Asian journal of neurosurgery最新文献

Giant fusiform aneurysm of the vertebral artery is not common and is usually associated with thrombosis due to swirling blood flow, and manifests as mass effect on the medullary region with slow progression of neurological sign and symptoms. Trapping and ligation combined with bypass surgery, endovascular surgery, and proximal occlusion and flow diverter placement have been described; however, the optimal treatment is still debatable. A 35-year-old female presented to us with complaints of mild occipital headache, moderate pain over the right side of the nape region, numbness, and tingling sensation transferring to the right upper shoulder for 1 month. Magnetic resonance imaging (MRI) of cervical spine and brain revealed normal cervical spine. Brain MRI and digital subtraction angiography were done that revealed an almost completely thrombosed giant fusiform aneurysm of the V4 segment of the vertebral artery. Patient underwent endovascular therapy with complete coils packing. Postoperative status went uneventful. She was discharged on the 7th day of procedure. Complete occlusion of thrombosed giant fusiform V4 segment vertebral artery aneurysm by endovascular therapy with coils embolization is safe and effective.

Concomitant pyogenic atlantoaxial spondylodiscitis alongside retropharyngeal abscesses, in conjunction with tuberculous spondylodiscitis manifesting as gibbus deformity, represents a rare but significant clinical entity. This dual infectious process poses considerable risks and can lead to severe, life-threatening complications if not appropriately managed. We present an atypical case of a 6-year-old Thai boy with concurrent pyogenic atlantoaxial spondylodiscitis, retropharyngeal abscesses, and tuberculous spondylodiscitis at the T6 to T8 levels, leading to a progressive kyphotic deformity. The surgical treatment involved transoral drainage of the abscesses, followed by debridement and vertebral column resection at T6 to T8. A titanium mesh cage was placed, and instrumentation from T3 to T11 was performed using pedicle screws and rods. Postoperatively, the patient showed favorable recovery, with the Cobb angle improving from 70 to 16 degrees. He received intravenous antibiotics for 2 weeks, then oral antibiotics for 4 weeks, along with 12 months of antituberculous chemotherapy. Over a 2-year follow-up period, the patient exhibited clinically significant improvement, and postoperative radiographs confirmed solid osseous fusion with no indications of loss of correction or implant failure. Concomitant pyogenic atlantoaxial spondylodiscitis with retropharyngeal abscess formation, alongside tuberculous spondylodiscitis leading to gibbus deformity, constitutes a rare yet serious clinical scenario. If not addressed promptly, the condition carries substantial risks, such as airway obstruction, sepsis, and potential neurological impairments. Management strategies should prioritize the elimination of infectious agents, prevention of neurological compromise, stabilization of the spinal column, and correction of kyphotic deformities.

Objectives: Brain tumors pose a significant global health challenge, contributing to both mortality and disability. While various risk factors have been proposed, the association between head injuries and brain tumor development remains debated. Understanding this link is particularly crucial in resource-limited regions like Afghanistan. This study aims to investigate the potential correlation between head injuries and brain tumor development in the Afghan population.

Materials and methods: This case-control study was conducted at Ali Abad University Hospital in Kabul from October 2022 to September 2023. Data were collected from 64 patients diagnosed with brain tumors (cases) and 159 matched controls without tumors. Patient demographics and history of head injuries were recorded and analyzed.

Results: The association between head injury and brain tumor incidence was assessed using the chi-square test and logistic regression. An odds ratio (OR) with a 95% confidence interval (CI) was calculated to determine the strength of the association, with statistical significance set at p  < 0.05. A history of head injury was reported in 42.2% of brain tumor cases, compared to 22% in the control group (p = 0.002). Individuals with a history of head injury had significantly higher odds of developing a brain tumor (OR = 2.585; 95% CI = 1.388-4.815). Most brain tumor cases (71.9%) were aged 36 to 65 years, with a gender distribution of 56.3% male and 43.7% female. In contrast, the control group had a higher proportion of males (72.3%).

Conclusion: This study suggests a significant correlation between head injuries and brain tumor development, aligning with findings from global research on this debated relationship. Further large-scale studies across Afghanistan are needed to validate these findings and provide deeper insights into the potential risks associated with head injuries and brain tumor development.

Study design: Retrospective cohort study.

