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Purpose: Chiari I malformation (CM-I) in pediatric patients can impose substantial neurologic and functional impairment. Additionally, the presence of syrinx is often a harbinger of clinical compromise, but little attention has been devoted to identifying features associated with syrinx development and the clinical impact of syrinx resolution. Therefore, this study aims to identify clinical and radiographic variables associated with preoperative syrinx presence and postoperative syrinx reduction in pediatric patients with CM-I and determine the relationship between postoperative syrinx reduction and clinical symptom improvement. Methods: The authors performed a retrospective analysis of 435 consecutive pediatric patients who underwent surgical treatment of CM-I from 2001 to 2021 at a single tertiary pediatric medical center. All patients underwent pre- and postoperative MRI, and clinical and radiographic variables were recorded and subject to inferential analysis. Results: Syrinx at presentation was independently associated with symptoms of spinal cord dysfunction at presentation (OR 2.17 (95% CI 1.05–4.48); p = 0.036), scoliosis (OR 5.33 (2.34–10.86); p = 0.001), and greater pB-C2 (posterior basion to C2 distance) measurement length (OR 1.14 (95% CI 1.01–1.30); p = 0.040). Syrinx at presentation was inversely associated with tussive headaches at presentation (OR 0.27 (95% CI 0.16–0.47); p = 0.001) and cranial nerve deficits at presentation (OR 0.49 (95% CI 0.26–0.92); p = 0.025). Postoperatively, patients with radiographic evidence of syrinx improvement had greater rates of symptom improvement (93.1% vs 82.1%; p = 0.049), better CCOS scores (15.4 vs 14.2; p = 0.001), and decreased rates of readmission (6.0% vs 25.0%, p = 0.002) and reoperation (0.5% vs 35.7%; p = 0.001). The difference in syrinx resolution was similar but not statistically significant (10.3% vs 16.7%; p = 0.251). AO joint anomaly (OR 0.20, 95% CI 0.04–0.95; p = 0.026) and foramen magnum diameter (OR 1.12, 95% CI 1.00–1.25; p = 0.049) were the only independent predictors of syrinx improvement, and surgical technique was the only predictor for syrinx resolution (OR 2.44, 95% CI 1.08–5.50; p = 0.031). Patients that underwent tonsil reduction surgery whose syrinx improved had a wider foramen magnum diameter than those whose did not improve (34.3 vs 31.7; p = 0.028). Conclusions: Radiographic syrinx improvement is associated with greater rates of symptom improvement and less readmissions and reoperations for CM-I. AO joint anomalies and narrower foramen magnums were independent risk factors for the lack of syrinx improvement. These novel insights will help guide preoperative patient counseling, pre- and intraoperative surgical decision-making, and postoperative clinical prognostication in the treatment of pediatric CM-I. [ABSTRACT FROM AUTHOR]

Objective While the transcondylar approach is technically challenging, it provides generous ventral and caudal exposure to the craniovertebral junction. This approach requires navigation around multiple eloquent neurovascular structures including the lower cranial nerves, vertebral artery and its branches, and the brainstem. Superficial exposure, including incision location and muscle dissection, can dramatically affect the surgical angle and maneuverability at depth. Methods We demonstrate the transcondylar approach in a step-by-step fashion in a formalin-embalmed, latex-injected cadaver head. Dissection within each layer of the suboccipital muscles was performed. A small cohort with an illustrative case is also included herein. Results The sternocleidomastoid (SCM) muscle was retracted anteriorly; the splenium capitis, semispinalis capitis, and longissimus capitis muscles were disconnected from the superior nuchal line and reflected inferomedially. The suboccipital muscle group was fully exposed. The superior and inferior oblique muscles were disconnected from the transverse process of C1. The superior oblique and the rectus capitis posterior major muscles were then dissected off the inferior nuchal line, and the suboccipital muscle group was retracted inferomedially en bloc. The greater auricular nerve was retracted laterally with the SCM, and the greater occipital nerve was retracted inferomedially with the suboccipital muscle group. Conclusion This technique avoids the obstructive muscle bulk that results from a myocutaneous approach while maximizing deep exposure. Understanding the detailed muscular anatomical relationship with the insertion location and suboccipital nerves is key to complete and safe extracranial dissection. Diligent dissection helps minimize postoperative pain and muscle spasm while optimizing the closure technique. [ABSTRACT FROM AUTHOR]

Simple Summary: Perineural anesthesia of the tibial nerve can be performed ultrasound-guided or blindly, with the latter still being commonly used in equine practice due to practical constraints, despite its lower accuracy and hence, its common failure to achieve desensitization. This may be associated with anatomical variations or inadequate landmarks for injection. In this anatomical study on the course of the tibial nerve on paired cadaveric limbs, we found that problems with perineural anesthesia cannot simply be attributed to anatomical variations. The large diameter of the tibial nerve (6 ± 1 mm) and the substantial amount of perineural tissue may present specific challenges for achieving adequate desensitization. Regarding landmarks, this study confirms that perineural injection should be performed 10 cm proximal to the proximocranial aspect of the calcaneal tubercle and 11 mm cranial to the superficial digital flexor. Perineural anesthesia of the tibial nerve can be performed ultrasound-guided or blindly, with the latter still being commonly used in equine practice due to practical constraints, despite its lower accuracy and hence, common failure to achieve desensitization. This may be associated with anatomical variations or inadequate landmarks for injection. To examine the course of the tibial nerve, document potential anatomical variations, and determine optimal landmarks for perineural injection, dissection was conducted along the medial aspect of the tibia in 10 paired cadaver hindlimbs. No anatomical variations of the tibial nerve were observed. Mean tibial nerve thickness was 6 ± 1 mm. The junction with the plantar nerves was located at a maximum of 85 mm and the junction with the medial cutaneous branch was at a maximum of 150 mm proximal to the proximal aspect of the calcaneal tubercle. The mean distance of the tibial nerve to the cranial border of the superficial digital flexor was 11 ± 6 mm. In conclusion, problems with perineural anesthesia of the tibial nerve cannot simply be attributed to anatomical variations. The thickness of the nerve and the amount of perineural tissue may present specific challenges for achieving adequate desensitization. Our results support the generally recommended site for tibial nerve perineural injection at 100 mm proximal to the calcaneal tubercle and 11 mm cranial to the superficial digital flexor. [ABSTRACT FROM AUTHOR]

