Cranial Nerve Deficits Research Articles

A rare case of acute pancreatitis due to scrub typhus: A case report

Abstract Scrub typhus is an acute febrile sickness, also known as tsutsugamushi fever, which is brought on by Orientia tsutsugamushi, a tiny, obligate intracellular gram-negative bacteria whose polysaccharides have an antigenic connection to proteus OX-K, which is utilised in serologic tests to confirm scrub typhus. The larva of trombiculid mites (chiggers), which are almost minute and frequently brilliantly colourful (red), bite people to transmit O. tsutsugamushi. The signs of onset include fever, headache, myalgia, coughing, and gastrointestinal symptoms after an incubation period of 6–21 days. The primary papular lesion, which the chigger fed on and can appear anywhere on the body, enlarges, experiences core necrosis, and crusts to create a flat black eschar. Regional lymphadenopathy and later generalised lymphadenopathy can be found. A macular rash may develop on the trunk, and the symptoms gradually worsen. In untreated cases, complications may develop and patient may have meningoencephalitis and at times, multiple cranial nerve deficits.

Cerebellopontine angle meningioma in a patient presented as acute cerebrovascular accident.

Here, the authors present a 66-year-old male patient with diabetes, hypertension, and hyperlipidemia who presented to the emergency department of our hospital with sudden onset walking difficulty (ataxia). On examination, the patient was fully conscious. There was no associated cranial nerve deficit, hearing loss, or focal/lateralizing weakness. All sensory modalities were intact. However, the patient had a gait impairment. Romberg and tandem gait tests were positive with the tendency to sway to the left. The patient was admitted with suspicion of acute cerebrovascular disease. The initial noncontrast brain computed tomography and subsequent diffusion MRI were inconclusive. A later brain MRI with contrast revealed a homogeneously contrast enhancing meningioma in the left CPA. The differential diagnosis of sudden onset ataxia is broad and should include the assessment of a possible CPA lesion. Sudden onset ataxia by a CPA meningioma is very rare as meningiomas grow very slowly. A brain MRI with contrast is essential for its diagnosis. Although stroke is the main cause of sudden onset ataxia in a patient with cerebrovascular risk factors, yet other less common causes may be found as in this case of CPA meningioma.

Extreme Lateral Approach to the Craniocervical Junction, Operative Technique and Approach Essentials: 2-Dimensional Operative Video.

The extreme lateral approach is useful for both extradural and intradural anterior and anterolateral lesions at the lower clivus down to the level of C2. The patient is evaluated with MRI, computed tomography (CT), and an angiogram. Special attention is given to vascular (vertebral artery course, dominance, tumor feeders) and bony (occipital condyle, jugular tubercle, foramen magnum and extent of bony involvement) anatomy. The patient is positioned lateral with the head flexed and tilted down without axial rotation. A hockey-stick incision is performed, and the myocutaneous flap is raised. A retrocondylar craniectomy is performed. The extradural vertebral artery is exposed for proximal control. A C1 hemilaminectomy is performed. Cephalad/caudal exposure and drilling of the occipital condyle are determined per case. The dura is opened, and the vertebral artery is released at the dural entry point to facilitate the tumor removal. The tumor is debulked and delivered inferoventrally away from the neuroaxis and cranial nerves. After removing the tumor, the dura is closed using an allograft.The patients consented to the procedure and to the publication of their images. • Cranial nerve deficits• Craniocervical instability• Postoperative hydrocephalus• Postoperative pseudomeningocele. A transmastoid extension of the craniectomy allows access further rostrally in the clivus. For C1-2 chordomas, the approach is extended inferiorly, and the vertebral artery is mobilized out of the C1-2 transverse foramina. For tumors involving the joints, an occipitocervical stabilization is required.Images in video reused with permission as follows: image at 00:16 from Revuelta Barbero et al, Endoscopic endonasal transclival-medial condylectomy approach for resection of a foramen magnum meningioma: 2-dimensional operative video, Oper Neurosurg, 16(2), 2018, by permission from the Congress of Neurological Surgery; images at 00:30, and top image at 00:52 reused from Wen et al, Microsurgical anatomy of the transcondylar, supracondylar, and paracondylar extensions of the far-lateral approach, J Neurosurg, 87(4), 1997, with permission from JNSPG; bottom images at 00:52 from Muthukumar et al, A morphometric analysis of the foramen magnum region as it relates to the transcondylar approach, Acta Neurochir, 147(8), 2005, by permission from Springer Nature.

