Background: The risk of developing immediate postoperative seizures in patients undergoing supratentorial brain tumor surgery without anti-epileptic drug (AED) prophylaxis is 15-20%. Patients who present with pre-operative seizures and patients with supratentorial meningioma or supratentorial low grade gliomas are at significantly higher risk. There is little data on the efficacy of levetiracetam as a prophylactic AED in the immediate postoperative period (within 7 days of surgery) in these patients. Methods: We conducted a retrospective chart review of 165 adult patients classified as higher risk for postoperative seizures who underwent brain tumor resection at Duke University Hospital between time May 2010 and December 2011. All patients had received levetiracetam monotherapy in doses of 1000-3000 mg/day in the immediate postoperative period. Results: We identified 165 patients with following tumor locations: Frontal 83 (50.3%), Temporal 37 (22.4%), Parietal 30 (18.2%), Occipital 2 (1.2%) and 13 (7.8%) with single lesions involving more than one lobe. Histology revealed: Glioma 98 (59.4%), Meningioma 57 (34.5%) and Brain Metastases 6 (3.6%). Preoperatively, 88/165 (53.3%) patients had presented with seizures. 12/165 patients (7.3%) developed clinical seizures (generalized 10, partial 2) in the immediate post-operative period. Other than somnolence in 7 patients (4.2%), no major side-effects were noted. Conclusions: The incidence of seizures was significantly lower in patients treated with levetiracetam (7.3%) when compared with the expected (15-20%) rate without AED prophylaxis based on the previous literature. Levetiracetam appears effective and safe for seizure prevention in patients undergoing brain tumor resection and who are at significantly higher risk of developing post-operative seizures. These findings warrant confirmation in a prospective randomized trial.

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Pituitary adenomas and Rathke's cleft cysts (RCCs) share a common embryological origin. Occasionally, these two lesions can present within the same patient. We present a case of a 39-year-old male who was found to have a large sellar lesion after complaints of persistent headaches and horizontal nystagmus. Surgical resection revealed components of a RCC co-existing with a pituitary adenoma. A brief review of the literature was performed revealing 38 cases of co-existing Rathke's cleft cysts and pituitary adenomas. Among the cases, the most common symptoms included headache and visual changes. Rathke's cleft cysts and pituitary adenomas are rarely found to co-exist, despite having common embryological origins. We review the existing literature, discuss the common embryology to these two lesions and describe a unique case from our institution of a co-existing Rathke's cleft cyst and pituitary adenoma.

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Neurenteric cysts at the craniovertebral junction are extremely rare, in that most are located ventrally in the midline. We report two patients with neurenteric cysts in an unusual location - the lateral craniovertebral junction. The embryological basis, clinical features, imaging characteristics, and management options in these patients have been discussed.

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Background and Importance: Oncocytomas are rare benign tumours often arising from the lacrimal or salivary glands, usually small in size. Clinical Presentation: We report a giant unilateral orbital oncocytoma in a 19-year-old male from Papua New Guinea, presenting with progressive proptosis-threatening vision. Due to retro-ocular extension of the lesion, surgical excision was performed via a fronto-orbitozygomatic craniotomy and orbitotomy. A sub-total excision of the lesion was achieved, with overall improvement in proptosis and cosmesis. Conclusion: This appears to be the first documented case of a giant intra-orbital oncocytoma being resected neurosurgically via craniotomy.

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Spinal hydatid disease, though rare, is one of the differential diagnosis of spinal cord compression syndrome especially in endemic areas. Surgery is the treatment of choice but surgery alone is not curative. Adjuvant drug therapy as well as intraoperative prophylaxis are indicated. Despite all measures, the disease has high recurrence rates and overall outcome is still poor. We report a case of 65 year old male with lumbosacral hydatidosis recurring after 13 years.