Background: Foraminal and extraforaminal disc herniations account for 7 to 12% of lumbar herniated discs. Various surgical methods, including midline approaches with facetectomy and paramedian techniques, involve significant bone removal, risking spinal instability. The percutaneous transforaminal approach for endoscopic access to lateral disc herniations presents several advantages over traditional techniques and may be more suitable for these cases.

Objectives: This article evaluates the clinical outcomes and potential complications associated with the treatment of foraminal and extraforaminal lumbar disc herniations at the L3/4 and L4/5 levels in patients who have undergone transforaminal percutaneous endoscopic lumbar discectomy.

Materials and methods: Between 2016 and 2020, a total of 32 patients diagnosed with single-level lumbar disc herniation at the L3/4 or L4/5 foraminal or extraforaminal levels, who had not responded to conservative management, underwent transforaminal endoscopic discectomy. Follow-up evaluations were performed on postoperative day 1 and at 2 weeks, 6 weeks, 3 months, and 12 months. Both pre- and postoperative assessments employed the visual analog scale (VAS) and the Oswestry Disability Index (ODI) to quantify pain levels and functional outcomes. Clinical outcomes were assessed according to the MacNab criteria to determine the efficacy of the surgical intervention.

Results: The average age of patients was 52.6 years, with L4/5 (81.3%) and L3/4 (18.7%) being the most affected levels. The median follow-up was 18.2 months (range, 1-44 months). There was a significant reduction in VAS and ODI scores at follow-ups compared to preoperative levels ( p  < 0.01). All patients with preoperative neurological deficits improved, though six patients (18.7%) experienced transient dysesthesia that resolved in 6 weeks. Per the MacNab criteria, clinical efficacy was excellent in 56.3% of patients, good in 37.5%, and fair in 6.2%.

Conclusion: Transforaminal endoscopic lumbar discectomy is a safe and effective minimally invasive procedure for foraminal and extraforaminal lumbar disc herniations at the L3/4 and L4/5 levels. It preserves spinal stability, minimizes blood loss, reduces postoperative pain, and allows for quicker recovery, presenting a strong alternative for patients needing surgery for these conditions.

Objectives Subarachnoid hemorrhage (SAH) resulting from rupture of basilar artery perforator aneurysm (BAPA) is a neurological rarity. With increased awareness and advancements in imaging modalities, they are now more frequently detected. However, concerns regarding their suboptimal treatment and lack of proper analysis still exist. We are hereby reporting our experience of treating this entity in a small cohort. Materials and Methods  It is a retrospective study of all the cases of SAH resulting from rupture of BAPA, which were treated by the same surgical team. Demographic data, treatment characteristics, and follow-up data of our cases along with published literature were studied. Results  Our cohort comprised of five patients (mean age 55 years). Three cases were treated with flow diverter alone and the rest underwent flow diverter and overlapping stent placement. Initial diagnostic cerebral angiography (digital subtraction angiography) was negative in three of them. There was one mortality and favorable outcome was encountered in the remaining cases. All of them demonstrated complete occlusion of the aneurysm in follow-up. Conclusion  Following treatment, all the cases demonstrated complete angiographic occlusion of the aneurysm. In available literature, studies have small sample sizes. Future randomized studies in a larger cohort and proper reporting and analysis of outcomes will help us formulating a treatment protocol for BAPA.

Objectives  Numerous factors can influence patient outcomes following microsurgical clipping of intracranial aneurysms (IAs). Some unique factors, such as aneurysm surgery during the COVID-19 pandemic, also play a role. This study aims to evaluate outcomes in patients with ruptured IAs undergoing microsurgical clipping and identify predictors for both immediate and long-term prognosis. Materials and Methods  This is a retrospective study with prospectively collected data of 500 patients with ruptured aneurysms undergoing microsurgical clipping over a period of 10 years (April 2011-November 2022). The follow-up period ranged from 2 to 10 years, and clinical outcomes were evaluated using the Glasgow Outcome Scale (GOS). Data were analyzed using STATA version 3.10. Logistic regression was used to calculate p -values, with a significance level of p  < 0.05. Results  Among 500 patients treated for ruptured IAs, 169 were males and 331 were females, with a median age of 53 years. Postoperative vasospasm was a major predictor of worse outcomes at discharge ( p  < 0.001), 6 months ( p  < 0.001), 1 year ( p  < 0.001), 5 years ( p  = 0.014), and 10 years ( p  = 0.006). Patients treated during the COVID-19 pandemic had worse outcomes at 6 months ( p  < 0.001) and 1 year ( p  = 0.001). Conclusion  Postoperative vasospasm, intraoperative rupture, and the COVID-19 pandemic were the most important predictors of worse outcomes. Factors such as age, hospital type, Miller Fisher grade, alcohol abuse, diabetes, aneurysm multiplicity, aneurysm size, neck size, ethnicity, hydrocephalus, brain retraction, and lamina terminalis fenestration did not significantly influence the outcomes.

