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Open access

Endoscopic endonasal optic nerve decompression in children younger than 2 years old with congenital optic canal stenosis: illustrative cases

Peter H Yang, John S Schneider, Michael R Chicoine, Albert H Kim, and David D Limbrick Jr

BACKGROUND

Congenital optic canal stenosis causing compressive optic neuropathy is a rare disorder that presents unique diagnostic and treatment challenges. Endoscopic endonasal optic nerve decompression (EOND) has been described for optic nerve compression in adults and adolescents but has never been reported for young children without pneumatized sphenoid sinuses. The authors describe preoperative and intraoperative considerations for three patients younger than 2 years of age with congenital optic canal stenosis due to genetically confirmed osteopetrosis or chondrodysplasia.

OBSERVATIONS

Serial ophthalmological examinations, with a particular focus on object tracking ability, fundoscopic examination, and visual evoked potential trends in preverbal children, are important for detecting progressive optic neuropathy. The lack of pneumatization of the sphenoid sinus presents unique challenges and requires the surgical creation of a sphenoid sinus with the use of neuronavigation to determine the limits of bony exposure given the lack of easily identifiable anatomical landmarks such as the opticocarotid recess. There were no perioperative complications.

LESSONS

EOND for congenital optic canal stenosis is safe and technically feasible even given the lack of pneumatization of the sphenoid sinus in young patients. The key operative step is surgically creating the sphenoid sinus through careful bony removal with the aid of neuronavigation.

https://thejns.org/doi/10.3171/CASE23559

Open access

Wartime penetrating skull base trauma with unpredictable internal fragment ricochet and migration: illustrative case

Andrii Sirko, Alex Valadka, Rocco Armonda, Anthony J Dragun, and Yurii Cherednychenko

BACKGROUND

Transnasal transsphenoidal penetrating craniocerebral injury is very rare even in wartime. Cases with good outcomes are even less common.

OBSERVATIONS

A 20-year-old male sustained multiple fragment wounds to his head and face from a landmine explosion. One metal fragment entered his right nostril, traversed the nasal septum and anterior sphenoid sinus, and ricocheted superiorly off the clivus. The fragment then traveled almost to the surface of the left parietal lobe. Subsequently, under its own weight, it migrated back down its original track. The patient suffered cerebrospinal fluid rhinorrhea, pneumocephalus, and right-sided hemiparesis. Digital subtraction angiography was followed by microscopic transnasal skull base reconstruction supplemented by external lumbar drainage. Follow-up brain computed tomogrpahy showed further metallic fragment migration through the ventricular system. The fragment was removed through a transcortical approach. The patient’s neurological examination and brain magnetic resonance imaging results demonstrated good recovery.

LESSONS

The absence of external signs of deep injuries does not exclude the presence of a penetrating craniocerebral injury. Metal fragments may undergo ricochet and internal migration in both the brain parenchyma and the ventricular system. Timely diagnosis including three-dimensional reconstruction of a projectile’s trajectory may facilitate appropriate surgical planning in complex cases. Intraventricular fragment migration may necessitate microsurgical removal.

https://thejns.org/doi/10.3171/CASE24128

Open access

Which is a more appropriate recipient for posterior circulation bypass surgery: V3 or V2? Differences in underlying disease and lesion sites between extracranial vertebral artery dissection and atherosclerotic changes. Illustrative cases

Shinjitsu Nishimura, Makoto Saito, Sumito Okuyama, Keiichi Kubota, Junko Matsuyama, Atsuhito Takemura, Tadao Matsushima, and Kazuo Watanabe

BACKGROUND

Revascularization for extracranial vertebral artery dissection or vertebral artery atherosclerotic occlusive lesions caused by vertebrobasilar insufficiency or posterior circulation infarction is relatively rare. When bypassing the cervical external carotid artery (ECA) or common carotid artery (CCA) using a radial artery (RA) or saphenous vein (SV) graft, it is difficult to determine whether the recipient site should be the V2 or V3 portion.

OBSERVATIONS

In case 1, cervical ECA-RA-V3 bypass was performed for bilateral extracranial vertebral artery dissection with the onset of ischemia, and cervical CCA-SV-V3 bypass was added 12 days later. Nine years after surgery, the bilateral vertebral artery dissection had improved, and the patient still had a patent bypass. In case 2, cervical ECA-RA-V2 bypass was performed for arteriosclerotic bilateral extracranial vertebral artery occlusion. The bypass was patent 5 years after surgery. The postoperative course was uneventful in both patients.

LESSONS

The authors present cases of posterior fossa revascularization using the vertebral artery V3 and V2 portions via skull base surgery and note that it is important to consider each patient’s individual characteristics when selecting the V3 or V2 portion.

