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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.

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.

Open access

Effects of ventro-oral thalamic deep brain stimulation in a patient with musician’s dystonia: illustrative case

Fauve Poncelet, Sara Smeets, Takaomi Taira, Veerle Visser-Vandewalle, Wim Vandenberghe, Jana Peeters, Tine Van Bogaert, and Bart Nuttin

BACKGROUND

Musician’s dystonia is a task-specific focal hand dystonia characterized by involuntary contraction of muscles while playing a musical instrument. Current treatment options are often insufficient.

OBSERVATIONS

We present the effects of ventro-oral thalamic deep brain stimulation in a patient with musician’s dystonia. The patient was a 67-year-old pianist with musician’s dystonia who underwent deep brain stimulation with the ventralis oralis anterior and posterior nuclei of the thalamus as targets. The Tubiana and Chamagne rating scale was used to evaluate the effects of stimulation. The outcome was evaluated independently by four clinicians in a blinded manner at 3 months postoperatively. There was a distinct reduction of symptoms during stimulation. At 15 months postoperatively, the beneficial effect remained. No lasting side effects were observed.

LESSONS

Further studies are warranted to evaluate the safety and long-term efficacy of this treatment modality.

Open access

Late-developing posttraumatic dural arteriovenous fistula of the vertebral artery: illustrative case

Hanna E Schenck, Thomas B Fodor, Bart A. J. M Wagemans, and Roel H. L Haeren

BACKGROUND

A dural arteriovenous fistula (dAVF) involving the vertebral artery (VA) is a rare vascular pathology that can result from damage to the VA, most frequently following cervical spine trauma. In most traumatic cases, the dAVF develops and manifests shortly after trauma.

OBSERVATIONS

A patient was admitted after a fall from the stairs causing neck pain. Computed tomography of the cervical spine revealed a Hangman’s fracture, and angiography showed a left VA dissection. The patient was treated with a cervical brace and clopidogrel. Three weeks after trauma, the patient was admitted because of bilateral leg ataxia, dizziness, and neck pain. Repeat imaging revealed increased displacement of the cervical fracture and a dAVF from the left VA with retrograde filling of the dAVF from the right VA. Embolization of the dAVF using coils proximally and distally to the dAVF was performed prior to placing a halo brace. At 6 months, all symptoms had disappeared and union of the cervical spine fracture had occurred.

LESSONS

This case report emphasizes the need for follow-up angiography after traumatic VA injury resulting from cervical spine fracture and underlines important treatment considerations for successful obliteration of a dAVF of the VA.

Open access

Management of rare atlantoaxial synovial cyst case with extension to the cerebellopontine angle: illustrative case

Shawn D’Souza, Vikram Seshadri, Harsh P Shah, Jan T Hachmann, and R. Scott Graham

BACKGROUND

Synovial cysts are a common finding in degenerative spine disease, most frequently involving the facet joints of the lumbar spine. Synovial cysts are less common in the cervical spine and rarely involve the atlantoaxial junction.

OBSERVATIONS

In this case report, the authors detail a unique presentation of a left atlantoaxial synovial cyst with large intracranial extension into the cerebellopontine angle causing progressive cranial nerve palsies resulting in tinnitus, vertigo, diminished hearing, gait imbalance, left trigeminal hypesthesia, left facial weakness, and dysarthria. The patient underwent a retromastoid craniectomy for resection of the synovial cyst, resulting in improvement and resolution of symptoms. Follow-up occurred at 6 weeks, 3 months, and 5 months postoperatively without recurrence on imaging.

LESSONS

The authors describe acute and long-term management of a unique presentation of an atlantoaxial synovial cyst including retromastoid craniectomy, intervals for follow-up for recurrence, and possible treatment options in cases of recurrence. A systematic literature review was also performed to explore all reported cases of craniocervical junction synovial cysts and subsequent surgical management.

Open access

Pterygoid venous plexus anastomosis in trigeminal percutaneous glycerol rhizotomy: illustrative case

Kevin Cordeiro, Jason Kim, Niall Buckley, Mark Kraemer, Conrad Pun, and Daniel Resnick

BACKGROUND

Percutaneous glycerol rhizotomy (PGR) is a common, effective, and relatively safe treatment for trigeminal neuralgia that is refractory to medical management. Anastomotic skull base venous anatomy should be considered when delivering percutaneous agents.

OBSERVATIONS

The authors report an anastomotic connection, not previously described in the literature, between the bilateral pterygoid venous plexuses upon air injection during PGR with computed tomography (CT) guidance for trigeminal neuralgia. Pertinent microsurgical and skull base venous anatomy is reviewed.

LESSONS

Anastomoses between the pterygoid venous plexuses present a potential passage for materials used during PGR to reach unintended contralateral neurovascular structures. The use of CT guidance may identify this anastomotic connection and decrease the likelihood of an aberrant flow of materials used during the PGR.

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.

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.

Open access

Dorsal root entry zone fenestration for intramedullary ependymal cyst: illustrative case

Shengxi Wang, Xingang Zhao, and Tao Fan

BACKGROUND

Intramedullary ependymal cysts are rare and difficult to distinguish from syringomyelia and neuroenteric cysts. Almost all cases in the literature have been case reports and have been performed with the traditional posterior median sulcus incision, which is difficult to identify accurately during spinal rotation. Approximately 40% of cases have transient neurological deterioration. The dorsal root entry zone has been proven to be an effective incision area in the treatment of intramedullary lesions, but so far, its utilization in intramedullary ependymal cysts has been rarely reported.

OBSERVATIONS

This study is the first to report on six cases of intramedullary ependymal cysts treated with an 8-mm incision in the dorsal root entry zone to fully establish the communication between the cyst and the subarachnoid space. Imaging changes and neurological improvement were analyzed in all cases before and after surgery and were followed up for 49.7 months.

LESSONS

The utilization of dorsal root entry zone fenestration in intramedullary ependymal cyst has demonstrated feasibility and effectiveness, ensuring the functional integrity of the posterior column.

Open access

Extra-axial cavernous malformations of the foramen magnum: illustrative cases

Bo-Han Yao, Da Li, Liang Wang, and Zhen Wu

BACKGROUND

Extra-axial cavernous malformations involving the foramen magnum are rare, and preoperative diagnosis becomes difficult when they mimic meningiomas.

OBSERVATIONS

The authors present 2 cases of extra-axial cavernous malformations involving the foramen magnum. Surgical removal of the lesions was performed via far lateral craniotomy. The authors investigate the disease and elaborate the differential diagnosis.

LESSONS

The authors recommend that extra-axial cavernous malformations should be considered in the differential diagnosis of lesions in the foramen magnum region. Intraoperative frozen sections are helpful to the diagnosis, and resection warranted a favorable long-term outcome.