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Open access

Samuel Wood and Gennadiy Fuzaylov

BACKGROUND

The authors report a case of venous air embolism (VAE) during a pediatric posterior fossa craniotomy with resulting pulmonary edema requiring postoperative ventilation. Pulmonary edema is a known but rare complication of VAE, and diagnosis and treatment are discussed.

OBSERVATIONS

The embolism was undetected during the surgical procedure, and the first clinical sign of respiratory decompensation appeared an hour after the initial insult, with imaging suggesting acute pulmonary edema. A transient but significant end-tidal carbon dioxide decrease was detected on postoperative review of the anesthesiology record.

LESSONS

This report highlights an uncommon sequela of VAE and the importance of post hoc automated record review for intraoperative event analysis.

Open access

M. Travis Caton, Kazim Narsinh, Amanda Baker, Adib A. Abla, Jarod L. Roland, Van V. Halbach, Christine K. Fox, Heather J. Fullerton, and Steven W. Hetts

BACKGROUND

The authors recently reported a series of children with vertebral artery (VA) compression during head turning who presented with recurrent posterior circulation stroke. Whether VA compression occurs during head positioning for cranial surgery is unknown.

OBSERVATIONS

The authors report a case of a child with incidental rotational occlusion of the VA observed during surgical head positioning for treatment of an intracranial arteriovenous fistula. Intraoperative angiography showed dynamic V3 occlusion at the level of C2 with distal reconstitution via a muscular branch “jump” collateral, supplying reduced flow to the V4 segment. She had no clinical history or imaging suggesting acute or prior stroke. Sequential postoperative magnetic resonance imaging scans demonstrated signal abnormality of the left rectus capitus muscle, suggesting ischemic edema.

LESSONS

This report demonstrates that rotational VA compression during neurosurgical head positioning can occur in children but may be asymptomatic due to the presence of muscular VA–VA “jump” collaterals and contralateral VA flow. Although unilateral VA compression may be tolerated by children with codominant VAs, diligence when rotating the head away from a dominant VA is prudent during patient positioning to avoid posterior circulation ischemia or thromboembolism.

Open access

Sarut Chaisrisawadisuk, Nithiwat Vatanavicharn, Verayuth Praphanphoj, Peter J. Anderson, and Mark H. Moore

BACKGROUND

Squamosal sutures are minor sutures of the human skull. Early isolated fusion of the sutures (squamosal synostosis) is rarely found.

OBSERVATIONS

The authors report a case of a girl who presented with an abnormal head shape and bilateral squamosal synostosis. Genetic testing revealed a chromosome 1p12–1p13.3 deletion. She has been managed with conservative treatment of the synostosis. She has global developmental delay and multiple anomalies due to the chromosome abnormality.

LESSONS

Isolated squamosal suture synostosis could be an uncommon feature of chromosome 1p12–1p13.3 deletion.

Open access

Ryuichi Noda, Shunsuke Yanagisawa, Masato Inoue, and Tetsuo Hara

BACKGROUND

Malignant pleural mesothelioma (MPM) is a rare cancer, and in 80% of cases the cause is asbestos exposure. In 1972, the World Health Organization (WHO) declared asbestos is a carcinogenic substance. Since then, every developed country has restricted and banned the product. Because of its high heat resistance, asbestos had been widely used as building material for decades. The WHO estimated that approximately 125 million people are exposed to asbestos, and more than 107,000 die from asbestos-related diseases annually. Because of its long incubation period, the number of patients is estimated to keep increasing in the near future.

OBSERVATIONS

The authors report a case of long-surviving MPM with a rushed clinical course after brain metastasis. A 69-year-old woman diagnosed with MPM (epithelial type) 6 years earlier presented with a brain metastasis. The pathological result of the brain metastasis was the sarcomatoid type. This case showed the possibility of subtype transition after long survival.

LESSONS

This article aids in understanding the long-term natural history of MPM and the possibility of epithelial-mesenchymal transition. Neurosurgeons have to be aware of its the natural history and the possibility of brain metastasis.

Open access

Christopher Lee, Lucinda Chiu, Pawan Mathew, Gabrielle Luiselli, Charles Ogagan, Rrita Daci, Brittany Owusu-Adjei, Rona S. Carroll, and Mark D. Johnson

BACKGROUND

Placement of a ventriculoperitoneal (VP) shunt is an effective treatment for several disorders of cerebrospinal fluid flow. A rare complication involves postoperative migration of the distal catheter out of the intraperitoneal compartment and into the subcutaneous space. Several theories attempt to explain this phenomenon, but the mechanism remains unclear.

