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Open access

Strangulation of the abducens nerve by an arachnoid band within an epidermoid cyst: illustrative case

Jacob Kosarchuk, Shrey Patel, Walter Dent, and Carl B Heilman

BACKGROUND

Intracranial epidermoid cysts (ECs) are rare benign lesions of ectodermal origin that can be found in the cerebellopontine angle (CPA). If large enough, they compress surrounding structures, causing cranial neuropathies, cerebellar dysfunction, and hydrocephalus.

OBSERVATIONS

In this case report, the authors present a patient with headaches and diplopia secondary to a CPA EC. The cyst had wrapped itself around and was strangulating the abducens nerve. This choking of the nerve was believed to have been the cause of the patient’s double vision. The arachnoid band was released with a myringotomy knife.

LESSONS

Intracranial ECs typically cause symptoms from mass effect on surrounding structures; it is unusual for one to have choked off the nerve in the fashion presented in this case. Knowledge of the potential ways that ECs can affect nervous structures is critical for resecting them without injuring normal tissue.

Open access

Symptomatic obstructive hydrocephalus caused by choroid plexus hyperplasia in a pediatric patient: illustrative case

Ana Sofia Alvarez, John P McGinnis, Rajan Patel, and Howard L Weiner

BACKGROUND

Choroid plexus hyperplasia has been described as a rare cause of communicating hydrocephalus due to cerebrospinal fluid (CSF) overproduction. However, this is the first report of symptomatic obstructive hydrocephalus caused by mechanical obstruction of the aqueduct by a hyperplastic choroid plexus.

OBSERVATIONS

A 4-year-old male presented with headaches and intermittent emesis. Magnetic resonance imaging (MRI) of the brain showed abnormal enlargement of the choroid plexus in the lateral ventricles with extension into the third ventricle, resulting in obstruction of the aqueduct of Sylvius, leading to obstructive hydrocephalus. Endoscopic third ventriculostomy (ETV) was chosen as the surgical treatment. During the procedure, high pressure flow of clear CSF was noted. Normal intraventricular anatomy was identified, and no cyst or tumor was found. The postoperative MRI showed a patent third ventriculostomy, without complication, and a significant decrease in supratentorial ventricular size. The patient was discharged 3 days after surgery with a complete resolution of symptoms.

LESSONS

Choroid plexus hyperplasia has the potential to cause obstructive hydrocephalus, and it can be effectively treated with ETV. Our hypothesis is that the change in pressure caused by the procedure may have led to an uncorking of the aqueduct by the hyperplastic choroid plexus, contributing to the observed improvement.

Open access

Three-stage correction of severe idiopathic scoliosis with limited skeletal traction during a humanitarian surgical mission: illustrative case

J. Manuel Sarmiento, Jordan Fakhoury, Angadh Singh, Cameron Hawk, Khalid Sethi, and Ravi Bains

BACKGROUND

Underprivileged and underserved patients from developing countries often present late with advanced, untreated spinal deformities. We report a three-stage all-posterior approach using limited skeletal traction with Gardner-Wells tongs (GWTs) for the management of severe idiopathic scoliosis during a humanitarian surgical mission trip.

OBSERVATIONS

A 17-year-old high-school female was previously diagnosed with juvenile idiopathic scoliosis (diagnosed at age 8) and progressed to a severe 135° kyphoscoliosis. Procedural stage 1 involved spinal instrumentation and posterior releases via posterior column osteotomies from T3 to L4. She then underwent 7 days of skeletal traction with GWTs in the intensive care unit as stage 2. In stage 3, rod engagement, posterior spinal fusion, and partial T10 vertebral column resection were performed. There were no changes in intraoperative neuromonitoring during either surgery and she woke up neurologically intact after both stages of the surgical procedure.

LESSONS

Skeletal traction with GWTs is a viable alternative to traditional halo-gravity traction in settings with limited resources. Three-stage spinal deformity correction using limited skeletal traction is a feasible and effective approach for managing severe scoliosis during humanitarian surgical mission trips.

Open access

Transvenous embolization via the facial vein for intraorbital dural arteriovenous fistula: illustrative case

Jumpei Ienaga, Tetsuya Tsukada, Toru Watanabe, Yosuke Sakai, Kenji Uda, Kazunori Shintai, Yoshio Araki, Tetsuya Nagatani, and Yukio Seki

BACKGROUND

Intraorbital arteriovenous fistula (IOAVF) is a rare type of intracranial fistula that presents with ocular signs similar to those of cavernous sinus dural arteriovenous fistula. The treatment of IOAVF is based on the vascular architecture of each case due to its infrequent occurrence. The authors report the case of an IOAVF that was successfully treated with embolization via the facial vein, with good outcomes.

