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Cover Journal of Neurosurgery: Case Lessons

Contralateral interhemispheric transcallosal transchoroidal approach to a thalamic glioma: illustrative case

Sayedali Ahmadi, Vrun J Mistry, and Basant Kumar Misra

BACKGROUND

Thalamic lesions located in the floor of the lateral ventricle pose significant surgical challenges, given their proximity to critical neurovascular structures. Transcortical approaches are often limited by risks of injuring the eloquent cortex and nearby vessels. Furthermore, lesions extending into the third ventricle further impede accessibility. The corticospinal tract (CST), situated close to the thalamus, presents a major obstacle. Diffusion tensor imaging plays a crucial role in overcoming these challenges by accurately delineating the CST’s location relative to the lesion, enabling surgeons to plan minimally invasive and safe access.

OBSERVATIONS

A 32-year-old female presented with progressive right-sided hemiparesis over several days. Magnetic resonance imaging revealed a cystic ring-enhancing thalamic lesion extending into the third ventricle. While supine, the patient underwent surgery via a right pericoronal parasagittal craniotomy followed by a contralateral interhemispheric transcallosal transchoroidal approach.

LESSONS

This case exemplifies the utility of the contralateral interhemispheric transcallosal approach for treating thalamic lesions, particularly those extending into the third ventricle. This minimally invasive approach minimizes retraction of the eloquent cortex and reduces the risk of neurovascular injury, potentially leading to improved surgical outcomes and faster recovery.

Open access

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Cover Journal of Neurosurgery: Case Lessons

Localized anaplastic lymphoma kinase–positive histiocytosis in a cerebellar hemisphere with long-term treatment: illustrative case

Eita Kumagai, Mio Tanaka, Fuminori Iwasaki, Masakatsu Yanagimachi, Daisuke Hirokawa, Hiroaki Goto, and Yukichi Tanaka

BACKGROUND

Anaplastic lymphoma kinase (ALK)–positive histiocytosis (ALK-H) is an emerging entity in the category of histiocytic neoplasms that was first reported as a multisystemic disease in three infants in 2008. The clinicopathological spectrum of ALK-H has been expanded to include localized disorders in specific organs, but the features of this subtype are not well known. The authors report a case of ALK-H localized in the central nervous system that was difficult to treat and review the relevant literature.

OBSERVATIONS

The authors reviewed archival histiocytic tumors at their institute and found a pediatric case of ALK-H localized in a cerebellar hemisphere that had previously been reported as histiocytic sarcoma. Chemotherapy (approximately 1 year), additional surgery, and conventional chemotherapy (approximately 2.5 years) led to clinical remission, and maintenance chemotherapy was continued (approximately 1.5 years). Three years after completing treatment, a high-grade glioma was found in a cerebral hemisphere, and the patient died of the glioma 2 years later.

LESSONS

Although the prognosis of ALK-H is generally good according to prior cases, the authors’ case required long-term conventional chemotherapy, suggesting the tumor displayed aggressive characteristics. Early administration of ALK inhibitors may be necessary.

Open access

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Cover Journal of Neurosurgery: Case Lessons

Erratum. Resection of an incidentally discovered spinal arachnoid web: illustrative case

Ali Bydon

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Cover Journal of Neurosurgery: Case Lessons

Primary intraosseous xanthoma of the frontal bone in a child: illustrative case

Peter J Madsen, Adam J Kundishora, Benjamin C Reeves, Anne M Coyle, Daniel T Nagasawa, Judith M Wong, Isaac Yang, and Alexander M Tucker

BACKGROUND

Skull lesions are a common finding in children, with dermoid cysts and eosinophilic granulomas observed most frequently. However, primary intraosseous xanthomas of the calvaria, which are lytic, expansile lesions that develop without underlying hyperlipidemic disease, are rare in children, with only one prior case reported.

OBSERVATIONS

The authors describe the case of a healthy 6-year-old male who presented with a 2-month history of an enlarging midline skull mass that developed after a recent minor trauma. Imaging showed a full-thickness, lytic frontal bone lesion with an aggressive appearance and heterogeneous contrast enhancement. The patient underwent gross-total resection of the lesion with placement of a mesh cranioplasty. Histopathology revealed a primary intraosseous xanthoma. The patient was discharged on postoperative day 2 and required no further treatment at the 1-month follow-up.

