Surgical neurology international最新文献

Background: Arachnoid cysts (ACs) complicated by chronic subdural hematoma (CSDH) are a rare but distinct entity.

Case description: A 27-year-old man previously diagnosed with Sylvian AC presented to the hospital with a persistent headache. He was not aware of any preceding head trauma. However, he frequently performed bench presses at the gymnasium, especially 4 weeks prior. The patient did not exhibit any neurological deficits at presentation. Computed tomography revealed slightly low-density areas in the right cerebral convexity. Magnetic resonance imaging revealed compressive masses in the right middle fossa and cerebral convexity. The patient underwent a craniotomy. Reflection of the dura mater exposed thickened arachnoid membrane. Making an incision resulted in the egress of fluid hematoma. The membrane separating the subdural hematoma and inner AC possessed fine vasculature and adjacent holes. Furthermore, there were fragile clots adhered to the inner wall of the cyst. Microscopic findings of the separating membrane were consistent with inflammatory granulation tissue, similar to those of the outer membrane of CSDH.

Conclusion: Exertional hypertension associated with the bench press may result in the rupture of fine arteries distributed over the AC wall. Under certain circumstances, the AC wall may transform into the outer membrane of CSDH.

Background: Advances in surgical techniques, neuroimaging, and white matter fiber dissection have facilitated the identification of critical tracts like the frontal aslant tract (FAT) that have garnered attention, despite remaining poorly recognized within the neurosurgical community.

Case description: We report the case of a 37-year-old male right-handed patient presenting with headache and epilepsy, in whom neuroimaging revealed an intra-axial lesion in the left middle frontal gyrus closely associated with FAT. Successful navigation-guided resection of the lesion was achieved, resulting in a favorable neurological outcome attributable to the preservation of the tract. This case is complemented by a review of the literature and anatomical dissection of FAT in a human specimen.

Conclusion: The FAT has emerged as a critical white matter structure in neurosurgery, given its involvement in speech and motor functions. This case demonstrates the importance of advanced imaging modalities and intraoperative technologies to ensure safe resection.

Background: Intracranial lipomas are rare, benign lesions with no neoplastic origin. Most affected patients are asymptomatic and are typically pediatric or young adults. We describe a case of a child with a quadrigeminal plate lipoma presenting with seizures and hydrocephalus.

Case description: A 6-year-old boy presented with dysarthria, spasticity, gait disturbances, headaches, and seizures. Magnetic resonance imaging revealed a lipomatous lesion in the quadrigeminal cistern with ventriculomegaly. An endoscopic third ventriculocisternostomy was performed for obstructive hydrocephalus, and a biopsy confirmed a lipoma. Over 6 years of follow-up, the patient's seizures remained controlled, and the lesion remained stable.

Conclusion: Conservative management with symptomatic control is recommended, given the typically benign progression of lipomas. Seizures are generally well managed with antiepileptic medications. Surgical resection should be reserved for cases where expansive lesions cause significant symptoms or hydrocephalus.

Background: Intraoperative neuromonitoring is an essential tool for detecting early intraoperative neurological changes during spinal surgery. Only rarely do seizures occur during transcranial motor-evoked potentials (TcMEP).

Case description: A 44-year-old male presented with a magnetic resonance (MR)--documented L5-S1 T2-hyperintense intradural mass that heterogeneously enhanced with Gadolinium and extended through the right S1 neural foramen. Utilizing transcranial motor-evoked potential (Tc-MEP) before the skin incision, the patient developed the 1^st seizure that lasted for 2 min. The 2^nd seizure occurred after the initial incision and lasted for around 15 min; at this point, the procedure was terminated. After brain MR studies documented no structural lesion and other etiologies of seizures were ruled out, the patient underwent an uneventful resection of the L5-S1 spinal lesion.

Conclusion: Although the risk of seizures from Tc-MEP is very low, it is crucial to be aware of this potential side effect. If they occur, surgical procedures should be aborted and diagnostic studies performed to rule out the presence of structural lesions and/or other reasons for seizure activity.

Background: The concurrent presentation of meningioma and intracranial aneurysm (IA) poses diagnostic and therapeutic challenges, with no standardized management protocol available. This study aims to address this through an updated systematic review, delineating optimal strategies for managing this dual pathology.

Methods: A systematic review was conducted across PubMed, Web of Science, and Embase databases. Articles were screened independently by two reviewers. Treatment strategies and patient outcomes were comprehensively analyzed to formulate a treatment framework based on several characteristics. In addition, one concurrent meningioma and IA case from our institution was presented.

Results: A total of 69 articles comprising 115 patients were included in the study. The cohort exhibited a female predominance (80%) with a mean age of 56 (±13) years. Meningiomas were primarily localized to the frontotemporal and sellar regions, while aneurysms favored the anterior circulation - notably, 16.5% of cases presented with ruptured aneurysms. Management strategies varied based on the spatial relationship between lesions and aneurysm rupture status. In unruptured cases, 34% underwent a single craniotomy for simultaneous resection of both pathologies, while endovascular intervention was favored when the IA originated from an artery feeding the meningioma (73%). Remarkably, postoperative aneurysm rupture occurred in 33% of cases managed solely through tumor resection (range 0-30 days postop).

