BACKGROUND AND IMPORTANCE:Eustachian tube dysfunction due to medial pterygoid nerve impairment is a rare complication after trigeminal schwannoma surgery. Eustachian tube dysfunction leads to fluid inside the mastoid air cell, which requires differential diagnosis with cerebrospinal fluid leakage.CLINICAL PRESENTATION:We present a 49-year-old male patient of trigeminal schwannoma. The extradural middle fossa rhomboid approach was performed. The mastoid air cell was opened during the drilling of the middle skull base. After surgery, mastoid air cell fluid was observed. The fluid volume did not increase during hospitalization. However, at 3 months after surgery, the mastoid air cell fluid gradually increased. Otolaryngological examination revealed serous otitis media on the surgical side. Furthermore, opening dysfunction of pharyngeal orifice of eustachian tube due to the medial pterygoid nerve impairment after trigeminal schwannoma surgery was suspected. Tympanotomy was performed, after which the mastoid air cell fluid disappeared.CONCLUSION:Eustachian tube dysfunction due to the medial pterygoid nerve impairment is a rare postoperative complication of trigeminal schwannoma. This condition can lead to serous otitis media and increased mastoid air cell fluid.
BACKGROUND AND IMPORTANCE:In side-to-side microvascular anastomoses, it's challenging to achieve vessel intima eversion on the back wall. It is sometimes necessary to lengthen the arteriotomy to compensate the elevated risk of thrombosis formation. This note demonstrates application of the horizontal mattress techniques with an illustrative case to maximize intima eversion, which has not been widely adopted in open vascular micro-neurosurgical practice. CLINICAL PRESENTATION:A 50-year-old female with multiple strokes with transient right sided weakness was diagnosed as bilateral moyamoya syndrome, we present a side-to-side bypass with the horizontal mattress technique. The indocyanine green angiography showed patency of the anastomosis. The patient remained neurologically intact postoperatively. In side-to-side anastomoses, this technique starts with an outside-in (extraluminal-to-intraluminal) stitch at the proximal aspect of the arteriotomy. An aneurysm clip is applied to anchor the suture, the horizontal mattress techniques are subsequently applied to the back wall with suture loops loose, an "outside-in" stitch is followed by an "inside-out" stitch on the contralateral side, and an "inside-out" stitch is followed by an "outside-in" stitch on the ipsilateral side. The suture loops were tightened sequentially proximal-to-distally. A simple tight stitch was then placed at the distal aspect as the inferior anchor, to which the inferior free end of the suture is tightened. Similarly, the proximal free end was tightened after the aneurysm clip is released to complete the backwall. CONCLUSION:Although technically challenging, the horizontal mattress technique can optimize the intima eversion on the back wall in side-to-side microvascular anastomoses.
BACKGROUND AND OBJECTIVES:Cholinergic degeneration in the nucleus basalis of Meynert (NBM) is implicated in the cognitive impairment seen in Parkinson disease (PD) and is being examined as a potential therapeutic target. We have previously shown the safety of delivering investigational autologous cell-based therapy, ie, peripheral nerve tissue (PNT), to the substantia nigra (SN) at the time of deep brain stimulation (DBS) surgery in PD (DBS-Plus). In this study, we assessed the safety and feasibility of simultaneously delivering that PNT to both the NBM and SN at the time of DBS. METHODS:Two patients with idiopathic PD and mild cognitive impairment, who underwent clinically indicated bilateral globus pallidus internus DBS, were consented for participation. At the time of lead placement, reparative autologous PNT (sural nerve) was harvested and stereotactically delivered to the NBM and SN contralateral to the patients' more severe motor symptoms. RESULTS:Delivery of PNT to both the SN and NBM was successfully achieved in both participants. There were no serious adverse events related to the delivery of the graft, and no adverse radiologic effects were observed. Both participants showed stable performance on standard PD testing. Neurocognitive testing at 18 months postoperatively in one participant showed expected decrements in certain domains and unique improvements in others. CONCLUSION:We report the feasibility and preliminary safety data of stereotactic delivery of reparative autologous PNT to two separate unilateral targets at the time of DBS lead placement. We plan to continue exploring the potential for this investigational cell-based therapy to restore function to damaged networks in PD.
BACKGROUND AND OBJECTIVES:Cadaver-based simulations are limited by financial and legal constraints, particularly in low- and middle-income countries (LMICs). Three-dimensional (3D) printing-based alternatives are often limited in scope and prohibitively expensive. This report describes a 3D-printed model that addresses these concerns by simulating a variety of craniotomy approaches in a cost-effective manner. METHODS:A craniotomy model was developed using medical imaging, 3D printing, and foam molding. Detailed manufacturing information for the model is provided. The model was assessed by 40 neurosurgery residents and young attendings in a Latin American LMIC with a questionnaire administered after they performed simulated craniotomies using the model. RESULTS:The total cost of the model was 47.52 USD, and it took 6 hours to produce. Thirty-four (85%) participants agreed that the simulated tissue elastance allowed for using the model to teach surgical approaches. Twenty-six (65%) participants agreed that the model provided realistic haptic feedback. All participants felt the model was useful in learning how to perform emergent craniotomies and that training with the model was transferable to clinical practice. Thirty-seven (93%) participants felt use of the model would help prevent serious intraoperative complications. Thirty-six (90%) participants agreed that the model would be useful in educating patients and families about their neurosurgical problem and the planned surgical approach. CONCLUSION:Most participants found that the craniotomy model provided clinically translatable neurosurgical skills, and it may be a viable alternative to cadaver-based training in LMICs.
BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) affects over 69 million people worldwide, most of whom suffer a so-called “mild” injury. Patients with mild TBI, defined as a Glasgow Coma Scale (GCS) of 13-15 on presentation, often have a significant symptom burden as detected by the Rivermead Post-Concussion Questionnaire (RPQ). In this study, we aimed to determine whether social determinants of health (SDOH) may influence patient self-report of symptoms within a month of injury. METHODS: Patients presenting to an academic Level I trauma center with GCS 13-15 were included in the study with data collected as part of a prospectively maintained neurotrauma registry. Overall, 451 individuals completed the RPQ at a follow-up clinic visit. Demographic variables, injury characteristics, comorbidities, and geocoded SDOH information were captured from the electronic medical record. Multivariable regression analysis was performed. RESULTS: Variables contributing to increased symptom burden on the RPQ included sex, living in an area with a high fraction of poverty, history of depression or anxiety, initial GCS score, history of illicit drug use, obesity, and positive head CT. CONCLUSION: In addition to the expected patient and injury characteristics, fraction living in poverty was a significant variable contributing to scores on the RPQ-3 and RPQ-13. Efforts to incorporate screening for SDOH factors should be considered to identify patients at risk of poor recovery after mild TBI.
