Surgical evacuation of spontaneous cerebellar hemorrhage: Comparison of safety and efficacy of suboccipital craniotomy and robotic-assisted stereotactic hematoma drainage

OBJECTIVE

This study compared the efficacies of robotic-assisted stereotactic hematoma drainage and suboccipital craniotomy (SC) in patients with spontaneous cerebellar hemorrhage (SCH).

METHODS

This retrospective study included 138 non-comatose patients with SCH (Glasgow Coma Scale score [GCS] >8), divided into the SC and Robotic Stereotactic Assistance (ROSA) groups. The study recorded and analyzed complications and prognoses 90 days after ictus.

RESULTS

The inclusion criteria were met by 138 patients: 61 in the SC and 77 in the ROSA group, with no significant differences in sex, age, GCS score, hematoma volume, and the time from ictus to operation. The time of operation was greater in the SC group (287.53±87.57) than in the ROSA group (60.54±20.03). The evacuation rate (ER) was greater in the SC group (93.20±1.58) than in the ROSA group (89.13±2.75). The incidence of pneumonia and stress ulcers, as well as the length or costs of medical services, were lower in the ROSA group than in the SC group. Ninety days after ictus, the modified Rankin Scale (mRS), Glasgow Prognostic Scale (GOS), and Karnofsky Performance Scale (KPS) scores significantly differed between the groups. The rate of good prognosis in the ROSA group was significantly higher compared with that in the SC group. The incidence of balance disorders was lower in the ROSA group than in the SC group; no statistically significant difference was found in the incidence of dysarthria and swallowing disorders.

CONCLUSION

Robotic-assisted stereotactic hematoma drainage may be suitable for non-comatose and stable condition patients with SCH. This procedure improves prognosis 90 days after ictus, lowers the incidence of pneumonia and stress ulcers, and reduces the length and costs of medical services.

Necrosectomy Versus Stand-Alone Suboccipital Decompressive Craniectomy for the Management of Space-Occupying Cerebellar Infarctions-A Retrospective Multicenter Study

BACKGROUND AND OBJECTIVES

Space-occupying cerebellar stroke (SOCS) when coupled with neurological deterioration represents a neurosurgical emergency. Although current evidence supports surgical intervention in such patients with SOCS and rapid neurological deterioration, the optimal surgical methods/techniques to be applied remain a matter of debate.

METHODS

We conducted a retrospective, multicenter study of patients undergoing surgery for SOCS. Patients were stratified according to the type of surgery as (1) suboccipital decompressive craniectomy (SDC) or (2) suboccipital craniotomy with concurrent necrosectomy. The primary end point examined was functional outcome using the modified Rankin Scale (mRS) at discharge and at 3 months (mRS 0-3 defined as favorable and mRS 4-6 as unfavorable outcome). Secondary end points included the analysis of in-house postoperative complications, mortality, and length of hospitalization.

RESULTS

Ninety-two patients were included in the final analysis: 49 underwent necrosectomy and 43 underwent SDC. Those with necrosectomy displayed significantly higher rate of favorable outcome at discharge as compared with those who underwent SDC alone: 65.3% vs 27.9%, respectively ( P < .001, odds ratios 4.9, 95% CI 2.0-11.8). This difference was also observed at 3 months: 65.3% vs 41.7% ( P = .030, odds ratios 2.7, 95% CI 1.1-6.7). No significant differences were observed in mortality and/or postoperative complications, such as hemorrhagic transformation, infection, and/or the development of cerebrospinal fluid leaks/fistulas.

CONCLUSION

In the setting of SOCS, patients treated with necrosectomy displayed better functional outcomes than those patients who underwent SDC alone. Ultimately, prospective, randomized studies will be needed to confirm this finding.

Indications for surgical evacuation of cerebellar intracerebral hemorrhage: consensus guidelines from the French Society of Neurosurgery (SFNC) and the French Society of Vascular Neurology (SFNV)

BACKGROUND

Cerebellar intracerebral hemorrhage (ICH) is associated with poor functional prognosis and high mortality. Surgical evacuation has been proposed to improve outcome. The purpose of this review was to determine the benefit of surgical evacuation of cerebellar ICH and to establish guidelines for when it should be performed.

METHOD

The writing committee comprised 9 members of the SFNV and the SFNC. Recommendations were established based on a literature review using the PICO questions. The American Heart Association (AHA) classification was used to define recommendation level. In case of insufficient evidence, expert opinions were provided.

RESULTS

Levels of evidence were low to moderate, precluding definitive recommendations. Based on available data, surgical hematoma evacuation is not recommended to improve functional outcome (Class III; Level B NR). However, based on subgroup analysis, surgical evacuation may be considered in strictly selected patients (Class IIb; Level C-EO): hematoma volume 15-25 cm3, GCS 6-10, and no oral anticoagulation or antiplatelet therapy. Moreover, surgical evacuation is recommended to decrease risk of death (Class IIa; Level B NR) in patients with a hematoma volume >15 cm3 and GCS score <10.

CONCLUSION

These guidelines were based on observational studies, limiting the level of evidence. However, except for strictly selected patients, surgical evacuation of cerebellar ICH was not associated with improved functional outcome, limiting indications. Data from RCTs are needed in this field.

Neuronavigation-assisted neuroendoscopy versus conventional craniotomy for hypertensive cerebellar hemorrhage: A comparative analysis of efficacy and outcomes

OBJECTIVE

Hypertensive cerebellar hemorrhage is a severe condition in neurosurgery, associated with high disability and mortality rates. The present study compares the efficacy and outcomes of neuronavigation-assisted neuroendoscopy versus conventional microscope (craniotomy) in treating patients with hypertensive cerebellar hemorrhage.

