Management of shunt dysfunction using noninvasive intracranial pressure waveform monitoring: illustrative case.

BACKGROUND: Normal pressure hydrocephalus (NPH) treatment consists of using valves for drainage, as it is for hydrocephalus in general. Despite this, complications can occur, putting the patient at risk, and neurological monitoring is crucial. OBSERVATIONS: A 61-year-old male, who had been diagnosed with NPH 3 years prior and was being treated with a ventriculoperitoneal shunt with a programmable valve, presented to the emergency department because of a traumatic brain injury due to a fall from standing height. No previous complications were reported. He had an altered intracranial pressure (ICP) waveform in the emergency room when monitored with the brain4care device, with a P2/P1 ratio of 1.6. Imaging helped to confirm shunt dysfunction. Revision surgery normalized the ratio to 1.0, and the patient was discharged. Upon return after 14 days, an outpatient analysis revealed a ratio of 0.6, indicating improvement. LESSONS: In selected cases of NPH, noninvasive ICP waveform morphology analysis can be effective as a diagnostic aid, as well as in the pre- and postsurgical follow-up, given the possibility of comparing the values of ICP preoperatively and immediately postoperatively and the outpatient P2/P1 ratio, helping to manage these patients.

Clipping of Bilateral Ophthalmic Artery Aneurysms Through a Single Craniotomy.

Bilateral ophthalmic aneurysms are rare and involve two aneurysms in the ophthalmic arteries, one on each, leading to potential symptoms such as vision loss and headaches. The treatment options for aneurysms, ranging from surgery and endovascular embolization to observation, depend on various factors, including aneurysm size and the patient's health. Microsurgery, while presenting complexities due to the intricate anatomy of the anterior clinoid region, offers potential advantages such as enhanced decompression rates and reduced aneurysm recurrence. The presented surgical video illustrates the treatment of bilateral ophthalmic artery aneurysms via a single craniotomy. This method reduces surgical duration and trauma, facilitating quicker patient recovery. However, this method bears potential risks, especially to both optic nerves. As underscored in the video, the utmost anatomical understanding in the anterior clinoid area is pivotal for successful outcomes and reduced complications.

Current State of Brazilian Neurosurgery: Evaluation of Burden of Care and Case Volume.

BACKGROUND: Low- and middle-income countries (LMICs) bear a heavier burden of neurosurgical diseases than high-income countries. Brazil, a growing middle-income country, holds promise as a health care market. However, there exists a lack of information to characterize the state of neurosurgical practice and access to care in Brazil. This study aimed to characterize neurosurgical practice in Brazil and identify barriers to care. METHODS: A collaborative survey was developed with Brazilian neurosurgeons and distributed by the Brazilian Society of Neurosurgery. The survey gathered demographic information, practice characteristics, case volume, referral patterns, income sources, and assessed barriers using a Likert scale. Descriptive statistics were employed for data analysis. RESULTS: One-hundred and forty-nine neurosurgeons participated (response rate: 17.5%), representing various states in Brazil. Neurosurgeons practiced in more than 4 different hospital systems on average, with most consultations and procedures occurring in public hospitals. Common procedures included tumor surgeries, general neurosurgery, spine surgeries, trauma surgeries, and hydrocephalus management. Equipment shortage and systemic issues were identified as major barriers to care. CONCLUSIONS: Neurosurgical practice in Brazil exhibits diverse age distribution, widespread distribution across states, and involvement in both public and private hospitals. Survey insights shed light on neurosurgical workload and neurosurgical practice characterization. Lack of equipment and inadequate postoperative resources pose significant barriers to care. The findings highlight the need for investments in equipment, critical care facilities, and improved health care system coordination to enhance access to neurosurgical care in Brazil.

Spinal Adhesive Arachnoiditis: A Literature Review.

Adhesive arachnoiditis (AA) is a rare inflammatory and scar-forming disease with several etiologies that may lead to incapacitating sequelae if not managed early. Nevertheless, as the onset of symptoms varies from days to years, the etiology is not often discovered. The disease is characterized by adhesions disrupting the cerebrospinal fluid flow and causing encapsulation and atrophy of the nerve root. Therefore, a range of clinical features may be present, including urinary, gastroenterology, dermatologic, and neurologic. In terms of diagnosis, magnetic resonance imaging is the gold standard showing pseudocysts with adherent and narrow nerve roots toward the center of the dural sac or peripherally cluster and narrow nerve roots with empty thecal sac. Despite its sensitivity and specificity, the imaging findings are not often associated with clinical manifestations, requiring treatment being based on anamneses and clinical findings. Nowadays, AA can be managed with pharmacological and non-pharmacological treatment, although none provides a completely satisfying result.

