Browse | jns (original) (raw)

Amirhossein Akhavan-Sigari, David J. Park, Paul M. Harary, Maya Chivakula, Debebe Theodros, Krishna L. Bharani, Yusuke S. Hori, Amit R. L. Persad, Fred C. Lam, Sara C. Emrich, Louisa Ustrzynski, Armine Tayag, and Steven D. Chang

BACKGROUND

The co-occurrence of Rathke cleft cysts (RCCs) and meningiomas in the sellar and parasellar regions represents an exceedingly rare clinical entity. Achieving maximal resection through a single operative approach while minimizing adverse events is challenging, often necessitating multiple surgical approaches, as suggested by previous reports.

OBSERVATIONS

The authors report the case of a 49-year-old female with a history of kidney transplant who presented with headaches and was diagnosed with coexisting RCC and meningioma in the sellar and planum sphenoidale regions, respectively. Given the prolonged, refractory nature of her symptoms and based on her treatment preferences, a two-stage surgical approach was planned. This involved an endoscopic transnasal transsphenoidal approach followed by a right craniotomy to achieve maximal tumor resection while minimizing potential complications. No residual disease or tumor remnants were present at the 6-month follow-up. The pituitary gland was preserved, and the patient’s preoperative symptoms had fully resolved.

LESSONS

The preoperative diagnosis of concurrent skull base tumors is essential for effective management planning and determining the optimal surgical approach. The proximity of these tumors to critical neurovascular structures necessitates meticulous surgical planning to minimize adverse effects while ensuring maximal tumor resection.

https://thejns.org/doi/10.3171/CASE24551

Aleksandra B. Lasica, Cornel Tancu, Zeid A. Abussuud, Laurence D. Watkins, and Patrick J. Grover

BACKGROUND

Stereotactic radiosurgery (SRS) is a well-established option for the management of intracranial tumors, including meningiomas. Although valued for its low invasiveness and precision, it still carries a risk of complications. Communicating hydrocephalus is a serious, albeit rarely reported, complication of SRS. Here, the authors report two cases of communicating hydrocephalus following Gamma Knife radiosurgery (GKRS) for periventricular meningiomas.

OBSERVATIONS

In both reported cases, the patients experienced a sudden deterioration in their clinical condition a few months after the second GKRS for recurrent periventricular World Health Organization grade II atypical meningiomas. The patients underwent ventriculoperitoneal shunt implantation, and cerebrospinal fluid (CSF) samples revealed elevated levels of total protein and albumin. Additionally, both patients underwent multiple resections before radiation, and some of their lesions were located near the venous sinuses.

LESSONS

Though rare, communicating hydrocephalus represents a significant potential sequela of SRS for meningiomas that clinicians should be aware of. Factors such as tumor volume and location, histology, and previous irradiation or surgery can exacerbate radiation-induced damage and collectively underlie the development of hydrocephalus. The authors also speculate that the CSF protein levels can serve as a unifying marker of SRS-induced radiation damage in the form of radiation-associated tumor necrosis, radiation-induced hyperpermeability, and inflammatory response.

https://thejns.org/doi/10.3171/CASE24722

M. Kodeeswaran, Gaurav R. Dhoka, Jamila Alagarsamy, K. P. Priyadharshan, Arun Narinder, Panchabakesan Manivannan, and Bipin Chaurasia

BACKGROUND

A 71-year-old male presented with weakness of the right upper limb and headache for the past 3 months. Brain magnetic resonance imaging (MRI) with contrast showed a left frontal space-occupying lesion, suggestive of a high-grade malignancy. Awake craniotomy with complete excision of the lesion was performed under immunofluorescence guidance. On postoperative day 2, the patient developed signs of meningoencephalitis and died. The histopathology report showed an abscess with parasitic infection, suggestive of primary amoebic meningoencephalitis (PAM), an infection caused by Naegleria fowleri.