Open access

“Open-window” craniectomy for the removal of frontal sinus mucosa to prevent a delayed mucocele: illustrative case

W. Caleb Rutledge, 1 2 MS, Ahmad Ozair, Javier E. Villanueva-Meyer, Brian Niehaus, and Michael W. McDermott

BACKGROUND

Frontal craniotomies for a medial subfrontal approach necessitate crossing the frontal sinus. Large superior extensions of the frontal sinus into frontal bone can result in mucosal retention in a free craniotomy bone flap, leading to a delayed mucocele with significant associated morbidity. The authors describe an “open-window” craniectomy technique that permits mucosal removal under direct vision and maintains the inner table on the bone flap’s inferior side, helping to seal off the sinus opening with a pericranial flap.

OBSERVATIONS

An illustrative case involving a medial right frontal craniotomy for a third ventricle mass in a patient with a large superior extension of the frontal sinus into frontal bone is presented. After creating a free frontal bone flap, the inner table was drilled out to the margins of the frontal sinus cavity and any remaining mucosa was cleared. A portion of the inner table above the bone flap’s inferior margin was left in place, resembling an open window when viewed from the inner table side. The remaining anterior and posterior wall of the flap inferiorly provided a matched surface for the opening into the remaining frontal sinus, which was covered by pericranium. Long-term follow-up indicated no major complications or delayed mucocele.

LESSONS

The open-window craniectomy technique can be considered for frontal sinus violations in patients with large superior frontal bone extension.

Open access

Brainstem anesthesia during awake craniotomy: illustrative case

Yun Chen, Mei Sun, Hongmin Bai, Ruixin Yang, and Huan He

BACKGROUND

Awake craniotomy (AC) is performed to remove the lesions near or in eloquent areas, during which the patients are alert and without any airway instrument. Apnea is a severe complication in AC. Here, the authors describe a case of sudden apnea induced by unexpected local anesthesia of the brainstem during AC.

OBSERVATIONS

A 42-year-old male underwent AC for a large, recurrent, bilateral frontal lobe mass and experienced transient apnea and loss of brainstem reflexes during the surgery. The patient recovered spontaneous breath rhythm just a few minutes after the removal of a lidocaine cotton pledget, which was found near the patient’s midbrain. Then the patient awoke and cooperated to finish the surgery.

LESSONS

The administration of a local anesthetic subdurally in AC is common but risky. The scouring action of cerebral spinal fluid can spread those agents and cause unexpected brainstem anesthesia. A lower concentration of the anesthetic and keeping away from the cistern can make it safer.

Open access

Management of frontoethmoidal osteoma causing pneumocephalus and cerebrospinal fluid leakage with minimally invasive techniques: illustrative cases

Nicholas G Candy, Kyle C Wu, Guilherme Finger, Kyle VanKoevering, and Daniel M Prevedello

BACKGROUND

Osteoid osteoma is a common benign bone tumor frequently seen in the frontoethmoid region. However, involvement of the skull base is rare, with few cases previously reported.

OBSERVATIONS

The authors report two cases of spontaneous, symptomatic frontoethmoidal osteoma: one presented with neurological deficit secondary to tension pneumocephalus and the other with cerebrospinal fluid leakage. The first case was managed with a transfrontal sinus craniotomy and pneumocephalus decompression with osteoma resection and skull base reconstruction. The second case was managed with a uninaral endoscopic endonasal approach to the anterior skull base with osteoma resection and reconstruction.

LESSONS

Given the paucity of cases with associated tension pneumocephalus described in the literature, it was relevant to describe the authors’ experience with surgical decision-making and the expected outcomes among patients with this pathology when using minimally invasive techniques.

Open access

BRAF-mutated suprasellar glioblastoma mimicking craniopharyngioma: illustrative case

Bryan Zheng, Belinda Shao, Jennifer Mingrino, Jonathan Poggi, Richard S Dowd, Douglas C Anthony, John E Donahue, and Curtis E Doberstein

BACKGROUND

Suprasellar masses commonly include craniopharyngiomas and pituitary adenomas. Suprasellar glioblastoma is exceedingly rare with only a few prior case reports in the literature. Suprasellar glioblastoma can mimic craniopharyngioma or other more common suprasellar etiologies preoperatively.

OBSERVATIONS

A 65-year-old male with no significant history presented to the emergency department with a subacute decline in mental status. Work-up revealed a large suprasellar mass with extension to the right inferior medial frontal lobe and right lateral ventricle, associated with significant vasogenic edema. The patient underwent an interhemispheric transcallosal approach subtotal resection of the interventricular portion of the mass. Pathological analysis revealed glioblastoma, MGMT partially methylated, with a BRAF V600E mutation.

LESSONS

Malignant glioblastomas can mimic benign suprasellar masses and should remain on the differential for a diverse set of brain masses with a broad range of radiological and clinical features. For complex cases accessible from the ventricle where the pituitary complex cannot be confidently preserved via a transsphenoidal approach, an interhemispheric approach is also a practical initial surgical option. In addition to providing diagnostic value, molecular profiling may also reveal therapeutically significant gene alterations such as BRAF mutations.

