Primary extranodal marginal zone mucosa-associated lymphoid tissue-type B-cell lymphoma involving the dura: A case report.

Background: Primary extranodal marginal zone mucosa-associated lymphoid tissue-type B-cell lymphoma (EMZMBCL), which presents as a dural mass, is a rare intracranial tumor that mimics a subdural hematoma or meningioma. Case Description: A 49-year-old woman presented to our hospital with transient right upper limb paresis, dysarthria for 10 min, and ongoing right upper-limb numbness. Computed tomography (CT) of the head revealed extra-axial lesions in the left frontal and parietal lobes. Based on the initial CT findings in the emergency room, an acute subdural hematoma was suspected. However, meningiomas and other intracranial tumors were also listed as differential diagnoses because there was no history of head trauma or coagulation abnormalities on blood examination, and further imaging studies were performed. Imaging findings suggested a subdural neoplastic lesion. A partial resection was performed for the lesion. Based on histopathological and immunohistochemical examinations, the patient was diagnosed with EMZMBCL. Whole-brain and intensity-modulated radiation therapies were administered as adjuvant therapies. The patient was discharged without neurological deficits. Conclusion: EMZMBCL is a rare disease that should be considered in the differential diagnosis of subdural lesions, especially when there is no history of trauma or abnormalities in the coagulation system. The patient had a favorable outcome after selecting radiotherapy as the adjuvant therapy.

A case of anterior arch fracture of the atlas associated with C1 laminectomy.

Background: Spontaneous anterior arch fracture of the atlas after a C1 laminectomy (CIL) is an extremely rare complication. Case Description: A 72-year-old male presented with the sudden onset of neck pain. His prior history included; a CIL for atlantoaxial subluxation, shunt closure for a spinal dural arteriovenous fistula at C3, a cervical laminoplasty from C3 to C6 for stenosis, and a prior anterior C4/5 and C5/6 fusion 14 years ago. Once the computed tomography documented a right C1 anterior arch fracture, and occipital-cervical fusion was performed utilizing C2 laminar screws and C4 pedicle screws with halo-vest placement. Postoperatively, the neck pain resolved and he remained stable. Conclusion: Neurosurgeons should be aware of the risk of anterior arch fractures following a CIL and may alternatively consider a C1 laminoplasty in the future.

Combined cervical laminoplasty and foraminotomy for coexistence of cervical myelopathy and unilateral radiculopathy: case series and preliminary results.

BACKGROUND: The clinical outcomes and radiographic changes of a one-stage procedure combining cervical laminoplasty and unilateral cervical foraminotomy for patients with coexisting cervical myelopathy and unilateral radiculopathy were evaluated. METHODS: Seven patients (two females and five males) with coexisting cervical myelopathy and unilateral cervical radiculopathy were included in this study. The mean age was 58.4 years (range 45-77 years). Cervical laminoplasty and unilateral cervical foraminotomy were performed on the recruited patients in a single stage. The quantitative clinical changes between the preoperative and 6-month postoperative assessment were analyzed using the Japanese Orthopedic Association (JOA) score, the JOA Cervical Myelopathy Evaluation Questionnaire (JOA-CMEQ), visual analog scale (VAS), and Neck Disability Index (NDI). Moreover, the preoperative and 6-month postoperative radiographic changes were assessed using the C2-7 angle and range of motion (ROM) between flexion and extension angle. RESULTS: There were significant differences in QOL in the JOA-CMEQ between the groups. Furthermore, the postoperative VAS values in the arms and hands generally improved, although not significantly, between the groups. CONCLUSIONS: The aforementioned surgical procedure may be safe and efficient for patients with coexisting cervical myelopathy and radiculopathy.

An interdural spinal cyst in the cervicothoracic spine: a review and proposal for a revised classification of spinal meningeal cysts. Illustrative case.

