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High cervical disc herniation presenting with C-2 radiculopathy

Case report and review of the literature

Vivek R. Deshmukh, Harold L. Rekate and Volker K. H. Sonntag

✓ The authors report the case of a 78-year-old man with a C2–3 disc herniation that had migrated rostrally, causing C-2 radiculopathy. The C-2 radiculopathy manifested immediately after the patient underwent placement of a ventriculoperitoneal shunt for normal-pressure hydrocephalus. Myelography and computerized tomography scanning of the cervical spine revealed an extradural lesion anterolateral to the thecal sac eccentric to the right. The patient underwent a C1–3 laminectomy, C-2 nerve root decompression, and excision of the lesion. Postoperatively the patient's radiculopathy resolved completely. To the authors' knowledge, this is the first case of a C2–3 disc herniation manifesting as C-2 radiculopathy and treated via a posterior extradural approach.

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Vivek R. Deshmukh, Leonardo Rangel-Castilla and Robert F. Spetzler

Object

Brainstem cavernous malformations (BSCMs) present a unique therapeutic challenge to neurosurgeons. Resection of BSCMs is typically reserved for lesions that reach pial or ependymal surfaces. The current study investigates the lateral inferior cerebellar peduncle as a corridor to dorsolateral medullary BSCMs.

Methods

In this retrospective review, the authors present the cases of 4 patients (3 women and 1 man) who had a symptomatic dorsolateral cavernous malformation with radiographic and clinical evidence of hemorrhage.

Results

All patients underwent excision of the cavernous malformation via a far-lateral suboccipital craniotomy through the foramen of Luschka and with an incision in the inferior cerebellar peduncle. On intraoperative examination, 2 of the 4 patients had hemosiderin staining on the surface of the peduncle. All lesions were completely excised and all patients had a good or excellent outcome (modified Rankin Scale scores of 0 or 1).

Conclusions

This case series illustrates that intrinsic lesions of the dorsolateral medulla can be safely removed laterally through the foramen of Luschka and the inferior cerebellar peduncle.

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Joshua J. Wind, P. Benjamin Kerr, Jennifer A. Sweet and Vivek R. Deshmukh

Pleomorphic xanthoastrocytomas are glial-based tumors that arise most frequently in young patients and usually follow a more benign and indolent clinical course than their other glial-based tumor counterparts. These tumors most frequently present with seizures, and only 3 previous case reports exist of hemorrhagic tumor as the clinical presentation. The authors present the first case of life-threatening intracerebral hemorrhage from pleomorphic xanthoastrocytoma in a child.

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Jonathan S. Hott, Vivek R. Deshmukh, Stephen M. Papadopoulos and Robert F. Spetzler

✓The authors describe a unique headholder device adapted to facilitate the placement of anterior odontoid screws. The patient’s head is affixed in the headholder equipped with an articulating arm that can be placed in a paramedian fashion. This configuration rigidly fixates the head and provides an unencumbered open-mouth view of the odontoid using radiographic images, thus making screw placement easier.

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Christopher P. Ames, Neil R. Crawford, Robert H. Chamberlain, Vivek Deshmukh, Belma Sadikovic and Volker K. H. Sonntag

Object. The authors tested the ability of a resorbable cannulated lag screw composed of a polylactide copolymer to repair Type II odontoid fractures. The resorbable screw was evaluated for its ability to restore strength and stiffness to the fractured odontoid process compared with traditional titanium screws.

Methods. Type II odontoid fractures were created in 14 human cadaveric C-2 vertebrae by applying a posterolaterally directed load and piston displacement was measured. Seven of these specimens were repaired using metal screws and seven were repaired using resorbable screws. Specimens were reinjured using the same mechanism as the initial fracture. Values of ultimate strength and stiffness during failure were statistically compared between metal and resorbable screws and between initial fracture and reinjury.

Conclusions. The stiffness and ultimate strength during initial fracture were significantly greater than those during reinjury in specimens repaired using resorbable screws or titanium screws (p < 0.001). The resorbable and titanium screws both restored 31% of the initial ultimate strength of the intact specimen (p = 0.95). The stiffness of the fractured odontoid process was restored to 15 and 23% of its initial value by repair with resorbable and metal screws, respectively (p = 0.07). The mode of failure in resorbable screws was usually breakage or bending, whereas that in metal screws was consistently cutout of the proximal shaft of the screw through the anterior C-2 vertebral body.

