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Open access

Radiofrequency thermocoagulation for the treatment of trigeminal neuralgia associated with a focal pontine lesion: illustrative case

Vadym Biloshytsky, Anna Skorokhoda, Inna Buvailo, and Maryna Biloshytska

BACKGROUND

Trigeminal neuralgia (TN) associated with a focal pontine lesion is a rare but challenging condition. The origin of the lesion, which does not fulfill the diagnostic criteria for multiple sclerosis, remains disputable. Pain in such conditions is often refractory to treatment, including microvascular decompression.

OBSERVATIONS

A 36-year-old female presented with a 3.5-year history of shooting pain in the right V2 distribution triggered by talking and chewing. She became less responsive to high-dose carbamazepine over time. Magnetic resonance imaging (MRI) revealed no neurovascular compression but an elongated lesion hyperintense on T2-weighted imaging and T2- fluid-attenuated inversion recovery and hypointense and nonenhancing on T1-magnetization prepared rapid gradient-echo imaging without restricted diffusion, hemorrhage, or supposed malformation along the right pontine trigeminal pathway (PTP). Two other similar lesions were found in the corpus callosum and left thalamus. All lesions were stable compared to MRI data obtained 2 years before. Cerebrospinal fluid contained no oligoclonal bands. Pain attacks ceased with right-sided gasserian radiofrequency thermocoagulation (RFTC), and at the 6-month follow-up, there was no recurrence.

LESSONS

In patients with TN, preoperative neuroimaging should assess for brainstem lesions along the PTP. RFTC can be considered a treatment option in medication-refractory TN associated with a focal pontine lesion.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 23 (Dec 2023)

Open access

Trigeminal neuralgia secondary to osteoma and vascular compression: illustrative case

Chenglong Cao, Mingwu Li, Min Wu, and Xiaofeng Jiang

BACKGROUND

Trigeminal neuralgia (TN) is a common neurosurgical issue that has a detrimental impact on patients’ quality of life. Osteoma at the petrous apex is a rare etiology of TN. Here, the authors present a case involving the co-occurrence of petrous osteoma and a vascular loop around the trigeminal nerve. Both exerted pressure or compression on the exit of the trigeminal nerve.

OBSERVATIONS

A 46-year-old male presented with a 3-year history of persistent severe pain in the right side of his face. Magnetic resonance tomographic angiography of the trigeminal nerve revealed an abnormal signal in the right prepontine cistern, along with a vascular loop accompanying the right trigeminal nerve. A computed tomography scan of the skull indicated a nodular calcified density. The combined anterior transpetrosal approach for petrous osteoma and microvascular decompression (MVD) for the offending vessel were successfully performed. The patient was discharged without any complications or facial pain.

LESSONS

Although extremely rare, TN simultaneously secondary to petrous osteoma and offending vessels should be considered in the diagnosis. In this case, the combined surgical removal of petrous osteoma and MVD for the offending vessels proved to be an effective treatment for TN secondary to osteoma and vascular compression.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 23 (Dec 2023)

Open access

Combined endoscopic and microsurgical approach for the drainage of a multisegmental thoracolumbar epidural abscess: illustrative case

Vincent Hagel, Felix Dymel, Stephan Werle, Vera Barrera, and Mazda Farshad

BACKGROUND

Spinal epidural abscess is a rare but serious infectious disease that can rapidly develop into a life-threatening condition. Therefore, the appropriate treatment is indispensable. Although conservative treatment is justifiable in certain cases, surgical treatment needs to be considered as an alternative early on because of complications such as (progressive) neurological deficits or sepsis. However, traditional surgical techniques usually include destructive approaches up to (multilevel) laminectomies. Such excessive approaches do have biomechanical effects potentially affecting the long-term outcomes. Therefore, minimally invasive approaches have been described as alternative strategies, including endoscopic approaches.

OBSERVATIONS

The authors describe a surgical technique involving a combination of two minimally invasive approaches (endoscopic and microsurgical) to drain a multisegmental (thoracolumbar) abscess using the physical phenomenon of continuous pressure difference to minimize collateral tissue damage.

LESSONS

The combination of minimally invasive approaches, including the endoscopic technique, may be an alternative in draining selected epidural abscesses while achieving a similar amount of abscess removal and causing less collateral approach damage in comparison with more traditional techniques.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 19 (Nov 2023)

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.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 19 (Nov 2023)

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.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 18 (Oct 2023)

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.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 18 (Oct 2023)

Open access

Spontaneous pseudoaneurysm of the superficial temporal artery in neurofibromatosis type 1: illustrative case

Fang Shen, Shi-ze Li, Yuan-yuan Shan, Xiao Ji, and Han-song Sheng

BACKGROUND

A pseudoaneurysm of the superficial temporal artery is an uncommon clinical entity that has largely been linked with direct traumatic causes. Neurofibromatosis type 1 (NF1)-related vasculopathy is a rare cause of idiopathic arterial bleeding in the craniofacial region.