OBSERVATIONS

A 78-year-old woman presented with left eyelid swelling, pulsatile ocular protrusion, and left ocular conjunctival hyperemia. Ophthalmological evaluation revealed elevated intraocular pressure; time-of-flight magnetic resonance angiography revealed a dilated left superior ophthalmic vein. Digital subtraction angiography showed an arteriovenous shunt in the left superior orbital fissure, which was treated using transvenous coil embolization. The patient experienced immediate improvement in left ocular protrusion and conjunctival hyperemia. Ophthalmological evaluation 1 month after treatment showed normal intraocular pressure in the left eye. No neurological symptoms were observed, and there was no recurrence of the arteriovenous shunt 3 months postoperatively.

LESSONS

The authors report a rare case of IOAVF treated with embolization via the facial vein with a good outcome. A thorough understanding of the vascular architecture using three-dimensional images is useful for determining endovascular access and procedures.

Open access

Impedance trend from a symptomatic perielectrode cystic cavity following deep brain stimulation: illustrative case

Brooke Elberson, Hayden Scott, Rohit Dhall, and Erika Petersen

BACKGROUND

Deep brain stimulation (DBS) is a well-established neurosurgical intervention for a growing number of neurological and psychiatric diseases. Patients who are affected by Parkinson’s disease may benefit from DBS of either the subthalamic nucleus or the globus pallidus internus. Patients who undergo DBS often notice a significant reduction in their clinical symptoms; however, the procedure is not without risks. Multicenter studies have reported postoperative complications such as hardware infection, intracranial hemorrhage, and perielectrode edema.

OBSERVATIONS

The authors report a case of a perielectrode cyst managed conservatively. Tracking the impedance trend was a novel approach to monitor for changes within the cyst and to herald a clinical change in the patient. Perielectrode cystic formation can be a transient process that resolves spontaneously or with conservative, nonoperative management, and all diagnostic information is valuable in making clinical decisions.

LESSONS

Impedance values have provided an appropriate estimation of this patient’s clinical picture. The authors suggest treatment of edema and a cyst after DBS lead implantation through conservative management and observation, avoiding the removal of hardware if a patient’s clinical picture is either stable or improving and forgoing additional clinical imaging if the impedance values are trending in an appropriate direction.

Open access

Intraoperative confocal laser endomicroscopy for interpretation of a sellar hemangioblastoma: illustrative case

Irakliy Abramov, Charuta G Furey, Yuan Xu, Jennifer M Eschbacher, Kris A Smith, and Mark C Preul

BACKGROUND

Intraoperative frozen sections play a critical role in surgical strategy because of their ability to provide rapid histopathological information. In cases in which intraoperative biopsy carries a significant risk of bleeding, intraoperative confocal laser endomicroscopy (CLE) can assist in decision-making.

OBSERVATIONS

The authors present a rare case of a large sellar hemangioblastoma. Preoperative radiographic imaging and normal pituitary function suggested a differential diagnosis that included hemangioblastoma. The patient underwent partial preoperative embolization and a right-sided pterional craniotomy for resection of the lesion. Gross intraoperative examination revealed a highly vascular sellar lesion requiring circumferential dissection to minimize blood loss. The serious vascularity precluded intraoperative frozen section analysis, and CLE imaging was performed. CLE imaging provided excellent visualization of the remarkable vascular structure and characteristic histoarchitecture with microvasculature, intracytoplasmic vacuoles, and atypical cells consistent with hemangioblastoma. Resection and decompression of the chiasm was accomplished, and the patient was discharged with improved vision. The final histopathological diagnosis was hemangioblastoma.

LESSONS

When the benefits of obtaining intraoperative frozen sections greatly outweigh the associated risks, CLE imaging can aid in decision-making. CLE imaging offers real-time, on-the-fly evaluation of intraoperative tissue without the need to biopsy a vascular lesion.

Open access

Delayed headache 11 years after a pub fight: an unusual spontaneous intracerebral hemorrhage succeeding a temporal glass shard injury. Illustrative case

Attill Saemann, Victor Schulze-Zachau, Raphael Guzman, and Gregor Hutter

BACKGROUND

Intracerebral hemorrhage (ICH) in young patients is rare and often associated with vascular malformations, drug abuse, or genetic conditions. Early diagnosis and treatment are critical because of the potential risk of rebleeding and long-term consequences. This case report presents an unusual correlation between a prior traumatic incident and the manifestation of an atypical ICH 11 years later.

OBSERVATIONS

A 37-year-old male presented with retroorbital headaches, confusion, and seizures. Imaging revealed an atypical ICH in the left middle temporal gyrus, accompanied by retained glass shards in the adjacent temporal muscle and bone. Angiography ruled out vascular malformations but suggested an eroded middle cerebral artery branch underneath an osseous defect potentially caused by a bone-transgressing glass shard. Surgical exploration confirmed the vessel as the source of the ICH and was followed by an uneventful hematoma removal and postoperative course.