The superior orbital fissure contains cranial nerves III, IV, VI, and V1 with their three branches: frontal, lacrimal, and nasociliary. Superior orbital fissure syndrome (SOFS) is rare and can occur as a result of compression of these nerves due to trauma, bleeding, or inflammation in the retrobulbar space, but no cases of SOFS after deep lateral orbital wall decompression (DLOWD) have been reported. The aim of this paper is to describe this pathology, its possible causes, management, and outcome. Retrospective study of 575 DLOWD in patients with disfiguring exophthalmos due to Graves' ophthalmopathy performed in our hospital between 2010 and 2023. Three cases of postoperative SOFS were identified based on clinical presentation, history, physical examination, and radiological study. All patients were observed for a minimum of 12 months. SOFS was diagnosed with the presence of ophthalmoplegia, ptosis, fixed and dilated pupils, hypo/anesthesia of the upper eyelid and forehead, loss of corneal reflex, and no loss of vision after DLOWD. Fractures, edema, and hemorrhages were excluded. They were treated with high-dose intravenous steroids and the patients recovered completely. DLOWD challenges orbital surgeons because it requires removing bones near the globe or neurovascular structures. SOFS may occur due to the proximity and increased pressure on these structures. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the alterations in extraocular muscles (EOMs) by magnetic resonance imaging (MRI) among patients diagnosed with Duane retraction yndrome (DRS) and congenital fibrosis of the extraocular muscles (CFEOM), who present with various cranial nerve anomalies in an attempt to enhance the clinical diagnostic process. Methods: A case–control study was conducted to evaluate 27 patients with DRS and 14 patients with CFEOM. All patients underwent MRI scans of the brainstem and orbital examination. Neurodevelopmental assessments were conducted through MRI, and maximum cross-sectional area and volumes of EOMs were obtained. Three types of models were constructed using machine learning decision tree algorithms based on EOMs to predict disease diagnosis, cranial nerve abnormalities, and clinical subtypes. Results: Patients with bilateral CN VI abnormalities had smaller volumes of LR, MR, and IR muscles compared to those with unilateral involvement (P < 0.05). Similarly, patients with CFEOM and unilateral third cranial nerve abnormalities had a smaller maximum cross-section of the affected eye's SR compared to the contralateral eye (P < 0.05). In patients with both CN III and CN VI abnormalities, the volume of SR was smaller than in patients with CN III abnormalities alone (P < 0.05). The prediction model using EOMs volume showed a diagnostic precision of 82.5% for clinical cases and 60.1% for predicting cranial nerve abnormalities. Nonetheless, the precision for identifying clinical subtypes was relatively modest, at only 41.7%. Conclusion: The distinctive volumetric alterations in EOMs among individuals exhibiting distinct cranial nerve anomalies associated with DRS or CFEOM provide valuable diagnostic insights into to Congenital Cranial Neurodevelopmental Disorders (CCDDs). MRI analysis of EOMs should thus be regarded as a crucial diagnostic modality. [ABSTRACT FROM AUTHOR]

A 62-year-old man presented with a slowly growing, painless lesion on his face. This eventually led to a progressive left-eye vision lesion, and the patient was subsequently diagnosed with advanced basal cell carcinoma (BCC). Of note, BCC involving cranial nerves is extremely rare, making this case unique and important to highlight. Standard treatment options for BCC involve surgery, radiation, or platinum-based chemotherapy. However, targeted therapies such as sonidegib and vismodegib - sonic hedgehog pathway inhibitors - have emerged that have been approved for treating BCC, as have anti-PD1 immunotherapies, such as cemiplimab, with their success likely based on the high tumor mutational burden seen in some of these tumors. Epidermal growth factor receptor (EGFR) inhibitors also serve a role in treating this condition as well. Molecular studies on metastatic/advanced BCC and other rare malignancies may inform treatment therapeutic decisions. [ABSTRACT FROM AUTHOR]

Background: The facial nerve is considered a crucial structure and is vulnerable to injury during middle ear and mastoid surgery. The facial canal could be dehiscent in certain populations; therefore, identifying it and avoiding injury to the nerve is an important step during otological surgeries. In this study, we assessed the rate of facial canal dehiscence (FCD) among patients undergoing surgery due to the presence of chronic suppurative otitis media (CSOM). Methods: A cross-sectional study was performed between June 2019 and May 2023. We included 102 patients (aged 8–70 years), admitted for primary tympanomastoid exploration due to the presence of CSOM with and without cholesteatoma at Azadi Teaching Hospital in Duhok/Iraq. Cases with a history of trauma or craniofacial abnormalities were excluded from the study. Also, none of the selected patients complained of facial nerve disorders. Results: Among the 102 patients who were admitted, 11.76% (n = 12) had FCD; they were between the ages of 11 and 58 (average: 30.9) years (18.8% ≤ 18 years vs. 10.5% > 18 years, p = 0.396). The dehiscence was more common in males than females (14.3% vs. 10.0%, p = 0.545) and was also more common on the left side than the right side (13.8% vs. 9.1%, p = 0.547). Of those with the dehiscent facial nerve, 83% (n = 10) had the dehiscence on the tympanic segment. The dehiscence was statistically more common in patients with cholesteatoma than those without (25.9% vs. 6.7%, p = 0.014). Conclusion: Dehiscence in the facial nerve can be encountered in patients with CSOM, particularly those with cholesteatoma. In such patients, the dehiscence is most commonly found on the tympanic segment of the facial nerve, so care should be taken during surgery for such cases to avoid injury of the nerve. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to investigate the association between intracerebral aneurysms and cranial nerve (CN) palsies, focusing on nerves other than the oculomotor nerve. It sought to determine the prevalence, risk factors, and clinical outcomes of these nerve palsies and compare the effectiveness of microsurgical clipping versus endovascular coiling in restoring nerve function. Methodology: Following PRISMA guidelines, a comprehensive literature search was conducted using databases like PubMed, Scopus, and Google Scholar, covering studies from 1975 to April 2024. The inclusion criteria targeted patients with non-oculomotor nerve palsies diagnosed with cerebral aneurysms. Studies published before 1975 and non-English studies were excluded. Data extraction included study design, patient characteristics, and intervention outcomes. The Joanna Briggs Institute and Newcastle-Ottawa scales were used to assess study quality. Data were synthesized narratively and statistically analysed using SPSS v27. Results: The analysis included 47 patients (53.2% female, mean age 44.8 years). The internal carotid artery (ICA) was the most common aneurysm site (44.7%), and the abducent nerve (CN VI) was most frequently affected. Ruptured aneurysms had better recovery outcomes (88.9%) than unruptured ones (66.7%). Hypertension was present in 9.2%. Unilateral aneurysms were seen in 80.9%, with 76.6% having a single nerve palsy. Non-ruptured aneurysms accounted for 58.1%, and ruptured for 41.9% of associated cranial nerve palsies. Treatment included microsurgical approaches (42.6%), endovascular approaches (34%), combined approaches (6.4%), and conservative management (17%). Recovery of the palsy was observed in 75.6%, with endovascular procedures showing higher recovery (93.3%) compared to conservative treatment (28.6%). Conclusion: Intracerebral aneurysms are significantly associated with non-oculomotor CN palsies. Endovascular procedures yield higher recovery rates than conservative management, particularly in ruptured aneurysms. Timely and appropriate treatment is crucial for improving nerve function recovery in these patients. [ABSTRACT FROM AUTHOR]

Background: Schwannomas are benign usually encapsulated nerve sheath tumors derived from the Schwann cells, and affecting single or multiple nerves. The tumors commonly arise from the cranial nerves as acoustic neurinomas but they are extremely rare in the pelvis and the retroperitoneal area. Retroperitoneal pelvic schwannomas often present with non-specific symptoms leading to misdiagnosis and prolonged morbidity. Case presentation: We report the case of a 59-year-old woman presenting with a feeling of heaviness in the lower abdomen who was found to have a retroperitoneal pelvic schwannoma originating from the right femoral nerve. She had a history of two resections of peripheral schwannomas at four different sites of limbs. After conducting magnetic resonance imaging, this pelvic schwannoma was misdiagnosed as a gynecological malignancy. The tumor was successfully removed by laparoscopic surgery. Pathological analysis of the mass revealed a benign schwannoma of the femoral nerve sheath with demonstrating strong, diffuse positivity for S-100 protein. Conclusions: Although retroperitoneal pelvic schwannoma is rare, it should be considered in the differential diagnosis of pelvic masses, especially in patients with a history of neurogenic mass or the presence of neurogenic mass elsewhere. [ABSTRACT FROM AUTHOR]

