Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature.

BACKGROUND: Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD: We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS: Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION: Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Traumatic atlantoaxial rotatory fixation in adults: a systematic review of published cases.

Atlantoaxial rotatory fixation (AARF) in adults is a rare and clinically challenging condition characterized by a spectrum of etiological factors, predominantly attributed to traumatic and inflammatory pathologies within the craniovertebral region. Trauma is the most frequently identified cause within the adult population, with the first case report published in 1907. This study aims to conduct a systematic review that addresses the clinical presentations and management strategies relating to traumatic atlantoaxial rotatory fixation in adults. A comprehensive search of the PubMed database was executed, adhering to the PRISMA guidelines. The inclusion criteria encompassed case reports and series documenting AARF cases in individuals aged 18 and above, spanning database inception to July 2022. Studies not published in the English language were excluded. A total of 61 articles reporting cases of AARF in the adult population were included in the study. The mean age of affected individuals was 36.1 years (± 15.6), with a distribution of 46% females and 54% males. Predominant mechanisms of injury included motor vehicle accidents and falls, constituting 38% and 22% of cases, respectively. Among the classification systems employed, Fielding and Hawkins type I accounted for the majority at 63%, followed by type II at 10%, and type III at 4%. Conservative management was used for treatment in 65% of acute (65%) cases and 29% of chronic cases. Traumatic AARF is a rare phenomenon in the adult population, is more common in younger adults, and does not often present with neurologic deficits. Patients diagnosed acutely are more likely to be successfully treated with conservative management, while patients diagnosed chronically are less likely to be reduced with conservatively and often require surgical treatment. Surgery should be considered for patients with irreducible dislocations, ligamentous injuries, unstable associated fractures, and persistent pain resistant to conservative management.

Clinical Outcome of Pedicle-Sparing Transfacet Diskectomy and Fusion with Segmental Instrumentation for Thoracic Disc Herniation.

BACKGROUND: Thoracic disk herniations (TDHs) are relatively rare compared with their cervical and lumbar counterparts. Posterior approaches allow for a simpler and less invasive surgery than anterior and lateral approaches. A pedicle-sparing transfacet approach was initially described in 1995, and modified in 2010. A few clinical series have reported the outcome of this procedure in patients with TDH. This study aimed to evaluate the outcomes and complications of pedicle-sparing transfacet diskectomy with interbody fusion and segmental instrumentation in patients with TDH. METHODS: Twenty-one consecutive patients with symptomatic TDH referred to our tertiary care center were included in this retrospective study. All patients underwent a pedicle-sparing transfacet diskectomy with polyetheretherketone (PEEK) cage interbody fusion and short segmental instrumentation. Distribution of TDH, operative duration, blood loss, Visual Analog Scale (VAS) pain scores, Nurick grades, modified Japanese Orthopaedic Association (mJOA) scores, and fusion rate were assessed. RESULTS: All patients had single-level herniations. The most common location was T12-L1 (38.1%), followed by T11-T12 (33.3%). All patients were successfully operated on with no cerebrospinal fluid (CSF) leaks or wrong-level surgery. The VAS scores significantly diminished from 4.9 (preoperatively) to 2 (18 months after surgery). The average mJOA score increased from 4.6 to 8.5, and the average Nurick grade decreased from 3.1 to 1.6. All patients reported significant improvement in quality of life relative to their preoperative status. CONCLUSION: A modified pedicle-sparing transfacet diskectomy combined with PEEK cage interbody fusion and segmental instrumentation offers a safe and less invasive approach for the treatment of TDHs.

Challenges in identifying ruptured aneurysms in cases of multiple aneurysms: Utilizing MRI with contrast for surgical planning-A case report.

Key Clinical Message: Accurately identifying the ruptured aneurysm in patients with subarachnoid hemorrhage and multiple aneurysms is critical to prevent rebleeding and optimize outcomes. Vessel wall MRI with contrast can aid in pinpointing the culprit aneurysm, informing a tailored surgical or endovascular management strategy for these complex cases. In patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms, MRI with contrast and DSA are crucial for identifying the ruptured aneurysm, guiding a shift from endovascular to microsurgical clipping. Successful single-session treatment and absence of postsurgical deficits highlight the effectiveness of a multidisciplinary approach. Further research on optimal strategies is needed. Abstract: Multiple intracranial aneurysms make up approximately 20% of cases of aneurysmal SAH. In patients with aneurysmal SAH and multiple intracranial aneurysms, definite treatment of the ruptured aneurysm causing SAH is of the highest priority. However, identifying the bleeding source can be challenging, and it may not be recognizable by the hemorrhage pattern. Misdiagnosis and mistreatment of a ruptured aneurysm in a patient with multiple aneurysms can lead to bleeding recurrence and an undesirable outcome. We report a 65-year-old woman who presented with severe sudden onset headache. Neuroimaging studies revealed diffuse SAH and concurrent PICA and ACom aneurysm with triplicate A2. However, the ruptured aneurysm responsible for the patient's symptoms was not obvious based on routine neuroimaging studies. Magnetic resonance imaging with contrast was performed, revealing circumferential enhancement of the PICA aneurysm. In this report, we demonstrate the real-world effect of vessel wall MRI with contrast on decision-making regarding identifying the ruptured aneurysm and surgical planning in cases of multiple aneurysms. Furthermore, we show that MRI and aneurysm wall enhancement could be a promising option in detecting ruptured aneurysms in cases of multiple aneurysms.

