What should otolaryngologists know about dural venous sinus stenting?

Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis. ENT doctors are the first to see these patients in their clinics, as sinus headaches, pulsating tinnitus, and dizziness are the most common symptoms. Previously, with limited success, high-dose diuretics and intracranial shunts had been the only options for treating these patients. Other methods, such as covering the sigmoid sinuses with graft material, appear to cause a sudden increase in intracranial pressure that can lead to blindness and even death. This overview summarizes the clinical and imaging characteristics of patients who will benefit from endovascular sinus stenting for elevated intracranial pressure.

Microsurgical Management of Complex Meningiomas Involving Dural Venous Sinuses: Operative Techniques, Case Illustrations and Long-Term Outcomes in a Series of 70 Cases.

BACKGROUND: Meningiomas involving the dural venous sinuses present unique therapeutic challenges. While gross total resection remains the mainstay of treatment for meningiomas, involvement of critical vascular structures may limit extent of resection and increase the risk of recurrence. Optimal management of meningiomas with venous sinus involvement has been discussed in the literature, with some advocating for subtotal resection with post-operative surveillance and radiation, if necessary, while others recommend total resection with reconstruction of resection of the involved sinus. METHODS: We performed a review of our series of 70 patients at a single institution who underwent resection of a meningioma involving the dural venous sinuses with reconstruction as needed, evaluating demographics, pre-operative assessment of venous anatomy, surgical technique, and outcomes. RESULTS: In our series, we found successful maximal safe resection was achievable in patients with dural venous sinus involvement. We identified no venous infarctions and a low rate of recurrence. CONCLUSIONS: Maximal safe resection, including resection and reconstruction of involved sinuses, may be a safe and effective treatment for many patients. Careful pre-operative assessment of venous anatomy and planning extent of resection and reconstruction are essential for safe and successful surgery in these patients.

Sacral sensory blockade from 27-gauge pencil-point dural puncture epidural analgesia or epidural analgesia in laboring nulliparous parturients: a randomized controlled trial.

BACKGROUND: The dural puncture epidural (DPE) technique has been associated with better sacral analgesia compared with a traditional epidural (EPL) technique in laboring parturients. The aim of this study was to investigate whether DPE with a 27-gauge pencil-point needle compared with a traditional EPL technique produces more rapid bilateral sacral blockade in nulliparous parturients. METHODS: Patients were randomized to a DPE or EPL technique. Epidural analgesia in both groups was initiated with ropivacaine 0.1% and sufentanil 0.5 µg/mL (15 mL) and maintained via programmed intermittent epidural boluses. Analgesic blockade was tested bilaterally beginning 10 min after initiation, and then at predefined intervals until delivery. The presence of an S2 blockade at 20 min was the primary outcome. RESULTS: Among 108 (54 per group) patients enrolled, bilateral sacral (S2) blockade at 20 min was significantly more common in the DPE than in the EPL group [47 (87%) vs. 23 (43%), absolute risk reduction (ARR) 44%, 95% CI 28 to 60; P < 0.001]. Time to a numeric pain rating scale score (0-10 scale) ≤ 3 (20 [20,30] min in both groups, HR 1.15, 95% CI 0.77 to 1.15; P = 0.50), number of rescue doses [0 (0, 1) vs 0 (0, 1); P 0.08], and presence of bilateral S2 blockade at delivery were not significantly different between groups. CONCLUSIONS: The DPE technique with a 27-gauge pencil-point spinal needle more often provides bilateral sacral blockade at 20 min following block initiation compared with the EPL technique. The time to adequate analgesia and need for supplemental analgesia did not appear to differ between techniques.

Headache that will not go away...Third ED visit is the charm?

Subdural hematoma is an uncommon complication of epidural analgesia or diagnostic lumbar puncture. Headache is a common complaint for patients with either a subdural hematoma or a post-dural puncture headache. Because post-dural puncture headaches are commonly seen in the Emergency Department, the potential to miss more serious pathology arises. We present the case of a young female who suffered bilateral subdural hematomas following epidural analgesia during childbirth. She presented twice to the Emergency Department and was treated for a post-dural puncture headache before computed tomography imaging revealed the diagnosis on the third Emergency Department encounter. This case highlights the importance of exploring all potential diagnoses when a patient presents with a headache after either epidural analgesia or a diagnostic lumbar puncture, especially if the patient returns after unsuccessful treatment for a presumptive post-dural puncture headache.

