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Open access

Preoperative examination and intraoperative cerebrospinal fluid leakage test for minimally invasive surgery of spinal extradural arachnoid cysts: illustrative case

Yoshihiro Sunada, Kenji Yagi, Yoshifumi Tao, Hirotake Nishimura, and Tomohito Hishikawa

BACKGROUND

Spinal extradural arachnoid cysts (SEACs) are rare and can cause spinal dysfunction. Total cyst removal and duraplasty via multiple laminectomies are commonly performed. However, to avoid postoperative spinal deformity and axial pain, a minimally invasive surgery via selective laminectomy may be optimal. Therefore, preoperative detection of the dural fistula site is required.

OBSERVATIONS

A 25-year-old male presented with a 2-month history of progressive gait disturbance and back pain. Conventional magnetic resonance imaging (MRI) revealed SEACs at the T9 to L2 level but did not reveal the dural fistula. Further examinations were performed using sagittal time-spatial labeling inversion pulse MRI and cone-beam computed tomography myelography with a spinal intrathecal catheter, which indicated a dural fistula on the left side at the T12 level. On the basis of these results, dural repair was performed via selective laminectomy. Furthermore, an intraoperative cerebrospinal fluid leakage test by intrathecally injecting saline via a spinal catheter confirmed complete closure of the dural fistula, with no other fistulas.

LESSONS

These comprehensive pre and intraoperative examinations may be useful for minimally invasive and selective surgeries in patients with SEACs.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 21 (Nov 2023)

Open access

Spinal metastases of pineal region glioblastoma with primitive neuroectodermal features highlighting the importance of molecular diagnoses: illustrative case

Aaryan Shah, Neelan J Marianayagam, Aroosa Zamarud, David J Park, Amit R Persad, Scott G Soltys, Steven D Chang, and Anand Veeravagu

BACKGROUND

Glioblastoma (GBM) is the most common primary brain tumor with poor patient prognosis. Spinal leptomeningeal metastasis has been rarely reported, with long intervals between the initial discovery of the primary tumor in the brain and eventual spine metastasis.

OBSERVATIONS

Here, the authors present the case of a 51-year-old male presenting with 7 days of severe headache, nausea, and vomiting. Magnetic resonance imaging of the brain and spine demonstrated a contrast-enhancing mass in the pineal region, along with spinal metastases to T8, T12, and L5. Initial frozen-section diagnosis led to the treatment strategy for medulloblastoma, but further molecular analysis revealed characteristics of isocitrate dehydrogenase–wild type, grade 4 GBM.

LESSONS

Glioblastoma has the potential to show metastatic spread at the time of diagnosis. Spinal imaging should be considered in patients with clinical suspicion of leptomeningeal spread. Furthermore, molecular analysis should be confirmed following pathological diagnosis to fine-tune treatment strategies.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 20 (Nov 2023)

Open access

Combined endoscopic and microsurgical approach for the drainage of a multisegmental thoracolumbar epidural abscess: illustrative case

Vincent Hagel, Felix Dymel, Stephan Werle, Vera Barrera, and Mazda Farshad

BACKGROUND

Spinal epidural abscess is a rare but serious infectious disease that can rapidly develop into a life-threatening condition. Therefore, the appropriate treatment is indispensable. Although conservative treatment is justifiable in certain cases, surgical treatment needs to be considered as an alternative early on because of complications such as (progressive) neurological deficits or sepsis. However, traditional surgical techniques usually include destructive approaches up to (multilevel) laminectomies. Such excessive approaches do have biomechanical effects potentially affecting the long-term outcomes. Therefore, minimally invasive approaches have been described as alternative strategies, including endoscopic approaches.

OBSERVATIONS

The authors describe a surgical technique involving a combination of two minimally invasive approaches (endoscopic and microsurgical) to drain a multisegmental (thoracolumbar) abscess using the physical phenomenon of continuous pressure difference to minimize collateral tissue damage.

LESSONS

The combination of minimally invasive approaches, including the endoscopic technique, may be an alternative in draining selected epidural abscesses while achieving a similar amount of abscess removal and causing less collateral approach damage in comparison with more traditional techniques.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 19 (Nov 2023)

Open access

Middle meningeal artery pseudoaneurysm and pterygoid plexus fistula following percutaneous radiofrequency rhizotomy: illustrative case

Rahim Ismail, Derrek Schartz, Timothy Hoang, and Alexander Kessler

BACKGROUND

Percutaneous treatment for trigeminal neuralgia is a safe and effective therapeutic methodology and can be accomplished in the form of balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation. These procedures are generally well tolerated and demonstrate minimal associated morbidity. Moreover, vascular complications of these procedures are exceedingly rare.

