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Open access

Acute morphological changes of impending rupture of vertebral artery dissection: clinical management of symptomatic but unruptured vertebral artery dissection. Illustrative case

Tatsuya Mori, Atsushi Fujita, Masaki Iwakura, Jun Imura, Kana Onobuchi, Masaaki Kohta, Hidehito Kimura, and Takashi Sasayama

BACKGROUND

The reported actual risk of rupture for vertebral artery dissection (VAD) in patients presenting with headache is very low, ranging from 0.4% to 1.0%. The authors report a case in which the dissection site dilated rapidly within several hours after the dissection occurred resulting in subarachnoid hemorrhage (SAH).

OBSERVATIONS

A 49-year-old healthy man who had participated in a marathon noticed a headache while running. Magnetic resonance imaging (MRI) performed 2 days later revealed no findings suspicious for right VAD, but a string sign was observed in the left side, suggesting left VAD. Three hours following MRI, he developed severe headaches and became unconscious at home, prompting emergency services to rush him to the hospital. A computed tomography scan showed diffuse SAH and a rapidly enlarged aneurysmal dilatation in the right vertebral artery. He underwent endovascular internal trapping to prevent rebleeding. He was discharged without any neurological symptoms. No recurrence or new dissection occurred after 2 years of follow-up.

LESSONS

Even in the absence of typical imaging findings, strict management, such as blood pressure control, is required when clinical findings strongly suggest VAD, and differentiation of VAD from primary headache is important.

https://thejns.org/doi/10.3171/CASE24202

Open access

Feasibility of targeting the cingulate gyrus using high-intensity focused ultrasound on a cadaveric specimen: illustrative case

Francesco Sammartino, James Mossner, Hunter Stecko, Nihaal Reddy, and Brian Dalm

BACKGROUND

Cancer is commonly associated with pain. For patients with advanced cancer and intractable pain, ablative neurosurgical procedures can significantly improve pain and transition patients out of inpatient settings. These procedures are normally invasive, and this poses an important risk in this population. Cingulotomy has been reported to improve pain perception and contribute substantially to the quality of life of cancer patients with refractory pain.

OBSERVATIONS

One fresh human cadaver specimen was used for the setup. The cingulate gyrus was targeted using intraoperative magnetic resonance images, and osseous aberrations were corrected after coregistration with the preoperative head computed tomography.

After accounting for sinuses, membrane folds, and calcifications, a total of 737 elements were available for thermal ultrasound ablation. On high-power sonications, the total energy delivered reached a peak temperature of 57°C (15,050 J, 350 W, 45 seconds) in the right cingulate and 52°C (13,000 J, 405 W, 46 seconds) in the left cingulate.

LESSONS

Despite the limitations of using a cadaver model (temperature, vascularization), cingulotomy appears to be feasible using high-intensity focused ultrasound.

https://thejns.org/doi/10.3171/CASE2459

Open access

Index-level fusion and adjacent segment disease following dynamic stabilization for lumbar degenerative disc disease: illustrative case

Kathleen R Ran, Tej D Azad, Bhavya Pahwa, Lydia J Bernhardt, and Ali Bydon

BACKGROUND

Dynesys dynamic stabilization (DDS) is an alternative to surgical fusion for the operative management of degenerative lumbar spondylosis. Compared to rigid instrumentation and fusion, DDS is purported to preserve a higher degree of spinal range of motion and reduce the risk of developing adjacent segment disease (ASD).

OBSERVATIONS

A 60-year-old female presented with severe back pain and bilateral leg pain, which had progressed over the prior 4 years. Nine years earlier, she had undergone DDS system implantation at L5–S1 for lumbar stenosis and spondylosis. Repeat imaging revealed an unintended fusion at the index level (L5–S1) and ASD causing severe lateral recess stenosis at L4–5. She underwent DDS system removal, decompression at L4–5, and extension of the fusion to L4.

