scholarly journals Extreme Lateral Supracerebellar Infratentorial Approach to the Lateral Midbrain

2018 ◽  
Vol 79 (S 05) ◽  
pp. S415-S417
Author(s):  
M. Kalani ◽  
William Couldwell
Keyword(s):  
Cranial Nerves ◽  
Sudden Onset ◽  
Superior Cerebellar Artery ◽  
Entry Zone ◽  
Cerebellar Artery ◽  
Sensory Disturbances ◽  
History Of ◽  
Supracerebellar Infratentorial Approach ◽  
The Right ◽  
Piecemeal Resection

This video illustrates the case of a 52-year-old man with a history of multiple bleeds from a lateral midbrain cerebral cavernous malformation, who presented with sudden-onset headache, gait instability, and left-sided motor and sensory disturbances. This lesion was eccentric to the right side and was located in the dorsolateral brainstem. Therefore, the lesion was approached via a right-sided extreme lateral supracerebellar infratentorial (exSCIT) craniotomy with monitoring of the cranial nerves. This video demonstrates the utility of the exSCIT for resection of dorsolateral brainstem lesions and how this approach gives the surgeon ready access to the supracerebellar space, and cerebellopontine angle cistern. The lateral mesencephalic safe entry zone can be accessed from this approach; it is identified by the intersection of branches of the superior cerebellar artery and the fourth cranial nerve with the vein of the lateral mesencephalic sulcus. The technique of piecemeal resection of the lesion from the brainstem is presented. Careful patient selection and respect for normal anatomy are of paramount importance in obtaining excellent outcomes in operations within or adjacent to the brainstem.The link to the video can be found at: https://youtu.be/aIw-O2Ryleg.

Microvascular Relations of the Trigeminal Nerve: An Anatomical Study

Neurosurgery ◽  
1986 ◽  
Vol 19 (4) ◽  
pp. 535-539 ◽  
Author(s):  
Boris Klun ◽  
Borut Prestor
Keyword(s):  
Trigeminal Neuralgia ◽  
Anatomical Study ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Marked Contrast ◽  
Entry Zone ◽  
Root Entry Zone ◽  
Cerebellar Artery ◽  
History Of ◽  
Trigeminal Root

Abstract The neurovascular relationships in the trigeminal root entry zone were studied in 130 trigeminal root entry zones of 65 cadavers. No history of facial or trigeminal pain had been obtained during life in these subjects. The technique of intravascular injection, which allowed good visualization and evaluation of the neurovascular relationships, is described. A total of 42 examples of contact with the root entry zone and 10 examples of compression were identified. In 30 of the examples of contact, the finding could be related to an artery; in the other examples, it appeared to be due to veins. Of the arterial compressions, the superior cerebellar artery was responsible in 53.8%, the anterior inferior cerebellar artery was responsible in 25.6%, and pontine branches of the basilar artery were responsible for the remaining 20.6%. Only one instance of unequivocal compression by a vein was found. Other anatomical observations of interest are reported. The absence of a history of trigeminal neuralgia in the 7% of examined nerves in which root entry zone showed arterial compression is in marked contrast to the finding of 80% or more in the operative series for trigeminal neuralgia. It seems that vascular compressions may be the predominant but not the sole cause of trigeminal neuralgia.

Lateral supracerebellar infratentorial approach for a ruptured cerebellomesencephalic fissure arteriovenous malformation resection

2021 ◽  
Vol 4 (1) ◽  
pp. V15
Author(s):  
Livio Pereira ◽  
Eduardo Vieira
Keyword(s):  
Arteriovenous Malformation ◽  
Male Patient ◽  
Sudden Onset ◽  
Superior Cerebellar Artery ◽  
Surgical Video ◽  
Link Type ◽  
Cerebellar Artery ◽  
Lateral Mesencephalic Vein ◽  
Supracerebellar Infratentorial Approach ◽  
Neurologically Intact

