Surgical neurology international最新文献

Background: Cerebral ischemia associated with common carotid artery (CCA) occlusion is a relatively rare condition, and the optimal surgical strategy remains controversial, with no established consensus. Herein, we report the first case of carotid endarterectomy combined with balloon thrombectomy for proximal CCA occlusion.

Case description: The patient was a 66-year-old male with orthostatic hypotension after C4 spinal cord injury who presented with posture-induced right hemiparesis and aphasia. Magnetic resonance imaging revealed left CCA occlusion proximally to the clavicle. Arterial spin labeling revealed a significant reduction in cerebral blood flow in the left hemisphere. In light of the emergence of new cerebral infarctions despite maximal medical therapy, surgical revascularization was deemed necessary. During the actual surgical procedure, recanalization was successfully achieved by advancing a balloon catheter through the arteriotomy and retrieving the thrombus. No complications occurred, and the patient experienced neurological improvement, being discharged to a rehabilitation facility.

Conclusion: This combined technique is less invasive and feasible for treating CCA occlusion located in anatomically challenging regions below the clavicle.

Background: Spinal nerve sheath tumors (NSTs), including schwannomas and neurofibromas, are slow-growing lesions often arising from dorsal sensory roots. Surgical resection is the gold-standard treatment, but the necessity of sacrificing the affected nerve root to achieve gross total resection remains controversial due to concerns about postoperative deficits.

Methods: A comprehensive review of the literature was conducted to evaluate neurological outcomes following nerve root sacrifice and the functional reorganization by adjacent roots during the resection of large spinal schwannomas and neurofibromas. In addition, we report a representative case of a patient with a 20-year history of a large left L5 schwannoma, showing preoperative and intraoperative electrophysiological evidence of chronic radicular impairment. The patient underwent microsurgical tumor excision under intraoperative neurophysiological monitoring, with sacrifice of the affected root to allow the resection of the lesion tightly adherent to adjacent structures.

Results: The literature consistently demonstrates that chronically compressed nerve roots in large, slow-growing NSTs are often nonfunctional or poorly functional, with compensatory reorganization by adjacent cranial and caudal roots. Reported rates of new postoperative motor deficits are low, even after root sacrifice. In our case, postoperative clinical and electromyographic follow-up confirmed the absence of new neurological deficits and the persistence of chronic, compensated impairment of the sacrificed root.

Conclusion: Chronic impairment of spinal nerve roots in patients with large neoplasms, as documented by preoperative and intraoperative electromyographic data, allows for the safe resection of adherent NSTs with the possibility of sacrificing nonfunctional nerve roots. Functional compensation by adjacent roots preserves motor function, thereby minimizing the risk of postoperative deficits following root sacrifice.

[This retracts the article DOI: 10.25259/SNI_118_2025.].

Background: Primary spinal epidural lymphoma (PSEL) is rare, accounting for just 0.1-6.5% of all extranodal lymphomas and 9% of all primary spinal epidural tumors. They are mostly located in the thoracic spine, with only occasional cervical spine involvement. Here, a 74-year-old male presented with a cervical epidural diffuse large B-cell lymphoma (DLBCL) that was successfully managed with an emergent surgical decompression.

Case description: A 74-year-old male presented with the acute onset of quadriparesis. The magnetic resonance imaging (MRI) revealed thickening of the posterior longitudinal ligament at C2-3, an epidural mass posterior to the spinal cord from C3-5, causing spinal cord compression, maximal at the C4-5 level. Six days after admission, the patient underwent a C2 partial and full C3-4 laminectomy; it resulted in improvement of quadriparesis. Pathology confirmed the diagnosis of CD20-positive DLBCL, and he subsequently received appropriate chemotherapy/radiotherapy.

Conclusion: Spinal cord compression is the sole presenting symptom in <5% of malignant lymphoma cases. Here, a 74-year-old male developed an acute quadriparesis attributed to a C3-C5 DLBCL that was successfully managed with a C2-C4 laminectomy, followed by appropriate chemotherapy and radiation.

Background: Hydatid cysts are uncommon parasitic lesions of the central nervous system (CNS). Among these, intraventricular involvement is exceptionally rare, with only a handful of cases reported in the literature. Occurrence within the third ventricle is particularly unusual.

Case description: We present the case of a 51-year-old male from an endemic region in Iraq who developed a third ventricular hydatid cyst presenting with hydrocephalus. The patient exhibited symptoms of obstructive hydrocephalus, including headaches, vomiting, and gait instability. Magnetic resonance imaging revealed a sharply marginated, cerebrospinal fluid-isointense, non-enhancing cystic lesion measuring approximately 2.8 × 2.5 × 2.3 cm within the third ventricle, obstructing the foramina of Monro, and resulting in triventricular hydrocephalus. Serological testing confirmed Echinococcus granulosus infection. The cyst was surgically removed intact through a transcortical-transventricular approach using the Dowling technique, avoiding rupture-related complications. Postoperative recovery was smooth, and adjunct albendazole therapy was administered.

Conclusion: This case highlights the importance of high clinical suspicion, precise imaging interpretation, and meticulous surgical technique when managing rare CNS hydatid cysts, especially in endemic areas. To the best of our knowledge, this represents one of the very few reported cases of a third ventricular hydatid cyst worldwide. The report highlights both the extreme rarity of this localization and the importance of meticulous surgical removal and adjunct antiparasitic therapy in preventing recurrence, offering valuable insights for neurosurgeons practicing in endemic regions.

