Ganglioneuroma of Glossopharyngeal Nerve in a Patient with Glossopharyngeal Neuralgia: A Case Report.

Ganglioneuroma is a rare tumor. Such tumor arising from cranial nerve is further rare. So far our knowledge, in the literature there is no report of ganglioneuroma involving glossopharyngeal nerve. Here, we report a case of very small glossopharyngeal nerve ganglioneuroma and the patient also had longstanding glossopharyngeal neuralgia (GPN). Case Report: A 40-year-old male diagnosed case of left GPN for last 7 years presented with gradual unresponsiveness of drug for last 5 years. Due to severity of pain sometime, he wished to do suicide. Magnetic resonance imaging (MRI) of head revealed only suspected loop of vessel in root entry zones of 9th and 10 cranial nerves on left side. The patient underwent explorative posterior fossa craniotomy. Careful dissection of arachnoid over 9th cranial nerve near jugular foramen (JF) revealed thick and red color nerve with nodularity (tumor like). Dissection of arachnoid at nerve root entry zones of 9th and 10th nerves also revealed an aberrant loop of posterior inferior cerebellar artery (PICA). The 9th nerve was transected and suspected "tumorous portion" of nerve was sent for histopathological examination. The PICA loop was dissected away from root entry zones by placing muscle and surgical between 10th nerve roots and PICA loop. He made an uneventful recovery. Histopathological examination revealed ganglioneuroma. Immunohistochemistry confirmed ganglioneuroma. Six months after the operation, he was free of symptoms. In this case, probably previously existing GPN was worsen by the growth of ganglioneuroma and surgical treatment brought gratifying result.

Bilateral Accessory C1 and C2 Facet Joints; Clinical, Neuroradiological and Peroperative Findings in an Adult with Quadriparesis

Objectives Accessory C1 and C2 facet joints are very rare. Only few cases were reported in the literature.We report a case of bilateral accessory facets in an adult with special attention to clinical, neuroradiological, as well as peroperative findings. Case report A 37-year-old male presented with progressive quadriparesis. Radiology revealed bilateral posterior accessory C1 and C2 facet joints compressing the spinal cord with craniovertebral junction (CVJ) instability. Both accessory C1 and C2 facets with the posterior arch of the C1 were removed. Lateral mass screws and plates fixation at the C1 and C2 level, as well as fusion, were performed. Postoperatively, the patient recovered well. Conclusion In accessory C1 and C2 facet joints, when symptomatic, neuroradiological findings can guide to the proper diagnosis, to pathological understanding, and, ultimately, to management strategy.

Condylar Joint Fusion and Stabilization (by Screws and Plates) in Nontraumatic Atlanto-Occipital Dislocation: Technical Report of 2 Cases.

BACKGROUND: Nontraumatic spontaneous atlanto-occipital dislocation (AOD) is rare. In this report, we discuss the technical steps of condylar joint fusion and stabilization (by screws and plates) in nontraumatic AOD. To the best of our knowledge, it is the first report of such techniques. MATERIAL AND METHODS: A young girl and a young man with progressive quadriparesis due to nontraumatic spontaneous atlanto-occipital dislocation were managed by microsurgical reduction, fusion, and stabilization of the joint by occipital condylar and C1 lateral mass screw and plate fixation after mobilization of vertebral artery. RESULT: In both cases, condylar joints fixation and fusion were done successfully. CONCLUSION: Condylar joint stabilization and fusion may be a good or alternative option for AOD.

Nonmissile Penetrating Injury to the Head: Experience with 17 Cases.

BACKGROUND: Penetrating nonmissile injuries to the head are far less common than missile penetrating injuries. Here we describe our experience in managing 17 cases of nonmissile injury to the head, likely the largest such series reported to date. We also highlight the surgical steps and techniques used to remove in situ objects (including weapons) in the penetrating wounds that have not been described previously. METHODS: We conducted a retrospective study of cases of nonmissile, low-velocity penetrating injuries of the head managed in our department. The recorded data of patients with penetrating head injuries were studied for the cause of the injury, type of object, type and extent of penetration, Glasgow Coma Scale score on admission, other clinical issues, evaluation and assessment, interval from penetration to operation, surgical steps and notes, difficulty during the operation, major and minor complications, follow-up, and ultimate outcome. RESULTS: Our 17 cases included 6 cases of accidental penetration and 11 cases of penetration as the result of violence. Weapons and other foreign objects causing injury included a teta (a pointed metal weapon with a wooden handle and a barb near the tip, used for hunting and fishing) in 4 cases, a dao (a sharp metal cutting instrument with a wooden handle used for cutting vegetables, fish, meat, bamboo, wood, etc.) in 3 cases, a bamboo stick in 3 cases, a metal rod in 2 cases, a knife in 2 cases, a sharp stone in 1 case, a metal steam chamber cover in 1 case, and a long peg in 1 case. GCS on admission was between 13 and 15 in 15 cases. Only 1 patient exhibited limb weakness. Four patients with an orbitocranial penetrating injury had 1-sided vision loss; 2 of these patients had orbital evisceration, and 1 of these patients died. In 14 patients, the foreign object was in situ at presentation and was removed surgically. Computed tomography scan and plain X-ray of the head were obtained in all patients. Postoperatively, 2 patients (11.7%) needed support in the intensive care unit but died early after surgery. One patient developed late osteomyelitis. The remaining patients were doing well at the most recent follow-up. CONCLUSIONS: The presenting picture of nonmissile penetrating injury to head may be daunting, but these cases can be managed with very good results with proper (clinical and radiologic) evaluation and simple neurosurgical techniques.

Avoidance and management of perioperative complications of endoscopic third ventriculostomy: the Dhaka experience.

