Background: Pneumocephalus is commonly encountered after surgical evacuation of chronic subdural hematoma (CSDH). This study was done to study the incidence, clinical presentation, and management of patients who developed pneumocephalus after surgical evacuation of CSDH. Materials and Methods: This prospective study was carried out on consecutive 50 patients who had received surgical treatment for CSDH. All the patients included were followed-up postoperatively with regular clinical and computed tomography (CT) examinations immediately postoperatively, before discharge, and 2 months after surgery. Pneumocephalus was classified into simple and tension, based upon the clinical and radiological criteria. The neurologic grading system of Markwalder et al was used to evaluate the surgical results. Results: The immediate postoperative CT scan showed pneumocephalus in 22 patients (44%). Tension pneumocephalus was found in two patients who did not require any further surgery. There was statistically significant increase in the incidence of pneumocephalus (immediate and postoperative) in the patients aged over 60 years as well as those presenting with a midline shift more than 5 mm in their CT scan. With regard to the 22 cases of pneumocephalus, good postoperative results were found in 16 patients (73%), while bad results were found in 6 patients (27%). No statistically significant difference in the outcome between patients who had pneumocephalus after surgery and those who had not. Conclusion: Pneumocephalus after surgical evacuation of CSDH is a common finding in the immediate CT scan as well as at time of discharge. Tension pneumocephalus may not require surgical intervention and simple aspiration of air using a syringe may be sufficient.

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Intramedullary dermoid cysts are rare tumors, especially those not associated with spinal dysraphism. Only six cases have been reported in the literature. Of these, only two cases have had magnetic resonance imaging studies. We report a case of an 18-year-old female patient, who presented with progressive weakness of both the lower limbs and wasting of both the upper limbs. Magnetic resonance imaging (MRI) showed an intramedullary lesion extending from C3 to D2 with peripheral enhancement on contrast. Decompression of the cystic contents with partial removal of cyst wall was done. Hair with oily cholesterol and keratin debris was encountered. Histopathology confirmed the diagnosis of dermoid cyst. This case adds to the previous reported cases of the rare and uncommon intramedullary space occupying lesions of the spinal cord.

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Astroblastomas are uncommon neuroepithelial tumors of uncertain origin. These occur predominantly in the cerebral hemisphere of young adults and children. They form only 0.45-2.8% of all neuroglial tumors. They can be easily misdiagnosed as they are rarely encountered in clinical practice and share common radiological and histopathologic appearance with other glial neoplasms. A 12-year-old female presented to us with progressive headache and diplopia. Her neurological examination showed right 6 ^th nerve paresis with papilledema. Brain magnetic resonance imaging (MRI) revealed well-demarcated, peripherally enhancing solid cystic mass of 6 cm in right parietal lobe with mass effect. She underwent gross total resection of the lesion through right parietal craniotomy. The histopathologic diagnosis was suggestive of low-grade astroblastoma. The patient had no evidence of recurrence of tumor without adjuvant radiotherapy during the last 14 months of follow-up. Supratentorial astroblastomas are very rare tumors. Complete excision without radiotherapy is sufficient in low-grade variants.

