Middle cerebral artery infarction, A rare complication of intracranial cryptococcoma in an immunocompetent patient: A case report and literature review.

Background: This report presents the first case of intracranial cryptococcoma arising from the right frontal lobe causing right middle cerebral artery infarction. Intracranial cryptococcomas usually occur in the cerebral parenchyma, basal ganglia, cerebellum, pons, thalamus, and choroid plexus; they may mimic intracranial tumors, but seldom cause infarction. Of the 15 cases of pathology-confirmed intracranial cryptococcomas in the literature, no case has been complicated by middle cerebral artery (MCA) infarction. Here, we discuss a case of intracranial cryptococcoma with an ipsilateral middle cerebral artery infarction. Case Description: A 40-year-old man was referred to our emergency room due to progressive headaches and acute left hemiplegia. The patient was a construction worker with no history of avian contact, recent travel, or human immunodeficiency virus (HIV) infection. Brain computed tomography (CT) showed an intra-axial mass, and subsequent magnetic resonance imaging (MRI) delineated a large mass of 53 mm in the right middle frontal lobe and a small lesion of 18 mm in the right caudate head, with marginal enhancement and central necrosis. A neurosurgeon was consulted in view of the intracranial lesion, and the patient underwent en-bloc excision of the solid mass. The pathology report later identified a Cryptococcus infection rather than malignancy. The patient underwent 4 weeks of postoperative treatment with amphotericin B plus flucytosine; he then received subsequent oral antifungal treatment for 6 months, and had neurologic sequelae that manifested as left side hemiplegia. Conclusion: Diagnosis of fungal infections in the CNS remains challenging. This is especially true of Cryptococcus CNS infections that present as a space-occupying lesion in an immunocompetent patient. A Cryptococcus infection should be considered in the differential diagnoses in patients with brain mass lesions, as this infection can be misdiagnosed as a brain tumor.

The clinical outcome of balloon-assisted maturation procedure between autogenous radiocephalic fistula and brachiocephalic fistula in a single-center experience.

OBJECTIVE: Balloon-assisted maturation (BAM) by an endovascular method plays an important role in treating an immature arteriovenous fistula. However, the results between radiocephalic fistula and brachiocephalic fistula were rarely reported. This retrospective study aimed to investigate the effectiveness and outcome of BAM in different sites of autogenous arteriovenous fistulas. METHODS: This single-center retrospective study included patients who underwent BAM procedures from January 2015 to December 2016. Of 148 patients, 117 and 31 patients had a radiocephalic fistula (RC) and a brachiocephalic fistula (BC), respectively. The primary outcome was BAM success. Data regarding fistula lesions, balloon types and size, frequency of procedures, and maturation time were collected for BAMs. The secondary outcome was the patency of a fistula in the follow-up period. RESULTS: No difference was observed in procedure of BAM frequency between the RC and BC groups. The total success rate was 77.7%, without significant difference between the RC and BC groups (81.20% vs 64.50%; P = .055). Within the procedures, the culprit lesion of juxta-anastomosis segment (73.5% vs 25.5%; P < .001) and arterial inlet (21.2% vs 7.8%; P = .04) were more common in the RC group, whereas the venous outlet was more common in the BC group (88.2% vs 57.7%; P < .001). Both groups had an equivalent patency rate after the BAM within the follow-up period (P = .272). CONCLUSIONS: BAM was an effective procedure for immature fistulas, without significant difference between RCs and BCs. Through the procedure, the culprit lesions causing non-maturation were found to be different between the two groups. The patency rate between the two groups after surgery seems to be equivalent within the follow-up period.

A poor outcome in non-occlusive thrombo-embolic limb ischaemia related to the dislocation of mural thrombus from an abdominal aortic aneurysm.

