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   2014| April-June  | Volume 9 | Issue 2  
    Online since July 15, 2014

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Complication avoidance in transcallosal transforaminal approach to colloid cysts of the anterior third ventriclen: An analysis of 80 cases
Nigel P Symss, Ravi Ramamurthi, Ravindranath Kapu, Santhosh Mohan Rao, Madabushi Chakravarthy Vasudevan, Anil Pande, Goutham Cugati
April-June 2014, 9(2):51-57
DOI:10.4103/1793-5482.136708  PMID:25126118
Object: The objective of the present study is to analyze the complications and their avoidance in a series of 80 patients operated by transcallosal transforaminal approach to colloid cysts of the anterior third ventricle. Materials and Methods: The surgical outcome and complications of 80 patients operated by transcallosal transforaminal approach for colloid cysts in the anterior third ventricle was analyzed. A detailed pre- and post-operative neurological assessment was done in all patients. Neurocognitive assessment of corpus callosal function was done in the last 22 cases. CT scan of the brain was done in all patients, before and after surgery. Results: All patients underwent transcallosal transforaminal approach. Total excision of the lesion was achieved in 79 patients and subtotal in one. The complications encountered were postoperative seizures in six, acute hydrocephalus in four, venous cortical infarct in four, transient hemiparesis in four, transient memory impairment, especially for immediate recall in nine, mutism in one, subdural hematoma in one, meningitis in three, and tension pneumocephalus in one patient. There were two mortalities. There was no incidence of postoperative disconnection syndrome. Conclusion: Colloid cyst is surgically curable. With good knowledge of the regional anatomy and meticulous microsurgical techniques, there is a low mortality and minimum morbidity, when compared to the natural history of the disease. With increasing experience, most of the complications are avoidable. The limited anterior callosotomy does not result in disconnection syndromes.
  4,357 552 12
Spinal dysraphism: A challenge continued to be faced by neurosurgeons in developing countries
Amit Agrawal, Sunil Sampley
April-June 2014, 9(2):68-71
DOI:10.4103/1793-5482.136713  PMID:25126121
Objectives: The incidence of spinal dysraphism has significantly decreased over the last few decades, all over the world; however, still the incidence is much higher in developing countries with poor socioeconomic status. Materials and Methods: The present study includes all patients managed for spinal dysraphism over a period of one year (January 2011-December 2011). Details including demographics, antenatal care history, site and type of lesion, neurological examination, imaging finding, associated congenital anomalies, management offered, and outcome were recorded. Results: A total of 27 children were operated for spinal dysraphism during the study period (17 males and 11 females). Median age was 120 days (age range, 1 day to 6 years). Mothers of 15 children did not seek any regular antenatal checkup and only 13 mothers received folic acid supplementation during pregnancy. Fourteen children were delivered at home and 13 were at hospital. The most common site was lumbosacral region (67.8%). Seven patients had rupture of the sac at the time of presentation, one child had local infection, and four patients had hydrocephalus (requiring shunt before surgical repair). Two patients developed hydrocephalus at follow up, needing shunt surgery. The mean hospital stay was 7 days (range, 5 days to 31 days; median, 10 days). Conclusion: Spinal dysraphism is still a major public health problem in developing countries. Management of patients with spinal dysraphism is complex and needs close coordination between pediatrician, neurologist, neurosurgeon, and rehabilitation experts. A large number of factors influence the outcome.
  4,281 523 1
Spheno-orbital encephalocele: A rare entity - A case report and review of literature
Mayur Sharma, Rahul Mally, Vernon Velho, Vivek Agarwal
April-June 2014, 9(2):108-111
DOI:10.4103/1793-5482.136728  PMID:25126130
Objective: To report a rare case of basal encephalocele (spheno-orbital encephalocele), managed successfully in our institute. This is one of the rarest type of encephaloceles with very little literature available. In this case, sphenoid dysplasia was not associated with type 1 Neurofibromatosis. Settings: Grant Medical College and Sir J.J Group of Hospitals, Byculla, Mumbai, Maharashtra, India. Methods: A 22 year old male presented with a history of protrusion of right eye since the age of 7 years followed by progressive diminution of vision in the same eye for 5 months. MRI scan was suggestive of sphenoid dysplasia with herniation of right fronto-temporal lobe. The patient was operated upon with right frontal craniotomy with excision of encephalocele and repair of skull base. Subsequently, the patient underwent plastic surgery for facial skin remodeling. Results: Patient's encephalocele reduced completely after excision and repair with good cosmetic results and no neurological deficits. There is no evidence of recurrence till recent follow-up. Conclusion: Basal encephaloceles are very rare. Complete excision of encephalocele with repair of the defect should be the aim to achieve cure.
