Surgical neurology international最新文献

Background: Combination therapy with BRAF and MEK inhibitor holds promise for treating gliomas harboring the BRAF V600E mutation; however, the development of acquired resistance remains a challenge.

Case description: We describe a case of repeated recurrent BRAF-mutant pleomorphic xanthoastrocytoma (central nervous system World Health Organization grade 3) treated with combination therapy with BRAF and MEK inhibitor. The patient received dabrafenib (BRAF inhibitor) and trametinib (MEK inhibitor); however, she developed resistance to the combination therapy. Remarkably, incidental drug discontinuation contributed to the disappearance of the resistant tumor. The same phenomenon was repeatedly observed after that. Genetic analysis demonstrated that the resistant tumor had BRAF V600E amplification; the resistant tumor remained BRAF→MEK→ERK pathway dependent, and drug resistance might be due to elevated BRAF V600E expression. We speculated that ERK1/2 signal extremes caused by the discontinuation of the combination therapy affected the resistant tumor survival.

Conclusion: This case study provides important insights into novel treatment strategies and their underlying mechanisms for gliomas with BRAF mutations.

Background: Penetrating orbital trauma from a wooden foreign object is rare and challenging to identify, as it cannot be detected with a computed tomography (CT) scan. This report highlights the clinical presentation, diagnosis, and management of such a case.

Case description: A 19-year-old female experienced penetrating orbital trauma from a wooden object following a traffic accident. She intermittently visited the hospital with eye swelling and headache, without visible penetrating wounds on the palpebra. The swelling persisted for weeks, accompanied by increasing signs of ocular and cerebral infection. The suspicion of a non-metallic foreign body penetrating the brain was confirmed 3 months after the initial visit, delayed by the hidden entry wound between the eyelid and eyeball and orbital edema mimicking non-penetrating trauma. A multidisciplinary team managed the case. Procedures included debridement, retro-orbital exploration, retro-orbital abscess evacuation, and frontal basal trephination exploration, successfully removing the wooden object that had penetrated the medial orbit, frontal bone, and brain, along with cerebral abscess evacuation. Postoperative CT scans showed complete removal of the foreign object and successful abscess evacuation. The patient showed improvement in ocular symptoms, resolution of headaches, and no wound leakage. She was discharged on the 14^th day after completing antibiotic treatment and having the dressing removed.

Conclusion: This case is notable for its rarity, high risk of misdiagnosis, and potentially fatal consequences if not promptly managed. We emphasize the importance of patient involvement in routine consultations, careful anamnesis, clinical examination, and a multidisciplinary approach for optimal outcomes.

Background: Achromobacter xylosoxidans (AX) is an aerobic Gram-negative opportunistic bacteria known to inhabit various environments and is most commonly associated with nosocomial infections in immune-compromised patients. Although rare, AX can cause a variety of neurological infections, such as meningitis, ventriculitis, and osteomyelitis. Intravascular catheters, intrathecal pumps, and contaminated surgical instruments are potential vectors for such patients.

Case description: Here, we present a unique case of multidrug-resistant AX-positive meningitis secondary to infection of a nonfunctional intrathecal narcotic pump. The patient has a complex past medical history leading up to infection, and care was significantly compromised by homelessness and inflammatory bowel disease (IBD). Treatment included catheter removal and antibiotics.

Conclusion: Patients who suffer from homelessness or IBD show a possible increased risk of this infection. This case emphasizes the need for increased care regarding these patients, along with describing the complications and timeline when treating this rare type of meningitis.

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare type of skin cancer that arises in the deeper layers of the skin, most commonly on the trunk and limbs. The presentation of DFSP on the scalp is worth documentation due to its extremely rare occurrence in the literature.

Case description: We describe a case of a 41-year-old female presented with a lump on the back of the head with gradual enlargement. It was solitary with a size 19 × 12 × 10 cm with purulent discharge and intermittent pain. A computed tomography-scan showed an isodense mass at mid occipital without intracranial involvement. Tumor extirpation and the free flap were performed collaborated with plastic surgery. The patient was discharged unremarkably on the 7^th postoperative day without any neurological deficits.

Conclusion: Our case is distinct because, after 24 months without any adjuvant therapy and without any recurrence, the patient is still doing well. This is a very rare clinical entity.

Background: Aneurysms of the lower basilar artery (BA) are rare, accounting for <1% of all intracranial aneurysms. This location has been described as "No man's land" since it poses a potential challenge for microsurgery. Recently, endovascular treatment has become an alternative option; however, there are some disadvantages regarding the obliteration rate, patency of the parent, and perforating arteries.

