Spinal Intradural Extramedullary Ependymoma with Intracranial Metastasis and Leptomeningeal Spread: A Case Report and Comprehensive Review of Literature.

Dorsolumbar intradural extramedullary ependymoma is a rare entity. Spinal metastases in patients with intracranial ependymoma are well described, but it is extremely rare for a spinal ependymoma to metastasize to brain. We describe a case of aggressive dorsolumbar intradural extramedullary ependymoma mimicking arachnoid cyst radiologically, which developed intracranial metastasis.

Neurogenic Fever in Severe Traumatic Brain Injury Treated with Propranolol: A Case Report.

The causes of intractable fever in severe traumatic brain injury (TBI) patients can be diverse. Neurogenic fever (NF) which is a rare entity can develop due to autonomic dysregulation in the absence of infection or any other cause of fever. It manifests as fever, tachycardia, paroxysmal hypertension, dilated pupils, tachypnea, and extensor posturing in cases of severe TBI, brain neoplasms or brain haemorrhage. We found propranolol to be effective in controlling many of the manifestations of neurogenic fever in our patients with severe TBI. Fever in severe TBI patients is not an uncommon phenomenon, but when intractable with negative fever workup, a central cause should be considered. Propranolol is deemed as one of the most efficacious drugs for managing NF due to dysautonomia. We want to apprise the readers about this entity and its treatment with beta-blockers.

Craniovertebral junction evaluation by computed tomography in asymptomatic individuals in the Indian population.

BACKGROUND: The available literature on the anatomy and imaging of the craniovertebral junction (CVJ) focusses on the osteometric indices described for the detection of abnormal relationships between the components of CVJ. However, a knowledge of the normal osteometry of this region in the Indian population is critically important for the operating surgeon as it may influence the surgical technique as well as the choice, size and configurations of the implants. It is also important to determine whether critical differences exist between the osteometric data of Indians and the rest of the world for this part of the anatomy. Accordingly, the present study is an attempt to quantitate the osteometric indices for the anatomically normal CVJ in Indian subjects. MATERIALS AND METHODS: We retrospectively studied the imaging data of 49 consecutive adult patients (31 males, 18 females) who underwent a computed tomographic (CT) angiogram for suspected vascular conditions unrelated to the craniovertebral junction. Several parameters related to the atlanto-dental relationship, foramen magnum, atlas and axis vertebrae were recorded, including the dimensions of the commonly instrumented bony regions and also the indices related to the CVJ bony relationships. The data was also compared between the two genders, statistically through the Student's t-test using the statistical program "R". RESULTS: No patient had an atlanto dens interval >2.5 mm. The mean distance of the odontoid tip from the McRae line in this series was 5.11 mm and no patient had the odontoid tip above the McRae line. Female subjects had significantly smaller diameters of C1 lateral masses and odontoid screw trajectory length when compared to males. Additionally, in the Indian population, the length range of odontoid screw trajectory and the thickness of the narrowest part of the C2 pedicles was smaller with respect to similar data from other geographical regions. However, the rest of the parameters resembled the data from studies conducted on populations with other ethnicities. CONCLUSION: The osteometric parameters of the CVJ in the Indian population are largely similar to those described globally. However, there are some important differences too which can influence the design of surgical implants suited to the Indian population.

Comparison of Stereotactic and Ultrasound-guided Biopsy of Solid Supratentorial Tumor: A Preliminary Report.

INTRODUCTION: The computed tomography (CT) guided stereotactic biopsy (STB) is considered as method of choice for biopsy of intracranial mass lesions. However, it's disadvantages are frame fixation, time requirement for transportation between CT scan suit to the operation theater with added much higher equipment cost in the relatively resource scarred developing country. Ultrasound-guided biopsy (USGB) is relatively simpler, economical, less time consuming, and real-time procedure. CLINICAL MATERIALS AND METHODS: Thirty-seven consecutively admitted patients with supratentorial brain tumors, who underwent biopsy of the lesion using CT compatible stereotactic and ultrasound-guided (USGB) procedure formed cohort of the study. Based on location and size of the lesions, the cases were divided into two groups, superficial and deep. Twenty-two patients underwent ultrasound-guided biopsy and 15 with STB. RESULTS: The diagnostic yield of STB was 93% and 91% for ultrasound-guided biopsy. The mean operation time of STB group was 149.00 min and 94 min for USGB, which was statistically significant. Two cases in each group developed hematoma; however, one case in USGB group needed surgical evacuation. The real-time monitoring detected two hematoma intraoperatively, which were further also confirmed on postoperative CT scan head. CONCLUSIONS: The ultrasound-guided biopsy procedure (USGB) was simple, relatively shorter time-consuming procedure and equally efficacious and utilizing economical equipment and can act as a safer alternative to CT STB process for biopsy of the intracranial mass lesion. Furthermore, USGB also provided intra-operative real-time monitoring, which provided clue for close monitoring in the postoperative period after completion of biopsy to look for development of fresh hematoma development not only at the biopsy site but also along the biopsy track and adjoining area. Perhaps, a longer period of ultrasonic monitoring following the procedure would be of greater help to detect hematoma formation, which is one of the most common complications of the biopsy procedure.

