Journal of Neurosurgery: Case Lessons
Volume 5 (2023): Issue 6 (Feb 2023)
Open access

BACKGROUND

Spontaneous thrombosis of a developmental venous abnormality (DVA) is a rare complication associated with hypercoagulability. The objective of this case report is to describe an association between DVA thrombosis and mild coronavirus disease 2019 (COVID-19) infection in a vaccinated patient.

OBSERVATIONS

A 28-year-old male with hypertension presented with severe headache and left-sided hemiparesis. Five weeks prior to presentation, the patient experienced mild respiratory symptoms and tested positive for COVID-19. Admission brain computed tomography (CT) showed a large right parieto-occipital intracerebral hemorrhage with surrounding edema. CT venography and catheter angiography showed a thrombosed DVA with associated venous infarction as the hemorrhage etiology. He was treated with decompressive hemicraniectomy, external ventricular drain placement, and systemic anticoagulation. The patient was functionally independent (modified Rankin Scale score, 2) at 4-month follow-up. Hypercoagulability work-up was unremarkable.

LESSONS

Delayed DVA thrombosis after the COVID-19 infectious period may represent an association between the infection and a protracted systemic viral-induced hypercoagulable state. The severity of COVID-19 symptomatology does not appear to correlate with risk of DVA thrombosis. Young patients with a recent history of COVID-19 infection who present with venous infarction should be evaluated for an underlying thrombosed DVA.

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BACKGROUND

Spontaneous intracranial hypotension (SIH) is a relatively rare and underdiagnosed disease. SIH can lead to subdural hematomas (SDHs) and other complications. SDHs secondary to SIH are difficult to manage, with no consensus in management, and SDHs commonly recur if underlying SIH is not treated.

OBSERVATIONS

A 46-year-old male with vague sensory and orientation symptoms presented with bilateral SDHs, which were treated with middle meningeal artery (MMA) embolization and burr hole evacuation. The patient improved initially but had recurrent encephalopathy and SDHs. The patient received 3 epidural blood patches (EBPs) over 8 days with continued improvement. A 78-year-old female presented with headaches, and imaging revealed a left chronic SDH. She underwent MMA embolization and mini-craniotomy for SDH evacuation. Her symptoms returned and imaging revealed a recurrent SDH. Pan spine computed tomography myelography showed a high thoracic cerebrospinal fluid (CSF) leak. She underwent 3 EBPs over 8 days with neurological improvement and stabilization of her SDH.

LESSONS

The authors show that, if SDH recurs after initial treatment with MMA embolization, then SIH should be strongly considered and treated with EBPs. Further investigation is required to determine the role of targeted or blind EBPs and the use of imaging to find the source of occult CSF leaks causing SIH.

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BACKGROUND

There is currently no case described in the literature of epidural hematoma associated with subarachnoid hemorrhage due to dissection of a spontaneous radiculomedullary artery at the lumbar level and therefore its incidence and prevalence are not known. However, its etiology is thought to be similar and may not be diagnosed given its nonspecific symptomatology.

OBSERVATIONS

The authors present the case of an adult patient who consulted the emergency department for 2 weeks of low back pain. On physical examination there were negative signs of radiculopathy without neurological focalization. The patient was evaluated by neurosurgery via thoracic and lumbosacral spine magnetic resonance imaging, with findings of epidural hematoma associated with subarachnoid hemorrhage in the lumbosacral region. After that, panangiography was done. In the study, it was possible to visualize a dissection of the radicular artery at the L2 level. The patient was not a candidate for surgical management and continued with medical pain management. The patient has a good clinical evolution and was discharged.

LESSONS

The aim of the present case is to describe a unique case of radiculomedullary artery dissection as a cause of spontaneous epidural hematoma associated with a subarachnoid hemorrhage in the lumbar region.

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BACKGROUND

Lipomatous meningiomas are an extremely rare, benign meningioma subtype subcategorized under metaplastic meningioma in the most recent 2021 update to the World Health Organization classification. They make up less than 0.3% of all meningiomas and, to date, less than 70 cases have been reported in the literature, none of which have undergone molecular profiling. This study aims to promote the utility of molecular profiling to better diagnose these rare tumors.

OBSERVATIONS

The authors present the first case of a lipomatous meningioma with DNA methylation profiling that both confirmed its benign biology and uncovered unique cytogenetic changes. Molecular characterization of a lipomatous meningioma confirmed its diagnosis as a distinct, benign meningioma subtype and revealed several copy number variations on chromosome 8 and in NF2 and SMARCB1. Here we discuss some of the radiological and histopathological features of lipomatous meningiomas, how they can be used to distinguish from other meningiomas and other similarly presenting tumors, and a brief literature review discussing the pathophysiology and presentation of this rare tumor.

LESSONS

This study provides evidence supporting the use of molecular profiling to diagnose lipomatous meningiomas and guide their clinical management more accurately.

