Cryptococcal meningitis presenting as anterior spinal cord syndrome with accessory nerve palsy in immunocompetent patient: A case report

Background: Cryptococcus has a tropism for the nervous system with a higher prevalence of infection in immunosuppressed patients; it remains a major cause of human immunodeficiency virus (HIV)-related mortality worldwide. Neurological compromise caused by this microorganism mainly debuts as a meningeal syndrome, spinal involvement has been reported in literature, neuropathological assessments have found Cryptococci in spinal roots and meninges, with perineuritic adhesions probably explaining compromise lower cranial nerves and even spinal nerve roots. Case Description: 39-year-old male seronegative for HIV, with a surgical history of hydrocephalus treated with ventriculoperitoneal shut 1 year before, he presented with progressive weakness in the four extremities evolving to be disabling with bilateral accessory nerve palsy and loss of sensation below his neck. The MR imaging showed diffuse leptomeningeal thickening both supra and infratentorial and over the spinal canal up to C5 with a cystic formation shown in the craniocervical union causing compression of the medullary bulb. The patient underwent a medial suboccipital craniectomy with resection of the posterior arch of c1 for sampling and decompression, pathologically appears numerous spherical organisms that have a thick clear capsule and are surrounded by histiocytes forming a granuloma compatible with Cryptococcus. Postoperatively, the patient’s prior neurological deficits resolved. Conclusion: It is an infrequently suspected pathology in immunocompetent patients, usually requiring only antifungal treatment with adjustment of immunosuppressive or antiretroviral management. In special and rare situations like our case as presenting with lower cranial nerve and spinal involvement, surgical treatment is a priority for the resolution of the pathology and improves disabling neurological deficit.

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Resection of a Lower Clival Meningioma via Posterolateral Approach: Two-Dimensional Operative Video

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1714407 ◽

2020 ◽

Author(s):

Pinar E. Ocak ◽

Selcuk Yilmazlar

Keyword(s):

Cranial Nerve ◽

Cranial Nerves ◽

Posterolateral Approach ◽

Left Vertebral Artery ◽

Posterior Arch ◽

Upper Cervical Spine ◽

Two Dimensional ◽

Lower Cranial Nerve ◽

Complex Anatomy ◽

Microsurgical Resection

Abstract Objectives This study aimed to demonstrate resection of a craniovertebral junction (CVJ) meningioma via the posterolateral approach. Design The study is designed with a two-dimensional operative video. Setting This study is conducted at department of neurosurgery in a university hospital. Participants A 50-year-old woman who presented with lower cranial nerve findings due to a left-sided lower clival meningioma (Fig. 1). Main Outcome Measures Microsurgical resection of the meningioma and preservation of the neurovascular structures. Results The patient was placed in park-bench position and a left-sided retrosigmoid suboccipital craniotomy, followed by C1 hemilaminectomy and unroofing the lip of the foramen magnum, was performed. The dural incision extended from the suboccipital region down to the posterior arch of C2 (Fig. 2). The arachnoid overlying the tumor was incised, revealing the course of the cranial nerve (CN) XI on the dorsolateral aspect of the tumor. The left vertebral artery (VA) was encased by the tumor which was originating from the dura below the jugular foramen. The mass was resected in a piecemeal fashion eventually. At the end of the procedure, all relevant cranial nerves and adjacent vascular structures were intact. Postoperative magnetic resonance imaging (MRI) confirmed total resection and the patient was discharged home on postoperative day 3 safely. Conclusions Microsurgical resection of the lesions of the CVJ are challenging as this transition zone between the cranium and upper cervical spine has a complex anatomy. Since adequate exposure of the extradural and intradural segments of the VA can be obtained by the posterolateral approach, this approach can be preferred in cases with tumors anterior to the VA or when the artery is encased by the tumor.The link to the video can be found at: https://youtu.be/d3u5Qrc-zlM.

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Partial Transcondylar Approach for Ventral Foramen Magnum Neurenteric Cyst: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy300 ◽

2018 ◽

Vol 16 (3) ◽

pp. E81-E81

Author(s):

Ken Matsushima ◽

Michihiro Kohno ◽

Hitoshi Izawa ◽

Yujiro Tanaka

Keyword(s):

Cranial Nerves ◽

Three Dimensional ◽

Posterior Part ◽

Foramen Magnum ◽

Neurological Deficits ◽

Cystic Tumor ◽

Occipital Condyle ◽

Neurenteric Cyst ◽

Posterior Arch ◽

Transcondylar Approach

Abstract The anterior foramen magnum area, ventral to the brainstem is one of the most difficult regions to access surgically, and the extent of osseous drilling through the far-lateral or transcondylar approach should be planned in each case based on the tumor extension.1,2 This video, reproduced after informed consent of the patient, demonstrates a case of a ventral foramen magnum neurenteric cyst surgically treated using the partial transcondylar approach. A 27-yr-old woman presented with gait disturbance, oscillopsia, and transient arm numbness. Neuroimaging revealed a ventral foramen magnum cystic tumor involving the basilar and bilateral vertebral arteries. The tumor extended inferiorly from the middle clivus to the C1 level, and occupied the whole premedullary cistern compressing the bilateral lower cranial nerves. The left partial transcondylar approach was performed with drilling the condylar fossa, superior part of the occipital condyle, C1 posterior arch, and posterior part of the jugular process to achieve the sufficient surgical view from the inferolateral side. The drilling of the occipital condyle was minimized so that the articular facet of the occipital condyle was preserved. The tumor on the bilateral side was completely removed as enabled by the sufficient surgical field without new neurological deficits. Three-dimensional reconstructed images based on the postoperative computed tomography scans demonstrated the appropriate extent of the osseous drilling.

