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Open access

Thoracic spinal cord injury after surgical removal of a ruptured cerebellar arteriovenous malformation in a patient in the Concorde position: illustrative case

Kohei Ishikawa, Hideki Endo, Yasufumi Ohtake, Toshiichi Watanabe, and Hirohiko Nakamura

BACKGROUND

Thoracic spinal cord injury after posterior cranial fossa surgery in younger patients is a rare complication. There have been reports of this complication in tumor and spine fields but not in vascular surgery.

OBSERVATIONS

A 22-year-old-man experienced cerebellar arteriovenous malformation rupture, and the malformation was surgically removed with the man in the Concorde position. After surgery, the man had severe paraplegia, and a thoracic spinal cord injury was diagnosed.

LESSONS

In younger patients, cervical hyperflexion in the Concorde position can cause thoracic spinal cord injury even in surgery for cerebrovascular disease.

Open access

Isolated unilateral alar ligamentous injury: illustrative cases

Benjamin C Reeves, Marcus Valcarce-Aspegren, Stephanie M Robert, Aladine A Elsamadicy, Alexander M Tucker, Phillip B Storm, Michael L DiLuna, and Adam J Kundishora

BACKGROUND

Isolated unilateral alar ligament injury (IUALI) is a rare and likely underreported occurrence after upper cervical trauma, with only 16 cases documented in the literature to date. Patients generally present with neck pain, and definitive diagnosis is typically made by magnetic resonance imaging (MRI). Unfortunately, likely due in part to its rarity, there are no formal guidelines for the treatment of an IUALI. Furthermore, there is a limited understanding of the long-term consequences associated with its inadequate treatment.

OBSERVATIONS

Here, the authors report on three pediatric patients, each found to have an IUALI after significant trauma. All patients presented with neck tenderness, and two of the three had associated pain-limited range of neck motion. Imaging revealed either a laterally deviated odontoid process on cervical radiographs and/or MRI evidence of ligamentous strain or discontinuity. Each patient was placed in a hard cervical collar for 1 to 2 months with excellent resolution of symptoms. A comprehensive review of the literature showed that all patients with IUALI who had undergone external immobilization with either rigid cervical collar or halo fixation had favorable outcomes at follow-up.

LESSONS

For patients with IUALI, a moderate course of nonsurgical management with rigid external immobilization appears to be an adequate first-line treatment.

Open access

Electric burn of the skull: treatment by applying trepanations and wound dressing. Illustrative case

Sergio M Georgeto, Marcio F Lehmann, Adriano T Antonucci, Marcel Schiavini, Shiro M. A Shimoakoishi, Anibal R Neto, Lutero C. M Santos, Dalmo G Correia, Murilo Scapin, and Eloah S Marcilio

BACKGROUND

Although electric injuries to human tissue are uncommon in contemporary times, their occurrence implies a high degree of morbidity and mortality. These are primarily attributed to the impact of electric current on cellular membranes, resulting in the disruption of ionic changes.

OBSERVATIONS

In this paper, the authors present the case of an electric burn on the skull in a 50-year-old male, treated by utilizing trepanation and daily sterile wound dressing. This approach differs from the conventional treatment involving tissue grafts.

LESSONS

Although the techniques utilized in this case are not commonly chosen as the initial treatment option, they have demonstrated effectiveness. Despite the absence of tissue flaps or grafts, satisfactory coverage of the skull cap was achieved.

Open access

Infantile traumatic pericallosal aneurysm: illustrative case

Zachary S Hubbard, Conor M Cunningham, Brian F Saway, Matthew J Triano, Aaron T Miller, Guilherme Porto, Libby Kosnik Infinger, and Alejandro M Spiotta

BACKGROUND

Traumatic aneurysms are a rare sequela of nonaccidental head trauma in infants. The rate of nonaccidental trauma (NAT) in the pediatric population is increasing; therefore, traumatic aneurysms are an important consideration in the evaluation of pediatric patients with abusive head trauma.

OBSERVATIONS

A 24-day-old infant with no significant past medical or birth history presented with twitching and poor oral intake for 1 day. The patient was found to have bilateral subdural hematomas, multifocal contusions, and traumatic subarachnoid hemorrhage. NAT work-up was remarkable for a period of repeated and prolonged abuse. Magnetic resonance angiography revealed a right pericallosal traumatic aneurysm that was treated by means of coil and Onyx embolization.