  3,795 343 7
Ventriculoperitoneal shunting: Laparoscopically assisted versus conventional open surgical approaches
Fares Nigim, Ajith J Thomas, Efstathios Papavassiliou, Benjamin E Schneider, Jonathan F Critchlow, Clark C Chen, Jeffrey J Siracuse, Pascal O Zinn, Ekkehard M Kasper
April-June 2014, 9(2):72-81
DOI:10.4103/1793-5482.136717  PMID:25126122
Objectives: Ventriculoperitoneal shunting (VPS) is a mainstay of hydrocephalus therapy, but carries a significant risk of device malfunctioning. This study aims to compare the outcomes of laparoscopic ventriculoperitoneal shunting versus open ventriculoperitoneal shunting (OVPS) VPS-placement and reviews our findings in the pertinent context of the literature from 1993 to 2012. Materials and Methods: Between 2003 and 2012, a total of 232 patients underwent first time VPS placement at Beth Israel Deaconess Medical Center. Of those, 155 were laparoscopically guided and 77 were done conventionally. We analyzed independent variables (age, gender, medical history, clinical presentation, indication for surgery and surgical technique) and dependent variables (operative time, post-operative complications, length of stay in the hospital) and occurrence of shunt failure. Results: Mean operative time was 43.7 min (18.0-102.0) in the laparoscopic group versus 63.0 min (30.0-151.0) in the open group, (P < 0.05). Length of stay was similar, 5 days in the laparoscopic and in the open group, (P = 0.945). The incidence of shunt failure during the entire follow-up period was not statistically different between the two groups, occurring in 14.1% in the laparoscopic group and 16.9% in the open group, (P = 0.601). Kaplan-Meier analysis demonstrated no difference in shunt survival between the two groups (P = 0.868), with functionality in 85% at 6-months and 78.5% at 1-year. Conclusion: According to our study, LVPS-placement results compare similarly to OVPS placement in most aspects. Since laparoscopic placement is not routinely indicated, we suggest a prospective study to assess its value as an alternate technique especially suitable in obese patients and patients with previous abdominal operations.
  3,397 539 13
Thoracic cord compression by extramedullary hematopoiesis in thalassemia
MA Hashmi, S Guha, P Sengupta, D Basu, S Baboo, Neha
April-June 2014, 9(2):102-104
DOI:10.4103/1793-5482.136726  PMID:25126128
Extramedullary hematopoiesis (EMH) refers to hematopoiesis occurring outside the medulla of bone. It may be physiologic or due to pathological conditions like hematopoietic disorders. EMH can involve liver, spleen, thorax, and lymph nodes. It can involve paraspinal tissues with extension and involvement of spinal canal. In our case, the diagnosis was confirmed by the history of the patient stating underlying hematological condition and by magnetic resonance imaging (MRI) findings showing large soft tissue masses in paraspinal areas with involvement of spinal canal and leading to cord compression.
  3,621 303 3
EC-IC bypass for cavernous carotid aneurysms: An initial experience with twelve patients
G Menon, Sudhir Jayanand, K Krishnakumar, S Nair
April-June 2014, 9(2):82-88
DOI:10.4103/1793-5482.136718  PMID:25126123
Aims: Need for performing a bypass procedure prior to parent artery occlusion in patients with good cerebral vascular reserve is controversial. We analyze our experience of 12 giant internal carotid artery aneurysms treated with extracranial-intracranial (EC-IC) bypass and proximal artery occlusion. Materials and Methods: Retrospective analysis of the case records of all complex carotid aneurysms operated in our institute since January 2009. Results: The study included eleven cavernous carotid aneurysms and one large fusiform cervical carotid aneurysm reaching the skull base. Preoperative assessment of cerebral vascular reserve was limited to Balloon test occlusion with hypotensive challenge. Eleven patients who successfully completed a Balloon test occlusion (BTO) underwent low flow superficial temporal artery to middle cerebral artery (STA-MCA) bypass, while one patient with a failed BTO underwent a high flow bypass using a saphenous vein graft. Parent artery ligation was performed in all patients following the bypass procedure. Check angiogram revealed thrombosis of the aneurysm in all patients with a graft patency rate of 81.8%. We had one operative mortality, probably related to a leak from the anastomotic site. The only patient who had a high flow bypass developed contralateral hemispheric infarcts and remained vegetative. All the other patients had a good recovery and with a Glasgow outcome score of 5 at last follow-up. Conclusion: We feel that combining EC-IC bypass prior to parent vessel occlusion helps in reducing the risk of post operative ischemic complications especially in situations where a complete mandated cerebral blood flow studies are not feasible.
