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Open access

Cerebral tumor embolism from thyroid cancer treated by mechanical thrombectomy: illustrative case

Yuta Fujiwara, Kentaro Hayashi, Yohei Shibata, Tatsuya Furuta, Tomohiro Yamasaki, Kazuhiro Yamamoto, Masahiro Uchimura, Fumio Nakagawa, Mizuki Kambara, Hidemasa Nagai, and Yasuhiko Akiyama

BACKGROUND

Development in mechanical thrombectomy is progressing dramatically. Tumor embolism has been rarely reported on the basis of pathological study of the retrieved thrombus. Herein, the authors report a case of cerebral tumor embolism from advanced thyroid cancer, which was successfully treated with mechanical thrombectomy.

OBSERVATIONS

A 57-year-old man was diagnosed with thyroid cancer with multiple lung metastases and chemotherapy was planned. He experienced left hemiparesis and was bought to the emergency section of the authors’ hospital. Magnetic resonance angiography revealed right internal carotid artery occlusion and endovascular treatment was performed. Using a combination of aspiration catheter and stent retriever, white jelly-like embolus was retrieved. The pathological study demonstrated thyroid cancer embolism. Pulmonary vein invasion following lung metastasis of thyroid cancer was most presumably the cause of the tumor embolism.

LESSONS

Lung metastasis invading the pulmonary vein may be a cause of tumor embolism. Mechanical thrombectomy using a combination of stent retriever and aspiration catheter is effective in removing the tumor embolus and the pathological examination of the embolus is essential.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Open access

Cerebrospinal fluid fistula as a complication of reverse transcriptase–polymerase chain reaction collection for the detection of coronavirus disease 2019: illustrative cases

Lucca B. Palavani, Camila V. F. Andrade, Renato A. Andrade, Egmond Alves, Marcio Falchi Barros, and João F. Barbieri

BACKGROUND

The most used method to detect coronavirus disease 2019 during the pandemic is reverse transcriptase–polymerase chain reaction with nasal swab. Despite being highly effective, the test does not leave the patient risk-free and can lead to serious complications. These can be traumatic nasal cerebrospinal fluid (CSF) fistula and its consequences, such as meningitis.

OBSERVATIONS

In this article, the authors present 4 case reports and a literature review. The following MeSH terms in the research were used: “CSF leak case report and covid 19.” Six results were found and after searching the references and keywords 16 articles were identified. By using them, the authors tried to clarify the etiology of the fistula, its influences, and complications.

LESSONS

The authors conclude that professionals must receive training, since CSF fistula originates from technical failure and lack of anatomical knowledge. The diagnosis cannot be neglected because it can bring complications to the patient’s health.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Open access

Intracranial aspergilloma mimicking metachronous meningioma following transsphenoidal removal of a tuberculum sellae meningioma: illustrative case

Daisuke Sato, Hirotaka Hasegawa, Hironobu Nishijima, Kyotaro Kawase, Koh Okamoto, Akiko Iwasaki, Yuki Shinya, Masahiro Abe, Yoshitsugu Miyazaki, and Nobuhito Saito

BACKGROUND

Endoscopic transsphenoidal surgery (eTSS) is a well-established approach for resection of skull-based pathologies such as tuberculum sellae meningiomas; however, central nervous system (CNS) fungal infection is a potential complication, particularly in a patient with concomitant sinusitis.

OBSERVATIONS

A 58-year-old woman with a tuberculum sellae meningioma causing progressive visual disturbance and concurrent asymptomatic chronic maxillary sinusitis underwent eTSS. Six months later, a de novo dura-based mass with peripheral edema, which was assumed to be an aggressive metachronous meningioma, developed in the middle cranial fossa. The patient underwent frontotemporal craniotomy for complete resection of the lesion, and subsequent histological examination revealed an aspergilloma. She was then treated with an antifungal agent and endoscopic sinus surgery to clear the sinusitis, and no recurrent fungal infection occurred thereafter.

LESSONS

CNS fungal infections may appear as a dura-based mass mimicking meningioma. The current case reiterates the importance of the appropriate management of sinusitis prior to eTSS.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Open access

L5 mononeuritis, an uncommon cause of foot drop: illustrative case

Oleg Peselzon, Michael Colditz, and Liam R. Maclachlan

BACKGROUND

New-onset adult foot drop is commonly encountered in neurosurgical practice and has a broad differential, including radiculopathy, peroneal nerve palsy, demyelinating diseases, and central causes. Etiology is commonly identified with comprehensive history, examination, imaging, and investigations. Despite familiarity with the management of lumbar spondylosis and peroneal nerve compression causes, rare or uncommon presentations of nonsurgical causes are important to consider in order to avoid nonbeneficial surgery.

OBSERVATIONS

The authors report a very uncommon cause of foot drop: new-onset isolated L5 mononeuritis in a 61-year-old nondiabetic male. They provide a review of the etiology and diagnosis of foot drop in neurosurgical practice and detail pitfalls during workup and the strategy for its nonsurgical management.

