Asian journal of neurosurgery最新文献

Deep brain stimulation of subthalamic nucleus (STN-DBS) is recognized as the gold standard for symptomatic treatment of advanced Parkinson's disease (PD). However, despite adherence to screening protocol, perioperative neuropsychiatric complications are increasingly being recognized. The rapid development of psychiatric symptoms within less than 24 hours is rare, and acute episodes occurring during surgery are uncommon. We present a 57-year-old female patient diagnosed with PD, with good premorbid personality. However, mild depression was detected on neuropsychological assessment. After thorough deliberation and family meeting, patient was cleared to undergo STN-DBS as the expected benefits outweighed the potential risks. Intraoperatively, during microstimulation of the left STN, patient developed sudden onset of aggressive behavior. The behavioral change lessened when the DBS lead location was adjusted to a more lateral location. The psychiatric symptoms were then controlled with quetiapine until the behavioral changes had resolved after 7 days. No recurrence was noted during follow-up consults.This case report confirms the importance of fundamental knowledge and understanding of the neuroanatomical structures affected in DBS of the STN, and their clinical implications. A thorough preoperative psychiatric evaluation is essential for comprehensive management and allows anticipation of possible adverse events.

Idiopathic intracranial hypotension (IIH) is an uncommon condition characterized by cerebrospinal fluid leakage, which may lead to complications such as chronic subdural hematoma (CSDH). Management of recurrent CSDH in the context of IIH remains a therapeutic challenge. A 50-year-old man presented with bilateral CSDH associated with symptoms of IIH. Initial conservative treatment was followed by burr hole drainage due to deteriorating consciousness. Despite temporary improvement, hematoma recurrence necessitated repeat drainage. Subsequently, bilateral middle meningeal artery embolization (MMAE) was performed. The patient showed rapid clinical recovery, and no recurrence was observed at 3-month follow-up. MMAE may be an effective and minimally invasive treatment option for recurrent CSDH associated with IIH, especially when surgical intervention poses risks or proves insufficient. Early recognition of IIH and tailored intervention strategies are essential for optimal outcomes.

Objective: Mismatch repair deficiency (MMRD), a hallmark of microsatellite instability (MSI), has been extensively studied in gastrointestinal and endometrial cancers but remains underexplored in gliomas. Deficiencies in mismatch repair (MMR) proteins, such as MLH1, MSH2, MSH6, and PMS2, may contribute to tumor progression, treatment resistance, and responsiveness to immune checkpoint inhibitors. This study aimed to evaluate the expression of MMR proteins in gliomas using immunohistochemistry (IHC) and analyze their association with patient age, histological subtype, and central nervous system (CNS) World Health Organization (WHO) (2021) tumor grade.

Materials and methods: A total of 64 glioma cases were retrospectively analyzed, including a range of histologic subtypes and grades. IHC for MLH1, MSH2, MSH6, and PMS2 was performed to detect MMR protein expression. Cases showing MMR deficiency by IHC were further evaluated using next-generation sequencing (NGS) for MSI and frameshift mutations in MMR genes. Statistical analyses were conducted to assess associations with clinicopathological parameters.

Analysis: Quantitative variables were expressed as mean and standard deviation. Quantitative variables were expressed as percentage or proportion. Chi-square test and Fisher's exact test were done to associate MMR protein deficiency with age, histopathological type, and CNS WHO grade of glioma. p -Value of <0.05 was considered significant.

Results: MMR deficiency was observed in 3 of 64 cases (4.69%), all showing isolated loss of MSH6 expression. These included two IDH-mutant astrocytomas and one pilocytic astrocytoma. No significant associations were found between MMRD and age ( p  = 1.000), histological subtype ( p  = 0.448), or WHO grade ( p  = 0.448). NGS revealed one MSI-high and one MSI-low tumor, both harboring frameshift mutations in multiple MMR genes.

Conclusion: MMR deficiency is rare in gliomas, with isolated MSH6 loss being the most common finding. While not significantly associated with tumor grade or patient demographics, MMRD may have clinical relevance in specific subgroups. NGS findings highlight the potential utility of integrating molecular diagnostics for identifying MSI and guiding immunotherapy decisions.

