Surgical neurology international最新文献

Background: Anterior cervical disc arthroplasty (ACDA) may rarely result in esophageal perforation.

Case description: A 56-year-old male underwent a C5-c6 ACDA for a cervical disc herniation. Three months postoperatively, trauma led to anterior dislocation of the interbody prosthesis, resulting in the acute onset of dysphagia accompanied by wound drainage. The delayed diagnosis of esophageal perforation was established when the cervical computed tomography documented anterior migration of the screws/plates and an air/fluid level in the surgical field. Despite a multidisciplinary approach, including anterior surgical revision followed by posterior stabilization, the patient became septic and expired.

Conclusion: The incidence of esophageal perforation following ACDA ranges from 0.02% to 1.52%, with hardware failure being the leading cause. Prompt recognition and multidisciplinary management are essential for optimizing patient outcomes. Here, trauma-induced prosthesis dislocation warranting circumferential surgery failed to control sepsis, and the patient died.

Background: Anterior spinal cord syndrome (ASCS) is an extremely rare condition defined as an infarction of the anterior two-thirds of the spinal cord. The type and timing of the clinical presentation, combined with the radiological findings, can provide a focused clinical picture of the severity and outcomes and direct the management plan. We present a rare case report of a pediatric patient with ASCS in acute settings due to a fibrocartilaginous embolism (FCE).

Case description: We report a 10-year-old girl who was medically and surgically free. She presented with ASCS features 30 min after lifting her younger sister in her back. The clinical presentation consisted of bilateral lower limbs weakness 0/5 according to the medical research council's scale, weak anal tone, with pain and temperature significantly altered and absent up to T4 level. A diagnosis of anterior spinal infarction due to FCE was made after excluding the possible anterior cord syndrome etiologies. The management consisted of aspirin and extensive physiotherapy, and she significantly recovered over 1 month.

Conclusion: We report a rare case of acute presentation of a pediatric patient with ASCS due to FCE. The timing of a diagnosis affects clinical results. Correlating the radiological findings to the clinical presentation can narrow the differential diagnosis. The literature on the management of these cases is lacking. Animal studies reported a trial of medical therapy.

Background: Spinal extradural meningiomas are rare and must be distinguished from malignant tumors due to their invasive nature and intense activity. We report a case of a cervical epidural meningioma presenting with atypical imaging findings.

Case description: A 51-year-old woman presented with progressive paresis in both the upper and lower limbs. Magnetic resonance imaging revealed an extradural lesion at the C2-C4 level with homogeneous contrast enhancement. The lesion extended from the intervertebral foramen into the posterior cervical musculature. Computed tomography demonstrated diffuse calcification, spanning from the spinal canal to the posterior cervical musculature. The patient underwent tumor resection and decompression surgery, which led to an improvement in her neurological symptoms. Pathological examination confirmed the diagnosis of a psammomatous meningioma.

Conclusion: Cervical epidural meningiomas are extremely uncommon, and differential diagnosis can be challenging, especially in cases involving invasion into the posterior cervical muscles and calcification. Severely invasive lesions are often difficult to resect completely and necessitate careful follow-up.

Background: Cerebral amyloid angiopathy (CAA) is a neurological condition characterized by the deposition of amyloid beta particles within the cerebral vasculature over time. A rare complication of CAA is an autoimmune inflammatory syndrome to cerebrovascular amyloid deposits. In this report, we present a case of CAA-related inflammation (CAA-RI) and discuss the diagnostic and management considerations when encountering this pathology.

Case description: A 69-year-old man with a history of hypertension, hyperlipidemia, obstructive sleep apnea, benign prostatic hyperplasia, and major depressive disorder presented to the clinic with rapidly progressive cognitive impairment over the preceding 2 months. Magnetic resonance imaging (MRI) of the brain demonstrated white matter hyperintense lesions associated with innumerable microbleeds asymmetrically concentrated in the right parietal lobe, with subtle hyperattenuation of the sulci. These findings suggested a diagnosis of probable CAA-RI. The patient was started on intravenous methylprednisolone, one gram daily for 5 days, followed by a prolonged prednisone taper over the next 6 weeks.

Conclusion: Patients with CAA-RI typically present with cognitive decline, followed by focal neurologic deficits, seizures, and headaches. On MRI of the brain, T2/fluid-attenuated inversion recovery asymmetric hyperintense white matter lesions local to cerebral microbleeds are characteristic. Management of CAA-RI involves high-dose corticosteroids with emerging investigation of immunosuppressive therapies.

Background: Granular cell tumors (GCTs) are rare, usually benign, tumors with classic histomorphology. This tumor can occur throughout the body, but the spine is a distinctly rare location. Here, we report a very rare case of intramedullary GCT arising in the thoracic spinal cord.

