Surgical neurology international最新文献

Background: Pineal region tumors comprise 0.4% of all central nervous system tumors in adults and 2.8% in children aged up to 19 years. Pineal gland tumors exhibit histological variability and necessitate a multidisciplinary approach. The first step in managing hydrocephalus is to treat it with either endoscopic third ventriculostomy (ETV) or a shunt surgery.

Case description: We present a case of a child with a massive intratumoral hemorrhage located in the pineal region. An 8-year-old boy with a suspected germinoma in the pineal area accompanying noncommunicating hydrocephalus underwent a right ventriculoperitoneal shunt procedure. He experienced a sudden decline of consciousness following the procedure. The subsequent imaging showed an extensive hyperdense lesion within the brain ventricles, indicating intratumoral hemorrhage. Given that intratumoral hemorrhage in pineocytoma following the placement of ventriculoperitoneal shunt surgery is uncommon, it is a significant factor contributing to morbidity and mortality. It should be considered when cerebrospinal fluid (CSF) diversion is performed before a craniotomy.

Conclusion: A hypothesis suggests that changes in CSF flow after diverting CSF can be the main trigger for intratumoral hemorrhage although uncommon. In this study, we present our experience with our patients and provide a comprehensive evaluation of the existing literature.

Background: This study aims to evaluate the surgical outcomes of elderly patients with Chiari malformation (CM) who underwent suboccipital craniectomy (SC) with duraplasty (DP) or dural splitting (DS). The focus is on symptom relief, changes in syrinx size, hospital admission duration, and postoperative complications.

Methods: A retrospective study was performed to evaluate the outcomes of elderly CM patients who underwent SC with DP or dural splitting (DS). Patients older than 60 years who underwent posterior fossa decompression (PFD) together with DP or DS who underwent surgery from 1989 to 2022 were included in the study. Patients were divided into two categories based on their surgical approach - SC with DP and SC with dural splitting (DS) surgery. Demographic details, co-morbidities, clinical features, management details, Chicago Chiari Outcome Scale (CCOS), complications, and follow-up details were obtained.

Results: Of the seven patients, five were females, and two were males. The mean age at the time of the operation is 65.14 years. Among the seven patients, six had syrinx, with a mean diameter of 6.17 mm; one patient had hydrocephalus, and one had scoliosis. All the patients underwent PFD; six patients also underwent DP, and one patient underwent DS. The median CCOS at the time of discharge is 13.

Conclusion: In elderly CM patients, surgery improved symptoms for most but led to reoperations in two cases. Despite a slight increase in syrinx diameter and a drop in the CCOS score, better outcomes were associated with smaller syrinxes. Further research is needed to optimize treatment strategies for this population.

Background: Tuberculum sellae meningiomas (TSMs) represent a distinct entity among intracranial meningiomas. Both transcranial approaches (TCAs) and endoscopic endonasal approaches (EEAs) have provided neurosurgeons with options for managing these difficult tumors. Still, controversies persist regarding the selection criteria for the most optimal approach.

Methods: The authors retrospectively reviewed 45 patients treated surgically for TSM between 2018 and 2023. The clinical reports of all subjects were assessed pre-and post-operatively, encompassing demographic information, clinical symptoms, imaging results, ophthalmological evaluations, operative details, and any complications.

Results: A total of 45 patients were included in this study, with 21 patients undergoing EEAs and 24 TCAs. TSMs treated with EEA are smaller than TCA (P = 0.0014), less prevalent in optic canal invasion (P = 0.0291) and in arterial encasement (P = 0.0050), and have no lateral extension (P < 0.0001). The majority of patients (36/45) had visual improvement or stabilization following the surgery, with the rate of achieving gross total resection (GTR) was higher in the EEA group (17/21) than in the TCA group (9/24) (P = 0.0032). The mortality tends to be higher in the TCA group and is related to arterial encasement, although statistically insignificant.

Conclusion: Both traditional TCAs and EEAs offer options for the surgical management of TSM, each with its advantages and limitations. Based on our experiences, several factors (lateral extension and arterial encasement) may guide the suitable approach, and multidisciplinary considerations, with the overarching goals of achieving maximal tumor resection and minimizing postoperative complications.

