NMC case report journal最新文献

Traumatic dural venous sinus injury is uncommon but potentially fatal because of massive hemorrhage at presentation or during surgery, and intracranial hypertension caused by impaired venous outflow. We report a case of a young woman with an open depressed skull fracture over the vertex caused by repeated blunt assault. Computed tomography revealed a large midline depressed fracture with bony fragments penetrating the superior sagittal sinus. On arrival, the patient was in hemorrhagic shock, with a semicoma status and right hemiparesis. Emergency surgery was performed for hemostasis and wound debridement. Because the wound was contaminated, irregular, and associated with a crushed sinus wall, direct sinus suturing was considered unsuitable for this patient. After temporary hemostasis with head elevation and Gelfoam compression, the injured superior sagittal sinus was reconstructed using an autologous fascia lata patch reinforced with fibrin glue. A postoperative epidural hematoma at the fracture site required immediate evacuation. On day 2, severe intracranial hypertension developed despite the initial surgery, and multimodal neurocritical care was instituted, including intracranial pressure monitoring, external ventricular drainage, deep sedation and analgesia, neuromuscular blockade, hypertonic saline, targeted temperature management, and pentobarbital infusion. The intracranial pressure gradually stabilized, and the patient was extubated on postoperative day 14. She was transferred for rehabilitation and ultimately achieved an excellent functional outcome, with a modified Rankin Scale score of 1. This case highlights the importance of preserving superior sagittal sinus patency using autologous patch repair in contaminated open injuries and promptly escalating intracranial pressure-directed intensive care when delayed venous outflow impairment is suspected.

Brain metastases from non-small cell lung cancer are typically managed with local therapies, such as surgery and radiotherapy, whereas systemic treatments have historically demonstrated limited efficacy in the intracranial setting. Immune checkpoint inhibitors, particularly programmed cell death-1 inhibitors, have recently demonstrated potential in this context. We report a case of a 48-year-old man with lung adenocarcinoma who developed a radiation-resistant brain metastasis with postoperative recurrence and severe neurological deterioration. Despite multiple courses of stereotactic radiosurgery and surgical resection, the lesion progressed, accompanied by seizures, impaired consciousness, and poor performance status. Pembrolizumab monotherapy was initiated as salvage treatment. Although initial clinical and radiological worsening, rapid tumor regression was observed within 1 month, along with marked neurological recovery. Notably, the patient achieved sustained complete remission without additional systemic therapy and remained alive for more than 7 years after treatment. Histopathological evaluation revealed increased programmed cell death-ligand 1 expression in brain metastasis compared to that in the primary tumor, possibly influenced by prior radiotherapy. This case highlights the potential synergy between radiotherapy and immune checkpoint inhibitors. Even in patients with poor performance status and refractory intracranial disease, programmed cell death-1 blockade may provide durable clinical benefits in selected patients.

Orbital metastasis from endometrial cancer is rare. In particular, metastasis to the extraocular muscles has not been reported. Herein, we present a case of endometrial metastasis to the extraocular muscles. A 70-year-old woman presented with a history of endometrial cancer, with complaints of pain, proptosis, and swelling in her left eyelid. Since magnetic resonance imaging revealed a left orbital tumor, she was referred to our hospital. The tumor was 25 mm in size and was located in the inferior medial extraocular muscle. As the tumor had ring enhancement, and the patient was undergoing treatment for endometrial cancer, orbital metastasis was suspected. We performed tumor resection and orbital decompression by endoscopic endonasal surgery. The pathology results revealed metastasis from the endometrial cancer. After the surgery, her symptoms improved, and stereotactic radiation therapy was initiated. Although, treatment resulted in the shrinkage of the orbital metastasis tumor, the primary tumor progressed, and she died 4 months after her initial visit to our department. The endoscopic endonasal approach to extraocular muscle metastasis was minimally invasive and was effective in reducing pain. In addition, radiotherapy showed a marked effect on the residual tumor, suggesting that combination of these treatments was beneficial.

Chronic subdural hematoma associated with malignant tumors rarely occurs and is frequently characterized by early recurrence and poor prognosis. Dural metastasis is the most common underlying mechanism; however, metastatic involvement of the hematoma outer membrane is extremely rare. A case of rapidly recurrent chronic subdural hematoma caused by metastatic esophageal cancer involving the dura mater and the hematoma outer membrane is reported. A 74-year-old man with stage IVB esophageal squamous cell carcinoma presented with persistent headache without a history of head trauma. Magnetic resonance imaging revealed a right-sided chronic subdural hematoma with midline shift, and burr-hole drainage was performed. However, symptoms recurred after 3 days. Contrast-enhanced magnetic resonance imaging revealed a mildly enhancing mass attached to the falx cerebri. Craniotomy revealed a dural metastatic lesion, and pathological examination confirmed poorly differentiated squamous cell carcinoma. Identical metastatic tumor cells were also found in the hematoma outer membrane. The patient recovered without new neurological deficits and subsequently underwent whole-brain irradiation. Six weeks post treatment, a cystic intracerebral lesion developed adjacent to the resection cavity and was successfully treated by cyst drainage. The patient remained free of recurrent chronic subdural hematoma and neurological deterioration until the terminal stage but ultimately died from complications associated with primary esophageal cancer 110 days after the initial surgery. Metastatic disease should be considered in patients with rapid recurrence of chronic subdural hematoma after burr-hole drainage. In such cases, craniotomy with resection of both the dural metastasis and hematoma outer membrane may be considered as a treatment option to reduce recurrence and preserve neurological function in selected patients.