Decompressive Hemicraniectomies as a Damage Control Approach for Multilobar Firearm Projectile Injuries: A Single-Center Experience.

BACKGROUND: While firearms projectile injuries to the head carry a high rate of morbidity and mortality, current literature in clinical management remains controversial. Decompressive hemicraniectomy (DHC) has been previously described in the neurosurgical literature for traumatic brain injuries, with positive results in the reduction of mortality. Here we aim to assess DHC as a damage control approach for multilobar firearm injuries to the head and compare our results with what is present in the literature. METHODS: A retrospective review of patients who sustained multilobar firearm injuries to the head admitted to our center from January 2009 to April 2021 was performed. Exclusion criteria were a Glasgow Coma Scale (GCS) score <5, and/or brain stem dysfunction that persisted despite stabilization and medical therapy for intracranial hypertension. RESULTS: A total of 20 patients were analyzed, with an average GCS on admission of 8.35. The 60-day mortality rate for all 20 patients was 20% with a total of 4 deaths, 1 of which was due to pulmonary sepsis in the critical postoperative care unit. The mean hospital stay of surviving patients was 22 days. CONCLUSIONS: DHC should be considered as a damage control strategy for young patients with multilobar firearm injuries and GCS >5, having yielded favorable results in this study when compared to current literature.

Minimally invasive craniotomies for lesions of the anterior and middle fossa.

Minimally invasive craniotomies are the subject of increasing attention over the last two decades in neurosurgery, following the current trend of attempting to increase patient safety by providing surgeries with less tissue disruption, blood loss, and decreased operative time. However, a significant information overlap exists among the various keyhole approaches regarding their indications and differences with more invasive techniques. Therefore, the present study aims to comprehensively review, illustrate, and describe the potential benefits and disadvantages of minimally invasive techniques to access the anterior and middle fossa, including the mini-pterional, mini orbito-zygomatic, supraorbital, lateral supraorbital, and extended lateral supraorbital approaches while comparing them to classic, more invasive approaches.

A Giant Internal Carotid Bifurcation Aneurysm as a Rare and Dangerous Differential Diagnosis of a Craniopharyngioma.

Craniopharyngiomas are supra/parasellar lesions that often present with general, unspecific symptoms. Similarly, internal carotid artery (ICA) bifurcation giant aneurysms may also produce calcified, heterogeneous, parasellar expansive lesions, posing a relevant differential diagnosis due to their inherently different surgical strategies and risks. We report the case of a 54-year-old female presenting with progressive disorientation and apathetic behavior. CT and MRI reports described a suprasellar heterogenous mass with calcifications associated with an adjacent, laterally located fluid collection suggestive of a craniopharyngioma. During the surgical procedure, perfuse and unexplained arterial bleeding ensued, prompting the surgical team to review a previous contrast-enhanced CT scan. Careful inspection revealed an image suggestive of vascular pathology, with an area of continuous hyperdensity along the right ICA bifurcation. The Sylvian fissure was dissected, and an aneurysmal neck was encountered and successfully clipped. Giant intracranial aneurysms are rare but essential differential diagnoses to be considered during the workup and surgical approach toward parasellar mass lesions. This case illustrates the importance of performing a CT angiogram (CTA) for skull base lesions, even when the size is more suggestive of tumor pathology.

E.L., a modern-day Phineas Gage: Revisiting frontal lobe injury.

