Navigated Anterior Full-Endoscopic Transcervical Approach Odontoidectomy for Traumatic Posterior Atlantoaxial Dislocation Without Odontoid Fracture.

BACKGROUND AND IMPORTANCE: Complete posterior atlantoaxial dislocation (PAAD) with an unfractured odontoid process is a rare condition where a dislocated but intact odontoid process is positioned ventrally to the anterior arch of C1. This lesion is related to transverse and alar ligament rupture secondary to hyperextension and rotatory traumatic injury and is often associated with neurological deficit. The treatment strategy remains controversial, and in many cases, odontoidectomy is required. Traditional approaches for odontoidectomy (transnasal and transoral) are technically demanding and are related to several complications. This article describes a 360° reduction and stabilization technique through a navigated anterior full-endoscopic transcervical approach (nAFETA) as a novel technique for odontoidectomy and C1-C2 anterior transarticular fixation supplemented with posterior fusion. CLINICAL PRESENTATION: A 21-year-old man presented to the emergency room by ambulance after a motorcycle accident. On evaluation, incomplete ASIA B spinal cord injury was documented. Imaging revealed a complete PAAD. We performed a two-staged procedure, a nAFETA odontoidectomy plus C1-C2 anterior transarticular fixation followed by posterior C1-C2 wired fusion. At a 2-year follow-up, the patient had a 10-point Oswestry Disability Index score and neurological improvement to ASIA E. CONCLUSION: PAAD can be successfully treated through minimally invasive nAFETA. Noteworthy, the risks of the transoral and endonasal routes were avoided through this approach. In addition, nAFETA allows anterior transarticular fixation during the same procedure providing spinal stability. Further studies are required to expand the use of nAFETA in this field.

Collet-Sicard syndrome: a scoping review.

Collet-Sicard syndrome (CSS) is the unilateral palsy of the cranial nerves (CN) IX, X, XI, and XII. To our knowledge, no review describes the characteristics of patients diagnosed with CSS. Therefore, this review aims to collect and describe all cases in the literature labeled as CSS. We performed a scoping review of the literature and conducted a database search in Embase and PubMed. We included articles and abstracts with case reports or case series of patients with CSS diagnosis. We classified the cases into two groups: "CSS", referring to patients presenting exclusively with IX-XII nerve involvement, and "CSS-plus", which corresponds to cases with CSS and other neurological impairments. We included 135 patients from 126 articles, of which 84 (67.7%) were male. The most common clinical manifestations reported were dysphagia and dysphonia. The most common etiology was tumoral in 53 cases (39.6%) and vascular in 37 cases (27.6%). The majority of patients showed partial or total improvement, with just over half receiving conservative treatment. The most frequent anatomic space was the jugular foramen (44.4%) and the parapharyngeal retrostyloid space (28.9%). Approximately 21% of the patients had other CN impairments, with the seventh and eighth CN most frequently compromised. We conclude that although there is a need for greater rigor in CSS reporting, the syndrome has a clear utility in identifying the localization of jugular foramen and parapharyngeal retrostyloid space pathology.

Onyx Embolization of an Indirect Carotid-Cavernous Fistula with Cortical Venous Reflux: Technical Note.

BACKGROUND: Indirect carotid-cavernous fistulas (iCCFs) are shunts between meningeal branches of the internal carotid and/or the external carotid arteries and the cavernous sinus. They account for 83% of all carotid-cavernous fistulas (CCFs). Symptomatic iCCFs and those with increased risk of hemorrhage should be treated. Transvenous endovascular treatment is the preferred treatment modality. However, in complex cases, a combination of transarterial and transvenous approaches (multimodal treatment) is required. METHODS: A middle-aged woman presented with signs of increased intraocular pressure, blurry vision, diplopia, left proptosis, chemosis, conjunctival injection, ptosis, and cranial nerve VI palsy. Imaging confirmed the presence of a Barrow type D and Thomas type 4 iCCF with cortical venous reflux (CVR). RESULTS: The patient underwent transarterial and transvenous onyx embolization of the shunt, achieving a complete obliteration of the fistula. No complications occurred and the patient had a satisfactory postprocedural evolution. CONCLUSION: Multimodal onyx embolization is an effective option for the treatment of a complex symptomatic iCCF. If CVR is identified, these lesions should be promptly treated to prevent hemorrhage secondary to rupture.

Cerebrospinal fluid leak following penetrating trauma to the spine without neurological deficit: A case report.

