Management of a rare case of intraventricular ruptured dermoid cyst and chemical meningitis.

INTRODUCTION: Intraventricular dermoid cyst are very rare benign tumour. Due to benign nature, it may go un-noticed for years and might present with sudden rupture. Ruptured cyst can cause chemical meningitis, hydrocephalus, seizures etc. Due to lack of data, there are no defined guidelines about its management. We are reporting an interesting case of ruptured intraventricular dermoid cyst and chemical meningitis, who was managed successfully and will review the literature. CASE REPORT: A 48 years male patient was brought with complaint of sudden mental deterioration, irritability, headache, vomiting for 3 days. He had history of seizures for 1 year. On examination, his higher mental functions were deteriorated, had neck rigidity and left lower limb weakness. CT/MRI brain confirmed diagnosis of right frontal horn ruptured dermoid cyst with scattered fat droplets, hydrocephalus and ventriculitis. Excision of cyst was done via right trans-sulcal (superior frontal sulcus) approach. Patient recovered well. DISCUSSION: Intraventricular dermoid cyst are a rare benign lesion. Due to potential of rupture, it must be surgically treated. Steroids should be used to treat chemical meningitis. Various individual case reports have shown good outcome after surgical management. CONCLUSION: We recommend early surgery, thorough ventricular wash with ringer lactate, post-operative extraventricular drain and steroid cover to manage ruptured cyst and chemical meningitis.

Ring graft technique for microvascular decompression.

INTRODUCTION: Various nerve compression syndromes, such as trigeminal neuralgia (TN), glossopharyngeal neuralgia (GN), and hemifacial spasm (HFS), are caused by compression of the concerned nerve by the adjacent vessel. Patients who do not respond to medical management are usually treated by "microvascular decompression (MVD) of the nerve." Teflon patch graft is the most commonly used material for MVD. This graft has been used in various shapes like a patch, in the shredded form, or as a sling. This is done to prevent recurrence because of graft failure. We used a teflon ring graft to perform a successful MVD in 10 patients. MATERIAL AND METHODS: Out of 10 cases, 6 cases were of TN, 2 of HFS, 1 of GN, and 1 case was of cochleovestibular nerve compression syndrome (CNCS). After MVD, every patient underwent a follow up assessment for 5 years. RESULTS: There was no major postoperative complication, except in the patient with CNCS who suffered from a temporary episode of facial palsy. All cases were symptom free at a follow-up duration of equal to or more than 5 years. CONCLUSION: Ring teflon graft may be used as an alternative as well as a safe method to perform MVD and has a good success rate.

Intraventricular Tuberculoma in a Child: A Rare Location.

Intracranial tuberculoma is an uncommon presentation of tuberculosis, and its occurrence in an intraventricular location is very rare. It is usually confused with glioma, parasitic cyst, and craniopharyngioma. Few case reports exist in the literature on this entity. We report a case of tuberculoma at the foramen of Monro in a 7-year-old child and review the literature in terms of diagnostic dilemma.

Assessment of surgical risk factors in the development of ventilator-associated pneumonia in neurosurgical intensive care unit patients: Alarming observations.

BACKGROUND: Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in patients receiving mechanical ventilation (MV) and contributes to a longer intensive care unit (ICU) stay, duration of MV, and a high morbidity and mortality. OBJECTIVE: The purpose of study was to determine the incidence of VAP in neurosurgery ICU patients and to assess the probable contributing neurosurgical risk factors like the site and nature of the lesion in the brain, the duration of surgery, blood loss during surgery, and infection elsewhere in the body, in the development of VAP. MATERIALS AND METHODS: The prospective clinical study included patients with a Glasgow Coma Scale (GCS) score>8 undergoing a neurosurgical procedure and postoperatively receiving MV for> 48 hours, who were followed for the development of VAP. The diagnosis of VAP was in accordance with the Centers for Disease control (CDC) guidelines and was confirmed with a positive quantitative culture in the endotracheal tube aspirate samples. RESULTS: The incidence of VAP in our study was 70%. Aneurysmal subarachnoid hemorrhage (SAH) [Grade 3, 4 and 5] was the most common underlying condition followed by posterior fossa surgery, and surgery of the craniovertebral junction and cervical spine. Patients with a supratentorial compartment etiology had a slightly higher incidence (53%) of VAP as compared to the infratentorial compartment one. Patients with significant intraoperative blood loss and receiving blood transfusion had a higher incidence of pulmonary complications. Acinetobacter baumannii was the most common pathogen isolated followed by Pseudomonas aeruginosa, with high resistance trends being prevalent among the commonly used antibiotics in the ICU. CONCLUSION: The incidence of VAP is high. Patients of aneurysmal SAH are at higher risk and VAP is as common in patients with supratentorial lesions as in those with infratentorial pathologies. The increase in resistance to the commonly used antibiotics is a cause for concern. Efforts should be taken to evolve more effective preventive measures.

