Neurosurgical Literature Research Articles

Spinal epidural abscess due to tropical pyomyositis in immunocompetent adolescents

Pyomyositis, a suppurative infection of skeletal muscle, is a disease not frequently encountered by neurosurgical providers. While previously considered an infection localized to tropical and semitropical locations, clinical reports of pyomyositis in temperate climates have increased over the past decade. Paraspinal involvement is uncommon in pyomyositis; however, the potential exists for spread into the epidural space resulting in a spinal epidural abscess (SEA). Early diagnosis of an SEA is frequently hampered by the absence of specific signs, unfamiliarity with the disease, atypical manifestations, and a broad differential diagnosis that includes more common causes of back pain. To date, 1 such case of paraspinal pyomyositis associated with an SEA has been reported in the neurosurgical literature. The authors present 2 cases of pyomyositis with an SEA and review the epidemiology, pathophysiology, diagnostic workup, and management of this disorder.

Extramedullary hematopoietic tumor mimicking a thoracic nerve root schwannoma

Extramedullary hematopoiesis secondary to chronic anemia is well reported throughout the literature. A rare presentation of this condition is in the central nervous tissue reported most frequently as an epidural mass causing spinal cord compression. The authors report the case of a 51-year-old man with beta-thalassemia and chronic anemia who was found to have a 4-cm paravertebral mass suggestive of a schwannoma. The patient underwent transthoracic resection of the mass. Histological examination confirmed an extramedullary hematopoietic tumor. In this article the authors propose a method to distinguish extramedullary hematopoietic tumors from schwannomas. To the authors' knowledge, this is the first reported case in the neurosurgical literature of this phenomenon.

Believe It or Not

Access to timely neurosurgical care in particular remains limited worldwide, and is associated with increased morbidity and mortality, a decrease in overall life expectancy, and catastrophic economic costs. To date, access to neurosurgical care has not been completely studied and reported in the Caribbean neurosurgical literature. In this study, we aim to understand the geographic distribution of hospital facilities with neurosurgical capacity among the CARICOM member states to determine timely access to neurosurgical care.We assessed geographical access to facilities capable of providing neurosurgical care in the Caribbean. The GPS coordinates of the hospitals that provide neurosurgical care were identified using street addresses and satellite imaging from Google Maps. Facilities with neurosurgical care were mapped in ArcGIS Pro (Version 2.6.0). using Manhattan distance. We identified the area around each facility and stratified by 30- minute, 1-hour, 2-hour, and 4-hour geographic driving intervals.A total of 16 hospitals were identified as providing neurosurgical care in the Caribbean. Our results suggest that 14 million people (76% of the population) had 4-hour geographic access to a facility capable of providing neurosurgical care. In addition, 7 million people (40% of the population) had 2-hour geographical access to neurosurgical care.Timely access to care is an important tenet of global neurosurgery. We found that 3.5 million Caribbean residents are outside of the access zone to neurosurgical capacity. Public health advocates, governments, providers, and patients should be aware of the inequity in access to neurosurgical care and should collectively work to close the gap.

Leptomeningeal dissemination of a pediatric neoplasm with 1p19q deletion showing mixed immunohistochemical features of an oligodendroglioma and neurocytoma

Leptomeningeal dissemination of an oligodendroglioma is rarely reported in the neurosurgical literature, especially in cases with a classical 1p19q deletion. The authors describe a case wherein a 1p19q deletion in a disseminated tumor with mixed immunohistochemical features of oligodendroglioma and neurocytoma was encountered and treated. Stereotactic right frontal craniotomy was undertaken for obtaining definitive histological diagnosis. The results revealed a neuroectodermal neoplasm with histologic and immunohistochemical features of oligodendroglioma and neurocytoma. FISH analysis confirmed classical 1p19q deletion. The patient was treated postoperatively with chemotherapy and radiation therapy. He showed good clinical response and remains alive 16 months after diagnosis.