METHODS

A retrospective study was conducted by analyzing medical records of patients with hypertensive cerebellar hemorrhage treated at Wuhan No.1 Hospital between February 2015 and February 2019. The study included 65 patients who underwent either neuronavigation-assisted neuroendoscopy (n = 35) or conventional microscopy treatment (n = 30). All patients underwent standard neurological and clinical examinations, as well as routine laboratory tests upon admission. The diagnosis of hypertensive cerebellar hemorrhage was based on computed tomography (CT) findings. Basic parameters, clinical status on admission, imaging results, management, and outcome measures were evaluated and compared between the two groups.

RESULTS

Neuronavigation-assisted neuroendoscopy showed advantages over craniotomy in terms of surgical procedure time and intraoperative blood loss ((81.91 ± 17.77) min vs (195.20 ± 31.97) min, (63.66 ± 12.42) ml vs (335.00 ± 104.26) ml, P < 0.01). The hematoma evacuation rate was higher in neuroendoscopy group ((94.37 ± 5.174)% compared to the craniotomy group ((90.80 ± 5.404)%, P < 0.01). Additionally, the time of ventricular drainage was shorter in the neuroendoscopy group ((4.83 ± 1.671) days) than in the craniotomy group ((7.70 ± 1.878) days, P < 0.01). Neuroendoscopy group also resulted in fewer surgical complications and a shorter hospital stay (P < 0.05). There was no significant difference in the risk of rebleeding and mortality between the neuroendoscopy and craniotomy group (P > 0.05).

CONCLUSION

Neuronavigation-assisted neuroendoscopy is a rapid, safe, and effective minimally invasive technique for the treatment of hypertensive cerebellar hemorrhage. It offers potential benefits in reducing surgical complications and hospital stay compared to conventional craniotomy.

Cerebellar Abscess Induced by Cochlear Fistula due to Chronic Suppurative Otitis Media

Cochlear fistulas with cholesteatoma as the primary disease have been reported frequently in the relevant literature. However, there are no reports of cochlear fistula without cholesteatoma due to chronic suppurative otitis media with intracranial complications. We report a case of cochlear fistula due to chronic otitis media that was diagnosed after the onset of a cerebellar abscess. The patient was a 25-year-old man with severe autism. He was admitted to our hospital with otorrhea from his left ear, emesis, and impaired consciousness. Computed tomography (CT) of the head showed left suppurative otitis media, left cerebellar abscess, and brainstem compression due to hydrocephalus. Right extra-ventricular drainage and brain abscess drainage were urgently performed. The next day, foramen magnum decompression and abscess drainage with partial resection of the swollen cerebellum were performed for decompression purposes. He was subsequently treated with antimicrobial therapy, but magnetic resonance imaging of the head showed an increase in the size of the cerebellar abscess. Re-examination of the temporal bone CT scans revealed a bony defect in the left cochlear promontory angle. We assumed that the cochlear fistula was responsible for the otogenic brain abscess. Thus, the patient underwent surgical closure of the cochlear fistula. After the operation, the cerebellar abscess lesion gradually shrank, and his general condition stabilized. Cochlear fistula should be considered in the management of patients with inflammatory middle ear disease associated with otogenic intracranial complications in the middle ear.

Orthostatic Enlargement of a Supracerebellar Arachnoid Cyst With Cerebellar Descent Visualized by Upright Computed Tomography

BACKGROUND

Posterior fossa arachnoid cysts are often asymptomatic, but can rarely cause postural headache, the mechanism of which remains unknown.

CASE DESCRIPTION

We present a 40-year-old woman with an asymptomatic supracerebellar arachnoid cyst. Upright computed tomography (CT) showed enlargement of the arachnoid cyst and caudal descent of the cerebellum compared with supine CT with narrowing of the craniocervical junction cerebrospinal fluid space.

CONCLUSIONS

This finding aids in understanding the association of posterior fossa arachnoid cysts with orthostatic headache. Clinicians should be aware of possible posture-related changes in intracranial structures.

An Uncommon Case of Neuroenteric Cyst Located at the Lateral Cerebellomedullary Cistern

We present the case of a 42-year-old woman with a 5-week history of headache, progressive dysphagia, dysphonia, and hoarseness. A brain magnetic resonance imaging revealed an extra-axial cyst of the left lateral cerebellomedullary cistern. The subsequent histopathologic examination diagnosed a neuroenteric cyst. This case sheds light on the pivotal role of histologic identification of neuroenteric cyst, which could be crucial for further diagnostic investigations, especially in pediatric patients.

Pediatric post-operative cerebellar mutism syndrome, cerebellar cognitive affective syndrome, and posterior fossa syndrome: historical review and proposed resolution to guide future study

BACKGROUND

Cerebellar mutism (CM), pseudobulbar palsy, posterior fossa syndrome (PFS), and cerebellar cognitive affective syndrome (CCAS) are terms that have been used, sometimes interchangeably, to refer to the complex neurological constellation that occurs following surgical removal of cerebellar and fourth ventricular tumors, mostly in children, but also sometimes in adults.

METHODS

This paper reviews the origins of what is now regarded as pediatric post-operative cerebellar mutism, the cerebellar cognitive affective syndrome, and the neurological manifestations of injury to or disruption of brainstem and cerebellar structures. It examines the specific components of each of these phenomena in the context of the evolving understanding of the role of the cerebellum in nervous system function.

RESULTS

Children undergoing surgical management of tumors in the posterior cranial fossa are at risk of experiencing cranial neuropathies, corticospinal damage, cerebellar ataxia and related motor disorders, neuropsychiatric and cognitive changes, and in some patients, mutism. These clinical presentations are differentiated from each other and examined in the context of the relevant anatomical structures and distributed neural circuits. The term posterior fossa syndrome is not sufficiently helpful in distinguishing the different elements of the clinical phenomena from each other, and because of this lack of precision and specificity, there is consensus among investigators in the international Posterior Fossa Society that the designation be retired.