An Alternate Vista in Rehabilitation of Cranial Defects: Combining Digital and Manual Techniques to Fabricate a Hybrid Cranioplast.

The desired features of a cranioplast include providing an acceptable contour, continuity with the remaining skull (marginal adaptation), improvising the aesthetic outcome, providing a strengthened prosthesis to avoid fracture in case of repeat trauma, and protecting the remaining neurological structures. Combining digital and manual techniques to fabricate a hybrid polymethylmethacrylate cranioplast during the rehabilitation of a pediatric patient with cranial defect has been described. Utilization of digital techniques (rapid prototyping to obtain skull analog) and manual (hand) sculpting of the prosthesis strengthened with glass fiber enabled the authors to fabricate a hybrid cranioplast. Satisfactory outcome was achieved.

Adult Brainstem Astroblastoma: Unusual Presentation of a Rare Tumor.

Astroblastoma is a rare tumor, which is mostly found in pediatric population. Due to scarcity of literature, the data about treatment is lacking. We are reporting case of brainstem astroblastoma in an adult female. A 45-year-old lady presented with complaint of headache, vertigo, vomiting, and nasal regurgitation for 3 months. On examination, she had weak gag, left hemiparesis. Magnetic resonance imaging brain reported medulla oblongata mass, dorsally exophytic. She underwent suboccipital craniotomy and decompression of mass. Histopathology confirmed diagnosis of astroblastoma. She underwent radiotherapy and recovered well. Brainstem astroblastoma is an extremely rare entity. The surgical resection is possible due to well-defined plane. For best outcome, maximum resection and radiation are indicated.

An Uncommon, Extensive Involvement of Hydatid Cyst-Cervical Spine to Brachial Plexus.

Introduction: Hydatid cyst usually involves liver and lung. But it has been reported in uncommon locations like the spine and brain. There are few reports of cervical spine to brachial plexus. This report is about such extensively involved hydatid cyst management. Case Report: A 32-year-old male had complaints of neck pain, left-hand weakness, and atrophy. MRI of cervical spine and thorax revealed a multicystic lesion involving the cervical spine, vertebrae, brachial plexus, and lung apex. The lesion was removed in two stages. Discussion: Due to scarcity of literature, dense adhesions with dura and surroundings, risk of rupture, anaphylactic shock, and its management require proper planning. Excision of cervical, followed by plexus lesion, might help. Long-term use of albendazole prevents recurrence as suggested by other reports. Conclusion: Extensive spinal hydatid cyst is exceptionally challenging. These behave like malignant lesions. To get the best results, surgical planning is as essential as medical management.

Extensive titanium mesh invasive cranial fibrous dysplasia.

BACKGROUND: Craniofacial fibrous dysplasia (FD) is a benign lesion. It presents as bony swelling. Even after complete excision, it has a tendency to recur due to some residual lesion in normal bone. Recurrence at same site is common, but it recurs in bone. We are reporting a rare case of recurrent FD engulfing titanium mesh. CASE DESCRIPTION: A 22-year-old girl, who underwent frontal FD excision and reconstruction using titanium mesh surgery 2 years back, came with complaint of progressive bony swelling at same site for 1 year. CT head confirmed bony lesion involving mesh, frontal air sinus. She underwent complete excision of lesion and cranioplasty using bony cement. Biopsy confirmed recurrence of FD and invasion of titanium mesh. CONCLUSION: Recurrence of FD, involving cranioplasty titanium mesh, is extremely rare. It suggests local invasiveness of lesion. Recurrence can be prevented by excision of lesion with free bony margins.

A Rare Case of Intramedullary Lipoma of Brainstem to Thoracic Cord--What to Do?

INTRODUCTION: Intramedullary lipomas are rare, representing 1% of spinal cord tumors. There are less than 25 case reports about cord lipoma extending into brain. Due to paucity of literature, etiology and management are not well established. CASE REPORT: A 14-month-old baby girl was brought with complaints of torticollis toward right side, left upper limb monoplegia, and swallowing difficulty for 6 months. Magnetic resonance imaging brain and spine confirmed the diagnosis of cervicothoracic intramedullary lipoma extending till pontomedullary junction, invading subcutaneous fat. She underwent partial resection of lesion along with decompression. The recovery was good. CONCLUSION: Such lipoma needs extensive pre-, intra-, and postoperative planning. The goal should be decompression, rather than excision. Outcome is good with partial resection.

