Extraneural recurrence of an intracranial nongerminomatous germ cell tumor to cervical lymph nodes in a pediatric patient: Case report.

BACKGROUND: Intracranial germ cell tumors (GCTs) comprise 3%-5% of pediatric primary central nervous system (CNS) tumors in Western countries. Though they are related in embryonic origin to gonadal GCTs, which are considered highly treatable with cisplatin-based chemotherapy regimens, intracranial GCTs vary in malignant potential and sensitivity to radiation and chemotherapy, generally carrying a worse prognosis. Metastases of intracranial GCTs outside of the CNS are rare, indicate a poor prognosis, and their salvage treatment is not well established. CASE: A 15-year-old boy presented with bifocal (suprasellar and pineal) intracranial nongerminomatous germ cell tumors of mixed origin. The tumors were treated to full response with a multimodal approach of neoadjuvant chemotherapy, surgical resection, and adjuvant craniospinal proton radiation. Nine months following treatment completion, the patient presented with an enlarged cervical lymph node determined on excisional biopsy to be a recurrence of pure germinoma from the primary tumors. Salvage treatment involved high-dose chemotherapy and autologous stem cell transplantation; however, the patient denied further treatment prior to planned focal radiotherapy. Thirty months post-treatment, the patient is well with no evidence of recurrence. CONCLUSION: This case demonstrated the successful salvage treatment of an extraneural recurrence of an intracranial GCT using surgical resection and a high-dose chemotherapy and autologous stem-cell transplantation regimen, highlighting the unique factors which led to the selection of this regimen.

Infected subgaleal hematoma in a 4-month-old girl.

Subgaleal hematoma is an uncommon, but potential sequela of birth trauma and instrument-assisted delivery of neonates, as well as head trauma in young children. A rare complication is an infection of the subgaleal hematoma, which typically happens due to concomitant scalp lacerations. Escherichia coli is the most common causative pathogen in peripartum cases, and Staphylococcus aureus predominates in trauma cases. An even more rare complication is infection of the hematoma with intact overlying skin, the proposed mechanism of action of which is a hematogenous spread of the bacteria. In this case, we report a 4-month-old unimmunized girl who sustained a subgaleal hematoma after a falling incident that did not result in any scalp laceration. She presented 5 days later with fever, irritability, increased scalp swelling, skin erythema, and site tenderness. Her blood culture remained sterile, but the hematoma aspirate culture grew Streptococcus pneumoniae. The patient had a recent upper respiratory tract infection that we suspected to be the primary source of infection. She responded well to antibiotic therapy and required no surgical intervention. Conclusion: Subgaleal hematoma infection should be suspected in a child who presents with increased hematoma swelling, irritability, fever, and local signs of infection. Early recognition and treatment with antibiotics can prevent further complications, such as abscess formation and skull osteomyelitis.

Gigli saw facilitates safe minimal access sagittal suturectomy in infants.

The authors describe the use of the Gigli saw for craniectomy in minimal access surgery to address sagittal craniosynostosis. This modification allows for supine positioning and avoidance of potential brain compression with endoscopic instruments, and provides visually clear, safe, and facile removal of the fused suture and surrounding calvaria. The video can be found here: https://vimeo.com/511568750.

Intraneural nodular fasciitis of the radial nerve with rapidly progressive motor symptoms.

BACKGROUND: Nodular fasciitis is a benign mesenchymal tumor arising from fascia that typically presents as a rapidly growing, subcutaneous mass. Intraneural cases are very rare and can present with neurological symptoms, requiring surgical resection. CASE DESCRIPTION: A 31-year-old woman presented to us with painful paresthesias in her elbow and progressive motor deficits, for which she underwent surgery. CONCLUSION: The authors report the first case of intraneural nodular fasciitis occurring in the radial nerve and highlight the possibility of rapidly progressive motor deficit in patients presenting with this rare clinical entity.

Establishing a surgical skills laboratory and dissection curriculum for neurosurgical residency training.

Surgical education has been forced to evolve from the principles of its initial inception, in part due to external pressures brought about through changes in modern health care. Despite these pressures that can limit the surgical training experience, training programs are being held to higher standards of education to demonstrate and document trainee competency through core competencies and milestones. One of the methods used to augment the surgical training experience and to demonstrate trainee proficiency in technical skills is through a surgical skills laboratory. The authors have established a surgical skills laboratory by acquiring equipment and funding from nondepartmental resources, through institutional and private educational grants, along with product donations from industry. A separate educational curriculum for junior- and senior-level residents was devised and incorporated into the neurosurgical residency curriculum. The initial dissection curriculum focused on cranial approaches, with spine and peripheral nerve approaches added in subsequent years. The dissections were scheduled to maximize the use of cadaveric specimens, experimenting with techniques to best preserve the tissue for repeated uses. A survey of residents who participated in at least 1 year of the curriculum indicated that participation in the surgical skills laboratory translated into improved understanding of anatomical relationships and the development of technical skills that can be applied in the operating room. In addition to supplementing the technical training of surgical residents, a surgical skills laboratory with a dissection curriculum may be able to help provide uniformity of education across different neurosurgical training programs, as well as provide a tool to assess the progression of skills in surgical trainees.

