Brainstem Compression Research Articles

Surgical Resection Followed by Stereotactic Radiosurgery (S+SRS) Versus SRS Alone for Large Posterior Fossa Brain Metastases: A Comparative Analysis of Outcomes and Factors Guiding Treatment Modality Selection

Background/Objectives: Around 20% of cancer patients will develop brain metastases (BrMs), with 15–25% occurring in the posterior fossa (PF). Although the effectiveness of systemic therapies is increasing, surgery followed by stereotactic radiosurgery (S+SRS) versus definitive SRS remains the mainstay of treatment. Given the space restrictions within the PF, patients with BrMs in this location are at higher risk of brainstem compression, hydrocephalus, herniation, coma, and death. However, the criteria for treating large PF BrMs with S+SRS versus definitive SRS remains unclear. Methods: We reviewed a prospective registry database (2009 to 2020) and identified 64 patients with large PF BrMs (≥4 cc) treated with SRS or S+SRS. Clinical and radiological parameters were analyzed. The two endpoints were overall survival (OS) and local failure (LF). Results: Patients in the S+SRS group were more highly symptomatic than patients in the SRS group. Gait imbalance and intracranial pressure symptoms were 97% and 80%, and 47% and 35% for S+SRS and SRS, respectively. Radiologically, there were significant differences in the mean volume of the lesions [6.7 cm3 in SRS vs. 29.8 cm3 in the S+SRS cohort, (p < 0.001)]; compression of the fourth ventricle [47% in SRS vs. 96% in S+SRS cohort, (p < 0.001)]; and hydrocephalus [0% in SRS vs. 29% in S+SRS cohort, (p < 0.001)]. Patients treated with S+SRS had a higher Graded Prognostic Assessment (GPA). LF was 12 and 17 months for SRS and S+SRS, respectively. Moreover, the S+SRS group had improved OS (12 vs. 26 months, p = 0.001). Conclusions: A higher proportion of patients treated with S+SRS presented with hydrocephalus, fourth-ventricle compression, and larger lesion volumes. SRS-alone patients had a lower KPS, a lower GPA, and more brain metastases. S+SRS correlated with improved OS, suggesting that it should be seriously considered for patients with large PF-BrM.

Stress Maneuver for Basilar Invagination Reduction: A Technical Report

BackgroundBasilar invagination (BI) is a prolapse of the odontoid process cranially and posteriorly towards the foramen magnum. Several surgical treatment options are available for this condition. Herein, we describe a stress maneuver technique for BI reduction using a single-stage posterior approach. MethodsWe described the case of a 56-year-old male diagnosed with type A BI and brainstem compression, who was treated with posterior fossa decompression and occipitocervical fusion. The BI was reduced intraoperatively using a stress maneuver, and cranial traction or atlantoaxial joint distraction was not necessary. ResultsPostoperative imaging revealed a reduction of the odontoid process and adequate brainstem decompression. The patient showed progressive improvement of his symptoms. ConclusionIn selected cases, stress maneuvers for BI reduction can be a less morbid, easier, and replicable option within the already existing technical arsenal.

SIGNET: protocol for a multicentre, single-blind prospective, group sequential, randomised controlled trial to evaluate the benefits of a single dose of simvastatin given to potential organ donors declared dead by neurological criteria on outcomes in organ recipients

IntroductionSuccessful organ transplantation in patients with end-stage organ failure improves long-term survival, improves quality of life and reduces costs to the NHS. Despite an increase in the number of deceased...

