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Management of a challenging dura-embedded anterior inferior cerebellar artery loop during a retrosigmoid hearing-preserving vestibular schwannoma resection: microsurgical technique and operative video. Illustrative case

Jaime L. Martínez Santos, Robert C. Sterner, and Mustafa K. Başkaya

BACKGROUND

Anatomical variants of the anterior inferior cerebellar artery (AICA), such as an anomalous “AICA loop” embedded in the dura and bone of the subarcuate fossa, increase the complexity and risk of vestibular schwannoma resections. Classically, osseous penetrating AICA loops are the most challenging to mobilize, as the dura must be dissected and the surrounding petrous bone must be drilled to mobilize the AICA away from the surgical corridor and out of harm.

OBSERVATIONS

The authors present a rare case of a dura-embedded, osseous-penetrating AICA loop encountered during a hearing-preserving retrosigmoid approach in which they demonstrate safe and efficient microdissection and mobilization of the AICA loop without having to drill the surrounding bone.

LESSONS

Although preoperative recognition of potentially dangerous AICA loops has been challenging, thin-sliced petrous bone computed tomography scanning and high-quality magnetic resonance imaging can be useful in preoperative diagnosis. Furthermore, this report suggests that a retrosigmoid approach is superior, as it allows early intradural recognition and proximal vascular control and facilitates more versatile mobilization of AICA loops.

Open access

Ondine’s curse: clinical presentation with diaphragmatic pacing and spontaneous respiratory recovery. Illustrative case

Alexander J. Schupper, Alex Devarajan, Dong-Seok Lee, Enrique Perez, and Raj K. Shrivastava

BACKGROUND

The complexity of posterior fossa surgery can often lead to rare complications due to the anatomy involved. Vestibular schwannoma resection is a common pathology in the posterior fossa, often requiring surgical intervention. Given the proximity of this space to the brainstem, cranial nerve VII/VIII complex, and posterior inferior cerebellar artery (PICA), neurovascular complications are not infrequent. A rare vascular complication from this surgical approach is a lateral medullary infarction from injury to the lateral medullary segment of the proximal PICA, leading to central hypoventilation syndrome (CHS).

OBSERVATIONS

This report presents a unique case of a 51-year-old man who underwent a retrosigmoid craniectomy for resection of a vestibular schwannoma. Following surgery, the patient was unable to be weaned off the ventilator and was noted to become apneic while he slept, a clinical picture consistent with Ondine’s curse.

LESSONS

This report discusses the anatomical considerations of this surgical corridor leading to this complication and the management of a patient with acquired Ondine’s curse and reviews the scarce literature on this uncommon cause of acquired CHS.