LESSONS

Uncommon, nonsurgical causes for foot drop, even in the setting of degenerative lumbar spondylosis, should be considered during workup to reduce the likelihood of unnecessary surgical intervention. The authors review strategies for investigation of new-onset adult foot drop and relate these to an uncommon cause, an isolated L5 mononeuritis, and detail its clinical course and response to treatment.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Open access

Leptomeningeal metastasis from neuroendocrine carcinoma of the cervix: illustrative case

John D. Patterson, Andrew M. Farach, Monisha Singh, Gavin W. Britz, and Robert C. Rostomily

BACKGROUND

Leptomeningeal carcinomatosis is a rare feature of metastasis that is characterized by thickening and increased contrast enhancement throughout the meninges of the central nervous system (CNS). Leptomeningeal disease (LMD) can occur as spread from primary CNS tumors or as a manifestation of metastasis to the CNS from primary tumor sites outside the CNS. Leptomeningeal disease is, however, rare in cervical cancer, in which metastasis occurs typically from local invasion.

OBSERVATIONS

The authors discuss the case of CNS metastasis with LMD from the rare neuroendocrine carcinoma of the cervix (NECC). Cervical cancer infrequently metastasizes to the CNS, but NECC is an aggressive variant with greater metastatic potential. Many of these patients will have previously received pelvic radiation, limiting their candidacy for craniospinal radiation for LMD treatment due to field overlap. This illustrative case documents the first known case of NECC CNS metastasis accompanied by LMD treated with intrathecal chemotherapy.

LESSONS

Reported is the first known case of NECC with CNS metastasis accompanied by LMD. The authors highlight the potentially critical role of intrathecal chemotherapy, in addition to radiotherapy, in treating leptomeningeal metastasis from cervical cancer.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Open access

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

Maxwell Gruber, Nate Klingele, Christy Monson, and Eric A. Sribnick

BACKGROUND

After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home.

OBSERVATIONS

Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection.

LESSONS

In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Open access

Rapidly progressive diffuse leptomeningeal glioneuronal tumor in an adult female: illustrative case

Jonathan Bao, Jared F. Sweeney, Yang Liu, Frank L. Genovese, Matthew A. Adamo, and Robert S. Heller

BACKGROUND

Diffuse leptomeningeal glioneuronal tumor (DLGNT) is a rare brain tumor only recently classified by the World Health Organization in 2016 and has few reports on its incidence in adults.

OBSERVATIONS

The authors describe a case of DLGNT presenting in a 47-year-old female with seizures, cranial neuropathies, and communicating hydrocephalus with rapid clinical progression. Workup demonstrated progressive leptomeningeal enhancement of the skull base, cranial nerves, and spine, and communicating hydrocephalus. Elevated serum rheumatological markers and early response to systemic corticosteroids and immunosuppressant therapy complicated the diagnosis. Multiple biopsy attempts were required to obtain diagnostic tissue. Pathology demonstrated hypercellularity surrounding leptomeningeal vessels with nuclear atypia, staining positive for GFAP, Olig2, S100, and synaptophysin. Molecular pathology demonstrated loss of chromosome 1p, BRAF overexpression but no rearrangement, and H3K27 mutation. Repeat cerebrospinal fluid (CSF) diversion procedures were required for hydrocephalus management due to high CSF protein content.

LESSONS

This report describes a rare, aggressive, adult presentation of DLGNT. Leptomeningeal enhancement and communicating hydrocephalus should raise suspicion for this disease process. Biopsy at early stages of disease progression is essential for early diagnosis and prompt treatment. Further study into the variable clinical presentation, histological and molecular pathology, and optimal means of diagnosis and management is needed.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Open access

Treatment of adverse radiation effects with Boswellia serrata after failure of pentoxifylline and vitamin E: illustrative cases

Ronald E. Warnick

BACKGROUND

Adverse radiation effects (AREs) can occur after stereotactic radiosurgery (SRS), and symptomatic cases are often treated with corticosteroids, pentoxifylline, and vitamin E. The supplement 5-Loxin (Boswellia serrata) is an extract of Indian frankincense that inhibits vascular endothelial growth factor expression and has been shown to reduce perilesional edema in brain tumor patients undergoing fractionated radiation.

OBSERVATIONS

Three patients underwent SRS for meningioma or metastasis and developed symptomatic AREs at 4 to 8 months. They were initially treated with corticosteroids, pentoxifylline, and vitamin E with transient improvement followed by recurrent neurological symptoms and imaging findings as steroids were tapered off. All patients were rescued by the administration of 5-Loxin with resolution of neurological symptoms and imaging changes, discontinuation of steroids, and no medication side effects.

LESSONS

The author’s early experience with 5-Loxin has been encouraging, and this supplement has become the author’s first-line treatment for acute radiation effects after SRS. The author reserves bevacizumab for significant mass effect or failure of oral therapy. 5-Loxin has many advantages including low cost, ease of use, and patient tolerability. More experience is needed to confirm the role of 5-Loxin in the upfront treatment of AREs.

