Joyce Koueik, Sarah Larson, Azam Ahmed, Amgad S Hanna
{"title":"Large vertebral artery pseudoaneurysm masquerading as a schwannoma: illustrative case.","authors":"Joyce Koueik, Sarah Larson, Azam Ahmed, Amgad S Hanna","doi":"10.3171/CASE23168","DOIUrl":"10.3171/CASE23168","url":null,"abstract":"<p><strong>Background: </strong>Extracranial vertebral aneurysms or pseudoaneurysms are rare and result primarily from trauma. Large pseudoaneurysms can masquerade as mass lesions, making it challenging to identify the correct diagnosis.</p><p><strong>Observations: </strong>This is a case report in which a large vertebral pseudoaneurysm posed as a schwannoma and biopsy was attempted. It was later identified as a vascular lesion and treated appropriately with no complications.</p><p><strong>Lessons: </strong>Vascular etiologies should always be included in the differential diagnosis of spine and nerve pathologies especially lesions that are in the vicinity of major vascular channels such as the transverse foramina of the cervical spine.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/c3/3d/CASE23168.PMC10555631.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9795116","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Awais Abbas, Kiran Hilal, Aniqa Abdul Rasool, Ume-Farwah Zahidi, Muhammad Shahzad Shamim, Qalab Abbas
{"title":"Low-field magnetic resonance imaging in a boy with intracranial bolt after severe traumatic brain injury: illustrative case.","authors":"Awais Abbas, Kiran Hilal, Aniqa Abdul Rasool, Ume-Farwah Zahidi, Muhammad Shahzad Shamim, Qalab Abbas","doi":"10.3171/CASE23225","DOIUrl":"10.3171/CASE23225","url":null,"abstract":"<p><strong>Background: </strong>Conventional magnetic resonance imaging (cMRI) is sensitive to motion and ferromagnetic material, leading to suboptimal images and image artifacts. In many patients with neurological injuries, an intracranial bolt (ICB) is placed for monitoring intracranial pressure (ICP). Repeated imaging (computed tomography [CT] or cMRI) is frequently required to guide management. A low-field (0.064-T) portable magnetic resonance imaging (pMRI) machine may provide images in situations that were previously considered contraindications for cMRI.</p><p><strong>Observations: </strong>A 10-year-old boy with severe traumatic brain injury was admitted to the pediatric intensive care unit, and an ICB was placed. Initial head CT showed a left-sided intraparenchymal hemorrhage with intraventricular dissection and cerebral edema with mass effect. Repeated imaging was required to assess the brain structure because of continually fluctuating ICP. Transferring the patient to the radiology suite was risky because of his critical condition and the presence of an ICB; hence, pMRI was performed at the bedside. Images obtained were of excellent quality without any ICB artifact, guiding the decision to continue to manage the patient conservatively. The child later improved and was discharged from the hospital.</p><p><strong>Lessons: </strong>pMRI can be used to obtain excellent images at the bedside in patients with an ICB, providing useful information for better management of patients with neurological injuries.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/c2/c6/CASE23225.PMC10555635.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9795122","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Karina A Lenartowicz, Robert J Spinner, Kimberly K Amrami, Shawn W O'Driscoll
{"title":"Posterior interosseous nerve paralysis secondary to an extraneural ganglion cyst from a radial neck pseudarthrosis: illustrative case.","authors":"Karina A Lenartowicz, Robert J Spinner, Kimberly K Amrami, Shawn W O'Driscoll","doi":"10.3171/CASE23218","DOIUrl":"10.3171/CASE23218","url":null,"abstract":"<p><strong>Background: </strong>Many benign and malignant tissue or bony lesions have been reported as causes of extrinsic or intrinsic posterior interosseous nerve (PIN) neuropathy at the proximal forearm/elbow region. The authors describe an unusual cause of external compression of the PIN due to a ganglion cyst arising from a radial neck pseudarthrosis (a false joint).</p><p><strong>Observations: </strong>Decompression of the PIN with the release of the arcade of Frohse was performed with resection of the radial head and the ganglion cyst. By 6 months postoperatively, the patient had a complete neurological recovery.</p><p><strong>Lessons: </strong>This case illustrates a previously unreported cause of extraneural compression of the PIN from a pseudarthrosis. The mechanism for compression in this case from the radial head pseudarthrosis is likely attributable to the sandwich effect, in which the PIN is sandwiched between the arcade of Frohse at the supinator from above and the cyst below.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/2e/6b/CASE23218.PMC10555629.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9739968","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Masamichi Abe, Takahiro Ono, Felix Hinz, Masataka Takahashi, Yuko Hiroshima, Koya Kodama, Michihiro Yano, Hiroshi Nanjo, Tsutomu Takahashi, Andreas von Deimling, Hiroaki Shimizu
