Varicocele complicating an anterior lumbar interbody fusion: a case report.

Anterior lumbar interbody fusion (ALIF) is performed for the surgical management of lumbar degenerative disc disease with excellent results, particularly for discogenic low back pain. Commonly reported complications associated with this approach include vessel injury, retrograde ejaculation, and ureteral and viscus organ injury. The development of a varicocele after ALIF has not been previously described in the literature. We report a case of varicocele in a 35-year-old patient who underwent ALIF via a left retroperitoneal approach. No intraoperative complications were identified. The postoperative course was uneventful. He was discharged from the hospital on the 5th postoperative day. Three months after surgery, he complained of discomfort and scrotal pain. Examination revealed a grade 3 varicocele according to the Dubin and Amelar classification. Scrotal Doppler US demonstrated dilatation of the veins of the pampiniform plexus. A lumbar CT scan revealed a bulky left spermatic vein closed to the ureter. The patient was treated with platelet anti-aggregation. He was seen at control intervals of 1, 3 and 5 months. Progress was seen as we had a regression of clinical signs. Varicocele appears as an uncommon complication of ALIF. After reviewing the literature, we describe the occurrence of a varicocele following ALIF, its pathophysiology, and its treatment options.

A Case of Histoplasma duboisii Brain Abscess and Review of the Literature.

Histoplasmosis is a fungal disease caused by Histoplasma capsulatum var. capsulatum (Hcc) and H. capsulatum var. duboisii (Hcd). Central nervous system (CNS) involvement is rare. So far, the few cases reported having Histoplasmosis associated brain abscesses were caused by H. capsulatum var. capsulatum. Herein, we report a unique case of brain abscess caused by H. capsulatum var. duboisii occurring in a 42-year-old immunocompromised woman with HIV. Initially, she presented with hypothermia, vomiting, frontal headache, evolving over one month. She then progressed to have a generalized seizure. Brain MRI showed multifocal brain abscesses and a frontal osteitis. The frontal osteitis was biopsied and confirmed the diagnosis of H. capsulatum var. duboisii. She was successfully treated with liposomal amphotericin B (150 mg daily) for the first four weeks and itraconazole (200mg twice daily) for six months.

Reliability of MRI for predicting characteristics of neurovascular conflicts in trigeminal neuralgia: implications for surgical decision making.

OBJECTIVEThe choice of microvascular decompression (MVD), among the several other surgical options, for treating refractory classical trigeminal neuralgia (TN) relies mostly on preoperative imaging, but the degree of reliability of MRI remains a matter of debate. The authors approached the question of predictability of neurovascular conflict (NVC) in a series of 100 protocolized MRI studies from patients with TN who underwent MVD, by reexamination of MR images, blinded to the clinical data and surgical findings, including the side of the neuralgia.METHODSPatients included in the study were those who underwent MVD after surgical indication had been determined based on a protocolized imagery workup (3D high-resolution T2-weighted cisternography centered on the trigeminal nerve, 3D time-of-flight angiography, and 3D gadolinium-enhanced T1-weighted imaging) performed at our institution. All MR images were blindly reexamined, and neurovascular relationships were described on both sides, noting the existence of compression, vessels involved, situation along the root, and degree of compression. The results of MRI evaluation were then compared with actual surgical findings. The extent of agreement and quality of the prediction were expressed with Cohen's kappa coefficient (κ) and receiver operating characteristic (ROC) statistics.RESULTSA conflict had actually been found during surgery in 94 of 100 patients. The sensitivity of MRI to detect a conflict was 97% and the specificity was 50%. Vessel type was identified with high reliability (κ = 0.80), while the grade of the conflict and its situation along the root showed poor to average reliability (κ = 0.38 and κ = 0.40, respectively). The area under the ROC curve for predicting the presence of a conflict according to the grades of conflict seen on MRI was 0.93, which is considered very good. The positive predictive value was differentiated according to the grade of conflict, with a very high value for high grades of vascular conflict.CONCLUSIONSThis study shows an overall good reliability of MRI to predict the existence of an NVC. The prediction value is excellent for high grades of compression. Some apparent low-grade compressions on MRI may be revealed as false positives in surgical exploration. This raises the question of what other imaging methods might be used to determine not only the existence of a conflict but also its degree of compression. The degree of compression is of paramount importance to predict the probability of long-term pain relief, and therefore in the decision to propose MVD as the first choice of surgical treatment.

Microsurgical Anatomy of the Labyrinthine Artery and Clinical Relevance.