OBSERVATIONS

The authors report the case of a 37-year-old nonobese woman who underwent placement of a VP shunt for idiopathic intracranial hypertension. Postoperatively, the distal catheter of the VP shunt migrated into the subcutaneous space on three occasions despite the use of multiple surgical techniques, including open and laparoscopic methods of abdominal catheter placement. Notably, the patient repeatedly displayed radiographic evidence of chronic bowel distention consistent with increased intraperitoneal pressure.

LESSONS

In this case, the mechanism of catheter migration into the subcutaneous space did not appear to be caused by pulling of the catheter from above but rather by expulsion of the catheter from the peritoneum. Space in the subcutaneous tissues caused by open surgical placement of the catheter was permissive for this process. Patients with chronic increased intraabdominal pressure, such as that caused by bowel distention, obesity, or Valsalva maneuvers, may be at increased risk for distal catheter migration.

Open access

Shivani Gillon, Jacqueline C. Junn, Emily A. Sloan, Nalin Gupta, Alyssa Reddy, and Yi Li

BACKGROUND

Angiomatoid fibrous histiocytoma (AFH) is a rare, slowly progressive neoplasm that most commonly occurs in soft tissues. AFH rarely occurs in bone such as the calvaria. The authors present a case of AFH in the petrous temporal bone, which, to their knowledge, is the first case of AFH in this location.

OBSERVATIONS

A 17-year-old girl presented with worsening positional headaches with associated tinnitus and hearing loss. Imaging demonstrated an extraaxial mass extending into the right cerebellopontine angle, with erosion of the petrous temporal bone, with features atypical for a benign process. The patient underwent retrosigmoid craniotomy for tumor resection. Pathology was consistent with a spindle cell tumor, and genetic testing further revealed an EWSR1 gene rearrangement, confirming the diagnosis of AFH. The patient was discharged with no complications. Her symptoms have resolved, and surveillance imaging has shown no evidence of recurrence.

LESSONS

The authors report the first case of AFH in the petrous temporal bone and only the second known case in the calvaria. This case illustrates the importance of the resection of masses with clinical and imaging features atypical of more benign entities such as meningiomas. It is important to keep AFH in the differential diagnosis for atypical masses in the calvaria and skull base.

Open access

Lei Han, Jie Lu, Luxiong Fang, Songtao Qi, and Ye Song

BACKGROUND

Simultaneous intracranial and testicular germ cell tumors (GCTs) are extremely rare, leading to a lack of adequate experience in their treatment. Therefore, the authors report a case of this kind of GCT.

OBSERVATIONS

A 5-year-old boy was admitted to the hospital with headache and vomiting. Computed tomography and magnetic resonance imaging suggested the possibility of a GCT in the pineal region. The value of the serum tumor marker alpha-fetoprotein (AFP) was 5,396.1 μg/L, and β-human chorionic gonadotropin levels were within the normal range. Subsequently, the tumor was removed, and the final pathological result was a mixed GCT. Therefore, chemotherapy and radiation were added. However, the authors found a testicular tumor on ultrasound at the same time, and pathology after surgery suggested a mature cystic teratoma. Following treatment, the patient recovered well, and AFP levels dropped to normal values.

LESSONS

To the authors’ knowledge, this report is the fourth case of simultaneous intracranial and testicular GCTs and the first case of a simultaneous mixed GCT in the pineal region and mature teratoma of the testis. A combination of surgery, chemotherapy, and radiation therapy for mixed GCTs in the pineal region and surgical excision for testicular reproductive cell tumors are effective in these patients, but long-term monitoring is required.

Open access

Matthew T. Neal, Alexandra E. Richards, Kara L. Curley, Kliment Donev, Mark K. Lyons, and Maziyar A. Kalani

BACKGROUND

Intramedullary spinal cord tumors represent a minority of intradural tumors. Among intramedullary spinal cord tumors, hemangioblastomas are uncommon, and schwannomas are extremely rare. Collision tumors are histologically distinct tumors that are intermingled and growing together.

OBSERVATIONS

In this report, the authors describe a patient with a cervical intramedullary collision tumor involving a hemangioblastoma and schwannoma. To the authors’ knowledge, no prior spinal intramedullary collision tumor involving multiple neoplasms has been described. The patient’s presentation and management are described.

