Romanian Neurosurgery

Endovascular stenting for Wallenberg syndrome secondary to symptomatic vertebral artery kinking

Juan Camilo Zapata-Castro — 2026-03-15

Background: Anatomical anomalies of the vertebral arteries—such as looping or kinking—are frequently incidental findings on vascular imaging and often dismissed as clinically benign. Nonetheless, evidence is accumulating that such dolichoarteriopathies can alter hemodynamics or precipitate thrombogenic conditions, thereby contributing to posterior-circulation cerebrovascular events.

Case presentation: We report a 52-year-old male with no prior cardiovascular risk factors who developed a sudden, severe occipital (“thunderclap”) headache during sexual intercourse, followed by dysarthria, dysphagia, truncal ataxia and hemisensory deficits. Imaging revealed an acute right dorsolateral medullary infarct consistent with Wallenberg syndrome and bilateral kinking of the vertebral arteries with contrast stagnation. Given the presumed causative vascular anomaly, the patient underwent bilateral rigid stenting via the endovascular route, tolerated the intervention uneventfully and achieved significant neurological improvement on discharge.

Conclusions: This case underscores that vertebral?artery kinking should not be dismissed as a benign anatomical variant. In selected patients presenting with posterior-circulation stroke without conventional atherothrombotic risk factors, recognition of this vascular anomaly may permit targeted endovascular intervention and reduce stroke recurrence. The case further highlights the need for heightened clinical vigilance, advanced imaging to assess flow dynamics, and individualised management strategies beyond conservative therapy.

Delayed thalamic infarction following transvenous vein of Galen malformation embolization

Ivan Andres Freire-Figueroa — 2026-03-15

Background: Vein of Galen malformation embolisation achieves favourable outcomes in most patients through staged endovascular approaches. However, severe neurological complications occur in up to 30% of cases, with mechanisms of delayed ischemic events following near-complete occlusion remaining incompletely understood. This is particularly concerning in asymptomatic patients with favourable preoperative profiles, where the risk-benefit balance of pursuing complete angiographic cure versus accepting substantial flow reduction remains unclear.

Case Presentation: A 15-month-old asymptomatic boy with mural-type Vein of Galen malformation and high Bicêtre score (15 points) underwent three staged transarterial embolisations, achieving progressive flow reduction. The first two sessions successfully reduced flow by approximately 70% without complications. Given small-calibre residual arterial feeders in the third session, a combined transarterial and transvenous approach was employed, achieving near-complete occlusion. Eighteen hours post-procedure, the patient developed acute left hemiparesis. Imaging revealed right thalamic infarction with intraventricular haemorrhage. Conservative management with intensive rehabilitation resulted in complete functional recovery within one month. Follow-up angiography demonstrated persistent occlusion without recanalisation and development of superficial venous collateral drainage.

Conclusion: This case demonstrates that severe neurological complications can occur even in optimal candidates undergoing staged embolisation. The delayed thalamic infarction with hemorrhagic component following transvenous occlusion suggests acute venous hypertension as the primary mechanism, compromising deep venous drainage before adequate collaterals developed. In asymptomatic patients achieving substantial flow reduction through transarterial approaches, accepting incomplete occlusion may be safer than pursuing complete angiographic cure via transvenous techniques when collateral venous pathways appear limited. Extended neurological monitoring for 48-72 hours after high-grade occlusion procedures is essential. Despite severe complications, excellent functional recovery is achievable through aggressive early rehabilitation.

Spinal dural arteriovenous fistula

Walid Bennabi — 2026-03-15

Spinal dural arteriovenous fistulas (SDAVFs) are vascular lesions caused by the interactions between the arterial and venous vascular systems of the spinal cord, leading to venous congestion of the spinal cord. They are the most frequent vascular malformation of the spine. These acquired lesions occur most commonly in the thoracic and lumbar spine of middle-aged men. Although the natural history of SDAVFs is not clearly defined, their clinical course is characterised by progressive neurologic decline leading to functional disability.

Here we report a case of a 60-year-old male patient admitted with complaints of back pain that irradiated to the lower legs, intermittent claudication, who then developed progressive paraparesis, gait disorder, and sphincter disturbances. The symptoms were typically progressive for four months with increasing severity. On MRI, on sagittal T2-weighted images, the cord oedema is depicted as a centromedullary hyperintensity, extended in dorso-lumbar (Th4-L1), and numerous serpiginous vessels dorsal to the spinal cord. Based on physical examination and magnetic resonance imaging findings, a preliminary diagnosis of SDAVF was made. The diagnosis was confirmed by spinal angiography, with a selective injection of the left Th9 segmental vessels, which demonstrates a dorsal intradural AVF. The aim of treatment in SDAVF is to occlude the shunting zone, the most distal part of the artery, together with the most proximal part of the draining vein, either by superselective embolisation with a liquid embolic agent or by neurosurgical approach. Our patient was treated by Microsurgery.