OBSERVATIONS

The patient presented with the above symptoms. Intraoperatively, the lesion exhibited fluorescence uptake and had a firm consistency. The patient did not exhibit any new neurological deficits during surgery, but on postoperative day 2, signs of meningitis emerged, and his condition deteriorated, ultimately leading to his death.

LESSONS

PAM typically manifests with nonspecific symptoms of meningitis, progressing to a rapidly developing, severe form of meningitis that has a high mortality rate. The patient displayed obscure symptoms, and brain MRI revealed a space-occupying lesion with fluorescence uptake during surgery, suggestive of a high-grade malignancy. The diagnosis of PAM as a high-grade malignant space-occupying lesion was confirmed postmortem through histopathological analysis, a presentation considered exceedingly rare and unprecedented in the literature.

https://thejns.org/doi/10.3171/CASE24358

Jorge Zumaeta, Raul Martinez, Noe Santiago Rea, William Efrain Anicama-Lima, Sandro Casavilca-Zambrano, and Jose Valerio

BACKGROUND

Astroblastoma is an extremely rare tumor of the central nervous system, and its origin and validity as a different entity are still being debated. Because of its rarity and similarities to other glial neoplasms, it is often misdiagnosed, impacting treatment and outcomes.

OBSERVATIONS

Astroblastoma is very rare and mainly affects children and young adults. It does not have a definitive World Health Organization grade and is divided into low- and high-grade categories. The clinical presentation is consistent with signs of intracranial hypertension. Radiographic imaging shows a bubbly, solid-cystic supratentorial mass with irregular contrast enhancement. The case reported herein is unusual because the intratumoral hemorrhage caused compression and midline shift, requiring urgent surgery.

LESSONS

Astroblastoma with intratumoral hemorrhage is atypical and is associated with high-grade tumors. Managing severe intracranial hypertension requires emergency surgery to prevent fatalities. Treatment can include adjunctive chemotherapy and radiation therapy based on the extent of tumor resection.

https://thejns.org/doi/10.3171/CASE24486

Zein Al-Atrache, Stanley Dennison, Mazen Zaher, Joshua Santucci, and Daniel A. Tonetti

BACKGROUND

External ventricular drains (EVDs) provide an invaluable diagnostic method for accessing cerebrospinal fluid and therapeutically treating elevated intracranial pressure. Although complications including hemorrhage and infection have been well documented, the formation of iatrogenic pseudoaneurysms following EVD placement has rarely been reported. The authors present a case of this exceedingly rare complication of iatrogenic pseudoaneurysm formation following EVD placement.

OBSERVATIONS

In this report, the authors document the formation of a pseudoaneurysm within the A4 segment of the anterior cerebral artery in a 77-year-old female following frontal EVD placement, which was promptly recognized and successfully embolized endovascularly. They discuss the suspected pathophysiology, given the literature citing similar complications, and the differing management strategies following the discovery of iatrogenic pseudoaneurysms.

LESSONS

Although rare, iatrogenic vascular injury following EVD placement or removal should not be overlooked. If hemorrhage following catheter placement or manipulation develops, suspicion for iatrogenic vascular injury should be high, and appropriate vascular imaging should be performed. As reported here, prompt treatment with endovascular embolization provides a safe and effective means to prevent future rupture and worsening hemorrhage. This case and the literature review emphasize the importance of rapid diagnosis of postprocedural pseudoaneurysm formation and treatment to prevent continued secondary brain injury.

https://thejns.org/doi/10.3171/CASE24558

Masahiro Indo, Soichi Oya, Sho Nakamura, Ikuo Kobayashi, Shinsuke Yoshida, Masaaki Shojima, and Shigeru Nemoto

BACKGROUND

The presence of significant tortuosity in access routes to aneurysms can interfere with catheter guidance and manipulation and significantly impact treatment strategies.

