Surgical neurology international最新文献

Background: Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide, with road traffic accidents being the predominant cause in Pakistan. Computed tomography (CT) scans have become the cornerstone of investigation for all TBIs, but their widespread use raises concerns about cost-effectiveness, radiation exposure, and incidental findings. This study aimed to validate the applicability of the Canadian CT head rule (CCHR) and New Orleans Criteria (NOC) in the Pakistani population and compare their sensitivity and specificity.

Methods: A cross-sectional study was conducted in a tertiary care academic hospital in Pakistan, including consecutive patients with acute, mild brain injury. The primary outcome was "clinically important brain injury," while the secondary outcome was "need for neurosurgical intervention." Univariate analysis using Chi square was performed for each variable to assess association with CT findings. Sensitivity, specificity, and accuracy were calculated to evaluate the performance of each decision rule.

Results: Most of the patients in our study had a Glasgow Coma Scale (GCS) score of 15 (92.6%). Headache was the most common parameter overall (61.7%). Clinically important CT was detected in 68 (6.7%) patients. Only 1 of the NOC and 4 CCHR variables demonstrated statistically significant association with clinically significant CT. The CCHR was 64% sensitive for detecting clinically important CTs in trauma patients with GCS of 13-15, and the NOC was 86% sensitive, with respective specificities of 70% and 33%. For predicting the need for neurosurgical intervention, the sensitivities of CCHR and NOC were 61% and 85%, and specificity was 68% and 32%, respectively.

Conclusion: We concluded that the CCHR was more specific and accurate, and it has the potential to have a greater influence on CT ordering rates than the NOC. Further studies are recommended to validate the tools for the Pakistani population.

Background: Jael's syndrome is defined as an intentional injury caused by a knife in the skull or the face. It is a rare yet challenging situation in clinical practice. Initial triage is the key to optimal management.

Case description: We describe the case of a right-handed 30-year-old man presenting to the emergency for headaches 15 days after a stabbing attack into the skull using a kitchen knife. He was conscious with no neurological deficit or history of seizures. The wound had already healed. A cerebral computed tomography (CT) scan showed a retained kitchen knife blade. The stab wound extended through the temporal lobe and ended a few centimeters before the brainstem. The blade was removed under general anesthesia. Postoperative follow-up was satisfying without any neurological worsening. The control CT scan showed a remaining knife edge in the bone flap. It was decided to monitor the patient regularly, and he was discharged 3 days later.

Conclusion: This case highlights the medicolegal importance of physical examination and radiological exploration in penetrating head injury.

Background: Gram-positive opportunistic bacteria of the Nocardia species are responsible for a large spectrum of infections, such as pneumonia, skin infections, and more widespread conditions, including brain abscesses.

Case description: A 67-year-old male patient suffered from headache, gait disorder, and vertigo for a week before admission to our department. An enhanced magnetic resonance imaging scan revealed a mediosagittal hyperintense infratentorial lesion with concomitant compression of the fourth ventricle. The patient underwent surgical treatment with general anesthesia. The frozen section did not reveal any tumoral tissue but rather a purulent content. He was comatose on the 1^st postoperative day, and he underwent a follow-up computed tomography (CT) scan, which revealed triventricular hydrocephalus. The external ventricular drain was performed, and a follow-up CT scan revealed significant improvement of hydrocephalus. Matrix-Assisted Laser Desorption Ionization Time of Flight did not reveal any causative agent from the intraoperative content, but the 16s ribosomal DNA method confirmed Nocardia cyriacigeorgica. The patient was intravenously treated with ceftriaxone and trimethoprim/sulfamethoxazole and died on the 5^th postoperative day.

Conclusion: Nocardiosis presents a rare Gram-positive bacterial infection that typically affects immunocompromised hosts. Nocardia-caused brain abscesses present a significant challenge in its treatment for its atypical presentation and slow culture growth.

Background: Arteriovenous malformation (AVM) and developmental venous anomaly (DVA) rarely coexist. Developing a surgical strategy to treat this co-occurrence is difficult due to the unclear pathogenesis. We report the use of super-selective digital subtraction angiography (DSA) and Three-dimensional (3D) rotational digital subtraction venography (DSV) to develop a surgical strategy for complex AVM draining into a DVA.

Case description: A 58-year-old woman presented with left hemiparesis and unconsciousness. Plain and contrast computed tomography showed a right frontal subcortical hematoma and a heterogeneous contrast lesion anterior to the hematoma, leading to a dilated vessel. The hematoma was removed due to worsening unconsciousness. DSA revealed a right frontal AVM of Spetzler-Martin grade 2 with superficial drainage into a DVA, and 3D-DSV revealed that the intermediate part of the DVA involved normal parenchyma. Interventional transarterial embolization and surgical nidus removal were planned. Preoperative super-selective DSA showed two medullary veins draining from the AVM into the DVA. Thus, we decided to separate the two medullary veins from the nidus. Postoperative angiography revealed complete removal of the AVM and preservation of the DVA.

