Asian journal of neurosurgery最新文献

Objective: This article aims to understand the clinical course of symptomatic internal carotid artery (ICA)-posterior communicating artery (PCom) aneurysms and the outcomes of post-coiling for unruptured symptomatic aneurysms by analyzing the anatomical imaging data and patient backgrounds of patients treated in our institute in the last 5 years.

Materials and methods: This study enrolled 82 patients with ICA-PCom aneurysms. Anatomical factors, including age, sex, side, aneurysm dome and neck size, aneurysm depth/neck width ratio (ASPECT ratio), family history of cerebral aneurysm, history of hypertension, smoking habit, angle between aneurysm dome protrusion and ICA C2 portion, angle between ICA C2 and C3 portions, and PCom diameter, were analyzed. In the outcome analysis of coil embolization for symptomatic unruptured ICA-PCom aneurysms, we evaluated age, sex, side, aneurysm dome and neck side, ASPECT ratio, volume embolization ratio, and time from onset.

Statistical analysis: Mann-Whitney U and Fisher's exact tests were utilized for quantitative and categorical variables, respectively.

Results: In both ruptured and unruptured ICA-PCom aneurysms, the angle between the aneurysm dome protrusion and ICA C2 portion and the angle between the ICA C2 and C3 portions were smaller in the oculomotor palsy group than in the nonoculomotor palsy group. Other factors such as age, sex, side, aneurysm dome, neck, ASPECT ratio, family history, hypertension, smoking, and PCom diameter did not significantly influence oculomotor palsy. Early coil embolization led to better recovery of neural function, with immediate intervention offering the highest chance of full recovery.

Conclusion: Overall, this study showed that sharp ICA siphon and aneurysm dome protrusion are significant factors in symptomatic ICA-PCom aneurysms. We propose that immediate surgery be recommended for patients with ICA-PCom aneurysm-induced oculomotor nerve palsy to prevent functional disability and potential aneurysm rupture.

Objective: Intraoperative neuromonitoring (IONM) using lateral spread response (LSR) has been mostly studied as a tool in optimizing the benefits of microvascular decompression (MVD) in cases of hemifacial spasm (HFS). Although evidence suggests its utility as a prognostic marker, our experience with the same remains otherwise. The significance of the time of disappearance of LSR is also less studied as a factor determining the outcome. This is a pilot study involving a series of patients operated on for HFS using MVD. The prime objectives of the study are: (1) to review LSR in HFS as a prognosticator of outcome and (2) to study the significance of time of disappearance of LSR and its correlation with outcome.

Materials and methods: Patients operated on for HFS with MVD under IONM guidance, between August 2022 and June 2024, were observed in the postoperative period in three phases-immediate, early, and late. The outcomes were divided into-complete, partial or no improvement, and recurrence. The results were studied against the corresponding findings of LSR in those cases.

Results: A total of six patients were studied. Of these, three were males and three were females. Intraoperatively, all the patients showed complete loss of LSR after separating the compressing vessel from affected facial nerve. In the immediate postoperative phase, two out of six patients had incomplete improvement in symptoms which later improved in one of the patients in early postoperative phase. The remaining one patient who had partial improvement of symptoms had increased symptoms within 3 months of follow-up.

Conclusion: Although LSR monitoring indicates adequate facial nerve decompression, in our experience, LSR disappearance was not congruent with the absence of symptoms in postoperative phase of HFS. The time of disappearance of the LSR waveform intraoperatively has a significant role in determining the outcome.

Ossification of the ligamentum flavum (OLF) predominantly affects the thoracic spine; cervical involvement is rare and often underrecognized, typically progressing slowly with motor or sensory symptoms. Here, the authors present a 70-year-old male who has experienced a subacute progression of hemiparesis, which is atypical for OLF and could easily be misdiagnosed as a stroke attack, attributed to OLF that resolved following a laminectomy. A 70-year-old man with diabetes mellitus developed initial bilateral upper limb numbness, followed by progressive left upper and lower extremity weakness over 1 month. Initial stroke suspicion was negated by normal brain imaging. A cervical magnetic resonance imaging revealed ossified lesions at C5-C6 with posterior spinal cord compression. Cervical laminectomy was performed, and pathological examination confirmed OLF. Neurological symptoms improved steadily following surgery and rehabilitation. Cervical OLF may cause severe hemiparesis in such a short period of time, presenting in an atypical manner for its nature and may resemble cerebrovascular disease. Accurate and timely diagnosis is essential to prevent permanent neurological deficit through appropriate surgical decompression, such as laminectomy.