Background: Cerebellar infarction can lead to severe morbidity and mortality. Current surgical options include decompressive craniectomy (DC) and endoscopic minimally invasive evacuation of necrotic tissue (MEN), but no randomized studies compare their outcomes.This study compares outcomes between DC and MEN in patients with cerebellar infarct using the Glasgow Coma Scale (GCS) and Scale for the Assessment and Rating of Ataxia (SARA) scores.

Methods: Retrospective review of 37 patients treated for cerebellar infarct between 2010 and 2020. Patients were divided into DC and MEN groups, with outcome measures assessed postoperatively.

Results: Both techniques produced similar improvements in GCS and SARA scores, though MEN showed faster healing time and shorter surgery duration.

Conclusion: MEN may offer advantages over traditional surgery in terms of healing and shorter operative time, warranting further investigation.

Background: The surgery on the craniocervical junction is associated with complex techniques that endanger the vertebral artery (VA), especially if there are some anatomical variations present, thereby increasing the risk of vascular injury, particularly during cervical decompression or instrumentation.

Case description: A case of a 60-year-old female with progressive myelopathy and craniocervical junction malformation is presented. Key preoperative imaging findings included basilar invagination, C1 assimilation, and os odontoideum, along with VA anomalies such as a tortuous, hypoplastic left VA arising anomalously from the aortic arch and a right VA with a V2 segment forming a high-riding medial loop into the C2 vertebral body. The surgical procedure was performed through a posterior approach using C-arm fluoroscopy, Doppler ultrasound, and intraoperative neurophysiologic monitoring, which achieved adequate deformity fixation and anterior decompression.

Conclusion: Computed tomography angiography is the gold standard for assessing the preoperative VA anatomy at the craniocervical junction. Intraoperative Doppler ultrasound is invaluable because it minimizes the risk of sudden accidental injury to VAs in cases with abnormal anatomies.

Background: The prevalence of central nervous system tuberculosis (TB) is about 1-2% of all TB cases. Atypical cases like the present case, being interpreted as leptomeningeal metastasis in magnetic resonance imaging (MRI), can pose a dilemma, delaying or even leading to mistreatment.

Case description: A 19-year-old male presented with acute onset paraparesis and bowel bladder involvement presented with an MRI lumbar spine suggesting leptomeningeal metastasis from D11-L5 levels who underwent decompression biopsy which on histopathological examination revealed to be tubercular granulomatous infection. Anti-tubercular drug (ATD) started, and significant improvement was seen in the lower limb power and tone. The outcome of treatment has been unpredictable. Previous case studies having neurological deficits due to severe compression, including ours, show good recovery after surgical decompression and ATD regime.

Conclusion: Such cases should be managed with high suspicion as they can be easily misdiagnosed to be tumors, leading to mistreatment or delayed treatment.

Background: Primary intracranial sarcomas (PISs) are very rare malignant tumors, and there is paucity of data on it, exclusively in patients <18 years old. We report pediatric PIS at a tertiary hospital in Peru, where the incidence of PIS has increased in recent years.

Methods: We retrospectively analyzed data in children diagnosed with PIS based on clinical presentation, imaging studies, and histopathology between January 2020 and December 2023.

Results: Twenty-five cases were identified. The median age was 5 years. There is slight female predominance (56%). On presentation, 68% of patients had features of intracranial hypertension (ICH), others had convulsions or motor deficits. There was radiologic evidence of cerebral hemorrhage in 80% of those with features of ICH and convulsion. All but one case had a supratentorial tumor. Emergency craniotomy was done in 84% of cases, and gross total resection (GTR) was achieved in the first surgery in 72% of cases. We used an adjuvant chemotherapyradiotherapy-chemotherapy (CTX-RT-CTX) regimen in 72% of cases, but 12% started this scheme 2 weeks after surgical resection. The cases followed up for more than a year that were managed with CTX-RT-CTX after GTR had a survival greater than a year, compared to the cases that received complementary treatment after 4 weeks.

Conclusion: PIS among children represents an infrequent pathology that, in the last years, its incidence has increased in Peru. The presence of intracerebral hemorrhage is a very suggestive finding of this diagnosis; therefore, emergent surgical management is an option before an irreversible ICH presents. Adjuvant treatment with the CTX-RT-CTX regimen started 2 weeks after GTR may improve survival in children with PIS.