Spinal dural AVFs diagnosis should not be overlooked, and it should be kept in mind that early diagnosis and treatment prevent severe morbidities. The gold standard for the diagnosis is selective spinal angiography. Angiography is used for localization of the vascular lesion and treatment. Microsurgery and endovascular embolisation are effective methods for the treatment of SDAVF. Following occlusion of the fistula, the progression of the disease can be stopped, and improvement of symptoms is typically observed.

In this article, we report a case of SDAVF Intradural dorsal AVFs presenting with progressive paraparesis, gait and sphincter disturbances, bladder in the light of literature data.

Dural metastasis of chordoma

Alejandra Arévalo saenz — 2026-03-15

Background: Chordoma is a rare malignant bone tumour derived from notochordal remnants, characterised by slow growth and aggressive local behaviour. Although distant metastases are increasingly recognised, dural metastasis remains exceptionally rare.

Case description: We describe the case of a 72-year-old female patient with a history of a suprasellar chordoma, initially resected 8 years ago. The patient presented with tumour recurrence at the original site and a newly identified frontal dural metastasis. Imaging revealed growth of the residual clival tumour along with a well-circumscribed dural-based lesion in the frontal convexity. Surgical management consisted of resection of the recurrent clival lesion and complete excision of the frontal dural metastasis. The procedures were well tolerated, and postoperative recovery was uneventful, with resolution of preoperative neurological symptoms. Histopathological analysis confirmed the diagnosis of recurrent chordoma and dural metastasis.

Conclusion: Dural metastasis of chordoma is an uncommon but important diagnostic entity that should be considered in patients with a history of chordoma presenting with new dural-based lesions. Early recognition is crucial to avoid misdiagnosis and guide appropriate management.

Ruptured intraventricular dermoid cyst

Walid Bennabi — 2026-03-15

Dermoid cysts are rare, congenital cystic tumours that compose < 0.5% of primary intracranial tumours. They derive from embryonic ectodermal tissue during neural tube closure, and are usually located in the midline or parasagittal region of the skull, although their most common location is the spinal canal.

Rupture into the subarachnoid spaces and ventricles is extremely rare, which may occur spontaneously or after closed-head trauma. Tumour rupture may be asymptomatic or give rise to recurrent chemical meningitis due to spillage of its contents into the subarachnoid space and ventricular system, manifesting with seizures, vasospasm with cerebral infarction and death.

We report a 47-year-old male patient who presented with a sudden onset of severe headache, accompanied by nausea and vomiting without disturbed consciousness. The patient was progressively worsening. On admission, body temperature was 37.8 C, and the patient's vital signs were within normal limits. A CT scan demonstrated a hypodense lesion, and T1-weighted MRI scans revealed a round hyperintense lesion in the left frontal horn, with dilated ventricles, compatible with an intraventricular rupture of a left frontal horn dermoid cyst. There was also significant hydrocephalus. Successful surgical intervention followed, resulting in the complete removal of the cyst and the patient's subsequent full recovery with the resolution of symptoms. In this case, we are reporting on the management of a case of intraventricular ruptured dermoid cyst and reviewing the literature.

Anatomical variations of the floor of the third ventricle and their surgical implications for endoscopic third ventriculostomy

Charishma Vidyala — 2026-03-15

Endoscopic third ventriculostomy (ETV) is an established treatment for obstructive hydrocephalus. Anatomical variations of the floor of the third ventricle (FTV) may significantly influence surgical safety and outcomes. We retrospectively reviewed 53 ETV procedures performed between July 2022 and December 2023. Anatomical variations of the FTV were identified in 11 patients (20.7%), including thinned, partially effaced, thickened or opaque, and ballooning or herniated floors. Recognition of these variations is essential for safe fenestration and optimal outcomes.

Infectious sacroiliitis mimicking mechanical lumbar pain. The diagnostic role of MRI

Alejandro Rojas Urrea — 2026-03-15

Introduction: Infectious sacroiliitis is a rare condition that occurs when there is inflammation of the sacroiliac joint and typically presents with lower back pain that can radiate to the buttocks and lower limb. Its diagnosis is often complex due to its clinical manifestation and rarity.

