BACKGROUND AND IMPORTANCE: Nasal dermoid sinus cysts (NDSCs) are rare congenital midline anomalies caused by incomplete separation of ectoderm and neuroectoderm during embryogenesis. Intracranial extension, although uncommon, increases the risk of infection, recurrence, and neurological complications. Hartley type IV lesions involve the intradural compartment and represent the most complex subtype. CLINICAL PRESENTATION: A 13-year-old boy presented with a congenital nasal tip pit associated with recurrent swelling and serous discharge since age 9. MRI and computed tomography revealed a midline fistulous tract extending through the foramen cecum, with extradural intrafalcine and intradural frontobasal components, consistent with a type IV NDSC. Complete excision was achieved through a combined transnasal interalar and transcranial transfrontal approach. The extracranial tract was dissected to the foramen cecum, and the intracranial component was removed by interhemispheric dissection. Endoscopic assistance confirmed a deformed foramen cecum, reconstructed with polymethylmethacrylate. The postoperative course was uneventful, with no neurological deficits. Imaging confirmed complete resection without recurrence. Histopathology demonstrated abundant keratinous debris, confirming a dermoid lesion. CONCLUSION: This case highlights the importance of multidisciplinary planning and tailored craniofacial strategies in managing complex NDSCs with intracranial extension. The combined transnasal and transcranial approach enabled radical excision while preserving anatomic and functional integrity.
BACKGROUND AND IMPORTANCE: Ventriculoperitoneal (VP) shunt placement remains a standard treatment of hydrocephalus, yet the commonly used method of freehand proximal catheter placement is associated with high rates of malposition. Although stereotactic navigation increases accuracy, it can introduce workflow inefficiency and increase intraoperative complexity. Augmented reality (AR) is an emerging technology that provides real-time integration of 3-dimensional imaging directly onto the surgical field. This report aimed to describe the feasibility and technical nuances of AR-guided proximal catheter placement using the Novarad VisAR system during a VP shunt surgery. CLINICAL PRESENTATION: An eighty-one-year-old man with normal pressure hydrocephalus underwent elective VP shunt placement. CONCLUSION: Proximal catheter placement was successfully accomplished on first pass using AR guidance. Postoperative computed tomography head confirmed accurate placement consistent with preoperative planning. This case illustrates the first use of AR guidance for presurgical planning and intraoperative placement of a proximal ventricular catheter and demonstrates the feasibility of this technique.
BACKGROUND AND OBJECTIVES: A vascular closure device that provides rapid hemostasis is useful for neuroendovascular patients, especially for those with altered mental status or high intracranial pressure that limits compliance with bedrest. CELT ACD ® (arterial closure device) has demonstrated effectiveness and safety in non-neurological cohorts, and thus, the aim of this study was to evaluate the effectiveness of CELT in neuroendovascular interventions. METHODS: We conducted a prospective cohort study at our institution, enrolling consecutive patients undergoing neuroendovascular intervention with femoral access and subsequent CELT closure. We used a CELT-first approach for femoral closure during the study period, with all patients undergoing immediate head-of-bed (HOB) elevation postprocedurally. Primary outcomes included immediate device failure, time to hemostasis (TTH), time to HOB elevation, and risk of access-site hematoma 12 hours after hemostasis (delayed hematoma). RESULTS: Fifty consecutive patients undergoing neuroendovascular interventions were closed with CELT. All patients (n = 50, 100%) underwent immediate postprocedure HOB elevation after a straight-leg test, and there was no immediate device failure or delayed hematoma. The average TTH and HOB/mobility liberalization was 1.1 (±2.2) minutes. There was no lower extremity ischemia attributable to CELT closure. CONCLUSION: In this prospective study, we reported the first experience with CELT closure in neuroendovascular interventions and found an excellent safety and efficacy profile. CELT may be considered first line for patients requiring rapid TTH and early HOB elevation, particularly in the context of high intracranial pressure concerns.
BACKGROUND AND OBJECTIVES: Middle meningeal artery (MMA) embolization is used in chronic subdural hematoma (cSDH). The safety of resuming antithrombotic (AT) therapy after MMA embolization remains unclear. This study evaluates the impact of AT resumption on hematoma resolution, recurrence, and reoperation rates, while assessing thromboembolic risks associated with interrupting AT therapy. METHODS: A retrospective review was conducted of patients undergoing MMA embolization for cSDH at a Level I trauma center from 2020 to 2023. Cases were stratified based on postprocedural AT resumption. Primary outcomes included >50% reduction in cSDH size and reoperation rate. Secondary outcomes included recurrence, functional outcomes measured by the modified Rankin Scale (mRS), and rate of thromboembolic complications in patients who withheld AT medications. Kaplan-Meier analysis compared recurrence-free survival between groups. RESULTS: A total of 120 patients (160 embolization cases) were included (mean age 72.1 ± 12.2 years; 48.5% women). AT therapy was resumed in 40 patients (53 cases, 33.1%) with a median restart time of 44 days. The non-AT group had similar initial hematoma thickness (13.7 ± 5.8 mm vs 12.0 ± 6.5 mm; P = .093). There were no differences in >50% hematoma reduction, recurrence, or reoperation rates between the groups ( P = .18, .50). Complete resolution was more frequent in the AT group (67.9% vs 43.0%). Partial resolution was more common in the non-AT group (67.5% vs 35.0%). Recurrence did not differ based on AT resumption within 30 days ( P = 1). Five patients (9.3%) experienced thromboembolic complications within 30 days before AT resumption, without an increase in mRS at last follow-up ( P = .33). The non-AT group had higher mRS scores overall ( P = .049). CONCLUSION: Resuming ATs within 30 days of MMA embolization did not affect recurrence or reoperation rates. Resumption of AT therapy within 2 weeks of MMA embolization may reduce thromboembolic complications.
BACKGROUND AND IMPORTANCE: Sunken flap syndrome (SFS) is a neurological decline that results from paradoxical brain shift following decompressive hemicraniectomy. It is thought to arise from a gradient between atmospheric and intracranial pressure and can cause neurological morbidity if not surgically corrected. In most cases, this involves autologous or synthetic cranioplasty. However, in select patient populations, this is not possible—either because of recent infection, availability of cranioplasty implant, anticoagulant use, or other patient-specific factors. CLINICAL PRESENTATION: In this case report, we present 3 patients with SFS who could not undergo cranioplasty due to a recent surgical site infection. Instead, their SFS was managed nonoperatively with a makeshift “external cranioplasty” that resulted in significant improvement in their midline shift and mental status. CONCLUSION: We believe this fast, economical approach can be applied to future patients with SFS who are unable to undergo surgical intervention.
