Surgical neurology international最新文献

Background: Brain metastases from follicular thyroid carcinoma (FTC) are exceptionally rare, especially in the infratentorial region. Even rarer is when such a lesion precedes the diagnosis of the primary tumor. This case highlights the importance of maintaining diagnostic vigilance for metastatic disease, even in patients with seemingly benign thyroid pathology.

Case description: A 55-year-old female presented with progressive imbalance and headache. Magnetic resonance imaging revealed a solid-cystic lesion in the cerebellar vermis compressing the fourth ventricle. She had a prior diagnosis of colloid goiter based on fine-needle aspiration cytology (FNAC). Intraoperatively, the lesion mimicked a hemangioblastoma; frozen section supported this diagnosis. However, final histopathology and immunohistochemistry confirmed metastatic FTC. Subsequent positron emission tomography-computed tomography and repeat thyroid FNAC confirmed the primary tumor, leading to total thyroidectomy and radioactive iodine therapy.

Conclusion: This case is likely the first reported instance of isolated cerebellar metastasis from FTC, masquerading as a primary central nervous system tumor. Surgeons should maintain a high index of suspicion when encountering posterior fossa tumors with atypical features, even with a prior benign thyroid FNAC.

Background: Thalamic gliomas are rare tumors with unique anatomical and histopathological characteristics which make them challenging to identify and manage. The aim of the present meta-analysis is to consolidate the evidence for clinical outcomes, tumor grade, laterality, operation type, and complications of thalamic gliomas.

Methods: We conducted a Preferred Reporting Items for Systematic Reviews and Meta-analyses - conformant systematic review and meta-analysis. 327 patients were included in 15 studies. Statistical analysis included heterogeneity testing for tumor grades, laterality, and outcome of operations using pooled proportions. Dichotomous outcomes were analyzed using odds ratios (ORs) and random-effects models. Complications and adjuvant treatments were also examined.

Results: The statistical analysis showed a significant association between tumor grade and clinical outcome, with clinical improvement occurring in 83% of low-grade versus 46% of high-grade thalamic gliomas (odds ratio = 0.366; P = 0.006). Laterality had no significant impact on outcomes (improvement: right-sided 42%, left-sided 41%). Subtotal resection showed higher improvement (54%) than gross total resection (32%), though differences were not statistically significant. Pediatric patients had slightly better improvement (54%) and lower mortality (11%) compared to adults (49% improvement and 15.8% mortality). The most common complication was hemiplegia (35.4%). The transventricular approach was most used (36.4%).

Conclusion: Tumor grade remains the strongest prognostic factor in thalamic glioma surgery. While laterality and extent of resection appear less predictive, tailored surgical approaches supported by advanced imaging and intraoperative monitoring can optimize outcomes. Further research incorporating molecular subtypes is warranted to refine surgical strategies and prognosis.

Background: Subthalamic nucleus-deep brain stimulation (STN-DBS) is a well-established treatment for Parkinson's disease (PD). Contralateral dyskinesias are often observed during intraoperative testing and are considered predictors of the best postoperative effects on Parkinsonian's motor disability. Ipsilateral and bilateral dyskinesias are unusual and raise questions about the bilateral functional connectivity within basal nuclei circuitry in PD patients.

Case description: A 47-year-old right-handed male patient with advanced PD presented with freezing of gait, motor fluctuations, and disabling dyskinesias predominantly affecting the left side, despite optimized pharmacological treatment. He was subsequently selected for STN-DBS implantation. During the surgery, the proper, bipolar stimulation of the distal contact (contact 0, cathode; contact 1, anode) at 2 mA induced severe dyskinesia manifesting as chorea, starting in the right lower limb and extending bilaterally. The dyskinesias ceased when stimulation was interrupted. On the left STN, stimulation of the distal contact induced only contralateral lower limb dyskinesias.

Conclusion: This case report adds to the discussion on basal nuclei circuitry and its bilateral connections, enhancing our understanding of the physiological mechanisms underlying both the therapeutic and adverse effects of unilateral STN-DBS. It supports the hypothesis of abnormal bilateral connectivity in some PD patients, explaining bilateral dyskinesias and therapeutic implications.

Background: Intraoperative neuromonitoring (IONM) is critical for preserving cranial nerve function during cerebellopontine angle (CPA) tumor surgery, particularly when multiple cranial nerves are involved. We report a case of an epidermoid cyst resection in which IONM waveforms were projected in real time onto the surgical microscope display.