Background: Posttraumatic spinal cerebrospinal fluid leak (CSFL) without neurological deficit is a rare entity. Historically, the first-line treatment is a nonsurgical approach, which includes Trendelenburg positioning, carbonic anhydrase inhibitor (acetazolamide), and subarachnoid catheter, with a high successful rate of leak correction. However, in some cases, this first-line treatment could fail, being necessary the surgical approach. Case Description: A 23-year-old male with a recent stab wound to his lumbar region, complained of positional headache and fluid outflow through his wound. On physical examination, an active CSFL was detected without evidence of neurologic deficit. Imaging studies showed a CSF collection extending from the right L4 lamina to the subcutaneous tissue. CSF studies revealed bacterial meningitis. The treatment with carbonic anhydrase inhibitors, Trendelenburg position, lumbar subarachnoid catheter, and antibiotics was initiated. Failure of conservative measures prompted a surgical treatment to resolve the CSFL. Intraoperatively, a dura mater defect was identified, and an autologous paravertebral muscle flap was used for water-tight closure of the defect. The patient recovered without further complications and with CSFL resolution. Conclusion: Even though the nonsurgical approach is the first-line of treatment of traumatic CSFL cases, failures can occur. The evidence of a CSF trajectory in imaging studies could be a predictor of treatment failure of the nonsurgical treatment. The surgical treatment as second-line treatment has outstanding results regarding CSFL correction and should be considered when the prediction rate to nonsurgical approach failure is high.

Transient third cranial nerve palsy after pipeline shield treatment of a ruptured anterior cerebral artery dissecting aneurysm: Case report.

BACKGROUND: Intracranial dissecting aneurysms (IDAs) are rare vascular lesions usually arising from the posterior circulation. The anterior cerebral artery (ACA) is an unusual location for this pathology. Even rarer is the occurrence of a transient de novo third cranial nerve (CN) palsy after flow-diverting device (FDD) treatment of an ACA dissecting aneurysm. CASE DESCRIPTION: A middle-aged man with a prior history of hypertension was admitted to our emergency department with severe headache and loss of consciousness after sexual intercourse. Imaging revealed a subarachnoid hemorrhage with stenosis of the left A1 segment of the ACA. Cerebral digital subtraction angiography confirmed a dissecting aneurysm of the left A1 segment. The aneurysm was treated with an FDD (Pipeline Shield). Transient isolated incomplete third CN palsy was documented 12 h after treatment. No evidence of ischemic or hemorrhagic strokes was found. The condition improved after a few days of empiric steroid treatment. CONCLUSION: An FDD is a suitable alternative for the treatment of a ruptured IDA of the anterior circulation. Some infrequent complications associated with the device, such as de novo cranial neuropathies, are yet to be studied.

Management of recurrent schwannoma of the cauda equina: A case report.

BACKGROUND: Schwannomas of the cauda equina are rare intradural primary spinal tumors. Many of these patients initially present with cauda equina syndromes, and only 2.2% demonstrate clinical recurrence. Gross total excision is the procedure of choice. CASE DESCRIPTION: A 62-year-old female had undergone resection of a cauda equina schwannoma 5 years previously. She newly presented with cauda equina symptoms attributed to a recurrent schwannoma. Following gross total secondary tumor resection, the patient's preoperative deficits fully resolved, and the tumor never recurred. CONCLUSION: Secondary gross total excision of schwannomas of the cauda equina is critical to avoid further tumor recurrence.

Emergent Hybrid Treatment of a Ruptured Scalp Arteriovenous Fistula with Eyelid involvement: Technical Note.

BACKGROUND: Scalp arteriovenous fistulas (AVFs) are a rare vascular disease usually presenting as a progressively increasing pulsating mass in the scalp. These lesions can be associated with mild to severe complications, including congestive heart failure. If ruptures, this pathology constitutes a life-threatening medical emergency because of its potential to cause severe bleeding and acute anemia. METHODS: We describe the case of a young woman with a ruptured Yokouchi type C scalp AVF with eyelid involvement. RESULTS: The patient presented with hypovolemic shock and acute anemia due to severe bleeding from the lesion. Emergent treatment through a combined endovascular and open surgical approach was required to stop bleeding and stabilize the patient. CONCLUSIONS: Emergent and effective treatment is required to stop bleeding when a scalp AVF ruptures. A combination of endovascular embolization and microsurgical excision of the shunt is a treatment option.

Direct transcranial coil and Onyx embolization of a dural arteriovenous fistula: Technical note and brief literature review.

Intracranial high-grade dural arteriovenous fistulas (DAVFs) have higher bleeding rates compared to other intracranial vascular malformations. Endovascular treatment is usually recommended for high-grade lesions, aiming at a complete fistula obliteration. However, some patients have vascular abnormalities that limit endovascular access to the precise location of the shunt. Alternative techniques may be considered in this scenario. A middle-aged man presented with intracranial hypertension secondary to a high-grade DAVF. Because of vascular abnormalities precluding transvenous access to the intracranial venous circulation, the patient required treatment by a direct transcranial coil and Onyx embolization of the shunt. Direct transcranial cannulation of a dural sinus is an alternative and effective route for transvenous embolization of DAVFs, especially if abnormal venous anatomy precluding venous access to the required cranial venous system is identified.