Primary papillary epithelial tumor of the sella: a case report of an emerging tumor type.

Primary papillary epithelial tumor of the sella (PPETS) is a newly described tumor entity with prototypical location in the sella. Only two case series with ten cases have been described so far. These tumours have a typical papillary architecture with bland nuclear features, TTF-1 immunopositivity and low MIB-1-labelling index. Many of these tumours were previously assigned under the category of 'ectopic choroid plexus papilloma'. PPETS expands the group of TTF-1 positive tumours of the central nervous system. Histomorphology plays an essential role in making this diagnosis. We report a case of 44-year-old female with a sellar mass lesion, who presented with progressive loss of vision and diagnosed as primary papillary epithelial tumor.

Tuberculum Sella Meningioma: Surgical Management and Results with Emphasis on Visual Outcome.

Background Tuberculum sella meningioma form a distinct surgical entity with significant morbidity for the patient due to early and profound visual involvement. Surgical treatment of tuberculum sella meningioma is challenging in view of the proximity of vital neuro-vasculature. These lesions may be approached via a high-route (trans-cranial) or a low-route (trans-sphenoidal). Materials and Methods The authors present a consecutive series of 36 patients, operated by the first author from 1996 onward, with an analysis of clinical presentation (emphasizing visual deterioration), imaging features, operative approaches, and outcome with postoperative visual status. Results There were 36 patients (72 eyes) in the series, 75% females and 25% males. The mean age of patients was 48.05 ± 10.02 years. In all, 88.89% had visual diminution, 50% had headache, 5.56% had behavioral changes, and 2.78% had seizures. The mean tumor size was 4.01 ± 1.01 cm. The frontotemporal approach was employed in 66.67% of patients, and all patients underwent a right-sided approach. There was no significant difference between improvement in the vision between the right eye and left eye, despite the fact that right-sided approach was employed in nearly cases. Conclusion While tuberculum sella meningioma have profound morbidity in terms of visual deterioration, timely surgical intervention may help patients gain serviceable vision postoperatively. We advocate the trans-cranial approach and find no difference in visual outcomes on employing right-sided approach, regardless of the side with worse vision.

Trans-Thoracic Extra-Pleural Percutaneous Spinal Fixation-A Technical Note.

Study Design: Cross-sectional analysis of defined parameters of patients who underwent the presented technique. Patients undergoing thoracic spine fixation for various pathologies. Objective: This technique attempts to limit the incision size in extrapleural thoracotomy for multi-level spinal fixation. Summary of Background Data: Dorsal spine is traditionally approached by either transpleural or extrapleural approach. The extrapleural approach carries a limitation of being restricted in number of levels it can address. By incrementally modifying the present technique, we were able to employ the approach in greater number of levels with lesser morbidities. Method: Classical extrapleural thoracotomy approach is employed with incision size limited to the levels of pathology (~5 cm). Thereafter, proper exposure using Kittner dissection and defining of screw entry points follows. Stab incision is made and screws placed percutaneously through a K-wire-defined trajectory. Results: Eighteen patients underwent fixation through this technique, of which 11 were infectious, four were traumatic, and the rest were neoplastic in pathology. None except three patients had ICU stay of more than 1 day. All patients had a pain score of 6 or lower except for two. Conclusion: Combining the technique of percutaneous screw placement with traditional extrapleural thoracotomy reduces the size of the incision, tissue damage, and morbidity while reducing the cost and duration of hospitalization without comprising the extent of pathology that can be dealt with.

Ophthalmic Segment Aneurysms: Surgical Treatment and Outcomes.

Background Surgical treatment of ophthalmic segment aneurysms (OSAs) remain challenging because of complex anatomy surrounding the aneurysm and entails extensive drilling of anterior clinoid process to define proximal neck of the aneurysm and carotid exposure in the neck for proximal control. Materials and Methods Authors present a retrospective analysis of 36 aneurysms in 35 patients with OSAs operated surgically by first author. Surgical clipping was done for the aneurysms as primary modality of treatment along with wrapping and trapping as required. Results Commonest age group was 40 to 60 years with female preponderance of 3:1. Maximum (23) patients presented with subarachnoid hemorrhage (WFNS Gr 1), followed by asymptomatic patients (six). There were 18 small, 14 large, and four giant aneurysms, 15 dorsal wall, 17 ventral wall, three proximal posterior wall, and one blister aneurysm. Good outcome, as measured by Glasgow Outcome Score (GOS) was achieved in 29 patients. Conclusion OSAs are technically demanding aneurysms, but with due diligence to surgical principles, good outcomes may be obtained.

