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Open access

Delayed symptomatic cerebral vasospasm following vestibular schwannoma resection: illustrative case

Paurush Pasricha, Alay V Khandhar, and Basant K Misra

BACKGROUND

Symptomatic cerebral vasospasm following posterior fossa extraaxial tumor resection is a rare phenomenon, with only 13 cases previously reported in the literature. The condition appears similar to vasospasm following supratentorial tumor resection, intraaxial posterior fossa tumor resection, and aneurysmal subarachnoid hemorrhage (aSAH). The majority of patients were not evaluated for vasospasm prior to symptom onset, leading to a delay in diagnosis.

OBSERVATIONS

The authors present their experience in a 56-year-old female who developed delayed cerebral vasospasm after excision of a solid-cystic vestibular schwannoma. Routine postoperative brain computed tomography showed evidence of subarachnoid hemorrhage in the basal cisterns. She was discharged on the 9th postoperative day. On the 11th day after tumor excision, she developed left hemiparesis, dysarthria, and dysphagia and was readmitted. Angiography confirmed bilateral diffuse cerebral vasospasm. The patient responded to standard hyperdynamic therapy used for vasospasm secondary to aSAH.

LESSONS

Symptomatic distant cerebral vasospasm after posterior fossa extraaxial tumor excision is a rare but challenging complication with a very high morbidity rate in reported cases. A high index of suspicion is required for early diagnosis and prompt management for a favorable outcome.

Open access

Management of a challenging dura-embedded anterior inferior cerebellar artery loop during a retrosigmoid hearing-preserving vestibular schwannoma resection: microsurgical technique and operative video. Illustrative case

Jaime L. Martínez Santos, Robert C. Sterner, and Mustafa K. Başkaya

BACKGROUND

Anatomical variants of the anterior inferior cerebellar artery (AICA), such as an anomalous “AICA loop” embedded in the dura and bone of the subarcuate fossa, increase the complexity and risk of vestibular schwannoma resections. Classically, osseous penetrating AICA loops are the most challenging to mobilize, as the dura must be dissected and the surrounding petrous bone must be drilled to mobilize the AICA away from the surgical corridor and out of harm.

OBSERVATIONS

The authors present a rare case of a dura-embedded, osseous-penetrating AICA loop encountered during a hearing-preserving retrosigmoid approach in which they demonstrate safe and efficient microdissection and mobilization of the AICA loop without having to drill the surrounding bone.

LESSONS

Although preoperative recognition of potentially dangerous AICA loops has been challenging, thin-sliced petrous bone computed tomography scanning and high-quality magnetic resonance imaging can be useful in preoperative diagnosis. Furthermore, this report suggests that a retrosigmoid approach is superior, as it allows early intradural recognition and proximal vascular control and facilitates more versatile mobilization of AICA loops.

Open access

Ondine’s curse: clinical presentation with diaphragmatic pacing and spontaneous respiratory recovery. Illustrative case

Alexander J. Schupper, Alex Devarajan, Dong-Seok Lee, Enrique Perez, and Raj K. Shrivastava

BACKGROUND

The complexity of posterior fossa surgery can often lead to rare complications due to the anatomy involved. Vestibular schwannoma resection is a common pathology in the posterior fossa, often requiring surgical intervention. Given the proximity of this space to the brainstem, cranial nerve VII/VIII complex, and posterior inferior cerebellar artery (PICA), neurovascular complications are not infrequent. A rare vascular complication from this surgical approach is a lateral medullary infarction from injury to the lateral medullary segment of the proximal PICA, leading to central hypoventilation syndrome (CHS).

OBSERVATIONS

This report presents a unique case of a 51-year-old man who underwent a retrosigmoid craniectomy for resection of a vestibular schwannoma. Following surgery, the patient was unable to be weaned off the ventilator and was noted to become apneic while he slept, a clinical picture consistent with Ondine’s curse.

LESSONS

This report discusses the anatomical considerations of this surgical corridor leading to this complication and the management of a patient with acquired Ondine’s curse and reviews the scarce literature on this uncommon cause of acquired CHS.

Open access

Delayed motor weakness following peripheral nerve schwannoma resection: illustrative cases

Rohin Singh and Robert J. Spinner

BACKGROUND

Delayed facial palsy (DFP) after vestibular schwannoma resection is a well-documented, yet poorly understood condition. The exact pathophysiological mechanisms of DFP are unknown, although diminished intraoperative nerve response has been shown to be a prognostic factor. To date, no such condition has been described in regard to peripheral nerve schwannomas.

OBSERVATIONS

Here the authors present the first reported cases of delayed motor weakness (DMW) after peripheral schwannoma resection of the ulnar nerve at the elbow and peroneal nerve in the popliteal fossa. Both patients presented with a mass lesion and radiating paresthesias and had normal motor function preoperatively. Immediately after surgical resection, the patients had full strength. Within 24 hours, both patients exhibited marked weakness that gradually resolved over the course of several weeks.

LESSONS

DMW after peripheral schwannoma resection is a rare condition likely akin to delayed facial nerve palsy after VS resection. The mechanism of this phenomenon remains unknown, although symptoms appear to self-resolve with time. A better understanding of the processes driving this condition may allow for therapies that can expedite and improve long-term outcomes.

Open access

Pial brainstem artery arteriovenous malformation with flow-related intracanalicular aneurysm masquerading as vestibular schwannoma: illustrative case

David D. Liu, David B. Kurland, Aryan Ali, John G. Golfinos, Erez Nossek, and Howard A. Riina

BACKGROUND

Lesions of the internal auditory canal presenting with partial hearing loss are almost always vestibular schwannomas (VSs). Intracanalicular anterior inferior cerebellar artery (AICA) aneurysms are extremely rare but can mimic VS based on symptoms and imaging. The authors report the case of a flow-related intracanalicular AICA aneurysm from a pial brainstem arteriovenous malformation (AVM) masquerading as VS.

OBSERVATIONS

A 57-year-old male with partial left-sided hearing loss and an intracanalicular enhancing lesion was initially diagnosed with VS and managed conservatively at an outside institution with surveillance imaging over 3 years. When he was referred for VS follow-up, new imaging raised radiological suspicion for vascular pathology. Cerebral angiography revealed a small pial AVM located at the trigeminal root entry zone with an associated flow-related intracanalicular AICA aneurysm. The AVM was obliterated with open surgery, during which intraoperative angiography confirmed no AVM filling, preservation of the AICA, and no further aneurysm filling.

LESSONS

Intracanalicular AICA aneurysms and other lesions, including cavernous malformations, can mimic radiographic features of VS and present with hearing loss or facial weakness. Modern vascular neurosurgical techniques such as endovascular intervention and open surgery in a hybrid operating room allowed definitive management of both lesions without untoward morbidity.

Open access

Herpes simplex meningitis after vestibular schwannoma surgery: illustrative case

Leonidas Trakolis, Georgios Naros, Vassilios Vougioukas, and Marcos Tatagiba

BACKGROUND

Herpes is the most common cause of viral encephalitis in the young population. Herpes meningitis following brain surgery is very rare, however. Only a few cases are reported in the literature, and only one concerned an infection after vestibular schwannoma surgery.

OBSERVATIONS

The authors report a case of a 44-year-old patient who developed severe herpes meningitis a few days after removal of a large cystic vestibular schwannoma.

LESSONS

Herpes simplex virus meningitis following a posterior fossa surgery must be considered when patients develop atypical symptoms a few days after surgery.