Journal of neurosurgery. Case lessons最新文献

{"title":"Transabdominal muscle action potential lessons learned: when should decompression precede fusion? Illustrative cases.","authors":"Kyle W Dann, Michael R McDermott, Alfred-John Bayaton, Mihir Chandra, Tristan G Moskovic, Luke C Budil, Dane Wheeler, Ashish Patel","doi":"10.3171/CASE2680","DOIUrl":"https://doi.org/10.3171/CASE2680","url":null,"abstract":"<p><strong>Background: </strong>Single-position prone lateral lumbar interbody fusion (pLLIF) enables interbody placement, posterior instrumentation, and adjunct decompression to be performed without repositioning. Beyond operative efficiency, prone positioning provides flexible surgical sequencing and intraoperative decision-making. While sequencing might not influence outcomes in most cases, particular scenarios may warrant more careful consideration. Advanced intraoperative neuromonitoring, like transabdominal muscle action potential (TMAP) monitoring, offers real-time feedback and identifies the neurological implications of operative sequencing decisions.</p><p><strong>Observations: </strong>Two patients with nearly identical pathology, proximal lumbar canal stenosis and distal degenerative pathology, underwent pLLIF with concomitant proximal decompression but in opposite operative sequences. In the first case, interbody fusion preceded decompression and was associated with TMAP threshold elevations and postoperative motor deficit. In the second case, proximal decompression performed first resulted in stabilization and improvement of TMAP signals, followed by completion of interbody fusion without neurological complication. Aside from surgical sequence, these cases were otherwise comparable.</p><p><strong>Lessons: </strong>The flexibility of surgical sequencing with prone positioning may be clinically meaningful in patients with proximal canal stenosis. Event-based TMAP monitoring provides real-time insight into sequence dependent neural stress that might otherwise go unrecognized. Thoughtful surgical sequencing and integration of sensitive neuromonitoring enhance intraoperative decision-making and neurological safety. https://thejns.org/doi/10.3171/CASE2680.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793278","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rare concomitant thoracic deformities: navigating the interplay between Scheuermann kyphosis and pectus excavatum. Illustrative case.","authors":"Dustin J Kress, Jason J Haselhuhn, Randi L Lassiter, David W Polly","doi":"10.3171/CASE25496","DOIUrl":"https://doi.org/10.3171/CASE25496","url":null,"abstract":"<p><strong>Background: </strong>Scheuermann kyphosis and pectus excavatum rarely present concomitantly. The sternal-rib complex functions as a \"fourth column\" of thoracic spine support; its disruption can destabilize the spine and exacerbate kyphosis progression. Traditional surgical indications include curves exceeding 70°-75°, but compensatory mechanism assessment may provide additional indicators.</p><p><strong>Observations: </strong>A 16-year-old male presented with thoracic kyphosis (77°) and pectus excavatum (Haller index 2.8). Staged treatment included the Nuss procedure followed by observation. Despite physical therapy, kyphosis prog ressed to 90° over 28 months. Equal standing versus supine extension lumbar lordosis measurements (78°) indicated exhausted compensatory mechanisms. The patient underwent T2-L2 posterior spinal fusion with Smith-Petersen osteotomies while the Nuss bar remained in place, with bar removal 8 months later.</p><p><strong>Lessons: </strong>This case demonstrates the biomechanical interdependence between thoracic spine and anterior chest wall as a fourth column and introduces compensatory mechanism assessment as a novel surgical indication. The successful retention of the Nuss bar during spinal correction represents a technical innovation minimizing surgical morbidity. This paradigm shift from curve magnitude-based to functional capacity evaluation may revolutionize timing decisions for spinal deformity correction. https://thejns.org/doi/10.3171/CASE25496.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793178","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sodium fluorescein-guided resection of an intramedullary spinal cord clear cell meningioma: illustrative case.","authors":"Zabiullah Bajouri, Oliver Kirsch, Vishva Natarajan, Charles Mazof, Stephanie A Ihezie, Chun-Chieh Lin, George J Zanazzi, Linton T Evans","doi":"10.3171/CASE251031","DOIUrl":"https://doi.org/10.3171/CASE251031","url":null,"abstract":"<p><strong>Background: </strong>An intramedullary spinal cord clear cell meningioma (CCM) is an exceptionally rare diagnosis; there are only 2 similar cases reported in the literature. The authors present a case of an intramedullary spinal cord CCM that was successfully resected with the assistance of sodium fluorescein to guide resection.