Use of the Neurological Pupil Index to Predict Postoperative Visual Function After Resection of a Tuberculum Sellae Meningioma: A Case Report.

The Neurological Pupil index (NPi) is a standardized method for evaluating pupil reactivity that removes inter-examiner variability. Changes in the NPi can predict clinical deterioration in patients with traumatic brain injury (TBI); however, its use to predict visual impairment after the resection of parasellar meningiomas has not been described. A 71-year-old female underwent a modified expanded bifrontal craniotomy for resection of a 3.1 cm tuberculum sella meningioma that caused compression of the optic chiasm and resulted in left temporal and right superior temporal visual field deficits. Postoperatively, she lost vision in the right eye. Pupillometer measurements demonstrated an asymmetrically low NPi at that time, which improved to normal prior to partial vision recovery. The average NPi in the right pupil was 1.67 during the time of vision loss compared to 3.47 in the left pupil (p=1.7x10-10). Statistical analysis was performed with the Student's t-test and the significance level was set at p-value < 0.01. Resection of parasellar meningiomas is challenging because of the proximity of the optic apparatus. We report a case of unilateral vision loss after resection of a tuberculum sella meningioma in which the impaired eye's NPi value correlated closely with visual function. NPi values that decrease below 3 predict spikes in intracranial pressure in TBI patients; similarly, increases in the NPi value above 2.5-3 predict improvement in vision in the case reported here. By monitoring the proximal portion of the oculomotor reflex, the NPi can be a marker of visual impairment after surgery

Prospective comparison of long-term pain relief rates after first-time microvascular decompression and stereotactic radiosurgery for trigeminal neuralgia

OBJECTIVE Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD), stereotactic radiosurgery (SRS), and radiofrequency ablation (RFA). Although the efficacy of each procedure has been described, few studies have directly compared these treatment modalities on pain control for TN. Using a large prospective longitudinal database, the authors aimed to 1) directly compare long-term pain control rates for first-time surgical treatments for idiopathic TN, and 2) identify predictors of pain control. METHODS The authors reviewed a prospectively collected database for all patients who underwent treatment for TN between 1997 and 2014 at the University of California, San Francisco. Standardized collection of data on preoperative clinical characteristics, surgical procedure, and postoperative outcomes was performed. Data analyses were limited to those patients who received a first-time procedure for treatment of idiopathic TN with > 1 year of follow-up. RESULTS Of 764 surgical procedures performed at the University of California, San Francisco, for TN (364 SRS, 316 MVD, and 84 RFA), 340 patients underwent first-time treatment for idiopathic TN (164 MVD, 168 SRS, and 8 RFA) and had > 1 year of follow-up. The analysis was restricted to patients who underwent MVD or SRS. Patients who received MVD were younger than those who underwent SRS (median age 63 vs 72 years, respectively; p 5 years of follow-up (60 of 164 and 64 of 168 patients, respectively). Immediate or short-term (< 3 months) postoperative pain-free rates (Barrow Neurological Institute Pain Intensity score of I) were 96% for MVD and 75% for SRS. Percentages of patients with Barrow Neurological Institute Pain Intensity score of I at 1, 5, and 10 years after MVD were 83%, 61%, and 44%, and the corresponding percentages after SRS were 71%, 47%, and 27%, respectively. The median time to pain recurrence was 94 months (25th–75th quartiles: 57–131 months) for MVD and 53 months (25th–75th quartiles: 37–69 months) for SRS (p = 0.006). A subset of patients who had MVD also underwent partial sensory rhizotomy, usually in the setting of insignificant vascular compression. Compared with MVD alone, those who underwent MVD plus partial sensory rhizotomy had shorter pain-free intervals (median 45 months vs no median reached; p = 0.022). Multivariable regression demonstrated that shorter preoperative symptom duration (HR 1.005, 95% CI 1.001–1.008; p = 0.006) was associated with favorable outcome for MVD and that post-SRS sensory changes (HR 0.392, 95% CI 0.213–0.723; p = 0.003) were associated with favorable outcome for SRS. CONCLUSIONS In this longitudinal study, patients who received MVD had longer pain-free intervals compared with those who underwent SRS. For patients who received SRS, postoperative sensory change was predictive of favorable outcome. However, surgical decision making depends upon many factors. This information can help physicians counsel patients with idiopathic TN on treatment selection