LESSONS

Although DDS has been marketed as a motion-preserving system that avoids fusion and reduces the risk of ASD, unintended index-level fusion and ASD can still occur after DDS system surgery. These potential complications should be assessed when determining the optimal primary surgical treatment for patients with lumbar degenerative disc disease.

https://thejns.org/doi/10.3171/CASE24179

Open access

Rare simultaneous fetal posterior cerebral artery and conventional posterior cerebral artery duplication in a patient with a ruptured posterior communicating artery aneurysm: illustrative case

Abrar A Ahmed, Gökce Hatipoglu Majernik, Alonso Alvarado-Bolaño, Maria Bres-Bullrich, and Sachin K Pandey

BACKGROUND

The fetal-type posterior cerebral artery (PCA) is defined as a variant anatomy in which the posterior communicating artery (PCOM) is larger than the hypoplastic or aplastic P1 segment of the PCA. The authors present the novel case of a patient with a duplicated right PCA in parallel with fetal-type and conventional PCAs supplying adjacent components of the PCA cerebral territory.

OBSERVATIONS

A 59-year-old woman presented with a modified Fisher Scale score 4 subarachnoid hemorrhage. A right irregular PCOM aneurysm that measured 9.5 mm × 4.5 mm × 4.5 mm arose from the base of a variant branch supplying a portion of the PCA, rather than a conventional PCOM, and was found on digital subtraction angiography. Following endovascular coil embolization, the patient was discharged home.

LESSONS

The fetal-type variant has implications for thromboembolic events. If an embolism occludes the anterior circulation in a patient with a fetal-type PCA, it may result in an infarct in the PCA territory. Awareness of cerebral arterial anatomy, including an atypical collateral supply, informs a treating team’s latitude in tolerance of which sites must be preserved and which can be safely sacrificed.

https://thejns.org/doi/10.3171/CASE23735

Open access

Splenic rupture following prone lateral discectomy and arthrodesis: illustrative case

Alexandra Echevarria, Benjamin Hershfeld, Emily Arciero, and Rohit Verma

BACKGROUND

The prone lateral approach to lumbar spine surgery is known to have a multitude of potential complications, including damage to neurovascular structures, surrounding viscera, and intra-abdominal structures near the surgical site. However, iatrogenic injury to the spleen following prone lateral lumbar discectomy and arthrodesis as a potential complication has not yet been described in the literature.

OBSERVATIONS

The authors present the case of a 71-year-old female with a history of L3–S1 laminectomy and L3–5 arthrodesis who underwent a prone lateral discectomy of L2–3 with arthrodesis of the endplates for chronic lower-back pain. On postoperative day 1, the patient developed hypotension unresponsive to pressor medications, significant abdominal pain, and anemia requiring 2 transfusions. Bedside ultrasound revealed free fluid in the abdomen. She then underwent an exploratory laparotomy for splenic injury.

LESSONS

Although rare, splenic rupture should be considered as part of the differential diagnosis for patients with hemodynamic instability after lateral surgical approaches to the lumbar spine. Any patient with evidence of hypotension, anemia, and/or abdominal pain following lumbar surgery should be evaluated for splenic injury with an abdominal computed tomography scan and considered for surgical intervention.

https://thejns.org/doi/10.3171/CASE23639

Open access

Spontaneous resolution of traumatic cervical epidural hematoma: illustrative case

Grace R Fassina, Sherwin A Tavakol, Caple A Spence, and Christopher S Graffeo

BACKGROUND

Cervical epidural hematomas are rare and can arise for many reasons. Patients typically present with pain and/or symptoms of spinal cord compression. Prompt surgical decompression is typically pursued when deficits are present in an effort to improve long-term neurological outcomes. However, the authors report the case of a patient with a traumatic dorsal cervical epidural hematoma with spontaneous resolution within 16 hours.

OBSERVATIONS

A 49-year-old male with a history of C5–6 anterior cervical fusion 3 years prior presented with neck pain after blunt force trauma. The exam revealed only tenderness in the cervical spine. Initial computed tomography revealed fractures of C1 and C4. Urgent magnetic resonance imaging (MRI) demonstrated a dorsal cervical epidural hematoma causing compression of the spinal cord from the occiput to C5. An operation was scheduled for the following morning; however, after he reported new symptoms, repeat MRI was performed, which confirmed no evidence of a cervical epidural hematoma.