Case description: A 36-year-old woman presented to our hospital with an approximately 1-year history of gradually worsening numbness in the left toe and weakness in both lower limbs. Neuroimaging showed a tumor mass in the upper spine at the level of thoracic vertebrae 7-8, appearing hypointense on T2-weighted imaging (WI) and showing uniform gadolinium enhancement on T1-WI. Complete surgical resection was successfully performed. Histopathological examination revealed round or polygonal cells with abundant granular eosinophilic cytoplasm strongly staining for S-100 and SOX10, and benign intramedullary GCT in the thoracic spinal cord was diagnosed. Postoperative magnetic resonance imaging (MRI) showed no residual tumor, and the patient recovered well from this intervention, showing no sequelae. Follow-up neuroimaging after 2 years showed no signs of recurrence.

Conclusion: This report describes an extremely rare case of GCT arising from the intramedullary thoracic spinal cord, which is difficult to diagnose by routine neuroimaging. Therefore, accurate diagnosis requires careful identification of clinical signs, MRI including hypointensity on T2-WI, and analysis of combined morphologic and immunohistochemical studies.

Background: Intracranial epidermoid cysts are infrequent, benign, and slow-growing lesions derived from ectodermal vestiges. Although extremely uncommon, these lesions represent a great challenge from a diagnostic and surgical point of view because they are located close to major neurovascular structures with great potential for complications. Our work aims to analyze demographic, clinical, radiological, and surgical features in patients with intracranial epidermoid cysts and to assess post-surgical outcomes to define better management strategies.

Methods: We conducted a retrospective cohort study of patients diagnosed with histologically confirmed intracranial epidermoid cysts and treated surgically at Dr. Said Al-Witry's Neuroscience Hospital from January 2020 to September 2024. Demographic data, clinical presentations, imaging findings, surgical approaches, and postoperative complications were analyzed using descriptive statistics and Chi-square tests. Statistical significance was set at P < 0.05.

Results: Out of 40 patients, 75% were male, with headaches being the most common symptom (50%). Magnetic resonance imaging (MRI) findings demonstrated T1 hypo-intensity in 95% and T2 hyper-intensity in all cases. The retrosigmoid approach was the most frequently employed surgical method (60%), followed by frontotemporal (30%) and midline suboccipital (10%) approaches. Postoperative complications occurred in 35% of cases, including facial nerve palsy (15%), aseptic meningitis (10%), cerebrospinal fluid leaks (5%), and hydrocephalus (5%). Chi-square analysis showed significant associations between surgical approaches and postoperative complications (P = 0.048).

Conclusion: Intracranial epidermoid cysts show a high incidence in males and present mostly with nonspecific symptoms such as headaches and seizures. MRI remains the key investigation modality. The retrosigmoid approach shows less complication rate when compared to other techniques. Even though surgery has evolved, complications such as meningitis and nerve palsy persist, so much attention to detail is required in preoperative planning and follow-up in the long run for optimum outcomes for the patients.

Background: Tractography of cerebral white matter tracts is a technique with applications in neurosurgical planning and the diagnosis of neurological diseases. In this context, the approach based on the constrained spherical deconvolution (CSD) algorithm allows for more efficient and plausible segmentations. This study aimed to compare two CSD techniques for corticospinal tract (CST) segmentation.

Methods: This study examined 40 diffusion-weighted images (DWIs) acquired at 7T from healthy participants in the human connectome project (HCP) and 12 clinical 1.5T DWIs from patients undergoing neurosurgical procedures. Tractography was performed using two techniques: regions of interest-based approach and an automatic approach using the TractSeg neural network. The volume of the CST segmented by the two methods was compared using the Dice similarity coefficient.

Results: There was a low similarity between the CST volumes segmented by the two techniques (Dice index for the HCP: 0.479 ± 0.04; Dice index for the Clinical: 0.404 ± 0.08). However, both techniques achieved high levels of consistency in sequential measurements, with intraclass correlation coefficient values above 0.995 for all comparisons. In addition, all selected metrics showed significant differences when comparing the two techniques (HCP - volume P < 0.0001, fractional anisotropy [FA] P = 0.0061, mean diffusivity [MD] P < 0.0001; Clinical - volume P < 0.0001, FA P = 0.0018, MD P = 0.0018).

Conclusion: Both methods demonstrate a high degree of consistency; however, the automatic approach appears to be more consistent overall. When comparing the CST segmentations between the two methods, we observed only a moderate similarity and differences in all considered metrics.

Background: Spontaneous intracranial hypotension (SIH) is a rare but important condition characterized by cerebrospinal fluid (CSF) leakage, typically presenting with postural headaches. In severe cases, SIH can result in subdural hematomas (SDHs), brain herniation, and acute infarcts. The 2023 SIH guidelines recommend starting with nontargeted epidural blood patches as the initial treatment, with up to two attempts before considering a targeted patch. Nontargeted patches are effective in most cases by distributing blood widely in the epidural space. However, in rapidly deteriorating patients, targeted blood patches may be necessary, especially when a specific leak site has been identified. This report highlights the importance of timely, targeted interventions in severe SIH cases.