Open access

The infundibulochiasmatic angle and the favorability of an endoscopic endonasal approach in type IV craniopharyngioma: illustrative case

Guilherme Finger, Maria Jose C Ruiz, Eman H Salem, Matthew D Marquardt, Kyle C Wu, Lucas P Carlstrom, Ricardo L Carrau, Luciano M Prevedello, and Daniel M Prevedello

BACKGROUND

Lesions located in the floor of the third ventricle are among the most difficult to access in neurosurgery. The neurovascular structures can limit transcranial exposure, whereas tumor extension into the third ventricle can limit visualization and access. The midline transsphenoidal route is an alternative approach to tumor invading the third ventricle if the tumor is localized at its anterior half and a working space between the optic apparatus and the pituitary infundibulum exists. The authors introduce the “infundibulochiasmatic angle,” a valuable measurement supporting the feasibility of the translamina terminalis endoscopic endonasal approach (EEA) for resection of type IV craniopharyngiomas.

OBSERVATIONS

Due to a favorable infundibulochiasmatic angle measurement on preoperative magnetic resonance imaging (MRI), an endoscopic endonasal transsellar transtubercular approach was performed to resect a type IV craniopharyngioma. At 2-month follow-up, the patient’s neurological exam was unremarkable, with improvement in bitemporal hemianopsia. Postoperative MRI confirmed gross-total tumor resection.

LESSONS

The infundibulochiasmatic angle is a radiological tool for evaluating the feasibility of EEA when resecting tumors in the anterior half of the third ventricle. Advantages include reduced brain retraction and excellent rates of resection, with minimal postoperative risks of cerebrospinal fluid leakage and permanent pituitary dysfunction.

Open access

Endoscopic endonasal repair of temporal lobe meningoencephalocele in the lateral recess of the sphenoid sinus, complicated by intracerebral hematoma: illustrative case

Rasim Agaev, Ekaterina Gormolysova, Anton Kalinovskiy, and Jamil Rzaev

BACKGROUND

Anomalies in the anatomical structure of the nasal cavity and paranasal sinuses often serve as a potential cause of spontaneous cerebrospinal fluid (CSF) leakage and may result in the development of a meningoencephalocele. In this report, the authors present a case of surgically treated intrasphenoidal meningoencephalocele attributed to the persistence of the lateral craniopharyngeal canal, which was further complicated by the occurrence of an intracerebral hematoma.

OBSERVATIONS

A temporal lobe meningoencephalocele located in the lateral recess of the sphenoid sinus was successfully managed using endoscopic endonasal transpterygoid repair (EETR). However, an intracerebral hematoma developed after resection of the meningoencephalocele, necessitating additional surgical interventions. Despite this complication, the patient exhibited a favorable clinical outcome after the surgical interventions.

LESSONS

This case highlights the potential risk of intracerebral hematoma associated with EETR of a lateral sphenoid sinus meningoencephalocele. A thorough examination of magnetic resonance imaging scans, especially identifying vascular structures, is crucial during surgical planning. This knowledge can help to prevent the occurrence of complications, including intracerebral hematoma.

Open access

Disconnection of a jugular foramen dural arteriovenous fistula with cortical venous reflux via an intradural retrosigmoid approach: illustrative case

Richard Shaw, Johnny Wong, Hugo Andrade, and Ivan Radovanovic

BACKGROUND

Jugular foramen dural arteriovenous fistulas (DAVFs) are rare and challenging lesions. Described methods of treatment include embolization and microsurgical disconnection through a far lateral transcondylar approach. The authors present the case of a Borden type III jugular foramen DAVF, which was treated with a novel, less invasive retrosigmoid approach with intradural skeletonization and packing of the sigmoid sinus.

OBSERVATIONS

The patient presented with headache and visual field deficit. Neuroimaging demonstrated a right temporal intracerebral hematoma with mass effect. This was due to a Borden type III jugular foramen DAVF with cortical venous reflux into the vein of Labbe secondary to recanalization of a previously thrombosed sigmoid sinus. Microsurgical disconnection was performed via a retrosigmoid approach, in which the sigmoid sinus was identified intradurally at the jugular foramen. The sigmoid sinus was isolated by drilling at the pre- and retrosigmoid spaces to permit packing and clip ligation. Postoperative angiography revealed complete occlusion of the DAVF.

LESSONS

Jugular foramen DAVFs are rare entities, which have been traditionally treated through a far lateral transcondylar approach. An intradural retrosigmoid approach is a safe, less invasive alternative, which involves less soft tissue and bony dissection and does not have the associated morbidity of craniocervical instability and hypoglossal neuropathy.