Preliminary Clinical and Radiological Outcomes of the "No-Punch" Decompression Techniques for Unilateral Biportal Endoscopic Spine Surgery.

OBJECTIVE: To avoid the most offending surgical instrument for dural tears, we develop a "no-punch" decompression technique for unilateral biportal endoscopic (UBE) spine surgery. METHODS: This retrospective study enrolled 68 consecutive patients with degenerative lumbar spinal stenosis segments. The treatment results were evaluated using the visual analogue scale (VAS) for low back and leg pain, the Japanese Orthopaedic Association (JOA) scores, and the Oswestry Disability Index (ODI). Radiological outcomes were evaluated using the preoperative and postoperative magnetic resonance imaging. RESULTS: This study included 36 male and 32 female patients who received 109 segments of decompression, with an average age of 68.7 (37-90 years). The average operation time was 52.2 minutes. The average hospital stay was 3.1 days. There were no dural tears but 3 minor surgical complications, all treated conservatively. The VAS for low back and leg pain improved from 4.6 and 7.0 to 0.8 and 1.2. The JOA score improved from 16.2 to 26.8, with an improvement rate of 82.0%. The ODI improved from 50.1 to 18.7. All these improvements were statistically significant. The cross-sectional dural area improved from 61.1 to 151.3 mm2, with an average increase of 90.2 mm2 and 205.3%. 87.1% of the ipsilateral facet joints and 84.7% of the contralateral facet joints were preserved. In 61% of the decompressed segments, the ipsilateral facet joints were preserved better than the contralateral facet joints. CONCLUSION: The UBE "no-punch" decompression technique effectively avoids the dural tears. It provides effective neural decompression, excellent facet joint preservation, and good treatment outcomes.

The hybrid operation based on microsurgery assisted by intraoperative spinal angiography in patients with spinal dural arteriovenous fistula: a series of 45 cases from multicenter research.

BACKGROUND: To assess the clinical effects of hybrid surgery, which includes spinal angiography-assisted microsurgery, in the treatment of spinal dural arteriovenous fistulas (SDAVF). METHODS: We retrospectively reviewed 45 patients who underwent hybrid Spinal dural arteriovenous fistula (SDAVF) resection between September 2019 and June 2022. The hybrid surgery involved intraoperative digital subtraction angiography (DSA) of the spinal vessels to determine the source of the blood-supplying artery, location of the fistula and draining vein, indocyanine green fluorescence (ICG)-assisted microsurgical resection of the fistula, and postoperative DSA to verify therapeutic efficacy. The Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Visual Analog Scale (VAS), Barthel score, modified Rankin Scale (mRS) and modified Aminoff-Logue score (key indicator) were used to assess the clinical effects of SDAVF resection. RESULTS: A series of 45 patients with SDAVF were successfully treated with hybrid surgery without fistula recurrence. There were no intraoperative complications related to spinal angiography, and none of the patients died. Postoperatively, two patients experienced clinical deterioration of spinal cord function, which manifested as bilateral lower extremity paralysis and bladder sphincter dysfunction. Postoperatively, improvement in mALS scores was observed in 16 cases (35.6%) within 1-2 days, 12 cases (26.7%) at 1 week, and 7 cases (15.6%) at 6 months. No SDAVF recurrence was detected in the spinal MRA examination 6 months after surgery. When compared with preoperative mALS scores, 35 cases (77.8%) showed significant improvement in symptoms, 8 cases (17.8%), remained unchanged, and 2 cases (4.4%) deteriorated. Compared with the preoperative scores, the postoperative mALS score was significantly decreased [postoperative vs. preoperative: 2(1,3) vs. 3(2,4)], HAMD score [(12.2 ± 5.5) vs. (19.6 ± 6.3)], HAMA score [(15.6 ± 5.5) vs. (20.5 ± 6.5)], and VAS score [3(2,5) vs. 5(4,8)]. Conversely, Barthel scoresshowed significant increase [(74.6 ± 8.7) vs. (67.8 ± 9.2)] (P < 0.05). However, the mRS scores were lower than preoperatively [1(1,2) vs. 2(1,2.5)], but the difference was not statistically significant (P > 0.05). There was a significant increase in "good" neurological outcomes at follow-up compared with preoperative function (62.2% vs. 33.3%) (P = 0.023). CONCLUSION: Hybrid surgery is a safe and effective treatment for patients with SAVF, which is beneficial for improving anxiety, depression, spinal cord, and neurological function, and relieving pain. However, the treatment of patients with SDAVF is a complex, long-term process requiring further multidisciplinary interventions, including clinical care, psychosocial interventions, and neurorehabilitation.

