Remote supratentorial intraparenchymal bleed after posterior fossa surgery: A rare occurrence.

Background: Intraparenchymal hemorrhage at the operative site is one of the major complications of brain surgery. It is unusual to occur at a site remote from the operative site, but when it happens, it may cause significant morbidity and mortality. Case Description: We report the case of a 27-year-old male who presented with complaints of paresthesias over the left side of his face and decreased hearing from the left ear for two years. His radiology was suggestive of a large left cerebellopontine angle epidermoid cyst. The patient underwent left retro mastoid suboccipital craniotomy and near-total excision of the epidermoid cyst. The immediate postoperative non-contrast computed tomography scan of the brain was suggestive of no hematoma at the operated site but a remote left parafalcine frontoparietal intraparenchymal bleed, which was managed conservatively. At two months follow-up, he had no neuro deficits, and magnetic resonance imaging of the brain was suggestive of near-total excision of the epidermoid cyst with resolving left parafalcine frontoparietal bleed. Conclusion: We report this case due to the unique case observation of an intracranial bleed at a remote site rather than at the operated site.

Rhinocerebral mucormycosis (RCM): To study the clinical spectrum and outcome of 61 cases of RCM managed at a tertiary care center in India.

Background: Mucormycosis is a life-threatening infection of the paranasal sinuses and nasal cavities that can easily spread to the orbit and the brain. It is caused by fungi of the family Mucoraceae. We present a case series of 61 patients diagnosed and treated for rhinocerebral mucormycosis (RCM) at a single tertiary health care center. Methods: After obtaining ethical clearance, all patient files with a final diagnosis of RCM were thoroughly analyzed in departmental records and a master chart was prepared. The study evaluated the etiology, clinical spectrum, diagnosis, management, complications, and outcome at 3 months of RCM cases. Results: About 93.4% of the RCM cases were diabetic and an equal number had a past history of COVID infection. About 85.2% had received steroids for the treatment of coronavirus disease 2019 infection. The most common presentation of RCM was temporal lobe abscess (25.7%) followed by frontal lobe abscess (16.6%). At 3 months post-diagnosis, mortality in our study was 42.6%. About 26.2 % of the RCM cases had no disease, 23% had a static disease, and 8.2% had progressive disease at the end of 3 months. Conclusion: We report the largest single-center case series of RCM, comprising 61 patients. This case series underscores the importance of the early diagnosis and prompt treatment for a better prognosis for this dreadful disease. The three pillars of treatment for RCM cases include reversal of the immunosuppressive state, administration of antifungal drugs, and extensive surgical debridement. In spite of all this, mortality remains high.

Ectopic intraconal orbital meningioma - A rare case report.

BACKGROUND: Ectopic orbital meningiomas (OM) are a rare subset of OMs which are neither attached to the optic nerve sheath nor to the surrounding bone. CASE DESCRIPTION: We report the case of a 65-year-old female who presented with a 1 year history of proptosis followed by visual loss and restricted right eye movements since 3 months. Radiology of the orbits was suggestive of intraorbital, intraconal, and heterogeneous contrast enhancing right eye lesion which was completely excised through supraorbital orbitotomy approach. Intraoperatively, the right optic nerve, though compressed, and displaced inferiorly, was free from the lesion. The final histopathological diagnosis was "Meningioma WHO Grade I." At 3 months follow-up, patient's vision in the right eye improved from perception of light positive to 6/12 and there was no evidence of recurrence. CONCLUSION: Rarity of ectopic OM, total surgical excision with an excellent postoperative visual outcome prompted us to report this case.

A Giant Nondural-Based Lumbosacral Clear Cell Meningioma Mimicking Schwannoma: A Case Report and Review of the Literature.

Spinal clear cell meningiomas (CCMs) are rare and dural-based lesion usually affecting the younger population. We report the rare case of giant nondural-based spinal CCM mimicking schwannoma and review the literature. A literature search was performed at PubMed and Embase until January 1, 2020. A total of 19 cases of nondural-based spinal CCM was reported. The following relevant data were extracted: authors, publication year, patient and tumor characteristics, treatment, and outcome. The mean age of the presentation was 20.58 years. Twelve (63.16%) were female and seven patients (36.84%) were male. The most common location was lumbosacral region 15 (79%). Fifteen (79%) tumors had cranio-caudal dimension ≤2 vertebral level, and only four (21%) tumors had dimension ≥2 vertebral level. Gross total resection (GTR) was performed in 18 (95%) patients and subtotal resection (STR) in 1 patient. Recurrences were reported in five (26.14%) patients. Four of them showed recurrences within 6 months; earliest at 2.3 months in the patient had undergone STR. Our patient is 19-year-old male diagnosed with a lumbosacral intradural lesion. Craniocaudal dimension is ≥2 vertebral level shows the foraminal extension and vertebral scalloping. GTR is performed. Intraoperatively, the tumor has foraminal extension and shows attachment with right S1S2 nerve root. No dural attachment is found. Six-month follow-up magnetic resonance image shows no evidence of disease. Nondural-based spinal CCMs are extremely rare and should be kept as a differential diagnosis in young patients with giant intradural tumor, and whose radiological features suggesting of schwannoma. It affects young patients and usually involves more than one vertebral level. The chances of recurrences and metastasis are always high even after GTR; hence, close follow-up of the entire neuraxis is warranted.