Background: How the prefrontal cortex (PFC) recovers its functionality following lesions remains a conundrum. Recent work has uncovered the importance of transient low-frequency oscillatory activity (LFO; < 4 Hz) for the recovery of an injured brain. We aimed to determine whether persistent cortical oscillatory dynamics contribute to brain capability to support 'normal life' following injury. Methods: In this 9-year prospective longitudinal study (08/2012-2021), we collected data from the patient E.L., a modern-day Phineas Gage, who suffered from lesions, impacting 11% of his total brain mass, to his right PFC and supplementary motor area after his skull was transfixed by an iron rod. A systematic evaluation of clinical, electrophysiologic, brain imaging, neuropsychological and behavioural testing were used to clarify the clinical significance of relationship between LFO discharge and executive dysfunctions and compare E.L.´s disorders to that attributed to Gage (1848), a landmark in the history of neurology and neuroscience. Findings: Selective recruitment of the non-injured left hemisphere during execution of unimanual right-hand movements resulted in the emergence of robust LFO, an EEG-detected marker for disconnection of brain areas, in the damaged right hemisphere. In contrast, recruitment of the damaged right hemisphere during contralateral hand movement, resulted in the co-activation of the left hemisphere and decreased right hemisphere LFO to levels of controls enabling performance, suggesting a target for neuromodulation. Similarly, transcranial magnetic stimulation (TMS), used to create a temporary virtual-lesion over E.L.'s healthy hemisphere, disrupted the modulation of contralateral LFO, disturbing behaviour and impairing executive function tasks. In contrast to Gage, reasoning, planning, working memory, social, sexual and family behaviours eluded clinical inspection by decreasing LFO in the delta frequency range during motor and executive functioning. Interpretation: Our study suggests that modulation of LFO dynamics is an important mechanism by which PFC accommodates neurological injuries, supporting the reports of Gage´s recovery, and represents an attractive target for therapeutic interventions. Funding: Fundação de Amparo Pesquisa Rio de Janeiro (FAPERJ), Universidade Federal do Rio de Janeiro (intramural), and Fiocruz/Ministery of Health (INOVA Fiocruz).

Undiagnosed Sturge-Weber Syndrome as a Differential Diagnosis of Seizures and Deep Cerebral Venous System Dilation: A Case Report.

Sturge-Weber syndrome (SWS) is a capillary-venous malformation affecting the brain, the eye, and the adjacent trigeminal dermatomes of the skin. This illness is usually diagnosed during the first years of life. If left undiagnosed (and consequently untreated), the condition could develop into severe refractory seizures, ischemic strokes, visual loss, and early cognitive impairment. We report a case of a 23-year-old female patient with a port-wine facial stain, presenting her first convulsive episode in adulthood, associated with a moderate dilation of the deep venous system in the angiography, which raised the diagnostic of Sturge-Weber syndrome.

Hemorrhage due to attempted excision of a frontal exophytic lesion: A cautionary tale.

BACKGROUND: Despite mainly benign, exophytic subcutaneous cranial masses present with a myriad of differential diagnosis possibilities, ranging from simple, superficial lesions to complex lesions involving the central nervous system. Although the gold standard imaging modality for the diagnosis of these lesions is magnetic resonance imaging, Doppler Ultrasonography can be a useful, inexpensive, and available tool for evaluation of lesions that could potentially be safely treated in the primary care setting, and lesions that would demand advanced neurosurgical care. CASE DESCRIPTION: This patient presented with a complex exophytic plasmocytoma that was first diagnosed and erroneously approached as a subcutaneous lipoma with surgical resection in an outpatient surgical setting. This interpretive approach resulted in the failure of the procedure due to significant hemorrhage. The patient was immediately referred to neurosurgical care and transferred to our center. Admission doppler ultrasound imaging revealed absence of the frontal bone, the enriched and profuse vascularization, allowing further and proper diagnostic approach and treatment. CONCLUSION: Ultrasound could be a reliable, fast, and simple imaging method aiding practitioners to perform a better workup for patients with exophytic subcutaneous cranial masses.

Transcallosal-Transchoroidal Approach for a Symptomatic Third Ventricular Cavernous Malformation in a Pediatric Patient: Surgical Video.