LESSONS

This case demonstrates that a traumatic cervical epidural hematoma can resolve spontaneously within a short time frame. Close monitoring of these patients is vital, and it is important to reimage patients if new signs and/or symptoms arise to potentially change the timing and/or nature of the proposed surgery.

https://thejns.org/doi/10.3171/CASE24167

Open access

Stereo electroencephalography–guided radiofrequency ablation in focal epilepsia partialis continua: illustrative case

Mikael Levy, Nir Getter, Moshe Zer-Zion, Alexie Mirson, Fidda Abu Arisheh, Ahmad Kilani, Sandy Madar, Mordechai Lorberboym, Frida Shemesh, and Jehuda Sepkuty

BACKGROUND

Epilepsia partialis continua (EPC) is a variant of focal motor status epilepticus that can occur as a single or repetitive episode with progressive or nonprogressive characteristics.

OBSERVATIONS

The authors describe the feasibility of identifying focal EPC in a 33-year-old woman using video electroencephalography (VEEG), electroencephalography source localization, [18F]fluorodeoxyglucose positron emission tomography, magnetic resonance imaging, and psychiatric and neuropsychological assessments and of treating it with stereo electroencephalography–guided radiofrequency (SEEG-RF) ablation. EPC comprised recurrent myoclonus of the right thigh and iliopsoas with a progressive pain syndrome after left anterior-temporo-mesial resection. Switching between VEEG under regular and epidural block helped to define myoclonus as the presenting ictal symptom with a suspected seizure onset zone in the left parietal paramedian lobule. After the epileptic network was identified, SEEG-RF ablation abolished all seizures. No correlation was found between pain and VEEG/SEEG abnormalities. Rehabilitation began 3 days after the SEEG-RF ablation. By 1 year of follow-up, the patient had no EPC and could walk with assistance in rehabilitation; however, due to the abrupt abolishment of EPC and underlying psychological factors, the patient perceived her pain as overriding, which prevented her from walking.

LESSONS

The application of SEEG-RF ablation is an efficient therapeutic option for focal EPC with special concerns regarding concurrent nonepileptic pain.

https://thejns.org/doi/10.3171/CASE23611

Restricted access

An analysis of potentially avoidable neurosurgical transfers to a tertiary-care level I trauma center

Clifford M. Marks, Ryan C. Burke, Martina Stippler, and Carlo L. Rosen

OBJECTIVE

Previous studies of neurosurgical transfers indicate that substantial numbers of patients may not need to be transferred, suggesting an opportunity to provide more patient-centered care by treating patients in their communities, while probably saving thousands of dollars in transport and duplicative workup. This study of neurosurgical transfers, the largest to date, aimed to better characterize how often transfers were potentially avoidable and which patient factors might affect whether transfer is needed.

METHODS

This was a retrospective cohort study of neurosurgical transfers to an urban, tertiary-care, level I trauma center between October 1, 2017, and October 1, 2022. Prior to data analysis, the authors devised criteria to differentiate necessary neurosurgical transfers from potentially avoidable ones. A transfer was considered necessary if 1) the patient went to the operating room within 12 hours of arrival at the emergency department (ED); 2) a neurological MRI study was conducted in the ED; 3) the patient was admitted to the ICU from the ED; or 4) the patient was admitted to either neurology or a surgical service (including neurosurgery). Transfers not meeting any of the above criteria were deemed potentially avoidable. Patient and clinical characteristics, including diagnostic groupings from Clinical Classification Software categories, were collected retrospectively via electronic health record data abstraction and stratified by whether the transfer was necessary or potentially avoidable. Statistical differences were assessed with a chi-square test.

RESULTS

A total of 5113 neurosurgical transfers were included in the study, of which 1701 (33.3%) were classified as potentially avoidable. Four percent of all transferred patients went to the operating room within 12 hours of reaching the receiving ED, 23.4% were admitted to the ICU from the ED, 26.6% had a neurological MRI study performed in the ED, and 54.4% were admitted to a surgical service or to neurology. Potentially avoidable transfers had a higher proportion of traumatic brain injury, headache, and syncope (p < 0.0001), as well as of spondylopathies/spondyloarthropathies (p = 0.0402), whereas patients needing transfer had a higher proportion of acute hemorrhagic cerebrovascular disease and cerebral infarction (p < 0.0001).

