Deep motor cortex cavernoma resection supported by navigational intraoperative monitoring: A case report

Introduction: Cavernomas are benign hamartomas of cerebral and spinal vessels, accounting for less than 1% of all arteriovenous malformations. In general, surgical resection is the treatment of choice for enlarging cavernomas or those associated with medically refractory seizures. Herein, we report a case of an enlarged deep precentral gyrus cavernoma, with a discussion of the surgical approach and the impact of intra-operative neurophysiological monitoring on the preservation of motor function. Case description: A 30-year-old male was referred to our hospital due to 2-month history of focal seizures. Initial magnetic resonance imaging revealed right precentral cavernoma with minimal right parietal subarachnoid haemorrhage. Revealed the location of the cavernoma deep in the right primary motor cortex. Surgery was performed, trans-sulcal dissection was done with the aid of intraoperative ultrasonography neuro-navigation. The cortical motor map was localized by functional mapping with intra-operative neurophysiological monitoring, including somatosensory evoked potentials (SEP) and motor evoked potentials (MEP). Post-operatively, the left side weakness grade was 4/5, and the Glasgow coma scale was 15. Postoperative imaging confirmed successful resection of the cavernoma and associated hemosiderin ring with no SAH. Conclusion: The use of preoperative MRI and intraoperative ultrasonography supplemented by neurophysiological monitoring utilizing SEP, MEP, and cortical mapping is essential for the safe resection of paracentral cavernomas

The central sulcus

The central sulcus is an important anatomical landmark the location of most of the anatomical structures and cortical lesions are described by their relation to the central sulcus [9,19]. During direct observation of the cerebral cortex, it is not always easy to understand the cortical anatomy of the sulci and gyri due to the presence of arachnoid matter. Furthermore, there often is anatomical variation in this region [13]. Therefore, this paper presents the crucial methods for identifying the central sulcus's exact anatomical location as it is critical for the neurosurgical team and to discuss its surgical implications

The central sulcus: Perioperative identification and surgical implication

The central sulcus is an important anatomical landmark the location of most of the anatomical structures and cortical lesions are described by their relation to the central sulcus [9,19]. During direct observation of the cerebral cortex, it is not always easy to understand the cortical anatomy of the sulci and gyri due to the presence of arachnoid matter. Furthermore, there often is anatomical variation in this region [13]. Therefore, this paper presents the crucial methods for identifying the central sulcus's exact anatomical location as it is critical for the neurosurgical team and to discuss its surgical implications

Delayed intraoperative rupture of clipped aneurysm during the awaking from anaesthesia

Introduction. Intraoperative rupture (IOR) of an aneurysm is a frightful complication that causes significant morbidity and mortality worldwide. IOR can be attributed to various parameters, including hypertension, increased intracranial pressure (ICP), fragility of the vessels, and inadequate anaesthesia. IOR due to insufficient anaesthesia is scarcely reported in the literature. Here, we describe a re-ruptured anterior communicating artery (ACoA) after incomplete clipping of the neck during craniotomy closure due to unintended early wake-up from anaesthesia with a discussion about the management. Case description. A 38-year-old male suddenly developed a severe headache, a brief loss of consciousness, and vomiting. Computed tomography (CT) scan showed a subarachnoid haemorrhage in the basal cistern. CT angiography showed a bilobed right ACoA aneurysm with a wide neck and Murphy's teat. The patient was considered for surgery. Clipping of the aneurysm neck was done through two curved clips. During craniotomy closure, the patient started coughing and gagging then a huge IOR was encountered. These events can be mainly attributed to unintended inadequate anaesthesia, particularly muscle relaxants. The bleeding ceased after two suction catheters were inserted, temporary clips were applied, and the readjustment of permanent clips. After surgery, the patient showed a left-sided weakness. His postoperative CT scan showed a right distal anterior cerebral artery (ACA) territory infarction. The weakness improved in the follow-up period. Conclusion. Delayed IOR due to early awaking from anaesthesia should be considered a potential source of complications and bad outcomes in aneurysm surgery

