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Open access

Tentorial dural arteriovenous fistula with perimedullary venous drainage–associated cervical myelopathy: illustrative case

Sergi Cobos Codina, Luis Miguel Bernal García, José Antonio Rodríguez Sánchez, Tania Gavilán Iglesias, and Luis Fernández de Alarcón

BACKGROUND

Tentorial dural arteriovenous fistulas (DAVFs) with perimedullary venous drainage causing cervical myelopathy are very uncommon conditions with an extremely aggressive behavior. When the characteristic radiological clues are missing, the unspecific clinical picture may cause delay and make the diagnosis challenging.

OBSERVATIONS

Here the authors report a case of a 58-year-old man who developed progressive spastic tetraparesis and dyspnea with an extensive mild enhancing cervical cord lesion initially oriented as a neurosyphilis-associated transverse myelitis. Acute worsening after steroid administration redirected the diagnosis, and a tentorial Cognard type V DAVF was elicited. The microsurgical disconnection process is described, and previously documented cases in the literature are reviewed.

LESSONS

If a DAVF is highly suspected, it is important to consider the possibility of its intracranial origin, and spinal as well as cerebral arteriography must be performed.

Open access

Gross-total resection of a suprasellar with recurrent cerebellopontine angle region craniopharyngioma by endoscopic far-lateral supracerebellar infratentorial approach: illustrative case

Tao Xie and Xiaobiao Zhang

BACKGROUND

Craniopharyngiomas that rarely extend into the posterior fossa are treated with staged operations or combined approaches. The authors reported a patient undergoing gross-total resection of a suprasellar with recurrent cerebellopontine angle (CPA) craniopharyngioma using an endoscopic far-lateral supracerebellar infratentorial approach (EFL-SCITA).

OBSERVATIONS

The patient was a 15-year-old boy who presented with headache and decreased vision that lasted for half a year. He previously received three surgeries related to CPA craniopharyngioma. Preoperative magnetic resonance imaging revealed a suprasellar with recurrent CPA craniopharyngioma. Gross-total resection of this suprasellar and CPA tumor was achieved through EFL-SCITA. All symptoms and signs were improved. There were no postsurgical complications except for mild facial paralysis.

LESSONS

EFL-SCITA can be used not only for tumors in the posterolateral pontomesencephalon and ptero-clival-tentorial area but also for tumors in the suprasellar region with posterior fossa extension.

Open access

Intraoperative ultrasound evidence of accidental simultaneous cannulation of the common carotid artery and internal jugular vein: illustrative case

Aditya M. Mittal, Kamil W. Nowicki, Ricardo J. Fernández-de Thomas, Jessica Mayor, Ryan M. McEnaney, and Peter C. Gerszten

BACKGROUND

Establishing central venous access is important to provide fluid resuscitation or medications intravenously to patients.

OBSERVATIONS

Although accidental cannulation of the internal carotid artery has been reported in the literature, to our knowledge this report is the first documented intraoperative ultrasound video demonstrating accidental and simultaneous common carotid artery and internal jugular cannulation during central line placement in the internal jugular vein.

LESSONS

Ultrasound use minimizes accidental carotid cannulation during central line placement in the internal jugular vein. Carotid artery puncture can be managed by external application of pressure or surgical reexploration.

Open access

The use of an endoscopic endonasal approach for a secondary intraorbital meningioma: illustrative case

Breno W. M. Guedes, Joilson F. de Souza Júnior, Nelson A. D’Avila Melo, João M. B. de Menezes Neto, André Beer-Furlan, and Arthur M. P. Oliveira

BACKGROUND

Meningiomas are the most frequent primary tumors in the central nervous system (CNS), but intraorbital location is uncommon and accounts for only 0.2% to 4% of all CNS meningiomas. Lesions in this compartment could be classified as primary, secondary, or ectopic. The close relationship with the optic nerve sheath is a landmark to identify the tumor as primary, whereas secondary tumors commonly come from an extension of an intracranial meningioma, and ectopic meningioma is a concept not yet completely established.

OBSERVATIONS

The authors present a rare case of a secondary intraorbital meningioma operated through an endoscopic endonasal approach. Secondary meningiomas at the medial orbit are very uncommon, given their more common superior and lateral location as an extension of sphenoid meningiomas. The endoscopic endonasal route provides direct access to the medial orbit. The authors present an illustrative case of a meningioma located at the medial orbit and resected through an endoscopic endonasal approach that provided excellent visualization and anatomical exposure. Additionally, the authors review the concept and possible similarities between secondary and ectopic intraorbital meningiomas.

