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Background In accordance with German neurosurgical and neurological consensus recommendations, lead placements for deep brain stimulation (DBS) in patients with Parkinson’s disease (PD) are usually performed with the patient awake and in “medication off” state. This allows for optimal lead position adjustment according to the clinical response to intraoperative test stimulation. However, exacerbation of Parkinsonian symptoms after withdrawal of dopaminergic medication may endanger the patient by inducing severe “off” state motor phenomena. In particular, this can be a problem in awake craniotomies utilizing intraoperative airway management and resuscitation. Case presentation We report the case of a PD patient with progressive orofacial and neck muscle dystonia resulting in laryngeal spasm during DBS lead placement. This led to upper airway compromise and asphyxia, requiring resuscitation. Conclusions Laryngeal spasms may occur as a rare “off” state motor complication in patients with PD. Other potential causes of intraoperative difficulties breathing include bilateral vocal cord palsy, positional asphyxia, and silent aspiration. In our practice, we have adjusted our medication regimen and now allow patients to receive their standard dopaminergic medication until the morning of surgery. Neurologists and neurosurgeons performing lead placement procedures for PD should be aware of this rare but unsafe condition to most optimized treatment. peerReviewed

A 68-year-old female had a three-week history of severe low back pain radiating down the posterior left buttocks and left leg exacerbated by standing and walking. Lumbar spine MRI revealed cystic mass with similar intensity to cerebrospinal fluid located on dorsolateral left side of the sacral spinal canal inferior to the S1 pedicle. There was compression of left exiting S1 and traversing S2 nerve roots. Neurosurgery consult was requested to evaluate the cystic mass in the sacral spinal canal. After clinical evaluation, an unusually located synovial cyst was thought possible. Cyst contents were heterogeneous, suggestive of small hemorrhage and acute clinical history seemed reasonable. Left S1 and partial left S2 hemilaminectomy was performed and an epidural, partially hemorrhagic cyst was removed. There was no obvious connection to the ipsilateral L5-S1 facet joint. Pathology revealed synovial cyst, and the patient’s leg pain was improved postoperatively. This synovial cyst was unusual as it had no connection with the facet joint intraoperatively and its location in the sacral canal was uncommon.

Object Transnasal endoscopic (TNE) approaches have been proposed for the resection of anterior cranial base meningiomas. The purpose of this article was to evaluate the results of endoscopic resection of anterior cranial fossa meningiomas by reviewing available published data in addition to the authors' experience with 13 cases. Methods The literature was searched via OVID to identify all available disaggregate data pertaining to anterior fossa meningiomas treated primarily by TNE. In addition, the authors reviewed the records of a personal series of 13 patients who underwent TNE removal of parasellar meningiomas through a pure TNE approach. Results Meta-analysis from studies included a total of 69 patients with adequate disaggregated data to summarize. Mean age (± SD) at surgery was 53.3 ± 13.0 years (range 27–80 years); 78% of the patients were women. Tumor size was skewed toward smaller lesions, with a mean volume of 24.4 ± 2.9 cm3. Intraoperative impressions were of gross-total resection in 76% of cases. The most common complication reported was CSF leakage, occurring in 32% of the cases (22 of 69). The rate of CSF leakage was not affected by size (p = 0.52), location of tumor (p = 0.9), or age (p = 0.56). There was 1 death overall. The mean duration of follow-up was 21 ± 18 months. Conclusions Transnasal endoscopic resection of anterior cranial base meningiomas is feasible in selected cases. Reported resection rates are adequate, although the follow-up in the reported series is too short (mean 21 months) to make definitive conclusions regarding the long-term effectiveness. Cerebrospinal fluid leakage is a common complication, although it appears not to be associated with additional morbidity except for the need for reoperation. Long-term results are necessary before considering TNE resection as a valid alternative, in selected cases, to the more established transcranial techniques.