BACKGROUND Neuromodulation, including deep brain stimulation (DBS), is a treatment option for patients with medically intractable epilepsy who do not meet candidacy for resective surgery. DBS of the anterior nucleus of the thalamus (ANT) has been FDA approved for focal epilepsy, and stimulation of the centromedian nucleus of the thalamus (CMT) is increasingly being explored for generalized epilepsies including juvenile myoclonic epilepsy (JME). The authors present the case of a patient with JME and medically intractable seizures who underwent bilateral, sequential ANT and CMT DBS implantation. OBSERVATIONS This case describes a 51-year-old woman with medically intractable JME in whom adequate trials of more than 10 antiseizure medications and prior vagus nerve stimulation failed. She underwent bilateral ANT DBS, which reduced her generalized tonic-clonic seizures but did not improve her myoclonic jerks. Owing to persistent disability from daily myoclonus, she later underwent bilateral CMT DBS. Following CMT stimulation, she experienced rare myoclonic jerks. At 7 months postoperatively, her status remained Engel class IIb with sustained functional improvement. LESSONS This case highlights the complementary roles of ANT and CMT stimulation in modulating distinct thalamocortical pathways. Although CMT DBS has been described in patients with generalized epilepsy, this case demonstrates a meaningful reduction specifically in disabling myoclonic jerks that previously resulted in falls and dropped objects. https://thejns.org/doi/10.3171/CASE251033
Rose V Zach, James Kelbert, Robert W. Bina et al.· Journal of Neurosurgery: Cas...· 0 citations
Coccidioidomycosis is a fungal infection endemic to the southwestern United States that rarely involves the central nervous system (CNS) as a brain abscess or subdural empyema. These uncommon manifestations can mimic neoplastic or inflammatory lesions, making diagnosis particularly challenging.
We report two cases of disseminated coccidioidomycosis with atypical CNS presentations and imaging findings. In the first case, a patient with pulmonary sarcoidosis presented with a right parietal lesion and subdural empyema initially suspected to represent neurosarcoidosis or bacterial infection. In the second case, a patient with a history of resected CNS glioma developed a ring-enhancing lesion concerning for tumor recurrence. In both cases, the diagnosis of CNS coccidioidomycosis was established only after surgical intervention and histopathological examination. Both patients received prolonged antifungal therapy; however, outcomes differed, with one patient experiencing fatal disease progression and the other demonstrating neurological improvement.
These cases highlight the diagnostic challenges of atypical CNS coccidioidomycosis and emphasize the importance of maintaining a high index of suspicion in endemic regions, particularly when imaging findings resemble neoplastic or inflammatory lesions. Early tissue diagnosis and multidisciplinary management are essential, and further studies are needed to optimize treatment strategies for these rare CNS manifestations.
Dana Saleh, Ashley Carter, Avery Roe et al.· Surgical neurology internati...· 0 citations
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