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Na Zhang, Yingyi Xu, Xinke Xu, Cheng Chen, Yubing Guo, and Yonghong Tan

OBJECTIVE

Intraoperative blood loss is a major challenge in pediatric brain tumor removal. Several clinical and surgical factors may influence the occurrence of intraoperative blood loss and blood transfusion. This study aimed to identify the risk factors of intraoperative blood loss and intraoperative red blood cell (RBC) transfusion for pediatric patients undergoing brain tumor removal.

METHODS

A total of 297 pediatric patients undergoing brain tumor removal were selected in this retrospective, singlecenter study. Demographic data, laboratory data, imaging data, and surgical records were collected, and then independent risk factors for intraoperative blood loss and transfusion were identified using multivariate stepwise regression analysis.

RESULTS

The median intraoperative blood loss in our cohort was 23.1 ml/kg (IQR 10.0–60.0 ml/kg). In total, 284 (95.6%) patients received intraoperative RBC transfusion, with a median amount of 0.2 U/kg (IQR 0.0–2.6 U/kg). Age (β = −0.189; 95% CI [−1.359, −0.473]; p < 0.001); preoperative hemoglobin level (β = −0.141; 95% CI [−1.528, −0.332]; p = 0.003); anesthesia time (β = 0.189; 95% CI [0.098, 0.302]; p < 0.001); unclear tumor boundary (β = 0.100; 95% CI [2.067, 41.053]; p = 0.031); tumor size (β = 0.390; 95% CI [14.706, 24.342]; p < 0.001); and intraoperative continuous infusion of vasopressor (β = 0.155; 95% CI [13.364, 52.400]; p = 0.001) were independent predictors of intraoperative blood loss. Independent predictors of the need for RBC transfusion included age (β = −0.268; 95% CI [−0.007, −0.004]; p < 0.001); preoperative hemoglobin level (β = −0.117; 95% CI [−0.005, −0.001]; p = 0.003); anesthesia time (β = 0.221; 95% CI [0.001, 0.001]; p < 0.001); unclear tumor boundary (β = 0.110; 95% CI [0.024, 0.167]; p = 0.010); tumor size (β = 0.370; 95% CI [0.056, 0.092]; p < 0.001); intraoperative continuous infusion of vasopressor (β = 0.157; 95% CI [0.062, 0.205]; p < 0.001); and tumor grade (β = 0.107; 95% CI [0.007, 0.062]; p = 0.014).

CONCLUSIONS

Overall, age, preoperative hemoglobin, tumor size, anesthesia time, continuous infusion of vasopressors, and unclear tumor boundary were the main determinants for intraoperative blood loss and RBC transfusion in pediatric patients undergoing brain tumor removal.

Clinical trial registration no.: ChiCTR1900024803 (ChiCTR.org)

Open access

Kohei Ishikawa, Hideki Endo, Ryota Nomura, Daishi Yamaguchi, Koji Oka, and Hirohiko Nakamura

BACKGROUND

Vertebral artery (VA) size, anatomy, and occlusion status should be considered when selecting endovascular access for basilar artery mechanical thrombectomy. In a patient with concomitant basilar artery and VA occlusion and a patent but hypoplastic contralateral VA, the occluded VA should be selected. The authors report a technique that utilizes advancing a guiding sheath with attached dilator via an occluded VA.

OBSERVATIONS

A 65-year-old male presented with disturbed consciousness because of an acute infarction of the brainstem and cerebellum caused by a basilar artery occlusion. Cerebral angiography showed a hypoplastic right VA and occlusion of the left VA at the origin. A regular wire was easily advanced through the occlusion and a 4-Fr diagnostic catheter was advanced into the distal left VA. A 6-Fr guiding sheath with attached dilator was placed in the left VA beyond the occlusion by exchanging it over a long wire. After removing the basilar artery thrombus, balloon angioplasty was performed at the left VA origin. Complete revascularization of the posterior circulation was achieved.

LESSONS

A guiding sheath with dilator can advance across and dilate a VA occlusion at the origin to provide rapid access to the basilar artery.

Open access

Shinya Torimaki, Nobuhiro Sasaki, Jiro Ohara, Shigeo Ueda, and Minoru Hoshimaru

BACKGROUND

Ganglioneuroma is a benign and well-differentiated tumor derived from neural crest cells, which occurs infrequently, with most patients being female and adolescents. While predilection sites are the posterior mediastinum and retroperitoneal cavity, ganglioneuroma originating from the dorsal root ganglion is very rare. Here the authors report a case with C2 dorsal root ganglion-derived ganglioneuroma with some literature review.

