Spinal Tuberculosis: An Exhaustive Diagnosis.

BACKGROUND: The most common organ affected due to tuberculosis (TB) is the lungs. Extrapulmonary TB is less common. Musculoskeletal organs are affected in around 8% of all tubercular patients, of which the spine is affected in almost half of the patients. The criteria for diagnosing spinal TB are quite difficult and we use an array of investigations for the same. METHODS: A retrospective study was carried out in the Neurosurgery and Microbiology Department at IMS and SUM Hospital between January 2021 and November 2023, and data were collected and tabulated in an Excel sheet. One hundred patients with spinal TB were evaluated, and their age, sex, samples sent, diagnostic investigation, duration of diagnosis from hospital admission, histopathology results, and surgical intervention (done or not) were recorded. RESULTS: The best investigation done to diagnose spinal TB was imaging and surgical/computed tomography (CT)-guided biopsy. The earliest result to diagnose spinal TB was histopathology. The yield of positivity in pus culture, smear microscopy, and true nucleic acid amplification test (NAAT) was found to be low even though sensitivity was on the higher side. CONCLUSION: Even though we have an array of investigations for diagnosing spinal TB, the best and the earliest diagnosing test was imaging plus CT-guided biopsy. The confirmation is made in the biopsy. Finding acid-fast bacteria (AFB) and NAAT tests are additional beneficial tests to supplement the diagnosis. Hence, we can conclude that sending for tests like AFB in pus, NAAT, and GeneXpert is a wastage of biological samples and delays in diagnosis.

Pulsatile giant sacrococcygeal teratoma appearing like 2nd head.

Sacrococcygeal teratoma is a congenital tumor of early infancy. Eighty percent are present in the first month of life. It is considered to be an extragonadal germ cell tumor that can be diagnosed in utero. It is considered to be a rare tumor in infancy and childhood. Incidences in girls are more common as compared to boys. Association with other congenital abnormalities of the gastrointestinal system, cardiovascular system, and urological manifestations may be present. Association with spinal dysraphism may be present. A complete systemic evaluation needs to be done before any surgical intervention. We hereby present you a case of a 5-day-old male child, born from a non-consanguineous marriage, who presented to us with a large swelling at the coccygeal region. The mass had a variegated consistency with an ear-like appendage over it with associated hair, bones, and necrotic tissue in it. The patient was evaluated with imaging (MRI) which revealed a heterogeneously enhancing mass at the sacrococcygeal region with mild extension into the pre-sacral space suggesting sacrococcygeal teratoma. After a complete evaluation for congenital abnormal abnormalities of other sites, gross total excision of the mass was performed. The post-operative condition of the baby was uneventful. A biopsy of the mass revealed a mature cystic teratoma. The baby is under follow-up at present.

Role of prophylactic surgery in spinal tuberculosis: A retrospective study from Eastern India.

Background: Tuberculosis (TB) is broadly classified into pulmonary and extrapulmonary TB. Skeletal TB is considered to be a form of extrapulmonary TB whose incidence is around 1% of all forms of TB. The incidence of spinal TB is more than 50% of the entire skeletal TB. Methods: A total of 92 consecutive patients, treated over a period of 2 years (January 2021-January 2023), are retrospectively analyzed. Results: In our study, out of 92 patients, the pain had subsided in 90% of cases, and 12 patients showed improvement in motor power postoperatively. In our study, the patients have benefited due to the surgical intervention in decrease of pain and improvement in motor deficits in patients. The 29 patients who were operated on prophylaxis with pain as the only symptom benefitted from the resolution of the symptom of pain and did not develop any morbidity in their long-term follow-up. The sensory and bladder/bowel symptoms did not improve after surgery. Conclusions: In the author's view, prophylactic surgery for spinal TB is safe and effective with confirmation of the disease. However, a well-designed randomized controlled trial, to definitely and objectively prove the usefulness of prophylactic surgery, is needed.

Cerebral Myiasis Secondary to Burr Hole Evacuation: A Rare Illustrative Case Report.