BACKGROUND: Spinal cysts in the interdural space are extremely rare and are not included in the standard classification of spinal meningeal cysts. OBSERVATIONS: A 60-year-old female presented to our hospital with a spastic gait and numbness in both palms. Magnetic resonance imaging (MRI) revealed a spinal cyst from C4 to T4 compressing the spinal cord. Computed tomography myelography revealed a fistula at C4-5 and C5-6 that connected the cyst along the right C5 and C6 root sleeves. The cyst was located within the dura mater, and communication with the arachnoid space was achieved using a shunt tube. There was partial spastic gait amelioration after the procedure, but the patient experienced a relapse 2 months postoperation. A repeat procedure was performed without a shunt tube to allow greater communication between the cyst and the subarachnoid space. After this, marked improvement in gait function was observed, and MRI showed a significant reduction in cyst volume. LESSONS: Interdural spinal meningeal cysts are rare. When the interdural cyst cannot be removed entirely, surgery may be appropriate for providing a shunt tube or establishing communication between the cyst and arachnoid space to maintain the circulation of cerebrospinal fluid collected in the cyst cavity.

Asymptomatic spinal subdural epiarachnoid hygroma after lumbar laminectomy for lumbar spinal canal stenosis: illustrative case.

BACKGROUND: Spinal subdural epiarachnoid hygroma (SSEH) after lumbar laminectomy is an extremely rare complication. OBSERVATIONS: An 84-year-old man presented to the hospital with lower back pain, radicular pain, and numbness in the lateral aspect of the left leg. Magnetic resonance imaging (MRI) revealed anterior lumbar spondylolisthesis at L3, severe disc herniation at L3-4, and severe lumbar spinal canal stenosis at L3-4 and L4-5. Lumbar laminectomy at L3-4 and L4-5 and discectomy at L3-4 were performed without complications such as cerebrospinal fluid (CSF) leakage and durotomy intraoperatively. Although lower back pain and numbness at the lateral aspect of the left leg were resolved postoperatively, postoperative MRI showed spinal nerve deviation to the ventral side due to SSEH from T12 to S1. Conservative therapy was performed for asymptomatic SSEH, and MRI 1 week postoperatively indicated improved ventral spinal nerve deviation and reduced SSEH. LESSONS: SSEHs after posterior decompression without durotomy are extremely rare. Asymptomatic SSEHs may resolve with conservative treatment. However, surgery should be performed to decompress hygroma in patients with symptomatic SSEH.

Primary intramedullary spinal cord pilocytic astrocytoma with anaplasia in an adult: illustrative case.

BACKGROUND: Primary intramedullary spinal cord (IMSC) pilocytic astrocytoma (PA) with anaplasia is extremely rare. OBSERVATIONS: A 50-year-old man presented to our hospital with numbness of the left posterior rib region, back, and bilateral lower limbs. Contrast-enhanced T1-weighted magnetic resonance imaging (MRI) revealed an intramedullary lesion at T2-T3 with no contrast enhancement. The patient opted for conservative treatment. Eighteen months after the first consultation, the patient presented with slowly progressive numbness of the bilateral upper limbs, paraparesis, and dysuria, with rapid deterioration over the following 3 months. T1- and T2-weighted MRI revealed expansion of the intramedullary lesion, which extended from C7 to T5, and syringomyelia at C5-C6. Contrast-enhanced T1-weighted MRI revealed an enhancing intramedullary lesion at C7-T5. Open biopsy and C5-T5 laminectomy were performed for diagnosis and decompression. PA with anaplasia was diagnosed based on pathological and immunohistochemical findings. The patient received postoperative radiotherapy and chemotherapy. LESSONS: Rapidly progressive IMSC PA with a change in contrast enhancement is extremely rare in adults. PA may undergo a spontaneous malignant transformation during its natural clinical course. In this case, the change in contrast enhancement may have been associated with the malignant transformation of the PA.

Embolization of a vertebral artery encased in a regrowth cervical meningioma before resection.

