 (70.8%) of patients, was unchanged in 25 (18.2%), and worsened in 15 (11.0%).

Conclusion: We found in Pakistan that many of the 137 patients with spinal cord tumors presented late in their clinical course, often with significant neurological deficits; this highlights the need for earlier and better diagnostic capacity and referral pathways. Despite limited IONM availability due to limited resources, GTR rates and neurological improvement were achieved. Nevertheless, we still advocate using IONM where resources allow.

Background: Upper lumbar disc herniations (ULDHs) are rare and present significant technical challenges due to the inability to retract the conus medullaris. Here, we reviewed our outcomes treating 62 patients with L1-2-disc herniations with open laminectomy/microdiscectomy (OLM) without fusion.

Methods: Between 2005 and 2022, we performed 62 OLM procedures at the L1-2 level without fusion. Our analysis included demographic characteristics and outcomes assessments (Visual Analog Scale leg pain, Modified Japanese Orthopaedic Association score), plus 1-year postoperative dynamic X-rays to confirm stability.

Results: L1-2-disc herniations occurred in 0.9% out of a larger series of lumbar discs we reviewed. Patients' presenting symptoms typically included back (95%)/leg pain (82%), cauda equina symptoms/signs (64%), and neurogenic claudication (45%); more than 50% of patients had been symptomatic for over 1 year. Postoperatively, no discs recurred, and patients exhibited neither clinical nor radiological symptoms/signs of instability.

Conclusion: The OLM technique for removal of L1-2 lumbar disc herniations resulted in adequate outcomes without evidence of spinal instability.