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BACKGROUND

The etiologies of parkinsonism are diverse. A possible and rare cause of hemiparkinsonism is mechanical compression of the basal ganglia and its connecting white matter tracts. The authors present a case of hemiparkinsonism caused by a lateral sphenoid wing meningioma, discuss the underlying pathophysiology based on tractography, and systematically review the existing literature.

OBSERVATIONS

A 59-year-old female was referred for a left-sided tremor of the hand, accompanied by a cogwheel rigidity of the left arm. Symptomatology appeared 1 year earlier and worsened in the previous 6 months, finally also showing involvement of the left leg. Magnetic resonance imaging (MRI) showed a space-occupying suspected meningioma originating from the right lateral sphenoid wing and compressing the ipsilateral striatum. Tractography studies contributed to elucidate the underlying pathophysiology. Resection of the meningioma could be performed without complications. At the 4-month follow-up, the patient’s hemiparkinsonism had completely recovered.

LESSONS

An intracranial space-occupying lesion may be a rare cause of hemiparkinsonism. In new-onset parkinsonism, especially if a secondary form is suspected, brain MRI should be performed promptly to avoid misdiagnosis and treatment. Tractography studies help understand the underlying pathophysiology. After surgical decompression of the affected structures, symptoms can recover completely.

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BACKGROUND

Cystic postradiation degeneration has previously been described in the literature as a rare but potentially severe complication after central nervous system (CNS) irradiation for vascular malformations. Limited cases have been reported in the setting of brain metastases.

OBSERVATIONS

Thirty-six total cases, including three reported here, of cystic postradiation degeneration are identified. Of 35 cases with complete clinical information, 34 (97.25%) of 35 were symptomatic from cystic changes at diagnosis. The average time between initial radiation dose and cyst development was 7.61 years (range 2–31 years). Although most patients were initially treated conservatively with medication, including steroids, 32 (88.9%) of 36 ultimately required surgical intervention. The most common interventions were craniotomy for cyst fenestration or resection (25 of 36; 69.4%) and Ommaya placement (8 of 36). After intervention, clinical improvement was seen in 10 (67%) of 15 cases, with persistent or worsening deficit or death seen in 5 (33%) of 15. Cysts were decompressed or obliterated on postoperative imaging in 20 (83.3%) of 24 cases, and recurrence was seen in 4 (16.7%) of 24.

LESSONS

Cystic degeneration is a rare and delayed sequela after radiation for brain metastases. This entity has the potential to cause significant and permanent neurological deficit if not properly recognized and addressed. Durable control can be achieved with a variety of surgical treatments, including cyst fenestration and Ommaya placement.

Open access

BACKGROUND

The novel coronavirus disease 2019 (COVID-19) can be associated with various neurological manifestations, including cerebrovascular disease, seizures, peripheral nerve disease, and encephalitis. Intracranial abscess related to COVID-19 is rare but illustrates a serious complication in the studied cases.

OBSERVATIONS

The authors report 3 cases of patients presenting with COVID-19 complicated by sinusitis with associated intracranial abscesses. Each patient underwent craniotomy with washout and sinus debridement during their hospital stay. All 3 patients improved to their baseline following treatment. Similar outcomes have been observed in other cases of intracranial abscess associated with COVID-19 infections.

LESSONS

Patients achieved significant improvement following evacuation of the abscess and intravenous antibiotics. Further investigation is needed to determine treatment in relation to COVID-19, and the authors recommend following the standard treatment of intracranial abscess at this time.

Open access

BACKGROUND

Recent literature suggests that spinal infections are increasing in prevalence. Any compartment can be infected in the spine; however, multicompartmental infections are rare.

OBSERVATIONS

To the authors’ knowledge, this report is the only reported case of a tetra-compartmental spinal infection consisting of epidural, subdural, subarachnoid, and intramedullary components with a contiguous lumbar spondylodiscitis resulting in conus medullaris syndrome requiring surgical intervention.

LESSONS

This case highlights the importance of surgical intervention in severe cases such as the one illustrated in this report. Second, magnetic resonance imaging with and without contrast is required to check for spreading of the infection as these findings may change the surgical approach. Last, the use of intraoperative ultrasound is paramount to evaluate the subdural and intramedullary compartments in severe cases.

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BACKGROUND

Neuromuscular choristoma (NMC) is a rare congenital lesion in which muscle tissue is admixed with nerve fascicles within a peripheral nerve. Patients commonly present in early childhood with neuropathy, plexopathy, or chronic undergrowth in the distribution of the affected nerve.

OBSERVATIONS

The authors present the case of a 35-year-old man with unrecognized neuromuscular NMC of the sciatic nerve, which resulted in recurrent, multicentric NMC-associated desmoid-type fibromatosis (NMC-DTF) within the nerve territory in association with a Marjolin ulcer, a cutaneous malignancy.

LESSONS

Based on anatomical and pathophysiological findings described in this case report, the authors support the association between NMC-DTF and Marjolin ulcer.

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