Eosinophilic meningitis following suboccipital craniotomy without bovine dural graft: illustrative case

BACKGROUND Eosinophilic meningitis is a rare known complication after brain surgery associated with duraplasty using artificial bovine graft. However, eosinophilic meningitis after craniotomy without bovine dural graft has not been reported. OBSERVATIONS A 48-year-old female presented with lateral medullary infarction caused by a vertebral artery dissecting aneurysm incorporating the posterior inferior cerebellar artery (PICA). The authors performed occipital artery–PICA anastomosis and repaired the dura by primary suture without bovine graft. Thereafter, endovascular internal trapping using coils was conducted. Severe headache developed at postoperative day 17, and the patient was diagnosed with eosinophilic meningitis. After administration of a high-dose corticosteroid for 2 weeks, her symptoms and laboratory findings were improved. LESSONS Postoperative eosinophilic meningitis is rarely related to craniotomy without using bovine graft. Neurosurgeons should consider the possibility of eosinophilic meningitis after craniotomy without a xenogeneic dural material.

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Treatment of intracranial vertebral artery dissecting aneurysms involving the posterior inferior cerebellar artery origin

Surgical Neurology International ◽

10.25259/sni-281-2019 ◽

2019 ◽

Vol 10 ◽

pp. 116 ◽

Cited By ~ 3

Author(s):

Jason A. Chen ◽

Matthew C. Garrett ◽

Anton Mlikotic ◽

James I. Ausman

Keyword(s):

Vertebral Artery ◽

Complex Disease ◽

Treatment Options ◽

Posterior Inferior Cerebellar Artery ◽

Treatment Strategies ◽

Dissecting Aneurysm ◽

Parent Artery ◽

Illustrative Case ◽

Parent Vessel ◽

Cerebellar Artery

Background: Vertebral artery dissecting aneurysm (VADA) involving the origin of the posterior inferior cerebellar artery (PICA) is a complex disease entity in which the dual goals of preventing future rebleeding and maintaining perfusion of the lateral medulla must be considered. We present an illustrative case and review the literature surrounding treatment strategies. Case Description: We report a patient presenting with extensive subarachnoid hemorrhage due to rupture of an intracranial VADA involving the PICA origin. After consideration of the patient’s cerebral vasculature and robustness of collaterals, a flow-diverting stent was placed with angiographic resolution of the lesion and maintenance of antegrade PICA flow. Ultimately, the patient experienced a contralateral intraparenchymal hemorrhage leading to death. Review of the literature identified 124 cases of VADA involving the PICA origin described over the past decade. The methods of surgical and endovascular treatment of these cases were reviewed, with particular focus on the rationale of treatment, outcomes, and complications. Conclusion: Numerous treatment options for VADA involving PICA have been reported with different risk and benefit profiles. Flow-diverting stents appear to offer the most favorable balance of securing the aneurysm and avoiding medullary infarction, but the risks and optimal anti-thrombotic treatment strategy are incompletely understood. In select cases, in which the surgical risk is low or in which the anatomy is favorable (e.g., nondominant parent vessel or robust collateral circulation in the involved territories), parent artery trapping with or without microsurgical revascularization can be considered.

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Spontaneous Thrombosis of Ruptured Vertebral Dissecting Aneurysm after Occipital Artery-Posterior Inferior Cerebellar Artery Anastomosis and Proximal Vertebral Artery Occlusion: Case Report.

Surgery for Cerebral Stroke ◽

10.2335/scs.29.430 ◽

2001 ◽

Vol 29 (6) ◽

pp. 430-434

Author(s):

Masahiko KAWANISHI ◽

Keiko IRIE ◽

Nobuyuki KAWAI ◽

Katsuzo KUNISHIO ◽

Seigo NAGAO

Keyword(s):

Case Report ◽

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Artery Occlusion ◽

Dissecting Aneurysm ◽

Occipital Artery ◽

Spontaneous Thrombosis ◽

Vertebral Artery Occlusion ◽

Cerebellar Artery

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Far Lateral Approach (Transcondylar, Transtubercular) for Bypass and Trapping of a Ruptured, Dissecting PICA Aneurysm