OBSERVATIONS

We present the case of a 64-year-old female with prior microvascular decompression and balloon rhizotomy who presented after symptom recurrence and underwent a second balloon rhizotomy at our institution. Soon thereafter, she presented with pulsatile tinnitus and a right preauricular bruit on physical examination. Subsequent imaging revealed a middle meningeal artery (MMA) to pterygoid plexus fistula and an MMA pseudoaneurysm. Coil and Onxy embolization were used to manage the pseudoaneurysm and fistula.

LESSONS

This case illustrates the potential for MMA pseudoaneurysm formation as a complication of percutaneous trigeminal balloon rhizotomy, which has not been seen in the literature. Concurrent MMA-pterygoid plexus fistula is also a rarity demonstrated in this case.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 19 (Nov 2023)

Open access

Awake resection of recurrent astroblastoma with intraoperative 5-ALA–induced fluorescence: illustrative case

Anthony Price, Sean O’Leary, Kseniia Malkova, Preston D’Souza, Christian Ogasawara, Michelle M Felicella, and Patrick J Karas

BACKGROUND

Astroblastoma is a rare neoplasm characterized as a circumscribed glial neoplasm most often arising in the frontoparietal cerebral hemispheres in older children.

OBSERVATIONS

We report an intriguing case of an astroblastoma recurrence 21 years after gross-total resection and radiation. A 32-year-old right-handed female presented to the emergency department for a generalized tonic-clonic seizure. She had a history of bipolar disorder, intractable migraines, and prior seizures linked to an astroblastoma previously resected three times. Magnetic resonance imaging on the current visit showed growth of the recurrent lesion to a 3.8-cm maximal diameter. Left-sided awake craniotomy was performed to remove the tumor while using speech mapping and 5-aminolevulinic acid (5-ALA). Targeted next-generation sequencing of the tumor revealed in-frame MN1::BEND2 fusion transcripts.

LESSONS

We found that 5-ALA can be used in astroblastoma patients to assist in gross-total resection, which is important for long-term survival. Our astroblastoma case demonstrated classic astroblastoma morphology, with typical perivascular astroblastic rosettes, and was brightly fluorescent after 5-ALA administration.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 18 (Oct 2023)

Open access

Transvenous embolization for an intraosseous clival arteriovenous fistula via a proper access route guiding a three-dimensional fusion image: illustrative case

Yu Iida, Jun Suenaga, Nobuyuki Shimizu, Kaoru Shizawa, Ryosuke Suzuki, Shigeta Miyake, Taisuke Akimoto, Satoshi Hori, Kensuke Tateishi, Yasunobu Nakai, and Tetsuya Yamamoto

BACKGROUND

Intraosseous clival arteriovenous fistulas (AVFs), in which the shunt drains extracranially from the posterior and anterior condylar veins rather than from the cavernous sinus (CS), are rare. Targeting embolization of an intraosseous clival AVF is challenging because of its complex venous and skull base anatomy; therefore, a therapeutic strategy based on detailed preoperative radiological findings is required to achieve a favorable outcome. Here, the authors report the successful targeted embolization of an intraosseous clival AVF using an ingenious access route.

OBSERVATIONS

A 74-year-old woman presented with left-sided visual impairment, oculomotor nerve palsy, and right facial pain. A fusion image of three-dimensional rotational angiography and cone-beam computed tomography revealed a left CS dural AVF and a right intraosseous clival AVF. The shunt flow of the clival AVF drained extracranially from the posterior and anterior condylar veins via the intraosseous venous route. Transvenous embolization was performed by devising suboccipital, posterior condylar, and intraosseous access routes. The symptoms resolved after the bilateral AVFs were treated.

LESSONS

Accurate diagnosis and proper transvenous access based on detailed intraosseous and craniocervical venous information obtained from advanced imaging modalities are key to resolving intraosseous clival AVF.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 18 (Oct 2023)

Open access

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case

Shin Nemoto, Takuma Maeda, Keiichi Yamashita, Taro Yanagawa, Masataka Torii, Masaru Kiyomoto, Masaki Tanaka, Eishi Sato, Yoichi Harada, Toru Hatayama, Takuji Kono, and Hiroki Kurita

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature.