Lumbo-peritoneal shunt as treatment modality for visual symptoms in idiopathic intracranial hypertension: A single institution experience.

OBJECTIVES: To evaluate the efficacy of lumbo-peritoneal shunt (LPS) in patients of idiopathic intracranial hypertension presenting with visual symptoms. METHODS: Between Apr. 2014 and Mar. 2018, 70 patients of Idiopathic Intracranial Hypertension (IIH) underwent treatment at our institution. Patients were evaluated for neurological and ophthalmological status and were subjected to LPS depending on their symptoms. RESULTS: Mean opening pressure was 29.97±5.33cm of water and mean Body-Mass Index (BMI) was 26.51±3 and the two were significantly correlated (p-value 0.006). All patients with visual symptoms (23) underwent LPS and others (47) were managed medically. All patients with LPS and 25 of medically managed patients improved, while 22 medically-managed patients required LPS due to deterioration in visual symptomatology. The proportion of patients showing complete resolution of features of IIH was significantly different between the three groups. Of the 7 patients with shunt extrusion/migration, only 2 required revision. CONCLUSION: LPS is an equally effective and more technically familiar modality for treatment of IIH for neurosurgeons and should be offered to asymptomatic patients with objective visual signs. Shunt extrusion/migration may not always warrant revision due to "mini-shunt" that drains Cerebro-Spinal Fluid (CSF) through shunt tract even after extrusion.

Bone Sandwich Closure Technique for Posterior Fossa Craniectomy.

Background Surgery of posterior fossa including cerebellopontine (CP) angle involves either craniectomy or craniotomy. While there has been precedence of craniotomy in recent practice, the preferred access in resource-strapped centers still remains been craniectomy. Although the latter offers an excellent exposure, it is believed to carry increased risk of postoperative pseudomeningocoele and cerebrospinal fluid (CSF) leak compared with craniotomy. Methods We have suggested a technique by which after standard craniectomy for the posterior fossa surgeries the bony defect is covered by Gelfoam bone sandwich (GBS) technique. We studied this technique over a period of 25.6 years in 1,028 patients. Results and Conclusion We analyze the risk of pseudomeningocoele and CSF leak in our patients using GBS technique and reviewed literature to compare our outcomes with standard craniotomy and craniectomy procedures.

A system of radiological criteria for grading and prognosticating temporal lobe contusions.

INTRODUCTION: Temporal contusions are common in patients with head injuries and require close monitoring due to the propensity of these patients to deteriorate rapidly and fatally. This study attempts to introduce a radiological grading system for temporal lobe contusions and analyse its prognostic value so as to better identify patients at risk of deterioration. METHODS: The study was conducted as a cross-sectional observational study from April 2011-March 2017 on 42 patients with temporal lobe contusion. Each patients was graded according to the proposed system from a minimum of four to a maximum of 13 and then further grouped in three grades - grade 1 (score = 4), grade 2 (score 5-7) and grade 3 (score > 7) - and their clinical course was closely observed. RESULTS: The minimum and maximum scores observed were four and 11 respectively. The proposed grading system has statistically significant correlation to the Glasgow Coma Scale (p-value < 0.05). All patients in grade 1 (17) could be managed conservatively, while all those in grade 3 (five) needed immediate surgical intervention. Of 20 patients in grade 2, 11 had a score of 5-6 and did not require surgery, whereas nine patients had a score of seven and of these eight required delayed surgical intervention. This correlation was statistically significant (p-value < 0.05). CONCLUSION: The proposed temporal lobe contusion grading system is a good radiological tool to predict the clinical course of patients and thereby identify patients at higher risk of delayed deterioration.

Modified high cervical approach for C3-4 anterior pathology in difficult neck patients.