A comprehensive analysis of stroke admissions at a rural Nigerian tertiary health facility: Insights from a single-center study.

This research intended to examine the demographic and clinical attributes of stroke admissions in a rural Nigerian hospital. A retrospective analysis of stroke admissions was conducted over 1 year. All necessary data were obtained from patients' records and SPSS was employed for data analysis. P < 0.05 was deemed significant. There were 52 stroke cases, accounting for 5.9% of medical admissions. The patients' mean age was 62.81 ± 12.71 years, while females constituted 51.9% of cases. Common risk factors included hypertension (76.9%), hyperlipidemia (38.5%), alcohol (26.9%), and diabetes mellitus (26.9%). Clinical manifestations included hemiparesis/plegia (84.6%), altered consciousness (63.5%), slurred speech (61.5%), cranial nerve deficit (61.5%), aphasia (42.3%), and headache (34.6%). Ischemic stroke (71.2%) predominated over hemorrhagic stroke (28.8%). The average hospitalization duration was 17.62 ± 8.91 days, and the mean onset to arrival time was 121.31 ± 136.06 h. Discharge and mortality rates were 82.7% and 13.5%, respectively. The association between stroke subtypes and mortality was significant (P = 0.001). Stroke constitutes a significant portion of medical admissions in Nigeria, with ischemic stroke being more prevalent. High mortality rates underscore the urgent need to manage risk factors to prevent stroke.

Impact of Shape Irregularity in Medial Sphenoid Wing Meningiomas on Postoperative Cranial Nerve Functioning, Proliferation, and Progression-Free Survival.

Medial sphenoid wing meningiomas (MSWM) are surgically challenging skull base tumors. Irregular tumor shapes are thought to be linked to histopathology. The present study aims to investigate the impact of tumor shape on postoperative functioning, progression-free survival, and neuropathology. This monocentric study included 74 patients who underwent surgery for primary sporadic MSWM (WHO grades 1 and 2) between 2010 and 2021. Furthermore, a systematic review of the literature regarding meningioma shape and the MIB-1 index was performed. Irregular MSWM shapes were identified in 31 patients (41.9%). Multivariable analysis revealed that irregular shape was associated with postoperative cranial nerve deficits (OR: 5.75, 95% CI: 1.15-28.63, p = 0.033). In multivariable Cox regression analysis, irregular MSWM shape was independently associated with tumor progression (HR:8.0, 95% CI: 1.04-62.10, p = 0.046). Multivariable regression analysis showed that irregular shape is independently associated with an increased MIB-1 index (OR: 7.59, 95% CI: 2.04-28.25, p = 0.003). A systematic review of the literature and pooled data analysis, including the present study, showed that irregularly shaped meningiomas had an increase of 1.98 (95% CI: 1.38-2.59, p < 0.001) in the MIB-1 index. Irregular MSWM shape is independently associated with an increased risk of postoperative cranial nerve deficits and a shortened time to tumor progression. Irregular MSWM shapes might be caused by highly proliferative tumors.

Pituitary adenoma with cavernous sinus compartment penetration and intracranial extension: surgical anatomy, approach, and outcomes.

To understand the different characteristics and growth corridors of knosp grade 4 pituitary adenomas (Knosp4PA) with cavernous sinus (CS) compartments penetration and intracranial extension, aiming to improve the safety, effectiveness, and total resection rate of surgery. A case series of 120 Knosp4PA patients with 187 invaded compartments were retrospectively reviewed. A novel surgery-relevant grading system was proposed according to the CS penetrating features. The details of approach drafting, risk prediction, and complication avoidance were analyzed and integrated through illustrated cases. All enrolled tumor was Knosp4PA which was derived from Knosp subgrades 3A(62.5%) and 3B(37.5%). Based on the tumor growth pathway and its relevant features, five subclassifications of intracranial extension(n=98,81.7%) were classified, which derived from the superior (Dolenc's and Oculomotor subtype, 5% and 24.2%), lateral (Parkinson's subtype,18.3%), and posterior (cerebral peduncle and Dorello's subtype, 5.8% and 1.7%) CS compartment penetration. The size of intracranial extension is assessed by Lou's scale proposed here based on preoperative MRI characteristics. Under Lou's scale, the gross total rate (GTR) decreased (82%, 53%, 22%, and 19%) with grades increased (grade 0,1,2,3, respectively), and presents significant difference between the four groups (p=0.000), as well as between single and multiple compartments involved (p=0.001). Preoperative cranial nerve deficits included the optic nerve (53%), oculomotor nerve (24.2%), and abducent nerve (4.2%), with an overall rate of visual function improvement in 68.1%. Postoperative complications of transient diabetes insipidus, cerebrospinal fluid (CSF) leakage, and cranial nerve deficits were 6.7%, 0.8%, and 0%. No new cranial nerve deficits occurred. The mortality rate was 0.8%. The concept of "penetration" refines the extracavernous growth pattern, and the five intracranial subclassifications help to understand the potential extension corridors, enhancing adequate exposure and targeted resection of Knosp4PA. This grading system may benefit from its predictive and prognostic value, from which a higher GTR rate can be achieved.