In this surgical video, the authors present a case of a 24-year-old male patient who presented with sudden-onset headache and imbalance. On examination, he had a right-sided dysmetria and was otherwise neurologically intact. MRI showed a right cerebellar hematoma associated with multiple flow voids in the cerebellomesencephalic fissure and an enlarged lateral mesencephalic vein. Preoperative angiogram confirmed an arteriovenous malformation supplied by branches of the superior cerebellar artery. The patient underwent a lateral supracerebellar infratentorial approach for resection of the arteriovenous malformation (AVM). He recovered well from surgery and was discharged home on postoperative day 6. Postoperative angiogram confirmed complete AVM resection.The video can be found here: https://youtu.be/tY4Go2n7V80

Left suboccipital supracerebellar transtentorial approach for resection of tectal cavernous malformation

2019 ◽  
Vol 1 (2) ◽  
pp. V19
Author(s):  
Hussam Abou-Al-Shaar ◽  
Timothy G. White ◽  
Ivo Peto ◽  
Amir R. Dehdashti
Keyword(s):  
Nerve Palsy ◽  
Oculomotor Nerve ◽  
Oculomotor Nerve Palsy ◽  
Entry Zone ◽  
Third Nerve Palsy ◽  
History Of ◽  
Tectal Plate ◽  
The Right ◽  
Transtentorial Approach ◽  
Third Nerve

A 64-year-old man with a midbrain cavernoma and prior bleeding presented with a 1-week history of diplopia, partial left oculomotor nerve palsy, and worsening dysmetria and right-sided weakness. MRI revealed a hemorrhagic left tectal plate and midbrain cavernoma. A left suboccipital supracerebellar transtentorial approach in the sitting position was performed for resection of his lesion utilizing the lateral mesencephalic sulcus safe entry zone. Postoperatively, he developed a partial right oculomotor nerve palsy; imaging depicted complete resection of the cavernoma. He recovered from the right third nerve palsy, weakness, and dysmetria, with significant improvement of his partial left third nerve palsy.The video can be found here: https://youtu.be/ofj8zFWNUGU.

scholarly journals Thrombectomy in posterior circulation stroke through persistent primitive trigeminal artery: A case report

2015 ◽  
Vol 21 (6) ◽  
pp. 715-718 ◽  
Author(s):  
MJHL Mulder ◽  
GJ Lycklama à Nijeholt ◽  
W Dinkelaar ◽  
TPW de Rooij ◽  
ACGM van Es ◽  
...  
Keyword(s):  
Posterior Circulation ◽  
Superior Cerebellar Artery ◽  
Trigeminal Artery ◽  
Left Hand ◽  
Persistent Primitive Trigeminal Artery ◽  
Cerebellar Artery ◽  
Intervention Patient ◽  
Primitive Trigeminal Artery ◽  
The Right ◽  
Neurovascular Anatomy

We describe a case of intra-arterial treatment (IAT) of acute posterior circulation occlusion in a patient with a persistent primitive trigeminal artery (PPTA). The patient presented with an acute left sided hemiparesis and loss of consciousness (Glasgow coma score of 5). Computed tomography angiography showed an acute occlusion of the right internal carotid artery (ICA), the PPTA, distal basilar artery (BA), right posterior cerebral artery (PCA), and right superior cerebellar artery (SCA). Stent-retriever assisted thrombectomy was not considered possible through the hypoplastic proximal BA. After passage of the proximal ICA occlusion, the right PCA and SCA were recanalized through the PPTA, with a single thrombectomy procedure. Ten days after intervention patient was discharged scoring optimal EMV with only a mild facial and left hand paresis remaining. PPTA is a persistent embryological carotid–basilar connection. Knowledge of existing (embryonic) variants in neurovascular anatomy is essential when planning and performing acute neurointerventional procedures.