LESSONS

This case underscores the significance of recognizing delayed complications resulting from retained foreign bodies (FBs). Complete removal of extracranial FBs is imperative to prevent further harm. Clinicians should maintain an awareness of the potential long-term consequences and complications associated with FBs, utilizing comprehensive diagnostics to detect and localize FBs. Timely intervention such as resection or planned follow-up is essential for effective management and mitigation of adverse outcomes.

Open access

Diffuse-type tenosynovial giant cell tumor between the suboccipital bone and posterior C1 arch: illustrative case

Carl Porto, Cameron Ayala, Joshua Feler, Santos Santos-Fontanez, Jonathan Poggi, Michael Kritselis, and Curtis Doberstein

BACKGROUND

Tenosynovial giant cell tumor (TGCT) occurs most commonly in the appendicular skeleton and is only rarely found in the vertebral column. Lesions of the craniocervical junction are particularly rare, with only 4 cases reported in the literature. The authors describe the case of a diffuse-type TGCT at the craniocervical junction.

OBSERVATIONS

A patient presented with a 1-year history of right-sided neck pain and bilateral neurological symptoms in the distribution of the right occipital nerve. A 20-mm homogeneously contrast-enhancing mass in the suboccipital and posterior C1 region was discovered on magnetic resonance imaging of the cervical spine. The tumor was operated on via a posterior approach, and gross-total resection (GTR) was achieved. Immunohistochemical (IHC) examination revealed a diffuse-type TGCT. The patient had an uneventful recovery.

LESSONS

TGCT can arise at the craniocervical junction and is easily misdiagnosed because of its rare occurrence. IHC examination of a tumor specimen should be done to confirm the diagnosis. GTR is the objective when treating these tumors, especially when they are the diffuse type, as they have a high recurrence rate. Radiation and small-molecule therapies are viable postoperative therapies if GTR cannot be achieved or in cases of recurrence.

Open access

Selective upper trunk posterior division fascicular nerve transfer for proximal spinal accessory neuropathy: illustrative case

Kitty Y Wu and Robert J Spinner

BACKGROUND

Spinal accessory nerve palsy can lead to severe shoulder pain and weakness, lateral scapular winging, and limitations in overhead activity. It most often occurs because of iatrogenic injury from procedures within the posterior triangle of the neck.

OBSERVATIONS

The authors present the case of a 39-year-old male with symptoms of right shoulder weakness and neck pain after a total thyroidectomy and right neck dissection. With ultrasound findings of a neuroma-in-continuity but no clinical or electromyographic signs of reinnervation at 6 months, surgical intervention was indicated. Operative exploration confirmed a very proximal injury and nonconducting neuroma-in-continuity of the spinal accessory nerve. A selective distal nerve transfer from the posterior division of the upper trunk was performed. At the 2.5-year follow-up, the patient demonstrated excellent recovery of full active shoulder abduction and forward flexion, return to full-time employment, and mild residual scapular winging.

LESSONS

Distal nerve transfers should be considered in cases of late presentation when primary repair is not possible or long interpositional grafts are required. Selective fascicular transfer from the posterior division of the upper trunk provides the advantages of a single incision, short reinnervation time, and synergistic donor function to facilitate motor reeducation.

Open access

Thoracic pediculectomy for acute spinal cord decompression in high-risk spinal deformity correction: illustrative case

J. Manuel Sarmiento, Christina Rymond, Alondra Concepcion-Gonzalez, Chris Mikhail, Fthimnir M Hassan, and Lawrence G Lenke

BACKGROUND

Neurological complications are higher in patients with severe spinal deformities (Cobb angle >100°). The authors highlight a known technique for thoracic concave apical pedicle resection that is useful for spinal cord decompression in patients with high-risk spinal deformities in the setting of intraoperative neuromonitoring (IONM) changes.

OBSERVATIONS

A 14-year-old female with progressive idiopathic scoliosis presented for evaluation of her clinical deformity. Scoliosis radiographs showed a double major curve pattern comprising a 107° right main thoracic curve and a compensatory 88° left thoracolumbar curve. She underwent 2 weeks of halo-gravity traction that reduced her major thoracic curve to 72°. During thoracic posterior column osteotomies, the authors were alerted to decreases in IONM signals that were not responsive to increases in mean arterial pressure, traction weight reduction, and convex compression maneuvers. The dural surface was tightly draped over the two thoracic apical pedicles of T7 and T8, so emergent pediculectomies were performed at both levels for spinal cord decompression. IONM signals gradually improved and eventually became even better than baseline. The patient woke up without any neurological deficits.

LESSONS

Pediculectomy of the concave apical pedicle(s) should be considered for spinal cord decompression if there are IONM changes during high-risk spinal deformity surgery.