Case description: A 36-year-old woman presented with the left facial spasm and numbness. Magnetic resonance imaging (MRI) revealed a left CPA lesion extending from the medulla to the midbrain, compressing the brainstem and involving cranial nerves III-XII. The tumor was removed through a lateral suboccipital approach with the patient in the park-bench position. A microscope was integrated with the neuromonitoring system. Auditory brainstem responses were used for hearing monitoring, while continuous transcranial facial motor-evoked potentials and intermittent electrical stimulation assessed facial, trigeminal, and lower cranial nerves. Real-time waveform projection onto the microscope allowed immediate recognition of signal changes during dissection. The tumor was completely removed while preserving cranial nerves III-V, VII-VIII, and lower cranial nerves. No intraoperative deterioration in waveform amplitude occurred. Postoperative MRI confirmed complete removal, and histopathology diagnosed. Facial spasm and numbness resolved without hearing loss. The patient was discharged with a modified Rankin scale score of 0 and remained symptom-free and recurrence-free at one year.

Conclusion: Real-time IONM projection facilitated intraoperative communication and may contribute to safe, complete resection with cranial nerve preservation. Ethics committee approval was obtained, and the patient provided written informed consent for participation, surgical video, and publication.

Background: Tuberculous meningitis (TBM) is the most common central nervous system (CNS) infection caused by "Mycobacterium tuberculosis," leading to significant neurological deficits and high mortality rates. Effective treatment is essential to control the infection. This literature review aims to evaluate recent advancements in anti-tuberculosis therapy for TBM, focusing on optimizing treatment regimens.

Methods: This literature review primarily draws from studies available in the PubMed and Scopus databases on TBM regimens, focusing on publications that evaluate higher doses or novel drug therapies. Key search terms included "tuberculous meningitis," "anti-tuberculosis therapy," and "novel treatment regimens."

Results: Findings suggest that while standard tuberculosis (TB) regimens are effective for pulmonary TB, they may be suboptimal for TBM due to limited CNS drug penetration. Recent investigations propose higher drug doses and novel medications to enhance efficacy in TBM treatment.

Conclusion: The review highlights the need for TBM-specific treatment regimens with optimized dosing and new drug formulations to improve patient outcomes. Further research is needed to validate these emerging therapies.

Background: Cortical spreading depression (CSD) has been recognized recently as a potential driver of secondary brain injury following traumatic brain injury and subdural hematoma (SDH). It can propagate in metabolically compromised cortical tissue, leading to the spread of ischemia and delayed infarction.

Case description: The case is an 87-year-old man with atrial fibrillation on long-term anticoagulation who sustained an unwitnessed fall at home and was only found a day later. On presentation, he was alert but suffering from a profound left-sided hemiparesis, as well as significant dysarthria and confusion. Brain computed tomography (CT) showed an acute SDH causing only mild local mass effect. CT-angiogram showed no evidence of cervical or intracranial occlusion or dissection. Brain magnetic resonance imaging revealed extensive cortical acute infarcts, including territories far from the SDH, and with white matter sparing.

Conclusion: This case highlights the potential contribution of CSD, inferred from characteristic imaging findings, and spreading ischemia to delayed, diffuse hemispheric infarction in the setting of traumatic SDH, emphasizing its pathophysiological mechanisms, diagnostic challenges, and therapeutic implications.

Background: Intraoperative neurophysiology monitoring (IONM) has become a critical tool in spinal surgery, providing real-time feedback on neural integrity to help prevent postoperative neurological deficits. Despite its growing use, there remains variability in evidence regarding its effectiveness across diverse surgical contexts.

Methods: A systematic search of PubMed, Embase, Scopus, Cochrane Library, ClinicalTrials.gov, and Google Scholar identified studies assessing IONM in spine surgery. Risk of bias assessment was performed using ROBINS I tool.

Results: Our review found that IONM is associated with lower rates of neurological injury in controlled cohorts, although larger registries showed higher crude deficit rates confounded by surgical complexity. Intraoperative alerts were common but usually transient, enabling timely corrective actions. Diagnostic accuracy was high, with excellent specificity and negative predictive value, supporting IONM's role as an early-warning tool.

Conclusion: IONM enhances patient safety in spinal surgery by enabling early detection of neural injury and minimizing postoperative neurological deficits. Evidence supports the use of multimodal IONM with standardized protocols to improve neurological outcomes.

