Spontaneous intracranial hypotension presenting with bilateral subdural hematoma: Decision-making and treatment strategies.

BACKGROUND: The timing and decision to drain subdural hematoma (SDH) in spontaneous intracranial hypotension (SIH) remains a dilemma. We reviewed our experience of bilateral SDH secondary to SIH, focusing on decision making and treatment strategies. METHODS: We retrospectively reviewed bilateral SDH secondary to SIH between March 2010 and September 2021. Baseline characteristics of patients, diagnosis, radiologic findings, treatments, and clinical outcome were investigated. RESULTS: Fifteen patients (7 men, 8 women) with bilateral SDH secondary to SIH were included in this study. Initially, patients were treated conservatively (4 patients, 26.7 %), with an epidural blood patch (EBP, 3 patients, 20.0 %), and SDH drainage followed by the Trendelenburg position (8 patients, 53.3 %). All 3 patients that were initially treated with EBP required SDH drainage. Of the 8 patients initially treated with SDH drainage via burr hole followed by Trendelenburg position, 7 patients showed sustained improvements without EBP; however, 1 patient needed EBP. Deterioration to coma occurred in 6 out of 15 patients (40.0 %). All 6 deteriorated patients immediately recovered after SDH drainage with Trendelenburg position; 5 achieved sustained improvement without EBP and 1 required EBP. During the follow-up period, 14 out of 15 patients (93.3 %) showed good recovery. CONCLUSIONS: Evacuation of SDH is not always necessary in SIH; however, we did not hesitate to perform hematoma drainage, in deteriorated patients or those with thick hematoma that is associated with significant sagging and cistern effacement. This can prevent irreversible neurologic complications. Moreover, the Trendelenburg position may help to achieve sustained improvement without additional treatment.

Strategy for dealing with unfamiliar and thick vessels during microvascular decompression: A first case report of hemifacial spasm caused by a persistent primitive trigeminal artery.

RATIONALE: A persistent primitive trigeminal artery (PPTA) is a rare embryonic cerebrovascular anomaly. Hemifacial spasm (HFS) refers to involuntary contractions of facial muscles caused by the compression of blood vessels against the root exit zone of the facial nerve. There have been no reported cases of PPTA causing neurovascular contact and HFS. Microvascular decompression surgery effectively treats HFS, but operating on strong PPTA vessels poses challenges. We aim to introduce a more efficient approach for overcomes these difficulties and facilitates surgery. PATIENT CONCERNS: A 44-year-old male patient without any underlying medical conditions presented to our hospital with involuntary movements of the left side of his face accompanied by numbness in the left maxilla (V2 area). DIAGNOSIS: Brain magnetic resonance imaging and magnetic resonance angiography showed that PPTA was in contact with the left facial nerve. INTERVENTIONS AND OUTCOMES: Following a retro-sigmoid craniotomy, we attempted to interpose the facial nerve and the PPTA as an offender vessel, but the decompression was not sufficient. However, after transposing the vessel using the proximal Teflon transposition with interposition technique, the strength of the involuntary movements was reduced. Following surgery, there was no more lateral spreading response, and the patient symptoms improved. LESSIONS: In cases where the vessel causing HFS is particularly strong and thick, the proximal Teflon transposition with interposition technique for transposition may be advantageous. This method could simplify and enhance the efficacy of microvascular decompression, without compromising the quality of surgical outcomes.

Microsurgical strategies for small unruptured dorsal internal carotid artery aneurysms.

OBJECTIVE: This study aimed to develop microsurgical strategies based on the anatomical relationship between dorsal internal carotid artery (ICA) aneurysms, the falciform ligament (FL), and the anterior clinoid process (ACP). METHODS: Between 2017 and 2022, 25 patients with unruptured dorsal ICA aneurysms (less than 4 mm in diameter) underwent microsurgical direct clipping. These cases involved the left ICA (n=17) and the right ICA (n=8), with a mean aneurysm size of 3.3 mm (range, 2.5 to 4 mm). We used computed tomography angiography (CTA) and digital subtraction angiography to elucidate the anatomical relationship between dorsal ICA aneurysms and other structures. All procedures involved an ipsilateral pterional approach with securement of the ipsilateral cervical ICA for proximal control. RESULTS: Among the 25 dorsal ICA aneurysms, 8 (32%) were clipped without the FL being incised. Another 5 (20%) were clipped solely after the FL was cut. For the remaining 12 cases, the aneurysms were successfully clipped following FL incision and partial ACP removal. Patients exhibited favorable postoperative recoveries with good outcomes, and postoperative CTA revealed complete aneurysm clipping without any residual remnants. Conclusions: We were able to perform clipping without removing the ACP in 13 patients (52%), and in 8 of these (32%), the clipping was carried out directly without cutting the FL. Microsurgery, coupled with proximal control of the cervical ICA, can serve as a viable alternative for patients with small dorsal ICA aneurysms, especially when endovascular treatment options are limited, and 3D CTA confirms a clear anatomical relationship with the ACP.

The risk factors for herpes zoster in bortezomib treatment in patients with multiple myeloma.

BACKGROUND: Bortezomib has significant activity in treating multiple myeloma (MM). The risk of herpes zoster (HZ) has been reported to increase significantly with bortezomib treatment, but the predisposing factors for HZ are not clear. This study is a retrospective analysis of the relevant risk factors for HZ in Korean MM patients treated with bortezomib. METHODS: Sixty-six patients with refractory or relapsed MM who underwent chemotherapy with bortezomib were included in the study. Prophylactic antiviral drugs were not used for treatment. The following parameters were reviewed: age, gender, stage and type of MM, extent of previous treatment, history of HZ, duration from the time of diagnosis to the time of bortezomib treatment initiation, and absolute lymphocyte counts (ALC) at the time of bortezomib treatment initiation. RESULTS: The incidence of HZ was 16.7%. There were no intergroup differences between the HZ-positive and the HZ-negative groups with regard to a history of HZ, number of previous treatments, and exposure to steroids before bortezomib treatment. The median duration from the time of MM diagnosis to the time of bortezomib treatment initiation in the HZ-positive group was significantly shorter than that in the HZ-negative group. The median ALC at the time of bortezomib initiation in the HZ-positive group was significantly lower than that in the HZ-negative group. CONCLUSION: Bortezomib itself might act as a risk factor for HZ by inhibiting cell-mediated immunity, and patients with low ALC at the time of bortezomib treatment initiation were at greater risk of HZ during bortezomib treatment.