</p><p><strong>Observations: </strong>A 68-year-old male presented with gait instability, decreased sensation, and loss of proprioception in the lower extremities, concerning for thoracic myelopathy. MRI of the thoracic spine revealed an intradural, intramedullary contrast-enhancing mass most concerning for a spinal ependymoma or astrocytoma. Given his progressive neurological decline, need for tissue diagnosis, and tumor cytoreduction, fluorescence-guided resection of the mass was performed. Postoperative pathological analysis demonstrated the presence of polygonal tumor cells with clear cytoplasm that harbored a known pathogenic SMARCE1 frameshift mutation that supported the diagnosis of an intramedullary CCM.</p><p><strong>Lessons: </strong>The authors present the first reported case of a fluorescence-guided resection of an intramedullary CCM. https://thejns.org/doi/10.3171/CASE251031.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793275","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Caught in the web: ultrasonographic visualization of a carotid web thrombus prior to endarterectomy. Illustrative case.","authors":"Eric A Grin, Kaitlyn Lillemoe, Amanda Bilski, Alexandra Kvernland, Sara Rostanski, Julia Bevilacqua, Georges Ayoub, Evan G Stein, Sean N Neifert, Erez Nossek, Michela Rosso","doi":"10.3171/CASE2610","DOIUrl":"https://doi.org/10.3171/CASE2610","url":null,"abstract":"<p><strong>Background: </strong>Carotid webs are increasingly recognized as a significant cause of cryptogenic stroke in young adults, yet they remain frequently underdiagnosed due to their subtle radiographic appearance and atypical presentations. The natural history of untreated carotid webs includes high rates of recurrent ipsilateral ischemic events despite optimal medical therapy.</p><p><strong>Observations: </strong>The authors present the case of a 44-year-old man with four recurrent right hemispheric ischemic events over 5 years. Despite multiple angiographic studies, an underlying carotid web was initially misinterpreted. Digital subtraction angiography ultimately revealed a subtle posterolateral carotid web. Prior to endarterectomy, intraoperative ultrasound uniquely visualized a large thrombus adherent to the web, a critical finding not appreciated on preoperative angiography. Successful en bloc removal of the web and thrombus was performed with histopathological confirmation. The patient remained stroke free at the 1-year follow-up.</p><p><strong>Lessons: </strong>Atypical carotid webs may lack classic radiographic features and can be misclassified on noninvasive imaging. Intraoperative ultrasound provides real-time assessment of thrombus burden not visible on preoperative angiography, allowing for improved surgical planning. This case demonstrates that web-associated thrombi are dynamic and may not be apparent even on high-resolution angiography performed shortly before surgery. Surgical intervention with intraoperative ultrasound guidance offers definitive treatment and excellent long-term outcomes. https://thejns.org/doi/10.3171/CASE2610.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793110","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intracerebral atypical hemorrhages mimicking metastases in a patient with breast cancer history: diagnostic challenges and key insights. Illustrative case.","authors":"Mosab Ahmed Abker Adam, Sebastian Senger, Iván Nadir Camal Ruggieri, Dzmitry Kuzmin","doi":"10.3171/CASE251001","DOIUrl":"https://doi.org/10.3171/CASE251001","url":null,"abstract":"<p><strong>Background: </strong>Intracerebral hemorrhage (ICH) in cancer patients may reflect hypertension, vascular malformations, coagulopathy, or hemorrhagic metastases. Differentiating atypical hemorrhages from brain metastases is diagnostically challenging, particularly in patients with prior breast cancer.</p><p><strong>Observations: </strong>The authors describe the case of a 67-year-old female with a history of breast cancer who presented with a first generalized seizure and bifrontal headache. Imaging revealed atypical bilateral ICHs in the right frontal and left occipital lobes, without trauma or anticoagulation. CT and MRI findings favored subacute hemorrhage without enhancement. Given the patient's oncological history, surgery with biopsy was performed to exclude metastasis. Histopathological analysis revealed only organized hemorrhage, with no tumor cells or vascular malformation. The patient recovered well after craniotomy. The authors are not aware of previous reports of 2 atypical ICHs in the frontal and occipital lobes in a patient with a history of cancer, without trauma, and without blood-thinning drugs.</p><p><strong>Lessons: </strong>Atypical bilateral ICH in a breast cancer patient may mimic metastases. In such cases, biopsy and histological analysis are mandatory to guide treatment. Correct differentiation avoids overtreatment and enables tailored management. https//thejns.org/doi/10.3171/CASE251001.