Background: Primary central nervous system lymphoma (PCNSL) is a rare tumor, accounting for only 1-2% of all primary brain tumors, with most cases being diffuse large B-cell lymphoma (DLBCL). Because these lymphomas can rapidly worsen, prompt and accurate histological diagnosis, followed by early treatment initiation, are essential for improved prognosis. Extensive surgical resection has not demonstrated a clear survival benefit, and a minimally invasive biopsy is recommended. Hemorrhage within lesions is exceedingly rare, with few reports available.

Case description: A 73-year-old woman presented with progressive aphasia and right-sided hemiparesis. Imaging revealed a lesion from the left basal ganglia to the frontal lobe, suggestive of glioblastoma but not ruling out PCNSL. She developed deep vein thrombosis and pulmonary embolism, requiring anticoagulation therapy. Steroid therapy for acute brain edema provided transient improvement, but a massive intratumoral hemorrhage occurred. We performed a frameless robot-guided stereotactic biopsy and craniotomy for hematoma evacuation in a single operation. Final pathology confirmed DLBCL. Subsequent high-dose methotrexate plus rituximab therapy and radiation led to marked tumor shrinkage.

Conclusion: Combining robot-guided stereotactic biopsy with craniotomy in PCNSL with hemorrhage ensures precise diagnosis, effective decompression, and optimal treatment planning.

Background: The purpose of this video is to describe the microsurgical corridor of the trans-tonsillar approach for resection of a tumor located in the right lateral aspect of the medulla.

Case description: We presented a 56-year-old patient with headache and diplopia. On the preoperative magnetic resonance imaging (MRI), we found a localized tumor with surrounding edema in the anterior portion of the right cerebellomedullary fissure, and on the positron emission tomography-computed tomography, a hypermetabolic lesion in the right lung. We decided to excise the intracranial lesion given the risk of a postradiotherapy edema. We performed a suboccipital approach extended to the right side. At the intradural stage, the lesion was not reachable through a sub-tonsillar access because it was located in front of the right tonsil. For this reason, the surgical team decided to modify the initial plan, opting for a trans-tonsillar corridor instead. Pathological anatomy reveals metastasis of a lung adenocarcinoma. The patient evolved favorably, without neurologic deficit, and the postoperative MRI showed adequate resection and disappearance of the edema. The patient gave his written consent for the use of photographs, images, and surgical video in this work.

Conclusion: In the neurosurgical literature, there are descriptions of the suboccipital subtonsillar approach, including cadaveric studies, technical notes, and reports of its application in various pathologies. However, the use of the trans-tonsillar pathway is not described in the neurosurgical bibliography. This fact attracts attention, since resection or coagulation of only cerebellar tonsils does not generate a clinically significant neurological deficit. This suggests that the trans-tonsillar pathway, if necessary, is a valid option. The current work constitutes the first report of the usage of a suboccipital trans-tonsillar approach.

Background: Chordomas are rare malignant tumors of notochordal origin, with sacral chordomas being the most common. En bloc resection with negative margins is the preferred treatment for long-term disease control. However, the technical complexity of en bloc sacrectomy cannot be overstated. This case report highlights the use of a patient-specific 3D-printed cutting guide to assist in the precise en bloc resection of a large sacral chordoma.

Case description: A 51-year-old male with a history of refractory constipation and lower back pain was diagnosed with a large sacral chordoma. Preoperative planning included the creation of a patient-specific 3D-printed cutting guide used to make precise bony cuts while preserving critical structures. Complete en bloc resection with negative margins was achieved. The patient recovered well postoperatively; follow-up imaging at 13 months showed no tumor recurrence. At 25 months, however, a small recurrence was noted in the right piriformis/gluteal muscle.

Conclusion: The use of a 3D-printed cutting guide is a novel technology that can be used to facilitate en bloc resection of bony tumors. Use of the cutting guide simplified the technical difficulty involved with more traditional methods for sacrectomy.

Background: The efficacy of deep brain stimulation (DBS) relies on accurate stereotactic electrode placement. Post-implantation imaging enables assessment of electrode positioning and quantification of targeting accuracy. While DBS is typically performed through burr hole, this study examines targeting accuracy factors using a minimally invasive twist drill technique.

Methods: We retrospectively analyzed 86 patients (171 electrodes) who underwent DBS at our institution. Different measures of targeting error were defined and compared. Analysis focused on trajectory error (TE), the closest perpendicular distance between the electrode's center and target locus. Seventeen demographic, clinical, and procedural variables were assessed for potential impact on accuracy. Multivariate mixed effects models were applied to identify significant associations.

Results: Mean (±standard deviation) TE was 1.4 (0.7) mm. Electrodes tended to lie medial (0.3 ± 0.1 mm; mean ± 95% confidence interval), posterior (0.6 ± 0.1 mm), and superior (0.5 ± 0.1 mm) to targets. Three variables were independently and significantly associated with greater TE: use of one of two stereotactic frames (effect size 0.4 ± 0.2 mm), second-side implantation in bilateral surgery (0.3 ± 0.2 mm), and decreasing coronal approach angle (0.04 ± 0.03 mm/°). All three factors were associated with significantly more posterior implantation, while second-side and decreasing coronal angle also yielded a more superiorly located point of closest approach of the electrode.

Conclusion: We present a thorough multivariate analysis of targeting accuracy in DBS, identifying significant factors associated with accuracy within our workflow. We suggest that such targeting error analysis should be performed routinely by neurosurgeons undertaking DBS to audit targeting accuracy and identify error sources within their workflows.