NMC case report journal最新文献

Intracranial schwannomas account for approximately 8% of all primary brain tumors, and the majority arise in the cerebellopontine angle. Ectopic schwannomas that originate from non-cranial nerve sites, such as the dura mater or brain parenchyma, are rare, representing less than 1% of all intracranial schwannomas. These lesions often mimic meningiomas on neuroimaging, making preoperative diagnosis challenging. A woman in her 50s was referred to our department after a brain check-up incidentally revealed a mass lesion extending both above and below the tentorium. Neurological examination was unremarkable. Magnetic resonance imaging demonstrated a well-defined, heterogeneously enhancing extra-axial mass widely attached to the tentorium, suggestive of meningioma. The lesion was completely resected via a suboccipital approach. Histopathological examination revealed spindle-shaped tumor cells with palisading nuclei, positive for S-100 protein and negative for epithelial membrane antigen, confirming the diagnosis of schwannoma. The MIB-1 (Ki-67) labeling index was below 5%, consistent with a benign lesion. Postoperative magnetic resonance imaging confirmed total resection, and the patient's postoperative course was uneventful. No recurrence was observed during a 7-month follow-up period. Tentorial ectopic schwannoma is an extremely rare entity that can closely resemble meningioma both radiologically and intraoperatively. Awareness of this entity is important when evaluating tentorial extra-axial tumors. Although the clinical course is generally favorable following complete resection, careful preoperative evaluation is essential for accurate diagnosis and appropriate management.

Dural laceration is a critical complication in full endoscopic spinal surgery. We need to recognize precise surgical anatomy to avoid it. Recently identified dorsal meningovertebral ligaments, connecting the dorsal spinal dura mater to the ligamentum flavum, may contribute to this risk, but their role remains unclear. We present 2 cases of lumbar spinal canal stenosis treated with full endoscopic laminectomy. In both cases, dorsal meningovertebral ligaments anchored the dura to the ligamentum flavum and were visible through high-resolution endoscopy. Attempts to remove ligamentum flavum fragments caused dural traction via the dorsal meningovertebral ligament, nearly resulting in laceration. We modified our approach by detaching the dorsal meningovertebral ligament before flavectomy, preventing dural injury and ensuring uneventful recoveries. These cases highlight the importance of recognizing dorsal meningovertebral ligament as a potential risk factor for dural laceration during full endoscopic laminectomy. Although the presence of dorsal meningovertebral ligament cannot be predicted preoperatively, the enhanced visualization provided by full endoscopic spinal surgery allows for intraoperative identification. We recommend careful inspection for dorsal meningovertebral ligament before flavectomy during full endoscopic laminectomy. If identified, these ligaments should be detached prior to ligamentum flavum removal to minimize the risk of dural injury. This approach can significantly enhance the safety of the full endoscopic laminectomy procedure and potentially reduce the incidence of dural complications in full endoscopic spinal surgery.

Acute thrombosis is often observed following the rupture of an intracranial aneurysm, and optimal coil selection during endovascular coiling is challenging. A 75-year-old woman presented with a subarachnoid hemorrhage. Computed tomography angiography revealed aneurysms at the right anterior cerebral artery A2/3 junction and the right middle cerebral artery. Based on vessel wall imaging, the anterior cerebral artery aneurysm was diagnosed as the rupture site. Initial digital subtraction angiography demonstrated a 4.4 × 3.4 × 3.4 mm aneurysm with a 1.6 mm neck. Coil embolization was performed 1 day after diagnostic angiography. Preprocedural angiography revealed significant lumen shrinkage to 2.0 mm, probably due to aneurysmal thrombosis. A 4 mm framing coil was selected based on the initial digital subtraction angiography findings. Contrast extravasation occurred after coil deployment. Immediate protamine administration, blood pressure reduction, and coil embolization with smaller coils in the opacified aneurysm dome achieved hemostasis. Final angiography confirmed complete occlusion, without residual filling or distal thrombus migration. Postoperative computed tomography showed an intracerebral hematoma in the left frontal lobe, which subsequently resolved. The patient recovered without focal neurological deficits and was transferred to a rehabilitation hospital on day 18 with mild attention deficits. This case demonstrates the risk of intraprocedural rupture when coil sizing is selected based on pre-thrombosis dimensions rather than current lumen visualization in rapidly thrombosing aneurysms. When thrombosis reduces the lumen, selecting the coil size based on pre-thrombosis dimensions may increase the risk of intraoperative rupture. Coil size selection should match the currently visualized lumen.

