Surgical neurology international最新文献

Background: Anterior skull base meningiomas can cause significant symptoms such as mass effect and neuropsychological decline, necessitating surgical resection. The endoscopic extended transnasal approach has emerged as a minimally invasive alternative to craniotomy, offering a means to address these tumors despite challenges due to the proximity of critical neurovascular structures and the high risk of complications such as cerebrospinal fluid (CSF) leaks. This systematic review and meta-analysis evaluate the safety and efficacy of extended transsphenoidal techniques in anterior skull base meningiomas.

Methods: This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. A search was performed in Medline, Embase, Cochrane, and Ovid. Eligible studies included those (1) in English, (2) with patients having anterior skull base meningiomas, and (3) who underwent endoscopic surgical management. Endpoints included CSF leak, length of stay, complications, and mortality.

Results: The analysis included data from 23 studies involving 573 patients with a median age of 54.77 (range 39.5-67.3) years. Approximately 71% of participants were female. The mean length of stay was 7.50 days (95% confidence interval [CI]: 6.64-8.47). The overall complication rate was 35% (95% CI: 0.22-0.49), with minor complications also occurring in 6% of cases (95% CI: 0.02-0.10). Major complications were reported in 20% of cases (95% CI: 0.10-0.30). The CSF leak rate was 7% (95% CI: 0.04-0.10).

Conclusion: In the setting of complex anatomical challenges and inherent risks, the technique showed a moderate complication rate and length of hospital stay. This method demonstrated lower CSF leak and complication rates compared to previously published studies from the past decade.

Background: Endovascular treatment options for direct carotid-cavernous fistula (CCF) include transarterial or transvenous embolization with detachable coils and balloons, parent artery occlusion, or the use of flow-diverting stents across the fistula. Although combined transarterial and transvenous embolization is uncommon, it can be advantageous. We present a case of direct CCF treated successfully with a combined approach using a minimal number of detachable coils.

Case description: A 33-year-old female presented with tinnitus and headache following cesarean delivery and was transferred to our hospital. Cerebral angiography revealed a high-flow shunt from the superior lateral wall of the left cavernous internal carotid artery directly into the cavernous sinus, with a 3.5 × 2.8 mm shunted pouch. A diagnosis of direct CCF was confirmed. To maximize the packing density within the shunted pouch and to manage various situations during embolization, a combined transarterial and transvenous approach was utilized. Complete obliteration of the shunt was achieved without complications using only four detachable coils. The patient was discharged on postoperative day 3 with a modified Rankin Scale score of 0, and there has been no recurrence during the 6-month follow-up.

Conclusion: Direct CCF cases are relatively rare and complex to treat. This case illustrates practical strategies and considerations for achieving complete shunt obliteration with minimal intervention, highlighting the effectiveness of combined transarterial and transvenous embolization.

Background: Intracranial dural arteriovenous fistulas (DAVFs) involving the occipital sinus (OS) are rare vascular anomalies characterized by abnormal connections between meningeal arteries and venous sinuses or cortical veins. Trauma and venous hypertension are recognized factors in the pathogenesis of DAVFs, with previous injuries to the venous sinus and subsequent angiogenic responses contributing to abnormal arteriovenous shunt formation. The OS's variable anatomy and deep midline location add unique challenges to the diagnosis and treatment of DAVFs in this region.

Case description: We report two cases of OS DAVFs in patients with a history of remote cranial trauma. The first case describes a 36-year-old man with a 3-year history of progressive headache, recently worsening with severe headache, nausea, and vomiting. Imaging revealed a DAVF at the OS with cortical venous reflux. After an unsuccessful attempt at transarterial embolization, transvenous embolization achieved near-complete obliteration, and the patient remained asymptomatic at the 3-year follow-up. The second case involves a 54-year-old man with a history of a high fall. He initially presented with bilateral leg numbness and urinary retention, progressing to quadriparesis. Imaging demonstrated an OS DAVF with spinal venous congestion and cervical cord compression. Following an unsuccessful transarterial approach, he underwent a suboccipital craniotomy with OS ligation. Despite complete obliteration, he remained significantly disabled at the 1-year follow-up.

Conclusion: These cases highlight the role of trauma in the development of OS DAVFs and the challenges associated with their management. Successful treatment often requires a combined approach due to complex arterial feeders and venous drainage patterns. Early intervention is crucial in preventing irreversible neurological deficits caused by prolonged venous congestion, emphasizing the need for timely diagnosis and individualized treatment strategies for DAVFs involving the OS.

Background: The endoscopic endonasal approach (EEA) is increasingly used in minimally invasive surgeries for skull base lesions such as pituitary tumors. Although experienced facilities and neurosurgeons familiar with this technique can typically perform these surgeries routinely without special techniques or instruments, challenging cases can occasionally arise due to patient factors such as obesity. Here, we describe challenges encountered during neurosurgery in a patient with super-super obesity and introduce our unique technical nuances for management during tumor resection.

Case description: We report about a 47-year-old man with a body mass index of 62.24 kg/m² who presented for neurosurgery with a diagnosis of craniopharyngioma, for which tumor resection using the EEA under general anesthesia was performed. While planning tumor resection using the EEA, several limitations due to extreme obesity were encountered as follows: (1) management of the respiratory and circulatory systems under general anesthesia, (2) non-feasible positioning on a standard operating table, and (3) complications with lumbar drain (LD) replacement to prevent post-operative cerebrospinal fluid leakage. These challenges were overcome through (1) multidisciplinary collaboration with anesthesiologists and cardiologists, (2) the set-up of two operating tables side by side, and (3) LD placement under awake status in the sitting position, respectively. With these innovations, total tumor resection was achieved using the EEA.