Spontaneous regression of herniated cervical disc: A case report and literature review.

BACKGROUND: We have reviewed 75 cases plus our own single instance of spontaneous regression of herniated cervical discs. METHODS: We searched PubMed and EMBASE databases (until September 2020) utilizing the following keywords; "spontaneous regression," "herniated cervical disc," and "Magnetic Resonance Imaging (MRI) studies." RESULTS: In the literature, we found 75 cases of herniated cervical discs which spontaneously regressed; to this, we added our case. Patients averaged 40.95 years of age. Discs were paracentral or foraminal in 84% of the cases, with most occurring at the C5-C6 (51%) and C6-C7 (36%) levels. Symptoms included neck pain/radiculopathy (91%) or myelopathy (9%). The average interval between initial presentation and spontaneous regression of herniated discs on MRI was 9.15 months. Interestingly, on MRI, extruded/sequestrated discs were more likely to undergo spontaneous regression versus protruding discs. CONCLUSION: Successive MRI studies documented the spontaneous regression of herniated cervical discs over an average of 9.15 months. Although this may prompt greater consideration for conservative treatment in younger patients without neurologic deficits, those with deficits should be considered for surgery.

Effect of coronavirus disease 2019 pandemic on case volume, spectrum, and perioperative coronavirus disease 2019 incidence in neurosurgical patients: An experience at a tertiary care center in India.

BACKGROUND: The volume and spectrum of neurosurgical procedures being performed during the coronavirus disease 2019 (COVID-19) pandemic have significantly changed as compared to the pre-COVID-19 period. The objective of this study is to examine this change and draw useful conclusions. METHODS: We collected data retrospectively of all patients who attended outpatient clinics and who were operated at our institute under the department of neurosurgery from October 23, 2019, to August 23, 2020. These data were then divided into two groups (pre-COVID period and during the COVID pandemic) and compared. RESULTS: Out of the 388 surgeries performed, 284 surgeries were performed during the pre-COVID period, and 104 surgeries were performed during the COVID pandemic. During this ongoing COVID pandemic, the total number of surgeries performed by the department of neurosurgery decreased significantly by 63.38%, the proportion of routine surgeries performed decreased from 50.35% to 19.23% and the proportion of minor cases increased from 19.72% to 30.77%. The Outpatient Clinic Workflow decreased by 72.3% as compared to the pre-COVID period, and the perioperative COVID-19 reverse transcription-polymerase chain reaction positive incidence in our neurosurgical patients was 11.71%. CONCLUSION: This paper highlights the drastic reduction in the operative workflow and the outpatient clinic workflow during the ongoing corona pandemic which will have significant collateral damages in the long run. We will have to strike the right balance between providing our patients with the best medical treatment while limiting the spread of the COVID-19 infection.

Cervical C7 ganglion cyst causing compressive myelopathy: A rare case report.

BACKGROUND: Juxtafacet cysts, synovial and ganglion cysts, emanate from the facet joints. Patients with these cysts are typically asymptomatic but may rarely present with radiculopathy and/or myelopathy. CASE DESCRIPTION: A 72-year-old female presented with a 1-month history of progressive lower extremity weakness (left more than right), numbness, and urinary incontinence. Notably, she also had a C7 sensory level to pin appreciation of 1-month duration. The magnetic resonance imaging showed an extradural C7 cystic lesion whose capsule enhanced with gadolinium, causing severe cord compression. The patient underwent a left C7 hemilaminectomy for complete excision of the cyst; postoperatively in 2-weeks duration, she regained full neurological function. The final histopathology was consistent with a ganglion cyst. CONCLUSION: Cervical juxtafacet cysts rarely cause compressive myelopathy. They may be readily diagnosed and resected with excellent postoperative outcomes.

Primary angiosarcoma of the skull: A rare case report.

BACKGROUND: Angiosarcomas are rare high grade endothelial tumors characterized by rapidly proliferating anaplastic cells derived from blood vessels and lining irregular blood filled spaces. Primary neoplasms of the skull are rare, representing 2.6% of primary neoplasms of bone. Primary malignant neoplasms of the skull are even rarer, accounting for only 0.8% of primary malignant neoplasms of bone. CASE DESCRIPTION: We report a 32-year-old female who presented with right parieto-occipital swelling, which gradually increased in size. Radiology was suggestive of a calvarial soft tissue lesion in the right parieto-occipital region with destruction of the adjacent parieto-occipital bone with intracranial extra-axial extension. Complete surgical excision of the calvarial lesion was done under general anesthesia. Postoperative computed tomography (CT) scan of brain (plain and with contrast) showed complete excision of the tumor mass. Histopathological diagnosis was consistent with 'an angiosarcoma of the skull'. On immunohistochemistry, the atypical endothelial cells were highlighted by CD34, CD31, and factor VIII-related antigen. The patient received adjuvant radiotherapy to the tumor bed. CONCLUSION: Primary angiosarcoma of the skull is a rare tumor with less than 20 cases reported worldwide till date. The treatment should include complete surgical excision with a wide bony margin followed by adjuvant radiotherapy, which in our case has given a good locoregional control even at the end of 2 years. However, these patients should be followed up with repeated scans yearly to rule out locoregional as well as distant recurrence.