LESSONS

This is the first reported case of a primary intraosseous xanthoma in the frontal bone of a pediatric patient. It emphasizes the need to include primary xanthomas in the differential diagnosis for pediatric skull lesions, particularly when the lesion has an aggressive radiographic appearance or the patient has a history of focal trauma. Furthermore, our findings indicate that resection, together with subsequent monitoring for lesion reccurrence, is an adequate first-line treatment.

Open access

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Cover Journal of Neurosurgery: Case Lessons

Visual dysfunction and neurodegeneration caused by severe inflammatory optic neuropathy after coil embolization of a paraclinoid aneurysm: illustrative case

Tomohiro Okuyama, Kota Kurisu, PhD, Toshiya Osanai, Masaki Ito, Taku Sugiyama, Haruto Uchino, and Miki Fujimura

BACKGROUND

Visual impairment due to delayed optic neuropathy is a rare complication of the endovascular treatment of paraclinoid aneurysms. An inflammatory response induced in the treated aneurysm wall is a known mechanism underlying this pathophysiology. The authors describe a case with severe and progressive optic neuropathy leading to neuronal degeneration and severe visual dysfunction.

OBSERVATIONS

A 42-year-old female with a history of surgical clipping for a paraclinoid aneurysm presented with a recurrence. Although the patient was unaware of any visual dysfunction, a preoperative ophthalmological examination revealed mild inferior quadrantanopia in the left eye. The coil embolization procedure was uneventful; however, the following day, the patient experienced progressive visual impairment, which worsened despite the initiation of steroid therapy. Ophthalmological examination revealed a severe decrease in visual acuity and further deterioration of the visual field. Magnetic resonance imaging showed remarkable swelling and edema of the left optic nerve adjacent to the treated aneurysm. Despite continued steroid therapy, the patient’s visual function did not recover well due to subsequent optic nerve degeneration.

LESSONS

Optic neuropathy after endovascular procedures can lead to severe visual dysfunction. Careful management is essential, particularly when treating a symptomatic paraclinoid aneurysm, even if symptoms are only apparent on detailed examination.

Open access

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Cover Journal of Neurosurgery: Case Lessons

A child with unilateral abducens nerve palsy and neurovascular compression in Chiari malformation type 1 resolved with posterior fossa decompression: illustrative case

Olivia A Kozel, Belinda Shao, Cody A Doberstein, Natalie Amaral-Nieves, Matthew N Anderson, Gita V Harappanahally, Michael A Langue, and Konstantina A Svokos

BACKGROUND

Unilateral cranial nerve (CN) VI, or abducens nerve, palsy is rare in children and has not been reported in association with Chiari malformation type 1 (CM1) in the absence of other classic CM1 symptoms.

OBSERVATIONS

A 3-year-old male presented with acute incomitant esotropia consistent with a unilateral, left CN VI palsy and no additional neurological symptoms. Imaging demonstrated CM1 without hydrocephalus or papilledema, as well as an anterior inferior cerebellar artery (AICA) vessel loop in the immediate vicinity of the left abducens nerve. Given the high risk of a skull base approach for direct microvascular decompression of the abducens nerve and the absence of other classic Chiari symptoms, the patient was initially observed. However, as his palsy progressed, he underwent posterior fossa decompression with duraplasty (PFDD), with the aim of restoring global cerebrospinal fluid dynamics and decreasing possible AICA compression of the left abducens nerve. Postoperatively, his symptoms completely resolved.

LESSONS

In this first reported case of CM1 presenting as a unilateral abducens palsy in a young child, possibly caused by neurovascular compression, the patient’s symptoms resolved after indirect surgical decompression via PFDD.

Open access

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Cover Journal of Neurosurgery: Case Lessons

CyberKnife stereotactic radiosurgery for extramedullary plasmacytoma in the external auditory canal: illustrative case

Surya Patil, Elaheh Shaghaghian, Lorenzo Yuan, Aaryan Shah, Neelan J Marianayagam, David J Park, Scott G Soltys, Anand Veeravagu, Iris C Gibbs, Gordon Li, and Steven D Chang

BACKGROUND

Plasmacytoma, a rare plasma cell disorder, often presents as a solitary or multiple tumors within the bone marrow or soft tissues, typically associated with multiple myeloma. Extramedullary plasmacytomas (EMPs), particularly those located in the external auditory canal (EAC), are exceedingly rare and pose significant treatment challenges given their location, anatomical complexity, and high risk of recurrence.