Diagnosing Late-Onset Psychosis in a Medically Complex Patient: A Diagnostic Challenge.

This case report explores various possible causes of late-onset psychosis and highlights the importance of follow-up care. We report the case of a 65-year-old female with minimal available medical history or contacts, who presented to the hospital after being found unconscious after three weeks of strange behaviors, including partition delusions, multiple phone calls and texts to her friend, and lack of sleep. In the following days, she had various symptoms consistent with delirium, psychosis, and mania. However, she was also found to have a dural calcification and urinary tract infection on imaging and laboratories, respectively. We attempted to distinguish these possible etiologies and understand the best course of action for such a patient with a limited medical history who was subsequently lost to medical follow-up. Utilizing the psychiatric interview, mental status examination, laboratory work, imaging, and available medical and psychiatric history can all help narrow down the most likely etiologies. However, the lack of data given during follow-up visits, regarding patient response to treatment, their full medical and psychiatry history, as well as their understanding of their diagnosis, poses a significant challenge in reaching a definitive diagnosis in such a patient. This underscores the critical need for follow-up care, especially for patients treated for psychosis in acute settings.

De novo primary malignant lymphoma of the dura following recurrent episodes of subdural abscess presenting as chronic subdural hematoma: illustrative case.

BACKGROUND: Chronic inflammation of the thorax, as in tuberculosis-related pyothorax, can cause secondary malignant lymphomas. However, primary malignant lymphoma of the central nervous system, specifically of the dura mater, developing after intracranial infection or inflammation has rarely been reported. Herein, the authors describe a case of primary dural lymphoma that developed secondary to subdural empyema, with an initial presentation mimicking a chronic subdural hematoma. OBSERVATIONS: A 51-year-old man had undergone single burr hole drainage for subdural empyema 2 years prior. The patient subsequently underwent multiple craniotomy and drainage procedures, with successful remission of the subdural empyema. He was subsequently referred to the authors' hospital approximately a year after his initial treatment because of a recollection of subdural fluid, which was suspected to be recurrent empyema. After another single burr hole drainage, which revealed only a subdural hematoma, a histopathological diagnosis of B-cell lymphoma of the dural/subdural membrane was made. Subsequent radiation therapy was completed, with good local control and no recurrence of the subdural hematoma confirmed at 2 months posttreatment. LESSONS: Intracranial lymphoma triggered by chronic inflammation is rare but should be considered a differential diagnosis in subdural hematomas for which the background pathology is unclear. https://thejns.org/doi/10.3171/CASE24153.

Risk factors for postoperative late deterioration in patients with spinal dural arteriovenous fistulas.

Background: Approximately 86% of patients with spinal dural arteriovenous fistulas (SDVAFs) exhibit clinical improvement after surgery. However, 12%-55.8% of these patients experience late deterioration (LD) after an initial period of improvement. The risk factors for LD remain unclear. The aim of this study was to explore the risk factors for LD in SDVAF patients. Methods: The clinical data of patients who were admitted to two tertiary hospitals between June 2014 and May 2022 were reviewed. Patients were divided into two groups: the LD group and the no LD group. The severity of neurological dysfunction (NDF) was evaluated using the Modified Aminoff and Logue Scale. Univariable and multivariable Cox regression analyses were performed. Results: A total of 105 eligible patients were enrolled, with a mean age of 57.55 ± 9.42 years. The LD group comprised 37 individuals, while the no LD group consisted of 68 individuals. According to the univariable analysis, preoperative NDF severity and treatment strategy were associated with the risk of LD. According to the multivariable analysis, patients who underwent microsurgery (MS) had a lower risk of LD than did those who underwent endovascular treatment (EVT; HR 0.197, 95% CI 0.085-0.457), and patients with severe NDF had a higher risk of LD than did those with mild NDF (HR 3.604, 95% CI 1.226-10.588), whereas the risk of LD in patients with moderate NDF was similar to that of patients with mild NDF (HR 1.352, 95% CI 0.519-3.524). Conclusion: EVT and severe preoperative NDF are independent risk factors for LD.

Intracranial solitary fibrous tumors: Clinical, radiological, and histopathological insights along with review of literature.