The Anterolateral Approach, Revisited for Benign Jugular Foramen Tumors With Predominant Extracranial Extension: Microsurgical Anatomy and Case Series (SevEN-012).

The anterolateral approach (ALA) enables access to the mid and lower clivus, jugular foramen (JF), craniocervical junction, and cervical spine with added anterior and lateral exposure than the extreme lateral and endoscopic endonasal approach, respectively. We describe the microsurgical anatomy of ALA with cadaveric specimens and report our clinical experience for benign JF tumors with predominant extracranial extension. A stepwise and detailed microsurgical neurovascular anatomy of ALA was explored with cadaveric specimens. Then, the clinical results of 7 consecutive patients who underwent ALA for benign JF tumors with predominant extracranial extension were analyzed. A hockey stick skin incision is made along the superior nuchal line to the anterior edge of the sternocleidomastoid muscle (SCM). ALA involves layer-by-layer muscle dissection of SCM, splenius capitis, digastric, longissimus capitis, and superior oblique muscles. The accessory nerve runs beneath SCM and is found at the posterior edge of the digastric muscle. The internal jugular vein (IJV) is lateral to and at the level of the accessory nerve. The occipital artery passes over the longissimus capitis muscle and IJV and into the external carotid artery, which is lateral and superficial to IJV. The internal carotid artery (ICA) is more medial and deeper than external carotid artery and is in the carotid sheath with the vagus nerve and IJV. The hypoglossal and vagus nerves run along the lateral and medial side of ICA, respectively. Prehigh cervical carotid, prejugular, and retrojugular surgical corridors allow deep and extracranial access around JF. In the case series, gross and near-total resections were achieved in 6 (85.7%) patients without newly developed cranial nerve deficits. ALA is a traditional and invaluable neurosurgical approach for benign JF tumors with predominant extracranial extension. The anatomic knowledge of ALA increases competency in adding anterior and lateral exposure of extracranial JF.

Chiari I malformation: Clinical Characteristics, Symptoms, and Presentations. (P10-4.005)

<h3>Objective:</h3> We aim to conduct this retrospective study to compare surgery and conservative treatment’s demographics, clinical presentations, and interventions for CM-1 patients in a tertiary hospital in Jordan. <h3>Background:</h3> Chiari malformation type 1 (CM-1) is a congenital anomaly associated with herniation of tonsillar pillars due to abnormality in hindbrain. Standard practice in treatment of (CM-1) is surgical decompression or conservative observation. <h3>Design/Methods:</h3> We reviewed our hospital’s patients’ clinical records, Brain MRI, and surgical assessment notes for CM-1 patients who presented to our hospital for the period between 2000 to 2022. <h3>Results:</h3> We identified 37 patients with (mean age) of (26.5 +/−19.77) years old and a female predominance n=21 (56.75%). Most patients were incidentally diagnosed or presented without symptoms n=22 (59.45%). Out of the 37 patients identified n=7 (18.9%) underwent surgery while n=30 (81.1%) were treated conservatively. Patients who underwent surgery were older in age compared to those who did not with a (mean age +/− S.D.) of (33.00 years +/−16.5) and (25.03 +/−20.40), respectively (p=0.08). Surgery was associated with worsening of symptoms compared to observation 57.14% vs 13.33% (p=0.01). Females were as likely to undergo surgery compared to males 19.04% vs 18.75% (p=0.98). Headache was the initial presentation in n=15 (40.50%) of the patients, other common presentations include: cranial nerve deficits n=20 (54.05%), neck and back pain in n=8 (21.62%), and gait abnormalities n=4 (10.81%). <h3>Conclusions:</h3> Chiari malformation type 1 is a medical condition with a wide array of clinical presentations that is hard to diagnose. Optimum treatment for CM-1 and its association with symptoms alleviation needs further investigation. <b>Disclosure:</b> Mr. Al-Zamer has nothing to disclose. Dr. Aburahma has nothing to disclose. Dr. Khasawneh has nothing to disclose. Dr. Hazaimeh has nothing to disclose. Dr. Jbarah has nothing to disclose.

