A rare case of ruptured intracranial aneurysm arising from the retro-mastoid branch of the occipital artery

Background: Aneurysms of the occipital artery (OA) are rare, with few cases published in the literature. The pathophysiology is unknown, and the presentation is variable. We present a case of a ruptured intracranial aneurysm arising from a branch of the OA. Case Description: A 36-year-old male with a history of ankylosing spondylitis presented with altered mental status after an assaulted. On examination, he was intubated, with a Glasgow coma scale of 9, and imaging of the head and neck revealed a subdural hematoma of the posterior fossa and the cervical spine. The patient underwent suboccipital craniectomy and C1-5 laminectomy with the evacuation of the subdural hematoma. Postoperative cerebral angiography showed an intracranial aneurysm arising from the retromastoid branch of the OA on the left side. Furthermore, the parent vessel of the aneurysm supplied the left lower half of the cerebellar hemisphere. The aneurysm and the parent vessel were embolized using platinum coils. The patient tolerated the procedure well, and magnetic resonance imaging of the brain showed a minor left-sided cerebellar infarct, which was asymptomatic. The patient was discharged home with a modified Rankin scale of 2. There were no outpatient follow-up data available because the patient lost to follow-up. Conclusion: Intracranial OA aneurysms are extremely rare with no clear consensus concerning the management of these aneurysms. They can be treated using endovascular and or open surgical techniques depending on the aneurysm characteristics, patient condition, rupture status, and others.

Microsurgical resection of a giant cervico-medullary ependymoma: 2D-dimensional video

Background: Ependymoma is a slowly growing benign neoplasm that constitutes 3–9% of all neuroepithelial spinal cord tumors.[3,4] They rarely involve the cervicomedullary junction where they both compress the distal brainstem and upper cervical cord. Due to the critical contiguous structures, gross total resection of these lesions may result in significant morbidity/mortality.[1,2] Utilizing intraoperative neuromonitoring can help limit the risks of removing these lesions. Not when considering the risk/complications of partial versus total resection, the surgeon should keep in mind that they are benign slow growing tumors with relatively good long-term survivals following partial removals. This surgical video shows the surgical strategy and management of a giant cervicomedullary ependymoma performed in a 23-year-old female. Case Description: A 23-year-old female presented with cervical pain and quadriparesis of 1-year’s duration. The MR with/without gadolinium showed a large intradural, intramedullary cervical spinal cord tumor that severely expanded the spinal cord. It contained a significant cystic component, extending from the lower brain stem to the inferior aspect of C7. The lesion was hyperintense on T1 and T2 sequences and demonstrated minimal contrast enhancement. Surgery warranted a posterior cranio-cervical midline approach consisting of a suboccipital craniectomy with laminotomy. The pathological diagnosis was consistent with an ependymoma (WHO I). Fifteen days postoperatively, the patient was discharged with a minimal residual quadriparesis that largely resolved within 6 postoperative months. Three months later, the MRI confirmed complete tumor removal of the lesion. Notably, longer-term follow-up is warranted before complete excision can be confirmed. If there is a recurrence, repeat resection versus stereotactic radiosurgery may be warranted. Conclusion: This video highlights a safe and effective surgical technique for the resection of a giant cervicomedullary ependymoma.

Upward transtentorial herniation: A new role for endoscopic third ventriculostomy

Background: The placement of external ventricular drainage (EVD) to treat hydrocephalus secondary to a cerebellar stroke is controversial because it has been associated to upward transtentorial herniation (UTH). This case illustrates the effectiveness of endoscopic third ventriculostomy (ETV) after the ascending herniation has occurred. Case Description: A 50-year-old man had a cerebellar stroke with hemorrhagic transformation, tonsillar herniation, and non-communicating obstructive hydrocephalus. Considering that the patient was anticoagulated and thrombocytopenic, an EVD was placed initially, followed by clinical deterioration and UTH. We performed a suboccipital craniectomy immediately after clinical worsening, but the patient did not show clinical or radiological improvement. On the 5th day, we did an ETV, which reverses the upward herniation and hydrocephalus. The patient improved progressively with good neurological recovery. Conclusion: ETV is an effective and safe procedure for obstructive hydrocephalus. The successful resolution of the patient’s upward herniation after the ETV offers a potential option to treat UTH and advocates further research in this area.

Endoscopic Third Ventriculostomy With “Rescue” Fourth Ventriculocisternostomy: 2-Dimensional Operative Video

This case of endoscopic third ventriculostomy (ETV) and flexible endoscopy for lysis of fourth ventricle adhesions for obstructive hydrocephalus illustrates a key anatomical variant (anastomosis of posterior communicating arteries) that increases the difficulty of ETV and should be recognized preoperatively. The video further demonstrates flexible endoscopy for lysis of a fourth ventricular web and excellent third and fourth ventricular anatomy. This patient presented with normal pressure hydrocephalus-like symptoms and magnetic resonance imaging suggestive of a fourth ventricular outflow obstruction. An ETV would be an ideal intervention with a high chance of success1 and avoiding a ventriculoperitoneal shunt or a more invasive suboccipital craniectomy for fourth ventricle exploration; however, variant anatomy and resultant medialization of the bilateral posterior communicating arteries put their location directly beneath the tuber cinereum. After discussing the risks and benefits of the proposed procedure, the patient consented to proceeding with the surgery. Patient is not identifiable either by clinical vignette or through this operative video, which is entirely intraventricular. The care rendered was standard (nonexperimental). The patient did sign consent for filming and production of the educational video submitted. Here, we present operative video from our ETV, demonstrating an inability to confirm adequate fenestration and subsequent flexible endoscopy for fourth ventriculocisternostomy.

