Awake Craniotomy with Functional Mapping for Glioma Resection in a Limited-Resource-Setting: Preliminary Experience from a Lower-Middle Income Country.

BACKGROUND: Awake craniotomy with brain mapping aims to maximize resection of gliomas located within eloquent regions while minimizing the risk of postoperative deficits. This technique is common practice in the developed world but has yet to be implemented in most low- and middle-income countries (LMICs). We assessed the feasibility, safety, and efficiency of functional-based glioma resection using minimal facilities in a limited-resource institution. METHODS: This is a retrospective review of patients harboring gliomas within eloquent regions who underwent awake craniotomy and tumor resection guided by cortico-subcortical mapping at a tertiary hospital of an LMIC. Patient characteristics, surgical results, and functional outcomes were studied. RESULTS: Twenty consecutive patients with a mean age of 37 years were enrolled in the study. Seizure, present in 70% of patients, was the major presenting symptom. Eighteen patients had diffuse low-grade gliomas and 2 patients had high-grade gliomas. Intraoperative events were dominated by seizures, occurring in 5 patients (25%). The average extent of tumor removal was 89.5% and the rate of total and subtotal removal was 85%. New postoperative deficits were observed in 5 patients (25%), and permanent deficits were found in 1 patient (5%). The main hurdles encountered were the difficulties in investigating patients and human resource availability. CONCLUSIONS: Awake craniotomy with brain mapping for functional-based resection of gliomas can be safely achieved in a limited-resource institution with good functional and oncologic results.

Spontaneous atlanto-axial dislocation and trisomy 21: causal factors and management.

Spontaneous atlanto-axial (C1-C2) dislocation is an atlanto-axial instability, found in 10 to 30% of trisomy 21 patients, the majority of whom is asymptomatic. We report a case of a 21 years-old woman, with trisomy 21, admitted in our department presenting a spinal cord compression syndrome with right hemiparesis associated with a cervicalgia evolving for 3 months of admission without trauma. Standard cervical radiography showed a C1-C2 dislocation with posterior displacement of the odontoid process. A cervical computerized tomography revealed a C1-C2 dislocation with significant recoil of the odontoid process. A cervical magnetic resonance imaging (MRI) confirmed the bulbo-medullar junction compression on the dislocation. The surgical treatment consisted of a cervico-occipital fixation. The laxity of the transverse ligament is one of the main causes of C1-C2 dislocation; hypoplasia, malformation or complete absence of the odontoid process; are also predisposing factors. It must be early detected. The treatment of choice is surgical also by arthrodesis of C1 to C4 + graft and enlargement of the occipital foramen or occipito-cervical arthrodesis by synthetic graft and Cotrel-Dubousset system or occipito-C4 arthrodesis + laminectomy of C1 and enlargement of the occipital foramen.

Acute Lumbar Spinal Subdural Hematoma Inducing Paraplegia After Lumbar Spinal Manipulation: Case Report and Literature Review.

BACKGROUND: Traumatic spinal subdural hematoma is an extremely rare occurrence that requires urgent investigation and most often prompt intervention. To our knowledge, this is the first reported case related to a spinal manipulative therapy. CASE DESCRIPTION: This report describes a case of traumatic lumbar subdural hematoma after a spinal manipulative therapy without any predisposing factor. A 23-year-old man was admitted to the emergency department for partial cauda equina syndrome after a spinal manipulation performed by a physiotherapist. Magnetic resonance imaging showed an acute spinal subdural hematoma at L2-L3 level with cauda equina compression. The patient underwent an emergency L2 laminectomy with evacuation of the hematoma. He recovered completely his neurologic functions after 1 week. CONCLUSION: Practitioners of spinal manipulations should be aware of spinal subdural hematoma as a possible complication. A rapid diagnosis with magnetic resonance imaging is mandatory, and emergency surgical decompression is usually the optimal treatment for spinal subdural hematomas with severe neurologic deficit.

Paraganglioma of the sacral spinal canal.

Paragangliomas are tumors arising in the paraganglia. Involvement of the spine is less common, and usually takes the form of intradural compression of the cauda equina. We report here a case of a 60-year-old man with recurrent and progressive pain of his sacral and perineal area, accompanied by occasional rod and perineal hypoesthesia on admission. He underwent laminectomies of the vertebral bodies S1 and S2, and an en bloc resection of the tumor. Postoperative histopathological examination revealed a paraganglioma. Postoperative staging showed no pathological abnormalities, and no tumor recurrence after one year. Even though rare, the paraganglioma of the sacral spinal canal should be considered in the differential diagnosis of tumors occurring in the spine.

Primary liposarcoma of the lumbar spine.

BACKGROUND: We describe a rare case of the cauda equina syndrome caused by a primary pleomorphic liposarcoma of the lumbar spine. CASE REPORT: A 35-year-old man presented a 2-month history of back pain and slowly progressive weakness of lower limbs without sphincter dysfunction. It had a laminectomy for a supposed disc herniation three years previously. A diagnosis of recurrence hernia or fibrosis was discussed. RESULTS: Magnetic Resonance Imaging (MRI) and CT scan of the lumbar vertebral column shows diffuse involvement of L4/L5 vertebral bodies, and an intradural lesion surrounding the nerve roots of cauda equina. The tumor occupied almost the whole width of the spinal canal. The diagnosis of plasmocytoma or metastasis was advocated and the patient was managed by an extended posterior approach in emergency. Histopathological findings revealed a pleomorphic liposarcoma. The patient received a course of radiotherapy and unfortunately he died at 3 months follow-up. CONCLUSION: In spite of his unusual location in the spine, pleomorphic liposarcoma should be considered in the differential diagnosis of primary spinal tumors.

Spinal intramedullary arachnoid cyst in children.

The authors report an unusual case of a child who presented with progressive paraparesis that lasted 15 days, revealing an intramedullary cystic lesion extending from T(3) to T(4) as detected with spine magnetic resonance imaging. A laminotomy from T(3) to T(4) was performed and the lesion removed. Histopathological findings confirmed the diagnosis of arachnoid cyst. After surgery, the patient's neurological status improved. At the 4-month follow-up examination, the results of his neurological examinations remained normal. Arachnoid cyst is an entity that should be included in the differential diagnosis of intramedullary cystic lesions.