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793105","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Single-stage \"squeeze play\" strategy for the clipping of seven aneurysms: illustrative case.","authors":"Matias Costa, Sean O'Leary, Brian Oliver, Christopher C Young, Peter Kan","doi":"10.3171/CASE25985","DOIUrl":"https://doi.org/10.3171/CASE25985","url":null,"abstract":"<p><strong>Background: </strong>Multiple intracranial aneurysms (MIAs) pose complex management challenges due to their elevated cumulative rupture risk and the potential morbidity associated with staged or multimodal treatment. Single-stage microsurgical strategies have been explored to minimize cumulative procedural risk while providing durable aneurysm exclusion. The \"squeeze play\" technique, dual ipsilateral pterional and interhemispheric craniotomies performed through a single incision, offers a unified corridor for treating aneurysms arising from both sylvian and interhemispheric fissures. Few reports have detailed its use for treatment of multiple aneurysms.</p><p><strong>Observations: </strong>A woman in her 40s with seven unruptured anterior circulation aneurysms underwent single-stage microsurgical clipping using the squeeze play approach. A right-sided pterional craniotomy allowed successful clipping of the M1-M2, M2-M3, A1, and ophthalmic aneurysms, the latter requiring an anterior clinoidectomy and optic nerve unroofing. A parasagittal interhemispheric craniotomy exposed two pericallosal aneurysms and a callosomarginal aneurysm, all of which were clipped safely. Intraoperative indocyanine green angiography and Doppler ultrasonography confirmed complete aneurysm obliteration with preserved vessel patency. Postoperative CT angiography and digital subtraction angiography demonstrated no residual aneurysms, and the patient was discharged home on postoperative day 3 without neurological deficits.</p><p><strong>Lessons: </strong>This case highlights the feasibility, efficiency, and safety of microsurgery for comprehensive single-stage treatment of MIAs. Dual ipsilateral craniotomies through a single incision allow definitive clipping of both lateral and midline aneurysms while avoiding the cumulative risks of staged surgeries and the long-term recurrence concerns associated with endovascular therapy. Careful patient selection and meticulous microsurgical technique are essential to achieving optimal outcomes. https://thejns.org/doi/10.3171/CASE25985.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transforaminal full-endoscopic thoracic foraminoplasty performed under local anesthesia for foraminal stenosis associated with degenerative scoliosis: illustrative case.","authors":"Hiroshi Kageyama, Kosuke Sugiura, Seiya Watanabe, Takayuki Kitahara, Takafumi Ohshima, Saori Soeda, Daiki Nakajima, Makoto Takeuchi, Masatoshi Morimoto, Hiroaki Manabe, Fumitake Tezuka, Junzo Fujitani, Toru Maeda, Koichi Sairyo","doi":"10.3171/CASE26145","DOIUrl":"https://doi.org/10.3171/CASE26145","url":null,"abstract":"<p><strong>Background: </strong>Thoracic foraminal stenosis is an uncommon but clinically important cause of thoracic radiculopathy and intercostal neuralgia. In adult degenerative scoliosis, asymmetric narrowing of the intervertebral foramen on the concave side of the curve can result in focal nerve root compression. Surgical management is challenging because of complex 3D anatomy and the invasiveness of conventional open procedures.</p><p><strong>Observations: </strong>The authors present the case of a patient with severe adult degenerative scoliosis (Cobb angle 60°) complicated by focal thoracic foraminal stenosis causing refractory intercostal neuralgia. The symptomatic level was identified by imaging studies and a selective nerve root block. Targeted decompression was performed using transforaminal full-endoscopic thoracic foraminoplasty under local anesthesia. Intraoperative endoscopic visualization demonstrated stepwise bony decompression, exposure of the exiting thoracic nerve root, and restoration of nerve root mobility within a deformed thoracic anatomy. The patient experienced immediate and sustained pain relief without neurological complications and was able to ambulate shortly after surgery.</p><p><strong>Lessons: </strong>Transforaminal full-endoscopic thoracic foraminoplasty under local anesthesia enables direct visualization and safe decompression of the thoracic nerve root, even in the setting of severe scoliosis. This technique represents an effective minimally invasive alternative to extensive deformity correction in carefully selected patients with focal thoracic radiculopathy. https://thejns.org/doi/10.3171/CASE26145.