In Journal of Neurosurgery: Case Lessons Volume 5 (2023): Issue 5 (Jan 2023)

Restricted access

2-Hydroxyglutarate magnetic resonance spectroscopy in adult brainstem glioma

Hirofumi Iwahashi, Hiroaki Nagashima, Kazuhiro Tanaka, Takiko Uno, Mitsuru Hashiguchi, Masahiro Maeyama, Yuichiro Somiya, Masato Komatsu, Takanori Hirose, Tomoo Itoh, Ryohei Sasaki, and Takashi Sasayama

OBJECTIVE

Adult brainstem gliomas (BSGs) are rare tumors of the CNS that are poorly understood. Upregulation of the oncometabolite 2-hydroxyglutarate (2HG) in the tumor indicates the mutation of isocitrate dehydrogenase (IDH), which can be detected by magnetic resonance spectroscopy (MRS). Although histological examination is required for the definitive diagnosis of BSG, 2HG-optimized MRS (2HG-MRS) may be useful, considering the difficult nature of brainstem lesion biopsy. The aim of this study was to evaluate the utility of 2HG-MRS for diagnosing IDH-mutant adult BSG.

METHODS

Patients with a radiographically confirmed brainstem tumor underwent 3T MRS. A single voxel was set in the lesion with reference to the T2 or fluid-attenuated inversion recovery image and analyzed according to the 2HG-tailored MRS protocol (point-resolved spectroscopic sequence; echo time 35 msec). All patients underwent intraoperative navigation-guided or CT-guided stereotactic biopsy for histopathological diagnosis. The status of IDH and H3K27M mutations was confirmed by immunohistochemistry and direct DNA sequencing. In addition, the authors examined the relationship between patients’ 2HG concentrations and survival time.

RESULTS

Ten patients (7 men, 3 women; median age 33.5 years) underwent 2HG-MRS and biopsy. Four patients had an H3K27M mutation and 4 had an IDH1 mutation (1 R132H canonical IDH mutation, 2 R132S and 1 R132G noncanonical IDH mutations). Two had neither H3K27M nor IDH mutations. The H3K27M and IDH mutations were mutually exclusive. Most tumors were located in the pons. There was no significant radiological difference between mutant H3K27M and IDH on a conventional MRI sequence. A 2HG concentration ≥ 1.8 mM on MRS demonstrated 100% (95% CI 28%–100%) sensitivity and 100% (95% CI 42%–100%) specificity for IDH-mutant BSG (p = 0.0048). The median overall survival was 10 months in IDH–wild-type BSG patients (n = 6) and could not be estimated in IDH-mutant BSG patients (n = 4) due to the small number of deaths (p = 0.008).

CONCLUSIONS

2HG-MRS demonstrated high sensitivity and specificity for the prediction of IDH-mutant BSG. In addition, 2HG-MRS may be useful for predicting the prognosis of adult BSG patients.

In Journal of Neurosurgery Publish Before Print

Restricted access

Association of calcium channel blockers with lower incidence of intracranial aneurysm rupture and growth in hypertensive patients

*Qingyuan Liu, Jiangan Li, Yisen Zhang, Xinyi Leng, Mahmud Mossa-Basha, Michael R. Levitt, Shuo Wang, and Chengcheng Zhu

OBJECTIVE

Calcium channel blockers (CCBs) are antihypertensive agents with potential vascular protection effects. This study investigated whether CCB usage was associated with a lower incidence of unruptured intracranial aneurysm (UIA) instability (growth and rupture) in patients with hypertension.

METHODS

UIA patients were included in two prospective, multicenter cohort studies (IARP-CP and 100-Project cohorts). All patients received conservative treatment and were regularly followed up every 6 months by CT angiography for 2 years. Patients taking CCBs at least 5 days per week were considered CCB users; otherwise, they were considered non-CCB users. The primary endpoint was UIA instability (rupture, growth of > 20% and/or 1 mm in any dimension, or appearance of a new dome irregularity on imaging follow-up).

RESULTS

A total of 392 UIA patients with hypertension (191 male, 201 female; median age 57 years) were included with a mean follow-up duration of 21.7 ± 5.2 months. The primary endpoint was met in 81 patients (20.7%) during follow-up, including 68 patients with aneurysms that grew and 13 with aneurysms that ruptured. CCB users had a lower UIA instability rate than non-CCB users (27/237 [11.4%] vs 54/155 [34.8%], p < 0.001). Multivariable Cox analysis demonstrated that CCB use was associated with a lower risk of UIA instability (HR 0.37, 95% CI 0.22–0.61; p < 0.001). The protective effect of CCB use was consistent in patients taking a single antihypertensive agent (HR 0.22, 95% CI 0.12–0.40; p < 0.001) and patients taking > 1 antihypertensive agent (HR 0.42, 95% CI 0.20–0.87; p = 0.021). For patients with controlled hypertension, CCB use was still associated with a lower risk of UIA instability (HR 0.22, 95% CI 0.09–0.52; p = 0.001).

CONCLUSIONS

In UIA patients with hypertension, CCB use was associated with a lower incidence of aneurysm instability.

In Journal of Neurosurgery Publish Before Print