BACKGROUND: Acute thrombosis of an abdominal aortic aneurysm with acute limb ischaemia is an unusual complication and is associated with high mortality. Dislocation of the intrasaccular mural thrombus could be one of the mechanisms. For the most part, acute limb ischaemia presents with absent pulses, compatible with the clinical findings, which include pain, paraesthesia, and paralysis. Herein, we report a rare condition with detectable distal pulses in advanced limb ischaemia due to poor perfusion caused by the dislocation of mural thrombus from an abdominal aortic aneurysm. CASE PRESENTATION: A 74-year-old male patient with underlying hypertension and chronic renal disease presented at the emergency room with bilateral lower limb paralysis after falling on his back in the bathroom an hour prior. He reported numbness and weakness of his lower limbs, which was gradually worsening, over the past week. Physical examination showed cyanotic mottling of the lower limbs with paralysis. However, the dorsalis pedis pulse was intact. Computed tomography angiography showed a 7.3 cm abdominal aortic aneurysm containing highly irregular mural thrombus in the early phase, with slow perfusion of the contrast medium in the arteries below the bifurcation during the delayed phase. After traumatic spinal injury was excluded, an emergent endovascular aneurysm repair was performed. Although vital signs were initially stable post-surgery, both lower limbs were still paralysed and did not improve. He then experienced reperfusion injury with metabolic acidosis. There was no urine output despite intravenous hydration. Laboratory data included potassium 7.7 mEq/L, lactate 110 mg/dL, white blood cells 23,700/uL, and myoglobin 46,590 ng/mL. Even under critical medical care and continuous venovenous hemofiltration, his hemodynamic status worsened. He developed hypotension and needed endotracheal intubation because of loss of consciousness and respiratory failure. The patient finally died due to ventricular tachycardia even after several rounds of cardiopulmonary resuscitation with cardioversion. CONCLUSION: The unusual clinical presentation of detectable lower limb pulses in advanced limb ischaemia showed that poor blood perfusion related to dislocation of mural thrombus in abdominal aortic aneurysm might mislead clinicians and delay accurate diagnosis and treatment.

Spinal cord injury and spinal fracture in patients with ankylosing spondylitis.

BACKGROUND: Spinal cord injury (SCI) and spinal fracture are major complications in patients with ankylosing spondylitis (AS) who sustain spinal trauma. The purpose of this study was to investigate the incidence, predictors, and sequelae of spinal trauma in patients with AS. METHODS: This retrospective study included patients with AS who were admitted for spinal trauma between January 1, 2006, and June 30, 2016. The study compared clinical outcomes of patients between group 1: SCI alone, group 2: spinal fracture alone (no SCI), and group 3: both SCI and spinal fracture. RESULTS: Of the 6285 patients with AS admitted during the retrospective study period, only 105 suffered from spinal trauma and were enrolled in the study. Case number in group 1, 2, and 3 was 11(10.48%), 45(42.85%), and 49(46.67%), respectively. Among the patients with spinal fractures, 52.1% had SCI. Bamboo spine was significantly more prevalent in the fracture group than in the nonfracture group (78.7% vs. 36.4%; P = 0.006). Patients with SCI had more instances of subluxation or dislocation (48.3% vs. 8.9%; P < 0.001) and more cases of spinal epidural hematoma (SEH; 21.7% vs. 2.2%; P = 0.003) than patients without SCI. The rate of delayed diagnosis for spinal fracture was 31.4%, with one-third of patients developing delayed SCI. Among the patients with incomplete SCI, 58.3% achieved neurological improvement after treatment (P = 0.004). CONCLUSIONS: Patients with AS and bamboo spine at radiograph had a higher rate of spinal fracture, which may be an important factor in SCI in patients with AS. Spinal fractures involving the C3-C7 region, subluxation or dislocation, severe spinal fracture, and SEH were found to be predictive of SCI, and SCI in patients with AS resulted in higher mortality and complication rates.

Delayed Progressive Mass Effect After Secured Ruptured Middle Cerebral Artery Aneurysm: Risk Factors and Outcomes.

Objective: Delayed progressive mass effect (DPME) after securing an aneurysm is uncommon following microsurgical or endovascular repair and leads to a poor clinical outcome. Patients with ruptured middle cerebral artery (MCA) aneurysms have a high risk of postoperative oedema and mass effect, which may require decompressive treatment. Because few studies have discussed the risk and predictive factors, we focused on ruptured MCA aneurysms and evaluated the outcomes of these patients and the necessity of salvage surgery when DPME presented. Methods: Data on 891 patients with aneurysmal subarachnoid haemorrhage (aSAH) treated between January 2011 and February 2020 were extracted from the medical database of a tertiary referral centre. A total of 113 patients with aSAH resulting from at least one MCA aneurysm were identified. After excluding patients with several clinical confounders, we enrolled 80 patients with surgically treated aSAH. We examined the characteristics of aneurysms and hematomas, perioperative contrast pooling patterns, presence of distal hematomas, perisylvian low density, occlusive treatment modality, management strategies, the need for salvage surgical decompression, and postoperative 90-day outcomes to identify possible risk factors. Results: DPME was observed in 27 of the 80 patients (33.7%). The DPME and non-DPME group differed significantly in some respects. The DPME group had a higher risk of salvage surgery (p < 0.001) and poorer outcomes (mRS at day 90; p = 0.0018). The univariate analysis indicated that the presence of hematoma, CTA spot signs, perisylvian low density, and distal hematoma were independent risk factors for DPME. We also noted that DPME remained an independent predictor of a poorer 90-day functional outcome (mRS ≤ 2). Conclusion: DPME can lead to salvage decompression surgery and directly relates to poor outcomes for patients with a ruptured MCA aneurysm. Distal hematoma, perisylvian low density, and CTA spot signs on preoperative images can predict DPME.

