Case Studies of Specialized Neurological Services

This is a summary and sample case reports written by Dr. L. Sekhar to help patients and families understand the various types of Neurological Disorders he and our team of doctors treat at UW Medicine at both Harborview Medical Center and UW Medical Center in Seattle, Washington.

• Cerebrovascular Disorders – aneurysms, arteriovenous malformations
• Complex Brain Tumors – deep seated or difficult
• Microvascular Compression Disorders – trigeminal neuralgia, hemifacial spasm, disabling vertigo
• Cervical and Craniocervical Junction Disorders
• Cerebral Revascularization – for intractable ischemia
• Skull Based Tumors – acoustic neuromas, meningiomas, chordomas

Cerebrovascular Disorders

Arteriovenous malformations (AVM) of the brain are treated by microsurgery, embollization therapy, and radiosurgery, in various combinations. Cerebral Aneurysms are treatable by microsurgical clipping or endovascular coiling. Complex Aneurysms may require brain bypass operations, or clipping under deep hypothermic circulatory arrest technique. Patients with stroke or medically refractory cerebral ischemia may be treatable by brain bypass procedures, carotid surgery, or endovascular revascularization.

Case of a 25 year old woman with a giant frontal arterovenous malformation. A complete microsurgical resection of the AVM was performed with excellent results.

Complex Brain Tumors

Many patients with complex brain tumors are referred for advanced neurosurgergical procedures. Examples of such tumors include Meningiomas involving the venous sinuses, large or giant sized tumors, and deep seated tumors in the Ventricles, Pineal region, or the posterior Fossa.

Preoperative MRI indicates a giant intraventricular neurocytoma in a 28 year old woman, removed with good results. She underwent radiotherapy for residue. Left image - before surgery Right image - after surgery

Microvascular Compression Disorders

Compression of the Cranial nerves V, VII, VIII and IX by arteries or veins near the Brain Stem may lead to disorders such as Trigeminal or Glossopharyngeal Neuralgia, Hemifacial spasm, disabling vertigo or Tinnitus. When these problems are medically nonresponsive, a microvascular decompression procedure performed by a retrosigmoid craniotomy and endoscope-assisted microsurgery is indicated.

Two patients with trigeminal neuralgia–Intraoperative photographs show vessels compressing the trigeminal nerve. Note the groove on the nerve after microvascular decompression.

55 yr. old male presented with positional vertigo who underwent microvascular decompression of CN VIII with Teflon felt interpostion between the nerve and the contact vessel.

Cervical & Craniocervical Junction Disorders

Disorders of the cervical spine and especially at the craniocervical junction demand specialized approaches for decompression and stabilization. Minimally invasive endoscopic approaches are also being developed for these disorders.

This 73 year old man had difficulty with walking for several months. Upon examination, he had mild weakness in his arms and legs. MRI of the cervical spine showed a C2-C3 subluxation. He underwent a C2-C4 laminectomy with lateral mass plate, screw and wire fixation. He improved significantly postoperatively.

Cerebral Revascularization

The purpose of cerebral revascularization is to bring more blood to areas of brain ischemia. The types of revascularization are Therapeutic (emergent) revascularization and Preventive (elective) revascularization. Indications for revascularization are:
1. Cerebral ischemia, chronic and intractable
2. Cerebral ischemia, progressive
3. Moya moya disease
4. Inoperable (surgical-endovascular) aneurysms
5. Skull base tumors

Case #1 Giant Mid-Basilar Aneurysm
A 49-year old man with a giant mid-basilar aneurysm. A MCA-M2 to PCA-P2 bypass with a RAG and trapping of the aneurysm was performed.
Intra-Op figures showing the bypass graft and the trapping of the aneurysm.
Post-Op angiogram shows good filling of the graft & PCA vessels.   The patient made a complete recovery with no neurological deficit.
Case #2
A 53 y.o. female with long standing h/o incoordination, imbalance, diplopia and dizziness, presents with sudden severe H/A for 24 hrs, recurrent TIAs. Cerebral angiogram revealed bilateral VA and BA aneurysms. Treatment: – Failed Rt VA Test Occlusion – Left ECA to PCA Radial Artery Bypass – Endovascular Coil Occlusion Rt VA Aneurysm – Treatment of BA Aneurysm She did well and was discharged home on Plavix.
Case #3 Bilateral Carotid Ophthalmic Aneurysm
Before surgery		After surgery
In the case of a 55 year old woman with bilateral carotid-ophthalmic aneurysms, a 3-D CT angio (below) better demonstrates the aneurysm morphology. Operations were performed for both the right carotid aneurysm and for a left giant ICA aneurysm.
		The operative approach included a frontotemporal craniotomy with orbital osteotomy. A postoperative angiogram shows complete occlusion of the aneurysms. Patient did extremely well with good recovery.
Case #4 Right ICA Stenosis with Pseudoaneurysm
A 56 Y.O Woman with long history of headaches and multiple left sided TIAs not responding to medical management. Angiogram showed right ICA stenosis with pseudoaneurysm. She underwent double ECA–ICA bypass, using both radial arteries.

Skull Based Tumors

Tumors at the cranial base (e.g. acoustic neuroma, meningioma, pituitary adenoma, chordoma) require specialized operative techniques for approach, removal, and repair. Radiosurgery may be used in conjunction with microsurgery. Experience and expertise play a major role in good patient outcome.

Case #1 This 50 year old woman had a giant oflactory groove-planum meningioma and underwent a complete resection of the tumor.
Case #2 A 50 year old man with giant left acoustic neuroma underwent a complete resection of his tumor by microsurgical techniques with preservation of hearing, and normal facial function on that side.
Case #3 A 40 year old man with a 2cm right acoustic neuroma. Pre-op audiogram and post-op audiogram show hearing preservation after microsurgery.
Case #4 A 38 year old woman with a large petroclival meningioma with no brainstem edema. PLPA approach was used to expose tumor. After resection, post-op MRI shows no residual tumor. Post-op audiogram shows preservation of hearing on the left side.
Case #5 A 60 year woman with a large left sphenoid and cavernous sinus meningioma with vessel encasement and narrowing. Surgery was complex, and involved the dissection of artery and nerves free of tumor. The post-op MRI shows no residual tumor. Patient returned to normal life after surgery.
Case #6 A 40 year old man with a giant olfactory groove meningioma with vascular encasement.
(A) His angiogram reveals blood supply to tumor from the middle meningeal artery & ACA. Embolization of the tumor was performed using endovascular techniques. (B) MRI shows swelling of the tumor after embolization. (C) Post-op MRI shows complete excision of the tumor. Patient returned to normal life after three months.

Patient Care Introduction | Aneurysms | Brain Mapping | Case Studies | Chiari Malformation
Congenital Abnormalities | Epilepsy | Movement Disorders | Moyamoya Disease | Pain and Spasticity
Pediatrics | Peripheral Nerves | Radiosurgery and Radiotherapy | Spine
Stroke and Vascular Lesions | Trauma | Tumors

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