LESSONS

An endoscopic endonasal approach should be considered as a feasible treatment option for intraorbital meningiomas, especially if they are in the medial orbital wall.

Open access

Use of balloon-assisted nasal access to augment endoscopic endonasal transsphenoidal approach: illustrative case

Nolan Winslow, Jonathan Garst, James J. Klemens, and Andrew J. Tsung

BACKGROUND

Pituitary adenoma is a neurosurgical pathology commonly resected via endoscopic endonasal approach. Septal and nasal passage anatomy can affect the surgical corridor and may require septoplasty or other techniques for expansion.

OBSERVATIONS

The authors presented a case of pituitary macroadenoma with septal deviation with use of balloon-assisted nasal access for surgery.

LESSONS

This technique enhanced surgical width of field and instrument maneuverability via septal medialization for successful tumor resection.

Open access

Image-guided transthoracic transpedicular microdiscectomy for a giant thoracic disc herniation: patient series

Ethan J. Kilmister, Nicola Guy, Agadha Wickremesekera, and Helge Koeck

BACKGROUND

This case series reports on five consecutive patients who underwent image-guided transpedicular transthoracic microdiscectomy. The authors retrospectively reviewed five patients who had undergone Stealth image-guided transpedicular transthoracic microdiscectomy between 2015 and 2021.

OBSERVATIONS

Image guidance with O-arm verified critical anatomical landmarks in the setting of large central calcified and/or soft tissue disc prolapse. This allowed limited rib head resection, pedicle removal, and corpectomy to give adequate access and not require interbody fusion. The authors performed a partial posterior corpectomy anterior to the affected disc prolapse and microsurgical delivery of the affected disc anteriorly into the corpectomy cave away from the thecal sac. Electronic and radiographic records were analyzed at their initial presentation and at follow-up. The median patient age was 51 years (range, 44–56 years), with 80% of the patients being males. Four of five patients had significant improvement of their presenting clinical symptoms. One patient had a complicated postoperative recovery with a pneumothorax and subsequent bilateral pneumonia requiring intensive care. Another patient developed delayed postoperative worsening of paraparesis.

LESSONS

The use of Stealth image guidance with O-arm for transthoracic microdiscectomy for complex calcified thoracic disc herniation is an effective operative technical adjunct to verify anatomical landmarks and limit the microsurgical procedure.

Open access

Endoscope-assisted far lateral craniotomy for resection of posterior fossa neurocysticercosis: illustrative case

Jerrell Fang, Christopher Banerjee, Amanda Barrett, Bruce C. Gilbert, and Martin J. Rutkowski

BACKGROUND

Neurocysticercosis is a parasitic infection that commonly affects the ventricles, subarachnoid spaces, and spinal cord of the central nervous system. The authors report an unusual manifestation of purely posterior fossa neurocysticercosis treated with endoscope-assisted open craniotomy for resection.

OBSERVATIONS

A 67-year-old male presented with 2 months of progressive dizziness, gait ataxia, headaches, decreased hearing, and memory impairment. Imaging revealed an extra-axial cystic lesion occupying the foramen magnum and left cerebellopontine angle with significant mass effect and evidence of early hydrocephalus. Gross-total resection was accomplished via a left far lateral craniotomy with open endoscopic assistance, and pathological findings were consistent with neurocysticercosis. Postoperatively, he was noted to have a sixth nerve palsy, and adjuvant therapy included albendazole. By 9 months postoperatively, he exhibited complete resolution of an immediate postoperative sixth nerve palsy in addition to all preoperative symptoms. His hydrocephalus resolved and did not require permanent cerebrospinal fluid (CSF) diversion.

LESSONS

When combined with traditional skull base approaches, open endoscopic techniques allow for enhanced visualization and resection of complex lesions otherwise inaccessible under the microscope alone. Recognition and obliteration of central nervous system neurocysticercosis can facilitate excellent neurological recovery without the need for CSF diversion.

Open access

Ruptured aneurysm of the artery of Davidoff and Schechter: illustrative case

Lane Fry, Frank A. De Stefano, Kevin S. Chatley, Catherine Lei, Jeremy Peterson, and Koji Ebersole

BACKGROUND

The artery of Davidoff and Schechter (ADS) is an uncommonly encountered meningeal branch originating from the posterior cerebral artery typically identified in the setting of pathology, often dural arteriovenous fistulas (DAVFs). Here, the authors describe the first reported case of an ADS aneurysm, discovered in the setting of subarachnoid hemorrhage (SAH) and complicating a high-grade DAVF.