Background: Glomus tumors around the jugular foramen and inner ear can have variable presentations, including lower cranial nerve palsies, tinnitus, hearing loss, or palpable neck mass. In general, these tumors are benign paragangliomas with the definitive treatment consisting of radiosurgery or surgery. Endovascular embolization can be added as a critical adjunctive therapy to reduce the tumor vascularity before surgical resection. We present the first case of a glomus jugulotympanicum presenting with a severe otalgia-dominant form of glossopharyngeal neuralgia, Jacobson's neuralgia, that was resistant to radiosurgery and relieved successfully by targeted endovascular embolization.

Case description: A 51-year-old female presented with worsening right-sided lancinating ear pain radiating into the jaw and neck, exacerbated by brushing her teeth or any pressure on the skin - consistent with glossopharyngeal neuralgia, Jacobson's variant. Imaging revealed a dumbbell-shaped heterogeneously-enhancing mass in the middle ear cavity extending through the jugular foramen consistent with a glomus jugulotympanicum tumor. After treatment with single-fraction stereotactic radiosurgery, the neuralgia continued to worsen despite medical management and significantly impacted the patient's quality of life. After a multidisciplinary discussion, we performed targeted endovascular embolization of the tumor as palliative therapy. The patient subsequently reported complete relief of neuralgia and full resolution of tinnitus after the embolization procedure, remaining pain free at 20 months follow-up.

Conclusion: Targeted endovascular embolization may serve as a safe and potentially palliative option for refractory Jacobson's neuralgia induced by a glomus jugulotympanicum tumor.

Background: Histiocytic neoplasms are defined by too many histiocytes accumulating in various tissues, including the skin, bones, lymph nodes, and central nervous system. They are uncommon blood-related disorders that constitute <1% of cancers found in soft tissues and lymph nodes. Most referred to as Langerhans cell histiocytosis (LCH) or non-LCH, there are over 100 different sub-types that are divided into five groups. Here, a 76-year-old male presented with an intramedullary thoracic LCH.

Case description: A 76-year-old male presented with the month of slowly progressive bilateral lower extremity weakness (i.e., right > left) accompanied by decreased left-sided sensation below the T7 level. The enhanced thoracic magnetic resonance (MR) imaging documented an intradural intramedullary nodule at the T5 level with a syrinx extending from C7 to T10. The patient underwent a T4-T6 laminectomy for complete resection of the lesion. CD163 and CD68 studies highlighted a small, spindled-shaped tumor with occasionally enlarged histiocytes without co-positivity for S100. Pathologically, the lesion was considered an isolated intramedullary thoracic LCH.

Conclusion: A 76-year-old male presented with progressive paraparesis of 1 month's duration attributed to an enhanced MR-documented T5 single intramedullary T5 thoracic LCH that was successfully resected.

Background: Hemifacial spasm (HFS) is a neurovascular movement caused by vascular compression of the facial nerve in its root exit zone (REZ). Cases of HFS caused by double compression (DC) in both REZ and the cisternal portion (CP) have been sporadically reported. The nature of DC-type HFS is still not fully understood. Compression in CP is often overlooked, resulting in reoperation in DC-type HFS cases.

Case description: A 48-year-old man with a 3-year history of left HFS was admitted to our department. Magnetic resonance imaging revealed that the vertebral artery (VA) passed around REZ of the facial nerve, and the anterior inferior cerebellar artery (AICA) was in contact with the facial nerve in CP. Microvascular decompression was performed while monitoring any abnormal muscle response (AMR). Although VA was dissected and detached from REZ, AMR showed only a transient decrease and the amplitude of the AMR wave soon recovered and subsequently increased. No other vessels compressing REZ beneath VA were found. AICA attached to the facial nerve in CP and was compressed upward by VA. When AICA was moved from the facial nerve in CP after the transposition of VA, AMR was immediately resolved. After surgery, the patient was completely free from HFS.

Conclusion: In DC-type HFS, precise preoperative diagnosis and intraoperative identification of the culprit vessel are difficult. In DC-type HFS, decompression of one side of a vessel may exacerbate the compression of the other side. In such a case, AMR helps us become aware of compressions in CP that we may preoperatively overlook. AMR is useful for identifying the exact culprit vessels and recognizing any compression changes caused by intraoperative manipulations.