OBSERVATIONS

A 45-year-old male patient complained of persistent right-side throbbing occipital headache for more than a year. Magnetic resonance imaging (MRI) of the cervical spine revealed a dumbbell-shaped intradural extramedullary tumor from the C2 posterior surface of the odontoid to right C1–2 intervertebral foramen with high T2- and low T1-weighted signal intensities. The tumor displayed homogeneous contrast enhancement by MRI. The authors suspected schwannoma and performed a tumorectomy for both diagnosis and treatment purposes. Intraoperative findings showed that the tumor originated from the dorsal root ganglion, and pathological examination revealed ganglioneuroma. Immediately after the tumorectomy, the throbbing occipital headache disappeared and the patient was discharged from the hospital without major complications.

LESSONS

Although ganglioneuroma derived from the dorsal root ganglion is very rare, a differential diagnosis of the ganglioneuroma should be made, when schwannoma is suspected.

Open access

Hiroki Yamazaki, Tomohiko Ozaki, Tomoki Kidani, Yosuke Fujimi, Masahiro Nonaka, Masao Umegaki, Chisato Yokota, and Toshiyuki Fujinaka

BACKGROUND

Both filum terminale arteriovenous fistulas (FTAVFs) and filum terminale lipomas (FTLs) are rare. Because of this rarity, there is a paucity of data regarding concomitant FTAVF and FTL, and the optimal treatment remains to be defined. The authors describe a patient with coexisting FTAVF and FTL treated with single-stage surgery.

OBSERVATIONS

A man in his 70s was referred to the authors’ department because of a suspected spinal vascular malformation seen on magnetic resonance imaging that was performed to investigate lower limb weakness, intermittent claudication, and urinary incontinence. Previous imaging had shown a terminal lipoma with an internal flow void. Computed tomography angiography and digital subtraction angiography revealed an FTAVF, the feeder being a lateral sacral artery. The patient was treated surgically with curative intent. The FTL and tethered cord that had been identified by imaging were treated in the same procedure. Postoperative digital subtraction angiography showed absence of the abnormal vessels. The patient was discharged home on the 19th postoperative day.

LESSONS

When considering treatment, it is important to determine whether symptoms are attributable mainly to FTL, tethered cord, or FTAVF. One-stage treatment is useful because it eliminates both the FTAVF and the factors that led to its development.

Open access

Annabelle Shaffer, Ryan Johnson, Gina Guglielmi, Anant Naik, Daniel Najafali, Amir A. Khan, Frank J. Bellafiore, Paul M. Arnold, and Wael Hassaneen

BACKGROUND

Blastomyces dermatitidis is a fungus endemic to central and southern North America. While infection most commonly results in pneumonia, a small number of infections progress to systemic disease, which may include intracranial lesions. Progression to systemic disease is most common in immunocompromised patients, such as those with human immunodeficiency virus.

OBSERVATIONS

The authors present a 44-year-old immunocompetent male who presented following a tonic-clonic seizure. Initial workup revealed a 19-mm enhancing intracranial mass. There was avid uptake of fluorescein sodium, and an en bloc resection of the mass was performed. Histopathology revealed B. dermatitidis. Medical management included amphotericin B and azole therapy. Postoperative recovery was uneventful, and no focal neurological deficits were appreciated.

LESSONS

This case highlights the neurosurgical management of a rare intracranial fungal manifestation in an immunocompetent patient. A literature review was also performed to better understand the role of neurosurgery in fungal infections. There were limited cases of intracranial Blastomyces reported in immunocompetent patients, and neurosurgical management varied (no intervention, biopsy, resection) and was underreported. Too few cases are reported to suggest neurosurgical intervention for blastomycosis improves outcomes. Medical management was relatively standard with azole and amphotericin therapy.

Open access

Yuji Dekita, Yushin Takemoto, Kazutaka Ozono, Tadashi Hamasaki, Rin Yamada, Yoshiki Mikami, Jun-ichiro Kuroda, Nobuyuki Tsubota, and Akitake Mukasa

BACKGROUND

Intracranial cystic lesions are often a trigger for epileptic seizures. However, there has never been a report of a cystic lesion lined with fallopian tube-type epithelium.