Diffuse intracranial dural arteriovenous fistulas involving interconnected dural sinuses are uncommon lesions with complex angioarchitecture and an evolving clinical course. However, long-term treatment outcomes and surveillance strategies remain poorly characterized. We retrospectively reviewed 49 consecutive patients with intracranial dural arteriovenous fistulas treated at our institution for 10 years. The study included 9 patients with diffuse intracranial dural arteriovenous fistulas involving 2 or more interconnected dural sinus compartments. Endovascular treatment was used as the first-line therapy for symptomatic or hemodynamically significant lesions, and stereotactic radiosurgery was incorporated for residual low-flow shunts or selected lesions that were not amenable to safe or complete endovascular treatment. Follow-up magnetic resonance imaging and digital subtraction angiography were used to assess shunt occlusion, recurrence, and newly detected shunt lesion in other dural sinus compartments. Nine patients were male. On a sinus-compartment basis, 30 shunt-related sinuses were identified. Shunting most commonly involved the transverse-sigmoid sinus, followed by the torcular confluence and the superior sagittal sinus. Cortical venous reflux was observed in 6 patients. Five patients showed multi-compartment shunt involvement at diagnosis, whereas 4 indicated newly detected shunt involvement during follow-up. Staged multimodal treatment achieved complete occlusion in 18 shunting compartments and partial occlusion in 8 with improved venous drainage; the remaining 4 were managed conservatively. The mean follow-up was 49 months (range, 20-70 months), and patients had favorable outcomes with a modified Rankin Scale score of 0-2. Diffuse intracranial dural arteriovenous fistulas may follow an evolving angiographic course even after treatment, underscoring the importance of long-term follow-up and individualized staged management.

Gamma knife radiosurgery is an established minimally-invasive treatment for trigeminal neuralgia, but recurrence remains a concern, and the trigeminal division involved at relapse is rarely documented. A 63-year-old man developed recurrent trigeminal neuralgia 3 years after gamma knife radiosurgery for left V2-V3 pain, presenting this time with isolated V1 involvement. Magnetic resonance imaging revealed persistent, severe neurovascular compression of the left trigeminal root by a tortuous left vertebral artery with marked nerve flattening. Microvascular decompression achieved immediate and complete pain relief, and postoperative imaging confirmed full decompression. This case illustrates a V1-dominant recurrence pattern after gamma knife radiosurgery in the setting of persistent, deforming neurovascular compression by a tortuous vertebral artery. Although division-specific radiosurgical effects could not be confirmed, the complete resolution of pain after microvascular decompression supports the clinical importance of reassessing persistent mechanical compression when recurrent pain appears in a different trigeminal division.

Intracranial dermoid cysts are rare congenital lesions of ectodermal origin. Those arising in the Sylvian fissure are particularly rare, and rupture in this location has only infrequently been reported. A 54-year-old woman presented with a persistent headache after minor head trauma. Magnetic resonance imaging demonstrated a well-circumscribed 30-mm lesion in the left Sylvian fissure with heterogeneous hyperintensity on T1-weighted images. Multiple disseminated hyperintense droplets within the basal cisterns suggested cyst rupture. The patient underwent microsurgical resection via a trans-Sylvian approach. Intraoperatively, the cyst wall was partially deficient and adherent to the surrounding vessels. Owing to dense calcification of the wall and firm adhesion to adjacent neurovascular structures, the capsule was left in place, and the cyst contents were evacuated and curetted, followed by thorough irrigation. Histopathological examination confirmed a dermoid cyst. The postoperative course was uneventful, and no recurrence has been observed during 9 months of follow-up. Ruptured dermoid cysts in the Sylvian fissure are exceedingly rare. Recognition of disseminated lipid droplets is crucial for diagnosis, and safe resection with preservation of critical neurovascular structures is essential for favorable outcomes.

Vertebral compression fractures (VCF) after radiation therapy (RT) are uncommon, particularly in the mid- and lower cervical spine. Surgical management of symptomatic cases can be challenging. Here, we report the case of a 63-year-old woman with radiculomyelopathy and C7 VCF. The patient presented with neck pain and bilateral hand numbness without osteoporosis. Four years previously, she had been cured of esophageal cancer through endoscopic surgery and RT without chemotherapy. Imaging revealed a pathological C7 vertebral body fracture with kyphotic deformity. Symptomatic VCF was diagnosed. Because of concerns regarding complications with an anterior approach, posterior-only decompression and fixation were performed. Intraoperative biopsy at C7 vertebra confirmed a diagnosis of avascular necrosis without metastasis. Fixation was performed by inserting lateral mass screw at C5-, 6 and pedicle screw at T1-, 2, connected by a rod. A multipoint screw was used to enhance rostral stability. The symptoms were alleviated postoperatively, and the patient remained well at 2-year follow-up.