LESSONS

Traumatic intracranial aneurysms are a rare but serious sequela of pediatric abusive trauma. Traumatic intracranial aneurysms should be considered in the setting of intracranial pathology associated with high-energy trauma. Despite new methods for the management of traumatic aneurysms, this pathology remains challenging to identify and treat, and the prognosis remains poor because of the diffuse injury often involved in these patients.

Open access

Management of a recurrent spinal arachnoid cyst presenting as arachnoiditis in the setting of spontaneous spinal subarachnoid hemorrhage: illustrative case

Omar Hussain, Randall Treffy, Hope M Reecher, Andrew L DeGroot, Peter Palmer, Mohamad Bakhaidar, and Saman Shabani

BACKGROUND

Spontaneous spinal subarachnoid hemorrhage is a rare pathological entity with a variety of presentations depending on the underlying etiology, which often remains cryptogenic. The literature is sparse regarding the most efficacious treatment or management option, and there is no consensus on follow-up time or modalities. Additionally, there are very few reports that include operative videos, which is provided herein.

OBSERVATIONS

The authors present a case of spontaneous spinal subarachnoid hemorrhage without an underlying etiology in a patient with progressive myelopathy, back pain, and lower-extremity paresthesias. She presented to our institution, and because of progressive worsening of her symptoms and the development of compressive arachnoid cysts, she underwent thoracic laminectomies for evacuation of subdural fluid, fenestration of the arachnoid cysts, and lysis of significant arachnoid adhesions. Her clinical course was further complicated by the recurrence of worsening myelopathy and the development of a large compressive arachnoid cyst with further arachnoiditis. The patient underwent repeat surgical intervention for cyst decompression with an improvement in symptoms.

LESSONS

This case highlights the importance of long-term follow-up for these complicated cases with an emphasis on repeat magnetic resonance imaging. Unfortunately, surgical intervention is associated with short-term relief of the symptoms and no significant nonoperative management is available for these patients.

Open access

Successful management of delayed traumatic cervical spondyloptosis with neurological deficit: illustrative case

Ibrahim Dao, Salifou Napon, Ousmane Ouattara, Abdoulaye Sanou, Elie Nassoum, Sylvain Delwendé Zabsonré, and Abel Kabré

BACKGROUND

Cervical spondyloptosis is a serious condition scarcely encountered by spine surgeons. Few cases have been reported in the literature. There are no general guidelines for their management, especially in delayed cases. The authors describe their surgical technique for the management of cervical spondyloptosis 45 days after the trauma.

OBSERVATIONS

A 28-year-old patient was admitted 45 days after head and cervical trauma leading to quadriplegia with muscular strength at the C5 level. Cervical computed tomography scanning and magnetic resonance imaging revealed C6–7 spondyloptosis with complete slippage of the C6 vertebral body in front of C7. Posterior and anterior cervical spine approaches during the same surgery allowed decompression and stabilization, leading to a dramatic improvement in the neurological deficit. The patient was able to walk 18 months later with near normal balance.

LESSONS

Traumatic cervical spondyloptosis requires early management to increase the possibility of decompression through anatomical realignment and stabilization. In delayed cases, a combined anterior and posterior cervical spine approach according to our technique allows decompression and stabilization with a good postoperative outcome possible.

Open access

Chronic subdural hematoma associated with type II and type III Galassi arachnoid cysts: illustrative cases

Bac Thanh Nguyen, Van Dinh Tran, Jehan Bista, and Trung Van Trinh

BACKGROUND

Arachnoid cysts (ACs) are congenital abnormalities that can be located anywhere within the subarachnoid space along the cerebrospinal axis, although they are most often found on the left side in the temporal fossa and sylvian fissure. ACs comprise approximately 1% of all intracranial space-occupying lesions and are considered potential risk factors for subdural hematoma (SDH) in individuals of all age groups who have experienced traumatic brain injury. Although it is uncommon for an intracystic hemorrhage of an AC to occur without evidence of head trauma, it may be more common among children and young adults. Here, the authors present three cases of spontaneous AC intracystic hemorrhage with chronic SDH. Additionally, they provide a thorough review of the existing literature.