LESSONS

Clinicians should consider the possibility of collision tumors when evaluating intramedullary spinal cord tumors, especially when patient presentation and radiographic findings are atypical. When tumors with similar radiographic characteristics form collision tumors, distinction using preoperative imaging can be extremely challenging. In addition, surgical management of intramedullary collision tumors, like that for all intramedullary spinal cord tumors, should involve meticulous perioperative care and a methodical surgical technique. Maximal safe resection will depend upon histopathological diagnosis, anatomical location of the tumor, presence of distinct dissection planes, and stability of neuromonitoring. Finally, ongoing research on the genetics of intramedullary spinal cord tumors may identify underlying genetic links for intramedullary hemangioblastomas and schwannomas.

Restricted access

Anthony L. Mikula, Jeremy L. Fogelson, Soliman Oushy, Zachariah W. Pinter, Pierce A. Peters, Kingsley Abode-Iyamah, Arjun S. Sebastian, Brett Freedman, Bradford L. Currier, David W. Polly, and Benjamin D. Elder

OBJECTIVE

Pelvic incidence (PI) is a commonly utilized spinopelvic parameter in the evaluation and treatment of patients with spinal deformity and is believed to be a fixed parameter. However, a fixed PI assumes that there is no motion across the sacroiliac (SI) joint, which has been disputed in recent literature. The objective of this study was to determine if patients with SI joint vacuum sign have a change in PI between the supine and standing positions.

METHODS

A retrospective chart review identified patients with a standing radiograph, supine radiograph, and CT scan encompassing the SI joints within a 6-month period. Patients were grouped according to their SI joints having either no vacuum sign, unilateral vacuum sign, or bilateral vacuum sign. PI was measured by two independent reviewers.

RESULTS

Seventy-three patients were identified with an average age of 66 years and a BMI of 30 kg/m2. Patients with bilateral SI joint vacuum sign (n = 27) had an average absolute change in PI of 7.2° (p < 0.0001) between the standing and supine positions compared to patients with unilateral SI joint vacuum sign (n = 20) who had a change of 5.2° (p = 0.0008), and patients without an SI joint vacuum sign (n = 26) who experienced a change of 4.1° (p = 0.74). ANOVA with post hoc Tukey test showed a statistically significant difference in the change in PI between patients with the bilateral SI joint vacuum sign and those without an SI joint vacuum sign (p = 0.023). The intraclass correlation coefficient between the two reviewers was 0.97 for standing PI and 0.96 for supine PI (p < 0.0001).

CONCLUSIONS

Patients with bilateral SI joint vacuum signs had a change in PI between the standing and supine positions, suggesting there may be increasing motion across the SI joint with significant joint degeneration.

Restricted access

Dong Hyun Lee, Dong-Geun Lee, Jin Sub Hwang, Jae-Won Jang, Dae Hyeon Maeng, and Choon Keun Park

OBJECTIVE

Whereas the benefits of indirect decompression after lateral lumbar interbody fusion are well known, the effects of anterior lumbar interbody fusion (ALIF) have not yet been verified. The purpose of this study was to evaluate the clinical and radiological effects of indirect decompression after ALIF for central spinal canal stenosis. In this report, along with the many advantages of the anterior approach, the authors share cases with good outcomes that they have encountered.

METHODS

The authors performed a retrospective analysis of 64 consecutive patients who underwent ALIF for central spinal canal stenosis with instability and mixed foraminal stenosis between January 2015 and December 2018 at their hospital. Clinical assessments were performed using the visual analog scale score, the Oswestry Disability Index, and the modified Macnab criteria. The radiographic parameters were determined from pre- and postoperative cross-sectional MRI scans of the spinal canal and were compared to evaluate neural decompression after ALIF. The average follow-up period was 23.3 ± 1.3 months.

RESULTS

All clinical parameters, including the visual analog scale score, Oswestry Disability Index, and modified Macnab criteria, improved significantly. The mean operative duration was 254.8 ± 60.8 minutes, and the intraoperative bleeding volume was 179.8 ± 119.3 ml. In the radiological evaluation, radiological parameters of the cross-sections of the spinal canal showed substantial development. The spinal canal size improved by an average of 43.3% (p < 0.001) after surgery. No major complications occurred; however, aspiration guided by ultrasonography was performed in 2 patients because of a pseudocyst and fluid collection.

CONCLUSIONS

ALIF can serve as a suitable alternative to extensive posterior approaches. The authors suggest that ALIF can be used for decompression in central spinal canal stenosis as well as restoration of the foraminal dimensions, thus allowing decompression of the nerve roots.