Purpose: Several studies reported surgical outcomes for abducens nerve palsy, but information on factors that affect treatment success remains lacking. These factors are crucial for developing a treatment plan and providing disease counseling. This study aimed to investigate the outcomes of strabismus surgery for abducens nerve palsy and determine the factors that influence its success, including a review of relevant literature. Methods: This retrospective analysis included abducens nerve palsy cases, focusing on surgical interventions and relevant patient data, at the outpatient clinics of Phramongkutklao Hospital from April 1, 2012, to April 30, 2022. A relevant literature review included the surgical success rate and factors that influence surgical outcomes. Results: This study enrolled 32 patients, including 19 with partial and 13 with complete abducens nerve palsy. The overall success rate of strabismus surgery was 78.1%. Trauma was the leading cause of abducens nerve palsy in this population (28.13%). Fisher's exact and Mann–Whitney U-tests revealed that shorter abducens nerve palsy onset and smaller preoperative angle were significantly associated with successful surgical outcomes of strabismus surgery among the groups. In contrast, subgroup analysis revealed that only preoperative smaller angles were significantly associated with good surgical outcomes in horizontal strabismus surgery. However, the vertical rectus muscle transposition group demonstrated no significant factors. The literature review revealed that the success rate of surgery in abducens nerve palsy was 25%– 82.6% for horizontal rectus muscle surgery and 46.2%– 91% for rectus muscle transposition. Conclusion: The surgical success rate for abducens nerve palsy reached 78.1%, including 78.95% for partial and 76.92% for complete abducens nerve palsy. Notably, a shorter onset preceding surgery and a smaller preoperative angle significantly correlated with successful surgical outcomes one year postoperatively. Plain Language Summary: Numerous studies have been conducted to determine the effectiveness of eye muscle surgery for abducens nerve palsy. However, there is still a lack of information on the various factors that can influence the success rate of the treatment. Understanding these factors is crucial for developing appropriate treatment plans and guidance for individuals with this condition. Our study aimed to examine the effectiveness of strabismus surgery for abducens nerve palsy and identify the factors that affect its success. This was achieved by reviewing relevant literature and analyzing cases from Phramongkutklao Hospital between April 1, 2012, and April 30, 2022. We included 32 patients with partial or complete abducens nerve palsy, with trauma being the leading cause of the condition in our group. The results showed that the surgery was successful in 78.1% of cases. Our analysis revealed that getting surgery sooner after the palsy started and having a smaller misalignment angle before surgery were associated with better outcomes. However, these factors only mattered for horizontal eye muscle surgery, not vertical muscle transposition. Previous studies have reported success rates for this condition ranging from 25% to 91%. Our study concludes that earlier surgery and certain preoperative factors can improve outcomes for individuals with abducens nerve palsy after eye muscle surgery. [ABSTRACT FROM AUTHOR]

Herpes zoster ophthalmicus (HZO) occurs when latent varicella zoster virus reactivates in the ophthalmic division of the fifth cranial nerve (CNV1). HZO commonly affects older and immunocompromised patients. This disease is considered an ophthalmic emergency due to the wide range of associated ocular symptoms, including severe chronic pain and vision loss. HZO is typically a clinical diagnosis due to its classic presentation of a unilateral vesicular eruption in the dermatomes corresponding to CNV1. Timely treatment is imperative to minimize ocular morbidity in HZO, given that ocular involvement is present in 50% of affected patients. [ABSTRACT FROM AUTHOR]

Background and purpose: Takotsubo cardiomyopathy (TCM) is a serious autonomic complication of Guillain–Barré syndrome (GBS). However, the association between TCM and GBS has not been investigated in detail. We investigated the characteristics of GBS patients with TCM (GBS-TCM). Methods: Clinical features and anti-ganglioside antibody between the GBS-TCM patients and 62 classical GBS patients without TCM as control patients were compared. Results: Eight GBS-TCM patients were identified, in whom TCM was diagnosed at a mean of 6.5 [range 3–42] days after the onset of GBS. The age at onset of GBS was elder in the GBS-TCM patients than in the control GBS patients (76.5 [56–87] vs. 52 [20–88] years, p < 0.01). Notably, cranial nerve deficits, particularly in the lower cranial nerves, were observed in all GBS-TCM patients (100% vs. 41.9%, p < 0.01). Additionally, the GBS-TCM patients showed a higher GBS disability score at nadir (5 [4–5] vs. 4 [1–5], p < 0.01), and lower Medical Research Council sum scores at admission and nadir (37 [30–44] vs. 48 [12–60] at admission, p < 0.05, and 20 [12–44] vs. 40 [0–60] at nadir, p < 0.05, respectively). Mechanical ventilation was more frequently required in the GBS-TCM patients (62.5% vs. 11.3%, p < 0.01). Three GBS-TCM patients were positive for anti-ganglioside antibodies. Conclusions: TCM occurred at a relatively early phase of GBS. The characteristics of GBS-TCM were the elder, lower cranial nerve involvements, severe limb weakness, and respiratory failure. [ABSTRACT FROM AUTHOR]

Background: Neurosarcoidosis is rare, and among its manifestations, nerve root involvement has been reported in only a few cases. Therefore, magnetic resonance imaging (MRI) findings of neurosarcoidosis, particularly those involving nerve roots, are scarce in the literature. Methods: We presented the case of neurosarcoidosis involving cervical nerve roots and cranial nerves, alongside a systematic literature review. Results: A 28-year-old female suddenly developed right facial numbness as well as left upper extremity and left hand pain. Initial brain and spine MRI showed a bulging mass of T2 iso-to-high signal intensity in the left Meckel's cave/trigeminal nerve, as well as diffuse enlargement of the right C6 and C7 nerve roots. Follow-up MRI at 2 months revealed a reduction in the size of the initial lesion and the appearance of new similar lesions on the contralateral side (right Meckel's cave, left C3–C8 nerve roots). In particular, the lesions involving the nerve roots demonstrated central enlargement along the nerve roots, without involvement of the adjacent spinal cord. All these lesions exhibited enhancement, leading to the differentiation between sarcoidosis and lymphoma. Sarcoidosis was subsequently confirmed through biopsy of a hilar lymph node. Conclusions: This report presents a distinctive MRI feature of neurosarcoidosis involving spinal nerve roots, representing the first of its kind, and describes the evolution of MRI findings throughout the clinical course. [ABSTRACT FROM AUTHOR]

Traumatic optic neuropathy (TON) is a rare that causes severe visual impairment usually results from cranial or ocular trauma. TON manifests directly and indirectly, which is more common. The incidence rate ranges from 0.7% to 2.5%. Clinical indicators of TON include the presence of an afferent pupillary defect after trauma, decreased vision acuity and intact ocular structure. Surgical decompression appears to be a feasible option in cases with direct bone compression on the optic nerve or progressive vision impairment in indirect TON. However, the evidence supporting treatment efficacy for improvement in vision is still ambiguous. This review will examine surgical techniques for decompressing the optic canal. [ABSTRACT FROM AUTHOR]