Cavernous malformations of the third ventricle are rare, deep-seated lesions that pose a formidable surgical challenge due to the rich, surrounding anatomy. Despite the potential morbidity of surgical treatment, the possibility of catastrophic, spontaneous hemorrhage in this location is even more feared and aggressive treatment is warranted, especially if the patient had suffered previous hemorrhages and is currently symptomatic. We demonstrate this approach (Video 1) on a 16-year-old boy who presented with right-sided hemiparesis (power grade 4), intense headaches, difficulties with learning and concentration, and memory loss, mainly affecting short-term memory. The patient had a previous unsuccessful excision at another center 3 months after initial hemorrhage. The absence of hydrocephalus and medial thalamic location favored a modified transcallosal transchoroidal (or subchoroidal) approach. Due to the anatomy of the lesion, no other microsurgical approaches were considered. The surgery at our center (second attempt) was performed 5 months after initial hemorrhage. The head was placed in neutral position, with a slight elevation of the vertex and the midline in a vertical position. A callosotomy had already been performed during the patient's first excision attempt at another center. Although dissection through the tela choroidea is commonly performed medially to the choroidal fissure when one wants to enter the third ventricle, we chose to carefully dissect through this structure laterally, because this thalamic lesion extended almost into the ependymal surface of the third ventricle. This way, the choroidal plexus became a protective cushion for the fornix. On entering the third ventricle, a mulberry-like lesion was readily identified and the cavernoma was located. The central contents of the cavernoma were dissected initially, causing relative deflation of the lesion and more maneuverability to dissect it away from the surrounding structures. Neuromonitoring was used to avoid brainstem injury. Postoperative magnetic resonance imaging showed complete resection with no signs of hemorrhage or ischemia. The patient was discharged on postoperative day 5 with no new neurologic deficits. The patient was also able to return to school after 1 month and showed complete recovery. Unfortunately, neuropsychologic evaluation was unavailable to understand his improvement better. Microsurgical dissection images in this video are a courtesy of the Rhoton Collection, American Association of Neurological Surgeons (AANS)/Neurosurgical Research and Education Foundation (NREF).

Minimally invasive keyhole supraorbital craniotomy as treatment option for penetrating foreign body through orbital roof.

Intraorbital foreign body is a rare condition, especially when extending into the intracranial compartment. When facing this scenario in the ER, the neurosurgeon must carefully choose the optimal point of surgical access in order to reduce morbidity. The authors hereby report the case of a 66 year-old male with a penetrating trauma to the orbit reaching the anterior cranial base through the orbital roof and associated with an intracerebral hematoma. The removal of the foreign body was performed by a dual approach: an 'eyebrow' supraorbital keyhole craniotomy and an intra-orbital extra-ocular exploration, with later microsurgical drainage of the hematoma and evisceration of the eye 48 hours later. The patient developed a pseudomeningocele, which was treated with lumbar puncture and compressive dressing. After proper intravenous antibiotic prophylaxis, the patient was discharged 21 days after hospital admission.

The Fluorescent Patient: An Unusual Effect of Fluorescein Angiography.

Although fluorescein is widely used for intraoperative angiography, some of its side effects remain obscure. In this report, we present the case of a 41-year-old patient with chronic ischemia caused by moyamoya syndrome who underwent bypass revascularization with intraoperative fluorescein angiography (FA). Immediately after the surgery, the patient presented homogeneous fluorescence of the entire skin. We discuss this curious phenomenon as well as other side effects that may arise due to FA.

Acute Hydrocephalus Following a Spontaneous Ventriculoperitoneal Shunt Catheter Fracture With Scrotal Migration.

Genitalia-related complications of ventriculoperitoneal shunts, such as scrotal migrations, are rare and most frequently presenting during the first year of the system placement, usually in the pediatric population, due to several factors, including vaginal process patency and increased abdominal pressure. Despite being typically benign, hernias, hydroceles, perforations, and catheter migration to the scrotum can lead to permanent disabilities and lethal complications, such as ventriculoperitoneal shunt dysfunction. We report a case of a late-onset, atraumatic, ventriculoperitoneal shunt fracture and catheter migration to the scrotum in a 22-year-old male, six years after its implantation, presenting in the emergency department due to acute hydrocephalus symptoms.

Superficial Temporal Artery-Middle Cerebral Artery Bypass Ex Vivo Hybrid Simulator: Face, Content, Construct, and Concurrent Validity.

BACKGROUND: Cerebrovascular bypass surgical procedures require highly developed dexterity and refined bimanual technical skills. To attain such a level of prowess, neurosurgeons and residents have traditionally relied on "flat" models (without depth of field), such as chicken wings, live rats, silicone vessels, and other materials that stray far from the reality of the operating room, albeit more accessible. We have explored the use of a hybrid ex vivo simulator that takes advantage of the availability of placenta vessels and retains the complexity of surgery performed on a human skull to create a more realistic method for the development of cerebrovascular bypass surgical skills. METHODS: Twelve ex vivo simulators were constructed using 3 human placentas and 1 synthetic human skull for each. Face, content, construct, and concurrent validity were assessed by 12 neurosurgeons (6 trained vascular surgeons and 6 general neurosurgeons) and compared with those of other bypass models. RESULTS: The fidelity grade was ranked as low (Linkert scale score, 1-2), medium (score, 3), and high (score, 4-5). The face and content validity of the model showed high fidelity to superficial temporal artery-middle cerebral artery bypass surgery. Construct validity showed that cerebrovascular neurosurgeons had better performance, and concurrent validity highlighted that all surgical steps were present. CONCLUSION: The simulator was found to have strong face and content, construct, and concurrent validity for microsurgical cerebrovascular training, allowing for simulation of all surgical steps of the bypass procedure. The hybrid simulator seems to be a promising method for shortening the bypass surgery learning curve. However, more studies are required to evaluate the predictive validity of the model.

