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Open access

Kenji Fukutome, Shuta Aketa, Junji Fukumori, Takaaki Mitsui, Tsukasa Nakajima, Hiromichi Hayami, Ryuta Matsuoka, Rinsei Tei, Yasushi Shin, and Yasushi Motoyama

BACKGROUND

Compared with several reports of cerebral vasospasm after clipping for unruptured cerebral aneurysm, only one study to date has reported cerebral vasospasm after coil embolization. Herein, the authors report a rare case of cerebral vasospasm after coil embolization for unruptured cerebral aneurysm.

OBSERVATIONS

A 58-year-old woman with an unruptured anterior communicating artery aneurysm was referred to our department. Stent-assisted coil embolization was performed for the aneurysm, and no obvious adverse events were observed on cerebral angiography obtained immediately after the operation. However, the patient developed mild headache and slight restlessness soon after the operation and new-onset disorientation, left hemispatial neglect, and left hemiplegia the day after the operation. Emergency brain magnetic resonance imaging and cerebral angiography indicated vasospasm in the right middle cerebral artery, and intra-arterial injection of fasudil hydrochloride hydrate was performed to dilate the middle cerebral artery. Blood flow in the middle cerebral artery immediately improved, and she was discharged without neurological deficits 8 days after the operation.

LESSONS

Immediate intervention is necessary to prevent cerebral infarction in patients with cerebral vasospasm, which may occur even after coil embolization for unruptured cerebral aneurysm.

Open access

Michael Y. Zhao, Phillip H. Keys, Shahin Owji, Mohammad Pakravan, Chaow Charoenkijkajorn, Peter W. Mortensen, and Andrew G. Lee

BACKGROUND

Microvascular decompression is an effective treatment strategy for trigeminal neuralgia. However, there may be inadvertent complications involving adjacent cranial nerves during or months after the operation. This case lesson highlights the potential manifestations, both optical and nonneurologic (monocular) and binocular diplopia, after microvascular decompression in two patients. Neurosurgeons should recognize monocular versus binocular causes of diplopia after neurosurgical microvascular decompression.

OBSERVATIONS

The authors reported on two patients who presented with diplopia after microvascular decompression for trigeminal neuralgia. The first patient had binocular diplopia with a paradoxical head tilt potentially due to a contiguous trochlear nerve palsy. The second patient had monocular diplopia due to dry eye syndrome from trigeminal nerve dysfunction. However, within 2 years after their operations, both patients had resolution of their diplopia without additional surgical intervention.

LESSONS

Both monocular and binocular diplopia can be presenting symptoms of cranial neuropathies after microvascular decompression for trigeminal neuralgia. Most cases of postoperative diplopia (both monocular and binocular) resolve spontaneously over time without additional neurosurgical treatment.

Open access

Durga Neupane, Alok Dahal, Nimesh Lageju, Lokesh Shekher Jaiswal, Nimesh Bista, and Aakriti Sapkota

BACKGROUND

Sacrococcygeal teratomas (SCTs) are tumors that emerge in the sacrococcygeal area and contain tissue from all three germ layers. SCT affects about 1 in every 35,000–40,000 live births, with malignant transformation becoming more common as the patient gets older. Ultrasound helps in prenatal diagnosis. Surgical resection is the mainstay of treatment.

OBSERVATIONS

A couple gave birth to a neonate with a small mass over his sacral region that progressively increased in size. Diagnostic magnetic resonance imaging was performed, and a diagnosis of giant SCT was established. Complete resection with flap reconstruction was performed. In regular follow-up, he is in a good state of health.

LESSONS

One of the most common tumors in infancy, SCT should be carefully diagnosed. SCT is often confused with neural tube defects such as myelocystocele or myelomeningocele. Complete resection with appropriate reconstruction can ensure better treatment, and close follow-up until adulthood is recommended to keep a close view on its possible recurrence and to improve prognosis. Postoperative complications such as infection, bleeding, and urethral complications should be carefully watched.

Open access

Nozomi Sasaki, Yoshinori Kotani, Yohei Ito, and Shinji Noda

BACKGROUND

Hypoperfusion due to intracranial cerebral vasospasm after carotid artery stenting (CAS) is rare. The authors presented a case of selective intraarterial infusion of fasudil hydrochloride for cerebral vasospasm after CAS.

OBSERVATIONS

A 73-year-old man received CAS for asymptomatic right cervical internal carotid artery stenosis. Twelve hours after CAS, disturbance of consciousness, left hemiplegia, and right conjugate deviation appeared in the patient. Head computed tomography angiography showed diffuse vasospasm of the right middle cerebral artery (MCA). The authors hypothesized that the cause of the symptoms was hypoperfusion due to intracranial cerebral vasospasm. Medical treatment was started; however, the focal symptoms worsened rapidly. Therefore, the authors decided to infuse fasudil intraarterially. This treatment resulted in a remarkable improvement in blood flow and gradual recovery from neurological symptoms. Head magnetic resonance angiography on the day after fasudil infusion showed improved visualization of the right MCA. The neurological symptoms almost completely disappeared 22 hours after fasudil infusion (40 hours after CAS).