  2,919 474 7
Cerebral aspergilloma in a SLE patient: A case report with short literature review
Forhad Hossain Chowdhury, Mohammod Raziul Haque, Shafiqul Kabir Khan, Sarwar Morshed Alam
April-June 2014, 9(2):58-61
DOI:10.4103/1793-5482.136710  PMID:25126119
Aspergillosis of brain is very rare, and commonly seen in immunocompromised or immunosuppressed patient. Here, we report a cerebral aspergillosis condition in a late teen girl who is a Systemic Lupus Erythromatosis patient with steroid therapy. She developed headaches, vomitings, and convulsions. On the basis of clinical and neuroimaging, a diagnosis of cerebral tuberculoma was made, and she was put on anti-TB therapy, but she did not respond. Later, surgical partial excision biopsy confirmed the diagnosis. Her cerebral lesions responded with antifungal itraconazole therapy. The case will be presented with short literature review. Such a report in the literature is rare.
  2,868 374 2
Impact of clinico-radiological parameters on the outcome of treatment in brain tuberculosis
Manzoor Ahmad Lone, Farooq Ahmad Ganie, Altaf Umar Ramzan, Mohd Arif Kelam, Abdul Qyoom Khan, Masratul-Gani
April-June 2014, 9(2):62-67
DOI:10.4103/1793-5482.136711  PMID:25126120
Objectives: The Aim of this study was to evaluate the impact of clinico-radiological parameters on the outcome of the treatment in brain tuberculosis. Materials and Methods: This study was conducted in the Department of Neurosurgery and Neurology Skims Srinagar India for a period of two years from November 2009 to November 2011. A total of 61 patients presenting with brain tuberculosis admitted at skims during these two years were included in the study. Patients having clinical, laboratory and radiological findings suggestive of brain tuberculosis were included in the study. On correlating the CT characteristics-tuberculomas, basal exudates and hydrocephalus with sequelae at 6,12 and 18 months - focal deficit, cognitive impairment, and diplopia. Results: It was seen that basal exudates correlated with all the three neurological sequelae i.e.; with focal deficit (P = 0.001), cognitive impairment (P = 0.011), and diplopia (P = 0.021). Hydrocephalus correlated well with cognitive impairment (P = 0.031) and tuberculoma correlated with none of these clinical characteristics. Conclusion: We concluded that the mortality and neurologic sequelae were directly related to the clinical stage of disease at presentation. Correlating the CT characteristics we concluded that basal exudates correlated with all the three sequelae i.e.; with focal deficit, cognitive impairment, and diplopia. Hydrocephalous correlated well with cognitive impairment and tuberculoma correlated with none of these clinical characteristics.
  2,384 360 -
Intradural spinal granular cell tumor
Viren L Vaghasiya, Jitendra G Nasit, Pinki A Parikh, Priti P Trivedi
April-June 2014, 9(2):96-98
DOI:10.4103/1793-5482.136724  PMID:25126126
Granular cell tumor is a rare, usually benign tumor with classical histomorphology. Location of tumor varies widely within body, but spine is distinctly a rare location for this tumor. We report a rare case of granular cell tumor involving intradural extramedullary portion of lumbar region of spinal cord. Knowledge of which is important as subsequent prognosis differs from other tumor at same location.
  2,315 288 2
Aneurysmal bone cyst: An unusual presentation of back pain
DK Singh, N Singh, MC Pant
April-June 2014, 9(2):105-107
DOI:10.4103/1793-5482.136727  PMID:25126129
Aneurysmal bone cyst (ABC) is a rare benign tumor comprising 1.4% of all primary bone tumors. It commonly involves humerus, femur, tibia, and pelvic bones. Spinal involvement is rare. The pathological appearance of the lesion is one of the blown out distension with fluid filled cavities from which it gains the name aneurysmal bone cyst. The World Health Organization has defined it as an expanding lesion with blood filled cavities separated by septa of trabecular bone or fibrous tissue containing osteoclast giant cells. We describe the case of a 20-year-old Asian male who presented with backache and pain in right leg. Radiology was suggestive of an ABC involving the posterior elements of the lumbar vertebra. Excision was performed. We discuss this unusual case, reviewing the current literature on biological behavior and management of aneurysmal bone cyst.
  2,305 264 4
Primary Ewing's sarcoma of cervical vertebra: An uncommon presentation
Sonia Chhabra, Sunita Singh, Divya Sethi, Qury Sabita Mahapatra
April-June 2014, 9(2):99-101
DOI:10.4103/1793-5482.136725  PMID:25126127
Ewing's sarcoma is a malignant primary bone tumor primarily seen in the long bones. Primary Ewing's sarcoma of the cranium is quite uncommon occurring in 1% of the cases. We report the occurrence of this rare lesion in a 24-year-old male presenting with progressively increasing swelling in left mastoid region mimicking a mastoid abscess which was later diagnosed on Fine needle aspiration cytology (FNAC) as a small round cell tumor as Ewing's sarcoma. Contrast enhanced computed tomography (CECT) revealed a typical moth eaten appearance in the first and second cervical vertebra.