OBJECT: Although endoscopic third ventriculostomy (ETV) is a minimally invasive procedure, serious perioperative complications may occur due to the unique surgical maneuvers involved. In this paper the authors report the complications of elective and emergency ETV and their surgical management in 412 patients from July 2006 to October 2012 at Dhaka Medical College Hospital (a government hospital) and other private hospitals in Dhaka, Bangladesh. The authors attempted some previously undescribed simple maneuvers that may help to overcome the difficulties of managing complications. METHODS: The complication rate was determined by recording intraoperative changes in pulse and blood pressure, bleeding episodes, serum electrolyte abnormalities, CSF leakage, and neurological deterioration in the immediate postoperative period. RESULTS: Intraoperative complications included hemodynamic alterations in the form of tachycardia, bradycardia, and hypertension. Bleeding was categorized as major in 2 cases and minor in 68 cases. Delayed recovery from anesthesia occurred in 14 cases, CSF leakage from the wound in 11 cases, and electrolyte imbalance in 5 cases. Postoperatively, 2 patients suffered convulsions and 1 had evidence of third cranial nerve injury. Three patients died as a result of complications. CONCLUSIONS: Complications during endoscopy can lead to serious consequences that may sometimes be very difficult to manage. The authors have identified and managed a large number of complications in this series, although the rate of complications is consistent with that in other reported series. These complications should be kept in mind perioperatively by both surgeons and anesthesiologists, as prompt detection and action can help minimize the risks associated with neuroendoscopic procedures.

Endoscopic assisted microsurgical removal of cerebello-pontine angle and prepontine epidermoid.

Cerebello-pontine(CP) angle and prepontine epidermoid tumors are challenging lesions because they grow along the subarachnoid spaces around the very important neurovascular structures and often extend into the supratentorial compartment. They have typically been removed through a variety of anterolateral, lateral, and posterolateral cranial base microsurgical approaches. Sometime they were removed by the endoscope-assisted microneurosurgical (EAM) techniques. Here we report a CP angle and preontine epidermoid tumor extended to supratentorial compartment presented with trigeminal neuralgia that was removed by pure endoscopic visualization through retrosigmoid retromastoid lateral suboccipital approach. (The method of using endoscope along with surgical instruments passing along the sides of endoscope is termed as Endoscope-Controlled Microsurgery-ECM.) So far our knowledge, in the literature this type of report is probably very rare.

Endoscopic endonasal extended transsphenoidal removal of tuberculum sellae meningioma (TSM): an experience of six cases.

AIMS: Tuberculum sellae meningiomas (TSMs) are usually removed through a transcranial approach. Recently, the sublabial transsphenoidal microscopic approach has been used to remove such tumours. More recently, endonasal extended transsphenoidal approach is getting popular for removal of tuberculum sellae meningioma. Here, we describe our initial experience of endonasal extended transsphenoidal approach for removal of suprasellar meningiomas in six consecutive cases. MATERIALS AND METHOD: Six patients (four female and two male) who presented for headache and visual loss were investigated with MRI of brain that showed tuberculum sellae meningioma compressing visual apparatus. Average size was 3 × 3 cm in three cases and 4 × 4 cm in rest of the three. All patients underwent endoscopic endonasal extended transsphenoidal tumour removal, but in two patients with large tumour, microscopic assistance was needed. Complete tumour removal was done in all cases except one case where perforators seemed to be encased by the tumour and resulted in incomplete removal. The surgical dural and bony defects were repaired in all patients with thigh fat graft. Nasal packing was not used, but inflated balloon of Foley's catheter was used to keep fat in position. RESULT: There was mild postoperative cerebrospinal fluid (CSF) leakage in one patient on the fourth postoperative day after removal of lumbar CSF drain and stopped spontaneously on the seventh postoperative day. There were no postoperative CSF leaks or meningitis in the rest of the cases. In one patient, there was visual deterioration due to pressure on optic nerve by grafted fat and improved within 4 weeks. At 4 months after surgery, three patients had normal vision, two patients improved vision comparing with that of preoperative state but with some persisting deficit; one patient had static vision, no new endocrinopathy and no residual tumour on MRI in five cases but residual tumour in remaining case was static at the end of the ninth month. CONCLUSION: The endoscopic endonasal extended transsphenoidal approach appears to be an effective minimally invasive method for removing relatively small to medium tuberculum sellae meningiomas. With more experience of the surgeon, larger tuberculum sellae meningioma may be removed by purely endoscopic techniques in near future.

Endoscopic endonasal transsphenoidal exposure of circle of Willis (CW); can it be applied in vascular neurosurgery in the near future? A cadaveric study of 26 cases.

AIM: Endonasal transsphenoidal approaches are getting rapidly popular in removing many midline skullbase lesions from crista galli to foramen magnum. For safe removal of these lesions, familiarity with endoscopic endonasal anatomy of circle of Willis is very important. Furthermore, for safe development of this approach in vascular neurosurgery in the near future, endoscopic endonasal exposure of circle of Willis is a fundamental step. The goals in this study were to dissect the circle of Willis completely through the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using fresh cadaveric specimens. MATERIAL AND METHODS: After obtaining ethical clearance, 26 fresh cadaver heads were used without any preparation. Using a neuroendoscope, complete exposure of the circle of Willis was done endonasaly, and various observations including relation of circle of Willis was recorded. RESULTS: Complete exposure of the circle of Willis was made through an endonasal approach in all cases without injuring surrounding structures. CONCLUSION: Endoscopic endonasal extended transsphenoidal exposure of CW can make the surgeon more efficient in removing midline skullbase lesions with safe handling of different parts of circle of Willis and it may help in development of endonasal endoscopic vascular neurosurgery in the near future.