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Background: Over a 2-year period, 2008-2009, a total of 53 cases of split cord malformation (SCM) were treated at the All India Institute of Medical Sciences (AIIMS). This study is a retrospective analysis of clinical features, radiological findings, and surgical outcome of these patients. Materials and Methods: During this period, 53 cases of SCM were treated at AIIMS. They constitute around 27% of all spinal dysraphism surgeries performed at the department of Neurosurgery, AIIMS; as 200 cases of spinal dysraphism were operated during the study period. The data was obtained from case files, operation notes, discharge summaries, and follow-up files. Observations: There were 30 cases of SCM type I and 23 cases of type II SCM. Seven patients were adult above 18 years of age. Except 7 patients, remaining 46 were symptomatic. Bony deformity of spine was recorded in 24 patients; of them, 19 had scoliosis and 4 had kyphosis. Deformity of foot was recorded in 10 patients. Thirteen patients had hypertrichosis, while four had dermal sinus. Magnetic resonance imaging (MRI) was performed in all patients. MRI revealed syringomyelia in 14 patients; however, only one patient had associated Chiari malformation. Six patients had meningomyelocele. Intra-operative; thick filum was noticed in 10 cases and in another 9 cases, there was filum lipoma. Dermoid was encountered in 4 patients, one patient had epidermoid tumor. Site of split was thoracic in 22, followed by lumbar region in 21 patients. Only 3 patients had split in cervical spinal cord. Seven patients had two separate splits at two different levels. Two patients had posteriorly located bony spur. All patients underwent surgery. Seven patients, those who had no neurological deficits pre-op, remained unchanged post-op. Amongst the 46 patients who had preoperative neurological deficits, eight had neurological deterioration post-op; five had deterioration in motor power and three had urinary problem. Five of these patients had type Id split, 2 had type Ic split, and one had type Ib split. However, among 8 patients who deteriorated post-op, four improved to preoperative status by the time of discharge. Thus, 4/53(7%) patients had long-term deficits, all with type Id split. Follow-up data was available for 36 patients (68%) and mean follow-up period was 12 months (range 6-24 months). Follow-up MRI revealed decrease in syringomyelic cavity in 6 of the 14 patients (44%) who had syringomyelia on preoperative MRI scans. Conclusion: Overall, SCM is an uncommon condition. In all cases of progressive scoliosis, MRI must be carried out. We subjected all asymptomatic patients to surgery and none developed post-op deterioration. Overall post-op neurological deterioration was noticed in 15% patients, of which 8% had transient post-operative deterioration. The new Type I SCM subclassification system proposed by Mahapatra and Gupta is found to have a significant prognostic value in assessing post-operative neurological deterioration in patients with type I SCM.

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Telemedicine is rapidly developing telecommunication technology to provide medical information and services. The importance of telemedicine for neurosurgical emergencies was established with the fact that majority of the neurosurgical specialists are practicing in urban settings and in most of the rural areas, neurosurgical care is far off or non-existing. Countries with inadequate health care must incorporate telemedicine in their health care system. Telemedicine offers real benefits in a country as vast as India, where the majority of the population lives in remote areas with no access to even the most basic healthcare. Issues pertaining security, privacy, maintaining standards, and legal aspects are relevant. A recommended set of standards and guidelines for telemedicine needs to be set in place and constantly refined to promote the integrated growth of telemedicine in the country. The paper discusses various issues, shortcomings, and utility of telemedicine in India.

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Asystole during posterior fossa neurosurgical procedures is not uncommon. Various causes have been implicated, especially when surgical manipulation is carried out in the vicinity of the brain stem. The trigemino-cardiac reflex has been attributed as one of the causes. Here, we report two cases who suffered asystole during the resection of posterior fossa tumors. The vago-glossopharyngeal reflex and the direct stimulation of the brainstem were hypothesized as the causes of asytole. These episodes resolved spontaneously following withdrawal of the surgical stimulus emphasizing the importance of anticipation and vigilance during critical moments of tumor dissection during posterior fossa surgery.

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We report a case of intradural, intramedullary, spinal cord neurocysticercosis at dorsal 10-11 (D10-11) level in a mentally retarded male. A 38-year-old, mentally retarded male presented with weakness and stiffness in both the lower limbs and waist since one year. Magnetic resonance imaging revealed a D10-D11 intradural space occupying lesion with cord compression. Intraoperatively, the tumor was grayish white, soft, cystic, and intramedullary with a well-defined plane with surrounding cord tissue. Gross examination revealed a cystic lesion of 1.5×1×0.8 cm, with a whitish nodule of 0.3 cm in diameter. The cyst wall was thin, shiny, and translucent. Microscopic examination revealed cysticercous cyst. Spinal neurocysticercosis should be considered in differential diagnosis of spinal mass lesion in patients residing in endemic area such as India.

