"Rabbit ear" scalp deformity caused by massive subdural effusion in infant following bilateral bur-hole drainage failure: successfully managed with subduro-peritoneal shunt.

INTRODUCTION: Subdural effusion in an infant is a rare clinical scenario which may be secondary to a variety of etiologies. Massive subdural effusion is an extremely rare complication of head injury. CASE REPORT: Authors report a rare case of progressive massive subdural effusion which, despite bilateral bur-hole placement and drainage, failed and presented with visual deterioration and massive bulge of the scalp at bur-hole sites, producing a rabbit ear appearance in a 10-month-old infant. Ultimately, cystoperitoneal shunt was carried out in a desperate attempt to prevent impending rupture of scalp sutures at sites of previous bur-hole placement. This was followed by not only complete resolution of hygroma but also visual recovery. The patient is doing well at 6 months following shunt, regaining normal vision and appropriate developmental milestones. A MRI scan of the brain was carried out at last follow-up, which revealed mild ventriculomegaly with the rest of the brain being unremarkable, and subduro-peritoneal shunt in situ. Such a case has not been reported in the literature till date. DISCUSSION: Subdural effusion usually runs a self-limiting course. Though neurosurgical intervention is occasionally needed, different methods of surgical procedure for management include bur hole alone, bur holes with subdural drain placement, twist drill craniotomy with drain, and even craniotomy. Various methods of management are discussed along with a review of pertinent literature.

Extensive calvarial tuberculosis presenting as exophytic ulcerated growth on scalp in an infant: an interesting case report with review of literature.

INTRODUCTION: Extrapulmonary skeletal involvement of calvarium in tuberculosis is very uncommon and presentation in an infant has never been reported. It usually presents as a painless scalp swelling, often with a discharging sinus. DISCUSSION: We report here a case of extensive calvarial tuberculosis seen in an infant presenting as exophytic ulcerated growth on the scalp. Differential diagnosis, neuroimaging, and management issues with pertinent literature are reviewed.

Traumatic tentorial hematoma in two-wheeler riders: Correlation with helmet use.

BACKGROUND: Tentorial hematoma is frequently seen in traumatic brain injury (TBI) patients, especially in motorized two-wheeler riders following head injury. However its relevance and prognostic significance are not known. OBJECTIVE: To evaluate patients of TBI with tentorial hematoma using a simple grading system and attempt to correlate this grading with factors like helmet use and neurological outcome. MATERIALS AND METHODS: This prospective study over a 1-year period included patients with TBI who had tentorial hematoma in the initial plain head. Patients were divided into three grades based on the initial CT findings: Grade I: Isolated tentorial hematoma, grade II: tentorial hematoma with midline shift but open cisterns and grade III: Tentorial hematoma with effaced cisterns. Clinical and radiological records of patients including admission GCS and GOS at discharge were assessed in all cases. OBSERVATIONS: A total of 1786 patients of TBI were admitted during the study period. Of these, 106 (5.9%) patients had tentorial hematoma. 84.9% (n = 90) were male and 15.1% (n = 16) were female with the mean age being 36.5 years (range 2-66 years). The mean admission GCS was 13, 11 and 8 in patients with grade I, II and III tentorial hematoma respectively. 43.4% (n = 46) of the patients had grade I, 32.1% (n = 34) had grade II and 24.5% (n = 26) patients had grade III tentorial hematoma. Seventy-one patients (84.5%) were riding motorized two wheelers with 63 (89%) wearing helmets. The majority of the patients wearing helmets (58.8%) had grade I hematoma with 35% (n = 22) having grade II hematoma and only 6.3% (n = 4) having grade III hematoma. Overall, there were 20 deaths. 50% (n = 10) of the deaths were in patients with grade III hematoma and 40% (n = 8) of the deaths were in patients with grade II hematoma. There were two (10%) deaths in patients with grade I hematoma (both unrelated to head injury). The mean GOS at the time of discharge was 5, 4.1 and 2.2 in patients with grade I, II and III tentorial hematoma, respectively. CONCLUSIONS: Tentorial hematomas are very common in two-wheeler riders with TBI and could be a marker for indirect forces such as rotational forces experienced while wearing helmets.

Total Resolution of Large Scalp Swelling due to Calvarial Tuberculosis with Medical Management Only: Case Report and Review of the Literature.

Calvarial tuberculosis is rare. It presents with single or multiple discharging sinus or a localized focal scalp swelling with overlying skin discoloration. Usually subgaleal collection is associated with evolution of sinus formation in different stages. However, extensive scalp swelling spreading across bifrontal area and overlying healthy scalp is not reported. Pathologically it causes significant destruction of calvarium including erosion of both the tables with concurrent significant epidural granulation tissue deposits as dura acts as barrier to trans-dural spread. Concurrent surgical management and antitubercular medication is the standard treatment modality. Authors report a unique presentation of calvarial tuberculosis in 17-year- female presented with complaint of large painless scalp swelling extensively spreading over both frontal area from supraorbital margin to coronal suture without discoloration, puckering of overlying scalp or sinus formation, and neuroimaging showed absence of extradural granulation tissue deposits with very subtle bony architecture changes of adjacent calvarium. The swelling completely subsided with medical therapy alone. To the best of knowledge of authors such case of calvarial tuberculosis having large scalp swelling in western literature has not been reported. Clinical presentation, imaging, management and pertinent literature are reviewed.