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1701237 ◽

2020 ◽

Author(s):

Andrew S. Venteicher ◽

Ezequiel Goldschmidt ◽

Paul A. Gardner

Keyword(s):

Endovascular Treatment ◽

Posterior Inferior Cerebellar Artery ◽

Lateral Approach ◽

Dissecting Aneurysm ◽

Posterior Circulation ◽

Occipital Artery ◽

Unique Challenge ◽

Far Lateral Approach ◽

Posterior Circulation Aneurysms ◽

Far Lateral

AbstractAneurysms of the posterior circulation pose a unique challenge due to higher rupture rates, higher recurrence rates following endovascular treatment, and extended open cranial base approaches required to reach the ventrally located brainstem circulation. While endovascular therapy has made tremendous strides in successful treatment for most posterior circulation aneurysms, open microscopic approaches remain essential in specific circumstances. Here, we present a case of a patient who presented with acute, severe headache, and sixth nerve palsies, and who was found to have hydrocephalus and a dissecting aneurysm at the anterolateral medullary segment of the posterior inferior cerebellar artery (PICA). Interestingly, this patient had a history of alpha-1 antitrypsin deficiency that has been linked with spontaneous aortic and cervical arterial dissections. The fusiform geometry of the dissecting aneurysm was deemed suboptimal for endovascular treatment, so an open microsurgical approach for occipital artery to PICA bypass and aneurysm trapping was planned. Because this patient had cerebral edema in the setting of a ruptured aneurysm and hydrocephalus, a far lateral craniotomy combined with drilling of the occipital condyle and jugular tubercle was critical to enhance exposure of the first segment of the PICA and to minimize brain retraction. In this video, we highlight the key steps and nuances for harvest of the occipital artery, achieving control of the extracranial vertebral artery, performing the transcondylar and transtubercular far lateral approach, and bypass with trapping technique for these challenging posterior circulation aneurysms.The link to the video can be found at: https://youtu.be/dqgblwX6t0Q.

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Trapping and V3-radial artery graft-V4 bypass for ruptured dissecting aneurysm of the vertebral artery

Neurosurgical FOCUS ◽

10.3171/2015.v1.focus14465 ◽

2015 ◽

Vol 38 (videosuppl1) ◽

pp. Video1 ◽

Cited By ~ 3

Author(s):

Tomohiro Inoue ◽

Akira Tamura ◽

Isamu Saito

Keyword(s):

Vertebral Artery ◽

Radial Artery ◽

Cranial Nerves ◽

Artery Aneurysm ◽

Lateral Approach ◽

Dissecting Aneurysm ◽

Occipital Artery ◽

Spinal Root ◽

Suboccipital Craniotomy ◽

Far Lateral Approach

The authors show a surgical technique of trapping/resection of ruptured dominant vertebral artery aneurysm in conjunction with reconstruction of vertebral artery by V3–radial artery (RA) graft–V4 bypass through suboccipital craniotomy and far lateral approach. Step by step muscle dissection in posterior fossa enable fine exposure of occipital artery for possible OA-PICA bypass and V3 portion of vertebral artery. Extradural drilling of posterior one-third condyle and condylar fossa facilitate exposure of triangular surgical corridor made by medulla, spinal root of 11th nerve and lower cranial nerves, and thus enabling aneurismal resection and RA–V4 anastomosis.The video can be found here: http://youtu.be/LxsARGdHSVw.

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Occipital artery to p3 segment of posterior inferior cerebellar artery bypass in treating a complex fusiform aneurysm

BMJ Case Reports ◽

10.1136/bcr-2020-235023 ◽

2020 ◽

Vol 13 (6) ◽

pp. e235023

Author(s):

Peyton L Nisson ◽

Michael A McNamara ◽

Xiaolong Wang ◽

Xinmin Ding

Keyword(s):