LESSONS

As a complication after CAS, the possibility of hypoperfusion due to cerebral vasospasm should be considered. If symptoms due to hypoperfusion worsen even after medical treatment, intraarterial infusion of fasudil may be an effective option.

Open access

Kokoro Kamisaka, Shusuke Yamamoto, Taisuke Shiro, Emiko Hori, Daina Kashiwazaki, Naoki Akioka, and Satoshi Kuroda

BACKGROUND

Although most cases of internal carotid artery (ICA) agenesis are clinically silent due to a well-developed collateral pathway, some cases may develop ischemic symptoms when they are associated with other occlusive cerebrovascular disorders. The authors describe herein the first case with ICA agenesis that developed ischemic attack because of coincidence with moyamoya disease.

OBSERVATIONS

A 3-year-old girl was admitted to the authors’ hospital due to sudden onset of right arm weakness followed by clonic convulsion. Skull computed tomography could not identify the carotid canal on the left side. Simultaneously, magnetic resonance (MR) imaging and MR angiography demonstrated the luminal stenosis and outer diameter reduction of the carotid fork and posterior cerebral artery on the left side. She was diagnosed with unilateral moyamoya disease associated with ipsilateral ICA agenesis. She successfully underwent combined bypass surgery on the left side and has been free from any cerebrovascular events during a follow-up period of 6 months.

LESSONS

When patients with ICA agenesis develop ischemic symptoms, careful investigation of the cause and appropriate care, including surgical treatment, are required.

Open access

Tsuyoshi Izumo, Michiharu Yoshida, Kazuaki Okamura, Ryotaro Takahira, Eisaku Sadakata, Susumu Yamaguchi, Shiro Baba, Yoichi Morofuji, Takeshi Hiu, Takeo Anda, and Takayuki Matsuo

BACKGROUND

Intraoperative indocyanine green video angiography (ICG-VA) is useful for determining the extent of lesion removal during cerebral arteriovenous malformation (AVM) surgery. The authors described a case of surgical removal of an AVM presenting with early venous filling mimicking a residual nidus on intraoperative ICG-VA.

OBSERVATIONS

A 7-year-old girl experienced a sudden disturbance of consciousness. Computed tomography revealed right frontal intracerebral hemorrhage. Digital subtraction angiography showed a Spetzler-Martin grade 1 AVM in the right frontal lobe. The patient received surgical removal of the AVM after endovascular embolization. After removal of the nidus, the first intraoperative ICG-VA revealed early venous filling of the cortex around the excision cavity. Additional resection of the cortex around this area was performed. Histopathological examination of the lesion revealed a dilated normal vascular structure without an AVM.

LESSONS

Early venous filling in the surrounding brain tissue after AVM removal does not necessarily indicate a residual nidus. The need for additional resection of the lesion depends on the eloquence of the area.

Open access

William S. Dodd, Dimitri Laurent, Brandon Lucke-Wold, Katharina M. Busl, Eric Williams, and Brian L. Hoh

BACKGROUND

Recognizing rare signs of delayed cerebral ischemia (DCI) is crucial to caring for patients with subarachnoid hemorrhage. The authors presented a case of central hearing loss that occurred during the clinical course of a patient treated for aneurysmal subarachnoid hemorrhage.

OBSERVATIONS

The patient had a ruptured right posterior communicating artery aneurysm successfully treated with coil embolization but later developed severe vasospasm and DCI. She developed bilateral hearing loss, and imaging revealed DCI to the left temporal lobe and the right auditory cortex. Computed tomography angiography and digital subtraction angiography demonstrated severe vasospasm of bilateral internal carotid arteries, bilateral middle cerebral arteries, and bilateral anterior cerebral arteries. One month after hospitalization, the patient had recovered fully neurologically intact except for persistent hearing loss.

LESSONS

This case serves to teach important neuroanatomical features and discuss the unique pathophysiology of DCI affecting the auditory cortex.

Open access

Yoshio Araki, Takashi Mamiya, Naotoshi Fujita, Kinya Yokoyama, Kenji Uda, Fumiaki Kanamori, Kai Takayanagi, Kazuki Ishii, Masahiro Nishihori, Kazuhito Takeuchi, Kuniaki Tanahashi, Yuichi Nagata, Yusuke Nishimura, Takafumi Tanei, Shinsuke Muraoka, Takashi Izumi, Katsuhiko Kato, and Ryuta Saito

BACKGROUND

Symptomatic hyperperfusion after cerebral revascularization for pediatric moyamoya disease (MMD) is a rare phenomenon. The authors report a series of patients with this condition.