Evaluation of Correction of Radiologic Parameters (Angulation and Displacement) and Accuracy of C2 Pedicle Screw Placement in Unstable Hangman's Fracture with Intraoperative Computed Tomography-Based Navigation.

BACKGROUND: Opinions vary regarding optimal treatment of unstable hangman's fractures, including rigid orthosis and internal fixation. The anatomy of upper cervical spine is complex. The advent of intraoperative 3-dimensional navigation systems facilitates safe and accurate instrumentation. OBJECTIVE: To evaluate radiologic parameters of fracture morphology in unstable hangman's fracture in preoperative and postoperative period and accuracy of inserting axis pedicle screws by using intraoperative computed tomography-based navigation. METHODS: Fifteen patients with unstable hangman's fractures with age ranging from 17 years to 81 years were operated using computed tomography-based navigation from September 2011 to march 2016. Patient's age, sex, mechanism of injury, associated injuries, and neurologic status were noted. Clinical outcome, accuracy of screw insertion, preoperative and postoperative displacement, and angulation of C2 over C3 and bony fusion were assessed. RESULTS: Overall, 76 screws were inserted including 30 screws in C2 pedicle with 2 (2/60; 6.7%) malplaced screws in C2 pedicle. Mean follow-up period was 34 ± 18 months (range 7-80 months). Mean hospital stay was 12.8 ± 2.4 days. Mean preoperative and postoperative displacements were 4.09 mm ± 1.78 mm and 1.82 mm ± 1.14 mm respectively with a mean reduction of 2.27 mm ± 1.49 mm. Mean preoperative angulation was 7.23° ± 11.96° and postoperative angulation was 2.32° ± 4.77° with a mean reduction of 5.11° ± 11.96°. Bony fusion was achieved and rotation was preserved at C1-C2 joint in all cases. CONCLUSIONS: Intraoperative O-arm-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable hangman fracture and achieves good anatomical reduction.

Giant Bicompartmental Cystic Tentorial Schwannoma Mimicking a Meningioma.

BACKGROUND: Intracranial schwannomas most commonly arise from the vestibulocochlear nerve and less frequently from trigeminal, facial, and hypoglossal nerves. Intracranial schwannomas unrelated to cranial nerves are very rare; only approximately 50 cases have been reported in the literature. Tentorial schwannoma (TS) is even rarer, with only 13 cases reported to date. We present a rare case of giant TS. CASE DESCRIPTION: A 21-year-old man presented with generalized headache and dizziness for the past 6 months and worsening of symptoms for the past 2 months. On evaluation, he was found to have a cystic lesion arising from the right tentorium with multiple internal septa and fluid levels, with both supratentorial and infratentorial extension. The presence of a dural tail sign and tentorial origin led us to make a preoperative diagnosis of tentorial meningioma. The patient underwent complete excision, and a diagnosis of TS was made based on histopathologic analysis. CONCLUSIONS: TSs are extremely rare. Knowledge of radiologic and morphologic features can be helpful in making a preoperative diagnosis. The dural tail sign, which is considered a characteristic feature of meningioma, is commonly seen in TS as well, and thus TS should always be considered in the differential diagnosis of lesions arising from the tentorium.

Microvascular decompression for hemifacial spasm: A systematic review of vascular pathology, long term treatment efficacy and safety.

INTRODUCTION: Hemifacial spasm (HS) is a rare disorder caused by the compression of facial nerve root exit zone (REZ) at the brainstem by a vascular loop. Microvascular decompression (MVD) is a popular treatment modality for HS. OBJECTIVE: The purpose of this study was to determine the long-term efficacy and safety of MVD for HS by assessing the effect of the procedure from the literature published over the last 25 years. MATERIALS AND METHODS: A systematic data review from 1992 to 2015 using specific eligibility criteria yielded 27 studies on MVD for HS, the data of which were pooled and subjected to a meta-analysis. RESULTS: The pooled odds ratio (OR) revealed by the meta-analysis showed that anterior inferior cerebellar artery was the most common offending vessel in 37.8% (95% confidence interval [CI]: 27.8-47.7%) of the patients. Complete resolution of HS was seen in 88.5% (95% CI: 86.7-90.4%) of the patients after a long-term follow up. The complication rate was low following MVD, the most common being temporary facial paresis in 5.9% (95% CI: 4.3-7.5%) of patients. CONCLUSIONS: MVD is a safe and effective treatment for HS with long-term benefits and a low complication rate.

Randomized trial for superiority of high field strength intra-operative magnetic resonance imaging guided resection in pituitary surgery.

