Surgical neurology international最新文献

Background: Few studies demonstrated the efficacy of mechanical thrombectomy (MT) for the branches of the posterior circulation, such as the posterior inferior cerebellar artery (PICA). Here, we describe a patient who underwent MT for acute PICA occlusion and achieved a favorable outcome.

Case description: A 68-year-old man presented with dysarthria on waking, followed by movement difficulty. On examination, he had dysarthria, right-sided ataxia, decreased pain sensation on the left side below the neck, and no significant motor paralysis. The National Institutes of Health stroke scale score was 2. The electrocardiogram revealed atrial fibrillation. Diffusion-weighted imaging revealed right lateral medullary infarction. Magnetic resonance angiography revealed obstruction of the right proximal PICA, and fluid-attenuated inversion recovery imaging revealed hyperintensity in the PICA vermian branch of the fourth ventricle, suggesting thrombus. Emergency MT was performed, primarily using aspiration, resulting in partial reestablishment of the blood flow in the occluded vessel. Marked improvement in dysarthria was observed immediately after the procedure. Follow-up magnetic resonance image revealed no new ischemic changes. He experienced mild ataxia and sensory impairment and was transferred to a rehabilitation hospital on postoperative day 17 with a modified Rankin scale score of 2, which had improved to 1 on postoperative day 90.

Conclusion: Accurate diagnostic imaging and an appropriate endovascular treatment technique led to good recovery in the present case. Even in patients with incomplete reperfusion, restoring blood flow to the perforating branches supplying the brainstem can aid in preventing brainstem infarction.

Background: Arachnoid cysts and pilocytic astrocytomas (PAs) are pathologically distinct lesions. Arachnoid cysts are essentially cerebrospinal fluid (CSF)-filled collections lined by the arachnoid membrane, mostly congenital but sometimes developing later in life. In contrast, PAs are low-grade, solid-cum-cystic brain tumors arising from astrocytes that mainly affect children and young adults. Fourth ventricular PAs are exceptionally rare, with approximately 56 cases reported in the literature since the early 1990s.

Case description: We report a case of a 20-year-old female who presented with progressive headache, nausea, and gait imbalance. Magnetic resonance imaging (MRI) revealed a nonenhancing cystic lesion in the fourth ventricle, initially suspected to be an arachnoid cyst due to the absence of mural nodules or enhancing solid components. Given her symptomatic presentation, she underwent a midline suboccipital craniotomy with cyst fenestration. Intraoperatively, the appearance of the cyst did not resemble an arachnoid cyst; hence, the cyst wall was sent for histopathological evaluation, which confirmed the diagnosis of PA. Postoperatively, the patient experienced significant improvement in her symptoms, and her neurological examination normalized. Follow-up MRI at 1 year demonstrated no evidence of progression.

Conclusion: This case emphasizes the diagnostic difficulty of distinguishing cystic, nonenhancing PAs from arachnoid cysts on imaging alone, particularly in the fourth ventricle of adults. Our findings highlight the critical role of surgical exploration both for symptom relief and for obtaining tissue to establish a definitive diagnosis, as well as the importance of long-term radiological surveillance due to the limited resection achievable in this anatomically constrained region.

Background: Aplasia cutis congenita (ACC) is a rare congenital condition marked by the absence of skin layers and sometimes underlying structures. Its etiology is unclear, with up to 70% of cases involving the scalp. We report the first document case of ACC in Ghana.

Case description: A 1-day-old female, born through spontaneous vaginal delivery after an uneventful pregnancy, was referred for management of a scalp defect noted at birth. Examination revealed an 8 × 5.5 cm central scalp defect with absent cranial vault, partial fronto-parietal bone loss, dural defect, exposed arachnoid membranes, and visible superior sagittal sinus. Other physical findings were normal. Brain magnetic resonance imaging (MRI), whole-body MRI, and echocardiography were unremarkable. A brain computed tomography confirmed a skull defect. The patient underwent a duraplasty using bovine pericardium and received serial wound dressings with epithelial growth factors. The defect reduced to 4.5 × 3.6 cm post-surgery and continues to improve pending potential cranioplasty at 2 years. ACC is primarily diagnosed clinically, and this patient was diagnosed with type 1 ACC. Management depends on subtype, location, defect size, and infection risk. In this case, surgery was employed due to the size of defect and the risk it posed. Prognosis is generally favorable, but limited resources may delay and increase complications in low-income settings.

Conclusion: ACC with skull and dural involvement poses serious risks to infant survival in resource-limited settings, where systemic challenges are pervasive. This case highlights the importance of care that is locally adapted, affordable, and delivered through strong multidisciplinary collaboration.