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Felipe C. Albuquerque, David J. Fiorella, Patrick P. Han, Vivek R. Deshmukh, Louis J. Kim and Cameron G. Mcdougall

Object

Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and dramatic neurological injury. The authors reviewed the management of 23 cases in an effort to evaluate treatment efficacy and outcomes.

Methods

The records of 23 patients who underwent endovascular treatment were reviewed to determine symptoms, type of therapy, complications, and clinical outcomes. All patients were evaluated using records kept in a prospectively maintained database.

Ten men and 13 women (age range 35–72 years; mean age 49 years) were treated over an 8-year period. Twelve patients presented with poor-grade SAH, five with good-grade SAH, three with headache, and two with stroke. The other patient's aneurysm was discovered incidentally. Treatment included coil occlusion of the artery at the aneurysm in 21 patients and stent-assisted coil placement in two. Parent artery sacrifice was successful in all cases, whereas both patients treated with stent-assisted coil insertion suffered recurrences. No patient sustained permanent complications as a result of treatment. Two patients died due to the severity of their original SAH. Findings were normal in 14 patients on follow-up review (including five of the 12 presenting with poor-grade SAH), five had fixed neurological deficits but were able to care for themselves, and one was permanently disabled.

Conclusions

Despite their often aggressive neurological presentation, intracranial VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. Even patients presenting in poor neurological condition may improve dramatically.

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Eric M. Horn, Vivek R. Deshmukh, Gregory P. Lekovic and Curtis A. Dickman

✓ The management of spinal meningiomas with extensive involvement of the dura mater is controversial. The principal difficulty in performing a resection is the potential for complications associated with this approach. The authors present the case of a pregnant 35-year-old woman in whom bilateral lower-extremity numbness, weakness, gait ataxia, and myelopathy developed. Magnetic resonance imaging showed a recurrent thoracic meningioma with extensive infiltration of the dura mater. Durectomy, complete resection, and reconstruction were performed. The patient has not experienced a recurrence 21 months after her treatment. This case illustrates that thoracic spinal meningiomas with extensive dural involvement can be resected safely with a complete durectomy. The novel dural reconstruction involving the implantation of a fascia lata and bovine pericardium allograft is an effective way to reconstruct the dura to create an adequate barrier to cerebrospinal fluid.

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Nicholas C. Bambakidis, L. Fernando Gonzalez, Sepideh Amin-Hanjani, Vivek R. Deshmukh, Randall W. Porter, Philip C. Daspit and Robert F. Spetzler

Combined approaches to the skull base provide maximal exposure of the complex and eloquent anatomical structures contained within the posterior fossa. Common to these combined exposures are variable degrees of petrous bone removal. Understanding the advantages of each approach is critical when attempting to balance increases in operative exposure against the risk of potential complications. Despite their risks, aggressive combined exposures to the posterior fossa enable the greatest degree of visualization of the anatomy. Consequently, surgeons can approach lesions with maximal margins of safety, which cannot otherwise be realized. To minimize morbidity in all cases, the approach chosen must be applied individually, depending on the lesion and the patient's characteristics.

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Yin C. Hu, Vivek R. Deshmukh, Felipe C. Albuquerque, David Fiorella, Randal R. Nixon, Donald V. Heck, Stanley L. Barnwell and Cameron G. McDougall

Object

Delayed ipsilateral intraparenchymal hemorrhage has been observed following aneurysm treatment with the Pipeline Embolization Device (PED). The relationship of this phenomenon to the device and/or procedure remains unclear. The authors present the results of histopathological analyses of the brain sections from 3 patients in whom fatal ipsilateral intracerebral hemorrhages developed several days after uneventful PED treatment of supraclinoid aneurysms.

Methods

Microscopic analyses revealed foreign material occluding small vessels within the hemorrhagic area in all patients. Further analyses of the embolic materials using Fourier transform infrared (FTIR) spectroscopy was conducted on specimens from 2 of the 3 patients. Although microscopically identical, the quantity of material recovered from the third patient was insufficient for FTIR spectroscopy.

Results

FTIR spectroscopy showed that the foreign material was polyvinylpyrrolidone (PVP), a substance that is commonly used in the coatings of interventional devices.

Conclusions

These findings are suggestive of a potential association between intraprocedural foreign body emboli and post-PED treatment–delayed ipsilateral intraparenchymal hemorrhage.