A Case Report of Pituitary Apoplexy and Acute Ischemic Stroke (P2-5.004)

<h3>Objective:</h3> N/A <h3>Background:</h3> Pituitary apoplexy is a medical emergency resulting from acute hemorrhage or infarction of the pituitary gland. Symptoms include headache, diplopia, visual impairment, and encephalopathy. We present a diagnostically challenging case of pituitary apoplexy in a patient who presented with fever, headache, diplopia, cerebrospinal fluid showing neutrophilic pleocytosis with elevated protein, and neuroimaging showing a left basal ganglia infarct with diffuse cerebral vasospasm. <h3>Design/Methods:</h3> A 46 year old post-menopausal female exhibiting a two day prodrome of severe headaches, nausea, and double vision. She presented to the emergency department febrile (104.6 F), disoriented, with a left lateral rectus palsy and mild right hemiparesis. MRI brain revealed an enhancing suprasellar lesion extending into the sphenoid sinuses and left cavernous sinus with optic chiasm effacement. Diffusion weighted imaging showed evidence of a left recurrent artery of Heubner infarct. Intracranial CT angiography revealed anterior circulation vasospasm. Cerebrospinal fluid resulted in 300 nucleated cells with neutrophilic predominance and elevated protein (121 mg/dL). Her presentation and workup was concerning for an intracranial abscess versus pituitary apoplexy. The patient underwent transsphenoidal pituitary resection, confirming a macroadenoma and pituitary apoplexy. As her CSF infectious work up and biopsy cultures remained negative, the results were suggestive of sterile inflammation and her antibiotics were discontinued. Following surgical intervention and on six month follow up, the patient remained at her baseline functional status without deficits. <h3>Results:</h3> N/A <h3>Conclusions:</h3> Pituitary macroadenomas have varying severity of presentations. Pituitary apoplexy should be considered in a patient with altered sensorium, severe headache, and cranial nerve deficits. Cerebral infarcts can result from mechanical compression from mass effect or arterial vasospasm secondary to vasoactive substances released from necrotic and hemorrhagic pituitary tumor. Prompt diagnosis and early intervention can reduce mortality and morbidity and is critical for successful patient outcomes. <b>Disclosure:</b> Dr. Sandhu has nothing to disclose. Dr. Saini has nothing to disclose. Dr. Liang has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Abbvie.

A Quality Improvement Strategy to Improve Recognition and Identification of Atypical Stroke Presentations in the Pre-Hospital Setting (P13-2.006)

<h3>Objective:</h3> To improve recognition and identification of atypical stroke presentations by EMS. <h3>Background:</h3> Several stroke prediction scales have been devised to aid emergency medical staff (EMS) and physicians to timely recognize strokes in the prehospital setting. However, a significant proportion of strokes continues to be missed. The most common symptoms in false negative cases are dizziness, changes in mental status, and visual deficits. <h3>Design/Methods:</h3> The curriculum involves a lecture with 5 cases discussing presentations of posterior circulation stroke, that was preceded and followed by a survey. A 3-point Likert scale was utilized to assess comfort levels of EMS. Wilcoxon rank sum tests were performed on the null hypothesis to examine the effect of education on comfort levels as implemented in R (R version 3.5.3). <h3>Results:</h3> Eighty pre- and post-education surveys were included in the analysis. More individuals in the post-lecture group felt comfortable recognizing basilar artery occlusion stroke, stroke syndromes that could present as altered mental status or lethargy/somnolence, and cranial nerve deficits as brainstem stroke presentations compared to individuals in the pre-lecture group (p&lt;0.05). More individuals in the post-lecture group felt comfortable recognizing visual symptoms as stroke presentations compared to individuals in the pre-lecture group though the difference in distributions in the two groups did not differ significantly (W= 2854.4, p=0.08). <h3>Conclusions:</h3> In conclusion, our education strategy highlighted atypical stroke presentations that may be missed using conventional pre-hospital scales and resulted in statistically significant increased comfort levels among EMS abilities to recognize various atypical stroke symptoms. Visual symptoms did not increase significantly which was likely due to high comfort levels among EMS at baseline. This lecture was delivered both in-person and virtually, reflecting ease of our implementation strategy. Future work will evaluate the efficacy of our strategy by comparing acute stroke presentations associated with inaccurate EMS identification before and after intervention in our region. <b>Disclosure:</b> Dr. Reyes has nothing to disclose. Dr. Zobel has nothing to disclose. Dr. Ess has nothing to disclose.