Spontaneous intracranial hypotension (SIH) is a condition caused by cerebrospinal fluid (CSF) leakage, leading to low intracranial pressure (ICP), brain sagging, and subdural hematoma (SDH). Management of SIH complicated by SDH presents a clinical challenge: treating CSF leaks is performed by epidural blood patch (EBP), which elevates ICP, while SDH management typically requires hematoma evacuation, producing a reductive effect on ICP. Mismanagement can result in severe complications such as brain herniation or rebound intracranial hypertension. We report two cases of SIH-associated SDH successfully treated with simultaneous burr hole drainage and EBP, guided by continuous ICP monitoring. Both patients presented with significant SDHs and clinical signs of SIH. At the start of the procedure, subdural ICP was relatively low. After administration of autologous blood, ICP rose rapidly to over 30 mm Hg, reaching levels considered dangerously high if left unaddressed. The hematoma was evacuated without delay, and patients had no recurrence or complications. EBP under real-time monitoring facilitated timely intraoperative decisions and tailored responses to dynamic intracranial changes. This approach provides a framework for individualized and safe intervention in complex dual-pathology scenarios.

This article aims to present and interpret two instances of Dyke-Davidoff-Masson syndrome (DDMS), with the main features of cerebral hemiatrophy and compensatory skull changes, focusing on the clinical spectrum, imaging features, and variations in timing of presentation. Two male patients with left cerebral hemisphere involvement were evaluated. The first case was an 8-year-old child presenting with intellectual disability, delayed milestones, right hemiparesis, abnormal jerky movements, and generalized seizures. The second case was a 22-year-old adult with hemiparesis and generalized seizures since birth. Both underwent detailed neurological examination and magnetic resonance imaging (MRI) on a 3T scanner, including time-of-flight (TOF) angiography to assess cerebral vasculature. MRI of the first patient demonstrated left cerebral hemiatrophy with dilatation of the ipsilateral lateral ventricle and sulcal prominence, mild falcine deviation toward the affected side, and compensatory hypertrophy of the left calvarial bones (temporal, parietal, frontal, occipital) with enlargement of the frontal sinus and mastoid air cells and elevation of the left petrous ridge. Mild attenuation of the left middle cerebral artery (MCA) segments was seen on TOF imaging. The second patient's MRI revealed left cerebral hemisphere atrophy with gliosis in the MCA territory, left ventricular dilatation, ipsilateral sulcal prominence, and a neuroglial cyst in the left insular cortex with similar bony changes as those of the previous patient. TOF angiography showed attenuation of the left MCA segments without filling defects. DDMS is associated with a certain specific set of clinical and radiological features. Early recognition through MRI and computed tomography is essential for appropriate management and improved outcomes. These cases illustrate the variability in presentation and emphasize the importance of considering DDMS in the differential diagnosis of unilateral cerebral atrophy with neurological deficits.

Introduction: Posterior fossa ependymomas are classified into posterior fossa group A (PFA-EPN) and posterior fossa group B ependymomas. PFA-EPN shows immunohistochemical loss of H3 p.K27me3 expression. Molecular subgroup 1 (PFA-1) and 2 (PFA-2), encompass nine subtypes (PFA 1a-1f and 2a-2c). OTX2 and H3 p.K27M immunopositivity is noted in PFA-2c and 1f, respectively, with potential prognostic implications.

Aim: To assess the frequency of OTX2 and H3 p.K27M immunopositivity in PFA-EPN.

Materials and methods: This retrospective study included PFA-EPN diagnosed at our institute from 2016 to 2022, based on immunohistochemical loss of expression of H3p.K27me3. Immunohistochemistry for OTX2 and H3 p.K27M was carried out on them.