Conclusion: Treating a complex AVM draining into a DVA is challenging; surgeons have to remove only the AVM portion and preserve the DVA. Super-selective DSA and 3D rotational DSV were performed to develop the surgical strategy.

Background: Neurocysticercosis (NCC) is one of the leading parasitic infections of the brain. Giant NCC is rare, with only two cases of cerebellar involvement reported till now. In the presence of a host immune response, these giant NCCs can mimic primary central nervous system neoplasms. The objective of this article is to report a rare case of giant cerebellar NCC and its management strategy with a literature review.

Case description: A young male presented with a giant cerebellar ring-enhancing mass with features of raised intracranial pressure, and surgical excision was done. The patient made an uneventful recovery.

Conclusion: Surgical excision is safe for NCC, especially in the presence of a diagnostic dilemma.

Background: Vertebral artery (VA) stenosis can be caused by several factors, including arteriosclerosis, arterial dissection, and mechanical compression. Symptomatic vertebrobasilar insufficiency caused by VA stenosis due to mechanical compression associated with head rotation is well-known as Bow Hunter's syndrome. However, an accurate diagnosis of asymptomatic osteophyte compression-induced nonrotational VA stenosis is difficult. We report a case of left posterior inferior cerebellar artery aneurysm with severe left VA stenosis, treated with stent-assisted coil embolization following appropriate diagnosis.

Case description: A 72-year-old female patient was found to have severe asymptomatic VA stenosis at the V2 segment (C4-5 level of the cervical spine) on cerebral angiography. Osteophyte compression-induced VA stenosis was suspected, which was confirmed by cone-beam computed tomography. The VA stenosis improved by flexing the neck and fixing the head position, following which the endovascular treatment was successfully completed.

Conclusion: The site of the VA stenosis is critical in determining the etiology. Atherosclerotic VA stenosis often occurs at the origin of the artery or V4 segment, whereas bony compression-induced stenosis is more likely to occur at the V2 segment. Diagnosis and appropriate management of VA stenosis is based on determining the site.

Background: Adenoid cystic carcinoma (ACC) of the parotid gland often manifests as distant metastasis long after the initial surgery, resulting in a poor long-term prognosis. The most common sites of metastasis are the lungs, liver, and bones. Single intracranial metastasis is very rare.

Case description: A 43-year-old woman with a history of surgical removal of ACC 24 years prior presented with Gerstmann syndrome and right hemianopsia. Head magnetic resonance imaging revealed a solitary extra-axial tumor in the left occipital region. The tumor was surgically removed and pathologically diagnosed as a metastasis of cribriform-type ACC. Since she had no other systemic metastasis, she did not receive adjuvant treatment and has remained recurrence-free for 35 months postoperatively.

Conclusion: Very late intracranial solitary metastasis of ACC is extremely rare. Due to the risk of delayed recurrence in pathologically confirmed cribriform type ACC, long-term follow-up is recommended.

Background: Dermoid cysts result from embryonic fusion anomalies, with intracranial dermoid cysts being rare (0.1-0.7% of intracranial tumors). Often asymptomatic, they can manifest as midline swelling, headaches, seizures, or cerebral ischemia. Recognition and management are crucial for mitigating complications and ensuring favorable patient outcomes.

Case description: A 14-year-old girl presented with swelling at the occiput for 3 months. Initial imaging was suggestive of an extra-dural abscess in the occipital region with surrounding bone erosion. An infectious workup, including tests for tuberculosis, was non-contributory. A suboccipital craniectomy was done. On lifting, the bone flap, thick, purulent, and sebaceous contents with hair were spotted, which was adherent to the inner table of the skull and the dura overlying the torcular herophili, suggesting an infected dermoid cyst. A near-total excision was done, and culture-directed antibiotics were given. Postoperatively, the child made a complete recovery.

Conclusion: The diagnosis of a dermoid cyst must be kept in mind, and it should be considered in the differential diagnosis of midline posterior fossa lesions. The risk of postoperative recurrence from incomplete excision should be weighed against the risk of injuring the venous sinuses during the extensive resection of dermoid cysts adherent to the torcular region.

Background: Neuroepithelial cysts (NECs) are rare entities, occasionally causing neurological symptoms that can be overlooked.

Case description: A case of an occipital neuroepithelial cyst is discussed. The initial presentation consisted of mild homonymous hemianopia and gait impairment. Conservative management was suggested to start with, but at 6 months follow-up, the patient's symptoms were worsening. Surgery was performed under general anesthetic and using visual-evoked potentials. The cyst was marsupialized and connected with subdural space, and a few samples were sent for histological analysis. The patient experienced immediate improvement in her symptoms, and the visual tests at follow-up confirmed the resolution of the previously documented hemianopia.

Conclusion: NECs should be carefully assessed to rule out symptoms associated with mass effects. This case and others reported in the international literature show that occipital neuroepithelial cysts can benefit from surgical treatment with meticulous preoperative planning. The aid of neuromonitoring is crucial to identify anatomical variations and cortical functionality that are potentially distorted in the presence of these lesions.