Myiasis (maggot infestation) is a condition in which fly maggots feed off and develop in the tissues of living organisms. Most common in tropical and subtropical regions, human myiasis, is prevalent among individuals in close association of domestic animals and those inhabiting the unhygienic conditions. We, hereby, describe a rare case of cerebral myiasis (17th in the world, 3rd in India) that presented to our institution in Eastern India secondary in the operated site of craniotomy and burr hole few years back. Cerebral myiases are exceedingly rare conditions, especially in high-income countries with only 17 previously published cases with the reported mortality as high as 6 out of 7 cases dying of the disease. We additionally also present a compiled review of previous case literatures to highlight the comparative clinical, epidemiological features and outcome of such cases. Although rare, brain myiasis should be a differential diagnosis of surgical wound dehiscence in developing countries where conditions do exist in this country that permit myiasis. This differential diagnosis should be remembered, particularly when the classic signs of inflammation are not present.

Pedunculated Chiari 3 malformation with proatlas defect.

Chiari III malformation is considered to be a rare congenital abnormality in human with very high mortality rates. Seventy percent of Chiari III is found to be associated with C1 arch defect as reported by Cakirer (Clin Imaging 27:1-4, 2003). The herniation of posterior fossa elements or dysplastic neural tissue is a must to stamp it as Chiari 3 malformation. The malformation is a result of the abnormal development of craniovertebral junction (CVJ). The CVJ developed from the occipital somites and the first spinal sclerotome. The major role in the development of the CVJ is played by the fourth occipital somite, which is otherwise known as "proatlas." The Chiari III anomalies are due to a result of proatlas defect, which results from failures of segmentation, failures of fusion of different components of each bone, or hypoplasia and ankylosis. We are presenting a case of a 1-year 4-month-old female child who presented with pedunculated swelling at the suboccipital region. The swelling was cystic and with pulsation. On evaluation, we found Chiari III anomaly with C1 posterior arch deficiency (proatlas defect). He was surgically managed. The outcome of the patient was good. Despite literature concluding Chiari 3 malformation with an unfavorable outcome, however, meticulous management and good pre- and postoperative care, physical therapy, and follow-up are necessary for good outcome.

Complete intraventricular migration of ventriculo-peritoneal shunt: A rare case report.

INTRODUCTION AND IMPORTANCE: A ventriculoperitoneal (VP) shunt is a cerebral shunt used to treat hydrocephalus. This is used to remove the excessive accumulation of cerebrospinal fluid inside the ventricles. CASE PRESENTATION: We are reporting a rare case of complete intracranial migration of a ventriculoperitoneal shunt, a potentially fatal complication, presenting to us with hydrocephalous. The baby was taken up for surgery with endoscopic assisted shunt removal and shunt revision. CLINICAL DISCUSSION: Ventriculoperitoneal shunt is one of the common procedures used in infants and children, however, it is used in all age groups for hydrocephalous. The shunt is associated with multiple large number of complications like obstruction, infection, migration, and separation from the connected site. Etc. Shunt migration is a less common complication of which cranial migration is still less common. CONCLUSION: Optimum creation of the sub-galeal space for the shunt chamber, a smaller burr hole, a smaller dural opening, and proper anchorage of the chamber to the pericranium, are some of the measures that may be useful in obviating this complication.

The Keyhole Approach in Anterior Circulation Aneurysm - Current Indication and Limitation with Review of Literature.

INTRODUCTION: The keyhole approach has been an emerging technique for cerebral aneurysm surgery in the past two decades. The preoperative simulation and tailored-made approach for each patient make feasible to clip many cerebral aneurysms via keyhole approach. In our study, we reviewed the previous experiences of the keyhole approach, related specifically for anterior circulation aneurysm. MATERIAL AND METHODS: The comprehensive literature review was performed on PubMed, Google Scholar, ScienceDirect, and various neurosurgery and neurology journals. Then, each manuscript's reference list was reviewed for the potential relevant article. The data of total 17 articles, which met our inclusion criteria included for the final review. RESULTS: It was found that the anterior communicating artery, middle cerebral artery, and internal carotid- posterior communicating aneurysms were the most common locations treated by keyhole approach. The size of an aneurysm was <10 mm in most of the studies. Many studies treated multiple aneurysms by single keyhole approach. CONCLUSION: The keyhole approach has shown benefit in term of satisfactory aneurysmal occlusion rate, short operative time, less blood loss, short hospital stay, and good overall surgical outcome.

Mechanical Thrombectomy for Cerebral Venous Sinus Thrombosis: A Case Series and Technical Note.