Gamma Knife Thalamotomy for Disabling Tremor

Gamma knife thalamotomy (GKT) has been used as a therapeutic option for patients with disabling tremor refractory to medications. Impressive improvement of tremor has been reported in the neurosurgical literature, but the reliability of such data has been questioned. To prospectively evaluate clinical outcomes after GKT for disabling tremor with blinded assessments. Prospective study with blinded independent neurologic evaluations. University hospital. Consecutive patients who underwent unilateral GKT for essential tremor and Parkinson disease tremor at our center. These patients were unwilling or deemed unsuitable candidates for deep brain stimulation or other surgical procedures. Unilateral GKT and regular follow-up evaluations for up to 30 months, with blinded video evaluations by a movement disorders neurologist. Clinical outcomes, as measured by the Fahn-Tolosa-Marin Tremor Rating Scale and activities of daily living scores, and incidence of adverse events. From September 1, 2006, to November 30, 2008, 18 patients underwent unilateral GKT for essential tremor and Parkinson disease tremor at our center. Videos for 14 patients (11 with essential tremor, 3 with Parkinson disease tremor) with at least 6 months' postoperative follow-up were available for analysis (mean [SD] follow-up duration, 19.2 [7.3] months; range, 7-30 months). The Fahn-Tolosa-Marin Tremor Rating Scale activities of daily living scores improved significantly after GKT (P = .03; median and mean change scores, 2.5 and 2.7 points, respectively [range of scale was 0-27]), but there was no significant improvement in other Fahn-Tolosa-Marin Tremor Rating Scale items (P = .53 for resting tremor, P = .24 for postural tremor, P = .62 for action tremor, P = .40 for drawing, P > .99 for pouring water, P = .89 for head tremor). Handwriting and Unified Parkinson's Disease Rating Scale activities of daily living scores tended to improve (P = .07 and .11, respectively). Three patients developed delayed neurologic adverse events. Overall, we found that GKT provided only modest antitremor efficacy. Of the 2 patients with essential tremor who experienced marked improvement in tremor, 1 subsequently experienced a serious adverse event. Further prospective studies with careful neurologic evaluation of outcomes are necessary before GKT can be recommended for disabling tremor on a routine clinical basis.

Anatomy of the palmar branch of the ulnar nerve: application to ulnar and median nerve decompressive surgery

The palmar cutaneous branch of the ulnar nerve (PCUN) has received little attention in the literature, and to the authors' knowledge, has received no attention in the neurosurgical literature. The present study was performed to help the surgeon minimize postoperative complications of nerve decompression at the wrist. Forty cadaveric upper limbs underwent dissection of the ulnar nerve in the forearm, at the wrist, and in the palm. The PCUN was investigated and when identified, measurements were made and relationships documented between this cutaneous branch and the ulnar artery. The length and width of the PCUN were measured, as was the distance from the medial epicondyle of the humerus to the origin of the PCUN from the ulnar nerve. A PCUN was found on 90% of sides. The origin of the PCUN from the ulnar nerve was found to lay a mean of 14.3 cm distal to the medial epicondyle. The mean length and width of this branch were 13 and 0.08 cm, respectively. In the forearm, the PCUN traveled lateral to the ulnar artery on 75% of sides and on the medial side of this vessel on the remaining sides. The PCUN perforated the fascia of the anterior forearm just proximal to the distal wrist crease. In the palm, the PCUN traveled superficial to the superficial palmar arch on all but 5 sides, where it traveled deep to this vascular structure's distal extent. On 2 sides each, the PCUN communicated with the superficial and deep ulnar nerves. On 2 sides, the PCUN communicated with the palmar cutaneous branch of the median nerve. The majority of the terminal fibers of the PCUN were found on the ulnar side of a hypothetical line drawn longitudinally through the fourth digit and supplied an area roughly 3 × 3 cm over the proximal medial palm. The authors hope that the present data may be useful to the surgeon during decompressive procedures at the wrist, such as carpal tunnel and the Guyon canal. Based on this study, skin incisions of the palm made longitudinally along a line through the middle of the fourth digit would minimize injury to the PCUN.