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Dysphagia and Tongue Deviation: A Rare Case of Collett–Sicard Syndrome after Blunt Head Trauma

Neurology International ◽

10.3390/neurolint12030019 ◽

2020 ◽

Vol 12 (3) ◽

pp. 136-139

Author(s):

Eric Tamrazian ◽

Bijal Mehta

Keyword(s):

Head Trauma ◽

Skull Fracture ◽

Cranial Nerves ◽

Rare Condition ◽

Jugular Foramen ◽

Neurological Deficits ◽

Lower Cranial Nerve ◽

Cranial Nerve Palsies ◽

Blunt Head Trauma ◽

Initial Imaging

The jugular foramen and the hypoglossal canal are both apertures located at the base of the skull. Multiple lower cranial nerve palsies tend to occur with injuries to these structures. The pattern of injuries tend to correlate with the combination of nerves damaged. Case Report: A 28-year-old male was involved in an AVP injury while crossing the highway. Exam showed a GCS of 15 AAOx3, with dysphagia, tongue deviation to the right, uvula deviation to the left and a depressed palate. Initial imaging showed B/L frontal traumatic Sub-Arachnoid Hemorrhages (tSAH), Left Frontal Epidural Hematoma and a Basilar Skull Fracture. On second look by a trained Neuroradiologist c At 3 month follow up, patient’s tongue normalized to midline and his dysphagia resolved. Discussion: Collette-Sicard syndrome is a rare condition/syndrome characterized by unilateral palsy of CN: IX, X, XII. This condition has been rarely described as a consequence of blunt head trauma. In most cases, the condition is self-limiting with patients regaining most to all of their neurological functions within 6 months. Nerve traction injuries and soft tissue edema compressing the cranial nerves are the leading two hypothesis. In conclusion, injuries with focal neurological deficits which were not apparent on initial imaging should be reviewed by relevant experts with concomitant knowledge of the patient’s history.

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Classification and management of cervical paragangliomas

Annals of The Royal College of Surgeons of England ◽

10.1308/147870811x13137608455172 ◽

2011 ◽

Vol 93 (8) ◽

pp. 596-602 ◽

Cited By ~ 14

Author(s):

RJ Obholzer ◽

R Hornigold ◽

S Connor ◽

MJ Gleeson

Keyword(s):

Skull Base ◽

Carotid Body ◽

Infratemporal Fossa ◽

Cranial Nerves ◽

Senior Author ◽

Neurological Deficits ◽

Extensive Experience ◽

Lower Cranial Nerve ◽

Transcervical Approach ◽

Cranial Nerve Palsies

INTRODUCTION Cervical paragangliomas are slow-growing tumours that eventually cause lower cranial nerve palsies and infiltrate the skull base. Surgical treatment may cause the same deficits and, in some, risks more serious neurological deficits. We describe a classification used to guide investigation, consent and management of cervical paragangliomas based on extensive experience. METHODS The case notes of patients managed by the senior author at a tertiary referral skull base unit between 1987 and 2010 were reviewed retrospectively. A total of 87 cervical paragangliomas were identified in 70 patients (mean age: 46 years, range: 13–77 years). Of these, 35 patients had 36 vagal paragangliomas, 43 patients had 50 carotid body paragangliomas and 8 had both. One cervical paraganglioma arose from neither the carotid body nor the nodose ganglion. The main outcome measures were death, stroke, gastrostomy and tracheotomy. RESULTS All tumours were classified pre-operatively based on their relationship to the carotid artery, skull base and lower cranial nerves. Type 1 tumours were excised with a transcervical approach, type 2 with a transcervical-parotid approach and type 3 with a combined transcervical-parotid and infratemporal fossa approach. Type 4 patients underwent careful assessment and genetic counselling before any treatment was undertaken. There were no peri-operative deaths; two patients had strokes, one required a long-term feeding gastrostomy and none required a tracheotomy. CONCLUSIONS The use of a pre-operative classification system guides management and surgical approach, improves accuracy of consent, facilitates audit and clarifies which patients should be referred to specialised centres.

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XI cranial nerve cervical schwannoma – Case report

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1626267 ◽

2014 ◽

Vol 33 (02) ◽

pp. 160-163

Author(s):

Roger Schmidt Brock ◽

Marcelo Viana da Silva Barroso ◽

Iuri Santana Neville ◽

Marcos Queiroz Teles Gomes ◽

Alberto Capel Cardoso ◽

...