BACKGROUND: Cerebral venous sinus thrombosis is a rare cause of acute stroke. It may lead to hemorrhagic venous infarctions, brain swelling, or raised intracranial pressure and can be associated with significant mortality and morbidity. Low-molecular-weight heparin is the mainstay of treatment. Endovascular treatment is reserved for patients who deteriorate despite medical management. METHODS: Retrospective evaluation of our institutional databases from 2018-2019 revealed 7 patients who underwent aspiration thrombectomy using large-bore aspiration catheters for recanalization of the dural sinuses with or without intrasinus thrombolysis during the procedure. Their clinical, imaging findings, endovascular technique, and outcome are discussed. RESULTS: We treated 7 patients who did not respond to best medical management. Aspiration thrombectomy was the primary mode of endovascular treatment. Adjuvant low-dose (10 mg recombinant tissue plasminogen activator), short-duration (20-minute) intrasinus thrombolysis was used in 4 patients only during the procedure. Headache was the most common symptom, followed by seizures, focal neurologic deficits, and vomiting. There was improvement in clinical condition within 24 hours of procedure in all patients. The 30-day modified Rankin Scale score was 0 in 6 patients. One patient had residual hemiparesis and aphasia. There were no procedure-related complications. CONCLUSIONS: The described technique appears to be simple, safe, and effective and results in a relatively short procedure time in achieving complete or partial recanalization of the dural sinuses in patients who deteriorate despite clinical management. Endovascular thrombectomy along with conventional medical management restores the final drainage pathway of the brain with good clinical outcome.

Interhemispheric Approach to Anterior Communicating Artery Aneurysm: A Case Illustration.

There are two main types of approaches for anterior communicating artery (AcomA) aneurysms, namely pterional approach, and an interhemispheric (IH) approach. Pterional approach is the most common for anterior circulation aneurysms. However, this approach cannot be used without resection of gyrus rectus when aneurysm is located high within the IH fissure and directed posterosuperiorly, which is better handled with IH approach. In this article, we will describe the tricks of IH approach with a case illustration.

A 5-Year Follow-up of Intracranial Arterial Dolichoectasia: A Case Report and Review of Literature.

A patient with multiple dolichoectasia of the intracranial cerebral artery was followed sequentially with clinical and radiological progression of disease in the past 5 years. The patient was treated in multiple stages in the past 5 years with the endovascular and microsurgical clipping method. The maximum diameter of each major intracranial artery segment was recorded and compared in the follow-up year. The progression in size of the dolichoectatic segment was observed in spite of surgical intervention. In review diagnostic criteria, etiopathogenesis and treatment options have been discussed.

Development of contralateral extradural hematomas after evacuation of primary one.

The occurrence of bilateral extradural hematomas (EDH) is an uncommon consequence of closed head injuries. Incidence of bilateral EDH has been reported in various studies ranging from 2 to 25%. Bilateral EDH may develop simultaneously or second EDH develops few hours after first one. Development of second EDH after evacuation of primary one is rarely seen. We are reporting one such case. Awareness of this entity is required to detect such cases as timely intervention gives an excellent result like an acute EDH.

Transorbital penetrating brain injury by a wooden stick: A neuro-ophthalmologic emergency.

Accidental penetrating brain injury through transorbital route is an unusual occurrence in emergency practice of civilian cases. At time, it could be potentially life threatening. We report an interesting case of transorbital penetrating brain injury with a wooden stick in a 44-year-old male epileptic patient. The stick was removed successfully through transorbital exploration, without any neurovascular complications. The pertinent literature is reviewed and emergent management of such cases is discussed.

Intracerebellar haemorrage in a haemophilia child.

Hemophilia A is an inherited, X-linked, recessive disorder caused by deficiency of clotting factor VIII. Intracranial hemorrhage is the leading cause of morbidity and mortality in these patients. Use of factor replacement products and medications had improved outcome in these patients. But in developing countries many such patients are not able to afford factor replacement products. We report a case of traumatic intracerebellar hemorrage in a hemophilia child. This child presented to us as a case of sub-acute intracerebellar hemorrage, he was managed conservatively with six units of fresh frozen plasma transfusion. He improved clinically and on follow-up investigation hematoma was found to have dissolved spontaneously. Through this report we want to emphasize that those cases of hemophilia presenting with acute or sub-acute intracranial bleed, conservative approach through procoagulant transfusion and intravenous fibrinolysis inhibitors should be tried as first line of management. Before daring for surgery sufficient amount of factor replacement should be kept available.