Repeated complete atrioventricular block during remifentanil administration in a pediatric patient with brain tumor and acute hydrocephalus: a case report

BackgroundRemifentanil, an ultra-short-acting µ-opioid receptor agonist, is commonly used for anesthetic management due to excellent adjustability. Remifentanil is known to cause sinus bradycardia, however, because it has a direct negative chronotropic effect on the cardiac conduction system and there is an indirect negative chronotropic effect via the parasympathetic nervous system.Case presentationAn 8-year-old Japanese boy was diagnosed with acute hydrocephalus due to a brain tumor in the fourth ventricle and underwent emergency surgery. Imaging examination showed brainstem compression. Endoscopic third ventriculostomy and ventriculoperitoneal shunt surgery were scheduled. Remifentanil was started during induction of general anesthesia, but electrocardiogram showed sinus bradycardia, then Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was immediately discontinued, and we administered atropine sulfate. Complete atrioventricular block was restored to sinus rhythm. When remifentanil was restarted, however, the electrocardiogram again showed sinus bradycardia, Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was again immediately discontinued, we administered adrenaline, and then complete atrioventricular block was restored to sinus rhythm. Fentanyl was used instead of remifentanil with continuous infusion of dopamine. There has since been no further occurrence of complete atrioventricular block.ConclusionsThis is the first known case of complete atrioventricular block in a pediatric patient with increased intracranial pressure seemingly caused by administration of remifentanil.

Surgical and radiosurgical outcomes for Koos grade 3 vestibular schwannomas.

This study aimed to reveal the preferred initial treatment for Koos grade 3 vestibular schwannomas (VS). We performed a two-institutional retrospective study on 21 patients with Koos grade 3 VS undergoing resection at Yokohama Medical Center and 37 patients undergoing radiosurgery at Yokohama Rosai Hospital from 2010 to 2021. Tumor control, complications, and functional preservation were compared. The median pre-treatment volume and follow-up duration were 2845 mm3 and 57.0 months, respectively, in the resection group and 2127 mm3 and 81.7 months, respectively, in the radiosurgery group. In the resection group, 16 (76.2%) underwent gross total resection, and three patients (14.3%) experienced regrowth; however, no one required additional treatment. In the radiosurgery group, the tumor control rate was 86.5%, and three cases (8.1%) required surgical resection because of symptomatic brainstem compression. Kaplan-Meier analyses revealed that tumors with delayed continuous enlargement and large thin-walled cysts were significantly associated with poor prognostic factors (p = 0.0027, p < 0.001). The pre-radiosurgery growth rate was also associated with the volume increase (p = 0.013). Two cases (9.5%) required additional operation due to complications such as post-operative hematoma and cerebrospinal fluid leaks in the resection group, whereas temporary cranial neuropathies were observed in the radiosurgery group. Two patients (9.5%) had poor facial nerve function (House-Brackmann grading grade 3) in the resection group, while no one developed facial paresis in the radiosurgery group. Trigeminal neuropathy improved only in the resection group.Radiosurgery can be considered for the treatment of Koos grade 3 VS for functional preservation. However, resection may also be considered for patients with severe trigeminal neuropathy or a high risk of volume increments, such as large thin-walled cysts and rapid pre-treatment growth.

Revision Chiari surgery in adults: surgical evaluation algorithm and outcomes in a continuity-of-care practice.

Patients with a prior surgical history for Chiari malformation (CM) as a child or an adult who presents with a recurrence or persistence of symptoms pose a challenging clinical scenario. The authors analyzed preoperative presentations, surgical histories, and outcomes of adult CM revision cases to create an algorithm for the assessment of revision surgery in adult CM patients and contrast this with the care of pediatric CM patients within the context of an integrated continuity-of-care CM practice seeing pediatric and adult patients. The authors retrospectively reviewed the records of patients with CM0, -1, and -1.5 who were 21 years of age or older, had a prior history of CM surgery as either children or adults, and underwent revision surgery as adults at the authors' institution from December 2009 to February 2020. The cohort was divided into three groups depending on the type of revision surgery performed: posterior fossa decompression with or without duraplasty (PFD/D group), occipitocervical fusion without ventral decompression (OCF group), and ventral decompression in the form of endoscopic endonasal odontoidectomy (VD group). A total of 50 adult revision cases were divided into 30 PFD/D cases, 13 OCF cases, and 7 VD cases. Forty cases had previously undergone one CM surgery, and 10 had undergone two. Preoperatively, the PFD/D group had significantly fewer cases of diagnosed craniocervical instability (CCI), Ehlers-Danlos syndrome, and dysautonomia than the OCF and VD groups. A retroflexed odontoid was significantly more common in the VD group than in the PFD/D and OCF groups. Postoperatively, rates of improvement were 60.0% with PFD/D, 84.6% with OCF, and 85.7% with VD, but differences in these rates were not statistically significant. In this challenging group of CM patients, possible etiologies warranting additional surgery included residual dorsal compression, persistent syrinx, CCI, and ventral brainstem compression from a significant retroflexed odontoid. Outcomes after revision were often favorable, but careful evaluation, patient selection, and communication with patients are needed in deciding to reoperate. The suggested algorithm can aid decision-making.