Background: Managing intraoperative bleeding may be challenging when a cervical tumor encases the vertebral artery (VA). Here, a patient with a recurrent cervical meningioma between the C1/2 and C3/4 levels and encasement of the right VA injury developed intraoperative bleeding that was endovascularly embolized postoperatively. Case Description: A 30-year-old female presented with a progressive quadriparesis, most markedly involving the right upper extremity. Six years ago, she had a cervical meningioma resected at the C2/3 level. The new MR revealed regrowth of intraspinal tumor between the C1/2 to C4/5 levels accompanied by extradural encasement of the right VA within the C2/3 and C3/4 foramina. Before the first surgery, the right VA was embolized (i.e., after a balloon occlusion test proved negative). During the attempted resection of the intradural/extradural tumor, bleeding from the right VA was encountered; it was temporarily controlled. After complete occlusion of the right VA was angiographically confirmed, a second-stage procedure to fully resect the extradural remanent of the tumor was undertaken. Conclusion: Endovascular embolization of the right VA before the attempted resection of a recurrent intraspinal/extraspinal cervical meningioma failed to occlude the vessel entirely. The VA bleeding encountered intraoperatively was temporarily controlled. Delayed total VA occlusion was angiographically observed before full tumor resection could be completed.

Early postoperative sacral fracture after short-segment posterior lumbar interbody fusion for L5/S1 isthmic spondylolisthesis: A case report.

Background: Early postoperative sacral fractures are extremely rare complications of single-level posterior lumbar interbody fusions (PLIFs). Case Description: A 71-year-old female presented with lower back pain and right S1 radiculopathy attributed to MR-documented L5/S1 isthmic spondylolisthesis. Following a L5 laminectomy and bilateral L5/S1 PLIF, she experienced sacral pain while sitting. When the MR showed a sacral insufficiency fracture with anterolisthesis at L5/S1, a secondary posterior fusion was extended to the pelvis, utilizing bilateral iliac screws. Following this reoperation, the patient did well and went on to achieve arthrodesis. Conclusion: Early postoperative sacral fractures that occur following single-segment L5/S1 PLIF for isthmic spondylolisthesis warrant fusion to the pelvis with bilateral iliac screws.

Neurological Disturbance of the Upper Extremities After Cervical Laminoplasty: A Morphological Assessment Focused on the Intervertebral Foramen.

STUDY DESIGN: A retrospective study. OBJECTIVE: The aim of this study was to explore the relationship between postoperative neurological disturbance of the upper extremities (NDUE) after cervical laminoplasty and intervertebral foraminal stenosis. SUMMARY OF BACKGROUND DATA: The relationship between foraminal stenosis and neurological disturbance in the C5 segment (C5 palsy) has been reported, but the relationship at other levels has not been examined before. We evaluated foraminal stenosis morphologically using three-dimensional computed tomography (3D-CT), alongside other risk factors for NDUE. METHODS: We retrospectively reviewed patients treated by open-door laminoplasty at the authors' institution between January and June 2016. NDUE was defined as postoperative motor deterioration and/or newly emerged sensory disturbance within 2 weeks of surgery. Radiological measurements were performed in bilateral intervertebral foramina from C5 to C8, using 3D-CT. Investigation using magnetic resonance imaging (MRI) was also performed. RESULTS: Thirty-one patients were reviewed, and 10 (32.3%) developed NDUE. Nineteen NDUE were observed: seven were in the C5 segment, five in the C6 segment, three in the C7 segment, and four in the C8 segment. Four patients (40%) had NDUE from multiple segments. The mean width of the foramen was 2.60 ±â€Š1.26 mm and 3.66 ±â€Š1.66 mm (P = 0.007), and cross-sectional area was 32.8 ±â€Š10.8 mm and 41.6 ±â€Š12.4 mm (P = 0.003), in symptomatic (n = 19) and nonsymptomatic (n = 187) foramina, respectively. The mean transverse diameter of bony spurs and the maximum shift of the spinal cord on MRI was significantly larger in the NDUE group. The odds ratio of having a foraminal cross-sectional area under 28.0 mm in combination with a maximum spinal shift over 3.10 mm was 14.6 (P < 0.001). CONCLUSION: Stenosis of the intervertebral foramen could be a risk factor for NDUE after cervical laminoplasty, and could be aggravated by excessive posterior spinal cord shift. LEVEL OF EVIDENCE: 3.