Essential tremor is the most common adult movement disorder, typically presenting with kinetic and postural tremor that interferes with daily activities. For patients unresponsive to medications, surgical options such as radiofrequency thalamotomy, deep brain stimulation, and magnetic resonance-guided focused ultrasound can provide therapeutic benefit. Magnetic resonance-guided focused ultrasound, an incisionless lesioning modality, has gained clinical use; however, accurate targeting of the ventral intermediate nucleus remains challenging because the nucleus cannot be directly visualized on routine magnetic resonance imaging and exhibits substantial individual variability. This report describes 2 cases of medication-refractory essential tremor treated with magnetic resonance-guided focused ultrasound ventral intermediate nucleus thalamotomy under structurally complex conditions. One patient had a thick skull with a low skull density ratio, and the other exhibited marked thalamic distortion. In both cases, individualized ventral intermediate nucleus targeting was performed using multimodal imaging that combined a stereotactic planning platform, dentatorubrothalamic tract tractography, and Fast Gray Matter Acquisition T1 Inversion Recovery. The Fast Gray Matter Acquisition T1 Inversion Recovery sequence, which enhances gray-white matter contrast, provided relative contrast of intrathalamic structures, including signal patterns corresponding to the internal medullary lamina. When integrated with connectivity-based dentatorubrothalamic tract tractography, this approach provided complementary information to support anatomically guided targeting. Stepwise sonication with intraoperative thermal monitoring resulted in substantial tremor reduction without new neurological deficits. These observations suggest that combining Fast Gray Matter Acquisition T1 Inversion Recovery with tractography offers practical, complementary guidance for ventral intermediate nucleus targeting, including in settings without access to advanced commercial integration software. Although limited to 2 patients, this work suggests the value of accessible multimodal imaging for improving confidence in anatomy-informed targeting in magnetic resonance-guided focused ultrasound and potentially other lesioning procedures.

This report discusses the case of a 70-year-old male orthopedic surgeon with multilevel lumbar foraminal stenosis and degenerative scoliosis (Cobb angle 21°) who presented with right leg radiculopathy and foot drop. To accommodate his inability to take extended leave and his desire to avoid fusion, we performed a staged transforaminal full-endoscopic lumbar foraminotomy, consisting of one procedure per level, under local anesthesia. The procedures targeted the L5/S1, L4/5, and L3/4 levels sequentially at 1-month intervals. The patient's foot drop resolved immediately after the first surgery. At the 3-month follow-up after the final procedure, his motor deficits showed marked improvement, and his Oswestry Disability Index score decreased from 12% to 8%. He returned to his clinical duties the day after each discharge and was able to continue managing his private clinic without interruption. He resumed playing golf 2 months after the final surgery. A staged, non-fusion transforaminal full-endoscopic lumbar foraminotomy approach under local anesthesia was a safe and effective strategy for multilevel foraminal stenosis, even in the presence of deformity, providing excellent functional recovery with minimal disruption to the patient's professional life.

This report presents 2 cases demonstrating how a foraminal block served as both a diagnostic tool and an effective treatment for small far-lateral lumbar disc herniation at L5-S1 in elite athletes. The patients were a male swimmer in his early 20s and a female figure skater in her late teens, both of whom developed activity-related low back pain, with symptoms acutely exacerbated by the high flexion and extension loads inherent to their sports, which compromised their ability to compete at the highest level. A fluoroscopy-guided foraminal block was performed in each case; the key technical component was careful paraneural needle placement, stopping just short of the nerve root to minimize the risk of iatrogenic injury while targeting the inflammatory environment throughout the foramen. The diagnosis was confirmed in both athletes by reproducing their specific pain during injection. This non-operative intervention provided pain relief that was sufficient for successful participation in a major international competition in one case and continuation of a critical qualifying season for a premier global event in the other. This approach represents a critical diagnostic and therapeutic strategy that can avoid the need for surgery and preserve an elite athlete's immediate career goals.