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Epidermoid cysts are histologically benign, slow-growing congenital neoplasms of the central nervous system that may arise from retained ectodermal implants. The epidermoid lesions are generally caused during the 3 ^rd to 5 ^th week of gestation by an incomplete cleavage of the neural tissue from the cutaneous ectoderm, though it can also happen later in life due to introduction of skin elements by skin puncture, trauma or surgery. We present this unique case of a petromastoid epidermoid cyst associated with ipsilateral cerebellar abscesses, presenting 20 years after a penetrating trauma to the external auditory canal. Radical excision of both lesions and revision of the previous fistulous tract was performed. We present the diagnostic challenge and the operative treatment of this unique case, which to our knowledge is the first where an epidermoid cyst and an adjacent brain abscess occurred as a result of a single traumatic event.

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Osteochondromas of the vertebral column are rare tumors and constitute about 3-4% of all primary vertebral column tumors. We report a case of osteochondroma arising from C3 lamina presenting with acute quadriplegia following a trivial fall. Computed Tomography (CT) and Magnetic Resonance imaging (MRI) showed bony lesion arising from C3 laminar arch compressing the cord with underlying spinal cord contusion. Emergency C3 laminectomy and complete enbloc excision of the lesion was performed, following which patient showed gradual recovery in neurological status. This acute presentation in this rare, slow growing, tumor has never been reported in literature till date.

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Aims: Neurointensive care has reduced the mortality and improved the outcome of patients for severe brain damage, over recent decades, and made it possible to perform this therapy in safety. However, we have to understand the complications of this therapy well. The purpose of our study was to determine the systemic circulation disturbance during the initiation of therapeutic hypothermia by using this continuous neurointensive monitoring system. Materials and Methods: Ten severe brain damage patients treated with hypothermia were enrolled. All patients had Glasgow Coma Scale (GCS) less than or equal to 8, on admission. Results: We verified that heart rate, cardiac output, and oxygen delivery index (DO2I) decreased with decreasing core temperature. We recognized that depressed cardiac index (CI) was attributed to bradycardia, dehydration, and increased systemic vascular resistance index (SVRI) upon initiation of hypothermia. Conclusion: Although the hypothermia has a therapeutic role in severe brain damage patients, we have to carry out this therapy while maintaining their cardiac output using multimodality monitoring devices during hypothermia period.

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Encephalocele means if meninges and brain tissue protrude out of the cranium. There are different types of encephalocele. The occipital encephaloceles are the most common type. Craniocervical junction and upper cervical spine abnormalities can rarely be associated with occipital encephalocele. We discuss this case because there is rare association between torcular encephalocele and proatlas anomalies.

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More than one third of patients with subarachnoid hemorrhage (SAH) develop clinically significant vasospasm, as a leading morbidity and mortality factor for these patients. It is widely accepted that a) Degradation products of blood are the causative factors of vasospasm b) The amount of subarachnoid blood seen on admission CT is correlated to the risk of vasospasm c) Reducing the subarachnoid clot burden at the time of surgery reduces the risk of vasospasm. But there is no existing method to clear the blood from subarachnoid spaces satisfactorily. We have evaluated safety and feasibility of fluid exchange catheter system in SAH, to achieve this goal. We were successful in clearing cisternal blood in three patients with aneurysmal rupture with fluid exchange catheter system. Baseline CT scan of brain was performed immediately after the surgery and then at the end of irrigation. The amount of subarachnoid blood was evaluated. This innovative, fluid exchange catheter system infuses and aspirates micro volumes of drug solution in a cyclic mode, ensuring isobaric exchange of fluids. The result is good clearance of blood in subarachnoid spaces were seen in all the patients. Also, significant improvement in neurological deficits secondary to vasospasm was seen. We conclude that the fluid exchange catheter system is safe and adoptable in neurosurgical practice.

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