Chronic cerebrospinal fluid rhinorrhea as an initial presentation of chordoma: illustrative case.

Skull base chordomas are typically extradural and present with cranial nerve deficits, headache, and visual disturbances. Clival chordoma involving the dura and presenting as a spontaneous cerebrospinal fluid (CSF) leak is extremely rare and can be mistaken for other skull base lesions. Here the authors present a case of chordoma with an unusual presentation. A 43-year-old female who presented with clear nasal drainage was diagnosed with CSF rhinorrhea secondary to a clival defect previously thought to be ecchordosis physaliphora. The patient subsequently developed bacterial meningitis and underwent endoscopic, endonasal, transclival gross-total resection of the lesion with repair of the dural defect. Pathology revealed brachyury-positive chordoma. She received adjuvant proton beam radiotherapy and has remained stable for 2 years. Spontaneous CSF rhinorrhea can occur as a rare primary presentation of clival chordoma, requiring careful radiological interpretation and a high index of suspicion for diagnosis. Chordoma cannot be reliably differentiated from benign notochordal lesions based on imaging alone; thus, intraoperative exploration and immunohistochemistry play key roles. Clival lesions presenting with CSF rhinorrhea should undergo prompt resection to facilitate diagnosis and prevent complications. Future studies on connections between chordoma and benign notochordal lesions may help to establish management guidelines.

See-saw nystagmus associated with retinitis pigmentosa.

See-saw nystagmus is an uncommon form of nystagmus, and its pathophysiology remains poorly understood since the first case reported by Maddox in 1913. 1 Furthermore, see-saw nystagmus associated with retinitis pigmentosa is very rare. To the best of our knowledge, only 2 cases of see-saw nystagmus associated with retinitis pigmentosa have been reported since 1986. 2 Here, I report a case of seesaw nystagmus associated with retinitis pigmentosa. There were no clinical cranial nerve deficits and no cerebellar signs. Magnetic resonance imaging of the brain showed no lesions of the brainstem, cerebellum or evidence of demyelination. This case shows a rare association between see-saw nystagmus and retinitis pigmentosa. It is therefore important to recognise this, and future studies are needed to provide clarity on the underlying mechanism of this clinical entity.

The early clinical and laboratory predictors of GBS outcome: hospital-based study, Assiut University, Upper Egypt

BackgroundThis study was designed to identify factors that influence outcomes in a large group of well-defined Guillain–Barré syndrome (GBS) patients with a 3-month follow-up period. Sixty-two cases of GBS with a mean age of 37.15 ± 17.60 years (33 males and 29 females) were recruited in the first 2 weeks after onset. Clinical history, examination, and a variety of rating scales including Medial Research Council sum score (MRC), Erasmus Guillain-Barré respiratory insufficiency score (EGRIS), at admission and 10 days later were performed. Follow-up investigations at 3 months included the Hughes Disability Scale (HDS), and Overall Neuropathy Limitation Scale (ONLS).Results64.5% of participants had cranial nerve deficits, 45% had neck muscle weakness, 30.6% had dysautonomia, and 8.1% were mechanically ventilated. C-reactive protein was elevated in 38.7%, and hyponatremia was recorded in 30.6% of patients. Older age, antecedent events particularly diarrhea, neck muscles weakness, low MRC sum score, impaired cough reflex, dysautonomia, and hyponatremia, were all significantly associated with poor outcomes at 3 months using HDS and ONLS. Regression analysis with dependent variables of HDS outcome showed that the presence of an antecedent event particularly diarrhea, neck muscle weakness, hyponatremia and the presence cytoalbuminous dissociation of CSF at onset, and low MRC sum score at 10th day after treatment, were predictors of poor outcome.ConclusionClinical and laboratory predictors of poor outcome were older age, the presence of an antecedent event particularly diarrhea, low MRC sum score at the 10th day, elevated CRP, hyponatremia and the presence cytoalbuminous dissociation.

