Surgical neurology international最新文献

Background: Microvascular decompression (MVD) through a retrosigmoid approach is considered the treatment of choice in cases of hemifacial spasm (HFS) due to neurovascular conflict (NVC). Despite the widespread of neuronavigation and intraoperative neuromonitoring (IONM) techniques in neurosurgery, their contemporary application in MVD for HFS has been only anecdotally reported.

Methods: Here, we report the results of MVD performed with a combination of neuronavigation and IONM, including lateral spread response (LSR) in 20 HFS patients. HFS clinical outcome and different surgical-related factors, such as craniotomy size, surgical duration, mastoid air cell (MAC) opening, postoperative cerebral spinal fluid (CSF) leakage, sinus injury, and other complications occurrence, and the length of hospitalization (LOS) were studied.

Results: Postoperatively, residual spasm persisted only in two patients, but at the latest follow-up (FU) (mean: 12.5 ± 8.98 months), all patients had resolution of symptoms. The mean surgical duration was 103.35 ± 19.36 min, and the mean LOS was 2.21 ± 1.12 days. Craniotomy resulted in 4.21 ± 1.21 cm² in size. Opening of MAC happened in two cases, whereas no cases of CSF leak were reported as well as no other complications postoperatively and during FU.

Conclusion: MVD for HFS is an elective procedure, and for this reason, surgery should integrate all technologies to ensure safety and efficacy. The disappearance of LSR is a crucial factor for identifying the vessel responsible for NVC and for achieving long-term resolution of HFS symptoms. Simultaneously, the benefits of using neuronavigation, including the ability to customize the craniotomy, contribute to reduce the possibility of complications.

Background: Orbital roof fractures are often the result of high-velocity collisions and are seen in 1-9% of patients with craniofacial trauma. Although the majority of orbital roof fractures are displaced superiorly, a subset results in inferior displacement of fracture fragments, posing a risk for muscle/nerve entrapment and possible blindness. Many of these patients have severe traumatic brain injury (TBI) and, in addition to orbital fractures, also have elevated intracranial pressure (ICP). Management of depressed orbital roof fractures in the setting of severe TBI with elevated ICP represents a management dilemma.

Case description: Two cases of severe TBI with associated downward displacement of orbital roof fractures were reviewed. Both cases exhibited elevated ICP correlated with the degree of orbital roof fracture depression. Surgical intervention involving elevation and repair of the fractures was undertaken when there was a significant risk of injury to the extraocular muscles and/or the optic nerve due to the extent of the fracture depression.

Conclusion: Depressed orbital roof fractures may migrate in response to changes in ICP. Serial computed tomography scans and eye examinations may aid with determining the need for and timing of surgical intervention.

Background: Spontaneous spinal epidural hematomas (SSEHs) are exceedingly uncommon, especially in infants, with only two reported cases. Diagnosis can be delayed due to the nonspecificity of presenting symptoms.

Case report: We present a case of SSEH in a 10-month-old boy admitted to the pediatric emergency department with a 5-day history of progressive lower extremity motor weakness. There was no history of prior trauma. Magnetic resonance imaging of the spine revealed a posterior epidural hematoma extending from C7 to L4. After hematoma evacuation, the patient's neurological status gradually improved, and no sensorimotor deficit was present 3 weeks postoperatively.

Conclusion: Our case suggests that surgical intervention can lead to an excellent prognosis for SSEH in infants, even if the diagnosis is delayed.

Background: Plexiform schwannomas (PSs) are rare. Here, we describe the clinical features, diagnosis, treatment, and outcome of a 17-year-old male presenting with a T1-T4 intradural extramedullary (IDEM).

Case description: A 17-year-old male presented with back pain and pain radiating down both legs. The thoracic magnetic resonance revealed a left-sided T1-T4 IDEM mass. The patient underwent a T2-T4 laminectomy for gross total tumor excision, followed by posterior fusion. Immunohistochemical examination revealed S100 positivity, supporting the diagnosis of PS.

Conclusion: IDEM PSs are rare, may be readily diagnosed with MR, and can be successfully resected.

Background: Most pituitary neuroendocrine tumors are benign, except some adenomas that show invasiveness and are called invasive pituitary adenomas. These are challenging and rare pathologies.

Case description: We present a case of a 40-year-old male who presented to the emergency with seizures, rhinorrhea, headache, and drowsiness. Radiology images showed a sellar mass with supra-sellar extension and pneumocephalus. The pituitary profile was within normal limits. The patient underwent bifrontal craniotomy and maximum safe resection of the lesion with cerebrospinal fluid (CSF) leak repair and lumbar drain insertion. Histological examination and immunohistochemical stain were consistent with pituitary adenoma. Postoperatively, there was no CSF leak, and the patient's Glasgow Coma Scale improved.

Conclusion: Rhinorrhea is a unique presentation for pituitary adenoma. According to the current literature, surgery is the only effective treatment as part of the management of invasive pituitary adenomas, along with a multidisciplinary approach.

Background: Malaria, a prevalent disease in the developing world, is a significant cause of morbidity and mortality. Infection with Plasmodium falciparum, although uncommon, can lead to severe brain injury, including intracranial hemorrhages, resulting in serious neurological deficits. Malaria-induced coagulopathy, while rarely reported, poses a challenge in understanding the exact mechanisms behind the development of intracranial bleeds. Proposed mechanisms include sequestration of parasitized erythrocytes in the brain's microvasculature, leading to capillary occlusion, endothelial damage, cytokine activation, and dysregulation of the coagulation cascade.

