Clinical utility of intraoperative direct wave monitoring in patients with pre-operative motor deficits: Case series.

INTRODUCTION AND IMPORTANCE: D-wave (Direct waves) are Motor Evoked Potentials (MEPs) generated by a single transcranial stimulation and captured by attaching an epidural recording electrode caudal to the vulnerable area. Intraoperative neurophysiologic monitoring (IONM) is widely used in neurosurgery to recognize important neurological structures but can be challenging in the pediatric population due to incomplete neural development. CASE PRESENTATION: Case 1: A 48-year-old female presented to the outpatient department with complaints of difficulty walking for the past six months, numbness and weakness in bilateral lower limbs with recurrent falls for the past 1 month. Case 2: A 12-year-old boy presented to the emergency room with a history of inability to use both upper and lower limbs on the right side with tremulousness. CLINICAL DISCUSSION: Magnetic resonance imaging (MRI) Spine in the first case revealed a D9-D10 calcified meningioma with significant spinal cord compression. In the second case, MRI Spine showed C1-C2 Intramedullary Space Occupying Lesion (SOL) and was planned for C1-C2 laminectomy with midline myelotomy. The first case was planned for microsurgical excision of the lesion under IONM guidance. The procedure went smoothly. Microsurgical gross total resection (GTR) of the intramedullary SOL under IONM Guidance was done for the second case. Postoperatively, the first patient showed no neurological compromise or complications. In the second case, following surgery, the child recovered gradually from surgery. CONCLUSION: This case series demonstrates the successful surgical management of two cases of spinal cord tumors through an IONM-guided surgery and the effective use of D waves in such challenging cases.

Stabilizing the unstable: Tuberculosis of the odontoid process with atlanto-occipital instability-Case report and review of literature.

Key Clinical Message: Tuberculosis (TB) of the odontoid process is a rare but potentially, a debilitating condition. Surgical intervention, in the form of stabilizing the spine and decompressing the spinal cord, offers a tailored approach to managing this condition effectively and improving prognosis. Abstract: Odontoid process tuberculosis (TB) is a rare condition that can cause spinal instability and neurological complications. Diagnosis of odontoid process TB is difficult and requires a combination of clinical, radiographic, and histopathological examinations. This report describes the treatment of a 46-year-old female with quadriparesis and intermittent fever. Radiological findings showed TB of the odontoid process with atlanto-axial dislocation causing compressive myelopathy. She underwent C1-C3 decompressive laminectomy and stabilization from C1 to C5. GeneXpert for TB was positive and she was started on anti-tuberculous medications. She regained power gradually and at 1 year follow-up she was ambulant without any support. The C1-C5 lateral mass screw and C1-C3 decompressive laminectomy approach, as highlighted in this case, offers an effective solution, enhancing patient quality of life, and preventing disease progression.

Upper cervical intramedullary schwannoma of the spinal cord presenting with myelopathy: illustrative case.

BACKGROUND: Intramedullary schwannomas account for 1.1% of all spinal schwannomas. Preoperative diagnosis is best accomplished by thoroughly evaluating clinical and radiological characteristics, accompanied by a high index of suspicion. The authors report a case of C2-3 intramedullary schwannoma in a young male who presented with neck pain and vertigo. The current literature is also reviewed. OBSERVATIONS: The authors reviewed the data of a young male with a 2-month history of neck pain and vertigo. Magnetic resonance imaging of the brain and cervical spine showed an intramedullary mass at C2-3 with a syrinx extending into the cervicomedullary junction. Laminectomy, myelotomy, and microsurgical excision of the mass under intraoperative neurological monitoring (IONM) were done. Postoperative pathology reported the specimen as a schwannoma. LESSONS: Gross-total resection of a schwannoma using IONM is the treatment of choice because of the lesion's benign nature, a better prognosis, and defined cleavage plane. Schwannomas should be included in the differential diagnosis of intramedullary spinal tumors. Because of its progressive nature, early surgery is recommended in symptomatic patients.

Non-osseous intradural tuberculoma of the thoracic spine with compressive myelopathy.

