No abstract

Resection of a giant pre-sacral schwannoma originating from the right S2 nerve in a 22-year-old woman illustrates the potential for robotic surgery. The da Vinci Robot Surgical System facilitates visualization deep in the pelvis and allows for bimanual wristed instrument control to dissect the tumor from surrounding sensitive structures. Neurostimulation to identify critical nerves is possible and complete resection of the tumor can be achieved. There were no complications, she remained neurologically intact, the estimated blood loss was less than 75 ml, the total hospital stay was 3 days, and she returned to work within 2 weeks of her operation. In select patients, robot-assisted surgery may have advantages.The video can be found here: https://youtu.be/SYjUA-WcyGI.

ABSTRACT BACKGROUND AND IMPORTANCE Middle meningeal artery (MMA) pseudoaneurysms and middle meningeal arteriovenous fistulas (MMAVFs) are rarely reported after head injury. We report an unusual case of delayed MMA pseudoaneurysm formation after spontaneous thrombosis of an MMAVF, and review existing literature on MMAVF treatment and results. CLINICAL PRESENTATION A 59-yr-old male presented with a 5-d history of worsening left-sided headaches, followed by nausea, lethargy, and difficulty with speech. Non-contrast computed tomography demonstrated a left temporal intraparenchymal hemorrhage (IPH) and an acute left-sided subdural hematoma (SDH). Cerebral angiography found abnormal shunting between the right MMA and the right sphenoparietal sinus, consistent with an MMAVF. During the course of admission, the patient's neurological condition deteriorated requiring craniotomy for evacuation of SDH and IPH. Given the presumed incidental nature of the contralateral MMAVF, conservative management was recommended. Follow-up imaging 2 mo after surgery revealed spontaneous thrombosis of the right MMAV. Repeat imaging 5 mo later revealed an MMA pseudoaneurysm at the prior fistulous site, which was subsequently embolized with Onyx, occluding the pseudoaneurysm and the MMA both proximal and distal to the pseudoaneurysm. CONCLUSION Spontaneous thrombosis of an MMAVF is rare and only seen in 13.1% of cases. However, subsequent delayed formation of an MMA pseudoaneurysm has not been described. Our case therefore demonstrates that MMAVF thrombosis may not indicate complete healing of the underlying injury to the MMA, and suggests the need for continued follow-up of such lesions despite initial apparent resolution.