Cerebral cavernous malformations (CCMs) are vascular malformations that can cause seizures and hemorrhages. Managing CCMs associated with developmental venous anomalies (DVAs) becomes more complex due to the risk of venous infarction and hemorrhage if the DVA is disrupted. This case report describes a 55-year-old man presenting with intractable seizures who was found to have a hemorrhagic CCM and an adjacent DVA in the frontal lobe. Surgical management involved complete removal of the CCM while preserving the DVA. Postoperatively, the patient had no further seizures, highlighting the importance of careful surgical planning and execution in managing coexisting CCMs and DVAs.

Coronavirus disease 2019 (COVID-19) can lead to systemic vascular complications, such as endothelial damage and hypercoagulability. Although COVID-19-associated nonaneurysmal subarachnoid hemorrhage (SAH) has been reported, cases involving anterior cerebral artery (ACA) dissection, particularly in the A1 segment, are extremely rare. A 57-year-old man with a recent COVID-19 infection was brought to the emergency department in an unconscious state. Imaging revealed diffuse SAH, and computed tomography angiography identified dissection of the right ACA A1 segment. Urgent surgical intervention with clipping of the dissected segment was performed. Although the patient initially stabilized postoperatively, he subsequently developed severe cerebral infarction, leading to progressive neurological decline. Despite intensive care, the patient succumbed to these complications 10 days after the initial presentation. Although the overall threat of COVID-19 has diminished, vigilance is still required because its vascular complications remain potentially fatal. COVID-19-associated SAH may have a higher mortality rate due to mechanisms distinct from saccular aneurysm rupture, such as arterial dissection and systemic effects. Dissecting an aneurysm of the A1 segment of the ACA is an extremely rare but serious complication, and its management remains challenging. Further studies are required to understand and mitigate COVID-19-related vascular pathologies.

Neural tube defects (NTDs) are common congenital anomalies, with myelomeningocele (MMC) being the most severe form. Double-level MMC is exceedingly rare, with fewer than 60 cases reported worldwide and none from Southeast Asia. We report a 4-month-old male with two congenital swellings on his back, diagnosed as double MMC at the cervical and lumbar levels, along with hydrocephalus and Arnold-Chiari malformation. Surgical management, including ventriculoperitoneal shunting and MMC repair, resulted in good outcomes. This case highlights the importance of early diagnosis, timely surgical intervention, and prenatal folic acid supplementation to reduce NTD risk in resource-limited settings.

Introduction: Meningiomas are the most common primary brain tumors in adults, comprising 37.6% of central nervous system neoplasms. Though gross total resection is the treatment of choice, meningiomas recur even after complete resection. Additionally, meningiomas with a high Ki67/MIB-1 labeling index (LI) have a higher recurrence rate.

Aims: This article analyzes the clinico-histomorphological features of recurrent meningiomas and compares the expression of MIB-1 LI of primary and recurrent tumors.

Materials and methods: This was a retrospective observational study of 50 recurrent meningiomas diagnosed between 2019 and 2023. Tumors were analyzed for site, radiological/histopathological features, and expression of MIB-1 LI in both primary and recurrent tumors.

Results: Thirty-four percent of the recurrent cases were between 41 and 50 years of age, 58% of the recurrent cases were males. Recurrence was most commonly seen in the frontal region (26%; n  = 13) and 52% cases recurred between 1 and 10 years after primary resection. Of the primary tumors, 30 cases (60%) were grade 1, 16 cases (32%) were grade 2, and 4 cases (8%) were grade 3. Mean MIB-1 of primary meningiomas was 4.25% overall and 1.8% for grade 1. Progression in grade was noted in 15 cases with 5 cases showing brain invasion on recurrence while 17/30 grade 1, 14/16 grade 2, and 4/4 grade 3 tumors recurred with no change in grade. Overall mean MIB-1 LI of recurrent tumors was 5.4%.

Conclusion: Although MIB-1 LI is not an independent criterion for tumor grading, it can be used as an additional tool to identify at-risk patients and recommend close follow-up.