OBSERVATIONS

All three patients with AC were adolescent males. In all cases, AC was identified using the Galassi classification (type II or III) and associated with spontaneous intracystic hemorrhage and chronic SDH as seen on imaging.

LESSONS

Spontaneous intracystic hemorrhage is a rare complication and occurs most commonly on the left side. Surgery is the definitive treatment, requiring either craniotomy or burr hole for hematoma evacuation and microsurgical fenestration to drain the cyst into the subarachnoid cisterns.

Open access

Bilateral occipital condyle fracture with an avulsion fracture of the foramen magnum: nonoperative care guided by a traction test. Illustrative case

Amit R Persad, Eva Liu, Adam Wu, and Daryl R Fourney

BACKGROUND

Bilateral occipital condyle fractures (OCFs) with involvement of the inferior clivus, otherwise known as “avulsion of the anterior foramen magnum,” are an exceedingly rare injury with only a few published reports.

OBSERVATIONS

A 24-year-old male presented with bilateral OCFs with involvement of the clivus after a motor vehicle accident. The patient had no neurological deficits and was successfully managed nonoperatively using a halo vest. The authors used a traction test to guide the duration of nonoperative care. The operative and nonoperative management of this rare injury is discussed with respect to other cases in the literature.

LESSONS

External immobilization through a halo vest is an effective treatment option for bilateral OCFs with clivus involvement. The traction test can be used, along with computed tomography, to guide the duration of treatment.

Open access

Delayed neurological improvement in a patient with Duret hemorrhage secondary to an acute subdural hematoma: illustrative case

Youngkyung Jung, Yosef Ellenbogen, and Farhad Pirouzmand

BACKGROUND

Duret hemorrhage is a rare phenomenon wherein rapid transtentorial herniation results in brainstem injury and hemorrhage. It is usually regarded as a poor prognostic factor representing irreversible and often catastrophic brain injury. The authors report an unusual case of Duret hemorrhage with spontaneous delayed neurological recovery postoperatively after surgical treatment of an acute subdural hematoma (SDH).

OBSERVATIONS

The authors present the case of a 65-year-old male who initially presented to the hospital with a large acute left-sided SDH causing 1.3 cm of midline shift. He was taken urgently for a craniotomy, with no significant intraoperative swelling or visible contusions. Postoperative imaging revealed an unexpected pontine hyperdensity concerning for a Duret hemorrhage. He initially had no neurological improvement; however, at 3 weeks postoperatively, he gradually recovered and was able to follow commands and was extubated. At 10 weeks after surgery, his Glasgow Coma Scale score improved to 15, with mild residual left hemiparesis.

LESSONS

This case challenges a classic dogma that Duret hemorrhage carries a universally poor outcome. In select cases, patients can make meaningful recoveries in a delayed fashion. The lack of intraoperative contusions and swelling may have contributed to this patient’s recovery.

Open access

Vacuum-assisted scalp repositioning: a novel temporizing approach to acute sinking skin flap syndrome. Illustrative cases

Evan Courville, Joshua Marquez, Michael Homma, Michael Conley, Georgios P Skandalakis, Peter Shin, James Botros, and Christian Ricks

BACKGROUND

This report describes the use of a novel approach to address acute sinking skin flap syndrome (SSFS), a postcraniectomy complication arising from brain dysfunction beneath the skull defect. The authors present a case series of two patients, emphasizing the prospective application of an external plaster cast in tandem with a vacuum-assisted closure (VAC) device (wound VAC) to promptly reposition the scalp and relieve brain compression.

OBSERVATIONS

Following intervention, one patient showed immediate neurological improvement, with complete resolution of symptoms within hours. Conversely, the second patient developed nonconvulsive status epilepticus. Computed tomography scans postintervention validated the successful scalp repositioning and mass effect resolution in both instances. This temporary approach proved successful in one patient with moderate symptoms, serving as a bridge to cranioplasty.

LESSONS

The integration of an external plaster cast and wound VAC offers a cost-effective and prompt solution for patients with acute SSFS pending cranioplasty. Appropriate patient selection and heightened caution for those with severe symptoms should be exercised.