Case description: A 34-year-old male presented with a 6-month history of worsening headaches, impaired mobility, and stupor. On admission, his Glasgow Coma Scale was 12, which rapidly deteriorated to 5. Imaging revealed bilateral chronic SDHs, cerebellar tonsillar herniation, and signs of intracranial hypotension despite no history of trauma or anticoagulant use. Initial surgical evacuation of the hematomas failed to improve the patient's neurological status. Subsequent magnetic resonance imaging and computed tomography myelogram identified a CSF leak at the T12 level. Given the patient's critical state and rapid neurological decline, we opted for a targeted epidural blood patch at the L1/2 level. This intervention led to significant clinical improvement, with follow-up imaging demonstrating a reduction in the subdural collections and resolution of the leak. The patient fully recovered and remained asymptomatic at a 6-month follow-up.

Conclusion: This case highlights the need for flexibility in SIH management, particularly in severe cases with acute neurological decline. While nontargeted blood patches are typically recommended, early use of a targeted patch when imaging identifies the leak can lead to faster resolution and improved outcomes. Personalized treatment strategies are essential for managing complex SIH presentations and preventing further neurological complications.

Background: Neurovascular conflict is considered one of the main causes of Trigeminal neuralgia, and 3D fast imaging employing steady-state acquisition magnetic resonance imaging (MRI) is the diagnostic imaging of choice. However, no tool is available to confirm imaging findings as the primary cause of trigeminal neuralgia because neurovascular contact is frequently found in asymptomatic individuals, according to some literature, although very little data is available till now. Therefore, we aim to determine the frequency of trigeminal neurovascular contact, involved nerve segment, culprit vessel, and characteristics of contacts in asymptomatic individuals. Knowledge about this is very crucial so that every patient may not be labeled as having neurovascular conflict as the primary cause and can be saved from unnecessary surgeries.

Methods: A retrospective observational study was conducted on 105 MRI brain scans of asymptomatic individuals for trigeminal neurovascular relationships by two expert neuro-radiologists. Percentages calculated for categorical variables and for continuous variables Shapiro-Wilk test were used. The Fisher Exact test is used to assess the association between conflict and other variables. Inter-rater reliability was computed for the outcome and other variables and Cohen's kappa to evaluate the strength of agreement. All calculations were performed using STATA version 17.0.

Results: Out of 105 cases, neuro-vascular contact was identified in 64 cases. The most common contacting vessel was the superior cerebellar artery. The most common nerve segment involved was the cisternal segment, followed by the Root entry zone and porous trigeminus. In about 54 cases, the vessel was abutting the nerve, while in eight cases, it was compressing and, in two cases, displacing the nerve. The superior surface of the nerve was commonly involved. The inter-rater reliability between both neuroradiologists showed significant agreement.

Conclusion: Neurovascular contact is found in asymptomatic individuals, so just the presence of contact in symptomatic individuals on MRI should not be considered as only the cause of trigeminal neuralgia. It is important to identify nerve thinning and distortion, which are more reliable signs.

Background: Posterior fossa gangliogliomas with extension into the cerebellopontine angle are extremely rare and can be challenging to resect because they are infiltrative and the regional neurovasculature is complex.[1,2] Tumor grade may best predict oncologic outcome.[1] Histologic grading can be used to balance surgical aggression with the risk of cranial neuropathies.

Case description: During an evaluation for headaches, a 19-year-old woman was found to have a 5.3 × 4.0 × 3.5-cm left lateral cerebellar and cerebellopontine angle tumor, with an apparent intrinsic origin and significant exophytic extension. The lesion was minimally enhancing and partially cystic and had significant calcifications. On examination, she was neurologically intact, with the exception of mildly decreased left oropharyngeal sensation. She underwent a left retrosigmoid craniotomy for tumor debulking and tissue diagnosis; the tumor was found to be adherent to cranial nerves 7 through 11. Pathological evaluation demonstrated a ganglioglioma (World Health Organization grade I). A safe maximal resection was recommended on multidisciplinary review. A secondary left far lateral craniotomy and C1 hemilaminectomy were performed, allowing for a complete resection of the residual tumor. The patient was discharged on postoperative day 6 at her neurologic baseline, with the exception of new mild left V2-3 paresthesias that were resolved by 6-month follow-up. Postoperative and 6-month magnetic resonance imaging demonstrated a gross total resection with no complications.

Conclusion: For rare, low-grade tumors, a staged, histology-guided, safe maximal resection can maximize functional and oncologic outcomes.