An Institutional Experience of Fenestrated T-Bar Clip Use in The Management of Intracranial Aneurysms.

Surgical management of an intracranial aneurysm is mainly clipping. Various types of clips have been designed for complex, giant, and other aneurysms. Recently, the Yasargil-fenestrated T-bar clip has been introduced for the management of such complicated aneurysms. The literature regarding its efficacy, limitations, and method of application in complicated aneurysms is limited. We used the fenestrated T-bar clip in four patients of intracranial aneurysms - middle cerebral artery cortical branch aneurysm, anterior communicating artery partially thrombosed aneurysm, internal carotid artery paraclinoid simple aneurysm, and giant aneurysm. All aneurysms were successfully clipped with no residue or branch occlusion. The recovery of all patients was satisfactory. The fenestrated T-bar clip effectively reconstructed the parent artery and occluded the aneurysm in all cases. The application of this clip may be advantageous over the clip application in some uniquely challenging cases.

An Institutional Retrospective Study of Coil Loop Herniation and its Management.

INTRODUCTION: Endovascular coiling is a method of aneurysm embolization. Sometimes coil loops herniate in the lumen after deployment of the coil. It is usually seen in wide-necked aneurysms. It can cause migration of the coil and thromboembolic complications. There are different methods such as the use of a balloon, stent, and coil retriever to treat coil loop herniation. There are very few case series on coil loop herniation management. Most series are about the use of a stent/balloon for reposition. We are going to describe simple, novel techniques to treat coil loop herniation. MATERIALS AND METHODS: In the last five years, 13 aneurysms out of 325 coiled aneurysms had coil loop herniation. We used three different techniques in these patients according to our selection criteria. The first technique was loop trap with another coil, the second was balloon and coil-plasty to trap, and the third was rescue stent and flow control. RESULTS: The first, second, and third techniques were successfully used in five, five and three patients, respectively. There was a complete reposition of herniated coil and thus embolization of aneurysm in all cases. All patients recovered completely without any thromboembolic complications. CONCLUSIONS: We recommend the use of these techniques according to the proper selection criteria.

A Worst-Case Scenario-Undiagnosed Ruptured Arteriovenous Malformation Managed with Limited Resources.

BACKGROUND: Treatment of arteriovenous malformations (AVMs) is currently performed at specialized neurosurgical centers well equipped with microscopes with green filters, neurosurgical catheterization laboratories, and experienced neurosurgical teams. Patients in whom AVMs are diagnosed at smaller hospitals should be referred to such specialized centers. This case report describes the unavoidable worst-case scenario of an emergency unplanned surgical excision of an undiagnosed ruptured AVM with large hematoma. CASE DESCRIPTION: A 26-year-old man was brought to the emergency department with episodes of seizures and sudden loss of consciousness. His Glasgow Coma Scale score was 5. He had anisocoria. Computed tomography of the head showed right occipital hematoma with mass effect and herniation. Suspected diagnosis was spontaneous tumor or hypertensive bleed. Emergency surgery was performed. Intraoperatively, ruptured AVM was found. After explaining to family members about nonavailability of conventional instruments (i.e., microscope, clips, indocyanine green), we planned for excision of AVM with available resources. CONCLUSIONS: Postoperatively the patient recovered satisfactorily with right-side vision loss. He underwent cranioplasty after 6 weeks. In such a worst-case scenario, remaining calm, following basic surgical steps, using blood transfusion, and employing lateral thinking regarding using available resources can result in satisfactory management of the patient.

Study of Incidence and Factors: Risk and Preventive, of Chronic Subdural Hematoma/hygroma in Clipped Patients of Unruptured Intracranial Aneurysms - An Institutional Experience.

INTRODUCTION: One of the underreported complications of clipping of unruptured aneurysm is chronic subdural hematoma/hygroma (CSDH). It can cause sudden deterioration and might need emergency evacuation. Recently, very few papers have studied its incidence and predisposing factors. We are reporting our institutional experience of it along with the study of its risk factors and possible pathogenesis. METHODOLOGY: Totally 91 postoperative patients of unruptured aneurysms were retrospectively analyzed. Totally 21 patients had CSDH who were operated. In rest seventy patients, there was no CSDH. RESULTS: Male sex, old age, anticoagulant use, presence of pneumocephalus and dead space were significantly associated with occurrence of CSDH, whereas arachnoidoplasty significantly protected against it. There was no significant relation of CSDH with Gorei-san use. CONCLUSIONS: We recommend arachnoidoplasty should be carried out in all patients of clipping of unruptured aneurysm. Male patients or/and patients with dead space with pneumocephalus must be given extra attention like avoiding any dead space in postoperative period, doing arachnoidoplasty and regular follow up till 1st year.