{"title":"Detailed molecular and pathological analyses of primary intracranial embryonal rhabdomyosarcoma with a BRAF mutation: illustrative case.","authors":"Masamichi Abe, Takahiro Ono, Felix Hinz, Masataka Takahashi, Yuko Hiroshima, Koya Kodama, Michihiro Yano, Hiroshi Nanjo, Tsutomu Takahashi, Andreas von Deimling, Hiroaki Shimizu","doi":"10.3171/CASE23207","DOIUrl":"10.3171/CASE23207","url":null,"abstract":"<p><strong>Background: </strong>The etiological significance of the RAS and PI3K pathways has been reported in systemic embryonal rhabdomyosarcoma (ERMS) but not in primary intracranial ERMS (PIERMS). Herein, the authors present a unique case of PIERMS with a BRAF mutation.</p><p><strong>Observations: </strong>A 12-year-old girl with progressive headache and nausea was diagnosed with a tumor in the right parietal lobe. Semi-emergency surgery revealed an intra-axial lesion that was histopathologically identical to an ERMS. Next-generation sequencing indicated a BRAF mutation as a pathogenic variation, but the RAS and PI3K pathways showed no alteration. Although there is no established reference class for PIERMS, the DNA methylation prediction was closest to that of ERMS, indicating the possibility of PIERMS. The final diagnosis was PIERMS. The patient underwent local radiotherapy (50.4 Gy) and multiagent chemotherapy, with no recurrence for 12 months after surgery.</p><p><strong>Lessons: </strong>This may be the first case demonstrating the molecular features of PIERMS, especially the intra-axial type. The results showed a mutation in BRAF but not in the RAS and PI3K pathways, which is different from the existing ERMS features. This molecular difference may cause differences in DNA methylation profiles. Accumulation of the molecular features of PIERMS is necessary before any conclusions can be drawn.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/9e/0b/CASE23207.PMC10555630.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9795117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Aaron Miller, David A Paul, Prasanth Romiyo, Jonathan J Stone
{"title":"Delayed myelopathy after remote C1-2 sublaminar wire fixation: illustrative case.","authors":"Aaron Miller, David A Paul, Prasanth Romiyo, Jonathan J Stone","doi":"10.3171/CASE23126","DOIUrl":"10.3171/CASE23126","url":null,"abstract":"<p><strong>Background: </strong>Atlantoaxial sublaminar wiring complications, both early and delayed, have been documented. However, delayed neurological compromise 27 years after successful fusion is a rare but possible occurrence.</p><p><strong>Observations: </strong>A 76-year-old male, who had undergone C1-2 sublaminar wire fusion for atlantoaxial instability in 1995, presented with symptoms of progressive right arm weakness, falls, and incontinence of bowel and bladder over a 1-week period. Initial imaging workup revealed bowing of the C1-2 sublaminar wires resulting in cervical spinal cord compression and T2-weighted signal changes. A C1-2 laminectomy was performed to remove the wires and decompress the spinal cord with improvement in the patient's neurological status.</p><p><strong>Lessons: </strong>This rare case highlights the potential for delayed cervical myelopathy and cord compression from sublaminar wires, even after a successful fusion. In patients with a history of sublaminar wiring who experience new neurological deficits, it is essential to evaluate the hardware for migration.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"5 26","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/11/4c/CASE23126.PMC10550548.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9747535","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Disconnection of a stent retriever's pushwire caught by an accordion-like deformed aspiration catheter during mechanical thrombectomy: illustrative case.","authors":"Natsuki Akaike, Hiroyuki Ikeda, Minami Uezato, Haruki Yamashita, Masanori Kinosada, Yoshitaka Kurosaki, Masaki Chin","doi":"10.3171/CASE23147","DOIUrl":"10.3171/CASE23147","url":null,"abstract":"<p><strong>Background: </strong>In mechanical thrombectomy for acute large vessel occlusion, a combined technique of using both a stent retriever and an aspiration catheter has been widely used. The authors report a case in which a stent retriever's pushwire and a microcatheter were caught and disconnected by an accordion-like deformed aspiration catheter.