OBSERVATIONS

A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient’s blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0.

LESSONS

This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 17 (Oct 2023)

Open access

Symptomatic radionecrosis after postoperative but not preoperative stereotactic radiosurgery in a single patient: illustrative case

Bryce J Laurin, Michael Straza, George Noid, Jennifer M Connelly, Wade M Mueller, Joseph Bovi, and Max O Krucoff

BACKGROUND

Standard of care for brain metastases involves stereotactic radiosurgery (SRS). For cases that also require surgery because of lesion size, edema, or neurological symptoms, whether to provide pre- or postoperative SRS has become a prevalent debate.

OBSERVATIONS

Herein, the unique case of a patient with brain metastases of the same pathology and similar size in two different brain locations at two different times is described. The patient underwent surgery with preoperative SRS for the first lesion and surgery with postoperative SRS for the second lesion. Although both treatments resulted in successful local control, the location that received postoperative SRS developed symptomatic and rapidly progressive radiation necrosis (RN) requiring a third craniotomy.

LESSONS

Large randomized controlled trials are ongoing to compare pre- versus postoperative SRS for the treatment of symptomatic brain metastases (e.g., study NRG-BN012). Recent interest in preoperative SRS has emerged from its theoretical potential to decrease rates of postoperative RN and leptomeningeal disease. This valuable case in which both therapies were applied in a single patient with a single pathology and similar lesions provides evidence supportive of preoperative SRS.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 16 (Oct 2023)

Open access

Microsurgical resection of a ruptured intraventricular arteriovenous malformation in a neonate: considerations in management. Illustrative case

Lauren Stone, Reid Colliander, Melissa A LoPresti, Ali Shaibani, and Sandi Lam

BACKGROUND

Arteriovenous malformations (AVMs) are the most common cause of intracranial hemorrhage in children, although they are rarer in neonates. Age, location, lesion architecture, and rupture status define treatment options. Sparse literature exists to guide the management of clinically symptomatic intraventricular AVM rupture in neonates. We highlight the case of a neonate with a ruptured intraventricular AVM to showcase considerations in treatment, discuss surgical technique, and help guide management.

OBSERVATIONS

An 18-day-old female presented with lethargy in extremis and was found to have new intraventricular hemorrhage. Angiogram revealed a Spetzler-Martin grade 2 AVM with a right posterior choroidal feeder and deep venous drainage within the ventricle. Her age limited radiosurgical and endovascular interventions. She underwent an interhemispheric, transcollosal, intraventricular approach for complete AVM resection. Perioperative care was managed by a multidisciplinary team, successfully mitigating the patient’s high risk of hemovascular collapse.

LESSONS

Stereotactic radiosurgery, endovascular embolization, and microsurgery are options for AVM obliteration, and multimodal therapy must be tailored to the lesion and patient. Conservative management can also be considered. Each intervention carries risks and varying likelihoods of success. Balancing these outcomes is challenging without definitive, high-quality, evidence-based guidance. The best treatment maximizes the chance of AVM obliteration while minimizing morbidity.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 15 (Oct 2023)

Open access

Partially thrombosed giant basilar artery aneurysm with attenuated contrast enhancement of the intraluminal thrombus on vessel wall MRI after flow diversion treatment: illustrative case

So Matsukawa, Akira Ishii, Yasutaka Fushimi, Yu Abekura, Takashi Nagahori, Takayuki Kikuchi, Masakazu Okawa, Yukihiro Yamao, Natsuhi Sasaki, Hirofumi Tsuji, Ryo Akiyama, and Susumu Miyamoto

BACKGROUND

The effect of vessel wall magnetic resonance imaging (VW-MRI) enhancement in partially thrombosed aneurysms has previously indicated aneurysmal instability and a rupture risk. However, whether the contrast effect of the wall changes before or after flow diversion treatment is still under investigation.

OBSERVATIONS

The authors report a case of a partially thrombosed basilar artery aneurysm that increased in size over a short period, worsened brainstem compression symptoms, and was treated with a flow diverter stent with good results. In this case, VW-MRI after surgery showed a reduced contrast effect on the intraluminal thrombus within the aneurysm. The aneurysm thrombosed and markedly regressed over the next 5 months, with remarkable improvement in the brainstem compression symptoms.

LESSONS

This finding on VW-MRI may indicate an attenuation of neovascularization in the thrombus wall and be a sign of aneurysm stabilization.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 14 (Oct 2023)