AIM: To describe the origin, the course, and relationships of the labyrinthine artery (LA). MATERIAL AND METHODS: Thanks to a colored silicone mix preparation, ten cranial bases were examined using x3 to x40 magnification under surgical microscope. RESULTS: The LA often arose from the meatal loop of the anterior inferior cerebellar artery (AICA) (90%), or basilar artery (10%). The loop was extra-meatal of the internal auditory meatus (IAM) in 30%, at the opening of the internal auditory meatus in 20%, or intra-meatal in 35%. The AICA coursed in closed relationship to the VII and VIII cranial nerves. It coursed between VII and VIII cranial nerve roots in 85%, or passed over the ventral side of both VII and VIII cranial nerve. The average diameter of the LA was 0.2 +/- 0.05 mm. LA was single trunk in 60%, and bi-arterial in 40%. CONCLUSION: The implication of these anatomic findings for cerebello-pontine angle tumors surgery and neurovascular pathology such as infarction, aneurysm of the LA or the AICA are reviewed and discussed.

Long-term outcome of surgical disconnection of the epileptic zone as an alternative to resection for nonlesional mesial temporal epilepsy.

BACKGROUND: Pharmacoresistant epilepsy can be treated by either resection of the epileptic focus or functional isolation of the epileptic focus through complete disconnection of the pathways of propagation of the epileptic activity. OBJECTIVE: To evaluate long-term seizure outcome and complications of temporal lobe disconnection (TLD) without resection for mesial temporal lobe epilepsy (MTLE). METHODS: Data of 45 patients operated on for intractable MTLE using a functional disconnection procedure have been studied. Indication of TLD surgery was retained after a standard preoperative evaluation of refractory epilepsy and using the same criteria as for standard temporal resection. RESULTS: Mean follow-up duration was 3.7 years. At the last follow-up, 30 patients (67%) were completely seizure-free (Engel-Ia/International League Against Epilepsy class 1) and 39 patients (87%) remained significantly improved (Engel-I or -II) by surgery. Actuarial outcome displays a 77.7% probability of being seizure-free and an 85.4% probability of being significantly improved at 5 years. No patient died after surgery and no subdural haematoma or hygroma occurred. Permanent morbidity included hemiparesis, hemianopia and oculomotor paresis found in three, five and one patient, respectively, after TLD. CONCLUSIONS: TLD is acceptable alternative surgical technique for patients with intractable MTLE. The results of TLD are in the range of morbidity and long-term seizure outcome rates after standard surgical resection. We observed a slightly higher rate of complications after TLD in comparison with usual rates of morbidity of resection procedures. TLD may be used as an alternative to resection and could reduce operating time and the risks of subdural collections.

A rare third ventricle solitary tuberculoma.

The localization of the tuberculoma at the third ventricle is rare. The authors report a case of third ventricle solitary Tuberculoma which has occurred in a 10 year old patient and revealed by a syndrome of intracranial hypertension without tuberculosis stigma. This lesion appears clinically and radiologically as a primary brain tumor. A total removal using a subchoroidal approach to the third ventricle has been performed. Histological examination showed a tuberculous like granuloma. An adjuvant antituberculous chemotherapy practiced for 6 months brought the complete cure. The authors insist on the diagnostic and therapeutic difficulties in front of a third ventricle solitary tuberculoma.

Gamma knife radiosurgery for intralabyrinthine schwannomas.

OBJECT: To analyze indications and technical specificities of treatment of intralabyrinthine schwannoma (ILS) by Gamma Knife radiosurgery. METHODS: Six patients were treated by Gamma Knife irradiation for a schwannoma arising from the cochleo-vestibular structures. Patients presented hearing worsening at different stages, tinnitus, imbalance and/or vertigo. RESULTS: ILS was intravestibular/intracochlear/intravestibulocochlear/ transmacular in respectively 2/1/2/1 patients. We cover the entire tumor volume with a margin prescription dose of 12-Gy. The tumor volume remained unchanged at last follow-up in all cases; for 4 patients with functional hearing still present before treatment, the audiological status remained stable in 2 patients, worsened moderately in 1 patientand worsened to cophosis in 1 patient. No patient experienced worsening of tinnitus, imbalance or vertigo after irradiation. CONCLUSIONS: Gamma Knife treatment of ILS is technically feasible without risk thanks to the precision of current robotized Gamma Knife devices. Patients treated radiosurgically avoid some of the risks of microsurgery, could in some cases maintain useful hearing and prevent further symptoms worsening.