Conclusion: This study proposes a comprehensive treatment algorithm to guide neurosurgeons in managing concurrent meningioma and IA cases. By considering individual patient intricacies, the feasibility of simultaneous management, aneurysm rupture risk, and symptomatology, this framework is a valuable tool for clinical decision-making in these complex scenarios.

Background: Intracranial dural arteriovenous fistula (dAVF) is a rare arteriovenous malformation with potentially severe complications. This study investigates the efficacy and safety of transarterial embolization (TAE) in treating petrous dAVFs through a retrospective analysis and literature review.

Case description: A retrospective analysis of six patients with petrous dAVFs treated with TAE was conducted, accompanied by a systematic literature review to evaluate treatment outcomes. Data collection included patient characteristics, clinical presentation, Borden-Shucart and Cognard classifications, treatment specifics, and overall outcomes. TAE, particularly utilizing Onyx, demonstrated favorable outcomes in our six patients. Regarding literature review results, 102 articles were identified through PubMed Mesh tool search, but only five were included after careful evaluation. In addition, one article was manually added after searching for the remaining articles. Combining our six cases with literature findings, 79.8% (n = 75) of patients undergoing TAE achieved a cure with the technique, though Onyx was reported in only 13.9% (n = 13) of TAE cases. Complications were observed in 11.7% (n = 11) of TAE cases.

Conclusion: Our presented cases and literature review suggest that the TAE of dAVFs is feasible and curative for selected cases of petrous dAVFs. However, the complexity of these lesions and the availability of other treatment modalities should be taken into consideration to optimize cure rates and patient outcomes.

Background: Orbital schwannomas arising from the frontal nerve are a rare but distinct entity.

Case description: A 16-year-old girl presented to our hospital with gradually progressive proptosis. Computed tomography (CT) performed 2 years ago incidentally detected a retrobulbar mass in the left orbit measuring 13 mm × 14 mm × 10 mm, which was not identified on CT performed at the age of 4 years. CT taken at presentation revealed marked tumor growth over 2 years, measuring 24 mm × 20 mm × 17 mm. On magnetic resonance imaging (MRI), the tumor appeared homogeneously isointense both on the T1- and T2-weighted sequences. The patient underwent transcranial tumor resection. Following unilateral frontal craniotomy, an osteotomy was made to the left anterior fossa floor. On reflecting, the periorbita revealed the frontal nerve with the proximal segment intermingled with the tumor. The levator and superior rectus muscles were flattened and located immediately beneath the tumor. A gross total resection was performed. Microscopic findings of the resected tumor were consistent with schwannoma.

Conclusion: Frontal nerve schwannomas may grow rapidly under certain conditions. Periodic follow-up using MRI and timely resection is recommended when an asymptomatic orbital tumor, possibly a frontal nerve schwannoma, is detected in young patients.

Background: The use of intracranial catheters is a common procedure used for neurosurgical patients with a variety of pathologies. Despite its frequency of use, shunt failure and revision have been reported to be a common problem. Given that depth of insertion can significantly affect the catheter tip position, a single institution retrospective chart review was performed to examine the accuracy of shunt and external ventricular drain (EVD) placement.

Methods: Computed tomography (CT) images of the head following shunt or ventriculostomy insertion were analyzed to determine the delta between the final length of the intracranial catheter and the intended depth described in the operative notes.

Results: We found that there was a statistically significant difference in the accuracy of placement when comparing EVDs to shunts. The most used EVDs at our institution are marked with a solid black line in increments spaced 2 cm apart. The most used ventricular shunt catheter has a marking at 5 cm and 10 cm from the tip of the catheter. We believe that the visual confirmation that is afforded by metric unit markings on the EVD allows for better final placement of the catheter at the outer table of the calvarium.

Conclusion: The addition of regular millimeter metric unit markings by the manufacturer is imperative in decreasing the chances of error in the insertion of ventricular catheters and preventing potential neurovascular injury to the surrounding structures.

Background: Giant intracranial tuberculomas are rare space-occupying lesions in the brain parenchyma, with a diameter >2.5 cm. They can mimic gliomas, meningiomas, and metastases. Diagnosis of this disease can be difficult without histological evidence. Tuberculosis (TB) affects people of all ages but is a major health problem among children. Misdiagnosis is common, as many clinical and radiological features are non-specific.

Case description: Case 1: A 4-year-old child presented with intracranial hypertensive syndrome and Brave- Jackson seizures. Imaging showed a left temporoparietal lesion with intense peripheral ring enhancement after gadolinium injection, and attaching to the dura mater. Total surgical excision was performed, and histological analysis confirmed granulomatous TB. A month later, he presented to the emergency department with neurological deterioration. Magnetic resonance imaging revealed disseminated TB of the central nervous system, with tuberculomas in the brain stem. The child died after a month in intensive care. Case 2: An 11-year-old boy presented with a headache that had been progressively worsening for 7 months. Imaging revealed a right frontal process mimicking a high-grade glial tumor. The child underwent surgery with total excision of the tumor. After a few days, he developed tubercular miliaria and was put on anti-bacillary treatment.

Conclusion: Treatment includes antituberculosis therapy combined with surgery. This article describes the value of surgery for giant intracranial tuberculomas in two children under our care, with a review of the literature. We believe that the results of surgery for giant intracranial tuberculomas in children are favorable.