INTRODUCTION: The anterior approach to cervical pathologies is a time-tested versatile approach. It is, however, associated with a number of pharyngo-tracheo-laryngeal complications (PTL complications) such as dysphonia, dysphagia, and aspiration, more commonly in high cervical C3-4 inclusive pathologies and even more so in patients with "difficult neck." The modified high cervical approach was devised and employed to address these issues at our institution. MATERIALS AND METHODS: Patients who underwent surgery for anterior cervical C3-4 inclusive pathologies between January 2015 and April 2018 were included in the study. Parameters for considering difficult neck were defined. Patient subgroup with difficult neck underwent surgery through a modified high cervical approach, whereas others underwent surgery through a standard approach. The incidence of pharyngo-tracheo-laryngeal complications in both subgroups of this patient set was compared among itself as well with a similar patient set with the same two subgroups, both of which underwent surgery through standard approach alone from May 2010 to December 2014 - before the introduction of modified high cervical approach. RESULTS: A total of 280 patients underwent surgery for C3-4 level pathology between May 2010 and April 2018. There were 197 males and 93 females in this population. Mean age was 45.8 ± 6.3 years. Incidence of pharyngo-tracheo-laryngeal complications was 20.3% in patients who underwent surgery before the employment of modified high cervical approach - 32.4% of difficult neck and 16.6% of others developed features of pharyngo-tracheo-laryngeal complications. After employment of modified high cervical approach, 16.67% of difficult neck and 16.2% of other patients developed features of pharyngo-tracheo-laryngeal complications. CONCLUSION: The modified high cervical technique is a good surgical option to prevent pharyngo-tracheo-laryngeal complications in cases of anterior C3-4 pathology when operating of patients with difficult neck.

Case series of trigonal meningiomas.

BACKGROUND: Trigonal meningiomas have unique clinical presentation, unlike those in other areas of brain. Situated deep in the brain, the surgical nuances of this tumour are distinctive. We present our experience with this tumour including a discussion of surgical corridors that may be employed. METHODS: At our centre, 12 trigonal meningiomas were operated over past two decades. A retrospective analysis of case records of these cases was undertaken as regards age, sex clinical presentation, imaging and surgical approach. RESULTS: Mean time from heralding symptom to presentation was 10.4 months. At presentation, the most commonly encountered symptoms were those of non-localising symptoms attributable to raised ICP. Majority of lesions were more than 6 cm and on left side and the preferred surgical approach was inferior temporo-parietal. Most symptoms were relieved on long-term follow-up except homonymous hemianopia. CONCLUSION: The incidence of deficit is low on employing the "shortest route" approach, even in the dominant hemisphere and through eloquent area. This may be secondary to possible shift of eloquent area function due to longstanding lesion and may thus be a "workable" surgical option, especially in resource-limited centres where such resources as neuronavigation and tractography may be unavailable.

Surgical anatomy of lateral recess in paediatric auditory brainstem implant patients and its clinical correlates including grades of flocculus.

INTRODUCTION: Auditory brainstem implant (ABI), a standard technique in treatment of profound sensorineural hearing loss in patients with neurofibromatosis 2, is now being increasingly employed in children with congenital bilateral sensorineural hearing loss, as in Michele's deformity. A detailed knowledge of the relevant surgical anatomy of the lateral recess and its anatomical landmarks including the flocculus, the choroid plexus and the root entry zones of facial-vestibulocochlear and glossopharyngeal-vagus nerve complexes and their anatomical variants is mandatory, as it is the conduit for electrode array placement. The placement of electrode may be eased or impeded by these variations. MATERIALS AND METHODS: Thirty-two children with congenital bilateral hearing loss underwent surgery through retromastoid suboccipital approach for placement of auditory brainstem implant. The preoperative anatomy was reviewed in detail during procedure and again later in the operative videos. RESULTS: The flocculus was classified into four grades based on its anatomy and relations. Among these, grade II (11 children) was the commonest while grade IV (five children) was least common. Choroid plexus was variable in size across grades of flocculus. Difficulty in defining the anatomy was significantly more (p value = 0.003) in the group with higher grade flocculus (grade III and IV) than in lower grade flocculus (grade I and II). CONCLUSION: The flocculus in these patients is classifiable into one of the four grades and the surgical nuances such as difficulty in defining the anatomy for placement of ABI are dependent on the characteristics exhibited by the floccular anatomy and relations.

Quad Fever: Treatment through Lowering of Ambient Temperature.

Hyperpyrexia is a rare and at times fatal condition seen in an Intensive Care Unit setup. We encountered a case of a 65-year-old patient with road traffic accident presenting with dorsal spine fracture at D10 level. He underwent decompression and fusion for the same. He developed hyperpyrexia of sudden onset on the 10th day of admission with no source of infection and adequate broad-spectrum antibiotic coverage with adequate thrombo-embolic prevention in place. The patient showed no response to antipyretic agents and other cooling methods. The origin of hyperthermia was idiopathic, and we speculate that the cause was secondary to hyperthermic thermoregulatory dysfunction often quoted as "quad fever," seen in spinal cord injury. We present a brief review of literature and the importance of early identification and treatment of this potentially fatal condition.