ICU Management of Post-Craniotomy Patients with Schwannoma Vestibular Tumor Removal

Background: Vestibular schwannoma (VS) is a relatively common tumor that arises from the vestibulocochlear nerve (CN VIII) and represents 80% of cerebellopontine angle (CPA) masses. CPA tumors are mostly benign, slow growing with low malignant potential (~1%). VS have rarely been reported, and there is a lack of in-depth discussion on the experience of management of massive acoustic neuromas in ICU. It represents the case in which the patient presented with obstructive hydrocephalus and progressive neurological deficits. The purpose of this case report is to understand the management of post-operative patients with VS with several comorbidities in the ICU.Case: We present a 53 years old woman with a giant VS and obstructive hydrocephalus. An imaging findings revealed a brain tumor in the CPA region and obstructive hydrocephalus. Consequently, she relieved her hydrocephalus with a ventriculoperitoneal shunt (VP shunt). After 1.5 years, her mental condition deteriorated, and her left limb muscle strength gradually decreased. Under a joint consultation with Department of Neurosurgery and Anesthesiology, she underwent tumor removal. Upon discharge, the previously observed neurological deficits, which were reversible had been successfully resolved. The neuroimaging confirmed the complete tumor removal, while the neuropathologic examination revealed a VS.Discussion: If untreated, an acoustic neuroma can grow large enough to cause pressure on the brain stem. The tumor can block the flow of cerebrospinal fluid (CSF) between the brain and the spinal cord, causing a buildup of the fluid in the brain. Because the skull is a closed structure, excess fluid in the brain (hydrocephalus) can press against the brain, causing unsteady movement and lack of coordination (ataxia), headaches and confusion. Patients with brainstem compression had significantly longer mean LOS than patients without. Also, the dissection of the facial nerve from the tumor in order to preserve it can sometimes cause swelling, which can result in weakness or paralysis (complete or partial loss of muscle function). This is usually temporary but can take weeks to months to recover. After the operation, the patient was treated in the ICU, a ventilator was installed,insulin was given to regulate blood sugar and anti-hypertension medication for maintaining blood pressure. During treatment in the ICU, adequate fluids and nutrition are provided. Monitoring is carried out on cardiovascular function, hemodynamics and respiration by monitoring blood pressure, electrocardiogram (ECG), oxygen saturation. The patient was moved to high care unit (HCU) after being treated for 3 days in the ICU.Conclusion: Postoperative therapy is more focused on supportive therapy, including maintaining the airway, regulating blood sugar, blood pressure and providing mechanical ventilation to maintain adequate oxygenation.

Endoscopic Transclival Approach for Evacuation of Retroclival Hematoma: 2-Dimensional Operative Video.