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Objective: We evaluated the role of screening of the whole spine by sagittal magnetic resonance imaging (MRI) along with MR myelography in early detection and management of occult intrasacral meningocele. Materials and Methods: A prospective and retrospective analysis of MRI and MR myelography studies of the whole spine over a period of one year was performed. Results: Thirty cases with sacral meningeal cysts were seen. On MRI, six patients (three males, three females) fulfilled the criterion of occult intrasacral meningocele. These patients showed a cyst of cerebrospinal fluid (CSF) signal intensity in the sacral canal below the dural sac. This cyst communicated with the thecal sac through a narrow pedicle. Fat signal intensity in the filum terminale and occult sacral dysraphism in the form of an absent or hypoplastic neural arch was observed in all the patients. Low-lying conus medullaris with thick filum terminale was seen in five of these six patients. Excision of the cyst with the release of filum was performed in two patients with a favorable outcome. Conclusion: Screening MRI with MR myelography of the whole spine may play a role in the early detection and management of occult intrasacral meningocele. The commonly associated thick filum terminale and low-lying conus medullaris may be missed otherwise that may lead to a progression of symptoms.

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The diagnosis of primary central nervous system lymphoma (PCNSL) can be suggested by magnetic resonance imaging (MRI). Cerebral PCNSL in immunocompetent patients generally shows marked homogeneous contrast enhancement in MRI. However, confirmation of it requires demonstration of lymphoma cells in stereotactic biopsy of the lesion or in cerebrospinal fluid. In the present case, with radiologic diagnosis of glioma, complete resection of the lesion by micro-neurosurgical technique was performed. The tumor tissue was examined by squash smear, frozen section and paraffin sections. Cytologic appreciation of tumor cells as lymphoid origin in squash smears negated the other possibilities. The immunocytochemistry on squash smear and immunohistochemistry on paraffin sections confirmed the diagnosis of diffuse large B cell lymphoma of non-germinal center B cell phenotype

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Congenital lipomatous malformations of spinal cord constitute a diverse group of lesions and lipomyelocele is one of them. Here, we report a case of congenital lipomyelocele in a male child who presented at 7 years of age. Magnetic resonance imaging (MRI) revealed a lesion in lumbosacral region. The patient was operated and histologic examination diagnosed the case to be lipomyelocele. But after 8 years, recurrence of the lesion occurred and MRI revealed the lesion at the same location. This time histologic examination detected another new component (schwannomatous areas) in the lesion. The child was on 1-year follow-up which was uneventful.

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Background: Spinal cord injury often results in significant catastrophic disability. Placement of the intact omentum upon a recently traumatized spinal cord was found to be effective. It represents a very suitable organ for revascularization of the ischemic nervous tissue, due to its abundance in blood and lymph vessels and its capability to adhere to the surface of the lesion, with capillary overgrowing in 4-6 h. The traditional method of omentum transposition is a hectic and time-consuming two-stage procedure in which position is changed twice. The major disadvantage of this two-staged procedure is that it takes longer operative time, and there is high risk of infection due to change of position with an open wound. So there is a need for modifications so that the procedure can be made easier and complications can be avoided. Objective: To avoid the complications and to make the procedure easier, a single-staged procedure called 'chooramani technique' for omental transposition in spinal cord injury is proposed. Materials and Methods: The study was conducted on 16 patients of post-traumatic thoraco-lumbar spinal cord injury with paraplegia. Results : Complications like wound infection, incisional hernia, and CSF leak were avoided. Operative time reduced to approximately half. Conclusion : This modification of technique is relatively easy and can be adopted for patients undergoing omental transposition for spinal cord injury.

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A case of multiple intracranial abscesses in an immune-competent young girl is reported. She had chicken pox. Two weeks later, she presented with multiple intracranial abscesses. No significant cardiac abnormality was detected on transthoracic echocardiogram (TTE). The condition was treated medically. However, one of the abscesses adjacent to the CSF pathways enlarged on treatment and caused obstructive hydrocephalus that required stereotactic aspiration. Gram stain showed gram positive cocci in chain. Pus was sterile on culture. She was treated with broad spectrum IV antibiotics based on Gram staining report for 6 weeks followed by another 8 weeks of oral antibiotics. She made good recovery and had been leading a normal life. The abscess capsules took 30 months to resolve completely on MRI. A repeat TTE done in the follow up showed enlarged right heart chambers with a suggestion of a venosus ASD. A trans-esophageal echocardiogram (TEE) confirmed the presence of sinus venosus ASD from the SVC side with mainly left to right shunt. There was also partial anomalous drainage of the pulmonary veins. The patient underwent correction of the defect and has been doing well.

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