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Open access

Nebras M. Warsi, Ann Wilson, Armaan K. Malhotra, Jerry C. Ku, Ahmed A. Najjar, Esther Bui, Michael Baker, Eric Bartlett, and Mojgan Hodaie

BACKGROUND

The purpose of the present case report is to highlight the presentation, workup, clinical decision making, and operative intervention for a 68-year-old woman who developed rapidly progressive myelopathy secondary to idiopathic cervical intramedullary abscess.

OBSERVATIONS

The patient underwent laminectomy and aspiration/biopsy of the lesion. Intraoperatively, division of the posterior median sulcus released a large volume of purulent material growing the oral pathogens Eikenella corrodens and Gemella morbillorum. Broad-spectrum antibiotics were initiated postoperatively. At the 6-month follow-up, the patient had almost completely recovered with some persistent hand dysesthesia. Complete infectious workup, including full dental assessment and an echocardiogram, failed to reveal the source of her infection.

LESSONS

The authors report the first case of cryptogenic spinal intramedullary abscess secondary to Eikenella spp. and Gemella spp. coinfection. Intramedullary abscesses are exceptionally rare and most commonly develop in children with dermal sinus malformations or in the context of immunosuppression. In adults without risk factors, they can readily be mistaken for more common pathologies in this age group, such as intramedullary neoplasms or demyelinating disease. Prompt diagnosis and management based on rapidly progressive myelopathy, assessment of infectious risk factors and/or symptoms, and targeted imaging are critical to avoid potentially devastating neurological sequelae.

Open access

Salah-Eddine Achahbar, Thomas Somers, and Tony Van Havenbergh

BACKGROUND

Camurati-Engelmann disease (CED) is a rare condition characterized by hyperostosis of the long bones and skull base. Symptoms include contractures and pain in affected extremities but can also include manifestations of cranial hyperostosis such as intracranial hypertension, Chiari malformation, exophthalmia, frontal bossing, and several cranial neuropathies due to cranial foraminal stenosis.

OBSERVATIONS

This report describes a 27-year-old patient with suspected CED who developed progressive intermittent facial nerve paresis, hemifacial spasms, and a decrease in hearing. There were no symptoms of increased intracranial pressure or vertigo. Radiological evaluation showed a significant thickening of the skull base with serious bilateral internal auditory canal stenosis. Because of the progressive nature of the aforementioned cranial neuropathies in combination with the correlating severe radiological compression, a surgical decompression of the facial nerve and vestibulocochlear nerve was performed via a retrosigmoid approach with intraoperative monitoring. Postoperative facial nerve function was intact. Hearing and vestibular function were unchanged. There were no more episodes of facial nerve palsy or spasm.

LESSONS

To the authors’ knowledge, this is the first report to describe decompression of the internal auditory canal via a retrosigmoid approach for symptomatic facial and cochlear nerve compression in a patient with CED.

Open access

Katsuma Iwaki, Koichi Arimura, Ataru Nishimura, and Koji Iihara

BACKGROUND

The authors document the first case of pure arterial malformations (PAMs) of the posterior communicating artery (PCoA), which were successfully treated with microsurgical clipping of the main body of the PAMs. PAMs are defined as dilated, overlapping, and tortuous arteries with a coil-like appearance and/or a mass of arterial loops without any associated venous component. Although PAMs usually have a benign history and are often incidental findings, this case presented with acute progression of visual field impairment.

OBSERVATIONS

Because the patient’s right optic tract was affected by the loop of PAMs of the PCoA, the authors performed microsurgical clipping of the main body of the PAMs using endoscopy, which ceased the progression of symptoms without any complications.

LESSONS

There have been several reports of PAMs receiving surgical treatment for accompanying lesions. However, in this case, the lesion to the main body of PAMs was the cause of visual field impairment and was successfully treated with microsurgical clipping.