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793317","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intracranial mixed germ cell tumor mimicking a meningioma: illustrative case.","authors":"Flavio Hernández González, Federico Chávez Peón Pérez, Martín R De León Salazar, Blas E López Félix, Katia Hop García, Michelle Arrucha Cozaya, Erick U Zepeda Fernández","doi":"10.3171/CASE25855","DOIUrl":"https://doi.org/10.3171/CASE25855","url":null,"abstract":"<p><strong>Background: </strong>Germ cell tumors have a low incidence in the Hispanic population and most frequently present in pineal or suprasellar regions. Only a few cases have been reported with an initial image compatible with a meningioma-like appearance.</p><p><strong>Observations: </strong>A 24-year-old male with photopsias, headache, and left homonymous hemianopia presented with a right parieto-occipital extra-axial mass. MRI revealed a heterogeneous enhancing mass, with hemorrhagic zones and surrounding vasogenic edema. Surgery with a near-total resection was performed and an extra-axial lesion with infiltration of the deep venous system was found. Histopathological evaluation revealed a mixed germ cell tumor with a yolk sac tumor and immature teratoma. Postoperative investigation revealed elevated serum α-fetoprotein and pulmonary metastasis. Radiotherapy and chemotherapy followed surgical treatment.</p><p><strong>Lessons: </strong>Germ cell tumors can present as extra-axial dura-based lesions and should be suspected in young patients with imaging showing lesions with cystic or hemorrhagic components. Pulmonary metastases are infrequent but may be present. For successful treatment, chemotherapy and radiation therapy should always be considered. https://thejns.org/doi/10.3171/CASE25855.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Primary epidural extraosseous Ewing sarcoma of the spine in a 19-year-old male: illustrative case.","authors":"Zaid Salaheen, Vincent C Ye, Alexandra De Sequeira, Danyal B Ahmed, Julia Keith, Jetan H Badhiwala","doi":"10.3171/CASE2635","DOIUrl":"https://doi.org/10.3171/CASE2635","url":null,"abstract":"<p><strong>Background: </strong>Primary epidural extraosseous Ewing sarcoma (EES) is a rare form of spinal Ewing sarcoma with soft tissue invasion of the spinal canal and neural foramen, without involvement of the bony spinal column.</p><p><strong>Observations: </strong>The authors report the case of a 19-year-old male presenting to the hospital with a 1-month history of left leg dysesthesias and neuropathic pain, followed by acute left leg weakness evolving over 1-2 weeks. Imaging revealed an epidural lesion at L2 with extension into the left L2-3 neural foramen. The patient underwent urgent surgery given the evolving neurological deficits. Pathological analysis revealed Ewing sarcoma. He subsequently underwent chemotherapy and radiation therapy. At the 6-week follow-up, he had improvement in left leg strength without any evidence of tumor residual on imaging. A systematic review identified 80 cases of primary epidural EES. The mean age at presentation was 21.2 years, with 81.3% of patients < 30 years of age. Most patients were initially treated with surgery (86.2%), followed by adjuvant radiotherapy and chemotherapy (77.9%). Survival and progression-free survival at 1 year were 81.1% and 75.0%, respectively.</p><p><strong>Lessons: </strong>Given the rarity of primary epidural EES, defining common treatment strategies and prognostic markers is essential to guide clinical decision-making and patient counselling. https://thejns.org/doi/10.3171/CASE2635.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 17","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147793176","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Solitary thoracic Epstein-Barr virus-associated smooth muscle tumor presenting after kidney transplant: illustrative case.","authors":"Brandon M Zsigray, Andrew C Pickles, Heather Smith, Phillip McMullen, Paul M Arnold","doi":"10.3171/CASE25754","DOIUrl":"10.3171/CASE25754","url":null,"abstract":"<p><strong>Background: </strong>Epstein-Barr virus-associated smooth muscle tumors (EBV-SMTs) are rare neoplasms that primarily occur in the setting of immunosuppression from HIV/AIDS, solid organ transplant, or congenital/primary immunodeficiencies. The majority of posttransplant patients present with multifocal disease; however, solitary spine tumors can occur at initial presentation.</p><p><strong>Observations: </strong>The authors present the case of a solitary spinal EBV-SMT presenting 1 year after a renal transplant.</p><p><strong>Lessons: </strong>Although EBV-SMTs are a rare entity, they should be considered in the differential diagnosis of solitary spine tumors in immunocompromised or immunosuppressed patients. https://thejns.org/doi/10.3171/CASE25754.</p>","PeriodicalId":94098,"journal":{"name":"Journal of neurosurgery. Case lessons","volume":"11 16","pages":""},"PeriodicalIF":0.0,"publicationDate":"2026-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13097037/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147730939","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}