Posterior fossa ruptured dermoid cyst presenting with hydrocephalus.

Dermoid cysts are rare, benign lesions of embryological origin that represent 0.1-0.7% of all intracranial tumors. They are mainly located in the supra tentorial space, especially in the parasellar region. Their location in the posterior fossa remains uncommon. Rupture of intracranial dermoid cysts is a rare phenomenon. We present a case of dermoid cyst, which had ruptured into ventricular system. Computed Tomography and MRI revealed fat in the fourth ventricle, prepontine cistern, and cerebellomedullary cistern. Hydrocephalus was noted. We performed right ventriculo-peritoneal shunt on which patient improved and he continues to remain asymptomatic one year after.

Hydrocephalus after decompressive craniotomy: a case series.

BACKGROUND: Post-craniectomy hydrocephalus in patients with intracranial hypertension is becoming a major concern for neurosurgeons because of the increasing number of hospital admissions for head trauma, stroke and other lesions which may lead to severe brain oedema requiring decompressive craniectomy. METHODS: We collected records of all the paediatric patients who developed hydrocephalus following decompressive craniotomy from October 2011 to October 2013 and analysed their clinical profiles. RESULTS: We had 3 patients in this group, ranging in age from 6 to 18 years; 1 patient died and the other 2 patients continue to remain in follow-up. CONCLUSION: Post-traumatic hydrocephalus is one of the rare complications of decompressive craniotomy; CSF diversion remains the only option for improvement in neurological status.

Head injury caused by tear gas cartridge in teenage population.

OBJECTIVES: The aim of this study was to assess the head injury in children caused by an unusual projectile, a tear gas cartridge. The study is the only one on this subject which has been done in a teenage population. METHOD: This was a prospective study conducted over a period of 4 years in which all the patients aged less than or equal to 18 years and who had a head injury due to a tear gas cartridge were included. RESULTS: We had 5 patients in our study group. All the patients were males. Commonest CT scan finding was brain contusion with skull fracture. One of our patients died. One patient continues to be in vegetative state whereas 3 had a good outcome. CONCLUSION: Tear gas cartridge, though considered as one of the benign modalities of controlling agitated crowds, is not really benign. It can cause serious injuries and mortality. The personnel using them might be trained in a better way so that the people do not receive direct hits. In addition some changes in the design of tear gas cartridge can be done to decrease the impact to the skull.

Head injury in children due to cricket ball scenario in developing countries.

OBJECTIVES: The aim of the study was the assessment of head injury caused by cricket ball injury in children. In underdeveloped countries, this is particularly important due to the absence of safety precautions. The study was undertaken to increase the public awareness of the need to reduce the morbidity related to this sport. METHODS: This was a prospective study in which all the children <18 years who had sustained head injury due to cricket balls were enrolled. RESULTS: The study included 27 children, 26 males and 1 female. Out of these 21 cases of head injury were due to hard plastic cricket balls and the rest were due to conventional cricket balls. In 25 patients, CT scan was done, which revealed a lesion in 21 of them. Six patients required surgery, 3 for extradural hematoma, 1 for acute subdural hematoma, 1 for contusion and 1 for compound depressed fracture. One death occurred in our series. There was no significant difference in the nature of injury sustained by either plastic or conventional cricket balls. CONCLUSION: Head injury due to cricket balls can lead to serious consequences even if an innocuous plastic ball is used in place of a conventional cricket ball. Public awareness apart from safety measures is required so that helmets are worn during playing. Change in the nature of the balls may bring a reduction in the severity of head injury.

Spinal angiolipoma mimicking a schwannoma: A case report.

BACKGROUND: Angiolipomas rarely involve the spinal canal/foramina, and may prove difficult to differentiate from schwannomas. CASE DESCRIPTION: Here we report a patient who presented with a spinal angiolipoma contributing to spinal cord and neural foraminal compression that was difficult to differentiate from a schwannoma. CONCLUSION: Spinal angiolipomas rarely involve the spinal canal/foramina. Utilizing neurodiagnostic studies with pathological confirmation, these lesions may be differentiated from schwannomas.

Conservative management of craniovertebral junction injuries: Still a good option.

BACKGROUND: Injuries to the craniovertebral junction (CVJ) are not uncommon, and are among the few skeletal injuries that carry a high mortality rate. Successful management of these injuries depends on familiarity with the normal anatomic relationships of this region, as well as prudent decision making regarding surgical versus conservative management alternatives. METHODS: The purpose of this study was to analyze the indications for conservative treatment of CVJ trauma and to analyze the outcomes. RESULTS: Eighty-eight patients admitted with CVJ injuries were managed conservatively. More than half were nearly neurologically intact on admission; 91% improved whereas 80% (excluding deaths/lost to follow) ultimately achieved bony union without surgical intervention. CONCLUSION: This study documents that conservative management of CVJ injuries in a select population can yield good clinical results.

Squamous cell carcinoma arising from neglected meningocele.