Open access

Yosuke Sato, Yoshihito Tsuji, Yuta Kawauchi, Kazuki Iizuka, Yusuke Kobayashi, Ryo Irie, Tatsuya Sugiyama, and Tohru Mizutani

BACKGROUND

In epilepsy surgery for cavernoma with intractable focal epilepsy, removal of the cavernoma with its surrounding hemosiderin deposition and other extended epileptogenic zone has been shown to improve postsurgical seizures. However, there has been no significant association between such an epileptogenic zone and intraoperative electrocorticography (ECoG) findings. The authors recently demonstrated that high regular gamma oscillation (30–70 Hz) regularity (GOR) significantly correlates with epileptogenicity.

OBSERVATIONS

The authors evaluated the utility of intraoperative GOR analysis in epilepsy surgery for cavernomas. The authors also analyzed intraoperative ECoG data from 6 patients with cavernomas. The GOR was calculated using a sample entropy algorithm. In 4 patients, the GOR was significantly high in the area with the pathological hemosiderin deposition. In 2 patients with temporal cavernoma, the GOR was significantly high in both the hippocampus and the area with the pathological hemosiderin deposition. ECoG showed no obvious epileptic waveforms in 3 patients, whereas extensive spikes were observed in 3 patients. All patients underwent cavernoma removal plus resection of the area with significantly high GOR. The 2 patients with temporal cavernomas underwent additional hippocampal transection. All patients were seizure free after surgery.

LESSONS

The high GOR may be a novel intraoperative marker of the epileptogenic zone in epilepsy surgery for cavernomas.

Open access

Matthew T. Neal, Kara L. Curley, Alexandra E. Richards, Maziyar A. Kalani, Mark K. Lyons, and Victor J. Davila

BACKGROUND

Anterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections.

OBSERVATIONS

The authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors’ knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures.

LESSONS

When retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.

Open access

Yosuke Akamatsu, Santiago Gomez-Paz, Justin M. Moore, Christopher S. Ogilvy, and Ajith J. Thomas

BACKGROUND

Cervical arterial tortuosity is not uncommon in patients with spontaneous carotid artery dissections (CADs), but the tortuosity often precludes endovascular stent reconstruction. The authors report 2 cases of emergency recanalization of a carotid tonsillar loop dissection using a Pipeline embolization device (PED).

OBSERVATIONS

Two patients presented with symptomatic CAD involving tonsillar looping of the cervical internal carotid artery (ICA). Although the tonsillar loop prevented navigation of the carotid and peripheral stent delivery system, a PED was easily navigated and successfully deployed, resulting in successful recanalization of a looped ICA.

LESSONS

Emergency recanalization of a cervical CAD using a PED is a feasible alternative for treating a cervical CAD associated with tonsillar loops.

Open access

Naoki Kato, Issei Kan, Yukiko Abe, Katharina Otani, Michihisa Narikiyo, Gota Nagayama, Kengo Nishimura, Ryosuke Mori, Tomonobu Kodama, Toshihiro Ishibashi, and Yuichi Murayama

BACKGROUND

The authors describe a noninvasive intraoperative imaging strategy of three-dimensional (3D) digital subtraction angiography (DSA) with intravenous (IV) contrast injection, using indocyanine green (ICG) as a test bolus, during extracranial-intracranial (EC-IC) bypass surgery for moyamoya disease.

OBSERVATIONS

Four patients underwent EC-IC bypass surgery in a hybrid operating room. During the surgery, bypass patency was verified using ICG videoangiography and Doppler ultrasonography. After skin closure, the patients under anesthesia underwent IV 3D-DSA with a robotic C-arm in which the scan delay time for the 3D-DSA scan was estimated from the arrival time of ICG during the ICG videoangiography. One day after the surgery, the patients underwent magnetic resonance angiography (MRA). The IV 3D-DSA images were retrospectively compared with those obtained with other modalities. Good bypass patency was confirmed on IV 3D-DSA, ICG videoangiography, Doppler ultrasonography, and postoperative MRA in all cases. The delay time determined using ICG videoangiography as a test bolus resulted in IV 3D-DSA with adequate image quality, allowing assessment of the spatial relationships between the vessels and anastomoses from all directions.