CONCLUSIONS

Using contemporary brain imaging methods and guided by careful clinical observation and meticulous definition of clinical phenomenology, it is now feasible to perform detailed structure function correlation analyses to achieve two critical goals in the care of children with tumors in the posterior cranial fossa. The first goal is to identify and understand the neural circuits responsible for the different manifestations-arousal, cranial neuropathies, long tract signs, cerebellar motor syndrome, cerebellar vestibular syndrome, cerebellar cognitive affective syndrome including emotional dyscontrol, and mutism. The second goal is to transform this knowledge into practical clinical intervention, preventing the complications inherent in the necessary surgery whenever possible, and develop new approaches to treatment with methods including brain modulation targeting interconnected nodes of the damaged neural circuits.

Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage

Importance

The association of surgical hematoma evacuation with clinical outcomes in patients with cerebellar intracerebral hemorrhage (ICH) has not been established.

Objective

To determine the association of surgical hematoma evacuation with clinical outcomes in cerebellar ICH.

Design, Setting, and Participants

Individual participant data (IPD) meta-analysis of 4 observational ICH studies incorporating 6580 patients treated at 64 hospitals across the United States and Germany (2006-2015).

Exposure

Surgical hematoma evacuation vs conservative treatment.

Main Outcomes and Measures

The primary outcome was functional disability evaluated by the modified Rankin Scale ([mRS] score range: 0, no functional deficit to 6, death) at 3 months; favorable (mRS, 0-3) vs unfavorable (mRS, 4-6). Secondary outcomes included survival at 3 months and at 12 months. Analyses included propensity score matching and covariate adjustment, and predicted probabilities were used to identify treatment-related cutoff values for cerebellar ICH.

Results

Among 578 patients with cerebellar ICH, propensity score-matched groups included 152 patients with surgical hematoma evacuation vs 152 patients with conservative treatment (age, 68.9 vs 69.2 years; men, 55.9% vs 51.3%; prior anticoagulation, 60.5% vs 63.8%; and median ICH volume, 20.5 cm3 vs 18.8 cm3). After adjustment, surgical hematoma evacuation vs conservative treatment was not significantly associated with likelihood of better functional disability at 3 months (30.9% vs 35.5%; adjusted odds ratio [AOR], 0.94 [95% CI, 0.81 to 1.09], P = .43; adjusted risk difference [ARD], -3.7% [95% CI, -8.7% to 1.2%]) but was significantly associated with greater probability of survival at 3 months (78.3% vs 61.2%; AOR, 1.25 [95% CI, 1.07 to 1.45], P = .005; ARD, 18.5% [95% CI, 13.8% to 23.2%]) and at 12 months (71.7% vs 57.2%; AOR, 1.21 [95% CI, 1.03 to 1.42], P = .02; ARD, 17.0% [95% CI, 11.5% to 22.6%]). A volume range of 12 to 15 cm3 was identified; below this level, surgical hematoma evacuation was associated with lower likelihood of favorable functional outcome (volume ≤12 cm3, 30.6% vs 62.3% [P = .003]; ARD, -34.7% [-38.8% to -30.6%]; P value for interaction, .01), and above, it was associated with greater likelihood of survival (volume ≥15 cm3, 74.5% vs 45.1% [P < .001]; ARD, 28.2% [95% CI, 24.6% to 31.8%]; P value for interaction, .02).

Conclusions and Relevance

Among patients with cerebellar ICH, surgical hematoma evacuation, compared with conservative treatment, was not associated with improved functional outcome. Given the null primary outcome, investigation is necessary to establish whether there are differing associations based on hematoma volume.

Spontaneous cerebellar hemorrhage with severe brainstem dysfunction through minimally invasive puncture treatment by locating the simple bedside

This study aims to evaluate the feasibility and effectiveness of minimally invasive puncture treatment by positioning the simple bedside for spontaneous cerebellar hemorrhage.From January 2017 to March 2018, the investigators applied simple bedside positioning to perform the intracranial hematoma minimally invasive surgery for 21 patients with cerebellar hemorrhage.For these 21 patients, the bleeding amount and Glasgow Coma Scale (GCS) score before the operation were 18.5 ± 5.0 cc and 9.5 ± 3.3, respectively; 24 hours after the operation, the GCS score was 11.0 ± 4.6. Five patients died within 7 days of the operation and the head computed tomography (CT) was re-examined. It was found that the average bleeding amount was 3.4 ± 0.9 cc, the operation success rate was 76.2%, and the accurate puncture rate was 100%. Six months later, the Modified Rankin Scale (MRS) score was 2.5 ± 2.0. The postoperative recovery was good. The situation shows that patients with favorable outcomes (MRS score 0-2) accounted for 38.1% (8/21), and the fatality rate was 33.3% (7/21).The efficacy of the intracranial hematoma minimally invasive surgery by positioning the simple bedside for spontaneous cerebellar hemorrhage with severe brainstem dysfunction is good.

Case Report: What is Your Differential Diagnosis for Bilateral Cerebellar Infarct?

Neurovascular variants are not frequently described outside of specialty literature. Infarction involving these atypical neurovascular structures present with unusual clinical findings and radiologic imaging. A 63-year-old man with hypertension, diabetes, and former tobacco use presented from the Department of Corrections with global headache, nausea, vomiting, and double vision. He was found to be hypertensive to 240/120. CT imaging noted acute ischemic changes in the bilateral posterior inferior cerebellar artery distribution. Follow up 3-D time-of-flight (TOF) magnetic resonance angiography (MRA) of the cranial region demonstrated abrupt cut off of an azygous right posterior inferior cerebellar artery (PICA) and presumed absence of the left PICA. The patient underwent occipital craniotomy for evolving ischemic stroke and development of hydrocephalus, and ultimately recovered without neurologic deficits.

Central nervous system aspergillosis in an immunocompetent patient: Cure in a hospice setting with very high-dose itraconazole

Aspergillosis of the central nervous system (CNS) is a rare condition with exceedingly high mortality. This study describes the case of an immunocompetent 42-year-old man with a history of intravenous drug use and hepatitis C who developed multiple Aspergillus lesions in the cerebellum. Despite neurosurgery and antifungal therapy with amphotericin B, he had a protracted hospital course with multiple complications, eventually developing cognitive and motor impairment due to progressive cerebellar lesions. After transfer to hospice and palliative care service, oral itraconazole was escalated to 1600 mg/day with the hope of palliating headache, nausea, and cognitive impairment. Remarkably, the patient stabilized and improved over time. After 14 months, this unprecedented high-dose regimen was discontinued, and the patient was discharged home with only mild cerebellar motor impairment.

