Endoscopic spinal cord untethering using a 1 cm skin incision technique in pediatrics: a technical case report.

BACKGROUND: Spinal cord untethering by sectioning the filum terminale is commonly performed in tethered cord syndrome patients with minor abnormalities such as filar lipoma, thickened filum terminale, and low conus medullaris. Our endoscopic surgical technique, using the interlaminar approach, allows for sectioning the filum terminale through a very small skin incision. To our knowledge, this procedure has not been previously reported. This is the first case report involving a 1 cm skin incision. CASE PRESENTATION: A 9-month-old male patient was referred to our neurosurgical department due to a coccygeal dimple. MRI revealed a thickened fatty filum. After considering the treatment options for this patient, the parents agreed to spinal cord untethering. A midline 1 cm skin incision was made at the L4/5 vertebral level. Untethering by sectioning the filum terminale was performed by full endoscopic surgery using the interlaminar approach. The procedure was uneventful and there were no postoperative complications. CONCLUSIONS: In terms of visibility and minimizing invasiveness, our surgical technique of using the interlaminar approach with endoscopy allows for untethering by sectioning the filum terminale through a very small skin incision.

Surgical aspects using an exoscope for corpus callosotomy: initial experience for epilepsy surgery.

The exoscope is a new form of optic device that has begun to be used in the last decade. The exoscope provides high-quality magnification and illumination at depth, allowing easy manipulation of surgical instruments even in narrow surgical fields. Exoscopic corpus callosotomy (CC) has not been reported. We report herein our initial experience with the utility of exoscopic CC. A 3-year-old boy diagnosed with West syndrome at 4 months old was referred to our hospital. As the seizure spasms were considered to carry a risk of severe traumatic injury, we performed exoscopic CC as palliative therapy. An EX VITOM 3D exoscope and 4K-3D surgical monitor were used during the procedure. No surgical complications that could be related to exoscope use were noted. Operative time for exoscopic CC was comparable to that for microscopic CC, despite a lack of previous experience with the equipment. Stereoscopic vision was easily obtained. The exoscope was perceived as providing higher quality magnification. We report our first clinical experience of exoscopic CC. The exoscope appears useful in the field of epilepsy surgery.

Successful Hemispherotomy in a Patient with Encephalopathy with Continuous Spikes and Waves during Sleep Related to Neonatal Thalamic Hemorrhage: A Case Report with Intracranial Electroencephalogram Findings.

Neonatal thalamic hemorrhage is a strong risk factor for developing encephalopathy with continuous spikes and waves during sleep (ECSWS), even when not accompanied by widespread cortical destruction. The efficacy and indication of resective epilepsy surgery in such patients has not yet been reported. A 4-year-old boy was diagnosed with ECSWS based on strong epileptiform activation during sleep and neurocognitive deterioration. He had a history of left thalamic hemorrhage related to a straight sinus thrombosis during the newborn period. He presented with daily absence seizures that were refractory to medical treatment. At age 5, he underwent intracranial electroencephalogram (EEG) recording using depth and subdural strip electrodes placed in the left thalamus and over bilateral cortex, respectively. Interictal and ictal epileptiform discharges were observed in the thalamus, always preceded by discharges in the left or right parietal lobe. Left hemispherotomy successfully normalized the EEG of his unaffected hemisphere and extinguished his seizures. This is the first case report documenting resective epilepsy surgery in a patient with ECSWS due to neonatal thalamic injury without widespread cerebral destruction. Based on intracranial EEG findings, his injured thalamus did not directly generate the EEG abnormalities or absence seizures on its own. Patients with ipsilateral neonatal thalamic injury and even mild lateralized cortical changes may be candidates for resective or disconnective surgery for ECSWS.

Postoperative Pneumocephalus on Computed Tomography Might Predict Post-Corpus Callosotomy Chemical Meningitis.