Results: A total of 42 cases of PFA-EPN were encountered, ranging 10 months to 23 years, with a median of 4 years. OTX2 immunopositivity was seen in four cases (9.5%) and H3 p.K27M positivity in two cases (4.8%). Follow-up data were available partially and showed variable survival.

Conclusion: PFA-EPN can be segregated into OTX2 and H3 p.K27M immuno-positive tumors. Because of low frequency and few studies, long-term survival data are limited. Assessment of frequency of OTX2 and H3 p.K27M immunopositivity and their segregation into subsets with prognostic significance can help in diagnostics in routine laboratory settings. This can also potentiate open new therapeutic avenues in PFA-EPN.

This systematic review and meta-analysis aimed to study the real-world recanalization rates of mechanical thrombectomy (MT) in Indian stroke patients. A comprehensive literature search of PubMed, Scopus, and Embase was conducted for Indian observational studies on MT published up to September 30, 2024. The studies assessing recanalization using the modified thrombolysis in cerebral infarction (mTICI) met the inclusion criteria for review. Besides, only the studies that defined successful recanalization as mTICI ≥2b were included in the meta-analysis. Data on MT techniques, recanalization rates, number of passes, and first-pass effect were extracted. Risk of bias assessment was done using the MINORS tool. Meta-analysis was performed with a random-effects model. Heterogeneity was measured with I ² statistic, and publication bias was assessed via Egger's test. Subgroup and sensitivity analyses were also conducted to address heterogeneity and test the strength of our pooled estimates. Nineteen studies were included in our review out of which 15 retrospective studies entered the primary meta-analysis. The pooled recanalization rate was 80.7% (95% CI: 74.7-86.8%; I ²  = 88.76%). We performed a sensitivity analysis after excluding two outlier studies which reduced heterogeneity ( I ²  = 71.99%) significantly and increased the pooled rate to 82.1%. In the stent retriever subgroup, the pooled recanalization rate after sensitivity analysis was 80.9%. The overall pooled first-pass recanalization rate was 46.8%, and the same was 46.0% for stent retriever-only cases. Due to methodological heterogeneity and scarce data, pooled analyses for aspiration and combined techniques, posterior circulation strokes, and tandem occlusions could not be performed. MT in Indian stroke patients results in successful recanalization rates comparable to global data. We need further well-designed prospective studies for standardized outcomes, especially for contact aspiration technique, which has a potential to be the cost-effective first-line strategy for developing countries such as India.

Foreign-body granulomas secondary to synthetic materials used in neurosurgery are common. It has been reported that most of them occur after brain surgery than spinal surgery. Hirayama disease, which presents as a slow progressive upper limb muscle weakness and subsequently atrophy, obligates surgical intervention when the conservative management fails. It is managed by posterior cervical surgery followed by dural repair, while anterior cervical surgery is also an option. The component present in duroplasty material, ReDura, may cause exuberant granuloma formation. Foreign-body granuloma at the site of dural repair secondary to the synthetic dural component can cause spinal cord compression worsening the symptoms, requiring surgery. We hereby report a case of a young male with Hirayama disease who underwent posterior cervical surgery followed by duroplasty. The mass effect by the granuloma, secondary to dural repair, was relieved surgically and patient improved neurologically.

Burr hole craniotomy for the evacuation of subdural hematoma (SDH) can be performed under general anesthesia, surgical site local anesthesia, or scalp block. The prevalence of SDH is higher in the geriatric age group who often suffers from multiple comorbidities. The use of general anesthesia with polypharmacy and airway manipulation may adversely affect the systemic physiology in these patients with substantially decreased reserve. Relief of pain is often inadequate with surgical site local anesthesia leading to tachycardia, hypertension, adverse cardiovascular events, and poor patient satisfaction. Scalp block provides dense prolonged blockade of select target nerves and avoids sedation facilitating early recovery and discharge. However, it is associated with multiple complications including intraneural/arterial injection, and local anesthetic systemic toxicity. The use of ultrasound has ushered in a new era in the field of regional anesthesia; however, the use of ultrasound-guided scalp blocks is not routinely practiced. The use of ultrasound has an opioid-sparing effect and avoids complications like facial nerve palsy and hematoma. We report the first case series of successful ultrasound-guided scalp blocks for the evacuation of chronic SDH.