Dejerine Syndrome Variant Due to Medullary Perforating Artery Ischemia During Foramen Magnum Meningioma Resection: 2-Dimensional Operative Video

Abstract

Foramen magnum meningiomas are a formidable disease entity whose resection requires intimate knowledge of the relevant neurovascular anatomy. Due attention is given to the anterior spinal artery and the importance of its preservation to avoid devastating deficits from anterior spinal artery syndrome. There is an underappreciated but clinically significant set of perforating arteries arising from the distal vertebral arteries at the vertebrobasilar junction that supply the medial and anterior medulla through the ventrolateral sulcus. [1][2][3] Injury to or occlusion of these arteries causes a brainstem infarction known as medial medullary syndrome, or Dejerine syndrome, which mainly involves the pyramidal tracts, hypoglossal nucleus, and medial lemniscus. 4 Here, we describe an incomplete variant of Dejerine syndrome exclusively involving the pyramids, occurring during surgical resection of a foramen magnum meningioma. These arteries are analogous to the perforators of the distal basilar artery whose importance was highlighted by Drake's seminal work. 5,6 The patient underwent resection of a ventral foramen magnum meningioma, complicated by the need for vertebral artery stenting. The patient promptly lost motor-evoked potentials while somatosensory-evoked potentials remained perfectly at baseline. The patient was initially densely quadriplegic postoperatively, without sensory or cranial nerve deficits. MRI demonstrated T2 hyperintensity limited exclusively to the pyramids. After a long convalescence, she fortunately made a full recovery. We highlight the knowledge and preservation of the perforators at the vertebrobasilar junction during resection of foramen magnum tumors. The patient consented to surgery and publication of her images.

Commentary: Dejerine Syndrome Variant Due to Medullary Perforating Artery Ischemia During Foramen Magnum Meningioma Resection: 2-Dimensional Operative Video

“…The authors of this video publication describe their experience with a foramen magnum meningioma in which vascular injury lead to an incomplete Dejerine syndrome. 1 The authors present their approach and intraoperative management of this entity.…”