BACKGROUND: A corpus callosotomy (CC) is a procedure in which the corpus callosum, the largest collection of commissural fibers in the brain, is disconnected to treat epileptic seizures. The occurrence of chemical meningitis has been reported in association with this procedure. We hypothesized that intraventricular pneumocephalus after CC surgery represents a risk factor for postoperative chemical meningitis. The purpose of this study was to analyze the potential risk factors for postoperative chemical meningitis in patients with medically intractable epilepsy who underwent a CC. METHODS: Among the patients who underwent an anterior/total CC for medically intractable epilepsy between January 2009 and March 2021, participants were comprised of those who underwent a computed tomography scan on postoperative day 0. We statistically compared the groups with (c-Group) or without chemical meningitis (nc-Group) to determine the risk factors. RESULTS: Of the 80 patients who underwent a CC, 65 patients (25 females and 40 males) met the inclusion criteria. Their age at the time of their CC procedure was 0-57 years. The c-Group (17%) was comprised of seven females and four males (age at the time of their CC procedure, 1-43 years), and the nc-Group (83%) was comprised of 18 females and 36 males (age at the time of their CC procedure, 0-57 years). Mann-Whitney U-tests (p = 0.002) and univariate logistic regression analysis (p = 0.001) showed a significant difference in pneumocephalus between the groups. CONCLUSION: Postoperative pneumocephalus identified on a computed tomography scan is a risk factor for post-CC chemical meningitis.

Epilepsy in patients with focal cortical dysplasia may be associated with autism spectrum disorder.

INTRODUCTION: Patients with epilepsy associated with focal cortical dysplasia (FCD) may be associated with autism spectrum disorder (ASD). Therefore, the purpose of this study was to compare surgically treated patients with epilepsy secondary to FCD and normal volunteers without epilepsy and to review the neuropathological findings of patients with FCD. METHODS: This study involved 38 patients with medically intractable focal onset epileptic seizures who underwent epilepsy surgery (Group 1). All patients had epilepsy associated with FCD. These patients and 38 normal volunteers without epilepsy (Group 2) were administered the autism spectrum quotient (AQ) test, and the groups were compared. RESULTS: The 38 patients in Group 1 included 16 females and 22 males (age range 20-60, mean age, 33.0; standard deviation (SD), 11.8 years). The normal volunteers in Group 2 included 22 females and 16 males (age range 20-57, mean age, 30.6 years; SD, 8.8 years). Total AQ scores were significantly higher in Group 1 than Group 2 (p = 0.027). Patients with FCD I showed a higher AQ score than those with FCD II in the AQ test (p ≤ 0.001). CONCLUSION: Patients with epilepsy secondary to FCD were associated with higher ASD score than normal volunteers. This tendency was seen more strongly in patients with FCD I than FCD II.

Freedom From Seizures Might Be Key to Continuing Occupation After Epilepsy Surgery.

Introduction: We hypothesized that epilepsy surgery for adult patients with temporal lobe epilepsy (TLE) who obtained freedom from seizures could provide opportunities for these patients to continue their occupation, and investigated continuity of occupation to test this postulation. Methods: Data were obtained from patients who had undergone resective surgery for medically intractable TLE between October 2009 and April 2019 in our hospital. Inclusion criteria were as follows: (1) ≥16 years old at surgery; (2) post-operative follow-up ≥12 months; (3) seizure-free period ≥12 months. As a primary outcome, we evaluated employment status before and after surgery, classified into three categories as follows: Level 0, no job; Level 1, students or homemakers (financially supported by a family member); and Level 2, working. Neuropsychological status was also evaluated as a secondary outcome. Results: Fifty-one (87.9%) of the 58 enrolled TLE patients who obtained freedom from seizures after surgery continued working as before or obtained a new job (employment status: Level 2). A significant difference in employment status was identified between before and after surgery (p = 0.007; Wilcoxon signed-rank test). Twenty-eight patients (48.3%) were evaluated for neuropsychological status both before and after surgery. Significant differences in Wechsler Adult Intelligence Scale-III scores were identified between before and after surgery (p < 0.05 each; paired t-test). Conclusion: Seizure freedom could be a factor that facilitates job continuity, although additional data are needed to confirm that possibility. Further investigation of job continuity after epilepsy surgery warrants an international, multicenter study.

Case Report: Late-Onset Temporal Lobe Epilepsy Following Subarachnoid Hemorrhage: An Interplay Between Pre-existing Cortical Development Abnormality and Tissue Damage.