Retroclival hematomas are a rare entity, presenting anteriorly to the brainstem in the epidural, subdural, or subarachnoid space. Although those that develop in the epidural space often arise from trauma, subdural retroclival hematomas frequently occur spontaneously in the setting of coagulopathy, aneurysm rupture, or pituitary apoplexy, with many cases having an unknown etiology.1-4 Although most are treated with conservative management, surgical intervention is preferred for those presenting with evidence of brainstem compression, hydrocephalus, worsening neurological deficits, and clinical deterioration.5 In this report, we present the case of a 75-year-old woman with a medical history of mitral regurgitation, nonischemic cardiomyopathy, and atrial fibrillation on warfarin presenting with 4 days of temporoparietal headaches and double vision. On examination, the patient demonstrated right abducens and hypoglossal nerve palsies. Computed tomography revealed a subdural hemorrhage within the retroclival cistern, extending into the dorsal inferior aspect of the C2 vertebral body, resulting in posterior displacement of the pons, medulla, and proximal cervical spinal cord. Spinal and cerebral angiograms did not show evidence of any vascular malformation. An endoscopic transclival approach was selected for hematoma evacuation. Key surgical steps included harvesting of nasoseptal flap, endoscopic transnasal approach to the sellar/subsellar space, transclival drilling, retroclival hematoma evacuation, and clival reconstruction. The patient tolerated the procedure well and was discharged 15 days postoperatively with resolution of prior cranial nerve deficits. Postoperative computed tomography imaging revealed complete retroclival hematoma evacuation. At her 3-month follow-up, the patient remained neurologically intact with imaging confirming no residual subdural hematoma. Institutional Review Board approval was obtained for this submission (2018-9379). Patient consent was not obtained as personal identifying information was kept confidential, following guidelines set forth by Institutional Review Board requirements.

LGG-04. TRAMETINIB COMBINED WITH CHEMOTHERAPY FOR INFANT BRAF-FUSED CHIASMATIC GLIOMA

Abstract BACKGROUND Infant chiasmatic gliomas present a major therapeutic challenge due to large size, threat to vision and progressive nature. Infants &amp;lt;1 year respond poorly to Vincristine/Carboplatinum chemotherapy (SIOP-LGG2). BRAF fusion is common, so MEK inhibitors have been used second line in older children, but time to response is slow (median ~20 months). Data on the use of these drugs in infants is limited as is data on the safety and efficacy of combining chemotherapy with MEK inhibitors. METHODS We report two infants treated successfully for BRAF fused chiasmatic glioma - both presented age 5 months with nystagmus and diencephalic syndrome. Both had significant tumor progression within 6 weeks of starting Vincristine/ Carboplatin which responded rapidly to the addition of Trametinib. RESULTS Case 1 required tumor debulking at week 6 of chemotherapy due to progressive hyponatremia, hydrocephalus and brainstem compression. Surgery caused diabetes insipidus, hemianopia and hemiparesis. Tumor growth continued despite reinstating chemotherapy. Addition of trametinib caused tumor shrinkage by 75% within 12 weeks and 90% by 1 year. Minirin doses were reduced by 80% on Trametinib. After 1.3 years, chemotherapy was stopped &amp; Trametinib continued alone. Case 2 - tumor growth and severe hyponatremia by week 6 of chemotherapy prompted addition of Trametinib without surgery. There was tumor reduction of 50% over 6 months and improvement of severe failure to thrive. Hyponatremia, requiring sodium and urea supplementation, stabilized. Bilateral vision and age-appropriate development are maintained. Hypertension developed early, but resolved completely after stopping and then gradually reintroducing Trametinib. Recurrent diarrhea required dose reduction. CONCLUSIONS We show the safety and efficacy of combined treatment with chemotherapy and MEK inhibition in infants and postulate that both the combination and the young age at initiation of therapy may have contributed to the excellent outcome. We urge for clinical trials of combination therapy in this age group.

Vestibular schwannoma unveiled by pregnancy: A case report and literature review

BackgroundVestibular schwannomas – benign tumours originating from the vestibular nerve – are rare during pregnancy. The intricate interplay between the gravid uterus, maternal physiology and neoplastic growth imposes complexities that demand a careful and tailored approach. Case reportThis article reports a case of a pregnant woman in her 30 s diagnosed with a large vestibular schwannoma exhibiting brainstem compression, peritumoral oedema and cranial nerve encasement at 36 + 5 weeks of gestation. A multi-disciplinary team collaborated to devise a treatment plan considering the delicate balance between fetal well-being and the urgent need for intervention. A conservative approach involving close monitoring, corticosteroid therapy to manage peritumoral oedema, and detailed fetal assessments was initially employed. As the patient neared full term, a carefully planned caesarean section was performed, followed by a successful craniotomy to resect the vestibular schwannoma. Both the mother and the newborn showed favourable outcomes postoperatively. In addition, a literature review of cases of vestibular schwannoma in pregnancy was undertaken to inform optimal management strategies and enhance understanding of this complex scenario. ConclusionThis case highlights the complexity of managing vestibular schwannomas in pregnant women, and underscores the importance of a tailored, collaborative approach. The condition was resolved successfully, emphasizing the significance of timely diagnosis, meticulous planning and a patient-centred approach in these rare and intricate cases.