Septal agenesis and lissencephaly with colpocephaly presenting as the ′Crown Sign′

Developmental malformations of the cortex in neuronal migration disorders result in constellation of findings on radiological scanning. Isolated defects are common but sometimes they occur in varying degrees of combination giving a unique appearance on the imaging studies. We describe a case of neuronal migration disorder in which the computed tomography scan showed the presence of lissencephaly, colpocephaly. and Septal agenesis. These findings make the ventricular system appear in shape of a crown, which we refer to as “CROWN SIGN”, first described in neurosurgical literature..

Endolymphatic sac papillary carcinoma treated with surgery and post-operative intensity-modulated radiotherapy: A rare case report

Endolymphatic sac tumor is a rare papillary neoplasm of the temporal bone which can occur sporadically or in association with von Hippel-Lindau disease. Many cases have been reported in neurosurgical literature wherein surgical excision has proved to be the gold standard of treatment. This article highlights the rarity of the pathology and the role of radiotherapy to the residual lesion after surgery. Benefits of intensity modulated radiotherapy in such irregular-shaped tumor, which is in close vicinity to the critical structures, are also discussed.

Entrapment of the glossopharyngeal nerve in patients with Eagle syndrome: surgical technique and outcomes in a series of 5 patients

Eagle syndrome is characterized by unilateral pain in the oropharynx, face, and earlobe, and is caused by an elongated styloid process or ossification of the stylohyoid ligament with associated compression of the glossopharyngeal nerve. The pain syndrome may be successfully treated with surgical intervention that involves resection of the styloid process. Although nerve decompression is routinely considered a neurosurgical intervention, Eagle syndrome and its treatment are not sufficiently examined in the neurosurgical literature. A review was performed of cases of Eagle syndrome treated in the Department of Neurosurgery at the University of Illinois at Chicago Medical Center over the last 7 years. The clinical characteristics, radiographic imaging, operative indications, procedural details, surgical morbidity, and clinical outcomes were collected and analyzed. Of the many patients with facial pain treated between 2001 and 2007, 7 were diagnosed with Eagle syndrome, and 5 of these patients underwent resection of the elongated styloid process. There were 4 women and 1 man, ranging in age from 20 to 68 years (mean 43 years). The average duration of disease was 11 years. In all patients, a preoperative workup revealed unilateral or bilateral elongation of the styloid process. All patients underwent resection of the styloid process on the symptomatic side using a lateral transcutaneous approach. There were no surgical complications. All patients experienced pain relief immediately after the operation. At the latest follow-up (average 46 months, range 7 months to 7.5 years) all but 1 patient maintained complete pain relief. In 1 patient, the pain recurred 12 months postoperatively and additional interventions were required. Eagle syndrome may be considered an entrapment syndrome of the glossopharyngeal nerve. It is a distinct clinical entity that should be considered when evaluating patients referred for glossopharyngeal neuralgia. The authors' experience indicates that patients with Eagle syndrome may be successfully treated using open resection of the elongated styloid process, which appears to be both safe and effective in terms of long-lasting pain relief.

Multiple intracranial aneurysms and moyamoya disease associated with microcephalic osteodysplastic primordial dwarfism type II: surgical considerations

Microcephalic osteodysplastic primordial dwarfism type II (MOPD II) is a rare genetic syndrome characterized by extremely small stature and microcephaly, and is associated in 25% of patients with intracranial aneurysms and moyamoya disease. Although aneurysmal subarachnoid hemorrhage and stroke are leading causes of morbidity and death in these patients, MOPD II is rarely examined in the neurosurgical literature. The authors report their experience with 3 patients who presented with MOPD II, which includes a patient with 8 aneurysms (the most aneurysms reported in the literature), and the first report of a patient with both moyamoya disease and multiple aneurysms. The poor natural history of these lesions indicates aggressive microsurgical and/or endovascular therapy. Microsurgery, whether for aneurysm clip placement or extracranial-intracranial bypass, is challenging due to tight surgical corridors and diminutive arteries in these patients, but is technically feasible and strongly indicated when multiple aneurysms must be treated or cerebral revascularization is needed.