Surgical Management of Adult Traumatic Atlantoaxial Rotatory Fixation with Hangman Fracture: Case Report and Literature Review.

Atlantoaxial rotatory fixation (AARF) is a rare type of adult cervical spine injury. The classic symptoms are painful torticollis and limited neck range of motion. To avoid catastrophic consequences, early diagnosis is necessary. The present study presents the successful treatment of a scarce case of adult AARF with a Hangman fracture and a comprehensive literature review. A 25-year-old man presented to the trauma bay with left-sided torticollis after a motor vehicle accident. Cervical computed tomography scans revealed type I AARF. Torticollis resolved after cervical traction with partial reduction, and posterior C1-C2 fusion was performed as part of the therapy. Recognition of AARF after trauma requires a high index of suspicion, and early diagnosis is critical for the achievement of the best possible patient outcomes. Since the combination of a Hangman fracture and C1-C2 rotatory fixation is complex and unique, it must be tailored to the associated injuries.

Effects of dry needling on muscle spasticity of the upper limb in a survivor of traumatic brain injury: a case report.

BACKGROUND: Survivors of moderate and severe traumatic brain injury typically present with spasticity, an upper motor neuron lesion associated with hyperexcitability of the stretch reflex due to disinhibition of cortical influences on spinal cord circuits and structural and functional changes in skeletal muscle. There is growing evidence supporting the effectiveness of dry needling in abating spasticity. CASE PRESENTATION: The present case aims to quantify the effects of dry needling on upper limb spastic muscles in a survivor of severe traumatic brain injury in a 27-year-old Iranian man. The treated muscles were biceps brachii, brachialis, flexor digitorum superficialis and profundus, flexor carpi radialis, flexor carpi ulnaris, opponens pollicis, and adductor pollicis. Outcome measures were evaluated before and 1 hour after the intervention. Our results showed that the patient's upper limb recovery stage and hand function improved one grade according to Brunnstrom recovery stages. Spasticity assessed using the Modified Modified Ashworth Scale in all movements showed one-grade abatement, except in the forearm pronator. Passive resistance force decreased in all movements except in forearm supination. Active range of motion and passive range of motion increased in all movements except in active and passive forearm supination. Hand dexterity improved in both affected and unaffected hands. CONCLUSIONS: Results shown that dry needling could be a favorable option for reducing spasticity.

Traumatic Cervical Vertical Translational Injury: A Case Report.

Traumatic cervical translational injury is a notably rare and highly unstable subtype of type C sub-axial cervical spine injury with high morbidity and mortality rates. Hereby, we report a 41-years-old man who was a case of multiple trauma due to car rollover. He was completely conscious, complaining of cervical pain, with a GCS score of 15/15. His neurological examination was unremarkable. The cervical CT scan revealed a vertical translation at the C6-C7 level (roughly 11 mm) and bilateral facet joint diastases which are highly unstable injuries. A two-stage combined anterior and posterior fixation operation was performed. First, an anterior cervical discectomy and fusion with autologous graft and plate fixation, and then a posterior approach with lateral mass screw fixation was performed. Disruption of the anterior longitudinal ligament, annulus fibrosis, facet capsules, and severe strain of ligamentum flavum was noted intraoperatively. He had no early and late complications within 2 years of follow-up.

Intracranial Rhabdomyosarcoma of the Cerebellopontine Angle in a 6-year-old Child: A Case Report.

Rhabdomyosarcoma (RMS) is the most common soft-tissue malignancy in children under 15 years of age. Approximately, 35% of RMS cases originate from the head and neck region. Among various sites in the head and neck region, intracranial extension is more likely to occur with parameningeal tumors, which is also considered an unfavorable prognostic factor in children with RMS. About 20% of RMS occurs in a parameningeal site. Intracranial RMS are rare tumors that usually arise from parameningeal sites or metastasis from an extracranial site. Primary intracranial types are even rarer, with only 50 reported cases of primary intracranial RMS in the literature. Hereby, we report the case of a 6-year-old boy who presented with clinical and radiologic features of a cerebellopontine angle lesion, which turned out to be a RMS.

Acute Subdural Hemorrhage of a Convexity Meningioma in the Postpartum Period; Case Report and Literature Review.

New onset seizures in pregnancy or the postpartum period can be of great importance and denote various underlying pathologies. Eclampsia and cerebrovascular accidents are common, and brain tumors are uncommon causes of postpartum seizures among others. Acute presentation of brain tumors in pregnancy or the postpartum period is extremely rare. Meningiomas are the most common benign intracranial tumors. Although 1.3 to 2.4% of these benign tumors may bleed, acute presentation of them with hemorrhage is quite rare. Herein, we report a rare case of a 36-year-old lady who presented with severe headache, seizure, and loss of consciousness in the postpartum period, five days after delivery of a full-term baby. Primary emergency evaluation revealed an extra-axial lesion with subdural hemorrhage. A Decompressive craniectomy was performed, hematoma was evacuated, and the tumor was totally resected. Histopathologic evaluation was consistent with a fibroblastic meningioma (WHO grade I). She was discharged in good general condition. Our case highlights the significance of complete evaluation of patients with new-onset seizures in pregnancy or the postpartum period. Although uncommon, brain tumors in pregnancy can have potentially devastating outcomes which may necessitate prompt surgical intervention.