Pearls & Oy-sters: INO Plus From Downward Herniation-A Cautionary Tale Regarding Neuro-Ophthalmologic Signatures of Brainstem Compression.

Pupillary assessment is a quintessential part of the clinical examination in neuro-intensive care patients because it provides insight into the integrity of midbrain reflex arcs. Abnormal pupils, particularly anisocoria and later bilateral fixed mydriasis, are classically used to assess expansive intracranial processes because they are frequently considered early indicators of transtentorial midbrain compression due to elevated intracranial pressure. Complex ocular motor deficits mapping to the midbrain are rarely described in the setting of high transtentorial pressure. This is likely because ocular motor deficits typically occur in conjunction with decreased consciousness and corticospinal tract dysfunction reflecting advanced midbrain compromise. We present a case of left midbrain compression due to downward herniation in a patient with acute-on-chronic bilateral subdural hematoma. Ocular motor assessment demonstrated left internuclear ophthalmoplegia (INO) and an ocular tilt reaction, termed INO plus. However, pupillary, mental status, and sensorimotor examinations were unremarkable. Head magnetic resonance imaging revealed acute perforator ischemia in the left pontomesencephalic tegmentum, localizing to the ipsilateral medial longitudinal fasciculus and graviceptive oculocephalic circuits. Microvascular compromise secondary to mechanical pressure is discussed as a causative mechanism. We caution against overreliance on "telltale pupils" in suspected brainstem compression and recommend checking for other oculomotor signs.

Preoperative embolization and microsurgical resection of a cerebellar hemangioblastoma: embolization goals and technical nuances of the approaches. Illustrative case.

Resection remains the optimal treatment for hemangioblastomas, highly vascular tumors commonly located in the cerebellum or spinal cord. Preoperative embolization can be used with caution to reduce intraoperative blood loss and promote gross-total resection while reducing neurological morbidity. The authors report a case of a 44-year-old male who presented with worsening dizziness, gait imbalance, and diplopia. Imaging revealed a large vascular cerebellar mass with brainstem compression and hydrocephalus, concerning for hemangioblastoma. The patient underwent preoperative embolization of the main arterial supply from the right superior cerebellar artery, which devascularized the tumor and reduced the early venous shunting, followed by gross-total resection of the tumor. Preoperative embolization helped to facilitate safe microsurgical resection because this main arterial supply was deep to the planned surgical approach, and the Onyx cast served as a landmark of the dorsal midbrain and remaining arterial supply. This resulted in minimal intraoperative blood loss. At 2-year follow-up, the patient's diplopia and vertigo had resolved, and his gait continues to improve. Despite controversy regarding the use of preoperative embolization for hemangioblastoma resection, the authors emphasize its safety and utility during resection of a large cerebellar hemangioblastoma. Onyx embolization provided benefit in both reducing the tumor blood supply and serving as intraoperative visual guidance.

A Tailored Combined Petrosal Approach for the Resection of a Petroclival Meningioma With Pneumatized Apex: Checkmate to the Trigeminal Nerve: 2-Dimensional Operative Video.

Petroclival meningiomas are a challenge in skull base surgery, despite the advances in the knowledge of this pathology, there are still many controversies regarding their optimal treatment.1 The proximity and adherence to cranial nerves, major vessels such as the basilar artery, and brainstem compression explain the significant surgical risk.2,3 We present the case of a woman with a petroclival meningioma (WHO grade I) and pneumatization of the petrous apex. A tailored combined petrosal approach with a wide pedicled flap was performed for reconstruction of the pneumatized petrous apex. The decision to choose an appropriate surgical approach in this type of tumor depends on multiple factors including the surgeon's skill. We believe that in this particular case the pneumatization of the petrosal apex and the involvement of the trigeminal nerve by the tumor demanded a surgical approach that allowed a 360-degree view of the trigeminal nerve and at all angles of attack on the site of tumor implantation, we call this a checkmate of the trigeminal nerve. Transposition of the trigeminal nerve may be necessary in cases such as the one we present for adequate visualization of the petroclival region. This surgical video discusses the nuances of technique, surgical pearls, and anatomic landmarks in the combined petrosal approach. The patient consented to the procedure and to the publication of her image, and appropriate consent was obtained for publication of the cadaver's image.