Purpose: When operating near cranial motor nerves, transient postoperative weakness of target muscles lasting weeks to months is often observed. As nerves are typically intact at a procedure's completion, paresis is hypothesized to result from a combination of neurapraxia and axonotmesis. As both neurapraxia and axonotmesis involve Schwann cell injury and require remyelination, we developed an in vitro RSC96 Schwann cell model of injury using hydrogen peroxide (H2O2) to induce oxidative stress and investigated the efficacy of candidate therapeutic agents to promote RSC96 viability. As a first step in developing a long-term local administration strategy, the most promising of these agents was incorporated into sustained-release microparticles and investigated for bioactivity using this assay. Methods: The concentration of H2O2 which reduced viability by 50% was determined to establish a standard for inducing oxidative stress in RSC96 cultures. Fresh cultures were then co-dosed with H2O2 and the potential therapeutics melatonin, N-acetylcysteine, resveratrol, and 4-aminopyridine. Schwann cell viability was evaluated and the most efficacious agent, N-acetylcysteine, was encapsulated into microparticles. Eluted samples of N-acetylcysteine from microparticles was evaluated for retained bioactivity. Results: 100 µM N-acetylcysteine improved the viability of Schwann cells dosed with H2O2. 100 µM Microparticle-eluted N-acetylcysteine also enhanced Schwann cell viability. Conclusion: We developed a Schwann cell culture model of iatrogenic nerve injury and used this to identify N-acetylcysteine as an agent to promote recovery. N-acetylcysteine was packaged into microparticles and demonstrated promise as a locally administrable agent to reduce oxidative stress in Schwann cells. [ABSTRACT FROM AUTHOR]

Emerging evidence suggests that coronavirus disease 2019 (Covid-19) can significantly affect cranial nerves, resulting in various neurological complications. Predominant issues include anosmia, ageusia, and severe headaches. This study involved 30 recovered Covid-19 patients who underwent MRI Tractography with a Superconductor 1.5 Tesla machine and Diffusion Tensor Imaging (DTI). We analyzed correlations between gender, age, Covid-19 symptoms, pathological findings, diffusion metrics, motor and cognitive functions, and other clinical characteristics. Probabilistic constrained spherical deconvolution tractography and tract quantification were performed following diffusion tensor parameters, utilizing fiber tracking methods and fractional anisotropy (FA) metrics. Tractography reconstructions of cranial nerves were successfully achieved in all patients. Affected cranial nerves showed decreased FA and disrupted fibers, with lower axonal density in clinically recovered patients. Patients with moderate and severe symptoms had lower FA in the cranial nerves and slightly more brain abnormalities. Motor and cognitive deficits were prevalent among recovered patients. This study demonstrates that DTI provides essential qualitative and quantitative insights into the pathophysiology underlying neurological disorders in Covid-19 patients. These insights can be used to improve clinical outcomes and quality of life for patients' post-recovery. [ABSTRACT FROM AUTHOR]

Summary A five‐year‐old Dales gelding was presented with an eight‐week history of progressive, apparently nonpainful, cord‐like, subcutaneous masses across the face, neck, trunk and forelimbs. Physical and neurological examinations identified mild, diffuse weakness, hyperaesthesia and moderate tachycardia. Transcutaneous and transrectal ultrasonography and endoscopy of the guttural pouches confirmed marked enlargement of peripheral nerves and visible cranial nerves, respectively. Histopathology of the subcutaneous lesions was indicative of chronic lymphoplasmacytic polyneuritis with fibrosis. The horse failed to respond to treatment with glucocorticoids, showing progressive generalised weakness and was euthanised. Post‐mortem examination identified a generalised lymphadenopathy and widespread dissemination of neoplastic lymphocytes, throughout the peripheral and central nervous system, heart and liver, identified by immunohistochemistry as T‐cell rich B‐cell lymphoma. This is the first report in the veterinary literature of diffuse neurolymphomatosis presenting as visible branching subcutaneous masses. [ABSTRACT FROM AUTHOR]

Background: Adenoid cystic carcinoma is an uncommon malignancy primarily arising from salivary glands. An extremely rare site for adenoid cystic carcinoma is the skull base. We report a case of adenoid cystic carcinoma of skull base who presented with common complaints of pain and right ear discharge. The discussion is made with emphasis on imaging evaluation simulating infective etiology with adjacent skull base osteomyelitis. Careful observation of the imaging findings and further evaluation of the patient revealed the neoplastic nature of the lesion with the final diagnosis being adenoid cystic carcinoma. Case presentation: A 40-year-old female presented to our department with complaints of pain and right ear discharge since 6 months with progressive, extensive facial swelling and facial nerve palsy. The patient had undergone modified radical mastoidectomy thrice, but the details were not available. On imaging, there was a heterogenous extensive lesion extending from scalp till upper cervical region with extensive destruction of skull base and intra-cranial extension. The possibilities of temporal bone squamous cell carcinoma and extensive skull base osteomyelitis were considered. Further the biopsy of the lesion revealed adenoid cystic carcinoma. Conclusions: Extensive lesions of the skull base can be of infective, neoplastic and inflammatory etiology. Distinguishing between these conditions is crucial, as they have similar imaging characteristics but require different management approaches. The presence of a lesion that displaces or destroys fascial planes, accompanied by solid mass-like enhancement, indicates a higher probability of a neoplastic origin rather than an infectious etiology. With squamous cell carcinoma being the most common neoplasm, adenoid cystic carcinoma of the skull base also needs to be understood due to its propensity for perineural spread and a high likelihood of recurrence. [ABSTRACT FROM AUTHOR]

Background: Vestibular schwannoma (VS), also known as acoustic neuroma, is a benign, well-encapsulated, and slow-growing tumor that originates from Schwann cells, which form the myelin sheath around the vestibulocochlear nerve (VIII cranial nerve). The surgical treatment of this condition presents a challenging task for surgeons, as the tumor's location and size make it difficult to remove without causing damage to the surrounding structures. In recent years, fluorescein sodium (FS) has been proposed as a tool to enhance surgical outcomes in VS surgery. This essay will provide an analytical comparison of the use of FS in VS surgery, evaluating its benefits and limitations and comparing surgical outcomes with and without FS-assisted surgery. Methods: In a retrospective study conducted at San Filippo Neri Hospital, we examined VS cases that were operated on between January 2017 and December 2023. The patients were divided into two groups: group A, which consisted of patients who underwent surgery without the use of FS until January 2020 (102 cases), and group B, which included patients who underwent surgery with FS after January 2020 (55 cases). All operations were performed using the retrosigmoid approach, and tumor size was classified according to the Koos, et al. classification system. The extent of surgical removal was evaluated using both the intraoperative surgeon's opinion and postoperative MRI imaging. Preoperatively and postoperatively, facial nerve function and hearing were assessed. In group B, FS was used to assist the surgical procedures, which were performed using a surgical microscope equipped with an integrated fluorescein filter. Postoperative clinical and MRI controls were performed at six months and annually, with no patients lost to follow-up. Results: This study investigated the impact of intraoperative fluorescein exposure on tumor resection and clinical outcomes in patients with VS. The study found a statistically significant difference in the tumor resection rates between patients who received fluorescein intraoperatively (p = 0.037). Further analyses using the Koos classification system revealed a significant effect of fluorescein exposure, particularly in the Koos 3 subgroup (p = 0.001). Notably, no significant differences were observed in hearing loss or facial nerve function between the two groups. A Spearman correlation analysis revealed a positive correlation between tumor size and Koos, age, and size, but no significant correlation was found between facial nerve function tests. Conclusions: FS-assisted surgery for VS may potentially enhance tumor resection, allowing for more comprehensive tumor removal. [ABSTRACT FROM AUTHOR]