A Clinical Case Report About an Intracranial Lipoma

Intracranial lipoma is a uncommon congenital malformation, represent less than 0.1% of all intracranial tumors. Result from abnormal persistence and mal-differentiation of meninx primitiva, during embryogenesis. The cases in which the tumor presents an extracranial component are caused by a secondary dehiscence of the skull with evagination of a small tuft of primitive meninges. These lesions are frequently located in the inter-hemispheric fissure in the pericallosal region in 50% of cases, other locations as ambient or quadrigeminal cisterns present an incidence about 20-25%. In half of cases the patients present associate midline brain malformations of varying severity, the most frequent is the agenesia of the corpus callosus. The most accepted theory states that in embryonic phases, mesenchymal alterations at the level of the cranial sutures in the sagittal plane can cause anomalies of the SSS, sinus rectum, tentorium, and parietal bones that would explain the associated anomalies. Majority of intracranial lipomas are detected incidentally, being a third of the asymptomatic cases. As in all other pathologies certain localizations cause specific symptomatology of the involved area. The most common clinical manifestations are headache, epilepsy, mental dysfunctions and cranial nerve deficits. The clinical diagnosis is unclear and it is necessary release complementary exams in every suspected cases. Neuroimaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) make possible identify these lesions. We describe a clinical case about a 79-year-old woman with headache without any other symptoms. Was done CT and MRI that showed a inter-hemispheric lesion located in the pericallosal region, without any other abnormality associated. The development, during the last decades, of neuroimaging and histogenesis techniques increased the knowledge about this pathology and modified the management in recent times. The surgery is contraindicated in the majority of the cases, however still play a role in some cases especially in presence of hydrocephalus, uncontrollable seizures, and bony affectation with cosmetic influence. The medical control of the epilepsy is mandatory. We present a clinical case about pericallosal intracranial lipoma and review the current literature. Taking in account the clinical situation and the imaging findings, we decide for a conservative approach with clinical/neurological and radiological follow-up.

Proton Radiotherapy for Vestibular Schwannomas in Patients with NF2-Related Schwannomatosis: A Case Series.

(1) Background: This study aimed to evaluate the efficacy and treatment-related toxicity of proton radiotherapy (PRT) for vestibular schwannoma (VS) in patients with neurofibromatosis type 2-related schwannomatosis (NF2). (2) Methods: Consecutive NF2 patients treated with PRT for VS between 2004 and 2016 were retrospectively evaluated, focusing on tumor volume, facial and trigeminal nerve function, hearing, tinnitus, vestibular symptoms, and the need for salvage therapy after PRT. (3) Results: Eight patients were included (median age 36 years, 50% female). Median follow-up was 71 months. Five (63%) patients received fractionated PRT and three (38%) received PRT radiosurgery for VS. Six patients (75%) received prior VS surgery; three also received bevacizumab. Six patients (75%) did not require salvage therapy after PRT. Two patients (25%) with residual hearing lost it after PRT, and six had already lost ipsilateral hearing prior to PRT. Tumor and treatment-related morbidity could be evaluated in six patients. Following PRT, conditions that occurred or worsened were: facial paresis in five (83%), trigeminal hypoesthesia in two (33%), tinnitus in two (33%), and vestibular symptoms in four patients (67%). (4) Conclusion: After PRT for VS, the majority of the NF2 patients in the cohort did not require additional therapy. Tumor and/or treatment-related cranial nerve deficits were common. This is at least partly explained by the use of PRT as a salvage treatment after surgery or bevacizumab, in the majority of cases. There remains the further opportunity to elucidate the efficacy and toxicity of proton radiotherapy as a primary treatment.

Retrospective Analysis of Carotid Body Tumor Surgical Management: Roles of Preoperative Image Investigation and Preoperative Embolization

Carotid body tumors (CBT) surgery is a challenging procedure, and the role of embolization (EMB) in CBT surgery has remained unclear. This study is performed to analyze the management of CBTs, particularly the use of preoperative EMB and image features in minimizing surgical complications. A total of 200 CBTs were identified among 184 medical records involving CBT surgery. Regression analysis was used to explore the prognostic predictors of cranial nerve deficit (CND), including image features. In addition, blood loss, operation times, and complication rates were compared between patients who had surgery only versus patients who had surgery along with preoperative EMB. Overall, 96 males and 88 females were identified for inclusion in the study, with a median age of 37.0years. Computed tomography angiography (CTA) showed the presence of a tiny gap adjacent to the encasement of carotid vessels, which could help minimize carotid arterial injury. High-lying tumors that encased the cranial nerve were usually managed with synchronous cranial nerve resection. Regression analysis revealed that the incidence of CND was positively associated with Shamblin Ⅲ, high-lying, and a maximal CBT diameter of ≥ 5cm. Among 146 EMB cases, 2 cases of intracranial arterial EMB occurred. No statistical difference was found between the EBM and non-EBM groups in terms of bleeding volume, operation time, blood loss, blood transfusion requirement, stroke, and permanent CND. Subgroup analysis revealed that EMB decreased CND in Shamblin III and low-lying tumors. CBT surgery should be performed with preoperative CTA to identify favorable factors for minimizing surgical complications. Shamblin Ⅲ or high-lying tumors, as well as CBT diameter, are predictors of permanent CND. EBM does not reduce blood loss or shorten operation time.