Surgical Outcome of Vestibular Schwannoma in a Tertiary Care Hospital, Dhaka

Background: Presenting symptoms, treatment considerations, and outcome are strongly related to the extension of vestibular schwannomas (VS). The aim of the current retrospective study was to analyze the clinical features, microsurgical treatment, and outcome of VS with brainstem compression. Methods: 130 patients presented with VS who had undergone operative procedures performed in our unit from Jan, 2017 to may, 2022. The facial nerve function and hearing assessment was done according to House-Brackmann [HB] grading and pure tone audiometry (PTA) respectively. All patients were operated by retro-sigmoid retromastoid sub-occipital approach. Results: Most patients had large tumors and had no useful hearing (75.38%), had disabling cerebellar ataxia (84.61%) and presented with features of raised intracranial pressure (46.15%). Complete tumor excision was carried out 92.30% and anatomical preservation of facial nerve was achieved in 87.50% cases. Hearing preservation was achieved in eight patients. Cerebrospinal fluid leak with or without meningitis and transient lower cranial nerve paresis were common complications. The mortality rate was 7.69% Conclusions: Complete tumor excision with good facial nerve preservation can be achieved in large vestibular schwannomas. Hearing preservation is difficult in larger tumors. Primary microsurgical resection is an appropriate management option for large VS. In our experience, this goal can be achieved safely and successfully by using the retromastoid retrosigmoid sub-occipital approach. Bang. J Neurosurgery 2023; 12(2): 86-93

Preservation of cranial nerve function in large and giant trigeminal schwannoma resection: a case series.

Trigeminal schwannomas (TSs) are intracranial tumors that can cause significant brainstem compression. TS resection can be challenging because of the risk of new neurologic and cranial nerve deficits, especially with large (≥ 3cm) or giant (≥ 4cm) TSs. As prior surgical series include TSs of all sizes, we herein present our clinical experience treating large and giant TSs via microsurgical resection. This was a retrospective, single-surgeon case series of adult patients with large or giant TSs treated with microsurgery in 2012-2023. Seven patients underwent microsurgical resection for TSs (1 large, 6 giant; 4 males; mean age 39 ± 14years). Tumors were classified as type M (middle fossa in the interdural space; 1 case, 14%), type ME (middle fossa with extracranial extension; 3 cases, 43%), type MP (middle and posterior fossae; 2 cases, 29%), or type MPE (middle/posterior fossae and extracranial space; 1 case, 14%). Six patients were treated with a frontotemporal approach (combined with transmastoid craniotomy in the same sitting in one patient and a delayed transmaxillary approach in another), and one patient was treated using an orbitofrontotemporal approach. Gross total resection was achieved in 5 cases (2 near-total resections). Five patients had preoperative facial numbness, and 6 had immediate postoperative facial numbness, including two with worsened or new symptoms. Two patients (28%) demonstrated new non-trigeminal cranial nerve deficits over mean follow-up of 22months. Overall, 80% of patients with preoperative facial numbness and 83% with facial numbness at any point experienced improvement or resolution during their postoperative course. All patients with preoperative or new postoperative non-trigeminal tumor-related cranial nerve deficits (4/4) experienced improvement or resolution on follow-up. One patient experienced tumor recurrence that has been managed conservatively. Microsurgical resection of large or giant TSs can be performed with low morbidity and excellent long-term cranial nerve function.