Case report: We present a 55-year-old male patient who presented with lumbar pain radiating to the gluteal region. Magnetic resonance imaging (MRI) confirmed findings consistent with left sacroiliac infectious arthropathy, revealing a collection compatible with an abscess that compromised the ipsilateral iliopsoas muscle. The patient was successfully treated conservatively with antibiotic therapy, avoiding surgical drainage.

Discussion: In sacroiliitis, physical exams and medical history are crucial for suspecting the diagnosis; they help decide if imaging tests are needed and guide the right treatment to avoid risks and complications.

Conclusion: This case highlights a disease with low prevalence and emphasises the importance of proper physician examinations, medical history and advanced imaging, specifically MRI, in confirming diagnosis and guiding treatment options.

Successful management of double giant primary hydatid cyst of brain, that also revealed a cardiac location, in Yemeni centre

Muneer Alzekri — 2026-03-15

Hydatid cyst is a parasitic infection caused by the larval stage of the Echinococcus tapeworm. It is endemic in various parts of the world, including the Middle East. The liver and lungs are the most commonly affected organs. Intracranial hydatid disease is rare, occurring in only 1–2% of all Echinococcus granulosus infections. We report a rare case of a hydatid cyst located in the brain, successfully treated with complete microsurgical excision in a 22-year-old male.

A challenging case of an orbitocranial wooden foreign body in a child

Walid Bennabi — 2026-03-15

Orbitocranial penetrating injuries (OCPI) caused by wooden foreign bodies are very rare and life-threatening. They might pose unusual diagnostic and surgical challenges. Swift identification through appropriate imaging techniques and prompt extraction are imperative. We herein present the case of a young girl who has experienced an orbitocranial injury caused by a wooden foreign body (WFB) due to striking the tree branches while playing. She underwent exploration, and the foreign body was removed through the entry wound with an intracranial microscopic control through a modified orbito-zygomatic approach. This case describes the clinical manifestation, radiographic features, and treatment of this rare trauma, with an emphasis on imaging diagnosis and multi-disciplinary management.

Double epidural hematomas

Sharad Pandey — 2026-03-15

Double epidural hematomas are uncommonly seen in trauma, and they tend to have a higher mortality rate as compared to single EDH. We present the case of a 15-year-old male who presented with right frontal and right parietal acute EDH and underwent right fronto-temporo-parietal craniotomy and EDH evacuation. Double EDHs are usually associated with low GCS on presentation, and they need to be surgically evacuated rapidly. They are seen as a consequence of severe TBI with high morbidity and mortality.

Haemorrhagic lumbar synovial cyst

Ajit Singh — 2026-03-15

Hemorrhagic synovial cysts of the lumbar spine are uncommon but clinically significant due to their potential for rapid symptom progression. Patients often present with severe lower back pain and neurological deficits, which are exacerbated by bleeding within the cyst, leading to an increase in its size. This haemorrhage is typically linked to the rupture of fragile, newly formed blood vessels. MRI is crucial for diagnosis, with these cysts frequently appearing heterogeneously hyperintense on T1-weighted images, although signal characteristics may vary depending on factors such as protein content, blood degradation, and the timing of the hemorrhagic event. While many synovial cysts can be observed without intervention, hemorrhagic transformation often requires surgical excision, and in some cases, emergency surgery is necessary to address severe neurological symptoms. Early diagnosis and treatment are essential to prevent permanent deficits and improve outcomes.

Five-patient case series and literature review in post-traumatic tension pneumocephalus

Sajag Kumar Gupta — 2026-03-15

Tension pneumocephalus is a rare and potentially fatal neurological disease. To avoid deadly consequences, it demands urgent and rapid intervention. The most prevalent cause of tension pneumocephalus is a head injury. Air can enter the cranium by a fracture affecting the paranasal sinus or the middle ear cavity, or even more rarely, through a complex depressed fracture of the skull vault. Its treatment consists of a simple twist drill and aspiration of intracranial air with or without the insertion of an underwater seal. 100% oxygen should be delivered using a non-breathable mask that hastens air resorption. The authors provide a series of five examples with post-traumatic tension pneumocephalus, focusing on its treatment and review of literature.