Treatment and Outcome of Anterior Inferior Cerebellar Artery (AICA) Aneurysms: Helsinki Series of 15 Consecutive Patients.

Objective Anterior inferior cerebellar artery (AICA) aneurysms are rare posterior circulation lesions that are challenging to treat. This article presents the treatment and clinical outcome of AICA aneurysms in an unselected cohort of patients. Methods A retrospective analysis of patient record files, digital subtraction angiography, and computed tomography angiography images of 15 consecutive patients harboring AICA aneurysms treated between 1968 and 2017. Results Of the 15 AICA aneurysm patients reviewed, 12 (80%) were females. Twenty percent had intracerebral hemorrhage and 40% presented with intraventricular hemorrhage. Eleven out of 15 (73%) patients presented with subarachnoid hemorrhage (SAH); 82% of SAH patients had a good-grade SAH (Hunt and Hess grade 1-3). Eleven patients (73%) were treated surgically, three (20%) were treated conservatively, and one (7%) had coil embolization. In 27% of patients, a subtemporal approach with anterior petrosectomy was performed. A retrosigmoid approach was used in the remaining 73%. In 18% of the patients, a parent vessel occlusion was necessary to occlude the aneurysm. Five out of 11 (47%) of the patients developed postoperative cranial nerve deficits. Twenty-seven percent developed shunt-dependent hydrocephalus. All patients who presented with an unruptured AICA aneurysm had good clinical outcome (modified Rankin scale [mRS] 1-2). In patients with SAH, 82% achieved good clinical outcome and 18% had poor clinical outcome (mRS 3-6) after 1 year. Conclusion Surgical treatment of AICA aneurysms has a high rate of cranial nerve deficits but most of patients have a good long-term clinical outcome.

Abstract Number ‐ 80: Embolization of Carotid Cavernous Fistula Through Occluded Inferior Petrosal Sinus Access

Introduction Carotid cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus. The most common presenting symptoms are proptosis, chemosis, orbital bruit and headache. Visual disturbances such as diplopia, ophthalmoplegia and cranial nerve deficits can also occur. Pulsatile tinnitus is an unusual finding which necessitates further workup in this population. Endovascular obliteration with transvenous embolization for indirect fistulas is the preferred approach for CCF closure. Navigation is achieved through the inferior petrosal sinus or facial and superior ophthalmic vein. Here, we describe a case of carotid cavernous fistula that was successfully treated through occluded right inferior petrosal sinus access using coil and Onyx embolic material. Methods A 56‐year‐old‐male with no past medical history presented with right eye proptosis and pulsatile tinnitus. His eye symptoms progressively worsened with decrease in visual acuity, gaze restriction and exophthalmos which correlated with the resolution of pulsatile tinnitus. MRI demonstrated significant inflammation involving the right orbit and atypical enhancement of basal frontal lobe adjacent to orbit. MRA suggested early opacification of the right superior ophthalmic vein and subtle flow voids in posterior lateral aspect of right cavernous sinus. Further evaluation with cerebral angiogram revealed a Barrow Type D right carotid cavernous fistula supplied by meningo‐hypophyseal branches of bilateral internal carotid arteries and right internal maxillary branch. It demonstrated high flow retrograde shunting in right superior ophthalmic vein and a basal frontal isolated cortical vein. There was near complete occlusion of the right sigmoid sinus and inferior petrosal sinus due to significant thrombus burden as well as stenosis of the right internal jugular vein. Results Patient underwent embolization of right carotid cavernous fistula with transvenous approach. A microcatheter was advanced to the origin of the intercavernous sinus but was not able to cross due to exceptionally small channels connecting both cavernous sinuses. The right internal jugular vein was subsequently identified and injection demonstrated occlusion of right sigmoid sinus due to near complete occlusive thrombus in addition to occlusion of the major channels of the inferior petrosal sinus. The microcatheter was blindly advanced into the inferior petrosal sinus maintaining the symmetry from contralateral inferior petrosal sinus trajectory. We were able to reach the fistulous point in the posterior medial aspect of the right cavernous sinus using an Echelon 1045 microcatheter. Coils were subsequently deployed and fistula was noted to be occluded. Onyx was injected through the microcatheter to avoid recanalization of fistula. A follow‐up left internal carotid artery and right common carotid artery injections confirmed angiographic cure of the fistula. Conclusions Carotid cavernous fistula is a rare but treatable cause of rapidly progressive vision loss with pulsatile tinnitus as an unusual finding. We present a case of challenging access and successful treatment with transvenous approach through near complete occlusion of the inferior petrosal sinus.