Compressive Cervicothoracic Adhesive Arachnoiditis following Aneurysmal Subarachnoid Hemorrhage: A Case Report and Literature Review.

We present the case of a 55-year-old woman with diffuse adhesive arachnoiditis in the posterior fossa and cervicothoracic spine following posterior inferior cerebellar artery aneurysmal subarachnoid hemorrhage (SAH). She underwent aneurysm clipping with subsequent gradual neurologic decline associated with sensory disturbances, gait ataxia, and spastic paraparesis. Magnetic resonance imaging revealed diffuse adhesive arachnoiditis in the posterior fossa and cervicothoracic spine, syringobulbia, and multiple arachnoid cysts in the cervicothoracic spine along with syringohydromyelia. Early surgical intervention with microlysis of the adhesions and duraplasty at the clinically relevant levels resulted in clinical improvement. Although adhesive arachnoiditis, secondary arachnoid cysts, and cerebrospinal fluid flow abnormalities resulting in syrinx are rare following aneurysmal SAH, early recognition and appropriate intervention lead to good clinical outcomes.

MRI-guided laser interstitial thermal therapy in neuro-oncology: a review of its current clinical applications.

Magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) is a minimally invasive treatment modality with recent increasing use to ablate brain tumors. When originally introduced in the late 1980s, the inability to precisely monitor and control the thermal ablation limited the adoption of LITT in neuro-oncology. Popularized as a means of destroying malignant hepatic and renal metastatic lesions percutaneously, its selective thermal tumor destruction and preservation of adjacent normal tissues have since been optimized for use in neuro-oncology. The progress made in real-time thermal imaging with MRI, laser probe design, and computer algorithms predictive of tissue kill has led to the resurgence of interest in LITT as a means to ablate brain tumors. Current LITT systems offer a surgical option for some inoperable brain tumors. We discuss the origins, principles, current indications, and future directions of MRI-guided LITT in neuro-oncology.

Hurthle cell carcinoma presenting as a single choroid plexus metastasis.

Choroid plexus masses represent approximately 0.3-0.8% of intracranial tumors. Herein we present, to our knowledge, the first reported patient with an isolated Hurthle cell papillary thyroid carcinoma metastasis to the choroid plexus of the lateral ventricle. Unresponsive to iodine ablation and refusing surgery, the patient underwent Gamma Knife radiosurgery (Elekta AB, Stockholm, Sweden), receiving 15Gy to the 50% isodose line. The lesion regressed until 5years later at which time it was unresponsive to 18Gy and required surgical resection. Although extraneural metastatic cancers are recognized as potential sources for the single choroid plexus mass, we must consider even the unusual culprit in patients with a history of cancer.

Lumbar disc herniations 'to operate or not' patient selection and timing of surgery.

At times lumbar disc herniations present a quandary to the spine surgeon in regards to the most appropriate intervention and a need to optimize medical and surgical therapies. We discuss a case of ours and our experience in treating this common spinal pathology, along with a commentary on the article published by Kim et al. entitled 'Spontaneous regression of extruded lumbar disc herniation: three cases report in Korean J Spine. 2013 Jun;10(2):78-81.'

Use of high-field intraoperative magnetic resonance imaging to enhance the extent of resection of enhancing and nonenhancing gliomas.

BACKGROUND: Intraoperative magnetic resonance imaging (IoMRI) is used to improve the extent of resection of brain tumors. Most previous studies evaluating the utility of IoMRI have focused on enhancing tumors. OBJECTIVE: To report our experience with the use of high-field IoMRI (1.5 T) for both enhancing and nonenhancing gliomas. METHODS: An institutional review board-approved retrospective review was performed of 102 consecutive glioma patients (104 surgeries, 2010-2012). Pre-, intra-, and postoperative tumor volumes were assessed. Analysis was performed with the use of volumetric T2 images in 43 nonenhancing and 13 minimally enhancing tumors and with postcontrast volumetric magnetization-prepared rapid gradient-echo images in 48 enhancing tumors. RESULTS: In 58 cases, preoperative imaging showed tumors likely to be amenable to complete resection. Intraoperative electrocorticography was performed in 32 surgeries, and 14 cases resulted in intended subtotal resection of tumors due to involvement of deep functional structures. No further resection (complete resection before IoMRI) was required in 25 surgeries, and IoMRI showed residual tumor in 79 patients. Of these, 25 surgeries did not proceed to further resection (9 due to electrocorticography findings, 14 due to tumor in deep functional areas, and 2 due to surgeon choice). Additional resection that was performed in 54 patients resulted in a final median residual tumor volume of 0.21 mL (0.6%). In 79 patients amenable to complete resection, the intraoperative median residual tumor volume for the T2 group was higher than for the magnetization-prepared rapid gradient-echo group (1.088 mL vs 0.437 mL; P = .049), whereas the postoperative median residual tumor volume was not statistically significantly different between groups. CONCLUSION: IoMRI enhances the extent of resection, particularly for nonenhancing gliomas.