Decompressive craniectomy in children: indications and outcome from a tertiary centre.

INTRODUCTION: The role of decompressive craniectomy (DC) is as a rescue therapy for the treatment of intracranial hypertension. The indications for the DC are variable. METHODS: The clinical details, imaging, operative findings and follow-up data of children less than or equal to 18 years of age were reviewed for more information on the children who underwent DC in the last 5 years. RESULTS: During the study period, a total of 128 children underwent DC. The trauma cases were 66, and the non-trauma cases were 62. The common indication for DC was pure acute subdural hematoma 33 (50%), followed by contusion 10 (15%) in the trauma group, and in non-trauma, arterial infarction in 20 (32%) and cerebral venous thrombosis in 17 (27%). Hemicraniectomy was done in 114 (89%), and bifrontal craniectomy was done in 7 (5.4%) cases. The median duration follow-up was 7 months in non-trauma and 6 months in trauma. GCS was less than 8, the motor score was less than 3, and pupillary asymmetry, hypotension and basal cistern effacement were factors related to an unfavourable outcome in the non-trauma group. In regression analysis, only a motor score of less than three was associated with the non-trauma group. Age less than 10 years, GCS less than 8, motor score less than three and preoperative infarction were the predictive factors in univariate analysis, and only GCS less than 8 was the predictive factor for unfavourable factors in regression analysis in the trauma group. CONCLUSION: The DC is performed as a lifesaving procedure. The unfavourable outcome is slightly higher in non-trauma cases compared to trauma cases. However, the mortality rate is high in trauma cases.

Xanthogranulomatous Colloid Cyst in a 13-Year-Old Boy: A Case Report and Surgical Implications.

INTRODUCTION: Colloid cysts are relatively uncommon lesions in the pediatric population. The xanthogranulomatous (XG) variant is very rare with less than 30 reported cases. CASE REPORT: In this report, the patient was a 13-year-old boy who presented with transient episodes of headache with blurring of vision. His MRI brain showed a T2 hyperintense well-defined cystic lesion, with an eccentrically located T2 hypointense partially enhancing nodule, at the foramen of Monro. He underwent middle frontal gyrus transcortical, transchoroidal gross total excision of the cyst. The histopathology of the lesion revealed an XG colloid cyst. The patient recovered well from the procedure and was relieved of the symptoms. CONCLUSION: XG colloid cyst may present with altered radiological features compared to the normal variant. This can pose a diagnostic dilemma, and it is important to differentiate it from a craniopharyngioma or a parasitic cyst, as in our case. When considered preoperatively, surgeons should be conscious to review their surgical strategies. Stereotactic aspiration of the XG cyst should be avoided as contents are thicker and heterogeneous than the usual. The spillage of cyst contents should be prevented. Also, the XG cysts are likely to have a poor cyst-fornix or -choroid plexus interface due to inflammation limiting complete resection.

Management of a Persistent Oblique Occipital Sinus with Staged Ligation in a Case of Medulloblastoma: A Case Report.

INTRODUCTION: A patent persistent occipital sinus (OS) can be seen in 10% of adults. The presence of such a dominant draining OS can present as a challenge for posterior fossa surgeries. Occlusion or division of the sinus can cause venous hypertension, causing a cerebellar bulge or increased intra-op bleeding. CASE REPORT: A 3-and-a-half-year-old female child presented with a vermian medulloblastoma with hydrocephalus. MR venography (MRV) revealed a large patent OS draining from the torcula to the right sigmoid sinus. She underwent a left Frazier's point VP shunt followed by a midline suboccipital craniotomy for the lesion. The OS was divided during a "Y"-shaped durotomy. Following the sinus ligation, there was a significant cerebellar bulge and excessive bleeding from the lesion. We released cisternal CSF and punctured the tumor cysts to allow the brain bulge to settle. Hemostasis was secured, and surgery was deferred, an augmented duroplasty was done, and bone flap was removed to allow for intracranial pressure decompression. The patient was electively ventilated for 24 h and weaned off gradually. A repeat MRV at 7 days showed the reorganization of the venous outflow at the torcula. Reexploration with tumor resection was done on post-op day 10. The patient recovered well from the surgery and was referred for adjuvant therapy. CONCLUSION: Surgeons should carefully analyze venous anatomy before posterior fossa surgeries. The persistent dominant OS, when present, should be taken care of while planning the durotomy. A hypoplastic but persistent transverse sinus allowed us to ligate and divide the OS. By doing a staged division of the sinus, reorganization of the venous outflow from the torcula can be allowed to occur, and the lesion can be resected.

Anterior Odontoid Screw Fixation for C2 Fractures: Surgical Nuances, Complications, and Factors Affecting Fracture Union.

OBJECTIVE: Type II odontoid fractures are the commonest C2 fractures. The management of dens fractures remains controversial with various radiological and fracture morphological factors affecting the approach and outcomes. METHODS: All cases of anterior odontoid screw fixation between 2010 and 2020 were retrospectively analyzed. Patients' clinical, radiological (type of fracture, orientation, displacement, and diastasis), operative (single vs. double screw) and follow-up records were documented. The postoperative imaging findings were classified into grades I (excellent), II (good), and III (poor) based on the anatomical alignment with the screw. Follow-up cervical computed tomography was reviewed for fracture union. RESULTS: A total of 49 patients with a mean age of 37.3 ± 13.8 years were included in the study. The average time from injury to surgery was 23.1 ± 22.2 days. The bicortical screw purchase and superoposterior odontoid tip breach significantly affected the postoperative alignment (P = 0.035 each). Fracture union was noted in 41 (83.7%) patients. The horizontal fracture displacement ≥2.5 mm (P = 0.02) and poor postoperative fracture alignment (P < 0.001) resulted in worse fracture union rates. Transient dysphagia was the commonest complication (n = 12), whereas screw breakout (n = 2) and pullout (n = 2) were other hardware-related complications. One patient underwent re-exploration for screw readjustment and 2 underwent posterior instrumentation. CONCLUSIONS: Anterior odontoid screw fixation is technically straightforward, less morbid, and preserves biomechanical cervical mobility, when compared with the posterior instrumentation. With careful patient selection, meticulous surgical planning, and intraoperative image-guided screw insertion, good fracture union outcomes can be obtained. In the current study, we were able to achieve stable fracture union in 83.7% patients.