The surgical strategy for multilevel massive ossification of the posterior longitudinal ligaments.

Purpose: Creating enough decompression, favorable outcome, less complication, and maintain adequate lordosis and stability in the patients with cervical myelopathy due to multilevel massive ossification of the posterior longitudinal ligament (OPLL) still poses a challenge for surgeons. The aim of our study is to retrospectively evaluate our patients and try to seek a better surgical strategy. Methods: Between 2015 and 2019, 55 consecutive patients with multilevel massive OPLL underwent surgical treatment. Among these, 40 patients were treated with cervical laminectomy and then anterior decompression, fusion, and fixation (ADF), which was defined as group 1, and 15 patients were treated with cervical laminectomy and fixation simultaneously, which was defined as group 2. The patient's radiographic characteristics and postoperative outcomes were evaluated. Results: Better postoperative cervical sagittal lordosis and less long-term axial pain was achieved in group 1 (p < 0.001), though the functional outcome had no significant difference. In the multivariable analysis, anterior fixation accounts for independent factors for better cervical sagittal alignment (p < 0.001). No complications directly associated with cervical laminectomy were observed. Conclusion: In patients with cervical multilevel massive OPLL, laminectomy at compression level and then ADF depended on the severity and range of compression, but corpectomy of not more than two vertebral bodies is suggested, except K-line (+) and long-segment massive OPLL majorly involving the C2 and posterior laminectomy above and below the OPLL-affected levels with posterior fixation simultaneously.

Simultaneous acute limb ischemia related to acute Leriche syndrome and pulmonary embolism without existing patent foramen ovale: a case report.

BACKGROUND: Aortoiliac occlusion disease, also called Leriche syndrome, is characterized by atherothrombotic obliteration of the aortic bifurcation and bilateral common iliac arteries; typically, it has a chronic presentation. Pulmonary embolism is more related to venous thromboembolism rather than arterial thromboembolic events. Therefore, cases of simultaneous acute Leriche syndrome and pulmonary embolism are rare. Existing intracardiac right-to-left shunt were detected in most previous cases. Herein, we present the first likely documented case wherein acute Leriche syndrome and pulmonary embolism occurred simultaneously without a patent foramen ovale. CASE PRESENTATION: A 58-year-old man with hyperlipidemia and coronary artery disease presented with a 4-h history of bilateral lower limb numbness. He was a heavy smoker with a history of stroke. Computed tomography angiography revealed pulmonary embolism and aortoiliac artery occlusion. Although a massive thrombus straddled the bilateral pulmonary arteries, orthopnea was his only presentation, without right ventricle failure. Cyanosis of the affected limbs was noted, and muscle strength in both limbs had regressed to grade 1. Owing to acute limb ischemia, he underwent an emergency operation to salvage the limbs. On postoperative day 5, the general condition of both the legs improved; the muscle strength improved to grade 4. He was then transferred to the general ward and enoxaparin was continued. Computed tomography angiography was repeated to evaluate the pulmonary embolism on postoperative day 8; the thrombus remained lodged in the bilateral main pulmonary arteries. Owing to persistent orthopnea and chest tightness with intermittent tachycardia, he underwent a staged operation for the pulmonary embolism on postoperative day 13. During the surgery, intraoperative transesophageal echocardiography showed no patent foramen ovale or an existing right-to-left shunt. Postoperatively, he was closely monitored in the intensive care unit for 3 days and then transferred to the general ward for 10 days. A final computed tomography angiography performed on postoperative day 18 revealed thrombus resolution. He was then discharged on postoperative day 30 without any in-hospital complications. CONCLUSION: We present a case that might be the first documented report of acute Leriche syndrome co-occurring with pulmonary embolism without an existing patent foramen ovale.

Using cortical function mapping by awake craniotomy dealing with the patient with recurrent glioma in the eloquent cortex.