Contralateral anterior interhemispheric approach to medial frontal arteriovenous malformations: Surgical technique and results

BACKGROUND: Medial frontal arteriovenous malformations (AVMs) require opening the interhemispheric fissure and are traditionally accessed through an ipsilateral anterior interhemispheric approach (IAIA). The contralateral anterior interhemispheric approach (CAIA) flips the positioning with themidline still positioned horizontally for gravity retraction, but with the AVM on the upside and the approach from the contralateral, dependent side. OBJECTIVE: To determine whether the perpendicular angle of attack associated with the IAIA converts to a more favorable parallel angle of attack with the CAIA. METHODS: The CAIA was used in 6 patients with medial frontal AVMs. Patients and AVM characteristics, as well as pre- and postoperative clinical and radiographic data, were reviewed retrospectively. RESULTS: Four patients presented with unruptured AVMs, with 5 AVMs in the dominant, left hemisphere. The lateral margin was off-midline in all cases, and average nidus size was 2.3 cm. All AVMs were resected completely, as confirmed by postoperative catheter angiography. All patients had good neurological outcomes,with either stable or improved modified Rankin Scores at last follow-up. CONCLUSIONS: This study demonstrates that the CAIA is a safe alternative to the IAIA for medial frontal AVMs that extend 2 cm or more off-midline into the deep frontal white matter. The CAIA aligns the axis of the AVMnidus parallel to the exposure trajectory, brings its margins in view for circumferential dissection, allows gravity to deliver the nidus into the interhemispheric fissure, and facilitates exposure of the lateral margin for the final dissection, all without resecting or retracting adjacent normal cortex

Rapid sequential development and rupture of mycotic aneurysms within a period of days in a patient with graft-versus-host disease and angiotropic Scedosporium apiospermum infection.

BackgroundFungal origin mycotic aneurysms are rare and carry a high mortality rate. Scedosporium apiospermum is an ubiquitous fungus which has been described to cause devastating infections in immunocompromised hosts.Case descriptionWe report a case of a 23-year-old patient with Burkitt's lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis.ConclusionWe highlight the difficulties in treating fungal mycotic aneurysms and the associated high mortality. While a less aggressive approach might have been appropriate given the known poor outcomes, the age of the patients as well as the family wishes dictated the treatment decisions

Microsurgical resection of an intravestibular schwannoma: a review of surgical technique and management considerations

Intravestibular schwannomas are rare tumors within the intralabyrinthine region and involve different management considerations compared to more common vestibular schwannomas. In this report, the authors review a case of a 52-year-old woman who presented with hearing loss and vestibular symptoms and was found to have a left intravestibular schwannoma. Given her debilitating vestibular symptoms, she underwent microsurgical resection. In this video, the authors review the relevant anatomy, surgical technique, and management considerations in these patients. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2187

Pseudoaneurysm of Distal Anterior Cerebral Artery Branch Following External Ventricular Drain Placement.

BACKGROUND: External ventricular drains (EVDs) are routinely placed as part of the management of intracranial hypertension. Pseudoaneurysm formation after EVD placement is a rare complication that can occur as a result of direct trauma to the cerebral vasculature. Prompt recognition and treatment may prevent future rupture. OBJECTIVE: To present our management strategy of a unique case of pseudoaneurysm formation in the context of the medical literature on these rare complications. METHODS: An EVD was placed in a 58-year-old female patient who presented with intracranial hypertension after subarachnoid hemorrhage secondary to a ruptured posterior communicating artery aneurysm before coiling of the aneurysm. On postbleed day 10, a pseudoaneurysm was identified in the distal anterior cerebral artery adjacent to the EVD tract. RESULTS: The pseudoaneurysm was successfully treated with surgical resection. CONCLUSION: Pseudoaneurysm formation after EVD placement is a rare but serious complication. We do not recommend routine screening for this complication; however, further investigation may be warranted when a delayed EVD tract hemorrhage is encountered. Prompt treatment of pseudoaneurysms is necessary to prevent future hemorrhage

