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   2012| January-March  | Volume 7 | Issue 1  
    Online since May 4, 2012

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Posterior inferior cerebellar artery aneurysms: Anatomical variations and surgical strategies
Rohit K Singh, Sanjay Behari, Vijendra Kumar, Awadhesh K Jaiswal, Vijendra K Jain
January-March 2012, 7(1):2-11
DOI:10.4103/1793-5482.95687  PMID:22639684
Context: Posterior inferior cerebellar artery (PICA) aneurysms are associated with multiple anatomical variations of the parent vessel. Complexities in their surgical clipping relate to narrow corridors limited by brain-stem, petrous-occipital bones, and multiple neurovascular structures occupying the cerebellomedullary and cerebellopontine cisterns. Aims: The present study focuses on surgical considerations during clipping of saccular PICA aneurysms. Setting and Design: Tertiary care, retrospective study. Materials and Methods: In 20 patients with PICA aneurysms, CT angiogram/digital substraction angiogram was used to correlate the site and anatomical variations of aneurysms located on different segments of PICA with the approach selected, the difficulties encountered and the final outcome. Statistical Analysis: Comparison of means and percentages. Results: Aneurysms were located on PICA at: vertebral artery/basilar artery (VA/BA)-PICA (n=5); anterior medullary (n=4); lateral medullary (n=3); tonsillomedullary (n=4); and, telovelotonsillar (n=4) segments. The Hunt and Hess grade distribution was I in 15; II in 2; and, III in 3 patients (mean ictus-surgery interval: 23.5 days; range: 3-150 days). Eight patients had hydrocephalus. Anatomical variations included giant, thrombosed aneurysms; 2 PICA aneurysms proximal to an arteriovenous malformation; bilobed or multiple aneurysms; low PICA situated at the foramen magnum with a hypoplastic VA; and fenestrated PICA. The approaches included a retromastoid suboccipital craniectomy (n=9); midline suboccipital craniectomy (n=6); and far-lateral approach (n=5). At a follow-up (range 6 months-2.5 years), 13 patients had no deficits (modified Rankin score (mRS) 0); 2 were symptomatic with no significant disability (mRS1); 1 had mild disability (mRS2); 1 had moderately severe disability (mRS4); and 3 died (mRS6). Three mortalities were caused by vasospasm (2) and, rupture of unclipped second VA-BA junctional aneurysm (1). Conclusions: PICA aneurysms may present with only IV th ventricular blood without subarachnoid hemorrhage. PICA may have multiple anomalies and its aneurysms may be missed on CT angiograms. Surgical approach is influenced by VA-BA tortuosity and variations in anatomy, location of the VA-BA junction and the PICA aneurysm relative to the brain-stem, and the pattern of collateral supply. The special category of VA-PICA junctional aneurysms and its management; and, the multiple anatomical variations of PICA aneurysms, merit special surgical considerations and have been highlighted in this study.
  15 10,188 1,246
The economic divide in outcome following severe head injury
SS Dhandapani, D Manju, AK Mahapatra
January-March 2012, 7(1):17-20
DOI:10.4103/1793-5482.95690  PMID:22639686
Background: Socioeconomic status is an important determinant of the standard of living and health status of people. Objectives: To assess the influence of economic status on the outcome following severe head injury. Materials and Methods: Adult patients of severe head injury, whose guardians' volunteered information on family income, were enrolled for the study. The family per capita income was then calculated. They were studied prospectively in relation to various factors and followed-up. Results: Among 99 patients, monthly per capita income of Rs. <500, 500-1000, 1000-2000, and >2000 were noted in 20, 43, 22, and 14 patients, respectively. The credibility of information on income was confirmed by positive correlation with patients' mid arm circumference measurements (P<0.001). They were divided into two groups (family monthly per capita income ≤Rs.1000 and >Rs.1000). The comparability of both groups based on age, Glasgow Coma Scale, systemic injury, and surgical intervention was confirmed (P>0.05). Mortality at one month was 49% among patients whose monthly per capita income ≤Rs.1000 compared with 17% of the rest (Odds ratio [OR] 4.0, P=0.003). Unfavorable outcome at three months was noted in 63% of patients whose monthly per capita income ≤Rs.1000, as compared with 35% of those with per capita income >Rs.1000 (OR 4.1, P=0.01). In multivariate analysis, family monthly per capita income ≤Rs.1000 emerged as an independent risk factor for unfavorable outcome at three months (P=0.02). Conclusion: In patients of severe head injury, lower economic status is significantly associated with unfavorable outcome at three months, independent of other factors.
