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Open access

Neurocysticercosis of the third ventricle: illustrative case

John Choi, Grace Cullen, Dawn Darbonne, Dennis Adams, Christina Coyle, Joseph Cooper, and Harminder Singh

BACKGROUND

Neurocysticercosis is a parasitic infection of the central nervous system. Cysts located in the ventricles, intraventricular neurocysticercosis (IVNCC), can cause symptoms of increased intracranial pressure and, if untreated, can be fatal. Neuroendoscopic removal of IVNCC is recommended as the first-line treatment.

OBSERVATIONS

The authors present the case of a healthy 30-year-old male originally from Mexico who presented with headaches and vomiting. He was found to have a cyst in the third ventricle on imaging, consistent with IVNCC. The authors successfully performed neuroendoscopic surgery with removal of the cyst en bloc.

LESSONS

A multidisciplinary team of neurosurgery and infectious disease specialists is recommended for successful management of patients with IVNCC. These patients typically require neuroendoscopic surgical removal for definitive treatment. In this case, the authors show surgery resulted in an effective cure without the need for antiparasitic medication and excellent long-term outcomes.

Open access

Immunocompetent isolated cerebral mucormycosis presenting with obstructive hydrocephalus: illustrative case

Khoa N Nguyen, Lindsey M Freeman, Timothy H Ung, Steven Ojemann, and Fabio Grassia

BACKGROUND

Isolated cerebral mucormycosis is rare in immunocompetent adults and is only sparsely reported to be associated with obstructive hydrocephalus.

OBSERVATIONS

Here, the authors report a case of obstructive hydrocephalus secondary to central nervous system mucormycosis without other systems or rhino-orbital involvement and its technical surgical management. A 23-year-old, incarcerated, immunocompetent patient with history of intravenous (IV) drug use presented with syncope. Although clinical and radiographic findings failed to elucidate an infectious pathology, endoscopy revealed an obstructive mass lesion at the level of the third ventricle, which, on microbiological testing, was confirmed to be Rhizopus fungal ventriculitis. Perioperative cerebrospinal fluid diversion, endoscopic third ventriculostomy, endoscopic biopsy technique, patient outcomes, and the literature are reviewed here. The patient received intrathecal and IV amphotericin B followed by a course of oral antifungal treatment and currently remains in remission.

LESSONS

The patient’s unique presentation and diagnosis of isolated cerebral mucormycosis reveal this pathogen as a cause of ventriculitis and obstructive hydrocephalus in immunocompetent adult patients, even in the absence of infectious sequelae on neuroimaging.

Open access

Endoscopic third ventriculostomy in hydrocephalus patients with functioning ventriculoperitoneal shunts: challenging the dictum that shunts treat all types of hydrocephalus. Patient series

Gersham J Rainone, Cody Woodhouse, Dallas Kramer, Shahed Elhamdani, and Jody Leonardo

BACKGROUND

Although ventriculoperitoneal shunting is standard for hydrocephalus, shunting may not be ideal for aqueductal stenosis. A cohort of patients with aqueductal stenosis displayed symptoms of over- and underdrainage, despite a patent ventriculoperitoneal shunt (VPS) and optimized valve settings. Endoscopic third ventriculostomies (ETVs) were performed in a subset of these patients with successful treatment of their underlying hydrocephalus, despite a functioning shunt.

OBSERVATIONS

All patients who had undergone ETV with a history of ventriculoperitoneal shunting were retrospectively reviewed. Patients experiencing over- or underdrainage symptoms despite a patent shunt were included. Cerebral aqueduct anatomy and third ventricle bowing were reviewed on preoperative imaging. Seven patients met the study criteria. All showed cerebral aqueductal stenosis and third ventricle bowing. After ETV, all patients demonstrated decreased third ventricle bowing and clinical improvement without the need for secondary cerebrospinal fluid (CSF) diversion.

LESSONS

Despite a functioning VPS, patients with aqueductal stenosis may not be adequately treated. The underlying reasons are not clearly understood but suggest abnormal CSF dynamics due to aberrant parenchymal compliance. The authors theorize that ETV can more effectively treat these patients. ETV can be considered a viable treatment option in aqueductal stenosis despite a patent VPS, challenging the traditional teaching that shunts ideally treat all types of hydrocephalus.

Open access

Bifocal germ cell tumor of pineal germinoma and neurohypophyseal embryonal carcinoma: illustrative case

Yu Naruse, Shinya Jinguji, Ryo Hiruta, Ayako Toda, Kenichiro Nagai, Shingo Kudo, Hideki Sano, Rei Sekine, Osamu Suzuki, Mudathir Bakhit, and Masazumi Fujii

BACKGROUND

Bifocal germ cell tumors, with primarily identical tissue composition, occur concurrently in the neurohypophyseal and pineal regions.