The combined approach to intracranial aneurysm treatment

Background A consecutive series of patients with intracranial aneurysms in the practice of one neurovascular surgeon was retrospectively reviewed to illustrate that one physician can become proficient in microneurosurgery as well as endovascular surgery and achieve favorable outcomes in both disciplines. This supports one model of training for cerebrovascular surgeons that includes the complimentary practice of open microneurovascular surgery with endovascular surgery. Methods The senior author (HAR) treated 351 patients with 413 aneurysms between July 2001 and March 2007. Of these, 172 patients (216 aneurysms) were treated with open microneurosurgical techniques and 179 patients (197 aneurysms) were treated using endovascular techniques. Results Complete obliteration was attained in 94.3% of clipped aneurysms, and 61.9% and 65.9% of coiled aneurysms immediately and after at least 6 months of follow-up, respectively. At latest evaluation, 93% of endovascular patients and 90% of microneurosurgical patients had good clinical outcomes (GOS, 4 or 5; mean follow-up, 23 months; combines ruptured and unruptured cohorts). Procedure-related mortality included 1 surgical patient and 2 endovascular patients. Conclusions Because the fields of microvascular and endovascular surgeries are both technically complex, there has been concern that hybrid cerebrovascular surgeons cannot perform each technique with the skill necessary to achieve good outcomes. When compared to clipping and coiling reviews in the neurosurgical literature, we illustrate that one hybrid neurovascular surgeon is capable of attaining great facility in both techniques and that this type of physician will represent one practice model of cerebrovascular specialist in the future. This has potential implications for the training of hybrid cerebrovascular surgeons.

Fisch Approaches to the Infratemporal Fossa

Background: Infratemporal fossa procedures provide wide exposure of the skull base. The main indications for these approaches are glomus jugulare lesions; lesions of the petrous apex and clivus; and nasopharyngeal, sellar, and parasellar lesions—particularly those extending into the infratemporal fossa, orbit, parasellar region, and cavernous sinus. There are three main types of these procedures: A, B, and C. The type A approach is rarely performed today. Types B and C approaches are commonly used, especially by ENT surgeons. Neurosurgical literature lacks detailed anatomical dissection of these three approaches. In this study, we performed cadaver dissection studies of all three approaches and showed the bony, neural, and vascular structures relevant to the approach used.

The historical evolution of transsphenoidal surgery: facilitation by technological advances

Over the past century, pituitary surgery has undergone multiple evolutions in surgical technique and technological advancements that have resulted in what practitioners now recognize as modern transsphenoidal surgery (TSS). Although the procedure is now well established in current neurosurgical literature, the historical maze that led to its development continues to be of interest because it allows a better appreciation of the unique contributions by the pioneers of the technique, and of the innovative spirit that continues to fuel neurosurgery. The early events in the history of TSS have already been well documented. This paper therefore summarizes the major early transitions along the timeline, and then further concentrates on some of the more recent advancements in TSS, such as the surgical microscope, fluoroscopy, endoscopy, intraoperative imaging, and frameless guidance. The account of each of these innovations is unique because they were each developed as a response to certain historical needs by the surgeon. An understanding of these more recent contributions, coupled with the early history, provides a more complete perspective on modern TSS.