Effect of choice of treatment modality on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Shunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH. METHODS: The authors' multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH. RESULTS: A total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score-matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2-4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3-6) at discharge (OR 4.3, 95% CI 2.6-7.3; p < 0.001). CONCLUSIONS: SDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.

Enhanced Axonal Extension of Subcortical Projection Neurons Isolated from Murine Embryonic Cortex using Neuropilin-1.

The cerebral cortical tissue of murine embryo and pluripotent stem cell (PSC)-derived neurons can survive in the brain and extend axons to the spinal cord. For efficient cell integration to the corticospinal tract (CST) after transplantation, the induction or selection of cortical motor neurons is important. However, precise information about the appropriate cell population remains unclear. To address this issue, we isolated cells expressing Neuropilin-1 (NRP1), a major axon guidance molecule receptor during the early developmental stage, from E14.5 mouse embryonic frontal cortex by fluorescence-activated cell sorting. Aggregates of NRP1+ cells gradually expressed subcortical projection neuron markers, Ctip2 and VGluT1, and axon guidance molecule receptors, Robo1 and deleted in colorectal calcinoma (Dcc), in vitro, suggesting that they contained early-stage subcortical projection neurons. We transplanted NRP1+ cells into the frontal cortex of P2 neonatal mice. Compared with grafts derived from NRP1- or unsorted cells, those derived from NRP1+ cells extended a larger number of axons to the spinal cord along the CST. Our data suggest that sorting NRP1+ cells from the embryonic cerebral cortex enriches subcortical projection neurons to reconstruct the CST.

WNT-C59, a Small-Molecule WNT Inhibitor, Efficiently Induces Anterior Cortex That Includes Cortical Motor Neurons From Human Pluripotent Stem Cells.

UNLABELLED: The recapitulation of human neural development in a controlled, defined manner from pluripotent stem cells (PSCs) has considerable potential for studies of human neural development, circuit formation and function, and the construction of in vitro models of neurological diseases. The inhibition of Wnt signaling, often by the recombinant protein DKK1, is important for the induction of cortical neurons. Here, we report a novel differentiation method using a small-molecule WNT inhibitor, WNT-C59 (C59), to efficiently induce human anterior cortex. We compared two types of small molecules, C59 and XAV939 (XAV), as substitutes for DKK1 to induce cortical neurons from PSCs in serum-free embryoid body-like aggregate culture. DKK1 and XAV inhibited only the canonical pathway of Wnt signaling, whereas C59 inhibited both the canonical and noncanonical pathways. C59 efficiently induced CTIP2+/COUP-TF1- cells, which are characteristic of the cells found in the anterior cortex. In addition, when grafted into the cortex of adult mice, the C59-induced cells showed abundant axonal fiber extension toward the spinal cord. These results raise the possibility of C59 contributing to cell replacement therapy for motor neuron diseases or insults. SIGNIFICANCE: For a cell therapy against damaged corticospinal tract caused by neurodegenerative diseases or insults, cortical motor neurons are needed. Currently, their induction from pluripotent stem cells is considered very promising; however, an efficient protocol to induce motor neurons is not available. For efficient induction of anterior cortex, where motor neurons are located, various WNT inhibitors were investigated. It was found that one of them could induce anterior cortical cells efficiently. In addition, when grafted into the cortex of adult mice, the induced cells showed more abundant axonal fiber extension toward spinal cord. These results raise the possibility that this inhibitor contributes to a cell-replacement therapy for motor neuron diseases or insults.