OBSERVATIONS

In this report, the authors combined intentional staged aneurysm embolization with the construction of a new direct access route, which they call a “highway bypass,” for a symptomatic posterior circulation cerebral aneurysm that was difficult to access with a catheter. Notably, the highway bypass is used for catheter passage, and technical tips should be considered. The patient had a symptomatic unruptured cerebral aneurysm in the first segment of the left posterior cerebral artery with bilateral internal carotid artery occlusion and severe tortuosity of the bilateral vertebral arteries. The highway bypass using a radial artery graft was performed in the first stage; in the second stage, the aneurysm was accessed using the graft, and embolization was performed. The catheter was passed through the graft without complications. The aneurysm was successfully embolized, no ischemic lesions were found in the postoperative images, and the patient was discharged without worsening neurological findings.

LESSONS

Intentional staged aneurysm embolization combined with the highway bypass effectively treats aneurysms that are difficult to access. Anastomoses should be designed to allow catheters to pass through the graft.

https://thejns.org/doi/10.3171/CASE24527

Adham Halaoui, Melanie Estrella, Carol H. Yan, Vanessa S. Goodwill, and Thomas L. Beaumont

BACKGROUND

Rathke cleft cysts (RCCs) are benign sellar/suprasellar lesions that result from mucin-secreting vestigial remnants within the pars intermedia of the pituitary gland. When symptomatic, they can present with retro-orbital headaches, visual field defects, and/or pituitary dysfunction.

OBSERVATIONS

A 35-year-old female presented with subacute retro-orbital headache, right ptosis, and blurred vision. Workup revealed panhypopituitarism with central hypothyroidism and adrenal insufficiency. Imaging demonstrated a sellar/suprasellar mass with subacute intralesional hemorrhage, which was thought to represent chronic pituitary apoplexy. The patient underwent an endoscopic endonasal approach in which the initial intraoperative frozen section suggested papillary craniopharyngioma. Subsequent specimens suggested RCC, thus presenting a surgical management conundrum. Hemihypophysectomy with lesionectomy was performed. Final histopathology demonstrated RCC with squamous metaplasia (RCC-SM), rupture, and hemorrhage. BRAF V600E was not detected. However, activating mutations in KRAS and MAP2K1 were identified.

LESSONS

RCC can undergo SM and rupture, leading to a hemorrhagic-appearing cystic sellar/suprasellar mass associated with cranial nerve palsies and hypopituitarism that mimics pituitary apoplexy. Intraoperative frozen sections can be ambiguous due to overlapping histopathological features with craniopharyngioma, complicating surgical decision-making. The authors hypothesize that RCC-SM may represent a transitional state between RCC and craniopharyngioma. Neurosurgeons should be mindful of this transitional entity and be prepared to modify their surgical strategy accordingly.

https://thejns.org/doi/10.3171/CASE24657

Toshihide Takahashi, Kiyoyuki Yanaka, Minami Saura, Hitoshi Aiyama, Nobuyuki Takahashi, Aiki Marushima, Yuji Matsumaru, and Eiichi Ishikawa

BACKGROUND

Carotid webs are rare nonatherosclerotic disorders in the carotid artery and are increasingly recognized as factors of ischemic stroke in the young population. Asymptomatic webs can be treated with antithrombotic therapy, whereas symptomatic cases frequently require surgical interventions, including carotid endarterectomy (CEA). However, guidelines for the optimal timing of these treatments remain unestablished, especially compared to atherosclerotic stenotic lesions, due to the rarity of carotid webs.

OBSERVATIONS

A 50-year-old female patient had a carotid web–induced left hemispheric ischemic stroke. Mechanical thrombectomy successfully restored blood flow, but a thrombus reformed in the carotid web within 1 month following the procedure. This caused early CEA, during which the carotid web and thrombus were removed. This case highlights rapid thrombus reformation, indicating that some carotid webs can be more unstable than previously thought.