</p><p><strong>Observations: </strong>A 74-year-old man underwent mechanical thrombectomy for a left M1 occlusion. A stent retriever was deployed from the left M2 to the left distal M1, and an aspiration catheter was advanced to the left distal M1. When the stent retriever and microcatheter were pulled into the aspiration catheter at the distal M1 without releasing the deflection, traction resistance of the stent retriever occurred, and the aspiration catheter contracted and deformed like an accordion distal to the tip of the guiding catheter. The stent retriever's pushwire and the microcatheter were caught and disconnected.</p><p><strong>Lessons: </strong>When a stent retriever is pulled into a flexible aspiration catheter in a case with vascular tortuosity, it may be caught by an accordion-like deformed aspiration catheter and disconnected. It is necessary to release the deflection of the aspiration catheter once traction resistance of the stent retriever and deflection of the aspiration catheter occur.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"5 26","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/ca/49/CASE23147.PMC10550552.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10440299","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Fuat Arikan, Ivette Chocron, Helena Calvo-Rubio, Carlos Santos, Dario Gándara
{"title":"Metabolism changes during direct revascularization in moyamoya disease: illustrative case.","authors":"Fuat Arikan, Ivette Chocron, Helena Calvo-Rubio, Carlos Santos, Dario Gándara","doi":"10.3171/CASE23104","DOIUrl":"10.3171/CASE23104","url":null,"abstract":"<p><strong>Background: </strong>Cerebral revascularization is recommended for patients with moyamoya disease (MMD) with reduced cerebral perfusion reserve and recurrent or progressive ischemic events. The standard surgical treatment for these patients is a low-flow bypass with or without indirect revascularization. The use of intraoperative monitoring of the metabolic profile using analytes such as glucose, lactate, pyruvate, and glycerol has not yet been described during cerebral artery bypass surgery for MMD-induced chronic cerebral ischemia. The authors aimed to describe an illustrative case using intraoperative microdialysis and brain tissue oxygen partial pressure (PbtO2) probes in a patient with MMD during direct revascularization.</p><p><strong>Observations: </strong>The patient's severe tissue hypoxia situation was confirmed by a PbtO2:partial pressure of oxygen (PaO2) ratio below 0.1 and anaerobic metabolism by a lactate:pyruvate ratio greater than 40. Following bypass, a rapid and sustained increase in PbtO2 up to normal values (PbtO2:PaO2 ratio between 0.1 and 0.35) and the normalization of cerebral energetic metabolism with a lactate/pyruvate ratio less than 20 was observed.</p><p><strong>Lessons: </strong>The results show a quick improvement of regional cerebral hemodynamics due to the direct anastomosis procedure, reducing the incidence of subsequent ischemic stroke in pediatric and adult patients immediately.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"5 26","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/f8/ed/CASE23104.PMC10550542.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9747533","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Satoshi Hirai, Yoshifumi Tao, Hirotake Nishimura, Kiyoshi Nakazaki, Masaaki Uno
{"title":"Multifocal primary central nervous system angiosarcoma: illustrative case.","authors":"Satoshi Hirai, Yoshifumi Tao, Hirotake Nishimura, Kiyoshi Nakazaki, Masaaki Uno","doi":"10.3171/CASE23169","DOIUrl":"10.3171/CASE23169","url":null,"abstract":"<p><strong>Background: </strong>Angiosarcoma is a malignant mesenchymal tumor derived from vascular endothelial cells in which a primary intracranial origin is extremely rare. Most previous reports of primary central nervous system (CNS) angiosarcoma have been solitary cases.</p><p><strong>Observations: </strong>The authors report a case of primary CNS angiosarcoma that caused the development of multiple disseminated cerebral hemorrhagic lesions within a short period of time. This rapid progression of symptoms resulted in the death of the patient. During surgery, several nodules suggestive of a tumor were removed from just below the surface of the brain, mixed into the hematoma. A pathological examination revealed atypical cells mimicking blood vessels in the subarachnoid space that were positive for specific vascular endothelial markers.</p><p><strong>Lessons: </strong>In this case, multifocal angiosarcoma occurred on the brain surface and ventricles, suggesting cerebrospinal fluid dissemination. If multiple cerebral hemorrhages are found on the brain surface, multifocal angiosarcoma should also be considered.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"5 26","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/39/8d/CASE23169.PMC10550544.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9744414","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Roger Murayi, Megh M Trivedi, Joao Paulo Almeida, Gabrielle Yeaney, Carlos Isada, Varun R Kshettry