Spasmodic Torticollis Due to Neurovascular Compression of the Spinal Accessory Nerve by the Anteroinferior Cerebellar Artery: Case Report

Neurosurgery ◽  
2000 ◽  
Vol 47 (3) ◽  
pp. 768-772 ◽  
Author(s):  
Concetta Alafaci ◽  
Francesco M. Salpietro ◽  
Gaspare Montemagno ◽  
Giovanni Grasso ◽  
Francesco Tomasello
Keyword(s):  
Cranial Nerve ◽  
Neuromuscular Disorder ◽  
Spasmodic Torticollis ◽  
Accessory Nerve ◽  
Decompression Surgery ◽  
Neurovascular Compression ◽  
Cerebellar Artery ◽  
History Of ◽  
Microvascular Decompression Surgery ◽  
The Right

ABSTRACT OBJECTIVE AND IMPORTANCE Spasmodic torticollis is a neuromuscular disorder characterized by uncontrollable clonic and intermittently tonic spasm of the neck muscles. We report a case of spasmodic torticollis attributable to neurovascular compression of the right XIth cranial nerve by the right anteroinferior cerebellar artery (AICA). CLINICAL PRESENTATION A 72-year-old man with a 2-year history of right spasmodic torticollis underwent magnetic resonance imaging, which demonstrated compression of the right XIth cranial nerve by an abnormal descending loop of the right AICA. INTERVENTION The patient underwent microvascular decompression surgery. During surgery, it was confirmed that an abnormal loop of the right AICA was compressing the right accessory nerve. Compression was released by the interposition of muscle between the artery and the nerve. CONCLUSION The patient's postoperative course was uneventful, and his symptoms were fully relieved at the 2-year follow-up examination. This is the first reported case of spasmodic torticollis attributable to compression by the AICA; usually, the blood vessels involved are the vertebral artery and the posteroinferior cerebellar artery.

scholarly journals Retrosigmoid Craniotomy for the Removal of Left Sided Tentorial and Posterior Fossa Meningioma Combined with Microvascular Decompression for Hemifacial Spasm

2018 ◽  
Vol 80 (S 03) ◽  
pp. S294-S295
Author(s):  
Yu-Wen Cheng ◽  
Chun-Yu Cheng ◽  
Zeeshan Qazi ◽  
Laligam N. Sekhar
Keyword(s):  
Facial Nerve ◽  
Hemifacial Spasm ◽  
Microvascular Decompression ◽  
Preoperative Imaging ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Root Exit Zone ◽  
Tentorial Meningioma ◽  
Cerebellar Artery ◽  
The Right

This 68-year-old woman presented with repeated episodes of bilateral hemifacial spasm with headache for 5 years and with recent progression of left sided symptoms. Preoperative imaging showed a left sided tentorial meningioma with brain stem and cerebellar compression. Left facial nerve was compressed by the vertebral artery (VA) and the right facial nerve by the anterior inferior cerebellar artery (AICA). This patient underwent left side retrosigmoid craniotomy and mastoidectomy. The cisterna magna was drained to relax the brain. The tumor was very firm, attached to the tentorium and had medial and lateral lobules. The superior cerebellar artery was adherent to the lateral lobule of the tumor and dissected away. The tumor was detached from its tentorial base; we first removed the lateral lobule. Following this, the medial lobule was also completely dissected and removed. The root exit zone of cranial nerve (CN) VII was dissected and exposed. The compression was caused both by a prominent VA and AICA. Initially, the several pieces of Teflon felt were placed for the decompression. Then vertebropexy was performed by using 8–0 nylon suture placed through the VA media to the clival dura. A further piece of Teflon felt was placed between cerebellopontine angle region and AICA. Her hemifacial spasm resolved postoperatively, and she discharged home 1 week later. Postoperative imaging showed complete tumor removal and decompression of left CN VII. This video shows the complex surgery of microsurgical resection of a large tentorial meningioma and microvascular decompression with a vertebropexy procedure.The link to the video can be found at: https://youtu.be/N5aHN9CRJeM.

scholarly journals Not Your Typical Low T - Hypogonadism From a Feminizing Adrenal Carcinoma