LESSONS

This case emphasizes the importance of timely surgical intervention in symptomatic carotid webs to prevent recurrent strokes. Additionally, antithrombotic therapy can manage asymptomatic webs, but surgical treatment may be required in unstable cases. Thus, further studies are warranted to establish standardized treatment guidelines for carotid webs.

https://thejns.org/doi/10.3171/CASE24682

Gabrielle E. A. Hovis, Jordan Davies, Joseph Lockwood, and Frank P. K. Hsu

BACKGROUND

Intravascular injection of liquid adhesive hemostats is a rare but serious complication that can result in cerebral thromboembolism.

OBSERVATIONS

A 64-year-old female underwent orbitozygomatic craniotomy for posterior communicating artery aneurysm clipping with the routine use of a flowable hemostatic agent during extradural dissection. After placement of the aneurysm clip, flow was confirmed through the parent vessel and nearby branches. On postoperative day 1, the patient was found to have superficial middle cerebral vein thrombosis with retrograde embolization and subsequent hemorrhagic infarction of the temporal lobe.

Eight prior cases of intracranial infarction or hemorrhage secondary to thrombosis with intravascular liquid adhesive were identified. With a craniotomy approach, the transverse and sigmoid sinuses were the most common sites of thrombosis, and the vertebral and basilar arteries had the highest incidence of thrombosis after cervical fusion.

LESSONS

Intravascular injection of liquid adhesive agents can result in cerebral venous thrombosis, typically of a dural venous sinus. This may present following retrograde embolization, which has not previously been reported. The choice of hemostat, surgical approach, nearby vasculature, and anatomical variations should be carefully considered in the operative management of neurosurgical patients.

https://thejns.org/doi/10.3171/CASE24607

Ting Li, Wenao Liao, Jiang Hu, Wei Zhang, Yang Yu, Fei Wang, and Xilin Liu

OBJECTIVE

The potential of robot-assisted (RA) single-position (SP) lateral lumbar interbody fusion (LLIF) warrants further investigation. This study aimed to assess the efficacy of RA-SP-LLIF in improving both clinical and radiographic outcomes in patients undergoing lumbar spinal fusion surgery.

METHODS

A total of 59 patients underwent either RA-SP-LLIF (n = 31 cases) or traditional LLIF (n = 28 cases). Surgical parameters including operative duration, estimated blood loss, and fluoroscopy duration were recorded. Clinical outcomes were assessed using the visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and the 36-item Short-Form Health Survey (SF-36). Radiographic parameters were also evaluated.

RESULTS

There were no significant differences between the two groups in terms of postoperative and last follow-up times, but both groups demonstrated significant improvements in VAS scores. Similarly, ODI and SF-36 scores showed comparable improvements. Radiographic parameters did not significantly differ between the groups preoperatively, postoperatively, and at last follow-up (p > 0.05). Neither group showed significant improvements in pelvic tilt and sacral slope parameters compared to baseline postoperatively and at last follow-up (p > 0.05). However, the RA-SP-LLIF group exhibited significantly greater improvements in lumbar lordosis (LL; p < 0.01), segmental lordosis (SL; p < 0.01), and pelvic incidence–LL mismatch (PI-LL; p < 0.01) immediately postoperatively compared to baseline, although these differences were not significant at subsequent evaluations. Similarly, the traditional LLIF group improved the LL, SL, and PI-LL parameters postoperatively. Importantly, there was no statistically significant difference in the Bridwell grade and complications between the two groups (p = 0.83 and p = 0.88, respectively). However, the RA-SP-LLIF group had significantly shorter operative and fluoroscopy durations compared to the traditional LLIF group (p = 0.04 and p < 0.01, respectively).

CONCLUSIONS

Both RA-SP-LLIF and traditional LLIF surgeries achieved satisfactory lordotic correction. However, RA-SP-LLIF surgery demonstrated shorter operative and fluoroscopy times compared to traditional LLIF surgery. Therefore, RA-SP-LLIF is a promising technique for enhancing surgical efficiency, safety, and precision in lumbar spinal fusion procedures.