Aneurysms of the meningohypophyseal trunk are rare and usually asymptomatic, but because of the close anatomical relationship between the meningohypophyseal trunk and cranial nerves within the cavernous sinus, they can cause neurological deficits. We describe an 80-year-old woman who presented with acute horizontal diplopia exacerbated on rightward gaze. Neurological examination revealed isolated right abducens nerve palsy. Magnetic resonance angiography demonstrated an aneurysm arising from the right meningohypophyseal trunk in close proximity to the abducens nerve. Endovascular coil embolization was performed under dual antiplatelet therapy, and the aneurysm was successfully occluded while preserving meningohypophyseal trunk patency. The procedure was uneventful, although postoperative diffusion-weighted imaging revealed multiple small cerebral infarctions suggestive of distal embolism. The patient remained neurologically stable, and her diplopia gradually improved. At the 6-month follow-up, she exhibited complete recovery of abducens nerve function. This case highlights the anatomical vulnerability of the abducens nerve to compression by meningohypophyseal trunk aneurysms and underscores the importance of considering vascular lesions in the differential diagnosis of isolated cranial nerve palsies. Despite radiographic evidence of silent embolic infarction, endovascular coil embolization resulted in full clinical recovery, supporting its role as a safe and effective therapeutic option in appropriately selected symptomatic meningohypophyseal trunk aneurysms.

Choroid plexus cysts are typically benign lesions found within the ventricular system during prenatal imaging and are usually asymptomatic. Intraparenchymal choroid plexus cysts, especially in adults, are exceptionally rare, with very few reported cases. This case report aims to present a rare instance of a symptomatic, intraparenchymal choroid plexus cyst in an adult patient and to discuss the diagnostic and surgical considerations involved. We present the case of a 50-year-old man with complaints of lower extremity weakness and imbalance who was found to have a bilobulated cyst in the frontal cortex causing significant mass effect and midline shift. The patient underwent cyst fenestration through endoscope-assisted open craniotomy, with marked postoperative reduction in cyst size and resolution of neurological symptoms. Histopathology confirmed the diagnosis of a choroid plexus cyst. This case highlights the importance of considering rare pathologies such as choroid plexus cysts in the differential diagnosis of cystic brain lesions with mass effect in adults.

Although rare, thrombosed vertebral artery aneurysms can lead to severe symptoms and are challenging to treat due to their proximity to vital structures. The location of a thrombosed aneurysm on the anterior aspect of the brainstem poses a significant challenge to conventional microscopic approaches. We herein report a 78-year-old man with a thrombosed right vertebral artery aneurysm who developed progressive quadriparesis, dysphagia, and respiratory failure despite prior interventions, including flow diverter stent placement, parent artery occlusion, and microscopic thrombectomy. Given worsening medullary compression and poor clinical status, intra-aneurysmal thrombectomy was performed using an exo-endoscopic 2-step approach. The procedure involved reopening the previous suboccipital craniotomy, partial condylectomy, and C1 hemilaminectomy. Exoscopic thrombus de-bulking was followed by endoscopic evacuation of the residual thrombus compressing the ventral brainstem. Postoperatively, no complication was observed, and the patient demonstrated gradual neurological improvement, including recovery of spontaneous respiration and the ability to wean from mechanical ventilation within 3 weeks. Follow-up imaging confirmed resolution of medullary compression without thrombus recurrence. The exo-endoscopic 2-step approach is a viable option for surgical decompression of thrombosed vertebral artery aneurysms that cause brainstem compression. This enhances surgical access and visualization, particularly in the ventral brainstem, while potentially minimizing brainstem manipulation. Further investigation is warranted to better define the indications, efficacy, and safety of the management of complex thrombosed aneurysms.

Abusive head trauma in infants and young children can have a significant impact on neurological outcomes and, in severe cases, may be life-threatening. We report 3 cases of abusive head trauma that presented with acute subdural hematomas on computed tomography scans, accompanied by extensive low-density areas and parenchymal brain swelling. All patients exhibited impaired consciousness due to brain injury and underwent craniotomy for hematoma evacuation as well as extensive decompressive craniectomy. Despite the severity of the initial presentation, hemiparesis was mild and gradually improved over several months. Postoperative magnetic resonance imaging revealed widespread parenchymal injury but preservation of the corticospinal tract, including the precentral gyrus. In the acute phase, diffusion-weighted imaging showed no irreversible infarction in the motor cortex, and arterial spin labeling demonstrated increased perfusion in peri-motor regions of the affected hemisphere. These findings suggest that preserved corticospinal pathways and compensatory hyperperfusion may correlate with favorable motor recovery even in the presence of extensive parenchymal damage. These cases highlight the radiological features and short-term neurological outcomes of abusive head trauma, demonstrating preserved motor function despite extensive parenchymal damage.