OBSERVATIONS

A 48-year-old female presented with a cystic lesion in the right occipital lobe, which gradually grew over 8 years. Right occipital lobe epilepsy was diagnosed based on visual aura, convulsive seizures, and electroencephalogram findings and the cyst was surgically removed. Further examination revealed the cyst was lined with ciliated cells, which had morphological and immunohistochemical features similar to those of fallopian tube epithelium.

LESSONS

The characteristics of the cyst did not conform to any known types of benign cystic lesion. To the authors’ knowledge, no such cyst has been reported before. The authors discuss the origins and pathogenesis of this unfamiliar cystic lesion.

Open access

Nicholas T. Gamboa, Christopher Wilkerson, Bornali Kundu, Brandon A. Sherrod, Andrew T. Dailey, and William T. Couldwell

BACKGROUND

Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment.

OBSERVATIONS

The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion.

LESSONS

This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.

Open access

Nina Srour, Audrey Demand, Yi Zhang, William Musick, Annette Lista, and Jiejian Lin

BACKGROUND

Fusobacterium spp. are strictly anaerobic microorganisms and normal flora of the oropharyngeal, gastrointestinal, and female genital tracts. It is commonly associated with periodontal disease, pharyngitis, mastoiditis, and tonsillitis, with a tendency to abscess formation.

OBSERVATIONS

The authors report a case of brain abscesses complicated by ventriculitis and obstructive hydrocephalus caused by Fusobacterium nucleatum of suspected odontogenic source. While repeated bacterial cultures remained negative, the isolate was identified using bacterial sequencing.

LESSONS

Empirical antimicrobial coverage for F. nucleatum should be considered in patients presenting with brain abscess. Genetic bacterial sequencing utilizing 16S ribosomal RNA molecular diagnostic testing may assist in microorganism identification to guide antimicrobial therapy.

Open access

Jessica Y. Tong, James Slattery, Nick Vrodos, and Dinesh Selva

BACKGROUND

This study describes a transorbital apical approach to the cavernous sinus, where the greater wing of sphenoid (GWS) and superior orbital fissure (SOF) are drilled out to access the interdural incision zone and lateral wall of the cavernous sinus.

OBSERVATIONS

This was a retrospective series of 3 patients with periocular squamous cell carcinoma (SCC) and radiological evidence of perineural spread to the cavernous sinus. Following an orbital exenteration, the GWS was drilled to reach the lateral border of the SOF. The meningo-orbital band, a periosteal transition between the frontotemporal basal dura and periorbita, was incised to enter the lateral wall of the cavernous sinus. The relevant cranial nerves were biopsied to provide an accurate zonal classification of disease.

LESSONS

The transorbital apical approach via the SOF provides a corridor of access to the cranial nerves within the lateral wall of the cavernous sinus. This technique was successfully performed on 3 patients with periocular SCC. One case had radiological evidence of intracavernous oculomotor nerve involvement, 1 patient demonstrated nasociliary nerve enlargement at the SOF, and another had frontal nerve involvement extending into the cavernous sinus. Cerebrospinal fluid leak occurred in 1 case addressed with fat packing and fascial closure.

Open access

Laura-Nanna Lohkamp, Stephanie Holowka, Elysa Widjaja, Arbelle Manicat-Emo, and James T. Rutka

BACKGROUND

Transorbital penetrating head injuries (PHIs) are uncommon but can lead to substantial deficits, depending on intracranial involvement and the neuroanatomical structures affected. Complete recovery after such injuries is rare.

OBSERVATIONS

A 7-year-old boy sustained a PHI when he fell onto a garden spike while climbing a fence. Initial imaging showed an orbital roof fracture, focal subarachnoid hemorrhage, and an intraparenchymal hemorrhage in the right frontal lobe with associated linear tract extending to the contralateral superior temporal gyrus. Relevant neuroanatomical structures, including the anterior cerebral arteries (ACAs) and the basal ganglia, were spared. This is in keeping with superior transorbital PHI caused by a garden spike, which had transgressed the skull entering from the right superior orbit. Clinically, he experienced some transient right-sided weakness and mild speech disturbance. Some questionable vasospasm of the ACAs observed on interim magnetic resonance imaging was absent in a repeat imaging study, followed by an unremarkable radiographic follow-up at 6 months after injury. At 18 months after injury, he is neurologically intact without deficit.

LESSONS

Most PHIs bear serious lifelong consequences, but here was a case of a deep, penetrating object that managed to avoid all significant neuroanatomical pathways, leading to complete recovery in follow-up.