OBSERVATIONS

A 16-year-old male patient exhibited increased intracranial pressure symptoms, with concurrent tumors in the pineal and neurohypophyseal regions, causing obstructive hydrocephalus. His serum human chorionic gonadotropin level was elevated, measuring 506.6 mIU/mL. Upon gross endoscopic examination, the pineal tumor appeared white, whereas the neurohypophyseal tumor appeared red and hemorrhagic. Because of the limited sample size of the latter, a frozen section biopsy was feasible only for the pineal lesion, which indicated the presence of a germinoma. Subsequently, carboplatin and etoposide were administered, resulting in the reduction of the pineal tumor, but no effect was observed in the neurohypophyseal tumor. Histopathological analysis confirmed the pineal lesion as a germinoma, whereas the neurohypophyseal lesion was an embryonal carcinoma. Thus, the treatment was altered to ifosfamide, carboplatin, and etoposide (ICE), leading to a response in both tumors. The patient underwent three additional cycles of ICE therapy and high-dose chemotherapy, followed by whole craniospinal irradiation, achieving complete remission.

LESSONS

Although most bifocal germ cell tumors share the same histological tissue, occasional differences may arise, necessitating separate biopsies for accurate assessment.

Open access

Management of shunt dysfunction using noninvasive intracranial pressure waveform monitoring: illustrative case

Raphael Bertani, Caio Perret, Stefan Koester, Paulo Santa Maria, Savio Batista, Sophia de Andrade Cavicchioli, Sany Tomomi de Almeida Rocha Arita, Ruy Monteiro, Gianne Lucchesi, Fernando Augusto Vasconcellos, Matheus Miranda, Wellingson Silva Paiva, and Fernando Gomes Pinto

BACKGROUND

Normal pressure hydrocephalus (NPH) treatment consists of using valves for drainage, as it is for hydrocephalus in general. Despite this, complications can occur, putting the patient at risk, and neurological monitoring is crucial.

OBSERVATIONS

A 61-year-old male, who had been diagnosed with NPH 3 years prior and was being treated with a ventriculoperitoneal shunt with a programmable valve, presented to the emergency department because of a traumatic brain injury due to a fall from standing height. No previous complications were reported. He had an altered intracranial pressure (ICP) waveform in the emergency room when monitored with the brain4care device, with a P2/P1 ratio of 1.6. Imaging helped to confirm shunt dysfunction. Revision surgery normalized the ratio to 1.0, and the patient was discharged. Upon return after 14 days, an outpatient analysis revealed a ratio of 0.6, indicating improvement.

LESSONS

In selected cases of NPH, noninvasive ICP waveform morphology analysis can be effective as a diagnostic aid, as well as in the pre- and postsurgical follow-up, given the possibility of comparing the values of ICP preoperatively and immediately postoperatively and the outpatient P2/P1 ratio, helping to manage these patients.

Open access

Enlarged tumefactive perivascular, or Virchow-Robin, spaces and hydrocephalus: do we need to treat? Illustrative cases

Belal Neyazi, Vanessa Magdalena Swiatek, Klaus-Peter Stein, Karl Hartmann, Ali Rashidi, Seraphine Zubel, Amir Amini, and I. Erol Sandalcioglu

BACKGROUND

Perivascular spaces (PVSs) are spaces in brain parenchyma filled with interstitial fluid surrounding small cerebral vessels. Massive enlargements of PVSs are referred to as “giant tumefactive perivascular spaces” (GTPVSs), which can be classified into three types depending on their localization. These lesions are rare, predominantly asymptomatic, and often initially misinterpreted as cystic tumor formations. However, there are several reported cases in which GTPVSs have induced neurological symptoms because of their size, mass effect, and location, ultimately leading to obstructive hydrocephalus necessitating neurosurgical intervention. Presented here are three diverse clinical presentations of GTPVS.

OBSERVATIONS

Here, the authors observed an asymptomatic case of type 1 GTPVS and two symptomatic cases of type 3 GTPVS, one causing local mass effect and the other hydrocephalus.

LESSONS

GTPVSs are mostly asymptomatic lesions. Patients without symptoms should be closely monitored, and biopsy is discouraged. Hydrocephalus resulting from GTPVS necessitates surgical intervention. In these cases, third ventriculostomy, shunt implantation, or direct cyst fenestration are surgical options. For patients presenting with symptoms from localized mass effect, a thorough evaluation for potential neurosurgical intervention is imperative. Follow-up in type 3 GTPVS is recommended, particularly in untreated cases. Given the infrequency of GTPVS, definitive guidelines for neurosurgical treatment and subsequent follow-up remain elusive.