OBSERVATIONS

A 46-year-old male with clinical features of NF1 presented to the hospital with an enlarging and tender right temporal mass without a history of trauma. Computed tomography angiography suggested the development of a pseudoaneurysm, and surgery was performed to resect the mass. Histopathological examinations showed focal interruption of the epithelium layer and elastic lamina, well-demarcated thickening of the smooth muscle layers of the arterial wall, supporting the diagnosis of pseudoaneurysm.

LESSONS

NF1-associated vasculopathy is likely the predisposing factor for the development of a superficial temporal artery pseudoaneurysm.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 14 (Oct 2023)

Open access

Interlaminar endoscopic uniportal approach for implantation of a paddle lead larger than 10 mm for spinal cord stimulation: illustrative case

Gustavo V Lages, Ramon G Barbosa, Hugo S Souto, Natally M Santiago, José Oswaldo O Júnior, Marcus V. F. B. V. F Serra, Leandro F Batista, Camille L Silva, and Maria Fernanda A. V Toledo

BACKGROUND

The authors aim to describe a new technique for implantation of a spinal cord stimulation paddle lead sized over 10 mm through an endoscopic uniportal approach. A new endoscopic cannula was developed for the passage of a paddle lead width between 10 and 13 mm. The distal portion of the cannula was designed with a larger opening, providing better visibility of the anterior portion of the adjacent structures, thus allowing a panoramic view of the electrode passage. An electrode was implanted in an 11-mm paddle.

OBSERVATIONS

After searching PubMed, Cochrane, and Lilacs databases, the authors found no mention of the implantation of a paddle electrode with a width greater than 10 mm. The implantation of a paddle electrode less than 10 mm wide is possible via endoscopic access using 10-mm working channels. However, for electrodes with a width greater than 10 mm, access via endoscopy is impossible, since the working channel is only 10 mm.

LESSONS

The authors concluded that it is possible to pass electrodes safely and effectively with a paddle width between 10 and 13 mm using spinal endoscopy via uniportal interlaminar access. However, it is necessary to expand studies to elucidate this technique of endoscopic implantation of electrodes for neurostimulation.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 10 (Sep 2023)

Open access

Utilization of three-dimensional fusion images with high-resolution computed tomography angiography for preoperative evaluation of microvascular decompression: patient series

Takamitsu Iwata, Koichi Hosomi, Naoki Tani, Hui Ming Khoo, Satoru Oshino, and Haruhiko Kishima

BACKGROUND

High-resolution computed tomography (CT), outfitted with a 0.25-mm detector, has superior capability for identifying microscopic anatomical structures compared to conventional CT. This study describes the use of high-resolution computed tomography angiography (CTA) for preoperative microvascular decompression (MVD) assessment and explores the potential effectiveness of three-dimensional (3D) image fusion with magnetic resonance imaging (MRI) by comparing it with traditional imaging methods.

OBSERVATIONS

Four patients who had undergone preoperative high-resolution CTA and MRI for MVD at Osaka University Hospital between December 2020 and March 2022 were included in this study. The 3D-reconstructed images and intraoperative findings were compared. One patient underwent conventional CTA, thus allowing for a comparison between high-resolution and conventional CTA in terms of radiation exposure and vascular delineation. Preoperative simulations reflected the intraoperative findings for all cases; small vessel compression of the nerve was identified preoperatively in two cases.

LESSONS

Compared with conventional CTA, high-resolution CTA showed superior vascular delineation with no significant change in radiation exposure. The use of high-resolution CTA with reconstructed 3D fusion images can help to simulate prior MVD. Knowing the location of the nerves and blood vessels can perioperatively guide neurosurgeons.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 9 (Aug 2023)

Open access

Hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome: illustrative case

Shigeyoshi Shimura, Ryu Saito, Takashi Yagi, Hideyuki Yoshioka, and Hiroyuki Kinouchi

BACKGROUND

Intraspinal juxta-facet cysts of the spine are known to predominate at the lumbar level and is relatively rare at the cervical level. Most cervical spinal lesions are found incidentally, but they sometimes cause myelopathy or radiculopathy in a chronic course.

OBSERVATIONS

The authors present a rare case of hemorrhagic cervical juxta-facet cyst presenting with Brown-Séquard syndrome. An 86-year-old woman presented with acute-onset right hemiparesis following neck pain and was admitted to the local hospital. She was started on antithrombotic therapy with a suspected diagnosis of cerebral infarction, but quadriplegia progressed 2 days later. Cervical magnetic resonance imaging revealed an intraspinal mass at the C4–5 level and she was referred to the authors’ hospital. Her neurological findings on admission revealed right Brown-Séquard syndrome. In emergency surgery, the mass was resected with a posterior approach. Pathological findings showed hemosiderin deposition and fibroblast proliferation, consistent with a juxta-facet cyst with intracystic hemorrhage. The patient recovered well and returned to an independent daily life.

LESSONS

Rarely, juxta-facet cyst of the cervical spine can cause acute Brown-Séquard syndrome due to intraspinal hemorrhage. In a case of hemiparesis that develops following neck pain, hemorrhagic cervical juxta-facet cyst should be taken into consideration as a differentiation.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 22 (May 2023)