  11 3,138 406
Giant non-traumatic arteriovenous malformation of the scalp
Askin Esen Hasturk, Fuat Erten, Tulu Ayata
January-March 2012, 7(1):39-41
DOI:10.4103/1793-5482.95698  PMID:22639692
Arteriovenous malformation (AVM) of the scalp is an uncommon entity. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complications. The etiology of scalp AVMs may be spontaneous or traumatic. Clinical symptoms frequently include pulsatile mass, headache, local pain, tinnitus; and less frequently, hemorrhage and necrosis. Selective angiography is the most significant diagnosis method. Surgical excision is especially effective in AVMs and the most frequently used treatment method. In this article, we discussed the clinical features and surgical management of scalp AVMs.
  9 3,631 404
Pterional approach versus unilateral frontal approach on tuberculum sellae meningioma: Single centre experiences
Muhammad Zafrullah Arifin, Ignatius Mardjono, Roland Sidabutar, Beny Atmadja Wirjomartani, Ahmad Faried
January-March 2012, 7(1):21-24
DOI:10.4103/1793-5482.95691  PMID:22639687
Introduction: Tuberculum Sellae Meningioma is one of the most challenging surgeries among neurosurgeons. Many approaches have been established in the effort of removing the tumor and some of them are supported by an advanced neurosurgical technology. In this study, we aim to compare the efficacy of the two most common approaches, the pterional and the unilateral frontal. Materials and Methods: This was a restrospective study that aimed to observe the efficacy of the two most common approaches used in our center, the pterional and the unilateral frontal, in resecting the tuberculum sellae meningioma, which was held in Dr. Hasan Sadikin General Hospital, Bandung, from July 2007-July 2010. Twenty patients were enrolled with half of them operated by the pterional approach and the rest by unilateral frontal approach. We evaluated six parameters: tumor size, degree of tumor removal, surgery duration, post-operative cerebral edema, patients' outcome, and length of stay, which were evaluated to take measure of the efficacy of each procedure. Results: We found that the pterional approach gave more advantages than the unilateral frontal. Total tumor removal, especially in tumor size ≥ 3 cm was achieved in a greater number of subjects in the pterional (P<0.023). Other advantages of the pterional compared to the unilateral frontal were a shorter surgical duration (P=0.024), shorter length of stay (P=0.009) and less frequency of post-operative cerebral edema incidence (P=0.023). Conclusion: According to our facilities and conditions, it seems that the pterional approach have more advantages than the unilateral frontal approach in tuberculum sellae meningioma surgery.
  8 5,448 653
Primary glioblastoma multiforme of medulla oblongata: Case report and review of literature
Silky P Chotai, Hong-Joo Moon, Joo-Han Kim, Jong-Hyun Kim, Taek-Hyun Kwon
January-March 2012, 7(1):36-38
DOI:10.4103/1793-5482.95697  PMID:22639691
Glioblastoma multiforme (GBM) is the most common glial tumor of the adult brain. However, the primary GBM of medulla oblongata is a rarity. To the best of our knowledge, only four cases of GBM of medulla oblongata have been reported so far in the literature, and this is the second report of conventional GBM of the medulla oblongata in adults. We describe a case of 51-year-old female, who presented with a heterogeneous mass with exophytic feature located in the caudal brain stem that was approached and a near total tumor removal was achieved by median suboccipital route. A literature review with emphasis on anatomical location, radiological and histopathological findings, extent of tumor resectibility, and outcome is included.
  4 4,153 380
Anaplastic hemangiopericytoma manifesting as a rapidly enlarging extracranial mass lesion
Naoki Otani, Hiroshi Nawashiro, Kojiro Wada, Kenzo Minamimura, Satoru Takeuchi, Katsuji Shima
January-March 2012, 7(1):29-31
DOI:10.4103/1793-5482.95694  PMID:22639689
We, herein, present a patient with a recurrent anaplastic hemanigiopericytoma manifesting as a rapidly enlarging extracranial mass lesion, which was revealed by pathological and intraoperative findings. In practice, this case highlights the mandatory need for a careful long-term follow-up for patients with hemangiopericytoma, since recurrence with a greater degree of malignancy can develop following an extended disease-free interval, as such knowledge will be helpful for planning the optimal surgical procedures.
  3 2,383 328
Endoscopic anatomy of the velum interpositum: A sequential descriptive anatomical study
Ahmed Zohdi, Sherif Elkheshin
January-March 2012, 7(1):12-16
DOI:10.4103/1793-5482.95689  PMID:22639685
Background: The velum interpositum and structures lying within and over it undergo morbid anatomical changes with hydrocephalus that have not been mentioned in the literature. Objectives: The aim of this article is to describe the diverse endoscopic anatomical findings for this surgically important region. Materials and Methods: One thousand five hundred and twenty cranial endoscopic procedures performed from September 1993 till March 2011 have been retrospectively reviewed. Anatomical changes in the velum interpositum and covering layers have been reported in 40 cases. Results: The changes of the velum interpositum have four patterns. These are 1-Distraction mounting to disruption of layers, 2-Reverse in the normal curvature, 3-Reverse of the triangular shape with change in size, and 4-Cystic dilatation causing hydrocephalus. Conclusion: The velum interpositum and roof of the third ventricle are sites of changes associated with hydrocephalus that show specific patterns described in a sequential anatomical study.