Surgical management of spontaneous posterior fossa hematoma: predictors of the neurological outcome

ObjectiveTo detect demographic, clinical, and radiological predictors of patient outcomes and prognosis in spontaneous cerebellar hematoma patients that may guide accurate decision making.MethodsThis retrospective study was conducted on 45 patients with spontaneous cerebellar hematoma who underwent surgical treatment. The patient data including demographics (age, gender), preoperative consciousness at the time of admission, medical comorbidities (HTN, DM), radiological findings (location, volume, and diameter of the cerebellar hematoma, hydrocephalus, compression of the fourth ventricle, effacement of the quadrigeminal cistern, intraventricular hematoma, tight posterior fossa, and brain stem compression), and treatment methods were collected and correlated with prognosis. Outcome assessment was done using the Glasgow Outcome Scale (GOS), classified into good outcome (favorable result; GOS > 4) and poor outcome (unfavorable result; GOS < 4).ResultsThere was a statistically significant correlation (p = 0.030) between the time to surgery and GOS, with more favorable outcomes in patients who underwent early surgery compared to late surgery. Unfavorable outcomes were detected in patients with higher Taneda grade and Kirollos grade, and both were statistically significant (p = 0.001). The presence of hydrocephalus and/or brainstem compression had a statistically significant (p < 0.001) negative impact on outcomes. Patients with extensive IVH had an unfavorable outcome compared to other patients (p = 0.016). The mortality rate in our study was 28.9%.ConclusionsSurgical management of spontaneous cerebellar hematoma is challenging. Many factors influence the appropriate decision making and surgical outcome. Predictors of an unfavorable outcome include the level of consciousness at admission, delayed time to surgery, a higher grade of 4th ventricular effacement (Kirollos) and quadrigeminal cistern effacement (Taneda), extensive IVH, hydrocephalus, and brainstem compression (statistically significant). There was no statistical significance regarding gender, age, hematoma volume, or hematoma diameter in relation to an unfavorable outcome.

Analysis of risk factors related to the progression rate of hemifacial spasm.

Although there have been many researches on the etiology and risk factors with the onset of hemifacial spasm, researches on the risk factors related to progression rate are limited. This study aims to analyze the risk factors related to the progression rate of hemifacial spasm. The study enrolled 142 patients who underwent microvascular decompression for hemifacial spasm. Based on the duration and severity of symptoms, patients were classified into rapid progression group and slow progression group. To analyze risk factors, univariate and multivariate logistic regression analyses were conducted. Of 142 patients with hemifacial spasm, 90(63.3%) were classified as rapid progression group, 52(36.7%) were classified as slow progression group. In the univariate analysis, there were significant statistical differences between the two groups in terms of age of onset (P = 0.021), facial nerve angle (P < 0.01), hypertension (P = 0.01), presence of APOE ε4 expression (P < 0.01) and different degrees of brainstem compression in the Root Entry Zone (P < 0.01). In the multivariable analyses, there were significant statistical differences between the two groups in terms of age of symptom onset (P < 0.01 OR = 6.591), APOE ε4 (P < 0.01 OR = 5.691), brainstem compression (P = 0.006 OR = 5.620), and facial nerve angle (P < 0.01 OR = 5.758). Furthermore, we found no significant correlation between the severity of facial spasms and the progression rate of the disease (t = 2.47, P = 0.12>0.05). According to our study, patients with facial nerve angle ≤ 96.5°, severer compression of the brainstem by offending vessels, an onset age > 45 years and positive expression of APOE ε4, may experience faster progression of hemifacial spasm.

Cerebellar Tonsillar Herniation an Incidental Finding in Asymptomatic Patient

Cerebellar tonsillar herniation, often associated with Chiari malformation, involves the downward displacement of the cerebellar tonsils below the foramen magnum. This condition can lead to significant complications due to the limited intracranial space within the rigid skull. Timely diagnosis is crucial given its potentially fatal nature, with brain structural displacement evident on imaging studies. We present a case of a 27-year-old female with continuous headaches and dizziness, diagnosed with tonsillar herniation through MRI revealing 16 mm of tonsillar descent without associated hydrocephalus or syrinx. Tonsillar herniation, characterized by inferior descent of the cerebellar tonsils, may be congenital or acquired, with measurements typically referenced from the McRae line to the displaced tonsil tip. Complications include brainstem compression, obstruction of cerebrospinal fluid flow, syringomyelia, impaired blood flow, and various neurological and psychological symptoms. Management options vary based on symptom severity and may involve observation, medication, or surgical intervention to alleviate compression and improve cerebrospinal fluid flow. Consultation with a neurologist or neurosurgeon is essential for comprehensive evaluation and tailored management plans aiming to relieve pressure on the brainstem and spinal cord in tonsillar herniation cases.