Case Report ◽

Artery Bypass ◽

Bypass Graft ◽

Posterior Inferior Cerebellar Artery ◽

Dissecting Aneurysm ◽

Neurological Deficits ◽

Endovascular Coiling ◽

Occipital Artery ◽

Cerebellar Artery ◽

Arterial Bypass Graft

We provide a case report of a 58-year-old man who presented with a ruptured fusiform dissecting aneurysm located at the junction of the vertebral artery and posterior inferior cerebellar artery (PICA). Due to the lesion’s complexity, a two-step approach was planned for revascularisation of PICA using the occipital artery (OA) prior to coiling embolisation. An end-to-side OA–PICA bypass was performed with implantation at the caudal loop of the p3 PICA segment. Fifteen days after the procedure, the aneurysm underwent stent-assisted coiling for successful obliteration of the aneurysm. The patient tolerated this procedure well and now at 1.5 years of follow-up remains free from any neurological deficits (modified Rankin Score 0). This case report illustrates one of the unique scenarios where both the vascular territory involved and morphological features of the aneurysm prohibited the use of more conventional means, necessitating the use of an arterial bypass graft for successful treatment of this lesion. As open vascular surgery is becoming less common in the age of endovascular coiling, our article uniquely reports on the combined use of both endovascular and microsurgical techniques to treat a complex aneurysm of the posterior circulation.

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Right frontotemporal craniotomy for ECA-to-MCA direct and indirect bypass and occipital artery indirect bypass to the posterior circulation: case report

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.7.peds20181 ◽

2020 ◽

pp. 1-5

Author(s):

Mitchell W. Couldwell ◽

Samuel Cheshier ◽

Philipp Taussky ◽

Vance Mortimer ◽

William T. Couldwell

Keyword(s):

Case Report ◽

Pediatric Patients ◽

Posterior Circulation ◽

Occipital Artery ◽

Transient Ischemic Attacks ◽

Collateral Vessel ◽

Suboccipital Craniotomy ◽

Uncommon Disease ◽

Indirect Revascularization ◽

The Brain

Moyamoya is an uncommon disease that presents with stenoocclusion of the major vasculature at the base of the brain and associated collateral vessel formation. Many pediatric patients with moyamoya present with transient ischemic attacks or complete occlusions. The authors report the case of a 9-year-old girl who presented with posterior fossa hemorrhage and was treated with an emergency suboccipital craniotomy for evacuation. After emergency surgery, an angiogram was performed, and the patient was diagnosed with moyamoya disease. Six months later, the patient was treated for moyamoya using direct and indirect revascularization; after surgery there was excellent vascularization in both regions of the bypass and no further progression of moyamoya changes. This case illustrates a rare example of intracerebral hemorrhage associated with moyamoya changes in the posterior vascularization in a pediatric patient and subsequent use of direct and indirect revascularization to reduce the risk of future hemorrhage and moyamoya progression.

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RARE-29. PRIMARY CENTRAL NERVOUS SYSTEM NON-HODGKIN LYMPHOMA IN AN 11-YEAR-OLD BOY: A CASE REPORT

Neuro-Oncology ◽

10.1093/neuonc/noaa222.739 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii448-iii448

Author(s):

Jorge Luis Ramírez-Melo ◽

Regina M Navarro-Martin del Campo ◽

Manuel D Martinez-Albarran ◽

Fernando Sánchez-Zubieta ◽

Ana L Orozco-Alvarado ◽

...

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Hodgkin Lymphoma ◽

Central Nervous System Lymphoma ◽

Complete Response ◽

High Dose ◽

Illustrative Case ◽

Tumor Biopsy ◽

Non Hodgkin Lymphoma ◽

The Right

Abstract BACKGROUND Primary central nervous system lymphoma (PCNSL) are very rare in children. CLINICAL CASE: An 11-year-old male presented with a 2 months history with myoclonic movements in the upper right limb, and a sudden frontal headache, gait disturbance due to right hemiparesis and an ipsilateral convulsive episode. Upon admission he had critical condition, with hypertensive skull syndrome, Glasgow of 12, Karnofsky 40%, right hemiparesis, swallowing disorder, facial paralysis, and loss of photo motor reflex and unilateral amaurosis. A CT and MRI showed a huge tumor mass in the left tempo-parietal region, infiltrating the white matter and shifting the midline. A Tumor biopsy was done, and reported diffuse small cell non-Hodgkin lymphoma of high-grade, Burkitt type. Systemic lymphoma workup was negative. He received six cycles of chemotherapy based on high dose methotrexate, rituximab and triple intrathecal.After the second cycle an ophthalmologic evaluation was done, and found infiltration to the right retina, for which 6 cycles of intra vitreous chemotherapy with methotrexate were applied, he showed an excellent response, and recovered all his neurological functions except that right hemianopia persist. Control MRI showed partial response at 2nd cycle and complete response after the 4th cycle. No Radiation was performed. CONCLUSION This report highlights the fact that pediatric PCNSL may be effectively treated by a combination of HDMTX and rituximab-based chemoimmunotherapy without irradiation. Lack of awareness of this rare entity may lead to extense resections of brain, and potential permanent secuelae that were avoided in this illustrative case.