Case description: We present the case of a 69-year-old female with an incidentally found lower BA aneurysm. The imaging examinations revealed a wide-neck aneurysm size of 8.5 mm arising just distal to the vertebrobasilar junction, with involvement of the left anterior inferior cerebellar artery (AICA). After a discussion with the patient, she opted to undergo the surgical treatment. We described the detailed steps of our surgical techniques in performing a combined transpetrosal-transtentorial approach. First, the occipital artery (OA) was harvested. Then, the posterior transpetrosal (retrolabyrinthine) and a far-lateral suboccipital approach were conducted with tentorial sectioning to expose the aneurysm. After AICA was confirmed to arise from the aneurysm sac, the OAAICA bypass was established to ensure AICA patency, followed by complete aneurysm clipping. The approach provided both the presigmoid and retrosigmoid corridors for bypass and clipping procedures, respectively. The patient tolerated the procedure well. Postoperative imaging examinations showed complete aneurysm obliteration and bypass patency without complications. She was discharged without neurological deficits (modified Rankin Scale 0).

Conclusion: The combined transpetrosal approach is safe and effective for revascularization and clipping procedure for a lower BA aneurysm.

Background: Myeloid sarcoma (MS), a rare extramedullary tumor composed of myeloid blast cells, is classified by the World Health Organization as a subtype of acute myeloid leukemia (AML). Isolated, primary, or nonleukemic MS has an incidence of 2/1,000,000 adults and constitutes only 0.7% of all AML cases. MS presentations vary widely, with spinal involvement being rare.

Case description: A-year-old male presented with interscapular pain radiating to the right upper arm/neck but was neurologically intact. Once diagnosed with isolated spinal MS, he underwent a surgical decompression followed by local irradiation, systemic chemotherapy, and bone marrow transplantation. Eight months postoperatively, however, he experienced a graft-versus-host rejection and required additional therapies.

Conclusion: Establishing the diagnosis of MS is challenging and typically requires histological confirmation (i.e., the presence of myeloblasts and granulocytic cells). However, optimal treatment strategies remain elusive; despite radiation, chemotherapy, bone marrow transplant/other local therapies, the overall long-term prognosis for MS remains poor.

Background: In the setting of refractory neuralgia or other complex facial pains, the intensity of the pain does not decrease despite medical and even surgical interventions. This report aims to describe the experience of an institution in the management of refractory trigeminal neuralgia and other complex facial pains with Gamma Knife radiosurgery (GKR), including thalamotomy as a multitarget strategy.

Methods: We conducted a retrospective observational study. Data were obtained from 50 patients with complex trigeminal neuralgia treated with GKR, in whom the thalamus was included as a target. The Visual Analog Scale (VAS) and the Barrow Neurological Institute (BNI) scale were considered before treatment and at the follow-up. The Wilcoxon test was used to compare the VAS scores and the McNemar test for the BNI scale.

Results: The mean age was 62.7 years (standard deviation = 16.3). The indications for management with thalamotomy were neuralgia refractory to medical management (68%), recurrent pain after previous rhizolysis with GKR (20%), atypical deafferentation-type pain in patients with radiofrequency background (10%), and anatomical deformation of the trigeminal nerve by a tumor (2%). Before treatment, all patients were classified as BNI V. At follow-up, a satisfactory response to treatment was described in 82.05% of cases (P = 0.001 McNemar). The median preoperative pain evaluated with VAS was 10 (interquartile range [IQR] = 10-10), while at follow-up, it was 6 (IQR = 1-7) (P = 0.001 Wilcoxon).

Conclusion: The thalamus is a versatile, effective, and safe therapeutic target for ablative management in patients with complex facial pain.

Background: Primary leptomeningeal gliomatosis (PLG) is a rare neoplasm characterized by the diffuse spread of glial tumor cells throughout the leptomeninges without any evidence of a primary tumor source in the brain or spinal cord parenchyma. Here, we present a case of PLG potentially linked to prior interventional radiotherapy.

Case description: The patient was a 75-year-old woman with a history of interventional radiology for a left internal carotid cavernous sinus fistula 13 years before presentation. Routine follow-up fluid-attenuated inversion recovery magnetic resonance imaging revealed a high intensity region spreading from the deep white matter of the subventricular zone (SVZ) to the insular cortex and medial temporal lobe. Subsequently, contrast-enhanced T1-weighted imaging revealed an enhanced effect consistent with extensive leptomeninges extending from the basilar cistern to the left Sylvian fissure. The patient underwent surgery, and subsequently histological examination of extracted tissue revealed a glioblastoma (GBM). Despite postoperative concurrent chemoradiotherapy and adjuvant temozolomide chemotherapy, the tumor increased in size, and the patient died 2 months postoperatively.

Conclusion: This case highlights the importance of careful follow-up and early therapeutic intervention in PLG, as it can be difficult to diagnose leptomeningeal lesions alone. This case also raises the possibility of radiation-induced GBM, and the criteria for diagnosis were fully met. The progression of PLG from the SVZ to the leptomeningeal site was tracked using imaging, providing valuable insights into the pattern of spread of this rare condition.