LESSONS

To evaluate bypass patency and anatomical relationships immediately after EC-IC bypass surgery, IV 3D-DSA may be a useful modality. ICG videoangiography can be used to determine the scan delay time.

Restricted access

Sarah Stricker, Grégoire Boulouis, Sandro Benichi, Marie Bourgeois, Florent Gariel, Lorenzo Garzelli, Jean-François Hak, Quentin Alias, Basile Kerleroux, Kevin Beccaria, Anaïs Chivet, Timothée de Saint Denis, Syril James, Giovanna Paternoster, Michel Zerah, Manoelle Kossorotoff, Nathalie Boddaert, Francis Brunelle, Philippe Meyer, Stéphanie Puget, Olivier Naggara, and Thomas Blauwblomme

OBJECTIVE

Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM.

METHODS

This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King’s Outcome Scale for Childhood Head Injury.

RESULTS

A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71–0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13–26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3–10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I–II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently.

CONCLUSIONS

HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.

Restricted access

Eui Hyun Kim, Jihwan Yoo, In-Ho Jung, Ji Woong Oh, Ju-Seong Kim, Jin Sook Yoon, Ju Hyung Moon, Seok-Gu Kang, Jong Hee Chang, and Tae Hoon Roh

OBJECTIVE

The insula is a complex anatomical structure. Accessing tumors in the insula remains a challenge due to its anatomical complexity and the high chance of morbidity. The goal of this study was to evaluate the feasibility of an endoscopic transorbital approach (ETOA) to the insular region based on a cadaveric study.

METHODS

One cadaveric head was used to study the anatomy of the insula and surrounding vessels. Then, anatomical dissection was performed in 4 human cadaveric heads using a dedicated endoscopic system with the aid of neuronavigation guidance. To assess the extent of resection, CT scanning was performed before and after dissection. The insular region was directly exposed by a classic transcranial approach to check the extent of resection from the side with a classic transcranial approach.

RESULTS

The entire procedure consisted of two phases: an extradural orbital phase and an intradural sylvian phase. After eyelid incision, the sphenoid bone and orbital roof were extensively drilled out with exposure of the frontal and temporal dural layers. After making a dural window, the anterior ramus of the sylvian fissure was opened and dissected. The M2 segment of the middle cerebral artery (MCA) was identified and traced posterolaterally. A small corticectomy was performed on the posterior orbital gyrus. Through the window between the lateral lenticulostriate arteries and M2, the cortex and medulla of the insula were resected in an anteroposterior direction without violation of the M2 segment of the MCA or its major branches. When confirmed by pterional craniotomy, the sylvian fissure and the MCA were found to be anatomically preserved. After validation of the feasibility and safety based on a cadaveric study, the ETOA was successfully performed in a patient with a high-grade glioma (WHO grade III) in the right insula.

CONCLUSIONS

The transorbital route can be considered a potential option to access tumors located in the insula. Using an ETOA, the MCA and its major branches were identified and preserved while removal was performed along the long axis of the insula. In particular, lesions in the anterior part of the insula are most benefited by this approach. Because this approach was implemented in only one patient, additional discussion and further verification is required.

Restricted access

Dong Ah Shin and Dong Kyu Chin

Originally founded in 1885, Gwanghyewon later became the Severance Hospital (named after philanthropist Louis Severance, who supported and funded the construction of a modern hospital) and Yonsei University College of Medicine. The Department of Neurosurgery at Severance Hospital was established in 1957, and its residency program began in 1961. Currently, the Department of Neurosurgery has 34 professors and 17 fellows; specialties include vascular, functional, pediatric, tumor, skull base, and spine neurosurgery. With its state-of-the-art neurosurgical facilities and services, the Department of Neurosurgery has developed into a department of excellence within the Yonsei University Health System. In this vignette, the authors present a historic overview of the Department of Neurosurgery.