Posterior Fossa Midline Epidermoid Tumors: Role of the Inferior Medullary Velum and a Proposed New Imaging Classification.

Posterior fossa midline epidermoid tumors (PFMETs) include the epidermoid tumors of the cisterna magna (CM) and fourth ventricle (FV). To report tumor epicenter-based classification of PFMETs and its clinical and surgical implications with outcome. On retrospective analysis of operated cases of intracranial epidermoid tumors, 19 (N = 19) patients having tumor epicenter within FV, CM, or both were included. Cerebellopontine and prepontine cistern epidermoid were excluded. Tumor location was decided based on preoperative MRI and intraoperative findings. Major complication was defined as new onset or worsening of cranial nerve (CN) deficit, sensory motor impairment, or tracheostomy. The mean (±SD) age of the patients was 42.0 ± 11.6 years (range 25-61 years), with no sex predilection (male:female: 1:0.9). The most common symptoms were cerebellar dysfunction, headache, vomiting, and diplopia. Common CNs affected were VII, V, lower cranial nerve, and VI. The PFMETs were classified based on tumor epicenter as type 1 (tumor epicenter in CM, n = 4/21.1%), type 2 (FV, n = 5/26.3%), and type 3 (involved CM and FV, n = 10/52.6%). Type 2 tumors had a higher incidence of raised intracranial pressure and only facial nerve palsy as preoperative CN deficit. Type 1 tumors had the least incidence of postoperative major complications. Type 3 tumors were the largest and had a greater incidence of brainstem adhesion and postoperative complications. The tumor size, duration of symptoms, and patient age were higher in patients with brainstem adhesion (5.3 ± 1.0 cm, 21 ± 16 months, 44.1 ± 9.2 years) as against its absence (4.8 ± 1.3 cm, 11.2 ± 7.3 months, 38.2 ± 11.7 years). Inferior medullary velum and tela choroidea have a critical role in tumorogenesis, tumor extension, and brainstem adhesion. PFMETs can be classified into 3 subtypes based on tumor epicenter having clinical and surgical implications. Less aggressive dissection and near total excision in the presence of brainstem adhesion yield favorable outcomes.

Intratumoral hemorrhage in vestibular schwannomas after stereotactic radiosurgery.

Vestibular schwannomas (VSs) are benign tumors of the cerebellopontine angle that are typically managed with stereotactic radiosurgery (SRS). Intratumoral hemorrhage (ITH) of VSs is a rare occurrence that results in worsening vestibular and new cranial nerve deficits. Few reports have described the management and outcomes of this entity after SRS. To further delineate the incidence and impact of this event, the authors performed a retrospective review of their VS SRS patients at a single center. Between 1987 and 2022, 2058 patients with VSs underwent Gamma Knife radiosurgery (GKRS) at the University of Pittsburgh Medical Center. The authors performed a review of the prospectively maintained VS database at their center to identify patients with ITH. The presentation, management, and clinical and imaging outcomes of the patients are reported. A total of 1902 VS patients had sufficient clinical and imaging follow-up data. Five Koos grade III (n = 1) and IV (n = 4) VS patients developed ITH after GKRS, resulting in a cumulative incidence rate of 0.26%. The age at presentation ranged from 62 to 79 years, and 3 patients were male. The time from VS diagnosis to GKRS ranged from 1 to 13 months, and the time from GKRS to ITH ranged from 2 to 130 months. Three patients had bleeding risk factors. One patient required urgent surgical intervention due to the ITH volume, while the other 4 patients were initially observed. Three patients remained stable and required no delayed intervention; 1 patient required delayed resection because of symptom progression and hemorrhagic expansion. Histopathological analysis revealed multiple fragments of S-100-positive cells, hemorrhage, and hemosiderin-laden macrophages. At last follow-up, 4 patients had clinically improved and 1 patient remained stable. ITH after VS radiosurgery is a rare phenomenon with a cumulative incidence rate of 0.26% in this series. Patient-tailored management in the form of observation or resection is based on patient presentation, acuity, and ITH size.