OBSERVATIONS

In all three patients in this case series, the combined revascularization was on the left side, the patency of bypass grafts was confirmed after surgery, and focal hyperemia around the anastomotic site was observed on single photon emission computed tomography (SPECT). On the first to eighth days after surgery, all of the patients developed neurological manifestations, including motor aphasia, cheiro-oral syndrome, motor weakness of their right upper limbs, and severe headaches. These symptoms disappeared completely approximately 2 weeks after surgery, and all patients were discharged from the hospital. Quantitative SPECT was performed to determine the proportional change in cerebral blood flow (ΔRCBF) (to ipsilateral cerebellar ratio (denoted ΔRCBF) in the region of interest around the anastomoses, and the mean value was 1.34 (range, 1.29–1.41).

LESSONS

This rare condition, which develops soon after surgery, requires an accurate diagnosis by SPECT. One indicator is that the ΔRCBF has risen to 1.3 or higher. Subsequently, strategic blood pressure treatment and fluid management could prevent the development of hemorrhagic stroke.

Open access

Jorge A. Roa, Alexander J. Schupper, Kurt Yaeger, and Constantinos G. Hadjipanayis

BACKGROUND

The supracerebellar infratentorial approach provides wide flexibility as a far-reaching corridor to the pineal region, posterior third ventricle, posterior medial temporal lobe, posterolateral mesencephalon, quadrigeminal cistern, and thalamus. Traditionally, the patient is placed in the sitting position, allowing gravity retraction on the cerebellum to widen the supracerebellar operative corridor beneath the tentorium. What this approach gains in anatomical orientation it lacks in surgeon ergonomics, as the sitting position presents technical challenges, forces the surgeon to adopt to an uncomfortable posture while performing the microsurgical dissection/tumor resection under the microscope, and is also associated with an increased risk of venous air embolism.

OBSERVATIONS

In this article, the authors present the use of the three-dimensional (3D) exoscope with a standard prone Concorde position as an alternative for the treatment of lesions requiring a supracerebellar infratentorial approach for lesions in the pineal region, posterior third ventricle, and the superior surface of the cerebellar vermis. The authors present four illustrative cases (one pineal cyst, one ependymoma, and two cerebellar metastases) in which this approach provided excellent intraoperative visualization and resulted in good postoperative results. A step-by-step description of our surgical technique is reviewed in detail.

LESSONS

The use of the 3D exoscope with the patient in the prone Concorde position is an effective and ergonomically favorable alternative to the traditional sitting position for the treatment of lesions requiring a supracerebellar infratentorial approach. This technique allows improved visualization of deep structures, with a possible decreased risk of potential complications.

Restricted access

Dinal Jayasekera, Justin K. Zhang, Jacob Blum, Rachel Jakes, Peng Sun, Saad Javeed, Jacob K. Greenberg, Sheng-Kwei Song, and Wilson Z. Ray

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is the most common cause of chronic spinal cord injury, a significant public health problem. Diffusion tensor imaging (DTI) is a neuroimaging technique widely used to assess CNS tissue pathology and is increasingly used in CSM. However, DTI lacks the needed accuracy, precision, and recall to image pathologies of spinal cord injury as the disease progresses. Thus, the authors used diffusion basis spectrum imaging (DBSI) to delineate white matter injury more accurately in the setting of spinal cord compression. It was hypothesized that the profiles of multiple DBSI metrics can serve as imaging outcome predictors to accurately predict a patient’s response to therapy and his or her long-term prognosis. This hypothesis was tested by using DBSI metrics as input features in a support vector machine (SVM) algorithm.

METHODS

Fifty patients with CSM and 20 healthy controls were recruited to receive diffusion-weighted MRI examinations. All spinal cord white matter was identified as the region of interest (ROI). DBSI and DTI metrics were extracted from all voxels in the ROI and the median value of each patient was used in analyses. An SVM with optimized hyperparameters was trained using clinical and imaging metrics separately and collectively to predict patient outcomes. Patient outcomes were determined by calculating changes between pre- and postoperative modified Japanese Orthopaedic Association (mJOA) scale scores.

RESULTS

Accuracy, precision, recall, and F1 score were reported for each SVM iteration. The highest performance was observed when a combination of clinical and DBSI metrics was used to train an SVM. When assessing patient outcomes using mJOA scale scores, the SVM trained with clinical and DBSI metrics achieved accuracy and an area under the curve of 88.1% and 0.95, compared with 66.7% and 0.65, respectively, when clinical and DTI metrics were used together.

CONCLUSIONS

The accuracy and efficacy of the SVM incorporating clinical and DBSI metrics show promise for clinical applications in predicting patient outcomes. These results suggest that DBSI metrics, along with the clinical presentation, could serve as a surrogate in prognosticating outcomes of patients with CSM.