Chiari Type I Malformation Presenting with Unilateral Hearing Loss

Introduction Chiari type I malformations can present in different ways, but the most frequent symptom is an occipitocervical headache. Hearing loss as the main presenting symptom is rare. Case A young woman with progressive left-sided unilateral hearing loss was diagnosed with a Chiari type I malformation. She underwent a suboccipital craniectomy with C1 laminectomy and duraplasty. The hearing loss had resolved postoperatively with normalization of the audiometry. Conclusion Chiari type I malformation can present solely with hearing loss. Improvement after surgical decompression is possible. This phenomenon is not emphasized well enough within the neurologic community. In this report, we present a summary of the pathophysiology and management in Chiari type I malformations.

Nonoperative management of enlarging syringomyelia in clinically stable patients after decompression of Chiari malformation type I

OBJECTIVE The authors aimed to describe the natural history and optimal management of persistent syringomyelia after suboccipital craniectomy for Chiari malformation type I (CM-I). METHODS A cohort of all patients who presented to a tertiary pediatric hospital with newly diagnosed CM-I between 2009 and 2017 was identified. Patients with persistent or worsened syringomyelia were identified on the basis of a retrospective review of medical records and imaging studies. The management of these patients and their clinical courses were then described. RESULTS A total of 153 children with CM-I and syringomyelia were evaluated between 2009 and 2017. Of these, 115 (68.8%) patients underwent surgical intervention: 40 patients underwent posterior fossa decompression (PFD) alone, 43 underwent PFD with duraplasty, and 32 underwent PFD with duraplasty and fourth ventricle stent placement. Eleven (7.19%) patients had increased syringomyelia on subsequent postoperative imaging. Three of these patients underwent revision surgery because of worsening scoliosis or pain, 2 of whom were lost to follow-up, and 4 were managed nonoperatively with close surveillance and serial MRI evaluations. The syringes decreased in size in 3 patients and resolved completely in 1 patient. CONCLUSIONS Persistent or worsened syringomyelia after CM-I decompression is uncommon. In the absence of symptoms, nonoperative management with close observation is safe for patients with persistent syrinx.

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.

Vascularized Bone Grafts for Spinal Fusion—Part 3: The Occiput

BACKGROUND Obtaining successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. This challenge stems from the relatively hypermobile joints between the occipital condyles, the motion that occurs at C1 and C2, as well as the paucity of dorsal bony surfaces for posterior arthrodesis. While multiple different techniques for spinal fixation in this region have been well described, there has been little investigation into auxiliary methods to improve fusion rates. OBJECTIVE To describe the use of an occipital bone graft to augment bony arthrodesis in the supraaxial cervical spine using a multidisciplinary approach. METHODS We review the technique for harvesting and placing a vascularized occipital bone graft in 2 patients undergoing revision surgery at the craniocervical junction. RESULTS The differentiation from nonvascularized bone graft, either allograft or autograft, to a bone graft using vascularized tissue is a key principle of this technique. It has been well established that vascularized bone heals and fuses in the spine better than structural autogenous grafts. However, the morbidity and added operative time of harvesting a vascularized flap, such as from the fibula or rib, precludes its utility in most degenerative spine surgeries. CONCLUSION By adapting the standard neurosurgical procedure for a suboccipital craniectomy and utilizing the tenets of flap-based reconstructive surgery to maintain the periosteal and muscular blood supply, we describe the feasibility of using a vascularized and pedicled occipital bone graft to augment instrumented upper cervical spinal fusion. The use of this vascularized bone graft may increase fusion rates in complex spine surgeries.

Interlayer Dural Split Technique for Chiari I Malformation Treatment in Adult -- Technical Note

Objective: To present an alternative surgical technique in treating cases of Chiari I Malformation with mild-to-moderate syringomyelia after decompressive suboccipital craniectomy: incising only the outer layer of the dura mater, then dissecting it from the inner layer without opening the latter. Methods and Results: We utilized this technique in a short series of three cases who were admitted in our department for mild symptoms such as intermittent headache and dissociated sensory loss in the upper limbs, caused by a Chiari Malformation Type I. The patients were placed in the sitting position. We performed a reduced median suboccipital craniectomy and resection of the posterior arch of C1 adapted to the level of tonsil descent, from a limited superior half to a complete resection. Afterwards, we incised the outer dural layer, while sparing the inner one. Using a fine dissector, we then split apart the outer and inner layers to the margin of the craniectomy. Through the transparency of the inner layer and the arachnoid, the cerebellum and the medulla were visible and pulsating. An autologous fascia duraplasty was then performed. The postoperative course was favorable in all cases, patients being discharged without any deficits and with complete symptom resolution. Conclusions: Interlayer dural split technique can be used effectively in treating symptomatic cases of type I Chiari malformation in adults, with mild-to-moderate syringomyelia. It is less invasive than opening the dura and possibly more effective than decompressive craniectomy and C1 laminectomy alone. This technique must be validated in a larger case-control series.