Keyword(s):

Case Report ◽

Nerve Stimulation ◽

Nerve Palsy ◽

Rare Condition ◽

Neurological Status ◽

Posterior Arch ◽

Cervical Pain ◽

Spinal Accessory ◽

Suboccipital Craniectomy ◽

Complete Surgical Resection

Cisternal spinal accessory schwannoma are still a rare condition without neurofibromatosis with only 32 cases reported so far. We describe a cisternal accessory schwannoma presented in a 36-year-old woman with posterior cervical pain and cervical mieolopaty, defined by grade IV tetraparesia. A suboccipital craniectomy with C1 posterior arch resection was performed. During microsurgical dissection together with electrophysiological monitoring and nerve stimulation tumor was identified as having the spinal accessory root as its origins. Carefully intraneural dissection was then performed with complete lesion removal, histopatological examination confirmed the hypothesis of schwannoma. The patient was free from pain and improved her neurological status with no accessory nerve palsy. Complete surgical resection is indicated for such lesions and can be achieved with good outcome.

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Posttraumatic Delayed Jugular Foramen Syndrome in a Toddler

Neuropediatrics ◽

10.1055/s-0040-1722684 ◽

2021 ◽

Author(s):

Cristina Toledo-Gotor ◽

Nerea Gorría ◽

Miren Oscoz ◽

Katia Llano ◽

Pablo la Fuente Rodríguez-de ◽

...

Keyword(s):

Physical Examination ◽

Cranial Nerves ◽

Jugular Foramen ◽

Exceptional Case ◽

Cerebellar Tonsil ◽

Occipital Condyle ◽

Lower Cranial Nerve ◽

Cranial Nerve Palsies ◽

Blunt Head Trauma ◽

Condyle Fracture

Abstract Background Multiple lower cranial nerve palsies have been attributed to occipital condyle fractures in older children and adults, but no clinical details of other possible mechanisms have been described in infants. Case Report A 33-month-old boy suffered blunt head trauma. A bilateral skull base fracture was diagnosed, with favorable outcome during the first days after trauma. On the sixth day, the patient began to refuse drinking and developed hoarseness. Physical examination and additional investigations revealed paralysis of left VII, IX, X, and XI cranial nerves. A follow-up computed tomography (CT) scan disclosed a left petrous bone fracture involving the lateral margin of the jugular foramen, and a cranial magnetic resonance imaging (MRI) study showed a left cerebellar tonsil contusion. He improved after methylprednisolone was started. Three months later, he was asymptomatic, although mild weakness and atrophy of the left sternocleidomastoid and trapezius muscles remained 1 year later. Discussion A posttraumatic “jugular foramen syndrome” is rare in children, but it has been reported shortly after occipital condyle fracture, affecting mainly IX, X, and XI cranial nerves. In this toddler, delayed symptoms appeared with unilateral involvement. While an occipital fracture was ruled out, neuroimaging findings suggest the hypothesis of a focal contusion as a consequence of a coup-contrecoup injury. Conclusion This exceptional case highlights the importance of gathering physical examination, anatomical correlation, and neuroimaging to yield a diagnosis.

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Gasperini Syndrome: A Case Report and Systematic Review and Proposing a New Definition

Case Reports in Neurology ◽

10.1159/000510845 ◽

2020 ◽

Vol 12 (3) ◽

pp. 433-439

Author(s):

Riwaj Bhagat ◽

Siddharth Narayanan ◽

Marwa Elnazeir ◽

Thong Diep Pham ◽

Robert Paul Friedland ◽

...

Keyword(s):

Systematic Review ◽

Brain Mri ◽

Cranial Nerves ◽

Clinical Manifestations ◽

The Other ◽

Neurological Deficits ◽

Brainstem Stroke ◽

Neurological Features ◽

The Right ◽

Core Features

Gasperini syndrome (GS), a rare brainstem syndrome, is featured by ipsilateral cranial nerves (CN) V–VIII dysfunction with contralateral hemibody hypoesthesia. While there have been 18 reported cases, the GS definition remains ambiguous. We report a new case and reviewed the clinical features of this syndrome from all published reports to propose a new definition. A 57-year-old man with acute brainstem stroke had right CN V–VIII and XII palsies, left body hypoesthesia and ataxia. Brain MRI showed an acute stroke in the right caudal pons and bilateral cerebellum. After a systematic review, we classified the clinical manifestations into core and associate features based on the frequencies of occurring neurological deficits. We propose that a definitive GS requires the presence of ipsilateral CN VI and VII palsies, plus one or more of the other three core features (ipsilateral CN V, VIII palsies and contralateral hemibody hemihypalgesia). Additionally, GS, similar to Wallenberg’s syndrome, represents a spectrum that can have other associated neurological features. The revised definition presented in this study may enlighten physicians with the immediate recognition of the syndrome and help improve clinical localization of the lesions and its management.

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