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How I do it? Posterior inferior cerebellar artery-intracranial vertebral artery reimplantation bypass and trapping of dissecting aneurysm involving the proximal posterior inferior cerebellar artery

Acta Neurochirurgica ◽

10.1007/s00701-021-04918-9 ◽

2021 ◽

Author(s):

Zixiao Yang ◽

Jianping Song ◽

Peiliang Li ◽

Wei Zhu

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Dissecting Aneurysm ◽

Cerebellar Artery

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Association between Platelet-Associated Immunoglobulin G Levels and Response to Corticosteroid Therapy in Patients with Newly Diagnosed Immune Thrombocytopenia

Acta Haematologica ◽

10.1159/000511698 ◽

2020 ◽

pp. 1-6

Author(s):

Masuho Saburi ◽

Masao Ogata ◽

Yasuhiro Soga ◽

Takako Satou ◽

Kazuhito Itani ◽

...

Keyword(s):

Corticosteroid Therapy ◽

Immunoglobulin G ◽

Immune Thrombocytopenia ◽

High Dose ◽

First Line ◽

Laboratory Findings ◽

Platelet Production ◽

First Line Therapy ◽

Line Therapy ◽

Immature Platelet Fraction

Objective: Platelet-associated immunoglobulin G (PA-IgG) refers to IgG attached to the surface of platelets, while the immature platelet fraction (IPF) reflects the state of platelet production in bone marrow. Since PA-IgG and IPF are increased in patients with immune thrombocytopenia (ITP), reflecting amounts of platelet antibodies and compensatory platelet production, respectively, we hypothesized that these laboratory findings may provide useful markers for predicting treatment response in patients with ITP. We therefore retrospectively investigated associations between levels of these markers at diagnosis and response to first-line therapy in patients with ITP. Methods: Forty-three patients diagnosed with ITP at Oita Kouseiren Tsurumi Hospital between May 2010 and November 2018 were included. Patients were divided into 2 groups based on response to corticosteroid as first-line therapy. Laboratory findings were compared between responders and nonresponders. Results: Median PA-IgG was 285 ng/107 cells (range, 45.5–18,200 ng/107 cells), and median IPF was 15.5% (range, 5.4–62.1%). Median levels were higher than the respective upper limits of normal range (PA-IgG, 0–46 ng/107 cells; IPF, 1.1–9.5%). First-line therapy was performed using standard-dose prednisolone (0.5–1.0 mg/kg/day) in 32 patients and high-dose dexamethasone (40 mg/day, 4 days) or methylprednisolone (125–1,000 mg/day, 3–4 days) in 11 patients. Twenty-four patients (55.8%) responded to first-line therapy. In univariate analysis, type of corticosteroid (p = 0.17) tended to differ between groups but did not differ significantly, and no difference in IPF level was apparent between responders (15.35%; range, 5.4–41.5%) and nonresponders (16.7%; range, 6.3–62.1%; p = 0.15). PA-IgG was significantly higher among nonresponders (430 ng/107 cells; range, 101–18,200 ng/107 cells) than among responders (254.5 ng/107 cells; range, 45.5–470 ng/107 cells; p = 0.004). Multivariate analysis revealed PA-IgG was independently associated with response to first-line therapy (odds ratio, 1.000; 95% confidence interval, 1.000–1.010; p = 0.029). Conclusion: Our data suggested that PA-IgG at diagnosis could offer a useful predictor of response to first-line corticosteroid therapy for ITP.

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