Objectives  During anesthesia induction, fluctuations in systemic hemodynamic may also alter cerebral hemodynamic, especially in patients with intracranial tumors, as these patients might have impaired cerebral autoregulation. This study compared the effects of ketofol (a mixture of ketamine and propofol) and etomidate on cerebral blood flow, oxygenation, and systemic hemodynamics during anesthesia induction for craniotomy in patients with supratentorial tumors. Materials and Methods  This prospective, randomized, double-blind study included 50 patients aged 18 to 65 years, American Society of Anesthesiologists (ASA) classes I to II, undergoing elective craniotomy. Patients were assigned to receive either ketofol or etomidate for induction. Middle cerebral artery (right and left side) mean flow velocity (mFV) and pulsatility index (PI) were measured using transcranial Doppler, and cerebral oxygenation (rSO ₂ %) of both hemispheres was measured using near-infrared spectroscopy (NIRS) during the first 10 minutes (1, 3, 5, and 10 minutes) following anesthesia induction. Statistics  An independent sample " t " test and one-way analysis of variance was used for continuous data. Chi-squared test was used for categorical data. Linear correlation between two continuous variables was explored using Pearson's correlation (normally distributed data) and Spearman's correlation (non-normally distributed data). A p -value of less than 0.05 was considered statistically significant. Results  Both groups showed a fall in mFV (cm/s) following induction, with a greater fall in the etomidate group (38.32 ± 2.54 vs. 28.88 ± 3.07; p  = 0.001). In the etomidate group, mFV returned to baseline within 3 minutes and rose after laryngoscopy, while it remained below baseline in the ketofol group. rSO ₂ decreased immediately postinduction but was better preserved in the ketofol group. Mean arterial pressure and heart rate significantly increased during laryngoscopy in the etomidate group ( p  < 0.001). Conclusion  Ketofol provided more stable cerebral hemodynamics, cerebral oxygenation, and systemic parameters compared with etomidate during anesthesia induction in patients undergoing craniotomy for supratentorial tumors.

We present a case of hospital-acquired Aspergillus terreus spondylodiscitis following lumbar spine surgery. The objective is to highlight the need for a high index of suspicion for rare fungal pathogens as causative organisms in postoperative spinal infections. A 39-year-old female underwent posterior decompression, stabilization, and interbody fusion at L4-5. Six weeks post-surgery she developed fever, back pain, and right leg pain. A diagnosis of postoperative spinal infection was made. On exploration and debridement of the wound, the fungal cultures grew positive for A. terreus . She was treated with voriconazole for 6 months. Following debridement and antifungal therapy, symptoms and inflammatory markers subsided over a period of time. There was no recurrence of infection till the last follow-up at three and half years. To the best of our knowledge, this is the only case report of an A. terreus spondylodiscitis following lumbar spine surgery. The possibility of fungal infection should be considered in elderly and immune-compromised patients. In our institution, all postoperative spinal infections, irrespective of age and comorbidities, are subjected to microbiological cultures including fungal cultures and sensitivities. Thorough debridement, involvement of infection control specialists, and use of long-term antifungal therapy help resolve these infections.