Should kyphoplasty curettes be used in nonosteoporotic patients? A cautionary tale.

The authors present the first report of a fracture of the tip of a kyphoplasty curette inside the vertebral body, which occurred during a procedure in a patient with non-osteoporotic fracture. This highlights the need of further biomechanical research focused on the shear load failure properties of such type of pre-bent curettes.

Is Intraoperative Ultrasound a Valuable Tool for Brain Arteriovenous Malformation Diagnosis and Treatment? A Case Report.

The localization of arteriovenous malformations (AVMs) intraoperatively in the setting of an acute intracerebral hemorrhage (ICH) is crucial to avoid damage of delicate vascular structures that may even further exacerbate the bleed. Currently, surgical mapping using preoperative angiographic is the standard of practice. We report the use of intraoperative ultrasound for the diagnosis and localization of an AVM in the case of a 61-year-old female with reported iodine contrast allergy and previous severe reaction, in a setting with limited resources, without other imaging options or timely transfer to another facility readily available. Immediate surgical care was warranted to avoid further deterioration of the patient; intraoperative diagnosis and localization of the suspected underlying lesion were done using ultrasound. The ultrasound display showed tubular anechoic intertwined structures that demonstrated bidirectional flow, which is suggestive of an AVM. The intraoperative diagnosis allowed the surgeon to avoid an inadvertent approach to the vascular malformation nidus or vessels, which could have further complicated the case. We believe that intraoperative ultrasound may be valuable for the neurosurgeons today in many settings. Despite the fact that this case occurred in a scenario with limited resources and no other imaging method (such as magnetic resonance imaging (MRI), magnetic resonance angiography (MRA)) available, we advise readers not to rely solely on intraoperative ultrasound.

Neuronavigation as a minimally invasive tool in the treatment of intracranial gunshot injuries.

Gunshot injury is the most common cause of penetrating brain injury. The in-hospital mortality for civilians with penetrating craniocerebral injury is 52-95%. There are many surgical techniques suitable for the treatment of survivors. We report a surgical technique consisting of neuronavigation guidance for wound treatment with smaller incisions and craniotomies, followed by bullet removal if feasible. We report case of a 15 year old male patient who sustained an accidental firearm injury to the occipital region, submitted to surgical treatment that consisted in a minimally invasive approach guided by neuronavigation. Immediate neurological examination showed inferior homonymous quadrantanopsia alone as a clinical finding. Patient was discharged after one week, and no complications arised in follow-up. We conclude that using neuronavigation as a tool was effective in the reported case and that minimally invasive neurosurgical techniques may be a safe and efficient option for the treatment of traumatic brain injuries caused by firearm projectiles.

Development of a New Coupled Cobb-Suction Instrument for Posterior Spinal Approaches: Technical Note.

BACKGROUND: During dissection of paraspinal muscles in posterior surgical approaches, the spine surgeon usually holds a subperiosteal (Cobb) elevator in 1 hand and a monopolar cautery in the other hand. In such a scenario, both the surgical smoke generated by the monopolar and eventual bleeding constitute a significant hindrance to simultaneous bilateral dissection of the paraspinal muscles by 2 surgeons. METHODS: To address the identified shortcomings in the currently available instrumentation, we initially analyzed the most common surgical techniques employed by residents and fellows at our institution for paraspinal muscle dissection during posterior spinal approaches. Additionally, we collected trainees' feedback regarding the efficacy of available strategies for dealing with surgical smoke. RESULTS: A new coupled Cobb elevator-suction instrument was designed, manufactured, and tested by residents, fellows, and experienced spine surgeons, and small additional design modifications were performed. CONCLUSIONS: We present what we believe is the first description of a new coupled Cobb-suction instrument that has been developed to enable simultaneous retraction and suction with 1 hand, while allowing the spine surgeon to use the monopolar cautery with the other hand. In our preliminary institutional experience, this new tool has been proven to be especially useful in long posterior spinal approaches in the thoracolumbar region.