Introduction: The primary aim of meningioma surgery should be total excision. However, subtotal excision is considered first if the main vascular structures and the cranial nerves are at risk. The ‘primum non nocere’ principle should always be considered. A clinical study where the emphasis is on en bloc resection without debulking in suitable cases, in contrast to the classic approaches, could therefore prove useful. Method: The meningioma cases operated at the İzmir Bakırçay University Çiğli Training and Research Hospital’s Neurosurgery Clinic between 2021 and 2023 were retrospectively evaluated. There were no exclusion criteria. The demographic features of the patients who had undergone debulking or en bloc resection and the anatomical, pathological, surgical and clinical features of the meningiomas were evaluated and the results were presented as percentages. Results: A total of 21 patients, consisting of 5 males (23.8%) and 16 females (76.2%), were included in the study. The mean age was 58.8 (28-90) years. En bloc resection was performed in 18 (85.7%) and debulking in 3 (14.3%) of the 21 cases. The other results are presented within the article. Conclusion: En bloc resection could be an important surgical strategy to decrease the surgical duration and bleeding amount in appropriate cases. [ABSTRACT FROM AUTHOR]

Primary cranial neurolymphomatosis (PCNL) is a rare subtype of primary CNS lymphoma (PCNSL) in which infiltrative lymphomatous involvement is confined to cranial nerves. Here, we report a case of PCNL with successful genomic profiling. A 57-year-old male had a lengthy prediagnostic phase spanning approximately 30 months, characterized by multiple episodes of cranial neuropathies managed by steroids. At the time of diagnosis, the patient had right-sided cranial neuropathies involving cranial nerves (CN) V, VI, and VII. Pathological findings of the right cavernous lesion biopsy were consistent with large B-cell lymphoma-infiltrating nerve fibers. The clinical course was aggressive and refractory, characterized by relentless progression with the development of cervical spinal neurolymphomatosis, cerebrospinal fluid involvement, and ependymal and intraparenchymal cerebral involvement, despite multiple lines of therapy, including chemoimmunotherapy, Bruton's tyrosine kinase inhibitor, radiation, autologous stem cell transplant, chimeric antigen receptor T-cell therapy (CAR-T), and whole-brain radiation. The patient survived for 22 months from the time of the initial diagnosis and 52 months after the first episode of cranial neuropathy. Next-generation sequencing identified mutations (MYD88, CD79b, and PIM1) that are frequently observed in PCNSL. The unusual findings included a total of 22 mutations involving PIM1, indicating a highly active aberrant somatic hypermutation and two missense CXCR4 mutations. CXCR4 mutations have never been described in PCNSL and may have implications for disease biology and therapeutic interventions. We provide a literature review to further elucidate PCNL. [ABSTRACT FROM AUTHOR]

Several factors contribute to the anatomical complexity of the trochlear nerve, including small diameter, complex and longest intracranial course, deep location, and numerous neurovascular relationships. A 3-dimensional (3D) photorealistic model of the cranial nerves provides a detailed and immersive representation of the anatomy, enabling one to improve surgical planning, advanced surgical research, and training. The purpose of this work is to present a 3D photogrammetric study for a more intuitive and interactive way to explore and describe the entire course of trochlear nerve. Two injected-fixed head human specimens (4 sides) were examined. The dissection protocol was divided into the following steps: 1) brain hemisphere exposure; 2) hemispherectomy dissecting all cranial nerves and partial removal of the free edge of the tentorium; 3) middle fossa and lateral wall of cavernous sinus exposure; and 4) orbital exposure. A detailed 3D photogrammetric model was generated for each dissection step. Four main volumetric models were generated during a step-by-step layered dissection of the entire nerve pathway highlighting its different segments. Finally, a full and integrated model of the entire course of the nerve was created. The models are available for visualization on monoscopic display, virtual, and augmented reality environment. The present photogrammetric model provides a more comprehensive understanding of the nerve's anatomy in its different segments, allows for customizable views thus simulating different perspectives, and can be a valuable alternative to traditional dissections. It is an advanced tool for surgical planning and surgical simulation as well as virtual reality representation of the anatomy. [ABSTRACT FROM AUTHOR]

Intracranial mature cystic teratomas are benign neoplasms that commonly occur at the midline. Mature cystic teratomas at the cerebellopontine (CP) angle are very rare. They are unique germ cell tumours curable by safe total surgical resection and have good prognosis. This case report documents the clinical, radiological, histological features and operative findings of mature cystic teratoma at CP angle. We present a rare case of a mature cystic teratoma at the CP angle in a 24-year-old woman who presented with brainstem compression and cranial nerve deficits. Brain MRI showed atypical findings like hyperintense areas in both T1 and T2 weighted images, calcification and diffusion restriction in part of the lesion. She underwent near total resection of the tumour via right retrosigmoid approach. Intraoperatively, the lesion was intra-arachnoidal unlike schwannomas and the cyst contained sebum-like material, fibrous areas with calcification which are unusual features of common CP angle tumours. Histopathological examination showed well differentiated mature tissues from all three germinal layers and confirmed the diagnosis of a mature cystic teratoma arising from the right CP angle. Patient had good outcome with neurologic recovery. Mature cystic teratoma is a rare clinical entity and should be considered in patients with CP angle tumours when there are atypical findings in brain MRI imaging. Cysts with sebum-like material, fibrous areas with calcification and poor tumour-arachnoid plane intraoperatively strongly suggest the possibility of mature cystic teratoma. [ABSTRACT FROM AUTHOR]

Combined deficit of the four lower cranial nerves (CN IX, X, XI, and XII) was originally described by French physicians Collet (1915) and Sicard (1917) during World War I. To date though, this rare neurological clinical picture lacks systematic evidence regarding its epidemiology, clinical presentation, treatment strategies, and outcome. We conducted a systematic review and meta-analysis concerning Collet-Sicard syndrome (CSS) on Medline database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The research yielded 84 articles among which 73 individual case reports were eventually retained. Mean age was 53.7 (± 16) years old and the male-to-female ratio was 1.8/1. CSS was firstly caused by tumors (38.4%), following by vascular etiologies (28.8%), trauma (16.4%), and infection (6.8%), among others. Temporary enteral nutrition was required for 17 patients (23.3%). The four CN presented significant chances of complete or partial recovery: 52.1% for CN IX (p < 0.001), 46.6% for CN X and CN XII (p < 0.001), and 39.7% for CN XI (p = 0.002). Tumoral causes presented significantly lower chances of favorable CN recovery (7.1%) compared to infection (60%), vascular (52.4%), and trauma (41.7%) (p < 0.001). Older age (> 53 years old) was not associated with a dismal CN prognostic (p = 0.763). Most patients (71.2%) presented a favorable outcome (Glasgow Outcome Scale score ≥ 4). All the patients who died (6.8%) suffered from skull base tumors. CSS is a rare condition requiring prompt clinical and radiologic diagnostic and multidisciplinary management. Vascular or infectious-related CSS seem to present a rather good prognostic, closely followed by trauma, whereas tumoral-related CSS seem to suffer from a more dismal prognostic. [ABSTRACT FROM AUTHOR]