Intraoperative Rupture Cerebral Aneurysm and Computational Flow Dynamics.

Intraoperative aneurysmal rupture (IAR) is the most fearsome complication of aneurysm surgery. IAR associates with high morbidity and mortality. In recent years, we have many studies regarding using computational fluid dynamics (CFD) in aneurysm surgery. CFD helps in calculating the velocity of blood flowing in the aneurysm sac, the pressure in the aneurysm sac, and wall shear stress (WSS). CFD also helps in predicting nature of aneurysm wall and thus may warn about different intraoperative microscopy findings in aneurysms. Using its application, surgeon may become more careful in doing microsurgical sharp dissection. A 40-year-old female admitted with diagnosis of unruptured anterior communicating artery aneurysm. CFD analysis demonstrated high intra-aneurysmal pressure and divergent WSS in dome. During sharp dissection, there was intraoperative rupture aneurysm twice which was managed with cotton tamponade and glue and temporary clipping aneurysm. Indocyanine green video angiography showed working parent arteries and nonfunctioning aneurysm. After operation, the patient recovered fully and had a modified Rankin score of 1. This case demonstrated importance of preoperative planning of aneurysm surgery using CFD analysis. IAR is associated with an increased risk for an unfavorable outcome. Accurate preoperative planning with studying flow dynamics and structure of aneurysm may help in use sharp microsurgical dissection more cautiously.

Redo Microvascular Decompression in a Patient of Resistant Cochleovestibular Nerve Compression Syndrome.

Cochlea-vestibular nerve compression syndrome (CVCS) may present as recurrent attacks of vertigo, dizziness, imbalance, etc. Those patients who do not respond to medical management, are usually managed by "microvascular decompression (MVD) of cochlea-vestibular nerve." The success rate of MVD is not 100% and few patients present with the recurrence of symptoms. We are reporting management of one such resistant case of CVCS. A 40-year-old female patient who was a known case of CVCS, was managed by medical and surgical (MVD) management. She had no relief of symptoms. We did redo MVD of cochlea-vestibular nerve after full evaluation of symptomatology. Patient had complete relief in her symptoms. In failed MVD cases, redo MVD can be performed if patient is still having e/o nerve compression, adhesions on magnetic resonance imaging.

Occipital Intraparenchymal Myxopapillary Ependymoma: Case Report and Literature Review.

Myxopapillary ependymoma (MPE) is a histological variant of ependymoma found in the conus medullaris or filum terminale region. Intracranial occurrence of the tumor is a rarity. The most characteristic histological feature of myxopapillary tumors is the abundance of intercellular and perivascular mucin and the arborizing vasculature, which tends to form papillae. We are reporting a 14-year-old patient presented with seizures caused by the right occipital region intraparenchymal lesion. Histopathology confirmed it to be MPE. Lesion was excised completely. Literature reviews on the topic are discussed regarding the histological findings, natural history, and outcome of surgically treated MPE. This is the fifth reported case of cerebral intraparenchymal primary MPE.

Understanding the Course of Vertebral Artery at Craniovertebral Junction in Occipital Assimilation of Atlas: Made Simplified Using Conventional Angiography.

Introduction Preoperative assessment of vertebral artery (VA) is important to avoid its injury during surgery at craniovertebral junction (CVJ). The main concern is the course of third segment of VA (V3) while performing instrumentation at CVJ, that is, segment of VA from its course through transverse foramen of C2 to its course along the posterior arch of C1. This segment of VA includes its passage through C1 transverse foramen as well. This observational study was done to analyze the course, curvature, and termination of VA in patients with occipital assimilation of atlas at CVJ, a complex congenital anomaly, and compared with the normal course for better understanding especially by young neurosurgeons and spine surgeons. Materials and Method This is an observational study that included patients with occipitalized C1 with or without associated anomalies. Out of 30 patients of CVJ anomalies, 16 patients had occipitalized atlas. Digital subtraction angiography was done in all cases. It was done by selectively catheterizing the VA using standard Seldinger's technique and both anteroposterior and lateral projections were taken. Results The course of VA was not identical on either side in any individual. It was lengthened and tortuous in all patients. Different types of anomalous course were encountered like bypassing transverse foramen of C1, close relation with C1-2 facet joints, variable course along the posterior arch of C1, abnormal termination and fenestration of VA. Conclusion Craniovertebral junction anomalies are not only bony or neural, but are vascular too. Complex CVJ anomalies are associated with higher incidence of anomalous course of the VA, an important surgical consideration.