Conclusion: This case highlights the successful use of the EEA along with unique technical adaptations in a super-super obese patient with craniopharyngioma, demonstrating the importance of innovation and problem-solving in overcoming surgical challenges.

Background: The occurrence of multiple brain tumors of different cellular origins in a single individual is extremely rare. There is limited documentation regarding the incidence of intracranial neoplasms in individuals with preexisting neurocysticercosis (NCC).

Case description: We report the case of a 43-year-old male who had been under our care since he first suffered from seizures 2½ years ago when he was diagnosed with NCC. A year after the diagnosis of NCC, he presented to the emergency room with seizures, when he was found to have a new small left frontal meningioma, which was managed conservatively. In the next year, the patient was admitted to the emergency room in a disoriented state, and his imaging revealed a new lesion - a left frontal glioma, for which he was operated. Six months later, another glioma was found in the right frontal region, which was excised surgically. Four months after the second surgery, the patient was brought with intractable seizures when he was diagnosed with cerebrospinal fluid spread of NCC. During this admission, the patient expired due to a pulmonary infection.

Conclusion: This case report presents the sequential occurrence of neurocysticercosis, meningioma, and glioma in an Indian male patient. The occurrence of NCC with brain tumors is rarely reported in the literature; further research is needed to understand the occurrence of multiple brain tumors, especially in the setting of preexisting NCC.

Background: Hepatocellular carcinoma (HCC) contributes significantly to global cancer-related mortality, often because patients present at advanced stages of the disease. HCC commonly metastasizes to the lung, abdominal lymph nodes, and bone. However, even among bony metastases, calvarial lesions are exceptionally rare, especially in the initial presentation.

Case description: We describe a unique case of a 65-year-old African American woman who presented with a rapidly growing skull lesion as her first clinical sign of metastatic HCC. Imaging revealed an extensive soft-tissue mass involving the left calvaria and partially obstructing the superior sagittal sinus. We suspected that the lesion was a meningioma and offered surgery. Histological examination and further systemic workup later confirmed HCC. She was started on adjuvant therapy but unfortunately deteriorated from complications secondary to disease progression. We also reviewed the literature on cases of isolated calvarial metastases as the initial presentation of HCC. A total of 36 case reports were reviewed which included 38 patients. There were 32 males (84.2%), and the mean age was 58.97 ± 9.09 years old. The most common location of presentation was the parietal or occipital region (13, 34.2%), and 18 patients (47.4%) underwent neurosurgical treatment of the lesion. Among the 26 cases that had a follow-up, 84.6% (n = 22) did not survive treatment, and the mean survival time was 6.15 ± 5.94 months.

Conclusion: Isolated calvarial lesions are rarely the initial presenting sign of metastatic HCC. Often, these lesions may be misdiagnosed as benign tumors, such as meningiomas or hemangiopericytomas, given their appearance on imaging. However, early identification of HCC skull lesions is crucial to initiating treatment, including resection, radiation, and immunotherapy, which may help improve symptoms and extend survival. Our case report adds to the limited literature on this exceedingly rare entity.

Background: Cavernous sinus meningiomas are rare, and radiotherapy is considered because the risk of postoperative complications is high. Radiotherapy is useful for short-term control of meningiomas, but hydrocephalus may appear as a long-term complication.

Case description: A 71-year-old male patient suffered from a cavernous sinus meningioma with orbital involvement and communicating hydrocephalus. Radiotherapy was administered thrice due to tumor progression. Right intraorbital meningioma increased markedly, and right eye bulging and visual deterioration were aggravating. Tumor removal with orbital exenteration was performed to prevent left visual impairment due to tumor progression. The pathology was atypical meningioma (WHO grade 2). Postoperative cerebrospinal fluid (CSF) leakage from the right orbit, so-called oculorrhea, was difficult to repair due to hydrocephalus, requiring eyelid sutures and a lumboperitoneal shunt. The tumor never developed into the opposite cavernous sinus.

Conclusion: Radiation-induced hydrocephalus can lead to intractable postoperative CSF leakage from orbit after tumor removal with orbital exenteration and require surgery. In these cases, hydrocephalus treatment may lead to a cure for intractable CSF oculorrhea.

Background: Following myelomeningocele (MMC) repair, 10-30% of patients develop tethered cord syndrome (TCS). Surgical intervention is critical to reverse the stretching of the spinal cord. Here, we describe a technique for spinal cord untethering without dural opening in these patients.

Methods: Three patients underwent spinal cord untethering without dural opening. The surgical technique involved reopening the previous incision and dissecting the scar tissue attached to the dura. A Spongostan sponge was inserted, and lateral sutures were placed between the dural sac and the adjacent muscles. Clinical outcomes, imaging findings, and urodynamic results were evaluated postoperatively.

Results: The technique demonstrated positive outcomes in all three cases. Patients showed symptom improvement, better positioning of the spinal cord on imaging studies, and enhanced bladder function on urodynamic evaluations.

Conclusion: Spinal cord re-untethering without dural opening may be a viable surgical option for selected patients with MMC, offering favorable outcomes with reduced risk.