Background: Cerebral amyloid angiopathy (CAA) is a small- and medium-vessel cerebrovascular disease characterized by β-amyloid accumulation within cortical and leptomeningeal arterial walls. Although it most commonly manifests in older individuals as spontaneous lobar hemorrhage, uncommon cases have been reported in younger patients, especially those with risk factors such as previous head trauma, genetic predisposition, or prior exposure to cadaveric dura.

Case description: We describe a diagnostically challenging case of suspected CAA in a 42-year-old man with a history of multiple traumatic brain injuries, prior neurosurgical interventions, neuropsychiatric symptoms, and late-onset seizures. Importantly, during treatment for head trauma in early adulthood, he received a cadaveric dura transplant. Over subsequent years, he developed recurrent lobar hemorrhages and progressive cognitive and behavioral changes, raising concern for an atypical, possibly iatrogenic, form of CAA.

Conclusion: This case highlights the need to consider CAA - even in younger patients - when recurrent lobar hemorrhages and neuropsychiatric symptoms occur in the context of relevant risk factors such as previous head trauma or cadaveric dura exposure. We believe that such exposure may underlie this patient's gradual but persistent neurological and cognitive decline.

Background: We describe the case of a 23-year-old woman with a history of medullary thyroid cancer (MTC) who presented with a choroid plexus papilloma (CPP) and review the literature regarding the co-occurrence of these two pathologies.

Case description: A 23-year-old woman with a history of MTC treated with thyroidectomy 3 months prior was referred to neurosurgery with an incidental fourth ventricular mass found on prior imaging of her neck. She presented to the clinic with intermittent headaches and underwent MRI which demonstrated a hyperintense, heterogeneously enhancing lobular mass at the obex of the fourth ventricle. She underwent suboccipital craniotomy and C1 laminectomy for resection of tumor with pathology revealing CPP. No somatic mutations unique to the tumor were found after targeted exome sequencing and tumor-normal paired analyses. Interestingly, germline sequencing reveals a mutation in the tumor suppressor Cadherin 1(CDH1).

Conclusion: Mutations in CDH1 may play a role in an underlying predisposition toward the development of MTC and CPP. Current literature identifies no definitive connection between MTC and CPP, though future studies may suggest the role of this gene beyond a predisposition to gastric and breast cancer.

Background: Traumatic brain injury (TBI) is a primary cause of mortality and disability globally, with severe cases often resulting in long-term impairment. This study investigated key admission characteristics that predict outcomes in severe TBI patients, enhancing early mortality prediction through a comprehensive prognostic tool.

Methods: This prospective study involved 240 patients with severe TBI (Glasgow Coma Scale [GCS] ≤8) admitted to our university hospitals over 2.5 years. Clinical, radiological, and laboratory data were collected, including GCS, Best motor response (BMR), pupil reactivity, hypotension, and the Marshall computed tomography (CT) score. Transcranial Doppler (TCD) pulsatility index (PI) and S100B protein levels were also assessed. Outcomes were assessed by the Glasgow outcome score (GOS).

Results: Key findings demonstrated significant correlations between GCS, BMR, pupil reactivity, hypotension, and CT scores with GOS outcomes. Lower GCS scores and higher PI on Day 3 were associated with increased mortality. The madras head injury prognostic scale (MHIPS) effectively predicted outcomes with a strong correlation to GOS (P < 0.001). For patients with severe TBI, predictive thresholds for PI were established. On Day 1, a PI cutoff of ≤1.27 showed a sensitivity of 75%, specificity of 72.7%, and accuracy of 72.9% (area under the receiver operating characteristic curve [AUROC] 0.760, P = 0.001). On Day 2, a cutoff of ≤1.30 had 100% sensitivity, 49.4% specificity, and 53% accuracy (AUROC 0.694, P = 0.018). On Day 3, a cutoff of ≤1.03 provided a sensitivity of 87.5%, specificity of 56.3%, and accuracy of 69.4% (AUROC 0.729, P = 0.024). For mortality prediction, a Day 3 PI cutoff of >0.97 yielded a sensitivity of 86.5%, specificity of 51.4%, and accuracy of 69.4% (AUROC 0.692, P = 0.002). S100B protein measured on Day 1 at >264 ng/L had a sensitivity of 76.9%, specificity of 65%, and accuracy of 69.7% (AUROC 0.723, P = 0.027).

Conclusion: This study underscores the importance of integrating clinical, radiological, and laboratory parameters into prognostic models for severe TBI. The findings emphasize the predictive power of the TCD-measured PI and S100B protein levels as practical tools for estimating patient outcomes and mortality risk, facilitating improved clinical decision-making and resource allocation in intensive care settings.