BACKGROUND: A neural tube defect (NTD) is a common congenital anomaly with an incidence of 6.57-8.21 per 1000 live births. Patients usually present early because of obvious swelling or due to neurological deficit. However, neglecting the obvious cystic swelling on the back till its transformation into malignant tumor is rare. CASE DESCRIPTION: We describe a case of malignant transformation of meningocele in a 60-year-old man. Magnetic resonance imaging showed sacral meningocele. Neurological examination revealed intact motor and sensory examination with normal bladder and bowel function. There were no signs of meningitis and hydrocephalus. Excision was done and biopsy revealed it as squamous cell carcinoma. CONCLUSION: Meningocele should be treated early and possibility of malignant change should be kept in mind in neglected cases presenting in adulthood.

Subdural hydatid cyst presenting as recurrent subdural hygroma.

Intracranial hydatid disease is an uncommon entity that usually is parenchymal in location. Presence of hydatid cyst in subdural location is being reported for the first time in the literature. A 13-year-old female child with the diagnosis of hydatid disease of brain was operated. She was advised to take albendazole which she did not take. In postoperative period she developed recurrent subdural hygroma for which multiple surgical interventions were done and finally cause of recurrent subdural hygroma was found to be hydatid cyst in the subdural space. The patient had initially undergone craniotomy for the excision of hydatid cyst. Later on she developed subdural hygroma for which the burr hole drainage was done twice. At time of third recurrence subduro-peritoneal (SDP) shunt was done. When she had recurrence again along with hydrocephalus, than VP shunt and revision of the SDP shunt was planned. While doing revision of SDP shunt, hydatid cyst was seen emerging from the burr hole site. A craniotomy was done to remove the hydatid cyst from the subdural space. Since then there has been no recurrent collection. Complete surgical excision is the best treatment modality to treat hydatid cyst of brain. Accidental spillage of the contents can have lead to recurrence, so every effort must be taken to prevent spillage of contents. Postoperatively all the patients must be put on antihelminthics.

A prospective, randomized, double blind study to compare the effects of equiosmolar solutions of 3% hypertonic saline and 20% mannitol on reduction of brain-bulk during elective craniotomy for supratentorial brain tumor resection.

AIMS: The aim of the study was to compare the effect of mannitol (M) and hypertonic saline (HTS) on brain relaxation and electrolyte balance. SETTINGS AND DESIGN: Prospective, randomized, double-blind study. SUBJECTS AND METHODS: A total of 114 patients with American Society of Anesthesiologists status II and III, scheduled to undergo craniotomy for supratentorial brain tumor resection were enrolled. Patients received 5 ml/kg 20% mannitol (n = 56) or 3% HTS (n = 58) at the start of scalp incision. Hemodynamics, fluid balance and electrolytes, were measured at 0, 15, 30, and 60 min and 6 h after infusion. Intensive Care Unit (ICU) stay between the two groups was also recorded. The surgeon assessed brain relaxation on a four-point scale (1 = Relaxed, 2 = Satisfactory, 3 = Firm, 4 = Bulging). Appropriate statistical tests were used for comparison; P < 0.05 was considered significant. RESULTS: Brain relaxation conditions in the HTS group (relaxed/satisfactory/firm/bulging, n = 28/20/5/3) were better than those observed in the M group (relaxed/satisfactory/firm/bulging, n = 17/21/11/9). The levels of serum sodium were higher in the HTS group (P < 0.001). The average urine output was higher in the M group (5.50 ± 0.75 L) than in the HTS group (4.38 ± 0.72 L) (P < 0.005). There was no significant difference in fluid input, ICU stay, and hospital days between the two groups. CONCLUSION: We concluded that HTS provided better brain relaxation than mannitol during elective supratentorial brain tumor surgery, without affecting ICU and hospital stay.

Decompressive hemicraniectomy in supra-tentorial malignant infarcts.

BACKGROUND: Decompressive hemicraniectomy not only reduces the intracranial pressure but has been demonstrated to increase survival and decrease the morbidity in patients with supratentorial malignant brain infarcts (STMBI). The aim of this study was to assess the efficacy of surgical decompression to decrease the mortality and morbidity in patients with STMBI refractory to medical therapy and to compare the results with those of the medically managed patients. METHODS: All the 24 consecutive patients with clinical and radiological diagnosis of STMBI, refractory to medical management in 2 years, were included. Option of surgical decompression after explaining the outcome, risk and benefits of the procedure was given to the attendants/relatives of all patients who were fulfilling the inclusion criteria. The patient group, whose attendants/relatives were not willing to undergo surgery, were subjected to the same medical therapy and they were taken as the "control group." RESULTS: Supratentorial malignant infarcts were more common in the age group of 41-60 years. Mean age of presentation was 42.16 ± 16.2 years and the mean GCS on admission was 7.83 ± 2.1. Mortality was 16.7% in the surgically and 25.0% in the medically managed group. Patients operated early (<48 h), age ≤60 years, midline shift <5 mm and size of infarct less than 2/3(rd) of the vascular territory involved showed good prognosis. The functional outcome revealed by modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) was better in surgically managed patients. Results of the Zung Self-Rating Depression Score were better in surgically managed patients at 1 year. Barthal Index in the surgically managed group showed statistically significant results. CONCLUSIONS: Decompressive hemicraniectomy with duroplasty if performed early in STMBI not only decreases the mortality but also increases the functional outcome when compared with patients who were managed conservatively with medical therapy only.