This study aimed to study the various presentations of post COVID-19 invasive fungal sinusitis with 7th cranial nerve palsy and to correlate topodiagnostic tests and radiological findings to identify the site of lesion. A retrospective study was conducted at a tertiary care hospital where 11 patients with post COVID-19 invasive fungal sinusitis with facial palsy presented to our institute. Detailed history, clinical examination, radiological imaging were done for all patients. A total of 11 patients with post COVID-19 invasive fungal sinusitis with facial palsy were included in this study. The mean age of the patients was 44.8, with a male to female ratio of 4.5:1. Diabetes Mellitus was a major factor contributing to immunosuppression in our study with 9 patients who were known cases of diabetes mellitus and 2 newly diagnosed cases. On MRI, 10 patients had involvement of the Pterygopalatine fossa and 4 patients had involvement of the petrous apex. Post COVID-19 invasive fungal sinusitis can present with facial palsy, and diabetes mellitus is a major contributing factor to immunosuppression in these patients. The involvement of the petrous apex is a possible site of involvement, and MRI can aid in localizing the site of the lesion. Further studies are required to identify the exact mechanism of facial nerve palsy in invasive fungal sinusitis. [ABSTRACT FROM AUTHOR]

Trigeminal neuralgia (TN) is a chronic condition that is typically caused by a blood vessel exerting pressure on the V cranial nerve at the root entry zone. The gold standard for TN treatment is microvascular decompression (MVD). This illustrative case shows an advanced surgical technique that combines the use of an exoscope and endoscope to treat TN with an innovative addition of intraoperative indocyanine green (ICG) control that can improve arterial and venous compression identification. The use of exoscopes and endoscopes, offering 360° root assessment, represents a significant evolution in surgical approaches. Enhanced visualization with ICG aided in identifying complex neurovascular conflicts, improving decompression accuracy. The use of both exoscope and endoscope, offering a 360° root assessment, represents a significant evolution in the microsurgical approach of TN. The additional use of ICG monitoring in a dynamic mode may be useful in identifying the complex arteriovenous form of neurovascular conflict. The endoscopically assisted exoscopic surgery with the intraoperative use of ICG for MVD of the trigeminal nerve can improve the identification of complex impingements underlining its effectiveness and potential in neurosurgical practice. [ABSTRACT FROM AUTHOR]

Purpose: The present study aimed to provide our experience with patch closure (PAC) and primary closure (PRC) after carotid endarterectomy (CEA). Materials & methods: The present retrospective comparative study included 106 patients submitted to elective CEA. They comprised 50 patients in PRC group and 56 patients in PAC group. Patients were followed perioperatively, at three months and at one year for surgical complications, stroke, and restenosis. Results: Postoperatively, no significant differences were found between the studied groups regarding rates of stroke (6.0% versus 3.6%, p=0.740), infection (0.0% versus 3.6%, p=0.520), hematoma (2.0% versus 1.8%, p=0.940), pseudoaneurysm (0.0% versus 3.6%, p=0.520), cranial nerve injury (2.0% versus 1.8%, p=0.940), and cardiac events (2.0% versus 1.8%, p=0.940). At three months, three patients in PRC group and four in PAC group were lost to follow up. No significant differences were found between the studied groups regarding rate of restenosis at three months (2.1% versus 0.0%, p=0.960). At one year, patients in PRC group experienced significantly higher rate of restenosis (14.9% versus 1.9%, p=0.046). None of the studied patients died. Conclusions: CEA combined with patch angioplasty may be associated with lower restenosis rate. [ABSTRACT FROM AUTHOR]

The spinal accessory nerve, considered part of the eleventh cranial nerve, provides motor innervation to sternocleidomastoid and trapezius. A comprehensive literature review and two cadaveric dissections were undertaken. The spinal accessory nerve originates from the spinal accessory nucleus. Its rootlets unite and ascend between the denticulate ligament and dorsal spinal rootlets. Thereafter, it can anastomose with spinal roots, such as the McKenzie branch, and/or cranial roots. The spinal accessory nerve courses intracranially via foramen magnum and exits via jugular foramen, within which it usually lies anteriorly. Extracranially, it usually crosses anterior to the internal jugular vein and lies lateral to internal jugular vein deep to posterior belly of digastric. The spinal accessory nerve innervates sternocleidomastoid, receives numerous contributions in the posterior triangle and terminates within trapezius. Its posterior triangle course approximates a perpendicular bisection of the mastoid-mandibular angle line. The spinal accessory nerve contains sensory nociceptive fibres. Its cranial nerve classification is debated due to occasional non-fusion with the cranial root. Surgeons should familiarize themselves with the variable course of the spinal accessory nerve to minimize risk of injury. Patients with spinal accessory nerve injuries might require specialist pain management. [ABSTRACT FROM AUTHOR]

This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE). This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized. Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period. An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high. [ABSTRACT FROM AUTHOR]

Introduction: Tympanojugular paragangliomas (TJ PGLs) are rare tumors characterized by bone infiltration and erosion and a close relationship with critical structures, such as cranial nerves and internal carotid artery. For these reasons, their management represents a tough challenge. Since the fifties, radio-therapy (RT) has been proposed as an alternative treatment aimed at avoiding tumor progression. However, the indolent nature of the tumor, characterized by slow growth, is a crucial factor that needs to be considered before offering radiation. Methods: This study aims to examine tumor progression in RT patients through a systematic review of the literature and in TJ PGL patients who underwent solely wait and scan at our department. Results: The rate of tumor progression in the RT group was 8.9%, while in the wait and scan cohort was 12.9%. This data suggests the innate slow growth of PGLs. However, it is not possible to draw certain conclusions because of the wide heterogeneity of the studies. Conclusion: When complete surgical excision of TJ PGLs is not feasible, appropriate counseling and patient selection, including comprehensive tumor classification, should be performed before proposing RT to control tumor progression, since wait and scan may represent a reasonable option in selected cases. [ABSTRACT FROM AUTHOR]

Giant intracranial aneurysms represent a very challenging aspect of aneurysmal pathophysiology with very high mortality and morbidity if left untreated. Their variety in clinical presentation (subarachnoid hemorrhage, cranial nerve palsy, etc.) and pathological and imaging properties (location, anatomy, presence of collateral circulation) pose serious questions regarding the best treatment option. Admirable advances have been achieved in surgical techniques, while endovascular modalities with flow diversion techniques have become widely used. However, there is still lack of data regarding whether a single endovascular technique can be the universal treatment for such cases. In this review, we aim to summarize the current funds of knowledge concerning giant intracranial aneurysms and the role of endovascular management in their treatment. [ABSTRACT FROM AUTHOR]

Background and Objective: Understanding whether cranial nerve palsy (CNP) acts as an independent risk factor for kidney cancer could have important implications for patient care, early detection, and potentially the development of preventive strategies for this type of cancer in individuals with CNP. This study aimed to examine the risk of kidney cancer following the onset of ocular motor CNP and assess whether CNP could be considered an independent risk factor for kidney cancer. Materials and Methods: A population-based cohort study was conducted using data from the National Sample Cohort (NSC) database of Korea's National Health Insurance Service which was collected from 2010 to 2017. Follow-up was until kidney cancer development, death, or 31 December 2018. Cox proportional hazard regression analysis was performed to determine hazard ratios (HRs) for kidney cancer according to CNP status. Participants aged 20 years or more diagnosed with CNP from 2010 to 2017 were included. Exclusions comprised individuals with specific pre-existing conditions, inability to match a control group, and missing data, among others. CNP patients were age–sex matched in a 1:5 ratio with control cases. The primary outcome was incidence of kidney cancer during the follow-up period. Results: This study comprised 118,686 participants: 19,781 in the CNP group, and 98,905 in the control group. Compared to the control group, participants with CNP had a higher risk of kidney cancer (adjusted HR in model 4, 1.599 [95% CI, 1.116–2.29]). After a 3-year lag period, the CNP group had a significantly higher risk (adjusted HR in model 4, 1.987 [95% CI, 1.252–3.154]). Conclusions: Ocular motor CNP may be an independent risk factor for kidney cancer, as indicated by a higher incidence of kidney cancer in CNP patients. Further research is needed to elucidate the underlying mechanisms and explore potential preventive measures for kidney cancer in patients with ocular motor CNP. [ABSTRACT FROM AUTHOR]