Background: Primary meningeal melanoma is an exceedingly rare malignant neoplasm arising from leptomeningeal melanocytes, accounting for only 0.06-0.1% of all central nervous system tumors. These melanocytes, derived from neural crest cells, typically localize within the ventral leptomeninges of the spinal cord and brainstem. Lesions most often occur in the cervical or thoracic spine and may mimic meningioma, schwannoma, or metastasis. Due to its rarity and nonspecific imaging features, diagnosis relies on histopathologic and molecular confirmation following surgical resection. Complete excision with adjuvant radiation remains the mainstay of treatment, though long-term outcomes are poorly defined due to limited reports.

Case description: We present a 61-year-old woman with a multi-segmental thoracic lesion spanning T8-T12 causing progressive genital and low-back pain, paraparesis, and sensory deficits. Magnetic resonance imaging revealed a contrast-enhancing intradural lesion with ventral extramedullary and intramedullary components. The patient underwent T7-T12 laminectomies for microsurgical resection with continuous neuromonitoring. Following dural opening, the tumor was identified in the ventrolateral extramedullary space with focal invasion into the spinal cord. Resection of the extramedullary component of the tumor was first undertaken until the tumor coursed into the intramedullary compartment. Sharp dissection and meticulous pial entry allowed circumferential mobilization and safe removal of the intramedullary portion while preserving the spinal vasculature. A gross total resection was achieved. The patient had a transient exacerbation of her right lower extremity weakness, which improved back to baseline within a few weeks from surgery. Histopathology revealed a densely cellular melanocytic tumor with focal necrosis and low proliferative index. Genetic testing identified a guanine nucleotide binding protein, alpha q (GNAQ) missense variant, confirming primary meningeal melanoma. With no systemic disease, adjuvant fractionated radiation was planned. The patient's recovery was stable, and she was discharged to rehabilitation on postoperative day 9.

Conclusion: This case highlights the surgical nuances and diagnostic considerations involved in treating rare mixed intramedullary-extramedullary meningeal melanomas of the thoracic spine.

Background: Tanycytic ependymomas (TEs) are rare spindle-cell variants of spinal ependymomas. They are classified as central nervous system World Health Organization grade II, and they usually behave like ordinary spinal ependymomas especially following gross total resection (GTR).

Case description: A 43-year-old male presented with a progressive paraparesis and sensory level at T4 (pain/ temperature loss). The magnetic resonance imaging showed an intradural intramedullary tumor extending from Th2 to Th5. Only a subtotal resection was performed as a central portion was tightly adherent to the spinal cord itself. Histology revealed a predominantly grade II TE; the main component showed a low proliferative index, whereas the anaplastic focus had a markedly elevated index. Despite craniospinal tomotherapy (36 Gy), tumor recurred 6 years 7 months later. Local tomotherapy was repeated 3 times (41.4, 40, and 30 Gy), but each treatment produced only transient shrinkage followed by regrowth at shorter intervals. Further irradiation was contraindicated due to cumulative dose constraints. Seventeen years after the first surgery, rapid enlargement over 3 months caused paraplegia and bladder-bowel dysfunction. Reoperation achieved GTR, and at this point the pathology showed a diffuse anaplastic ependymoma; the MR 6 months later showed no tumor recurrence.

Conclusion: Although TE is usually indolent, it can harbor an anaplastic subclone and progress to malignancy after subtotal resection. Long-term surveillance and early reoperation when regrowth is first observed should be considered and is likely due to the development of anaplastic features.

Background: Posterior full-endoscopic cervical discectomy (pFECD) is a minimally invasive technique for removing highly migrated cervical disc herniations (CDHs). However, the optimal working corridor and extent of bone resection must be individually tailored according to the direction and degree of disc migration in each patient.

Methods: Two cases of highly migrated CDH were treated using pFECD with tailored bone removal. Case 1 (previously published) involved caudal migration of a C5/6 disc, which required partial pediculotomy. Case 2 involved cephalad migration of a C6/7 CDH, which was treated with partial upper pediculectomy.

Results: In both cases, the migrated disc fragments - both cephalad and caudal - were completely removed without any neurological sequelae.

Conclusion: Partial cephalad and caudal pediculotomy represents a safe and effective technical modification of the pFECD approach for significantly migrated CDHs.

Background: Hypertrophic olivary degeneration (HOD) is a rare trans-synaptic degeneration of the inferior olivary nucleus resulting from disruption of the dentato-rubro-olivary pathway, also known as the Guillain- Mollaret triangle. Unlike most degenerative processes, it produces olivary hypertrophy rather than atrophy. In oncology patients with prior posterior fossa or brainstem involvement, this condition can simulate tumor recurrence or radiation necrosis, leading to unnecessary interventions if unrecognized.