Epileptogenicity following brain insult depends on various factors including severity of the resulting lesion and extent of brain damage. We report a 54-year-old female patient who developed medically refractory epilepsy resulting from the interplay of pre-existing and post-insult pathologies. She presented with subarachnoid hemorrhage (SAH) due to a ruptured aneurysm and underwent clipping surgery. Seizures started 3 months post-operatively. MRI revealed cerebral ischemia and hemosiderin deposits in the left temporal lobes, and left hippocampal atrophy was suspected. As anti-seizure medications and vagus nerve stimulation failed to control her seizures, she underwent left temporal lobe resection and placement of a ventriculoperitoneal shunt for the post-operative complication of hydrocephalus. She remains seizure-free to date. Neuropathology revealed a previously undiagnosed focal cortical dysplasia (FCD) type 1a. Brain insult likely had a second hit effect in the late onset of epilepsy in this patient with pre-existing mild MCD, in whom secondary epilepsy can be attributed to the interplay of multiple underlying pathologies.

Higher intelligence may be a risk factor for postoperative transient disturbance of consciousness after corpus callosotomy.

INTRODUCTION: Corpus callosotomy (CC) is an established surgical option for palliative treatment of medically intractable epilepsy, especially for seizures with drop attacks. We postulated that specific risk factors for post-CC transient disturbance of consciousness (pCTDC) are associated with CC. The purpose of this study was to review patients with intractable epilepsy who underwent CC and to statistically analyze risk factors for pCTDC. METHODS: Inclusion criteria for patients who underwent CC between January 2009 and November 2019 were: (1) ≥2 years old and (2) followed up for more than 8 months. The state of consciousness before and after CC was evaluated with the Glasgow coma scale. We statistically assessed predictors for pCTDC as the primary outcome. RESULTS: Fifty-six patients (19 females, 37 males) were enrolled, and the age range was 2-57 years old. Thirty-seven (66.1%) patients developed pCTDC. The mean period from the beginning of the state of pCTDC to recovery to their baseline conscious level was 4.9 days (range: 2-25 days). All three (100%) normal intelligence level patients, 13 (81%) of 16 patients with a moderately impaired level of intelligence, and 21 (57%) of 37 patients with a severely impaired level of intelligence exhibited pCTDC. Univariate (p = 0.044) and multivariate (p = 0.006) logistic regression analyses for predictors of pCTDC showed that intellectual function was statistically significant. CONCLUSION: Two-thirds of patients developed pCTDC. One risk factor for pCTDC may be higher intellectual function.

Mechanical Thrombectomy for Internal Carotid Artery Occlusion in a Patient with POEMS Syndrome.

Objective: To report a case of mechanical thrombectomy (MT) for internal carotid artery (ICA) occlusion in a patient with polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome, a rare systemic disease associated with plasma cell proliferation. Case Presentation: A 52-year-old woman was taking steroids due to autoimmune hepatitis. She was diagnosed with acute cerebral infarction due to left ICA occlusion. Although MT was performed, recanalization was not achieved. Therefore, recanalization was carried out using a vasodilator and percutaneous transluminal angioplasty (PTA) in combination. Conclusion: PTA may be effective for large-vessel occlusion (LVO) in patients with POEMS syndrome.

Postoperative persistent fever may be a risk factor for hydrocephalus in hemispherical disconnection surgery.

INTRODUCTION: Hemispherical disconnection surgery such as hemispherotomy or posterior quadrant disconnection (PQD) surgery sometimes induces hydrocephalus. We postulated that some risk factors for postoperative hydrocephalus can be managed perioperatively. The purpose of this study was to clarify and statistically analyze perioperative risk factors for postoperative progressive hydrocephalus. METHODS: We reviewed patients who underwent hemispherotomy or PQD. We compared patients with and without progressive hydrocephalus with multivariate and univariate logistic regression analysis to identify risk factors for hydrocephalus. RESULTS: Twenty-four patients underwent hemispherectomy or PQD (age: 25 days-45 years old, mean: 13.3 years, median: 8 years, standard deviation: 13.9 years, 14 males). Among them, five patients (21%) required hydrocephalus treatment. Persistent fever was a risk factor for progressive hydrocephalus (multivariate analysis: p = 0.024, univariate analysis: p < 0.001). CONCLUSION: Postoperative persistent fever may be a manageable risk factor for postoperative hydrocephalus in hemispherotomy and PQD surgery.

Morphological Change of Cerebral Aneurysm with Possible Pseudoaneurysm at A2/3 of the Anterior Cerebral Artery on Three-dimensional Computed Tomographic Angiography.