Posterior auricular artery

Introduction: The posterior auricular artery (PAA) is the preterminal branch of the external carotid artery (ECA), arising superiorly to the occipital artery (OA). The PAA has quite a few anatomical variations and established neurosurgical applications. We conducted this study as an overview to illustrate all neurosurgical aspects regarding this artery, its reconstructive uses, and anatomical variation. Method:  We performed a literature review in Google Scholar and PubMed medical databases for studies discussing the PAA, its anatomical variations, and neurosurgical applications. Results: We identified 30 articles that discuss the anatomical variations and neurosurgical applications of the PAA. While reviewing the available articles and original works regarding PAA. Conclusion: The PAA has considerable anatomical variations regarding its origin, course, branches, and length. The related neurosurgical applications of PAA include bypass, embolization, aneurysm, AVM, and reconstruction flaps

Impact of dome projection on operative steps during clipping of a ruptured pure posteriorly directed posterior communicating artery aneurysms

Background: Ruptured posterior communicating artery (PCoA) aneurysms are common; they usually present with subarachnoid haemorrhage (SAH) and oculomotor nerve palsy. The aneurysmal dome projection may influence the safety access and aneurysmal neck clipping. Here, we discuss additional intraoperative steps that may be required to widen the surgical field to ensure safe surgical clipping of a rupture pure posteriorly directed PCoA aneurysm. Case description: A previously healthy 38-year-old male reported sudden severe headache and disturbed level of consciousness with a Glasgow coma scale (GCS) of 13. His initial computed tomography (CT) scan of the head showed SAH in the basal cistern. 3D-constructed CT angiography (CTA) revealed a left pure posteriorly directed PCoA aneurysm. In the surgery, through the left pterional approach, all intraoperative steps were carried out. Additional steps were performed as well. Three additional intraoperative steps were contemplated because a pure posteriorly directed PCoA aneurysm is not well appreciated and is often hidden behind the supra cliniold internal carotid artery (ICA). First, the extension of Sylvian fissure dissection to include the distal part and the proximal. Second, temporal pole mobilization is performed by cutting small anterior temporal veins. Third, a brain retractor is placed on the temporal lobe to gently tract the superficial part of the lobe. All these steps widened the surgical corridor to ensure the aneurysm's safe clipping. Conclusion: Surgical clipping is influenced by the aneurysmal dome projection. In a ruptured pure posteriorly directed PCoA aneurysm, further intraoperative steps may facilitate complete access and safe clipping of the aneurysm

Outcome measures in neurosurgery: is a unified approach better? A literature review

Background: Accurate assessment and evaluation of health interventions are crucial to evidence-based care. The use of outcome measures in neurosurgery grew with the introduction of the Glasgow Coma Scale. Since then, various outcome measures have appeared, some of which are disease-specific and others more generally. This article aims to address the most widely used outcome measures in three major neurosurgery subspecialties, "vascular, traumatic, and oncologic," focusing on the potential, advantages, and drawbacks of a unified approach to these outcome measures. Methods: A literature review search was conducted by using PubMed MEDLINE and Google scholar Databases. Data for the three most common outcome measures, The Modified Rankin Scale (mRS), The Glasgow Outcome Scale (GOS), and The Karnofsky Performance Scale (KPS), were extracted and analyzed. Results: The original objective of establishing a standardized, common language for the accurate categorization, quantification, and evaluation of patients' outcomes has been eroded. The KPS, in particular, may provide a common ground for initiating a unified approach to outcome measures. With clinical testing and modification, it may offer a simple, internationally standardized approach to outcome measures in neurosurgery and elsewhere. Based on our analysis, Karnofsky's Performance Scale may provide a basis of reaching a unified global outcome measure. Conclusion: Outcome measures in neurosurgery, including mRS, GOS, and KPS, are widely utilized assessment tools for patients' outcomes in various neurosurgical specialties. A unified global measure may offer solutions with ease of use and application; however, there are limitations.</p