Y-stent-assisted coil embolization for the management of unruptured cerebral aneurysms: report of six cases

The advent of stent-assisted coil embolization has revolutionized the endovascular management of complex intracranial aneurysms. Although performed routinely in most cerebrovascular centers, there are not many case series reported about the Y-stent technique for coil placement in cerebral aneurysms. The authors present the second largest series available within the neurosurgical literature. The authors have retrospectively reviewed the medical records and angiographic data of six patients who were diagnosed as having unruptured cerebral aneurysms and subsequently treated using "Y" stent-assisted coil embolization. Five out of six cerebral aneurysms in this study were located at the basilar tip while the remaining one was at the left MCA trifurcation. Aneurysms ranged in size from 8-22 mm. All patients were female with ages ranging from 37-70 years. One patient presented with recurrence of an aneurysm previously managed with a balloon-assisted coil embolization. Another patient presented after a failed trial of a balloon-assisted procedure. One patient had originally been diagnosed with multiple aneurysms of varying size and location. A "Y" configuration was successfully established in all six patients. Five patients have had a symptom-free recovery period at average follow-up period of 36.7 months. The remaining patient is notable for recurrence that was discovered on angiogram 32 months postoperatively. The proposed Y-stent technique is a safe and effective option that can be employed in the endovascular reconstruction of unruptured intracranial aneurysms of complex location and orientation. These methods serve as an acceptable alternative in the management of aneurysms traditionally managed with microsurgery. Hemodynamic assessment has shown Y-stenting to be an advantageous therapy option, yet further studies are required to assess these parameters in alternative therapies.

Preparing the ethical future of deep brain stimulation

Background Deep brain stimulation is an approved and effective neurosurgical intervention for motor disorders such as PD and ET. Deep brain stimulation may also be effective in treating a number of psychiatric disorders, including treatment refractory depression and OCD. Although DBS is a widely accepted therapy in motor disorders, it remains an invasive and expensive procedure. The ethical and social challenges of DBS need further examination, and discussion and emerging applications of DBS in psychiatry may also complicate the ethical landscape of DBS. Methods To identify and characterize current and emerging issues in the use of DBS, we reviewed the neurosurgical literature on DBS as well as the interdisciplinary medical ethics and relevant psychological and sociological literatures. We also consulted the USPTO database, FDA regulations and report decisions, and the business reports of key DBS manufacturers. Results Important ethical and social challenges exist in the current and extending practice of DBS, notably in patient selection, informed consent, resource allocation, and in public understanding. These challenges are likely to be amplified if emerging uses of DBS in psychiatry are approved. Conclusions Our review of ethical and social issues related to DBS highlights that several significant challenges, although not insurmountable, need much closer attention. A combination of approaches previously used in neuroethics, such as expert consensus workshops to establish ethical guidelines and public engagement to improve public understanding, may be fruitful to explore.

THE SURVIVAL IMPACT OF POSTOPERATIVE INFECTION IN PATIENTS WITH GLIOBLASTOMA MULTIFORME

The capacity for local infection to prolong survival in patients with cancer is a widely accepted but unsubstantiated principle. The neurosurgical literature contains anecdotal reports of patients with malignant gliomas who experienced prolonged remission of their tumors after a bacterial infection. This association has not been explored in a larger series of patients with malignant glioma with postoperative infections. A single-center operative experience accumulated over 10 years was examined to evaluate whether postoperative infections conferred a survival advantage in patients with glioblastoma multiforme. A total of 382 patients were examined, and 18 bacterial infections were identified. The vast majority (17 cases, 94%) of these were gram-positive infections. Cases were compared with age-matched controls. Survival differences were evaluated using Kaplan-Meier curves, and other differences were tested using the Mann-Whitney U test. Cases and controls were younger and survived longer than the overall study sample, but cases and controls were similar at baseline. A moderate, statistically insignificant survival advantage was seen in the case group (Kaplan-Meier P = 0.27). However, when patients with infections in the first quarter and first half of their postoperative survival were examined, this survival advantage disappeared. There was no significant survival difference in any subgroup analyzed, including deep infections, bone flap infections, or infections caused by any specific organism. In this single-center study, postoperative infection did not confer any survival advantage in patients with glioblastoma multiforme.