  3 4,514 611
Dorsal root entry zone approach in ventral and eccentric intramedullary tumors: A report of 2 cases
Ashish Kumar, Chandrashekhar E Deopujari, Vikram S Karmarkar
January-March 2012, 7(1):32-35
DOI:10.4103/1793-5482.95695  PMID:22639690
Intramedullary tumors constitute 2-4% of all the tumors affecting the central nervous system. They include low-grade astrocytomas and ependymomas in majority. Earlier, only biopsy or decompression used to be the best available options for these tumors, but with the upcoming technology and newer techniques, gross total excision with the aim of achieving complete removal has been the preferred treatment for these tumors. Usually, nearly all intramedullary tumors are approached from posterior midline myelotomy as this is the safest corridor to approach under neurophysiologic monitoring. But sometimes, if the tumor is exophytic, eccentric, or ventral to the cord, other routes of access may also be useful. These approaches are less frequently used these days and actually may be found useful in certain cases. Hence, they should not be termed "obsolete" and must be kept in mind for tumors in specific location. We describe a similar less commonly used dorsal root entry zone approach for near total excision of ventral and eccentric cervical pilocytic astrocytomas in two patients.
  2 3,319 297
Intra-axial CNS dermoid cyst
Vernon L Velho, Shadma W Khan, V Agarwal, M Sharma
January-March 2012, 7(1):42-44
DOI:10.4103/1793-5482.95700  PMID:22639693
Intracranial dermoid cysts are rare tumors. They constitute 0.3% of intracranial tumors. These are commonly seen in the midline and sylvian area. Intraaxial lesions are extremely rare. We report the case of a 35-years-old female with a large intraaxial dermoid cyst, which was reported as oligodendroglioma on imaging studies done preoperatively, but was confirmed to be a dermoid cyst intra-operatively and on histopathological examination; thus highlighting a diagnostic dilemma. Patient did well post operatively and there is no recurrence in the one year follow-up. To conclude, dermoid cysts are rare benign tumors, and intraaxial lesions are still rarer. Complete surgical excision may become difficult due to adherence to nerves and vessels.
  2 2,677 328
Role of conventional lumbar myelography in the management of sciatica: An experience from Pakistan
Ahmed Bakhsh
January-March 2012, 7(1):25-28
DOI:10.4103/1793-5482.95693  PMID:22639688
Objectives: A prospective study of 80 patients suffering from sciatica was conducted at Fauji Foundation Hospital, Rawalpindi, Pakistan. The aim of this study was to select patients for lumbar myelography on clinical grounds in the absence of magnetic resonance imaging (MRI)/computerized tomography (CT) facilities and to know the causes of sciatica. Materials and Methods: All patients underwent conventional lumbar myelography due to lack of MRI facility at a local hospital as well as financial constraints. Myelography was done with radio-opaque dye, Iopamidol , on outpatient basis. Results: Lumbar myelograms were positive in 77.5% and negative in 22.5% cases. Minor complications in the form of headache developed in 32.5% patients but no major complication like meningitis and archnoiditis developed. Lumbar disc prolapse and stenosis were found to be common causes of sciatica. Non-filling of nerve roots was seen in 33.87%, blocks (complete/partial) in 54.83%, and stenosis in 11.29% patients. Conclusions: Conventional myelography was found to be safe and an informative diagnostic technique in areas where facility of high-tech investigations like CT/MRI was not available. Conventional lumbar myelography could be recommended and performed with confidence on outdoor basis, in cases of sciatica with positive straight leg raising test, reflex loss, sensory, or motor deficit.
  2 2,841 362
The role of young neurosurgeons in the development of neurosurgery
Nimrod Juniahs M Mwang'ombe
January-March 2012, 7(1):1-1
DOI:10.4103/1793-5482.95686  PMID:22639683
  - 2,010 193
Paramdeep Singh, Kavita Saggar, Parambir Sandhu
January-March 2012, 7(1):45-46
DOI:10.4103/1793-5482.95702  PMID:22639694
  - 1,836 239
Limited unilateral partial laminectomy and lateral dural incision: One of the best approaches for spinal meningioma in selected cases
Manish Singh, Goutham Cugati, Ajai Kumar Singh, Pratibha Singh
January-March 2012, 7(1):46-47
DOI:10.4103/1793-5482.95704  PMID:22639695
  - 1,757 253