BACKGROUND: Intracranial solitary fibrous tumors (SFTs) are rare mesenchymal neoplasms, often challenging to diagnose due to their resemblance to meningiomas and other central nervous system tumors. While advancements in molecular genetics have aided in classification, diagnostic nuances and optimal management strategies remain areas of interest. MATERIALS AND METHODS: This retrospective study analyzed 11 cases of intracranial SFTs treated at a neurosurgical centre in India between February 2020 and January 2024. Clinical data, radiological findings, histopathological features, and follow-up details were reviewed. Immunohistochemistry, particularly STAT6, facilitated diagnosis confirmation. RESULTS: The median age of presentation was 32 years, with a male predominance. Headache was the most common presenting symptom, often leading to misdiagnosis as meningiomas on radiological imaging. Histologically, SFTs exhibited spindle to ovoid cells with staghorn vessels and collagenized stroma, posing challenges in differential diagnosis. WHO grading predominantly revealed grade 1 tumors, though recurrence occurred, emphasizing the importance of long-term follow-up. Immunohistochemistry, particularly STAT6, played a pivotal role in distinguishing SFTs from other entities. CONCLUSION: Intracranial SFTs present diagnostic challenges due to overlapping features with other tumors, warranting a comprehensive approach integrating clinical, radiological, and histopathological findings. Immunohistochemistry, particularly STAT6, emerges as a valuable diagnostic tool. Long-term follow-up is essential for monitoring recurrence and potential malignant transformation. Further research is needed to delineate optimal treatment strategies, including the role of radiotherapy in SFT management.

Coexistence of Intracranial Dural Arteriovenous Fistula and Cerebral Venous Sinus Thrombosis: Systematic Review and Outcome Analysis.

A substantial number of patients with intracranial dural arteriovenous fistula (dAVF) suffer from coexistent cerebral venous sinus thrombosis (CVST), yet this clinical relation is poorly studied. We aim to study the clinical and radiological outcome of patients with coexistent dAVF and CVST based on different treatment modalities and to examine various other parameters in such patients. A search strategy was performed on the following search engines: PubMed, Wiley, Microsoft Academia, and Google Scholar. Analysis was performed using R software. Thirty-five articles met the inclusion criteria. Most studies (n=30) used Digital Subtraction Angiography (DSA) alone to make the diagnosis. Treatment modality ranged from no treatment (n=7) to a combination of anticoagulation, endovascular therapy, and surgery (n=2). Radiological obliteration was achieved in the majority of patients (78%). However, there was no statistical significance between treatment modality and radiological outcome (p = 0.651). 72% of patients achieved clinical improvement, with no statistical significance between clinical improvement and treatment modality (p = 0.072). We did find a significant relationship between treatment modality and follow-up findings (p = 0.023). When analyzing factors such as age, gender, grade, arterial supply, and time between dAVF and CVST development, we found no statistical significance. Additionally, there was no significant association between the grade of fistula and the treatment modality. The clinical relationship between dAVF and CVST is poorly studied. This is the first systematic review that aimed to study this relationship. Results from subsequent large-scale studies comparing to our findings are warranted.

Diagnostic and therapeutic insights in individuals with persistent post-dural puncture headache: A cross-sectional study.

BACKGROUND: Post-dural puncture headache (PDPH) is a frequent complication following lumbar puncture, epidural analgesia, or neuraxial anesthesia. The International Classification of Headache Disorders, third edition categorizes PDPH as a self-limiting condition; however, emerging evidence, including our findings, suggests that PDPH can have a prolonged course, challenging this traditional view. OBJECTIVES: To elucidate the diagnostic characteristics and treatment outcomes of persistent PDPH (pPDPH), offering insights into its demographic profiles and diagnostic features. METHODS: We executed an anonymous, web-based survey targeting individuals aged ≥18 years diagnosed with or suspected of having pPDPH. Recruitment occurred through self-help groups on Facebook. The survey comprised questions regarding diagnostic procedures, treatment regimens, outcomes, and healthcare consultation. RESULTS: The survey achieved a response rate of 179/347 (51.6%) individuals completing the questionnaire. Cerebrospinal fluid (CSF) leaks were confirmed in nine of 179 (5.0%) cases. Signs of intracranial hypotension without a CSF leak were observed in 70/179 (39.1%) individuals. All participants underwent magnetic resonance imaging scans of the brain and spine, with computed tomography myelography performed in 113/179 (63.1%) cases. Medications, including analgesics, theophylline, and gabapentin, provided minimal short-term relief. Epidural blood patch treatments resulted in slight-to-moderate short-term improvement in 136/179 (76.0%), significant improvement in 22/179 (12.3%), and complete effectiveness in eight of 179 (4.5%) individuals. For long-term outcomes, slight-to-moderate improvement was reported by 118/179 (66.0%) individuals. Surgical interventions were carried out in 42/179 (23.5%) patients, revealing pseudomeningoceles intraoperatively in 20/42 (47.6%) individuals. After surgery, 21/42 (50.0%) of the participants experienced slight-to-moderate improvement, 12/42 (28.6%) showed more pronounced improvement, and five of the 42 (11.9%) achieved complete effectiveness. CONCLUSION: This study underscores the complexities of managing pPDPH. The delay in diagnosis can impact the effectiveness of treatments, including epidural blood patch and surgical interventions, resulting in ongoing symptoms. This underscores the importance of tailored and adaptable treatment strategies. The findings advocate for additional research to deepen the understanding of pPDPH and improve long-term patient outcomes.