Diagnosis of Nocardia paucivorans central nervous system infection by DNA sequencing from paraffin-embedded tissue

Infections by Nocardia spp. are generally regarded as opportunistic diseases in immunocompromised patients, but can also affect immunocompetent subjects. Such infections represent an important diagnostic challenge for clinicians and microbiologists, and diagnosis is frequently delayed or even conducted post mortem. A 54-year-old man was admitted to our hospital because of ventriculitis and relapsing brain abscess. Five months prior, this patient had undergone external ventricular drain and surgery for a cerebellar abscess. Histopathology demonstrated pyogenic inflammatory reaction, microbiologic investigations proved negative and empiric antimicrobial therapy was administered for a total of eight weeks. Six weeks later, the patient developed relapsing neurologic manifestations. On reviewing the patient's clinical history it emerged that the patient had suffered pneumonia two months prior to neurosurgery, treated with amoxicillin/clavulanate 3g a day and levofloxacin 500mg a day for three weeks. On the CNS relapsing manifestations, nocardiosis was suspected and DNA sequencing from the formalin-fixed paraffin-embedded cerebellar tissue collected during neurosurgery allowed diagnosis of Nocardia paucivorans infection. The patient received medical therapy for 11 months. At follow-up, eight months after treatment was discontinued, the patient was aymptomatic. Nocardia spp. infections need to be suspected not only in immunocompromised, but also in immunocompetent patients. Proper samples need to be collected for proper microbiologic investigations. Paraffin-embedded tissue genomic sequencing can be a useful tool for diagnosis of nocardiosis.

Ten years of experience in endovascular treatment of ruptured aneurysms of the posterior inferior cerebellar artery

BACKGROUND

The aim of this study is to present our 10 years of experience in endovascular treatment of ruptured posterior inferior cerebellar artery (PICA) saccular aneurysms and to compare clinical presentation and outcome after endovascular treatment between patients with PICA aneurysms and patients with aneurysms in different locations.

METHODS AND FINDINGS

Out of 932 patients with a ruptured intracranial aneurysm treated endovascularly in our institution, 38 aneurysms were located at the posterior inferior cerebellar artery. Clinical presentation, mean aneurysm diameter and outcome of the therapy in this group were compared with the same for ruptured aneurysms in other locations. Patients discharged with favourable outcomes were checked angiographically in the follow-up period. Thirty-four patients with ruptured PICA aneurysms were treated by selective endovascular coiling. Two patients with wide-necked aneurysms had endovascular stents implanted. In two cases, the parent vessel was occluded due to failure to catheterise the target aneurysm. The evaluated variables did not differ significantly between two groups, but significantly more ruptured aneurysms in the PICA group were under 6 mm in diameter. 29.4% of controlled aneurysms needed additional reembolisation in the follow-up period.

CONCLUSIONS

Clinical presentation, extension of subarachnoid haemorrhage and outcome after endovascular treatment did not differ significantly between patients with ruptured aneurysms located on the PICA and patients with aneurysms located elsewhere intracranially. Endovascular treatment is an effective method of therapy in patients with ruptured PICA aneurysms. In our experience, even when sacrificing of the PICA is required, the results of treatment are favourable.

Surgical Treatment of Cerebellar Cavernous Malformations: A Single-Center Experience with 58 Cases

OBJECTIVE

The goal of this study was to discuss the surgical indications, surgical approaches, and prognostic factors of cerebellar cavernous malformation (CM).

METHODS

We retrospectively reviewed the presentation, surgery, and outcome of 58 consecutive patients who underwent resection of cerebellar CMs between 2009 and 2013 in our center.

RESULTS

The study population consisted of 31 males and 27 females, mean age 39.9 years. Fifty-eight patients experienced 67 symptomatic hemorrhages. The median diameter of all lesions was 2.2 ± 0.9 cm (range, 0.8-4.8 cm). The locations were classified into 3 groups: group 1, cerebellar hemisphere (17 cases, 29.3%); group 2, vermis (18 cases, 31.0%); and group 3, cerebellar peduncle (23 cases, 39.7%). Complete resection was achieved in all patients without surgical mortality. Postoperatively, 11 patients developed new surgical complications, including facial paralysis in 6 patients, ataxia in 2 patients, dizziness in 2 patients, and decrease in facial sensation in 1 patient. The mean modified Rankin Scale (mRS) at final follow-up was significantly improved compared with the preoperative score (0.5 ± 0.5 vs. 1.4 ± 0.7, P = 0.035). The symptoms and neurologic deficits improved in most patients. The lesion location was the only factor that predicted a worse outcome, and the mRS was significantly lower in group 3 than groups 1 and group 2 (P = 0.019).

CONCLUSIONS

Patients with cerebellar CMs usually achieve favorable outcomes via surgery. Cerebellar peduncle CMs cause significantly more neurologic deficits than other locations. A reasonable surgical approach and meticulous manipulation are necessary to prevent impairment of neurologic function.

Augmented reality-assisted bypass surgery: embracing minimal invasiveness

OBJECTIVE

The overlay of virtual images on the surgical field, defined as augmented reality, has been used for image guidance during various neurosurgical procedures. Although this technology could conceivably address certain inherent problems of extracranial-to-intracranial bypass procedures, this potential has not been explored to date. We evaluate the usefulness of an augmented reality-based setup, which could help in harvesting donor vessels through their precise localization in real-time, in performing tailored craniotomies, and in identifying preoperatively selected recipient vessels for the purpose of anastomosis.