Key Clinical Message: An uncommon form of CNS tuberculosis called non-osseous IDEM tuberculoma frequently results from paradoxical drug interactions. It should be considered one of the differentials when patients receiving ATT experience acute neurological impairment. Abstract: Tuberculoma affecting the spinal cord is a rare condition in modern times. The occurrence of non-osseous intradural tuberculosis, specifically in the spine, is even more exceptional. In fact, it is uncommon to encounter an intradural extramedullary tuberculous granuloma that lacks radiological indications of vertebral involvement, especially within the thoracic region. We present a case of a patient with a neurological deficit caused by a non-osseous intradural tuberculoma in the thoracic region, without any associated bone involvement. The patient experienced a gradual deterioration of neurological function. An MRI of the thoracic spine revealed the presence of a tuberculoma located intradurally, extramedullary, and juxtamedullary of the T5 vertebra. The compression of the spinal cord resulted in paraparesis which was worsening to paraplegia. A D4-D6 laminectomy and microsurgical excision were performed under intraoperative neurophysiological monitoring (IONM), and the patient showed clinical recovery. Excellent clinical outcomes were achieved. However, it is crucial to consider the possibility of a non-osseous intradural tuberculoma as a rare condition when encountering a SOL, particularly in patients with a history of tuberculosis and spinal cord compression. In cases where a progressing neurological deficit is present, a combination of surgical intervention and anti-tuberculous treatment should be considered as the optimal approach.

Granular cell tumor of the brain: case report and review of literature.

Granular cell tumors are rare tumors that develop from Schwann cells, which are glial cells surrounding neurons of the peripheral nervous system, which serve in the process of myelination. Granular cell tumors are rarely associated with the central nervous system in humans. In this report, we analyze a patient with granular cell tumor and review the current literature.

A rare case of intra-parenchymal meningioma in a female patient who presented with seizures: A case report.

Key Clinical Message: Meningiomas are slow-growing tumors that develop from the arachnoid cap cells' meningothelial cells. Males are more likely to develop intra-parenchymal meningiomas, which also manifest earlier than ordinary meningiomas and are uncommon. Abstract: Meningiomas are slow-growing neoplasms which arise from the meningothelial cells of the arachnoid cap cells. Unlike other meningiomas, intra-parenchymal meningiomas do not originate from dura. Intra-parenchymal meningiomas are more common in males and develop earlier than regular meningiomas. Because of the rare occurrence the intra-parenchymal meningiomas, they are commonly misdiagnosed.

Current Updates on Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is one of the neurodegenerative diseases which can be treated surgically with favorable outcome. The gait disturbance, cognitive, and urinary symptoms are known as the clinical triad of iNPH. In this review, we have addressed the comorbidities, differential diagnoses, clinical presentations, and pathology of iNPH. We have also summarized the imaging studies and clinical procedures used for the diagnosis of iNPH. The treatment modality, outcomes, and prognosis were also discussed.

Direct Cerebral Revascularization: Extracranial-intracranial Bypass.

In 1967, the first extracranial to intracranial (EC-IC) arterial anastomosis was performed. Since that time, EC-IC bypass surgery has become a widely accepted surgical treatment for patients with IC stenotic or occlusive atherosclerotic lesions. This article will discuss the history, indications, types, surgical methods, and complications of the EC-IC bypass.

Does Age Affects the Surgical Outcome in Patients with Unruptured Cerebral Aneurysms? A 2-Year Retrospective Study from a Single Center in Japan.

BACKGROUND: The management of unruptured cerebral aneurysms (UCA) in elderly population is a challenge. With a very high life expectancy and high risk of rupture in Japan, the need for identifying the best treatment modality is essential to help the patients in decision-making. METHODS: This was a 2-year single-center retrospective comparative analysis of the outcomes of surgical clipping (SC) in patients aged above 75 and <75 years. The modified Rankin score was used to stratify the patients and to analyze the functional outcome. Functional status at discharge was the primary end point. RESULTS: There were 224 patients with 239 aneurysms. About 12.5% of the patients were more than 75 years with a mean age of 77.85. The mean age of patients <75 years was 60.96, and it was statistically significant. The overall male-to-female ratio was 1:3.3. The most common location was the middle cerebral artery followed by internal carotid artery at the posterior communicating and ophthalmic segments, and 22 patients had aneurysms of the posterior circulation. Nearly 77% of the aneurysms were <6 mm. There was no significant difference in size of the aneurysm as the age increased to more than 75 years. There were complications in 6 patients, and there was no mortality in the study population. There was no statistically significant difference in the outcome between the groups. CONCLUSIONS: SC can be considered a safe option for UCA in the aging population.

Posttraumatic Cavernous Segment Internal Carotid Artery Aneurysmal Rupture Presenting as Tentorial Subdural Hematoma.

Traumatic aneurysm rupture following a closed head injury is rare. The rupture of a cavernous internal carotid artery (ICA) aneurysm following a head injury presenting as a tentorial subdural hematoma has not been reported in the literature. We discuss a 50-year-old woman with a closed head injury with her initial computed tomography scan showing a tentorial subdural hematoma. Further investigations revealed the presence of a ruptured cavernous ICA aneurysm. We also conducted a literature review of posttraumatic ICA aneurysmal rupture.