OBSERVATIONS

The authors report the case of a 72-year-old male with a history of multiple myeloma, presenting with recurrent left EAC plasmacytoma. After initial conventional radiotherapy for the lesion, a recurrence was documented in 7 years. The patient subsequently underwent stereotactic radiosurgery, which proved successful, leading to complete resolution of the lesion without any long-term adverse effects or radiation-related complications over a 45-month period.

LESSONS

This case is a unique instance of utilizing stereotactic radiosurgery for recurrent EMP in the EAC, highlighting its potential as an effective approach in managing complex plasmacytomas.

Open access

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Cover Journal of Neurosurgery: Case Lessons

Angiographic evidence of an inadvertent cannulation of the marginal sinus following central line migration: illustrative case

Abdelaziz Amllay, Edwin Owolo, Kamil W Nowicki, Nanthiya Sujijantarat, Andrew Koo, Joseph P Antonios, Daniela Renedo, Charles C Matouk, and Ryan M Hebert

BACKGROUND

Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration.

OBSERVATIONS

A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well.

LESSONS

Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.

Open access

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Cover Journal of Neurosurgery: Case Lessons

Cartilage within lipomyelomeningocele and ulnar longitudinal deficiency syndrome as VACTERL association, alliance in SHH/GLI3, and Wnt pathway: illustrative case

Mikael Aseged Shimekit, Ermias Fikru Yesuf, Simon Mulugeta Teferi, and Mahlet Getachew Lemma

BACKGROUND

Lipomyelomeningocele associated with an ulnar club hand in the spectrum of VACTERL association ([costo-]vertebral abnormalities; anal atresia; cardiac defects; tracheal-esophageal abnomalities, including atresia, stenosis, and fistula; renal and radial abnormalities; limb abnormalities; single umbilical artery) is a very rare and infrequently reported phenomenon. Within the fat mass of the lipoma, it is not common to find a well-defined cartilaginous mass with no attachments to the surrounding tissue.

OBSERVATIONS

The authors present the case of a 3-month-old male with low-back swelling that was off-center to the left, accompanied by a left short forearm displaying outward bowing. Echocardiography showed an atrial septal defect. This rare VACTERL association comprises lipomyelomeningocele, atrial septal defect, and ulnar longitudinal deficiency syndrome. During surgical intervention for the lipoma, a well-defined cartilaginous mass was discovered within the adipose tissue.

LESSONS

The manifestation of VACTERL association can be partially explained by the Shh/Gli and Wnt pathway defects. It is prudent to screen children with neural tube defects to be aware of any associated syndromes. This case is very rare, and the literature has contained no prior report on the VACTERL association of lipomyelomeningocele, atrial septal defect, and ulnar longitudinal deficiency.

Open access

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Cover Journal of Neurosurgery: Case Lessons

Early cerebral venous drainage associated with focal seizures: a correlation of digital subtraction angiography and electroencephalography. Illustrative case

Olivia Holman, Joseph M Bibawy, Lara Wadi, Joel C Morgenlander, and Erik F Hauck

BACKGROUND

Early venous drainage is a critical diagnostic feature of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs). However, other conditions associated with early venous drainage can mimic AVMs and AVFs and mislead the treating physician team.

OBSERVATIONS

The authors present a unique case of a 56-year-old man with new left hemianopsia. Workup with magnetic resonance imaging and magnetic resonance angiography had revealed cortical enhancement and early venous drainage, possibly caused by an AVF or AVM. Catheter angiography confirmed the presence of early venous drainage of specifically the right occipital lobe. The early venous drainage occurred as the result of local hyperperfusion limited to the right occipital lobe. Subsequent electroencephalography confirmed focal seizure activity in the right occipital lobe. After seizure control with multiple antiepileptic medications, the patient regained his vision. Repeat digital subtraction angiography revealed restoration of normal cerebral blood flow.

LESSONS

Early venous drainage observed during catheter angiography can be associated with seizure activity. Differentiation from other conditions, such as AVM, AVF, or ischemic stroke, is critical to facilitate prompt and appropriate treatment.