Intracranial pseudoaneurysm formation due to a ruptured nontraumatic aneurysm is rare. We describe a case of ruptured aneurysm, which showed morphological change on radiological examinations. An 83-year-old woman developed subarachnoid hemorrhage (SAH) with ventricular rupture and intracerebral hematoma in the corpus callosum. Contrast-enhanced computed tomography (CE-CT) demonstrated an aneurysm at the right A2/3 junction of the anterior cerebral artery. CE-CT repeated 17 h after the initial one showed shortening of the lesion on both three-dimensional and raw images. The aneurysm was surgically clipped. In cases of SAH with a hematoma or thick SAH, there is a possibility that a pseudoaneurysm will form at the tip of the true aneurysm in an adjacent thrombus or existence of intraluminal thrombus. The morphology may change during the period between initial radiological evaluation and the operation in these cases. We should be aware that the intraoperative findings or subsequent radiological findings might be different from those observed on preoperative radiological examinations.

Ruptured hidden intracranial aneurysm during mechanical thrombectomy: A case report.

BACKGROUND: Acute ischemic stroke (AIS) patients have a higher prevalence of cerebral aneurysm than a healthy reference population. However, it was recently reported that cases of an unknown hidden aneurysm in AIS patients with large-vessel occlusion are rare. We report a rare case of subarachnoid hemorrhage (SAH) during mechanical thrombectomy (MT) using a stent retriever for AIS. CASE DESCRIPTION: A 46-year-old patient with the right internal carotid artery terminal occlusion presented with the left-sided hemiparesis, hemispatial neglect, and dysarthria and underwent MT. Initial thrombectomy using a stent retriever and reperfusion catheter was unsuccessful. Angiography just before the second attempt showed SAH. Fortunately, we achieved recanalization of the thrombolysis in cerebral infarction 2b and hemostasis by lowering the blood pressure followed by coil embolization of the ruptured aneurysm. Only a few cases of ruptured aneurysms have been reported during MT using a stent retriever. Stent withdrawal is suspected to cause aneurysm rupture in cases with an unknown hidden middle cerebral artery bifurcation aneurysm. CONCLUSION: Preinterventional detection of a hidden aneurysm is difficult. Therefore, surgeons must always consider the possibility of a hidden aneurysm rupture in vessels distal to the occlusion site and make adequate preparations for the prompt treatment of ruptured aneurysms after MT.

Preliminary Clinical Microneurosurgical Experience With the 4K3-Dimensional Microvideoscope (ORBEYE) System for Microneurological Surgery: Observation Study.

BACKGROUND: The exoscope has been reported as a novel neurosurgical instrumentation in clinical practice. OBJECTIVE: To investigate the possibility that ORBEYE (OE), a novel instrument that excludes eyepiece lenses and allows for microsurgery by observation of the 4K3D monitor, could replace microscopes. METHODS: We report 22 clinical cases by 5 experienced neurosurgeons and the comparative results of training 10 residents. An observation study with questionnaire survey was conducted on usability. Twelve items including image quality, eyestrain, and function of the arm were evaluated. RESULTS: The following 22 clinical procedures were conducted: surgery for intracranial hemorrhage (n = 2) and brain tumor (n = 8), laminectomy (n = 3), aneurysm clipping (n = 3), vascular anastomosis (n = 2), carotid endarterectomy (n = 2), and nerve decompression (n = 1). No complications were observed. The fluorescent study, including indocyanine-green and 5-aminolevunic acid, allowed for clear depiction on the 4K monitor. The surgeon could operate in a comfortable posture. Similar to the microscope, it was possible to change the optical and viewing axes with the OE, but the OE was switched to the microscope or endoscope in hematoma removal and pituitary surgery. Residents judged that eyestrain was strong (P = .0096). Experienced neurosurgeons acting as assistants judged that the scope arm's range of movement was narrow (P = .0204). Sixty percent of residents judged that the OE was superior to the microscope. CONCLUSION: Although based on limited experience, it was not possible to substitute the microscope with the OE in all operations; however, the OE surpasses the microscope in terms of ergonomic features.

The angiotensin II type I receptor antagonist losartan retards amygdala kindling-induced epileptogenesis.