Arteriovenous malformations in the optic apparatus: systematic literature review and report of four cases

OBJECTIVE: Rare arteriovenous malformations (AVMs) of the optic apparatus account for \u3c 1% of all AVMs. The authors conducted a systematic review of the literature for cases of optic apparatus AVMs and present 4 cases from their institution. The literature is summarized to describe preoperative characteristics, surgical technique, and treatment outcomes for these lesions. METHODS: A comprehensive search of the English-language literature was performed in accordance with established Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all published cases of AVM in the optic apparatus in the PubMed, Web of Science, and Cochrane databases. The authors also searched their prospective institutional database of vascular malformations for such cases. Data regarding the clinical and radiological presentation, visual acuity, visual fields, extent of resection, and postoperative outcomes were gathered. RESULTS: Nine patients in the literature and 4 patients in the authors\u27 single-surgeon series who fit the inclusion criteria were identified. The median age at presentation was 29 years (range 8-39 years). Among these patients, 11 presented with visual disturbance, 9 with headache, and 1 with multiple prior subarachnoid hemorrhages; the AVM in 1 case was found incidentally. Four patients described prior symptoms of headache or visual disturbance consistent with sentinel events. Visual acuity was decreased from baseline in 10 patients, and 11 patients had visual field defects on formal visual field testing. The most common visual field defect was temporal hemianopia, found in one or both eyes in 7 patients. The optic chiasm was affected in 10 patients, the hypothalamus in 2 patients, the optic nerve (unilaterally) in 8 patients, and the optic tract in 2 patients. Six patients underwent gross-total resection; 6 patients underwent subtotal resection; and 1 patient underwent craniotomy, but no resection was attempted. Postoperatively, 9 of the patients had improved visual function, 1 had no change, and 3 had worse visual acuity. Eight patients demonstrated improved visual fields, 1 had no change, and 4 had narrowed fields. CONCLUSIONS: AVMs of the optic apparatus are rare lesions. Although they reside in a highly eloquent region, surgical outcomes are generally good; the majority of patients will see improvement in their visual function postoperatively. Microsurgical technique is critical to the successful removal of these lesions, and preservation of function sometimes requires subtotal resection of the lesion

Factors Associated With Failed Focal Neocortical Epilepsy Surgery

BackgroundSeizure outcomes after focal neocortical epilepsy (FNE) surgery are less favorable than after temporal lobectomy, and the reasons for surgical failure are incompletely understood. Few groups have performed an in-depth examination of seizure recurrences to identify possible reasons for failure.ObjectiveTo elucidate factors contributing to FNE surgery failures.MethodsWe reviewed resections for drug-resistant FNE performed at our institution between 1998 and 2011. We performed a quantitative analysis of seizure outcome predictors and a detailed qualitative review of failed surgical cases.ResultsOf 138 resections in 125 FNE patients, 91 (66%) resulted in freedom from disabling seizures (Engel I outcome). Mean ± SEM patient age was 20.0 ± 1.2 years; mean follow-up was 3.8 years (range, 1-17 years); and 57% of patients were male. Less favorable (Engel II-IV) seizure outcome was predicted by higher preoperative seizure frequency (odds ratio = 0.85; 95% confidence interval, 0.78-0.93), a history of generalized tonic-clonic seizures (odds ratio = 0.42; 95% confidence interval, 0.18-0.97), and normal magnetic resonance imaging (odds ratio = 0.30; 95% confidence interval, 0.09-1.02). Among 36 surgical failures examined, 26 (72%) were related to extent of resection, with residual epileptic focus at the resection margins, whereas 10 (28%) involved location of resection, with an additional epileptogenic zone distant from the resection. Of 16 patients who received reoperation after seizure recurrence, 10 (63%) achieved seizure freedom.ConclusionInsufficient extent of resection is the most common reason for recurrent seizures after FNE surgery, although some patients harbor a remote epileptic focus. Many patients with incomplete seizure control are candidates for reoperation