Isolated thoracic (D5) intramedullary epidermoid cyst without spinal dysraphism: A rare case report.

Spinal epidermoid cyst, congenital or acquired, is mainly congenital associated with spinal dysraphism, rarely in isolation. Intramedullary epidermoid cysts (IECs) are rare with less than 60 cases reported so far; isolated variety (i.e., without spinal dysraphism) is still rarer. Complete microsurgical excision is the dictum of surgical treatment. A 14-year-old boy presented with 4-month history of upper backache accompanied with progressive descending paresthesia with paraparesis with early bladder and bowel involvement. His condition deteriorated rapidly making him bedridden. Neurological examination revealed upper thoracic myeloradiculopathy probably of neoplastic origin with sensory localization to D5 spinal level. Digital X-ray revealed no feature suggestive of spinal dysraphism. Contrast magnetic resonance imaging (MRI) characteristics clinched the presumptive diagnosis. Near-total microsurgical excision was done leaving behind a small part of the calcified capsule densely adhered to cord. Histopathological features were confirmative of an epidermoid cyst. Postoperatively, he improved significantly with a gain of motor power sufficient to walk without support within a span of 6 months. Spinal IECs, without any specific clinical presentation, are often diagnosed based upon intraoperative and histopathological findings, however early diagnosis is possible on complete MRI valuation. Complete microsurgical excision, resulting in cessation of clinical progression and remission of symptoms, has to be limited to sub-total or near-total excision if cyst is adherent to cord or its confines.

Primary hydatid cyst of brain: Two cases report.

Brain involvement with hydatid disease occurs in 1-2% of all Echinococcus granulosus infections. Isolated cerebral hydatid disease is a rare manifestation of it. In this report, we analyze two cases of isolated cerebral hydatid cysts and discuss their mode of presentation, radiological features, operative procedure and outcome. In our two cases, radiological features and surgical approaches were different from one another. The literature concerning isolated cerebral hydatid disease is reviewed.

Management of superior sagittal sinus injury encountered in traumatic head injury patients: Analysis of 15 cases.

BACKGROUND: Significant dural sinus injury occurs in 1.5- 5% of all head injuries and injury to superior sagittal sinus accounts for 70-80% of these. Its management is also a challenging issue to every neurosurgeon. MATERIALS AND METHODS: In a period of one year (Aug 2011 to july2012) out of 549 cases of head injuries operated in our department analysis of 15 cases (2.73%) shown to have superior sagittal sinus injury. Three dimensional reconstruction of skull bone during CT scan helped us to diagnose possible dural sinus injury pre-operatively. RESULTS: SSS injury was due to direct impact of fracture segment (5 cases), extension of fracture line over sinus area (4 cases) or due to coronal suture diastases (6 cases). Injury to anterior third of sagittal sinus occurred in 12 cases (80%) and injury to middle third occurred in 3 cases (20%). Small tear over superior sagittal sinus was found in 7 cases (46.66%) and was managed with Gelfoam(®) compression only and in two cases (13.33%) were large tear, which was managed with sinoraphy. In four cases (36.34%) hitch stitches over Gelfoam(®) to adjacent bone given and in rest two cases (13.33%) a strip of bone was left over the sinus area and bilateral hitch stitches were applied. CONCLUSION: Injury to SSS in traumatic head injury patient though rarely encountered during surgery, the management is challenging to every neurosurgeon. Preoperative suspicion and combination of surgical techniques rather than one single technique may be effective in decreasing the sinus related mortality rate.

Large vertex meningoencephalocele with schizencephaly: An interesting case with neurosurgical challenge.

An encephalocele is a developmental disorder of neural tube closure, where as schizencephaly is a developmental disorder of neuronal migration. There are only few case reports suggesting association of schizencephaly with meningoencephalocele. We report a case of 6-year-old child who was brought by her parent with complaints of progressive swelling over her vertex since birth, left sided hemiparesis and intermittent generalized tonic clonic convulsion for last 3 years. Clinical examination, computed tomography (CT) and magnetic resonance imaging (MRI) of brain revealed a large calvarial defect with meningoencephalocele and associated schizencephaly. Initially, ventriculoperitoneal (VP) shunt was carried out, followed by successful repairing of the defect. This case is interesting for late presentation, management difficulties and associated anomalies "schizencephaly", which is a rare developmental disorder.