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A146-A146
Author(s):  
Reshma Patel ◽  
Trevor E Angell
Keyword(s):  
Adrenal Insufficiency ◽  
Clinical Evidence ◽  
Sudden Onset ◽  
Breast Development ◽  
Total Testosterone ◽  
Histopathologic Diagnosis ◽  
Free Cortisol ◽  
History Of ◽  
Palpable Breast ◽  
The Right

Abstract Introduction: Adrenocortical Carcinoma (ACC) is a rare disease, with an incidence of 0.7–2 cases per million people. Approximately 80% of ACC tumors are functional, with the majority of tumors secreting glucocorticoids, however a small proportion concurrently secrete androgens in addition to glucocorticoids. Here, we describe a case of ACC presenting with feminization, without clinical evidence of Cushing’s syndrome. Case Description: A 35 year old male with no significant history presented with sudden onset non-radiating, 7/10, abdominal pain 4 days prior to admission. On exam, the patient had diffuse tenderness to palpation in the right upper quadrant without other abdominal findings. He also was noted to have palpable breast tissue bilaterally. Upon persistent questioning, he reported an 8-month history of gradual breast development, decreased libido and decreased morning erections. He had no history of hypertension, headaches, diabetes, palpitations, flushing, sweating, weight gain, striae, bruising, or muscle weakness. Diagnostic CT imaging of the abdomen and pelvis showed a 14 cm right adrenal mass without invasion or lymphadenopathy. Laboratory testing showed a total testosterone of 37 ng/dL (reference range:249–846 ng/dL), estradiol of 181 pg/mL (8–43 pg/mL), prolactin of 14.5 ng/ml (4.0–15.2), and FSH and LH were both <0.1 mIU/mL. Serum metanephrines and normetanephrines, renin and aldosterone showed no evidence of excess secretion. Urine free cortisol measurement was 111mcg over 24 hrs (<50 mcg/24hr) and ACTH was <1.0 pg/mL (7.2–63.3 pg/mL). Surgical resection was performed with histopathologic diagnosis of an 18cm ACC confined to the adrenal gland. Post-surgical prophylactic hydrocortisone replacement was given. At outpatient follow-up, testing revealed normalization of his estradiol and testosterone levels. The patient had no clinical evidence of adrenal insufficiency and plans were made to assess endogenous adrenal function. Conclusion: This case highlights the importance of discussing symptoms of hypogonadism, virilization or feminization with patients in detail when evaluating for ACC. Careful history and physical exam may be key to identifying sex hormone excess and prompting preoperative workup. In this case of a feminizing ACC, pre-surgical assessment allows for estrogen to be as a marker of tumor progression. A sex steroid producing ACC should be evaluated for cortisol secretion as prompt detection can avoid post-operative adrenal insufficiency.

Torsion of a parasitic leiomyoma: a rare but important differential in women presenting with lower abdominal pain

2021 ◽  
Vol 14 (1) ◽  
pp. e232797
Author(s):  
Clemmie Stebbings ◽  
Ahmed Latif ◽  
Janakan Gnananandan
Keyword(s):  
Abdominal Pain ◽  
Iliac Fossa ◽  
Lower Abdominal Pain ◽  
Sudden Onset ◽  
Greater Omentum ◽  
Caribbean Woman ◽  
History Of ◽  
Right Iliac Fossa Pain ◽  
The Right ◽  
Fat Stranding

A 39-year-old multiparous Afro-Caribbean woman attended the emergency department with sudden-onset severe right iliac fossa pain. Her inflammatory markers were mildly elevated. Computerised tomography of the abdomen demonstrated features of fat stranding in the right iliac fossa suspicious of acute appendicitis. The scan also noted uterine leiomyomas. The patient was taken to theatre for an emergency diagnostic laparoscopy where her appendix was found to be macroscopically normal. A necrotic heavily calcified parasitic leiomyoma was seen in the right adnexa, free of the uterus and adherent to the greater omentum on a long torted pedicle. The parasitic leiomyoma was successfully removed piecemeal laparoscopically. Complications of leiomyomas, namely, torsion and necrosis, are important differentials in women presenting with sudden-onset lower abdominal pain. A history of sudden-onset severe lower abdominal pain with a background of known leiomyoma should prompt the clerking surgeon to consider a complication of leiomyoma as part of the differential diagnoses.