METHODS

Our method was applied to 3 patients with Moya-Moya disease who underwent superficial temporal artery-to-middle cerebral artery anastomoses and 1 patient who underwent an occipital artery-to-posteroinferior cerebellar artery bypass because of a dissecting aneurysm of the vertebral artery. Patients' heads, skulls, and extracranial and intracranial vessels were segmented preoperatively from 3-dimensional image data sets (3-dimensional digital subtraction angiography, angio-magnetic resonance imaging, angio-computed tomography), and injected intraoperatively into the operating microscope's eyepiece for image guidance.

RESULTS

In each case, the described setup helped in precisely localizing donor and recipient vessels and in tailoring craniotomies to the injected images.

CONCLUSIONS

The presented system based on augmented reality can optimize the workflow of extracranial-to-intracranial bypass procedures by providing essential anatomical information, entirely integrated to the surgical field, and help to perform minimally invasive procedures.

Treatment of Secondary Tonsillar Herniation by Lumboperitoneal Shunt Revision

Background:

Idiopathic intracranial hypertension (IIH) is a condition that usually affects young, obese women. Management is aimed at controlling symptoms of increased intracranial pressure (ICP) and prevention of visual failure due to papilledema. A common surgical treatment for IIH is the insertion of a lumboperitoneal shunt (LP shunt). Secondary symptomatic tonsillar herniation is an uncommon side effect following lumbar cerebrospinal fluid diversion.

Methods:

We present two cases of symptomatic secondary tonsillar herniation, one associated with a syrinx, in patients with IIH following valved LP shunting. Treatment options for this side effect may include transplanting the shunt to the ventricular system or decompression of the foramen magnum.

Results:

In our cases we elected to alter the construct of the LP shunt by inserting a programmable valve which led to clinical and radiological reversal of the tonsillar herniation as well as a dramatic reduction in an associated syrinx.

Conclusions:

When faced with LP shunt induced symptomatic secondary tonsillar herniation, consideration may be given to altering LP shunt dynamics, prior to inserting a ventricular catheter into normal sized ventricles or decompressing the posterior fossa.

Cause and outcome of cerebellar mutism: evidence from a systematic review

PURPOSE

Cerebellar mutism is a serious neurosurgical complication after posterior fossa surgery, but the cause, incidence and outcome remain incompletely defined. The aim of this paper was to identify and review all reports of this phenomenon to better delineate and improve the evidence base.

METHODS

A systematic search and retrieval of databases was conducted using advanced search techniques. Review/outcomes criteria were developed, and study quality was determined.

RESULTS

The retrieval identified 2,281 papers of which 96 were relevant, identifying 650 children with cerebellar mutism. Causative factors, clinical features and outcomes were reported variably; papers focussed on multiple areas, the majority reporting incidence in single or series of case studies with little or no analysis further than description.

CONCLUSIONS

The complexity and variability of data reporting, likely contributing factors and outcomes make cerebellar mutism difficult to predict in incidence and the degree of impact that may ensue. A clear and accepted universal definition would help improve reporting, as would the application of agreed outcome measures. Clear and consistent reporting of surgical technique remains absent. Recommendations for practice are provided.

[Emotional disorders in patients with cerebellar damage--case studies]

AIM

Growing number of research shows the role of the cerebellum in the regulation of affect. Lesions of the cerebellum can lead to emotional disregulation, a significant part of the Cerebellar Cognitive Affective Syndrome. The aim of this article is to analyze the most recent studies concerning the cerebellar participation in emotional reactions and to present three cases: two female and one male who suffered from cerebellar damage and presented post-traumatic affective and personality change.

METHOD

The patients' neuropsychological examination was performed with Raven's Progressive Matrices Test--standard version, Trial Making Test, Wisconsin Card Sorting Test, Auditory Verbal Learning Test by Luria, Benton Visual Retention Test, Verbal Fluency Test, Stroop Interference Test, Attention and Perceptivity Test (Test Uwagi i Spostrzegawczości TUS), Frontal Behavioral Inventory (FBI).

RESULTS

The review of the literature suggest cerebellar participation, especially teh vermis and paravermial regions, in the detection, integration and filtration of emotional information and in regulation of autonomic emotional responses. In the described patients we observed: oversensitivity, irritability, impulsivity and self-neglect. The man and the woman with right-sided lesions presented similar symptoms: rigidity ofthought, stubbornness, lack of criticism,jocular and inappropriate behavior. The woman with left-sided cerebellar lesion was adynamic, apathic and passive, she presented emotional blunting, social isolation, lack of interests and motivation, general cognitive slowdown.

CONCLUSIONS

Both the analyzed research and the described cases indicate the connection between the cerebellum and emotion regulation. The symptoms presented by the described patients were most probably a consequence of damaged cerebellar projections to subcortical structures (the limbic system) and frontal areas. The diversification of symptoms depending on the localization of lesions had not been described yet and seems to indicate an interesting direction for future research.

Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere.

METHODS

The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review.

RESULTS

Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients.

CONCLUSIONS

Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.

[Central nervous system malformations: neurosurgery correlates]

Congenital malformations of the central nervous system are related to alterations in neural tube formation, including most of the neurosurgical management entities, dysraphism and craniosynostosis; alterations of neuronal proliferation; megalencefaly and microcephaly; abnormal neuronal migration, lissencephaly, pachygyria, schizencephaly, agenesis of the corpus callosum, heterotopia and cortical dysplasia, spinal malformations and spinal dysraphism. We expose the classification of different central nervous system malformations that can be corrected by surgery in the shortest possible time and involving genesis mechanisms of these injuries getting better studied from neurogenic and neuroembryological fields, this involves connecting innovative knowledge areas where alteration mechanisms in dorsal induction (neural tube) and ventral induction (telencephalization) with the current way of correction, as well as the anomalies of cell proliferation and differentiation of neuronal migration and finally the complex malformations affecting the posterior fossa and current possibilities of correcting them.