Dual Volume image fusion technique for Anatomical Evaluation of Cavernous Sinus Dural Arteriovenous Fistula: Usefulness for Transvenous Target segment Embolization.

OBJECTIVE: In this preliminary study, we investigated the value of fusion techniques by flat detector computed tomography based dual volume rotational angiography (DVRA) for the evaluation of the anatomical relationship of cavernous sinus dural arteriovenous fistula (CSDAVF) and assessed the possibility of transvenous target segment embolization. METHODS: Twenty-six patients with CSDAVF supplied by multiple feeders underwent DVRA for each feeding large vessel separately. We assessed the anatomical relationship of feeders, fistula points, and venous drainage with three dual volume image fusion techniques. Transvenous embolization was targeted to the segment of fistulous point for preserving those not involved and reducing coil mass effect. RESULTS: Dual vessel multi-planar reconstruction fusion technique could show which segment of the cavernous sinus supplied by feeding arteries. In the dual vessel volume rendering fusion technique, the association between feeding arteries, fistula points, and draining veins of 2 different vessels could be accurately identified in 3 dimensions. In addition, we could visualize the exact anatomical relationship between the components of CSDAVF and skull anatomy with the single vessel fusion technique. Based on various fusion images, target segment embolization was successfully performed in 8 patients. In this group, we achieved complete or near complete occlusion without complications, including cranial nerve palsy. CONCLUSIONS: Detailed anatomical information including accurate fistula point, specific feeding arteries, and draining veins could be obtained with various dual volume image fusion techniques. In addition, the target segment embolization of CSDAVF could be possible with understanding of the precise CSDAVF architectures.

Effectiveness of a Sellar Reconstruction Algorithm in Transsphenoidal Pituitary Surgery: Insights from 490 Cases.

BACKGROUND: Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. METHODS: From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. Four grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: No CSF leakage; cavity filled with absorbable material. Grade 1: Small defect; covered with fat and fascia lata grafts. Grade 2: Large defect; added lumbar drainage. Grade 3: Extended approach; added nasoseptal flap. RESULTS: Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (p=0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, 0% in Grade 3 (p=0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). Average hospital stay was 17.4 days with rhinorrhea, 5.2 without (p=0.024). CONCLUSIONS: Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS.

Spinal Dural Arteriovenous Fistulas in a Patient with Cowden Syndrome and a Phosphatase and Tensin Homolog Mutation.

Cowden syndrome (CS) is an autosomal dominant syndrome characterized by the development of hamartomas and an increased cancer risk. Most CS patients harbor mutations in the phosphatase and tensin homolog (PTEN) gene. We herein report a 70-year-old patient with CS who presented with lower extremity weakness caused by multiple thoracic dural arteriovenous fistulas. Genetic testing revealed a truncated PTEN mutation (c.485_487delACAinsCC and p.D162Afs*5). Vascular malformations are common in CS, particularly in the extremities. However, spinal dural arteriovenous fistulas (AVFs) are extremely rare. Furthermore, in our case, the number of AVFs increased, and both lower limbs became flaccid four months after embolization. Therefore, we suggest that physicians carefully observe the changes in symptoms for prolonged periods after embolization.

[Multiple dural arteriovenous fistulas showing isolated subcortical white matter T2 hyperintensity with gadolinium enhancement].