Case description: We present the case of a 53-year-old male rapidly deteriorating following a history of traumatic brain injury (TBI). Upon admission, a computed tomography scan revealed bilateral acute on chronic hematomas, necessitating a lifesaving craniotomy. Subsequently, the patient experienced three consecutive recurrent intracranial bleeds post-surgery, attributed to Falciparum-induced coagulopathy. Prompt recognition and intervention stabilized the patient's condition, leading to discharge on the 4^th post-operative day.

Conclusion: This case underscores the challenges posed by consecutive recurrent intracranial bleeds following TBI exacerbated by P. falciparum infection. It highlights the obstinate nature of malaria-induced coagulopathy and underscores the importance of timely and aggressive interventions in managing such cases.

Background: Aggressive brain tumors like glioblastoma multiforme (GBM) pose a poor prognosis. While magnetic resonance imaging (MRI) is crucial for GBM management, distinguishing it from other lesions using conventional methods can be difficult. This study explores advanced MRI techniques better to understand GBM properties and their link to patient outcomes.

Methods: We studied MRI scans of 157 GBM surgery patients from January 2020 to March 2024 to extract radiomic features and analyze the impact of fluid-attenuated inversion recovery (FLAIR) resection on survival using statistical methods, proportional hazards regression, and Kaplan-Meier survival analysis.

Results: Predictive models achieved high accuracy (area under the curve of 0.902) for glioma-grade prediction. FLAIR abnormality resection significantly improved survival, while diffusion-weighted image best-depicted tumor infiltration. Glioblastoma infiltration was best seen with advanced MRI compared to metastasis. Glioblastomas showed distinct features, including irregular shape, margins, and enhancement compared to metastases, which were oval or round, with clear edges and even contrast, and extensive peritumoral changes.

Conclusion: Advanced radiomic and machine learning analysis of MRI can provide noninvasive glioma grading and characterization of tumor properties with clinical relevance. Combining advanced neuroimaging with histopathology may better integrate oncology and radiology for optimized glioblastoma management. However, further studies are needed to validate these findings with larger datasets and assess additional MRI sequences and radiomic features.

Background: Intramedullary spinal cord metastases (ICSMs) are very rarely curable; these patients typically have very short-term survival rates. Here, a 22-year-old male with non-small-cell lung cancer (NSCLC) later developed ICSM twice; the first C4-C7 tumor responded well to surgery, radiation, and alectinib molecular-targeted therapy. The secondary ICSM C1 lesion seen years later (i.e., likely due to alectinib having been stopped) resolved once alectinib was again administered.

Case description: A 22-year-old male with a limited smoking history presented with advanced non-small-cell lung cancer (NSCLC) treated with pulmonary surgery followed by radiotherapy and chemotherapy. Four years later, he developed cervical myelopathy attributed to a C4-C7 stage IV NSCLC ICSM (i.e., notably associated with an anaplastic lymphoma kinase [ALK] rearrangement). After cervical surgery and irradiation (40 Gy/20 fr) of the resection cavity, he was also given alectinib; the patient remained disease-free for the next 7 years, remaining on alectinib. However, 1 year after alectinib was discontinued, he experienced a newly occurrent C1 ICSM lesion; the alectinib was restarted, and his tumor regressed over the next 3 years. At present, 14 years after the original ICSM surgery, the patient remains disease free but continued alectinib (Karnofsky Performance Scale: 90%).

Conclusion: Although the prognosis for ICSM is generally poor, molecular-targeted therapies, such as alectinib, as administered in this case, may provide long-term survival for patients with ALK-positive NSCLC tumors.

Background: Vagal paragangliomas (VPs) are rare tumors in the upper cervical region. Although surgical resection is the standard treatment for these tumors, it carries significant risks due to the tumor's high vascularity and proximity to vital structures. Stereotactic radiosurgery (SRS) for skull base paraganglioma could be a minimally invasive alternative.

Case description: We report the case of a 47-year-old man with a large, asymptomatic VP who was successfully treated with SRS with Gamma Knife Icon, which was performed in the parapharyngeal space (volume: 25.7 mL) using a marginal dose of 14 Gy to the 45% isodose line. This case illustrates the successful treatment of a lesion near the conventional limits (lower limit of C2 vertebral body) using noninvasive mask fixation. Excellent tumor control without neurological deficits was achieved for 25 months after SRS. The tumor volume decreased by 70% (final volume: 7.6 mL).

Conclusion: This study demonstrates the utility of Gamma Knife Icon, which facilitates optimal SRS for upper cervical lesions, including VPs.

Background: Ventriculoperitoneal shunt (VPS) is an effective intervention for managing hydrocephalus; however, various complications may arise, one of which is infection due to shunt exposure. In this study, we report the incidence, risk factors, clinical presentation, and management strategies of four cases of shunt exposure in patients with hydrocephalus.

Case description: The first case involves a 1-year-10-month-old female who underwent her initial VPS placement at 7 months old due to hydrocephalus. The second case is a 3-month-old female who had a VPS placed at 20 days old for obstructive hydrocephalus and ventriculomegaly secondary to toxoplasmosis. The third case is a 15-year-old female who received a VPS due to a cerebral abscess with a prior history of tuberculous meningoencephalopathy. The fourth case is a 38-year-old male who underwent VPS placement for hydrocephalus. Two years post-intervention, the fourth patient was diagnosed with VPS exposure and subsequently underwent shunt removal.

Conclusion: The identification of risk factors and clinical symptoms in patients, supported by ancillary examinations such as cerebrospinal fluid analysis, can predict the incidence of VPS infections. Bacterial VPS infections can be managed with appropriate antibiotics tailored to the specific bacterial species. However, in certain cases, surgical removal of the VPS may be considered as a measure to eradicate infectious pathogens.