Cervical Medulloblastoma mimicking a nerve sheath tumour in a child

Jaimin Modh — 2026-03-15

Medulloblastoma is the most common malignant pediatric brain tumour, accounting for nearly 20% of all childhood intracranial neoplasms. It is classified as an embryonal tumour and most commonly arises in the cerebellar vermis or hemispheres of children.¹ The 2021 World Health Organisation (WHO) classification recognises medulloblastoma as a molecularly heterogeneous entity with distinct clinical and prognostic implications.¹^,³

Primary extracranial or spinal medulloblastomas are exceedingly rare, with only isolated case reports and small series described in the literature.?^-? Cervical spinal presentation without intracranial disease is particularly uncommon and often leads to diagnostic confusion.?

Primary Phylum Terminale neuroendocrine tumour

Şule Göktürk — 2026-03-15

Background: Cauda equina and filum terminale neuroendocrine tumours are rare neoplasms that develop in the cauda equina or filum terminale region of the spinal cord. Paragangliomas are grade 1 tumours (WHO grade I) that originate from neural crest cells. The diagnosis of paragangliomas is primarily based on histopathological findings, as there are usually no specific clinical or radiological indications. On radiological examination, they present as tumours similar to schwannomas and ependymomas.

Observation(s): A 59-year-old male patient presented at the neurosurgery clinic with a history of chronic low back pain. The patient underwent contrast-enhanced magnetic resonance imaging of the lumbar vertebrae. On the basis of the MRI imaging, a differential diagnosis of a typical filum terminale ependymoma or neuroma was considered. The patient underwent a decompressive laminectomy, a surgical procedure performed to relieve pressure on the spinal cord. The mass was excised en bloc and submitted for pathological examination. A total of 13 distinct immunohistochemical examinations were conducted for the purpose of differential diagnosis.

Discussion: The histopathological diagnosis of paragangliomas is challenging, with the primary differential diagnosis being ependymoma and metastatic paragangliomas to this region. A meticulous approach is essential when dealing with tumours exhibiting such morphology, as this allows for the exclusion of other tumours with analogous histopathological findings and the performance of a comprehensive panel to ascertain the nosological origin.

Conclusion: Surgical intervention represents the primary treatment option, and there is currently no definitive consensus on the use of chemoradiotherapy.

“Eyes Tell the Tale”. Ophthalmic manifestations of traumatic midbrain contusion in a conscious patient

Shivam Sharma — 2026-03-15

Midbrain contusions are uncommon in civilian trauma and rarely present with isolated cranial nerve deficits. We present a rare case of a conscious 40-year-old male who developed bilateral ptosis, right medial rectus palsy, and left upgaze palsy following a motor vehicle accident. NCCT brain revealed multiple contusions in the midbrain, bilateral frontal, and right parietal lobes. The patient was managed conservatively. The constellation of neuro-ophthalmic signs correlated with damage to the midbrain tegmentum and dorsal structures. This case underlines the importance of careful neuro-ophthalmic examination in head injury and highlights rare presentations of traumatic midbrain injury.

Multiple brain carcinoma metastases treated surgically, long term survival

Marcel Sincari — 2026-03-15

We present the case of a 47-year-old woman diagnosed with breast cancer who underwent surgery and, 35 months later, was diagnosed with multiple brain metastases. She was treated surgically, followed by Whole Brain Radiation Therapy and chemotherapy. Clinical and imaging follow-up revealed no tumour recurrence after more than 5 years.

Carcinoma metastasis spread through cerebrospinal fluid pathway

Marcel Sincari — 2026-03-15

37-year-old lady with known systemic cancer, breast invasive carcinoma HER2 positive (score 3+) with negative progesterone and estrogenic receptors, treated surgically two years before diagnosing the pathological fracture Th12, associated with Th11 tumoral vertebral body infiltration.

S1 dermatomal numbness

Vuk Aleksić — 2026-04-15

Morton’s neuroma refers to a degenerative, compressive neuropathy affecting one of the common digital nerves in the forefoot, typically situated between the heads of the third and fourth metatarsal bones. The condition arises primarily due to repetitive compression and mechanical irritation of the interdigital nerve, particularly beneath the plantar portion of the transverse intermetatarsal ligament. Although historically labelled a “neuroma,” this entity lacks neoplastic features and is instead characterised by perineural fibrosis and nerve degeneration. It is known by several alternative terms in medical literature, including interdigital neuritis, intermetatarsal neuroma, Morton’s metatarsalgia, interdigital neuralgia, interdigital nerve entrapment, and interdigital compression neuropathy (1, 2).

This case report describes a 45-year-old female patient with a typical Morton’s neuroma, who underwent surgical treatment after experiencing symptoms for over a 15 years.