Case description: A 38-year-old woman with a history of human epidermal growth factor receptor 2-positive invasive ductal carcinoma of the breast and previously treated brainstem metastasis presented with progressive right facial paresthesias and gait instability. Neurological examination revealed dysmetria, impaired rapid alternating movements, and gait ataxia without motor or sensory deficits. Magnetic resonance imaging (MRI) demonstrated a nodular enhancing pontine lesion due to the treated metastatic lesion and a new enlargement involving the rostral aspect of the left central tegmental tract with associated hypertrophic change of the inferior olivary nucleus, consistent with unilateral HOD. Magnetic resonance spectroscopy and perfusion imaging excluded neoplastic recurrence. A multidisciplinary neuro-oncology board concluded that the findings were secondary to radiation-induced tract injury. The patient continued maintenance chemotherapy and received symptomatic management and rehabilitative therapy, with serial MRI showing stability.

Conclusion: HOD should be considered in patients with prior brainstem surgery or radiotherapy who develop delayed cerebellar signs and characteristic MRI findings. Recognizing its benign and self-limited nature is crucial to prevent misdiagnosis as tumor recurrence and avoid unnecessary oncologic or surgical interventions. Integration of advanced MRI techniques and multidisciplinary evaluation allows precise diagnosis and tailored management, ensuring appropriate treatment and long-term follow-up.

Background: Sacral neuromodulation (SNM) is a treatment used to manage urinary symptoms of both overactive bladder and non-obstructive urinary retention. The use of SNM in managing these symptoms has yielded positive results, contributing to a reduction in symptoms and an improvement in quality of life (QoL) for patients. This article aims to report on the electrical neurostimulation of sacral nerves to treat idiopathic non-obstructive urinary retention.

Case description: A 27-year-old female presented with chronic non-obstructive idiopathic urinary retention, using intermittent bladder catheterization, who did not respond to various treatments such as behavioral therapy, pelvic floor physiotherapy, and alpha-blockers. She underwent a sphincter injection of botulinum toxin type A. Due to the refractoriness of all previous treatments, electrical neurostimulation of the sacral nerves was proposed as an alternative. Two electrodes were implanted to stimulate the sacral nerves percutaneously in the foramina of S4 on both sides and connected to the neurostimulation system.

Conclusion: After the procedure, the patient experienced a reduction in the average voiding residue (47% immediately postoperative and 29% after 1 year), a significant decrease in urinary tract infections and bladder catheterizations (50% reduction), along with improvements in urinary symptoms, abdominal discomfort, and a substantial enhancement in QoL.

Background: Intradiploic encephalocele (IE) is a rare condition with very few reported cases in the literature. IE is defined as a herniation of the brain parenchyma through a dural defect into the diploic space.

Case description: We present a 59-year-old man with intradiploic cerebellar encephalocele diagnosed in a background of clicks on the head when pressing over the ipsilateral occipital bone. Imaging confirmed right cerebellar brain herniation through the diploic space. Two years of follow-up imaging revealed herniation size progression with no neurology. The patient chose a watch-and-see approach given the potential morbidity of the surgical treatment.

Conclusion: Asymptomatic or paucisymptomatic IE does not require surgical treatment. However, both clinicians and patients need to be aware of potential radiological progression during the follow-up period.

Background: The brainstem tumors are rare and extremely heterogeneous, presenting significant challenges in the surgical approach. For lesions that are not candidates for surgical resection, a definitive diagnosis is primarily obtained through stereotactic biopsy. However, the diagnostic yield, safety, and complication rate of frameless stereotactic techniques are still subject of debates in the literature, especially in eloquent or deep regions such as the brainstem. The aim of this study is to demonstrate that the frameless technique can achieve similar results to the frame-based technique, by comparing the results of the both techniques, even in critical regions, such as the brainstem.

Methods: Twenty-nine frame-based stereotactic biopsies and 17 frameless biopsies of brainstem lesions were analyzed. Diagnostic confirmation of the lesions was performed through histopathological and immunohistochemical analysis and compared between the two groups of patients. The Statistical Package for the Social Science (IBM^® Statistical Package for the Social Sciences) software was used for statistical analysis, testing normality between groups with the Kolmogorov-Smirnov and Fisher's tests to assess the association of the use of each technique in the diagnosis, the complication rate and mortality, in addition to assessing whether the was a correlation between the effectiveness of the methods and the age group, gender, approaches, Karnofsky performance scale, location of the tumors, contrast-enhancing in images, with a 95% confidence interval.

Results: Furthermore, it was observed that the only factor studied that increased the efficacy rate was the use of the transfrontal route, with an overall efficacy rate of 78.3% (36 patients) and P = 0.001.

Conclusion: The frameless and frame-based stereotactic techniques not show statistically significant differences in terms of diagnostic yield, complications rates and mortality. Both can be used depending on the availability and experience of the service, offering flexibility in choosing the approach for biopsy of brainstem lesions.