Management of anterior inferior cerebellar artery aneurysms: an illustrative case and review of literature

Aneurysms of the anterior inferior cerebellar artery (AICA) are relatively rare among intracranial aneurysms. They can occur in 1 of 3 regions of the AICA: 1) craniocaudal (high or low riding), 2) mediolateral-premeatal (proximal), and 3) meatal-postmeatal (distal). The management strategies for treatment differ according to the location and configuration of the aneurysm. The existing body of neurosurgical literature contains articles published on aneurysms arising from the AICA near the basilar artery (BA), intracanalicular/meatal aneurysms, and distal AICA. Several therapeutic options exist, encompassing microsurgical and endovascular techniques. The authors describe a case of treatment involving a large BA-AICA aneurysm approached via exposure of the presigmoid dura using a retromastoid suboccipital craniectomy and partial petrosectomy. Treatment of these lesions requires detailed knowledge of the anatomy, and an anatomical overview of the AICA with its arterial loops and significant branches is presented, including a discussion of the internal auditory (labyrinthine) artery, recurrent perforating arteries, subarcuate artery, and cerebellosubarcuate artery. The authors discuss the various surgical approaches (retromastoid, far lateral, subtemporal, and transclival) with appropriate illustrations, citing the advantages and disadvantages in accessing these AICA lesions in relation to these approaches. The complications of these different surgical techniques and possible clinical effects of parent artery occlusion during AICA surgery are highlighted.

Clival Fibrous Dysplasia: Case Series and Literature Review

fibrous dysplasia involving the clivus have been reported, primarily within the neurosurgical and radiology literature. This case series reviews the presentation of 3 patients with fibrous dysplasia of the clivus and reviews the literature regarding this topic. At the conclusion of this presentation, the participants should be able to: (1) Understand the presenting symptoms of patient with fibrous dysplasia of the clivus (2) Review finding of magnetic resonance imaging characteristic of clival fibrous dysplasia

Albert Wojciech Adamkiewicz (1850–1921): unsung hero behind the eponymic artery

The artery of Adamkiewicz is an important radiculomedullary artery supplying the spinal cord, especially the lumbar enlargement. Anatomical knowledge of this artery is important for avoiding serious neurological complications during surgery performed in this region--for neurosurgeons and interventional radiologists treating intramedullary tumors and spinal arteriovenous malformations, traumatologists performing spinal fusions, thoracic surgeons treating aortic aneurysms, and urologists and pediatric surgeons conducting retroperitoneal dissections. However, the biography of the talented Polish pathologist Albert Adamkiewicz, after whom the landmark artery is named, has not been described adequately in the existing neurosurgical literature. The authors bring to light the historical perspective of the eponymic artery and provide a recapitulation of other significant contributions made by Adamkiewicz, mostly involving the nervous system. His research papers on the histology of neuronal tissues and neurodegenerative diseases had high scientific merit, but the discovery of the anticancer antitoxin "cancroin" and his postulation of a cancer-causing parasite he named "Coccidium sarcolytus" met with harsh criticism and eventually led to his ill fame. The biography is supplemented with a brief overview of the important surgical implications of the artery of Adamkiewicz.

Spontaneous encephaloceles of the temporal lobe

Encephaloceles are pathological herniations of brain parenchyma through congenital or acquired osseus-dural defects of the skull base or cranial vault. Although encephaloceles are known as rare conditions, several surgical reports and clinical series focusing on spontaneous encephaloceles of the temporal lobe may be found in the otological, maxillofacial, radiological, and neurosurgical literature. A variety of symptoms such as occult or symptomatic CSF fistulas, recurrent meningitis, middle ear effusions or infections, conductive hearing loss, and medically intractable epilepsy have been described in patients harboring spontaneous encephaloceles of middle cranial fossa origin. Both open procedures and endoscopic techniques have been advocated for the treatment of such conditions. The authors discuss the pathogenesis, diagnostic assessment, and therapeutic management of spontaneous temporal lobe encephaloceles. Although diagnosis and treatment may differ on a case-by-case basis, review of the available literature suggests that spontaneous encephaloceles of middle cranial fossa origin are a more common pathology than previously believed. In particular, spontaneous cases of posteroinferior encephaloceles involving the tegmen tympani and the middle ear have been very well described in the medical literature.