Open access

BRAF-mutated suprasellar glioblastoma mimicking craniopharyngioma: illustrative case

Bryan Zheng, Belinda Shao, Jennifer Mingrino, Jonathan Poggi, Richard S Dowd, Douglas C Anthony, John E Donahue, and Curtis E Doberstein

BACKGROUND

Suprasellar masses commonly include craniopharyngiomas and pituitary adenomas. Suprasellar glioblastoma is exceedingly rare with only a few prior case reports in the literature. Suprasellar glioblastoma can mimic craniopharyngioma or other more common suprasellar etiologies preoperatively.

OBSERVATIONS

A 65-year-old male with no significant history presented to the emergency department with a subacute decline in mental status. Work-up revealed a large suprasellar mass with extension to the right inferior medial frontal lobe and right lateral ventricle, associated with significant vasogenic edema. The patient underwent an interhemispheric transcallosal approach subtotal resection of the interventricular portion of the mass. Pathological analysis revealed glioblastoma, MGMT partially methylated, with a BRAF V600E mutation.

LESSONS

Malignant glioblastomas can mimic benign suprasellar masses and should remain on the differential for a diverse set of brain masses with a broad range of radiological and clinical features. For complex cases accessible from the ventricle where the pituitary complex cannot be confidently preserved via a transsphenoidal approach, an interhemispheric approach is also a practical initial surgical option. In addition to providing diagnostic value, molecular profiling may also reveal therapeutically significant gene alterations such as BRAF mutations.

Open access

Approaches to ventriculoperitoneal shunt scalp erosion: countersinking into the calvarium. Illustrative case

Denise Brunozzi, Melissa A LoPresti, Jennifer L McGrath, and Tord D Alden

BACKGROUND

Ventriculoperitoneal shunting (VPS) is a standard procedure for the treatment of hydrocephalus, and the management of its complications is common in the practice of pediatric neurosurgery. Shunt exposure, though a rare complication, can occur because of thin, fragile skin, a young patient age, protuberant hardware, poor scalp perfusion, and a multitude of other patient factors.

OBSERVATIONS

The authors report a complex case of VPS erosion through the scalp in a young female with Pfeiffer syndrome treated with external ventricular drainage, empirical antibiotics, and reinternalization with countersinking of replaced shunt hardware into the calvarium to prevent internal skin pressure points, reduce wound tension, and allow wound healing.

LESSONS

Recessing the shunt hardware, or countersinking the implant, into the calvarium is a simple technique often used in functional neurosurgical implantation surgeries, providing a safe surgical strategy to optimize wound healing in select cases in which the skin flap is unfavorable.

Open access

Can we build better? Challenges with geospatial and financial accessibility in the Caribbean. Illustrative case

Ellianne J dos Santos Rubio, Chrystal Calderon, Annegien Boeykens, and Kee B Park

BACKGROUND

Within the Caribbean, Curaçao provides a neurosurgical hub to other Dutch Caribbean islands. At times, the inefficiency of neurosurgical referrals leads to unsatisfactory patient outcomes in true emergency cases.

OBSERVATIONS

This article reports an illustrative case of a patient in need of emergency neurosurgical care, who was referred to a tertiary health institution in Curaçao. This case highlights the challenges of timely neurosurgical referrals within the Dutch Caribbean.

LESSONS

Highlighting this case may provide a foundation for further discussions that may improve neurosurgical care and access. Limiting long-distance surgical referrals in the acute care setting will aid in saving lives.

Open access

Endoscopic placement of a triventricular stent for complex hydrocephalus and isolated fourth ventricle: illustrative case

V. Jane Horak, Beste Gulsuna, Melissa A LoPresti, and Michael DeCuypere

BACKGROUND

Hydrocephalus is commonly encountered in pediatric neurosurgery. The etiology is diverse, and complexity in management increases in patients with loculated or trapped ventricles. The authors sought to examine a treatment option of endoscopic placement of a triventricular stent in a pediatric patient with complex hydrocephalus and a trapped fourth ventricle.

OBSERVATIONS

In this case, the authors present the treatment of complex hydrocephalus with a trapped fourth ventricle in a pediatric patient using endoscopic placement of a triventricular aqueductal stent. The patient had a complex neurosurgical history, which included over 15 surgeries for shunted hydrocephalus. This case highlights the unique approach used, and the authors discuss surgical nuances of the technique, as well as learning points.

LESSONS

Complex hydrocephalus can be difficult to manage because patients often have multiple catheters, loculated or trapped ventricles, and extensive surgical histories. Endoscopic placement of a triventricular stent can decrease shunt system complexity, restore normal cerebrospinal fluid pathway circulation across the cerebral aqueduct, and promote communication between the ventricles. The authors’ treatment modality resulted in the successful resolution of the trapped fourth ventricle and symptomatic improvement in hydrocephalus.