{"title":"Rathke's cleft cyst presenting with recurrent aseptic meningitis and inflammatory apoplexy: illustrative case.","authors":"Roger Murayi, Megh M Trivedi, Joao Paulo Almeida, Gabrielle Yeaney, Carlos Isada, Varun R Kshettry","doi":"10.3171/CASE2383","DOIUrl":"10.3171/CASE2383","url":null,"abstract":"<p><strong>Background: </strong>Rathke's cleft cyst (RCC) is a benign sellar/suprasellar lesion often discovered incidentally. Rarely, symptomatic cases can present with headache and may exhibit concomitant aseptic meningitis or apoplexy. The authors describe a patient with an RCC presenting with recurring episodes of aseptic meningitis and ultimately inflammatory-type apoplexy.</p><p><strong>Observations: </strong>A 30-year-old female presented with three episodes of intractable headaches over 2 months. Each episode's clinical picture was consistent with meningitis though cerebrospinal fluid cultures, and viral tests remained negative. Imaging demonstrated a sellar lesion, initially thought to be coincidental. On the third presentation, there was rapid interval growth of the lesion, adjacent cerebritis, and new endocrinopathy. Resection was then performed via an endoscopic endonasal approach. Pathology showed an RCC with acute and chronic inflammation and no evidence of hemorrhage. Cultures were negative for organisms. The patient received several weeks of antibiotic treatment with the resolution of all symptoms and no recurrence.</p><p><strong>Lessons: </strong>Recurrent aseptic meningitis with apoplexy-like symptoms is a rare presentation of RCC. The authors propose the term inflammatory apoplexy to describe such a presentation without evidence of abscess, necrosis, or hemorrhage. The mechanism is unclear although may be due to intermittent microleakage of cyst contents into the subarachnoid space.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"5 26","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/27/7d/CASE2383.PMC10550551.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9744408","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Lokeshwar S Bhenderu, Khaled M Taghlabi, Taimur Hassan, Jaime R Guerrero, Jesus G Cruz-Garza, Rachel L Goldstein, Shashank Sharma, Linda V Le, Tue A Dinh, Amir H Faraji
{"title":"Internal iliac artery aneurysm masquerading as a sciatic nerve schwannoma: illustrative case.","authors":"Lokeshwar S Bhenderu, Khaled M Taghlabi, Taimur Hassan, Jaime R Guerrero, Jesus G Cruz-Garza, Rachel L Goldstein, Shashank Sharma, Linda V Le, Tue A Dinh, Amir H Faraji","doi":"10.3171/CASE23175","DOIUrl":"10.3171/CASE23175","url":null,"abstract":"<p><strong>Background: </strong>Schwannomas are common peripheral nerve sheath tumors. Imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT) can help to distinguish schwannomas from other types of lesions. However, there have been several reported cases describing the misdiagnosis of aneurysms as schwannomas.</p><p><strong>Observations: </strong>A 70-year-old male with ongoing pain despite spinal fusion surgery underwent MRI. A lesion was noted along the left sciatic nerve, which was believed to be a sciatic nerve schwannoma. During the surgery for planned neurolysis and tumor resection, the lesion was noted to be pulsatile. Electromyography mapping and intraoperative ultrasound confirmed vascular pulsations and turbulent flow within the aneurysm, so the surgery was aborted. A formal CT angiogram revealed the lesion to be an internal iliac artery (IIA) branch aneurysm. The patient underwent coil embolization with complete obliteration of the aneurysm.</p><p><strong>Lessons: </strong>The authors report the first case of an IIA aneurysm misdiagnosed as a sciatic nerve schwannoma. Surgeons should be aware of this potential misdiagnosis and potentially use other imaging modalities to confirm the lesion before proceeding with surgery.</p>","PeriodicalId":16554,"journal":{"name":"Journal of Neurosurgery: Case Lessons","volume":"5 26","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/22/50/CASE23175.PMC10550553.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9747536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}