Prognostic factors and long-term outcome following surgical treatment of 76 patients with spontaneous cerebellar haematoma

BACKGROUND

Although large spontaneous cerebellar haematomas are associated with high mortality, surgical treatment may be life-saving. We evaluated the clinical outcome and identified prognostic factors in 76 patients with cerebellar haematoma, all treated with suboccipital decompression, haematoma evacuation and external ventricular drainage.

METHODS

Patients receiving surgical and neurocritical care treatment within a 10-year period were included. Level of consciousness during hospitalisation was evaluated using the Glasgow Coma Scale (GCS) score. Outcome was assessed with the modified Rankin Scale (mRS). Predictive prognostic factors were analysed using univariate and multivariate regression analysis.

RESULTS

Prior to surgery, the median GCS score was 8.6 (range 3-13). At discharge it had improved to 12.1 (4-15) (p < 0.05). The median long-term follow-up period was 70.5 (22-124) months. At 6 months post-surgery, 19 patients were dead and 28 patients had a good outcome (mRS < 3). In the long term (70.5 months), 31 patients (41.9 %) were dead and the outcome was good in 27 patients (37.8 %). Although approximately 25 % of patients >65 years old had a favourable outcome, age was the strongest negative predictor for a bad outcome at 6 months and long term (p = 0.02 and p = 0.01, respectively). The level of consciousness before surgery did not influence the 6-month or long-term outcome (p = 0.39 and p = 0.65, respectively).

CONCLUSIONS

Although mortality was high, significant complications from the treatment were rare and most survivors had a good outcome, reaching functional independence. High age was the strongest prognostic factor for an unfavourable outcome.

Clinical outcome following surgical treatment for bilateral cerebellar infarction

OBJECTIVES

To analyze the initial clinical and radiological findings, the surgical treatment, and the clinical outcome following surgical decompression in patients with space-occupying bilateral cerebellar infarction.

MATERIALS AND METHODS

Ten patients with expansive bilateral cerebellar infarction and decreased level of consciousness were operated with suboccipital craniectomy, removal of the infarcted tissue, and placement of external ventricular drainage. Long-term outcome was assessed using the modified Rankin scale (mRS).

RESULTS

Mean Glasgow coma scale (GCS) score before surgery was 8.9 ± 3.3 and improved to 12.6 ± 3.6 at discharge. At the long-term follow-up (median 57.6 months), six patients had a favorable outcome (mRS 1.3 ± 0.8). Four patients, all with an associated brain stem infarct, had a poor outcome.

CONCLUSIONS

In the absence of brain stem infarcts, surgical treatment resulted in a favorable clinical outcome and should be considered a treatment option for patients with expansive bilateral cerebellar infarction.

[Operative approach for hydrocephalus associated with cerebellar tonsillar hernia]

OBJECTIVE

To assess the pre-operative examination and operative approach for hydrocephalus associated with cerebellar tonsillar hernia.

METHODS

A retrospective analysis was conducted for 24 patients of hydrocephalus associated with cerebellar tonsillar hernia. All subjects received both pre-operative and post-operative Cine MRI examinations to detect the velocity and quantity of cerebrospinal fluid (CSF) at the important sites in ventricular system. A majority of cases had endoscopic third ventriculostomy (ETV) while others underwent both ETV and endoscopic posterior cranial fossa decompression.

RESULTS

The pre-operative CSF hydrodynamics of all cases were abnormal at foramen magnum. A post-operative CSF flow through stoma might be detected by Cine MRI in all cases. The clinical symptoms improved to different extents in 21 cases while another two cases showed no improvement. Later these two patients underwent endoscopic posterior cranial fossa decompression. Cerebellar tonsillar hernia improved in 14 cases.

CONCLUSION

Cine MRI can detect the CSF hydrodynamics at craniocervical junction so as to help a surgeon determine the time and the plan of operation. Most cases of hydrocephalus associated with cerebral tonsillar hernia are of obstructive hydrocephalus. The efficacy of ETV for hydrocephalus has been confirmed. Also ETV has a therapeutic effect for cerebellar tonsillar hernia and syringomyelia.

[Primary intracerebellar hematomas: surgical indications, prognosis]

Intracerebellar primary hematoma are produced by spontaneous hemorrhages in the cerebellar parenchima and usually present an sudden onset. In the present study we analyzed a serie of 34 cases of primary intracerebellar hematoma, in patients of both genders, between 35 and 80 years old. Taking in account the incidence of symptoms, the clinical picture was dominated by the gait disturbances, headache and consciousness disorders. From the analyzed cases, 50% had had surgical indication and 50% benefits on conservative treatment. Even though the evolution was favorable in the great majority of cases,the mortality in the surgical treated group was lesser (5,88%) comparative to the conservative treated group (17,64%). The main criteria for surgical treatment were represented by GCS (Glasgow Coma Scale) score < or =13 or blood collections exceeding 3 cm in diameter.

Step-by-step education of the retrosigmoid approach leads to low approach-related morbidity through young residents

BACKGROUND

Neurosurgery requires a profound knowledge of anatomy and surgical skills. The skull base approach is the crucial step for successful intradural performance. Resident training at experienced institutions must consider this background when educating young neurosurgeons.

METHODS

From 2006-2008, 223 retrosigmoid approaches for various cerebellopontine angle pathologies have been performed at the Department of Neurosurgery Eberhard-Karls-University, Tübingen. After a minimum time of 6 months assisting, followed by participation of dissection courses and continuous anatomical training, later performing their first approaches under direct supervision of an experienced surgeon, residents perform their first retrosigmoid approaches autonomously in the operating theatre. With this study, we evaluate the surgical morbidity and the time factor related to the educational level of the surgeon.

RESULTS

Comparing surgical-related morbidity between approaches performed by experienced neurosurgeons (>100 procedures) and young residents (<20 procedures), we found no significant differences concerning the incidence of cerebrospinal fluid fistulae, sinus lacerations, wound infections, cranioplasty dislocations, or occipital nerve neuromas. Even the mean time for the procedure (positioning, time-to-dural incision) was not significantly longer in the trainee group.