Chondrosarcomas are malignant chondrogenic neoplasms that primarily affect the bones of the pelvis and appendicular skeleton. Approximately 15% of these tumors occur in the chest wall. They most commonly originate anteriorly from the costochondral junction or sternum. Posterior thoracic chondrosarcomas frequently arise from the costal angle and vertebral arch of the thoracic spine, and only rarely do they originate at the costovertebral junction. A total of 30 patients with chondrosarcoma arising from the costovertebral junction have been previously reported in the English literature. We report a case of giant costovertebral chondrosarcoma presenting as a large paraspinal mass and review the current literature on the topic. A 42-year-old female with no comorbidities presented with a 3-month history of chest pain and dry cough. Radiologic imaging revealed a massive irregularly calcified paraspinal mass extending from the T5 to T7 vertebral levels. A microsurgical excision of the lesion was performed using a posterolateral thoracic approach, and intraoperatively, the mass was seen arising from the right T5 costovertebral junction with extension into the T4-T5 neural foramen. Histological examination confirmed a diagnosis of grade 2 chondrosarcoma. The uniqueness of our case report lies in the size and location of the chondrosarcoma, with only one other case being as large as ours. Chondrosarcoma must be considered in the differential diagnosis of partly calcified paraspinal masses arising from the costovertebral junction.

Cerebral herniation is the movement of brain tissue due to increased intracranial pressure. Ascending transtentorial herniation (ATH) is a rare consequence of lesions in the posterior cerebral fossa, often associated with obstructive hydrocephalus. Cerebrospinal fluid (CSF) diversion can alleviate symptoms but may also lead to ATH, particularly after ventriculoperitoneal (VP) shunt procedures. Despite its high mortality, early diagnosis and immediate intervention are crucial. This case report describes a child with a left cerebellar anaplastic ependymoma (CNS WHO grade 3) and obstructive hydrocephalus who developed ATH post-VP shunt and recovered after timely surgical decompression. A 3-year-old boy with a month-long history of headache without associated fever was diagnosed with a cystic lesion in the left cerebellar hemisphere, with obstructive hydrocephalus. Despite an initial plan to avoid CSF diversion, he experienced a hydrocephalic attack, leading to an emergency VP shunt procedure. Postsurgery, he showed signs of ATH and underwent immediate surgical decompression, resulting in a successful recovery and adequate brainstem decompression. In patients with posterior cranial fossa tumors with associated hydrocephalus, it is advisable to do upfront tumor excision and avoid a preoperative CSF diversion procedure. In the rare instance where a patient undergoes CSF diversion procedure before definitive surgery, early detection and immediate intervention are critical for reversing ATH and preserving brain function.

This study aims to systematically examine the results of mechanical thrombectomy (MT) in managing acute ischemic stroke (AIS) among patients in Southeast Asia, addressing the current gap in region-specific data. A thorough search was performed in Scopus and PubMed databases from inception through February 2025, with additional sources identified through citation tracking. This review included observational studies involving adult AIS patients who underwent MT. The study quality was appraised using the Newcastle-Ottawa Scale. Key clinical endpoints assessed included favorable functional independence mRS scores (0-2), successful recanalization (TICI 2b/3), incidence of symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Outcome data were synthesized using pooled proportion estimates under a random-effects modeling. Statistical heterogeneity was evaluated using the I ² metric. A total of 12 observational studies encompassing 1,037 patients were included. The studies were from Vietnam, Singapore, Indonesia, Philippines, and Thailand. The pooled proportion of patients achieving functional independence mRS (0-2) was 48.3% (95% CI: 38.9 -57.8%; I ²  = 88.06%), while successful recanalization was achieved in 72.3% (95% CI: 63.3-81.2%; I ²  = 91.86%). The rates of sICH and mortality were 7.95% (95% CI: 4.9-11%; I ²  = 64.85%) and 17.3% (95%CI: 11 -23.6%; I ²  = 80.69%), respectively. Subgroup analysis showed that prospective studies had better outcomes than retrospective studies, with higher functional independence and lower mortality rates. outcomes varied across countries, likely reflecting differences in healthcare infrastructure, access to thrombectomy-capable centers, and stroke system maturity. Mechanical thrombectomy in Southeast Asia yields effectiveness and safety outcomes comparable to those observed in Western high-income countries, despite resource limitations. However, regional variations highlight the influence of healthcare infrastructure on stroke outcomes. Expanding MT programs, improving early access to care, and addressing financial barriers are essential steps toward optimizing regional stroke care.