Editor’s note
This month’s edition highlights the advancing accuracy of neurosurgery with four distinct, impactful cases. We see how 3D printing enhances planning for deep-seated tumors, and how histiocytic neoplasms can challenge even the most advanced diagnostic frameworks. Meanwhile, a minimally invasive bedside approach redefines safety for frail aSDH patient, and a case of adult-onset aqueductal stenosis underscores the need for anatomical awareness and adaptive strategies.
Together, these reports highlight a central theme: modern neurosurgery demands not just skill, but innovation, flexibility, and multidisciplinary thinking.
In This Issue
- Three-Dimensional Models Confront Deep-Seated Brain Tumors: How 3D-Printed Intraventricular Models Are Reshaping Surgical Planning and Resident Training.
- A Mystery in the Margins: Unclassifiable Histiocytic Brain Tumor –When molecular profiling fails to provide a definitive diagnosis.
- Clearing the Clot, Skipping the Scalpel – Minimally invasive bedside fibrinolytic therapy offers a life-saving option for fragile aSDH patients.
- The Silent Stenosis: Unmasking Late-Onset Aqueductal Obstruction in Adulthood – Adult hydrocephalus from congenital aqueductal stenosis reveals the need for flexible surgical planning.
Three-Dimensional Models Confront Deep-Seated Brain Tumors
There is now a 3D update for intraventricular tumor surgical preparation. A case series published in World Neurosurgery examined the efficacy of 3D-printed intraventricular tumor models in optimizing surgical planning for tubular retractor surgery, which is gaining popularity for addressing deep-seated tumors such as central neurocytomas.
Neurosurgeons from Chonnam National University Hospital in South Korea used both conventional CT-MRI fusion images and 3D-printed models to simulate the best entry points for tubular retractor-based resections in nine patients.
The outcome? Substantially enhanced precision and uniformity with the 3D prints. In simulations with non-professional neurosurgeons, puncture spots were significantly more matched with expert consensus when utilizing printed models. While acknowledging areas for development in imitating brain texture, experts lauded the precise depiction of tumor, ventricle, and nerve fiber structures.
Why it matters: These models are important because they can improve accuracy and safety as well as help resident training and anatomical knowledge.
A Mystery in the Margins: Unclassifiable Histiocytic Brain Tumor
Not all tumors fit neatly into a diagnosis, and this one most definitely didn’t. A 49-year-old woman exhibited right-hand weakness and was diagnosed with a diffuse left parietal brain lesion, which was initially thought to be a low-grade glioma, as reported in Brain Tumor Research and Treatment.
However, the mystery grew following craniotomy and resection. Histology revealed foamy histiocytes and lymphocytic infiltration, with immunohistochemical markers positive for CD68 and ALK (D5F3), while being negative for the hallmark markers of Langerhans cell histiocytosis, Erdheim-Chester disease, and ALK gene rearrangement. Next-gen sequencing and PET-CT failed to recognize the tumor as a known subtype.
Diagnosis? Histiocytic neoplasm, not otherwise specified (NOS)—a broad classification for cases lacking molecular insights. The patient showed a positive response to radiation and continues to be neurologically stable.
Why it matters: This case underscores the intricate diagnosis of histiocytic tumors in the CNS and emphasizes the necessity for advanced molecular profiling, collaborative efforts across disciplines, and the development of updated classification systems for exceptionally rare tumors.
Clearing the Clot, Skipping the Scalpel
Managing bilateral acute subdural hematomas (aSDHs) in elderly patients presents significant challenges, particularly when these individuals are too frail to undergo general anesthesia or open craniotomy. In a case study published in JNS Case Lessons, a 76-year-old woman with serious comorbidities recovered with pressure-controlled fibrinolytic irrigation therapy and a minimally invasive twist-drill craniostomy (TDC).
Surgeons utilized the IRRAflow and LiquoGuard 7 systems to insert catheters at the bedside, allowing for the direct delivery of urokinase-infused irrigation into the subdural space. No OR, no general anesthesia—just targeted clot lysis with continuous ICP monitoring. On the fifth day, the hematomas had almost completely resolved, and the patient was able to leave the hospital eight days after the operation, showing no signs of neurological deficits.
Why it matters: This case underscores the significance of advancing neurosurgery for high-risk patients, emphasizing approaches that are less invasive, more precise, and tailored to individual needs. This presents a persuasive case for broadening the application of bedside neurointerventions.
The Silent Stenosis: Unmasking Late-Onset Aqueductal Obstruction in Adulthood
Most cases of congenital aqueductal stenosis (CAS) are typically identified in early life. However, this silent brain abnormality sometimes remains in the background until it suddenly manifests in adulthood. This case report from the Journal of Neurological Surgery Reports details a 35-year-old man who experienced a 2-day history of severe headache and vomiting, ultimately diagnosed with acute hydrocephalus due to an aqueductal web.
Imaging showed typical signs of CAS: enlarged lateral and third ventricles, a thin membrane at the aqueduct of Sylvius, and a high-riding basilar artery, which excluded the option of endoscopic third ventriculostomy (ETV) because of the potential for vascular injury. Surgeons chose to use a ventriculoperitoneal (VP) shunt following a temporary diversion of CSF through an external ventricular drain (EVD).
Months later, complications arose: a large subdural hematoma due to overdrainage. A frontoparietal craniotomy was performed, followed by an eventual shunt valve upgrade to a programmable system, which stabilized the patient’s condition.
Why it matters: This case highlights the often overlooked issue of adult-onset CAS, the risks associated with excessive shunting, and the need for adaptable surgical approaches due to anatomical differences such as a high-riding basilar artery. As neurosurgeons maneuver through these complex anatomical challenges, accuracy and strategy are paramount.
That’s a wrap on this edition of The Short Report on Neurosurgery!
Which of these advancements intrigued you the most? Let’s discuss in the comments! 💬
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