We describe a 44-year-old man with a complaint of atonic seizures of the left upper limb, followed by generalized seizures. Brain MRI showed isolated juxtacortical white matter T2 hyperintensity with gadolinium (Gd) enhancement of the adjacent cortical gray matter and subcortical white matter in the right frontal convexity. Treatment with levetiracetam was effective for seizure suppression, and he had no other neurological abnormalities. Human leukocyte antigen typing revealed B54 and Cw1, which indicated the possibility of neuro-Sweet disease. However, a general examination, which included vital signs and eye and skin findings, was normal. A cerebrospinal fluid test showed a mild elevation in protein levels without pleocytosis and a normal range of interleukin-6. Electroencephalography showed intermittent slow waves without epileptic discharge in the bilateral temporal lobes. We detected subtle flow voids in the pia mater of the left frontal lobe, which suggested cerebrovascular disease, and specifically, the possibility of dural arteriovenous fistulas. Computed tomography angiography showed abnormally dilated perimedullary veins in the left frontal lobe. Cerebral angiography confirmed the existence of four dural arteriovenous fistulas, which included two retrograde leptomeningeal venous drainages in the right frontal cortical veins supplied by the anterior branch of the right middle meningeal artery. The other dural arteriovenous fistulas were retrograde leptomeningeal venous drainages in the left frontal cortical veins supplied by the anterior and posterior convexity branches of the left middle meningeal artery. The patient underwent successful endovascular embolization of all dural arteriovenous fistulas with Onyx injection. A follow-up MRI showed gradual improvement of the T2 hyperintensity and Gd enhancement. He remained seizure-free for 2 years following endovascular embolization.

Scalp vein sign caused by intracranial dural arteriovenous fistula.

A 68-year-old man presented with a headache that had started 1 month earlier. The scalp vein dilatation was observed at presentation. The findings of computed tomography and magnetic resonance imaging raised suspicion of a dural arteriovenous fistula, leading to the definitive diagnosis by digital subtraction angiography. Scalp vein signs can be a useful clue to suspect intracranial abnormalities, including dural arteriovenous fistula.

Primary Extraskeletal Falcine Myxoid Chondrosarcoma-A Case Report and Review of Literature.

Intracranial chondrosarcomas are rare malignant lesions. Both skull base and dural-based extraosseous chondrosarcomas have been reported to occur intracranially. Dural-based chondrosarcomas arising from the falx cerebri are rare lesions with only 19 cases reported till date. Although conventional, mesenchymal, and myxoid variants of chondrosarcomas have been reported intracranially, myxoid variant are the rarest with only 17 cases reported till date, among which only 2 were falcine. We are reporting the third case of falcine myxoid chondrosarcoma in a 32-year-old man who presented with seizures and subtle lower limb weakness. Radiological findings were suggestive of an atypical meningioma in the falcine region. Macroscopically total resection of the tumor was done. Histopathological examination confirmed myxoid chondrosarcoma, grade 1. Postoperative period was uneventful, and the patient remains asymptomatic 34 months after the surgery without the application of any adjuvant therapy. Falcine myxoid chondrosarcomas are extremely rare lesions with variable aggressiveness as suggested by the three cases reported till now including the present case.

Holocord myelopathy misdiagnosed as neuromyelitis optica spectrum disorder (NMOSD): A unique case of dural arteriovenous fistula at the craniocervical junction along first spinal nerve.

Background: Dural arteriovenous fistulas (DAVFs) at the craniocervical junction (CCJ) involving the first spinal nerve represent a particularly rare and challenging subtype of DAVFs, with holocord myelopathy secondary to cerebrospinal DAVFs being an exceedingly rare presentation. Case Description: We report the case of a 70-year-old woman who presented with progressive paraparesis over 2 weeks. Initial magnetic resonance imaging (MRI) of the spine showed extensive holocord myelopathy, leading to a misdiagnosis of inflammatory myelopathy and subsequent inappropriate steroid treatment at a local hospital, which exacerbated her neurological symptoms. On transfer to our institution and further evaluation with MRI and magnetic resonance angiography, a lower thoracic DAVF was initially suspected. However, comprehensive spinal angiography failed to localize the fistula, prompting cranial angiography, which ultimately identified a DAVF at the CCJ along the C1 nerve root, supplied by a small radiculomeningeal branch of the left vertebral artery. Successful management involved coagulation of the proximal draining vein, with follow-up imaging confirming complete fistula obliteration and resolution of the holocord edema. Conclusion: This case highlights the diagnostic and therapeutic challenges associated with DAVFs at the CCJ, particularly when presenting with holocord myelopathy. It underscores the importance of a high index of suspicion and the need for timely, accurate diagnosis and intervention to prevent permanent spinal cord damage in such rare and complex cases.