Objectives  Brain abscess is a worrisome condition with a 1-year mortality rate of 21% and a 32% rate of new-onset epilepsy. Brain magnetic resonance imaging (MRI) is strongly recommended as a screening modality with contrast-enhanced T1-weighted images, diffusion-weighted imaging (DWI), and attenuated diffusion coefficient. However, there is a 10% rate of false negative, which could potentially impact management and prognosis. Our systematic review aims at identifying risk factors for false negative. Materials and Methods  A database search of our institutions plus a systematic literature review was conducted using MEDLINE/PubMed, including studies of brain abscesses misdiagnosed as brain tumors. Data on patient demographics, clinical presentations, imaging findings, pathogens, treatments, and outcomes were extracted and analyzed. We present a case of a 59-year-old male with HIV, who developed a brain abscess misdiagnosed as a tumor. Initial symptoms included left-side weakness and weight loss. Imaging showed a ring-enhancing lesion in the right thalamus. The abscess was caused by T. gondii , and the patient was treated with sulfadiazine, pyrimethamine, ceftriaxone, and metronidazole, achieving a GOS-E score of 8 at 1 year. Results  The review included 14 studies, with 1 additional illustrative case, encompassing a total of 15 cases. Patients ranged from 39 to 77 years, with a mean age of 59 years. Comorbidities included human immunodeficiency virus (HIV), glioblastoma, breast cancer, arthritis, gastric cancer, and nephrotic syndrome. Common symptoms were hemiparesis, generalized seizures, headache, and confusion. Imaging often revealed ring-enhancing lesions with restricted diffusion on DWI. Lesions were located in various brain regions. Pathogens identified included 40% Nocardia species, Toxoplasma gondii , Mycobacterium tuberculosis , Aggregatibacter aphrophilus , Rickettsia typhi , Arcanobacterium haemolyticum , Aspergillus terreus , and Providencia rettgeri . Treatments involved antibiotics and, in some cases, surgical intervention. Outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E) at 1 year indicated good recovery in most cases. Conclusion  Despite the high sensitivity and specificity of brain MRI in diagnosing brain abscesses, the standard protocol used for the past two decades still results in a 10% false-negative rate. Such inaccuracies can significantly impact the patient's management, potentially delaying antibiotic therapy and impacting the surgical planning, hence affecting the outcome. Immunocompromised patients are particularly vulnerable to misdiagnoses of brain abscesses as brain tumors. To improve diagnostic accuracy, new imaging techniques and computational tools are currently under investigation.

Introduction  Lesions in the cerebellomedullary angle, anterolateral aspect of lower brainstem, and anterior foramen magnum can be accessed through far lateral approach and extreme lateral infrajugular transcondylar exposure. Detailed anatomical knowledge of this region is of paramount importance to avoid untoward complications. Objectives  Comprehensive anatomy of this microsurgical corridor is sparse. Our aim was to define the anatomy of this region with relevance to the surgical approach, which would enable the surgeon to navigate this region with ease during surgery. Materials and Methods  Cadaveric dissection was performed with focus on the various anatomical structures, which are of relevance to the operating surgeon. The same was correlated with the computerized scan and magnetic resonance imaging brain findings and intraoperative findings. The observations are presented. Discussion  Through the far lateral approach, the vagoaccessory triangle (VAT) and three subtriangles within it are exposed. Lateral boundary of the VAT is formed by the spinal accessory nerve, which follows a superolateral trajectory toward the jugular foramen. Medial boundary is formed by the medulla oblongata. Superior boundary is formed by the vagus nerve, which courses horizontally toward the jugular foramen. Rootlets of the hypoglossal nerve divide the VAT into infra-hypoglossal, supra-hypoglossal, and hypoglossal-hypoglossal subtriangles. The floor is formed by the inferior clivus, anterior foramen magnum, occipital condyle, and jugular tubercle. The roof is formed by the dura covering the lower part of the posterior fossa, biventral lobule, and tonsil of the cerebellum. The VAT contains three cisterns compartmentalized by three membranes, three nerves, and a fourth segment of vertebral artery (V4) with its three branches, in three subtriangles. Cisterns are the premedullary, lateral cerebellomedullary, and posterior cerebellomedullary. Membranes are the medial pontomedullary membrane, lateral pontomedullary membrane, and denticulate ligament. Nerves are the rootlets of hypoglossal, cranial accessory, and first cervical nerve. Posterior inferior cerebellar artery, anterior spinal artery, and posterior spinal artery are the three branches of V4. Conclusion  Detailed knowledge of each anatomical structure and its relationship would enable the surgeon to operate safely within the corridors naturally present in this region.