CONCLUSIONS

This study demonstrates that a large number of neurosurgical transfers can probably be treated in their home hospitals and highlights that the vast majority of patients transferred for neurosurgical conditions do not receive emergency neurosurgery. Further research is needed to better guide transferring and receiving facilities in reducing the burden of excessive transfers.

Restricted access

Association of earlier surgery with improved postoperative language development in children with tuberous sclerosis complex

Sina Sadeghzadeh, Thomas M. Johnstone, Jurriaan M. Peters, Brenda E. Porter, and S. Katie Z. Ihnen

OBJECTIVE

The authors evaluated the impact of the timing of epilepsy surgery on postoperative neurocognitive outcomes in a cohort of children followed in the multiinstitutional Tuberous Sclerosis Complex (TSC) Autism Center of Excellence Research Network (TACERN) study.

METHODS

Twenty-seven of 159 patients in the TACERN cohort had drug-refractory epilepsy and underwent surgery. Ages at surgery ranged from 15.86 to 154.14 weeks (median 91.93 weeks). Changes in patients’ first preoperative (10–58 weeks) to last postoperative (155–188 weeks) scores on three neuropsychological tests—the Mullen Scales of Early Learning (MSEL), the Vineland Adaptive Behavior Scales, 2nd edition (VABS-2), and the Preschool Language Scales, 5th edition (PLS-5)—were calculated. Pearson correlation and multivariate linear regression models were used to correlate test outcomes separately with age at surgery and duration of epilepsy prior to surgery. Analyses were separately conducted for patients whose seizure burdens decreased postoperatively (n = 21) and those whose seizure burdens did not (n = 6). Regression analysis was specifically focused on the 21 patients who achieved successful seizure control.

RESULTS

Age at surgery was significantly negatively correlated with the change in the combined verbal subtests of the MSEL (R = −0.45, p = 0.039) and predicted this score in a multivariate linear regression model (β = −0.09, p = 0.035). Similar trends were seen in the total language score of the PLS-5 (R = −0.4, p = 0.089; β = −0.12, p = 0.014) and in analyses examining the duration of epilepsy prior to surgery as the independent variable of interest. Associations between age at surgery and duration of epilepsy prior to surgery with changes in the verbal subscores of VABS-2 were more variable (R = −0.15, p = 0.52; β = −0.05, p = 0.482).

CONCLUSIONS

Earlier surgery and shorter epilepsy duration prior to surgery were associated with greater improvement in postoperative language in patients with TSC. Prospective or comparative effectiveness clinical trials are needed to further elucidate surgical timing impacts on neurocognitive outcomes.

Restricted access

A brief history of neurosurgery in Bosnia and Herzegovina: historical vignette

Ibrahim Omerhodžić, Bekir Rovčanin, Haso Sefo, Rasim Skomorac, Harun Brkić, and Kenan Arnautović

The modern period of neurosurgery in Bosnia and Herzegovina began with the first neurosurgical procedure performed by Dr. Karl Bayer in 1891 on 3 patients with depressed skull fractures and epilepsy. In 1956 the Department of Surgery in Sarajevo designated several beds specifically for a neurosurgical unit. A significant milestone in the history of neurosurgery in Bosnia and Herzegovina was the establishment of the Division of Neurosurgery at the Clinical Center University of Sarajevo in 1970. The first neurosurgeon to complete his training in Bosnia and Herzegovina was Dr. Faruk Konjhodžić. The first female neurosurgeon was Dr. Nermina Iblizović. Presently, there are 7 neurosurgical departments in the country, located in Sarajevo, Tuzla, Zenica, Mostar, Banja Luka, Bihać, and Foča. The Association of Neurosurgeons in Bosnia and Herzegovina, founded in 2003, is a member of the European Association of Neurosurgical Societies and the World Federation of Neurosurgical Societies. The aim of this historical paper is to provide a concise chronology of important events and mention key individuals who have contributed to the development of modern neurosurgery in Bosnia and Herzegovina.