  2,247 286 3
Bed wise cost analysis of in-patient treatment of brachial plexus injury at a Level I trauma Center in India
Nityanand Pandey, Deepak Gupta, Ashok Mahapatra, Rajesh Harshvardhan
April-June 2014, 9(2):89-92
DOI:10.4103/1793-5482.136721  PMID:25126124
Aim: The aim was to calculate, in monetary terms, total cost incurred by a Level I trauma center in providing in-patient care to brachial plexus injury patients during their preoperative and the postoperative stay. Subjects and Methods: All patients of brachial plexus injury admitted and discharged between January and December 2010 were included in the study. Total cost per bed was calculated under several cost heads in pre- and post-operative ward care. Intra-operative costs were excluded. Results: A total of 69 patients were admitted in the year 2010. Of these 60 were operated and the rest were planned conservative management. The total cost incurred by the trauma center in providing in-patient care to patients admitted in the ward, excluding high dependency unit, came out to be Rs. 3,650.00/patient/bed/day. Of this Rs. 2,234.645, the maximum amount was incurred in providing manpower alone. The average preoperative wait was 12 days (maximum 41 days and minimum 1-day). The average postoperative stay was 2 days. Total cost incurred in the preoperative period was Rs. 2,975,125 (US$ 59392) or Rs. 43,117/patient (US$ 861). It was Rs. 386,948 (US$ 7724) in the postoperative period (Rs. 6,449 or US$ 129/patient). Nine patients were not operated and had waited from 2 to 12 days before finally being planned for observant treatment. This itself cost the hospital Rs. 226,328 (US$ 4518). Conclusion: By just reducing the preoperative length of stay to 1-day the cost can be brought down by 93% for brachial plexus injury patients alone and the beds can be used to admit more critical patients.
  2,075 239 1
Multicystic oligodendroglioma with calvarial destruction
Ajay Bajaj
April-June 2014, 9(2):93-95
DOI:10.4103/1793-5482.136723  PMID:25126125
Context: Calvarial erosion is known to occur with some superficially located tumors. Very few case reports of calvarial erosion associated with oligodendroglioma are reported in the literature, but calvarial destruction with oligodendroglioma is very rare. Aim: To report an unusual case of multicystic frontoparietal oligodendroglioma with destruction of the calvaria and scalp involvement in the absence of prior surgery or radiation. Materials and Methods: A 30-year-old male presented with the history of left focal seizure with secondary generalization for last three to four years along with left sided weakness for the past one month. There was history of slowly progressive decreased vision in both eyes leading to complete blindness in both eyes for the past one month. On neurological examination, patient had left hemiparesis of grade-2/5 with perception of light absent in both eyes. Fundus examination revealed bilateral optic atrophy. Magnetic resonance imaging (MRI) of the brain showed a large supratentorial heterogenous multicystic ring enhancing mass lesion involving right frontal lobe, right frontotemporal opercular region, and posteriorly abutting the central sulcus and anteriorly destroying the calvaria. Patient underwent right frontoparietal craniotomy and near total excision of tumor. Histopathological examination revealed oligodendroglioma WHO grade-2. Patient received postoperative chemoradiotherapy. Results: At nine month follow-up patient neurological status was same and his seizure was controlled on single AED. There was no recurrence of seizure at nine month of follow-up. Conclusions: Calvarial destruction in association with extra and intra axial neoplasm should include oligodendroglioma especially in patients with long history of symptoms, although calvarial destruction is very rare. However, the final diagnosis is established by means of histopathological examination.
  1,784 250 2
Epidural hematoma secondary to solitary skull metastasis from an ovarian carcinoma
PM Kumar, M Manisha
April-June 2014, 9(2):112-114
DOI:10.4103/1793-5482.136729  PMID:25126131
We report a rare case of an acute epidural hematoma (EDH) due to solitary skull metastasis in a 60-year-old patient treated earlier for ovarian carcinoma. The patient presented with head injury followed by unconsciousness and computerized tomography showed a large EDH in the right parietal region along with a contusion of left temporal-parietal lobe and subarachnoid hemorrhage in left sylvian fissure. Emergency craniotomy and evacuation of the EDH was performed and the hemorrhage was determined to be secondary to skull metastasis of ovarian carcinoma; the patient recovered and received whole brain radiation therapy.
  1,708 272 3