CONCLUSION

Respecting the stepwise educational levels for skull base surgery, including microanatomical studies, educational courses, and expert guidance at surgery, the retrosigmoid approach can be performed by young residents without increased morbidity at experienced institutions.

Cerebellopontine angle ganglionic hamartoma: case report

Cerebellopontine angle (CPA) ganglionic hamartomas are rare. We present a case of a 49-year-old woman who presented with left-sided hearing loss of more than 4 years' duration and vertigo since childhood. Magnetic resonance imaging revealed a mass on the intracanalicular segment of cranial nerve VIII on the left side, consistent with acoustic schwannoma. She opted for observation of the tumor. The patient returned 21 months after the initial evaluation with new-onset left facial weakness. At this time, a working diagnosis of facial nerve neuroma was made. The lesion was excised, and pathology confirmed a diagnosis of left-sided CPA ganglionic hamartoma. Otolaryngologists should be familiar with this uncommon tumor and include it in the differential diagnosis of CPA lesions.

Cerebellopontine angle epidermoid cysts. Experience of 43 cases with long-term follow-up

BACKGROUND

Epidermoid tumors represent the third most common lesion of the cerebellopontine angle (CPA). Their evolution and clinical features are distinctively characteristic. We present a comprehensive review of the clinical, imaging and surgical aspects of epidermoid cysts of the CPA.

METHODS

We conducted a case series of patients diagnosed with epidermoid cyst of the CPA who were operated on between 1998 and 2005. Lesions were classified according to their anatomic extent: grade I(-) within the boundaries of the CPA, grade II(-) extension to the suprasellar and perimesencephalic cisterns, and grade III(-) parasellar and temporomesial region involvement.

RESULTS

This study was comprised of 43 patients with a mean follow-up of 85 months. Mean age was 34 years, and 67% of the patients were female. The initial symptom was headache in 58.1% of the cases and trigeminal neuralgia in 41.8%. According to our classification, temporomesial involvement (25.6%) was significantly (p = 0.001) associated with a higher incidence of seizures, and trigeminal neuralgia was present in patients with lesions limited to the CPA (p = 0.006). The lesions were reached essentially through a retrosigmoidal approach (39.5%) and surgical excision was deemed to be complete in 65% of the cases.

CONCLUSIONS

Our grading classification according to the anatomic extension correlates well with clinical presentation, type of surgical approach and extent of surgical removal. It is desirable to reach a consensus on the classification of tumor extension.

Otogenic cerebellar abscess: a case report

This case report describes the gradual deterioration of a healthy, highly functioning man who initially presented with a draining right ear. The patient's indolent neurologic decline and referral to an otologist ultimately led to the diagnosis and treatment of an otogenic cerebellar abscess, an increasingly rare intracranial complication of otitis media. We report this case to illustrate that severe complications of chronic otitis media still occur in the United States, to stress the importance of clinical suspicion in the postantibiotic era, and to review the literature regarding the most appropriate time to perform the otologic portion of the surgery.

Uncommon presentation of intracranial cryptococcal infection mimicking tuberculous infection in two immunocompetent patients

Cryptococcal infection of the brain is commonly seen in immunocompromised patients but rarely considered as the differential diagnosis in immunocompetent patients. We present two cases of cryptococcosis involving the brain in immunocompetent patients, which strongly mimicked tuberculous infection in both conventional as well as advanced magnetic resonance (MR) imaging, and the disease was only confirmed after histopathological/cerebrospinal fluid serological study. One patient was a 52-year-old woman, and the second patient was a 23-year-old man. These two cases highlight the need for workup of fungal infections in immunocompetent patients from the tuberculous endemic regions, even when the imaging is highly suspicious of tuberculous lesions. The imaging findings in advanced MR imaging techniques such as diffusion, perfusion, susceptibility-weighted imaging and MR spectroscopy are discussed.

[Diagnostic and treatment of hypertensive cerebellar hematomas]

Authors analyzed the results of treatment of 56 patients with hypertensive cerebellar hemorrhages (volume 0,5-41 cm3). Brain stem symptoms were found in 45 (80%) of patients. The dislocation of brain stem was observed in 38 (68%) cases, occlusive hydrocephaly - in 22 (39%), intraventricular hemorrhage - in 26 (46%). Severity of state depended on character of disease course, presence of stem symptoms, awakening level, volume and localization of cerebellar hematoma, development of intraventricular hemorrhage, occlusive hydrocephaly and dislocation of brain stem. Thirty-six patients were operated. After the neurosurgical intervention, 22 (61%) patients were discharged without or with the minimal neurological deficit, 1 (3%) with marked disability and 13 (36%) patients died. In conclusion, the removal of hematoma is recommended in dislocation of brain stem and disturbance of consiousnes: the ventricular drainage - in occlusive hydrocephaly developed as a consequence of hemotamponade of IV ventricular. The surgical treatment is not recommended to patients with cerebellar hematomas with the volume less than 7 cm3.

Transglabellar subcranial approach for the management of nasal masses with intracranial extension in pediatric patients

OBJECTIVE

To describe the use of the transglabellar subcranial approach for the management of congenital nasal masses in the pediatric population.

METHODS

Case series. Medical records of 5 patients who underwent resection of congenital nasal lesions via the subcranial approach were reviewed.

RESULTS

Five children underwent successful resection of congenital nasal lesions with intracranial extension via the subcranial approach. Lesions resected included nasal dermoids with intracranial extension (n = 3) and encephaloceles (n = 2). Patient age at the time of operation ranged from 13 months to 15 years. All lesions were resected successfully, and there have not been any recurrences. Follow-up has ranged from 1 to 12 years. There has been no apparent negative effect on facial growth in any of these patients.