Sudden Onset of Diplopia and a Skeletal Muscle Antibody

2021 ◽  
pp. 160-162
Author(s):  
John R. Mills
Keyword(s):  
Computed Tomography ◽  
Myasthenia Gravis ◽  
Patent Foramen Ovale ◽  
Time Course ◽  
Vision Loss ◽  
Sudden Onset ◽  
Foramen Ovale ◽  
Clinical Disorder ◽  
History Of ◽  
The Right

A 62-year-old man with a history of migraine came to the emergency department with sudden onset of horizontal diplopia and, subsequently, bilateral ptosis. He noted feeling unsteady when walking. He reported that the diplopia worsened throughout the day. He had a history of hepatitis C infection. He had some vision loss in his left eye, which was thought to relate to a retinopathy. He disclosed that he had a history of cold feet and had notably high arches. He had a pacemaker because of syncope attributed to sick sinus syndrome. Computed tomography angiography of the head and neck were ruled negative for intracranial stenosis, occlusions, or aneurysms. Computed tomography of the head indicated a tiny lacunar infarct in the right caudate head. Magnetic resonance imaging of the brain identified a tiny, periaqueductal, enhancing abnormality in the right midbrain that was thought to be likely ischemic, but there was some concern for a demyelinating or inflammatory lesion. Cerebrospinal fluid evaluation indicated an increased protein concentration. Serologic evaluation for myasthenia gravis striational antibodies were positive at a titer of 1:240. Serum protein studies indicated the presence of polyclonal hypergammaglobulinemia. Myasthenia gravis was effectively ruled out. Given the hyperacute time course, the patient’s clinical disorder was most probably explained by an ischemic stroke that affected the oculomotor nuclei regions causing ptosis and ophthalmoparesis. On follow-up, the patient was discovered to have a patent foramen ovale. Whether the patent foramen ovale was a contributing factor to the stroke is uncertain. The recurrence rate in this setting is thought to be low relative to other causes of stroke. Ultimately it was decided to not close the patent foramen ovale and to maintain the patient on clopidogrel and adult low-dose aspirin. The onset of diplopia is typically sudden, but this occurs exclusively with vascular pathologic processes. Diplopia that appears intermittently with diurnal variation suggests the possibility of a neuromuscular junction disease such as myasthenia gravis.

scholarly journals Microsurgical resection of ambient cistern arteriovenous malformation

2016 ◽  
Vol 40 (videosuppl1) ◽  
pp. 1
Author(s):  
Omar Choudhri ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Posterior Cerebral Artery ◽  
Cranial Nerves ◽  
Superior Cerebellar Artery ◽  
Technical Aspects ◽  
The Third ◽  
Cerebellar Artery ◽  
Basal Vein Of Rosenthal ◽  
Microsurgical Resection ◽  
Ambient Cistern

The middle tentorial incisural space, located lateral to the midbrain and medial to the temporal lobe, contains the ambient cistern through which courses the third, fourth, and fifth cranial nerves, posterior cerebral artery (PCA), superior cerebellar artery, and the choroidal arteries. Arteriovenous malformations (AVMs) in this compartment are supplied by the thalamogeniculate and posterior temporal branches of the PCA, and drain into tributaries of the basal vein of Rosenthal. We present a case of an AVM in this middle tentorial incisural space that persisted after embolization and radiosurgery, and was microsurgically resected through a subtemporal approach. This case demonstrates the anatomy of the middle incisural space and technical aspects in microsurgical resection of these rare AVMs.The video can be found here: https://youtu.be/V-dIWh8ys3E.

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