Summary: Background: Atraumatic subarachnoid haemorrhage (SAH) is associated with high morbidity and mortality. Proposed mechanisms for red blood cell (RBC) clearance from the subarachnoid space (SAS) are erythrolysis, erythrophagocytosis or through efflux along cerebrospinal fluid (CSF) drainage routes. We aimed to elucidate the mechanisms of RBC clearance from the SAS to identify targetable efflux pathways. Methods: Autologous fluorescently-labelled RBCs along with PEGylated 40 kDa near-infrared tracer (P40D800) were infused via the cisterna magna (i.c.m.) in female reporter mice for lymphatics or for resident phagocytes. Drainage pathways for RBCs to extracranial lymphatics were evaluated by in vivo and in situ near-infrared imaging and by immunofluorescent staining on decalcified cranial tissue or dural whole-mounts. Findings: RBCs drained to the deep cervical lymph nodes 15 min post i.c.m. infusion, showing similar dynamics as P40D800 tracer. Postmortem in situ imaging and histology showed perineural accumulations of RBCs around the optic and olfactory nerves. Numerous RBCs cleared through the lymphatics of the cribriform plate, whilst histology showed no relevant fast RBC clearance through dorsal dural lymphatics or by tissue-resident macrophage-mediated phagocytosis. Interpretation: This study provides evidence for rapid RBC drainage through the cribriform plate lymphatic vessels, whilst neither fast RBC clearance through dorsal dural lymphatics nor through spinal CSF efflux or phagocytosis was observed. Similar dynamics of P40D800 and RBCs imply open pathways for clearance that do not impose a barrier for RBCs. This finding suggests further evaluation of the cribriform plate lymphatic function and potential pharmacological targeting in models of SAH. Funding: Swiss National Science Foundation (310030_189226), SwissHeart (FF191155).

Vestibular paroxysmia (VP) is a rare condition. The pathogenesis is linked to a neurovascular conflict (NVC) between an abnormal arterial loop and the VII/VIII cranial nerve complex in the cerebello-pontine angle. Due to its rarity, intraoperative findings are only anecdotally reported. Here we reported on a case of VP, showing the radiological images and the intraoperative surgical video of microvascular decompression (MVD). Further we discussed our findings considering the pertinent literature. We think that in case of VP the concordance between the side of tinnitus/hypoacusia and the side of NVC on magnetic resonance imaging should be always looked for before considering MVD as a therapeutic option. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course. Background: Acquired synkinesis is a well-known phenomenon following oculomotor nerve injury. The abnormal movement appears within the distribution of 1 nerve, or other cranial nerves may be involved. The common misdirection of aberrant regeneration of oculomotor nerve involves the lid, extraocular muscles, or pupil. This report presents a case of aberrant connection between abducens and oculomotor nerve, which is quite rare. Case Report: A 21-year-old man with history of left-sided frontal, lateral orbital wall, and zygomatic fracture from head trauma in a motor vehicle accident presented for evaluation. He was comatose for 6 weeks in the intensive care unit. Six months later, he presented to the ophthalmology clinic for an eye examination. He had no history of eye problems prior to this accident. His best corrected visual acuity in the right eye was 20/20 and the left eye had no light perception. The right eye exam was normal, with normal ocular motility. The left eye exam showed small esotropia in primary position with markedly decreased adduction, elevation, and minimal depression, but on attempted abduction, the left eye would adduct instead. There was no globe retraction when left eye abduction was attempted. The abnormal movement seen resulted from third nerve function during sixth nerve stimulation, due to unusual ocular motility with abnormal connection between the sixth and third cranial nerves. Conclusions: The most likely pathophysiologic mechanism here is peripheral neuronal misdirection hypothesis after trauma. Careful and detailed examination of a patient presenting with unusual ocular motility after trauma is very important. The abnormal connection between the sixth and third cranial nerves is quite rare but can occur. [ABSTRACT FROM AUTHOR]

Bickerstaff brainstem encephalitis (BBE) is a variant of Guillain-Barré syndrome (GBS) characterized by inflammation of the brainstem and cranial nerves. We describe a 60-year-old man presenting with acute confusion, bilateral progressive facial drooping, difficulty swallowing, aphasia, and confusion over two days. Examination showed bilateral facial paralysis, impaired eye movements, ptosis, dysarthria, diminished gag reflex and fatigue. MRI brain was unremarkable. Intravenous immunoglobulin (IVIG) was promptly started with noticeable improvement in facial strength and swallowing by day three. At discharge two weeks later, he had near complete resolution. BBE likely involves autoantibodies triggered by infections causing nerve inflammation. Diagnosis is clinical based on bilateral facial and bulbar weakness. Early immunotherapy provides best recovery prospects. Further research can uncover immunological mechanisms to guide treatments. Optimized protocols tailored to BBE compared with GBS are needed. Distinguishing BBE facilitates prompt therapy and favourable outcomes from this rare syndrome. [ABSTRACT FROM AUTHOR]

A 40‐year‐old male farmer from rural West Bengal, India, presented with fever, headaches, seizure, eschar, and palsy of left cranial nerves VII, VIII, IX, and X as a rare clinical manifestation of scrub typhus. Positive IgM enzyme‐linked immunosorbent assay tests in serum and cerebrospinal fluid confirmed the diagnosis, with brain magnetic resonance imaging showing meningoencephalitis findings. Treatment with steroids and doxycycline led to neurological improvement. This case highlights the need for heightened clinician awareness toward early detection of scrub typhus's atypical presentations to ensure timely and effective treatment. [ABSTRACT FROM AUTHOR]