CONCLUSIONS

The subcranial approach is an effective technique for the resection of nasal masses with intracranial extension. These lesions have traditionally been managed with lateral rhinotomy, midface degloving, or external rhinoplasty approaches combined with a frontal craniotomy. The subcranial approach offers several advantages over a traditional frontal craniotomy. It provides excellent exposure, minimizes frontal lobe retraction, reduces the likelihood of cerebrospinal fluid leakage, and provides for an excellent cosmetic result. Long-term follow-up in 5 pediatric patients has shown no recurrence or negative effect on craniofacial growth. These factors make the transglabellar subcranial approach a useful and safe technique for the management of nasal lesions with intracranial extension in very young patients.

'Scapula alata' as a consequence of park bench position for a retro-mastoid craniectomy

We report on a patient who developed winged scapula on the contralateral side to the approach for a cerebellopontine tumour excision, an unreported complication following this procedure. We think this was due to damage of the long thoracic nerve in the dependant side, while in the park bench position.

A case of cerebellar infarction caused by vertebral artery injury from a stab wound to the neck

Vertebral artery injuries are the least common arterial injuries because of the deep location of the vessel in a bony canal. Injury of this vessel has not been associated with neurological deficits, and it is thought that many of these injuries are not recognized. The incidence of vertebral artery injury occurring after a penetration wound to the neck varies from 1.0% in gunshot wounds to 7.4% in stab wounds. However, even with vertebral artery injury in penetration wounds of the neck the association with cerebellar infarction is a rare occurrence. We describe a case of cerebellar infarction caused by vertebral artery injury from a stab wound that severed the vessel between the transverse processes of C3 and C4 with a hypoplastic contralateral vertebral artery. The patient ultimately suffered infarction of the cerebellum due to the lack of preservation of the posterior inferior cerebellar artery blood flow. Management is discussed and the medical literature is reviewed.

Acute cerebellitis presenting as tumor. Report of two cases

A pseudotumoral presentation of acute cerebellitis is rare. The authors report two cases of children with hemicerebellar involvement, neither case being postinfectious nor vaccination related. One patient underwent biopsy sampling revealing marked parenchymal and leptomeningeal inflammation, and in the other, near-complete resolution of neuroimaging abnormalities was demonstrated. The literature is reviewed and therapy considerations are emphasized.

Surgical management of cerebellar tonsillar herniation in three patients with macrocephaly-cutis marmorata telangiectatica congenita. Report of three cases

The authors report on three patients with a congenital brain overgrowth syndrome, macrocephaly-cutis marmorata telangiectatica congenita (M-CMTC), who experienced neurological sequelae associated with herniation of the cerebellar tonsils through the foramen magnum. In two of these patients, the authors document postnatal brain overgrowth that contributed to recurrent descent of the cerebellar tonsils and complicated the surgical treatment in one of the patients. The authors address the neurosurgical concerns related to this syndrome with special attention to acquired tonsillar ectopia and postulate that some patients may be at risk for progressive tonsillar herniation and consequent neurological symptoms due to cerebellar overgrowth. Ectopic cerebellar tonsils have been reported previously in cases of M-CMTC, and this phenomenon may be a secondary event associated with brain overgrowth rather than due to a congenitally small posterior fossa.

'Z-Pattern' Craniosynostosis

The majority of infants with multiple sutural craniosynostosis have identifiable syndromes, which affect both coronal sutures (Apert, Crouzon, Pfeiffer, and so on), and multiple sutural fusions not involving both these sutures are exceeding rare. We report a highly unusual pattern of trisutural fusion, which to our knowledge has not been previously described. A retrospective clinical review was performed of all cases of craniosynostosis, which had presented to the Craniofacial Center in Dallas, over a 15-year period. Two patients were identified with a unique pattern of craniosynostosis involving the left coronal, sagittal, and right lambdoid sutures creating a "Z-pattern." Both patients were treated with staged cranial vault reconstructive procedures with an initial posterior remodeling (3 to 4 months) followed by an anterior repair (7 to 8 months). Both patients developed cerebellar tonsillar herniation, and one symptomatic patient required surgical decompression. With a follow up of greater than 2 years, normocephaly has been maintained with growth, and both children appear to have normal intellectual development. A unique pattern of trisutural "Z-patterned" craniosynostosis is presented. This distinctive pattern of craniosynostosis appears to be associated with cerebellar tonsillar herniation. In this small series, a two-staged procedure successfully normalized the calvarial dysmorphism, and early growth and development appear normal.

Symptomatic Chiari type I malformation after radiation therapy in an infant: case report

OBJECTIVE

One previous case report has described the development of a Chiari I malformation in a child after fractionated radiation therapy to the anterior cranial base. The authors present an additional case of a 17-month-old girl treated for an isolated, malignant, rhabdoid tumor of the right neck with neoadjuvant chemotherapy, surgical exploration, and radiation therapy.

CLINICAL PRESENTATION

The patient developed a Chiari I malformation and cervical syringomyelia 1.5 years after the treatment. The patient experienced two episodes of unresponsiveness before diagnosis, and the malformation was then identified on magnetic resonance imaging scans.

INTERVENTION

Suboccipital decompressive craniectomy, and C1 laminectomy with autologous duraplasty were performed.

RESULTS

Postoperative magnetic resonance imaging scans revealed reconstitution of cerebrospinal fluid at the foramen magnum and ascent of the cerebellar tonsils. The patient remains asymptomatic 5.5 years after treatment.

CONCLUSION

The importance of this association is discussed in the context of the increasing use of radiation therapy in young children and infants.

Eumycetoma presenting as a cerebellopontine angle mass lesion

Eumycetoma in the cerebellopontine angle region is extremely uncommon with no case being reported as per an extensive review of the literature by the authors. The authors report a case of cerebellopontine angle eumycetoma in a young female managed by subtotal decompression and antifungal treatment. The pre-operative diagnosis of eumycetoma in this location is extremely difficult and the role of histopathology is very important to characterize this uncommon lesion. The prognosis of this bizarre pathology is dismal despite all treatment modalities as compared to the usual tumors of the cerebellopontine angle that generally have a favorable outcome.