Till date there are no randomized trials to suggest the superiority of intra-operative magnetic resonance imaging (IOMRI) guided trans-sphenoidal pituitary resection over two dimensional fluoroscopic (2D-F) guided resections. We conducted this trial to establish the superiority of IOMRI in pituitary surgery. Primary objective was to compare extent of tumor resection between the two study arms. It was a prospective, randomized, outcome assessor and statistician blinded, two arm (A: IOMRI, n=25 and B: 2D-F, n=25), parallel group clinical trial. 4 patients from IOMRI group cross-over to 2D-F group and were consequently analyzed in latter group, based on modified intent to treat method. A total of 50 patients were enrolled till completion of trial (n=25 in each study arm). Demographic profile and baseline parameters were comparable among the two arms (p>0.05) except for higher number of endoscopic procedures and experienced neurosurgeons (>10years) in arm B (p=0.02, 0.002 respectively). Extent of resection was similar in both study arms (A, 94.9% vs B, 93.6%; p=0.78), despite adjusting for experience of operating surgeon and use of microscope/endoscope for surgical resection. We observed that use of IOMRI helped optimize the extent of resection in 5/20 patients (25%) for pituitary tumor resection in-group A. Present study failed to observe superiorty of IOMRI over conventional 2D-F guided resection in pituitary macroadenoma surgery. By use of this technology, younger surgeons could validate their results intra-operatively and hence could increase EOR without causing any increase in complications.

Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review.

Calcified chronic subdural hematomas are an occurrence rarely seen in neurosurgical clinical practice. And when they occur bilaterally, the radiologic image they present is fascinating, as is the clinical presentation, but their management may be challenging. They have been reported to present with a multitude of neurologic deficits but never with diabetes insipidus, which is described here. Due to the rarity of this pathology, the management protocol is not well defined, though there have been quite a few papers on this condition. This review article gathers information published over the years on this rare entity to suggest a treatment protocol.

Intracranial germ cell tumors: a multi-institutional experience from three tertiary care centers in India.

OBJECTIVE: Central nervous system germ cell tumors (CNS GCTs) are relatively rare neoplasms. Incidence of CNS GCTs in Western literature is low (0.3-0.6 %) as compared to East Asia (3-4 %). No large study is available on CNS GCTs from India. METHODS: Intracranial GCT cases were retrieved from databases of three tertiary care institutes in India; clinicopathological data was reviewed. RESULTS: Ninety-five intracranial GCT cases were identified, accounting for 0.43 % of CNS tumors. Median age was 12 years (range, birth to 48 years); male preponderance was noted (66 %). Most patients (86.3 %) were aged <18 years. Pineal location was most common (45 %) and was associated with male gender and age >14 years. Germinoma was the commonest histopathological type (63.2 %), followed by teratoma (20 %). Suprasellar location was associated with germinoma histology. Follow-up was available for 71 patients (median, 15 months). Of these, 48 received adjuvant chemotherapy and/or radiotherapy. At the last follow-up, 44 patients showed no evidence of disease. Age >10 years, male gender, pineal location, and germinoma histology were associated with favorable outcome. CONCLUSION: This is the first multicentric study from India establishing that incidence of CNS GCT in India is similar to that in the West and differs from that in East Asian countries. However, similar to both, germinoma is the commonest histological type, and pineal location is most frequent. Studies on molecular alterations based on ethnicity and geographical location are necessary to provide clarity on differences in incidence. Attention needs to be focused on decreasing treatment heterogeneity and minimizing treatment-related morbidity and mortality, improving the cure rate of these highly treatable tumors.

The Role of Endoscopic Lavage in Recalcitrant Multidrug-Resistant Gram-Negative Ventriculitis Among Neurosurgical Patients.

INTRODUCTION: Ventriculitis is a serious infection associated with high mortality even when both intravenous (IV) and intrathecal (IT) antibiotics are administered. Poor outcome in patients with ventriculitis indicates the need to be more aggressive in our attempts to expeditiously eradicate the infection. The purpose of this study was to evaluate the role of endoscopic lavage (EL) in patients with severe purulent ventriculitis, unresponsive to IV and IT antibiotics. METHODS: All consecutive patients with severe ventriculitis caused by multidrug-resistant gram-negative bacteria, undergoing EL after failure of prolonged courses of IV and IT antibiotics, were included in the study. The outcome in all these patients was otherwise expected to be uniformly dismal. RESULTS: There were 5 males and 2 females. The age range was one month to 45 years. All patients had frank intraventricular pus. Acinetobacter baumannii was the most common organism grown in cultures. Two patients had multiple bacterial growth in cerebrospinal fluid cultures. The duration of pre-EL IV/IT antibiotics ranged from 3 to 8 weeks. Microbiological cure was achieved in all (7/7) and clinical cure in 86% of patients (6/7). One patient died despite achieving cerebrospinal fluid sterilization 3 months later as a result of progressive white matter edema. CONCLUSIONS: The addition of IT antibiotics has resulted in improved outcome in patients with ventriculitis; however, some patients continue to be unresponsive to antibiotics. EL can play a complementary role in eradicating such recalcitrant infections. EL should be considered in any patient with ventriculitis, if infection persists even after ∼7-10 days of IVand IT antibiotics.