Blood-brain barrier (BBB) breakdown and the subsequent exposure of the cerebral cortex to serum albumin are known to activate transforming growth factor ß (TGF-ß) signaling in astrocytes and to play key roles in epileptogenesis after brain injury. It was recently reported that the angiotensin II type I receptor antagonist losartan suppresses activation of TGF-ß signaling and prevents epileptogenesis in a rat vascular injury model. Here, we investigated the effects of losartan on epileptogenesis following amygdala kindling in rats. Systemic or intracerebroventricular (i.c.v.) administration of losartan significantly delayed the development of severe behavioral seizures and stimulus-induced seizures on EEG (afterdischarge) in the early stage of amygdala kindling, as assessed by electroencephalography. Losartan also significantly increased the number of stimulations required to reach the fully kindled state. However, losartan had no effects on the threshold for afterdischarge induction, the afterdischarge duration, or seizure severity in fully kindled rats. Evaluation of BBB permeability by Evans blue staining did not indicate BBB breakdown (extravasation of serum albumin) in any region of the brain in the fully kindled animals. Thus, losartan may be useful in preventing epileptogenesis, even in post brain-insult epilepsy, in the absence of BBB breakdown.

[A Case of Meralgia Paresthetica Treated with Neurolysis].

A 60-year-old woman presented with a 1-year history of pain and numbness in the left anterolateral thigh. The symptoms aggravated on walking and standing. Her visual analogue scale(VAS)score was 7.1/10. Tinel's like sign was positive over the lateral femoral cutaneous nerve(LFCN), in the inguinal ligament region. LFCN block at the trigger point, in the inguinal ligament, resulted in relief of the symptoms and we diagnosed meralgia paresthetica(MP), which is the entrapment neuropathy of the LFCN. Initially, we performed observation therapy with oral medication and LFCN blocks. However, these treatments failed to relieve the symptoms. Therefore, we performed neurolysis with a microscope under local anesthesia. The symptoms improved immediately after surgery and her VAS score of thigh symptom improved from 7.1 to 1.9 after 3 months. Conservative and surgical treatment for MP generally yield good outcome and we should pay attention to the MP as a differential diagnosis for thigh numbness and pain.

The Serum Phosphorylated Neurofilament Heavy Subunit as a Predictive Marker for Outcome in Adult Patients after Traumatic Brain Injury.

The serum phosphorylated neurofilament heavy subunit (pNF-H) is a nervous system-specific protein that is released from damaged neural tissue after traumatic brain injury (TBI). The aim of this study was to elucidate the usefulness of serum pNF-H as a predictive marker for the outcome of patients after TBI. Patients with TBI (Glasgow Coma Scale score of 13 or less on admission) were included. Patients who were younger than age 18, dependent on others for daily activities before injury, pregnant, or who were not likely to survive for more than 24 h after injury were excluded. The outcome was assessed using the Glasgow Outcome Scale at 6 months after injury. Blood was collected from subjects (n = 32), and the serum pNF-H value was assessed at 24 and 72 h after TBI. The optimal cutoff value and usefulness of the serum pNF-H value for predicting the long-term outcome were investigated. We found that the serum pNF-H value at 24 h after injury was a good predictive marker of death at 6 months (p < 0.001) after injury. The optimal cutoff value was 240 pg/mL, and the area under the curve in the receiver operating characteristic analysis was 0.930. The serum pNF-H value at 72 h after injury was correlated with an unfavorable outcome (vegetative state or death) at 6 months (p < 0.01) with a cutoff value of 80 pg/mL. Collectively, the results of this study indicate that the serum pNF-H value is a useful predictive marker for patient outcome after TBI.

Atlantoaxial intraspinal juxtafacet cyst.

A 69-year-old man presented with progressive paralysis of the right arm and leg with a past history of metastatic rectal cancer. Magnetic resonance imaging showed a cystic mass lesion posterior to the odontoid process. Under a preoperative diagnosis of intradural extramedullary tumor, partial transcondylectomy and C1 hemilaminectomy were performed, and the cyst was removed through a transdural approach, decompressing the medulla oblongata and the cervical spinal cord. The histological diagnosis was juxtafacet cyst (ganglion cyst). An atlantoaxial intraspinal juxtafacet cyst at the level of the odontoid process is extremely rare. In our case, the cyst was removed using a posterior approach, resulting in rapid improvement in symptoms.