OBSERVATIONS

A 57-year-old female presented after experiencing the worst headache of her life. Noncontrast computed tomography scanning of the head demonstrated SAH. Angiography revealed a high-grade DAVF centered around the anterior straight sinus, consistent with the Galenic subtype of tentorial DAVF. Predominant arterial supply was from the bilateral middle meningeal and occipital arteries. Vertebral artery imaging revealed a 12-mm irregular aneurysm. The prospect that the target artery represented the noneloquent ADS was confirmed by Wada testing. Given the fusiform nature of the aneurysm, treatment required concomitant coil embolization of the aneurysm and parent artery sacrifice. A week later, the DAVF was treated with liquid embolic. The patient tolerated treatment without neurological compromise.

LESSONS

The authors describe the first reported case of an ADS aneurysm discovered in the setting of SAH complicating a high-grade DAVF and the lessons learned during our experience managing this unique pathology.

Open access

Presacral mature cystic teratoma associated with Currarino syndrome in an adolescent with androgen insensitivity: illustrative case

Grant Koskay, Patrick Opperman, Frank M. Mezzacappa, Joseph Menousek, Megan K. Fuller, Linden Fornoff, and Daniel Surdell

BACKGROUND

Currarino syndrome is a rare disorder that classically presents with the triad of presacral mass, anorectal malformation, and spinal dysraphism. The presacral mass is typically benign, although malignant transformation is possible. Surgical treatment of the mass and exploration and repair of associated dysraphism are indicated for diagnosis and symptom relief. There are no previous reports of Currarino syndrome in an androgen-insensitive patient.

OBSERVATIONS

A 17-year-old female patient presented with lack of menarche. Physical examination and laboratory investigation identified complete androgen insensitivity. Imaging analysis revealed a presacral mass lesion, and the patient was taken to surgery for resection of the mass and spinal cord untethering. Intraoperative ultrasound revealed a fibrous stalk connecting the thecal sac to the presacral mass, which was disconnected without the need for intrathecal exploration. The presacral mass was then resected, and pathological analysis revealed a mature cystic teratoma. Postoperatively, the patient recovered without neurological or gastrointestinal sequelae.

LESSONS

Diagnosis of incomplete Currarino syndrome may be difficult but can be identified via work-up of other disorders, such as androgen insensitivity. Intraoperative ultrasound is useful for surgical decision making and may obviate the need for intrathecal exploration during repair of dysraphism in the setting of Currarino syndrome.

Open access

High-resolution micro-Doppler imaging during neurosurgical resection of an arteriovenous malformation: illustrative case

Sadaf Soloukey, Luuk Verhoef, Pieter Jan van Doormaal, Bastian S. Generowicz, Clemens M. F. Dirven, Chris I. De Zeeuw, Sebastiaan K. E. Koekkoek, Pieter Kruizinga, Arnaud J. P. E. Vincent, and Joost W. Schouten

OBJECTIVE

Given the high-risk nature of arteriovenous malformation (AVM) resections, accurate pre- and intraoperative imaging of the vascular morphology is a crucial component that may contribute to successful surgical results. Surprisingly, current gold standard imaging techniques for surgical guidance of AVM resections are mostly preoperative, lacking the necessary flexibility to cater to intraoperative changes. Micro-Doppler imaging is a unique high-resolution technique relying on high frame rate ultrasound and subsequent Doppler processing of microvascular hemodynamics. In this paper the authors report the first application of intraoperative, coregistered magnetic resonance/computed tomograpy, micro-Doppler imaging during the neurosurgical resection of an AVM in the parietal lobe.

OBSERVATIONS

The authors applied intraoperative two-dimensional and three-dimensional (3D) micro-Doppler imaging during resection and were able to identify key anatomical features including draining veins, supplying arteries and microvasculature in the nidus itself. Compared to the corresponding preoperative 3D-digital subtraction angiography (DSA) image, the micro-Doppler images could delineate vascular structures and visualize hemodynamics with higher, submillimeter scale detail, even at significant depths (>5 cm). Additionally, micro-Doppler imaging revealed unique microvascular morphology of surrounding healthy vasculature.

LESSONS

The authors conclude that micro-Doppler imaging in its current form has clear potential as an intraoperative counterpart to preoperative contrast-dependent DSA, and the microvascular details it provides could build new ground to further study cerebrovascular pathophysiology.