Understanding the association between dipstick-detected proteinuria and oculomotor cranial nerve palsy (CNP) could have significant implications for understanding the mechanism of CNP development and for developing preventive strategies against CNP development in patients with proteinuria. This study aimed to determine the relationship between dipstick-determined proteinuria and ocular motor CNP using National Sample Cohort (NSC) database from Korea's National Health Insurance Service (NHIS). A nationwide population-based cohort study was conducted using data from the NSC database of Korea's NHIS. These data were collected from 2009 to 2018. A one-year time lag was established to prevent a situation in which the causal link was inverted. Participants aged 20 years or more who were diagnosed with proteinuria in 2009 were included. Individuals with specific pre-existing CNP, missing data, and those who were newly diagnosed with CNP or who died within one year of being tested were excluded. The study population was classified into six groups according to the degree of proteinuria (negative, trace, or between 1 + and 4 +) based on the urine dipstick test. A Cox proportional hazard regression analysis was performed to determine the linkage between the degree of proteinuria and ocular motor CNP. A total of 5,807 (0.14% of subjects) with ocular motor CNP were assigned to the ocular motor CNP group and 4,047,205 subjects were assigned to the control group. After full adjustment of comorbidities, hazard ratios (HRs) for 1 + , 2 + , 3 + and 4 + proteinuria groups were 1.449 (95% confidence interval [CI] 1.244–1.687), 2.081 (1.707–2.538), 1.96 (1.322–2.904), and 3.011 (1.507–6.014), respectively, for developing ocular motor CNP compared to the proteinuria-negative group. In subgroup analysis, the HR of patients with proteinuria for the development of ocular motor CNP was higher in the younger age group (less than 40 years) (P = 0.0242) and the group with DM (P = 0.04). Our population-based cohort study demonstrated a significant association between proteinuria and the incidence of CNP, suggesting that urine protein level could be a new clinical marker for predicting the development of CNP. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) can have profound acute and chronic effects, leading to permanent disabilities and diminished quality of life. Pseudobulbar palsy and its infrequent subtype, Foix-Chavany-Marie Syndrome (FCMS), represent rare complications of TBI, manifesting as deficits in craniofacial motor function and automatic-voluntary dissociation. We present a case of a 58-year-old male who developed FCMS following severe TBI from a cycling accident. Initial imaging revealed extensive brain injury with subsequent development of FCMS characterised by bilateral cranial nerve dysfunction, notably facio-pharyngo-glosso-masticatory diplegia with preserved automatic motor function. This case contributes to the limited literature on traumatic FCMS, highlighting its distinct clinical features and potential for favourable outcomes compared to nontraumatic cases. Early recognition and comprehensive management, including supportive therapy and addressing underlying conditions, are paramount for optimising patient outcomes. [ABSTRACT FROM AUTHOR]

The topographic anatomy of the abducens nerve has been the subject of research for more than 150 years. Although its vulnerability was initially attributed to its length, this hypothesis has largely lost prominence. Instead, attention has shifted toward its intricate anatomical relations along the cranial base. Contrary to the extensive anatomical and neurosurgical literature on abducens nerve anatomy in humans, its complex anatomy in other species has received less emphasis. The main question addressed here is why the human abducens nerve is predisposed to injury. Specifically, we aim to perform a comparative analysis of the basicranial pathway of the abducens nerve in mammals and primates. Our hypothesis links its vulnerability to cranial base flexion, particularly around the sphenooccipital synchondrosis. We examined the abducens nerve pathway in various mammals, including primates, humans (N = 40; 60% males; 40% females), and human fetuses (N = 5; 60% males; 40% females). The findings are presented at both the macroscopic and histological levels. To associate our findings with basicranial flexion, we measured the cranial base angles in the species included in this study and compared them to data in the available literature. Our findings show that the primitive state of the abducens nerve pathway follows a nearly flat (unflexed) cranial base from the pontomedullary sulcus to the superior orbital fissure. Only the gulfar segment, where the nerve passes through Dorello's canal, demonstrates some degree of variation. We present evidence indicating that the derived state of the abducens pathway, which is most pronounced in humans from an early stage of development, is characterized by following the significantly more flexed basicranium. Overall, the present study elucidates the evolutionary basis for the vulnerability of the abducens nerve, especially within its gulfar and cavernous segments, which are situated at the main synchondroses between the anterior, middle, and posterior cranial fossae--a unique anatomical relation exclusive to the abducens nerve. The principal differences between the pathways of this nerve and those of other cranial nerves are discussed. The findings suggest that the highly flexed human cranial base plays a pivotal role in the intricate anatomical relations and resulting vulnerability of the abducens nerve. [ABSTRACT FROM AUTHOR]

Objectives: Schwannoma arising from cervical sympathetic chain (CSC) is a rare clinical entity. CSC is hard to preserve in CSC schwannoma (CSCS) surgeries, resulting in Horner's syndrome (HS) and first bite syndrome (FBS). This article aims to explore our experience in successful preservation of CSC in CSCS surgeries. Methods: This is a retrospective review of CSCS cases treated at our tertiary medical institution between Apr 2018 and March 2022. Only cases with successful intraoperative preservation of CSC were included. Results: In total, 3 cases were included. There were 2 male patients and 1 female patient. Their age was between 38 years old and 66 years old (average and median age was 52 and 51 years old, respectively). Presenting symptom was neck mass for all them, 2 of which were on the left side, while 1 was on the right. Intracapsular enucleation of the CSCS was attempted and achieved in all 3 cases. Hemorrhage from the inner surface of capsules was diffuse and heavy. Constant saline irrigation, suction, and bipolar coagulation were needed to achieve hemostasis. Postoperative HS presented between 4 hours and 14 hours after surgery for all 3 patients, which took 1 month to 3 months to recover, whereas FBS did not occur in any patient. Median duration of follow-up was 6 months. No recurrence was observed. Conclusions: Intracapsular enucleation should be attempted in CSCS surgeries, although hemorrhage might be diffuse and hard to control. When intracapsular enucleation was achieved, postoperative FBS can be avoided, while postoperative HS could occur, but its recovery was satisfactory. [ABSTRACT FROM AUTHOR]

Background/Objectives: Clivus metastases from distant neoplasms are uncommon occurrences both in clinical practice and the neurosurgical literature. Surgical management is debated, particularly about the role of surgery and the preferable approach. The aim of this study was to report our surgical experience and review the concerning literature. Methods: Our institutional registry was retrospectively reviewed, and patients who underwent surgical treatment for clival metastasis from 1998 to 2023 were included. A PRISMA systematic review of the literature was performed. Results: Four patients were enrolled, and all of them underwent an endoscopic endonasal approach (EEA). Three presented with cranial nerve (CN) VI palsy. The aim of surgery was biopsy in all cases. No complications were reported. Mean overall survival (OS) was 6 ± 1 months. The systematic review retrieved 27 papers reporting 39 patients who underwent the surgical treatment of clivus metastases. Most of them (79.5%) presented with CN palsies, and EEA was the preferred approach in 92.3% of the cases, to perform a biopsy in most patients (59%). Two hemorrhagic complications (5.1%) were reported, and the mean OS was 9.4 ± 5.6 months. Conclusions: Clival metastases are uncommonly observed, in most cases, during advanced stages of oncological disease. The aim of surgery should be the confirmation of diagnosis and symptomatic relief, balancing the risk–benefit ratio in a multidisciplinary context. EEA is the approach of choice, and it should be carried out in experienced tertiary skull base centers. [ABSTRACT FROM AUTHOR]

Brainstem surgery is more difficult and riskier than surgeries in other parts of the brain due to the high density of critical tracts and cranial nerves nuclei in this region. For this reason, some safe entry zones into the brainstem have been described. The main purpose of this article is to bring on the agenda the significance of the intrinsic structures of the safe entry zones to the brainstem. Having detailed information about anatomic localization of these sensitive structures is important to predict and avoid possible surgical complications. In order to better understand this complex anatomy, we schematically drew the axial sections of the brainstem showing the intrinsic structures at the level of 9 safe entry zones that we used, taking into account basic neuroanatomy books and atlases. Some illustrations are also supported with intraoperative pictures to provide better surgical orientation. The second purpose is to remind surgeons of clinical syndromes that may occur in case of surgical injury to these delicate structures. Advanced techniques such as tractography, neuronavigation, and neuromonitorization should be used in brainstem surgery, but detailed neuroanatomic knowledge about safe entry zones and a meticulous surgery are more important. The axial brainstem sections we have drawn can help young neurosurgeons better understand this complex anatomy. [ABSTRACT FROM AUTHOR]