Type one chiari malformation as a cause of central sleep apnea and hypoventilation in children

ObjectivesChiari type 1 malformation (CM1) may occasionally lead to central sleep apnea (CSA). We studied, in a large clinical cohort of pediatric CM1 patients, the effect of CM1 on breathing during sleep. MethodsThis is a retrospective single pediatric pulmonology center study with a systematic evaluation of pediatric CM1 patients under age 18 with polysomnography (PSG) during 2008–2020. Children with syndromes were excluded. All patients had undergone head and spine magnetic resonance imaging. ResultsWe included 104 children with CM1 with a median age of 7 (interquartile range (IQR) 5–13) years. The median extent of tonsillar descent (TD) was 13 (IQR 10–18) mm. Syringomyelia was present in 19 children (18%). Of all children, 53 (51%) had normal PSG, 35 (34%) showed periodic breathing or central apnea and hypopnea index ≥5 h−1, and 16 (15%) displayed features of compensated central hypoventilation and end-tidal or transcutaneous carbon dioxide 99th percentile level above 50 mmHg. TD had the best predictive value for central breathing disorders. In a linear model, both age (61%) and TD (39%) predicted median breathing frequency (R = 0.33, p < 0.001). ConclusionsAlthough severe CSA is a rare complication of brainstem compression in pediatric patients with CM1, short arousal-triggered episodes of periodic breathing and mild compensated central hypoventilation are common. TD shows the best but still poor prediction of the presence of a central breathing disorder. This highlights the use of PSG in patient evaluation. Posterior fossa decompression surgery effectively treats central breathing disorders.

Aggressive pituitary tumors and carcinomas: modern classification, advances and prospects in treatment

Despite slow growth of most pituitary tumors and high rates of total resection and/or effective therapy, pituitary neoplasms are characterized by aggressive behavior with high growth rate, frequent relapses and resistance to standard treatments in 10% of cases. In modern WHO classifications of tumors of the central nervous system, endocrine and neuroendocrine tumors, the authors propose the definition «pituitary neuroendocrine tumor» instead of previous «pituitary adenoma» and «metastasizing pituitary neuroendocrine tumor» instead of «pituitary carcinoma». Currently, there are no effective prognostic markers of aggressive tumors. This complicates early diagnosis. It is proposed to apply a five-stage prognostic classification based on proliferation rate (including mitotic count, Ki-67 index and p53 immunoexpression) and morphometric markers of invasiveness for all resected pituitary neoplasms. This approach would be valuable for earlier detection of aggressive tumors and pituitary carcinomas. Compression of visual pathways, third ventricle and brain stem due to rapid growth of aggressive tumors usually requires redo surgeries with subsequent radiotherapy. Hormonally active tumors require therapy with somatostatin analogues and dopamine agonists in maximum possible doses. Chemotherapy with temozolomide as first-line option is recommended if standard treatment is ineffective. Alternative treatment includes peptide receptor radionuclide therapy (PRRT), molecular targeted therapy (bevacizumab, tyrosine kinase inhibitors, everolimus and cyclin-dependent kinase inhibitors) and immunotherapy (checkpoint inhibitors). Considering the need for combined treatment, these cases should always be discussed by a multidisciplinary team (neurosurgeon, endocrinologist, radiotherapist, oncologist, pathologist) with necessary qualifications and experience in treating these patients. Treatment of aggressive tumors and pituitary carcinomas is becoming an active and rapidly developing direction in neurosurgery, endocrinology and oncology.