BACKGROUND: Awake craniotomy is an effective method by which to reduce postoperative neurologic deficit in newly-diagnosed glioma patients. However, the level of functional preservation in patients undergoing resection of recurrent glioma remains unknown. Therefore, this study aimed to evaluate functional outcomes in patients with recurrent glioma undergoing awake craniotomy as compared with conservative general anesthesia craniotomy for tumor resection. METHODS: We retrospectively reviewed 225 patients who had recurrent gliomas from May 2013 to January 2016 in our institution. New-onset neurological deficits were evaluated on postoperative day 7 (early) and at 3 months (late). General performance was assessed both preoperatively and at 3 months postoperatively. RESULTS: The early neurological deficit rate was 3.8% in the awake craniotomy group and 21.6% in the general anesthesia group (p. 0.032), while the late neurological deficit rates were 3.8% and 11.5%, respectively (p. 0.231). Moreover, 46.1% of patients in the awake craniotomy group and 12.6% in the general anesthesia group demonstrated an improvement in the Karnofsky performance status (KPS) score (p < 0.001). CONCLUSION: Awake craniotomy is an effective and safe method by which to perform recurrent glioma surgery. The neurological outcomes and general performance after awake craniotomy in recurrent glioma patients were better than those in patients undergoing general anesthesia craniotomy.

The Merits of Awake Craniotomy for Glioblastoma in the Left Hemispheric Eloquent Area: One Institution Experience.

OBJECTIVE: Awake craniotomy (AC) with intraoperative stimulation mapping is the standard treatment for gliomas, especially those on the eloquent cortex. Many studies have reported survival benefits with the use of AC in patients with glioma, however most of these studies have focused on low-grade glioma. The aim of this study was to evaluate the experience of one treatment center over 10 years for resection of left hemispheric eloquent glioblastoma. METHODS: This retrospective analysis included 48 patients with left hemispheric eloquent glioblastoma who underwent AC and 61 patients who underwent surgery under general anesthesia (GA) between 2008 and 2018. Perioperative risk factors, extent of resection (EOR), preoperative and postoperative Karnofsky Performance Score (KPS), progression-free survival (PFS) and overall survival (OS) were assessed. RESULTS: The postoperative KPS was significantly lower in the GA patients compared to the AC patients (p = 0.002). The EOR in the GA group was 90.2% compared to 94.9% in the AC group (p = 0.003). The mean PFS was 18.9 months in the GA group and 23.2 months in the AC group (p = 0.001). The mean OS was 25.5 months in all patients, 23.4 months in the GA group, and 28.1 months in the AC group (p < 0.001). In multivariate analysis, the EOR and preoperative KPS independently predicted better OS. CONCLUSION: The patients with left hemispheric eloquent glioblastoma in this study had better neurological outcomes, maximal tumor removal, and better PFS and OS after AC than surgery under GA. Awake craniotomy should be performed in these patients if the resources are available.

Trochlear Schwannoma Arising from Transition Zone of Nerve Sheath in the Pineal Region: Case Report and Review of the Literature.

BACKGROUND: This report presents the third case of trochlear schwannoma arising from the pineal region and the first case to be resected using a paramedian infratentorial supracerebellar approach. Schwannomas of cranial nerves have traditionally been thought to arise from the transitional point where the axonal envelopment switches from glial cells to Schwann cells; however, recent temporal bone histopathologic evidence from vestibular schwannomas challenges this view. Of the 38 cases of pathology-confirmed trochlear schwannoma in the literature, there are only 2 cases arising from the pineal region, where the nerve sheath transition zone is located. Here, we discuss an unusual case of trochlear schwannoma arising from this transition zone. CASE DESCRIPTION: A 65-year-old man was admitted to our institute after a traffic accident. He complained of headache and dizziness, and a computed tomography scan revealed an isodense mass in the pineal region with obstructive hydrocephalus. Magnetic resonance imaging with contrast showed an enhancing mass in the pineal region. The tumor was subtotally resected using a paramedian infratentorial supracerebellar approach, and pathology confirmed the diagnosis of trochlear schwannoma. CONCLUSIONS: Trochlear schwannoma should be considered when a mass is identified in the pineal region. This diagnosis should still be entertained for mass lesions along the free tentorial edge because the tumor may arise distant from the glial-Schwann transition zone located by the dorsal midbrain. We propose a treatment algorithm for this rare tumor that seeks to maximize functional outcome.