Missile injury to the pediatric brain in conflict zones.

OBJECT: This study was conducted both prospectively and retrospectively at one center over a period of 8 years. The population consisted of all patients with both an age 18 years or younger and a diagnosed penetrating missile injury (PMI) during the study interval. The authors analyzed factors determining outcome and demographic trends in this population, and they compared them with those in the more developed world. METHODS: Fifty-one patients were the victims of armed conflict, although no one was directly a party to any battle. This mechanism of injury is in strong opposition to data in the literature from developed countries, in which most missile injuries are the result of suicide or homicide or are even sports related. Moreover, all previous studies on the pediatric population have considered only injuries from gunshots, but authors of the current study have included injuries from other penetrating missiles as well. RESULTS: On cross tabulation analysis using the chi-square test, the factors shown to correlate with outcome included the Glasgow Coma Scale (GCS) score, pupillary abnormalities, patient age, hemodynamic status, and bihemispheric damage. On multinomial regression analysis, the two strongest predictors of death were GCS score and pupillary abnormalities. The GCS score and hemodynamic status were the strongest predictors of disability. CONCLUSIONS: There was no difference in the prognostic factors for PMI between developing or more developed countries. Glasgow Coma Scale score, pupillary abnormalities, and hemodynamic status were the strongest predictors of outcome. In conflict zones in developing countries the victims were mostly innocent bystanders, whereas in the more developed countries homicides and suicides were the leading etiological factors.

Stray bullet: An accidental killer during riot control.

BACKGROUND: The use of force to control public uprisings, riots, unruly mobs is an important tool in any administrative setup. Law enforcement agencies often resort to aerial firing, which can be responsible for unintended injuries due to stray bullets.This study was designed to study the pattern of stray bullet injuries and to generate awareness about the hazards related to the use of live ammunition during riot control. METHODS: This study was conducted in our unit of the neurosurgery department over a period of 18 months, from June 2008 to December 2010. We enrolled all patients who had head or spine injuries caused by stray bullets from firing during riot control far away from the site of injury. RESULTS: We had two patients with head injury and two with spinal injury sustained because of stray bullets. One of the patients with head injury was operated and the other one was managed conservatively; the latter died on the third day of injury, while the former is surviving with some residual neurological deficit. Amongst the patients with spinal injury, neurological deficits persist till date. None of the patients were aware that they had sustained a bullet injury, and it was only after inquiry that we came to know that the police had resorted to aerial firing for controlling public agitation in nearby areas. CONCLUSION: Aerial firing of live cartridges is generally considered an 'innocuous' method; however, in view of the potential for injury to innocent bystanders, we recommend that the use of live cartridges during aerial firing be banned.

Apoplexy in sellar metastasis: a case report and review of literature.

Apoplexy in sellar metastasis is very rare with only a few case reports in literature. A case of apoplexy in sellar metastasis from follicular thyroid carcinoma is reported and the literature is briefly reviewed. The patient presented with sudden onset headache and bi-lateral loss of vision following thyroidectomy in a case of follicular carcinoma thyroid with proven sellar metastasis. CT scan showed hyperdense blood in sellar mass suggestive of apoplexy in sellar metastasis. The patient underwent early trans-sphenoidal decompression. Apoplexy in sellar metastasis, although very rare, can be clinico-radiologically indistinguishable from pituitary apoplexy and should be especially considered in the differential diagnosis of patients with known primary neoplastic disease. In view of similar patho-physiological mechanism, sellar metastasis with apoplexy should be managed in a similar manner as pituitary apoplexy.

Intradiploic epidermoid causing spontaneous extradural hematoma: case report.

OBJECTIVE: A case of an intradiploic epidermoid tumor leading to spontaneous extradural hematoma is reported. Intradiploic epidermoids are not common intracranial tumors. This is the first reported case of intradiploic epidermoid presenting as a spontaneous extradural hematoma. CLINICAL PRESENTATION: The patient presented with sudden onset of headache and deterioration in the sensorium. A computed tomographic scan revealed a lesion causing erosion of both tables of the calvarium and a mixed intensity extradural hematoma. INTERVENTION: The patient underwent immediate operation, and evacuation of the hematoma and excision of the tumor were performed. CONCLUSION: Intradiploic epidermoid tumors so rarely present with extradural hemorrhage that prophylactic removal cannot be recommended in all such cases. However, in view of the seriousness of the hemorrhage, prophylactic removal may be recommended, especially if the patient, such as a sportsman, child, or elderly person, is prone to injuries.

Protrusion of a peritoneal catheter through the umblicus: an unusual complication of a ventriculoperitoneal shunt.

Protrusion of a ventriculoperitoneal (VP) shunt through the umblicus is one of the rare complications of shunt insertion reported in the medical literature. One such case is presented here in a child in whom a VP shunt had been placed for congenital hydrocephalus.