Clear Cell Meningioma with Tyrosine Crystals: a Case Report with Review of Literature.

INTRODUCTION OR BACKGROUND: Clear cell meningioma is a rare WHO grade 2 tumour and runs an aggressive course. Tyrosine crystals are very uncommon in meningioma. CASE PRESENTATION: We present a case of a 43-year female with right middle and posterior cranial fossa space occupying lesion (SOL) diagnosed as clear cell meningioma with presence of numerous tyrosine crystals. DISCUSSION AND CONCLUSION: Whether these crystals are incidentally noted or if there is an actual relationship of these crystals with tumour environment must be found as they are seen in many other conditions too.

Optochiasmatic Cavernomas: Updated systematic review and proposal of a novel classification with surgical approaches.

Cavernomas are histologically benign vascular malformations found at different sites in the brain. A rare site for such cavernomas, however, is the anterior optic pathway, comprising the optic nerve, chiasma, and optic tract-called optochiasmatic cavernomas (OCC). These lesions usually present with sudden onset or progressive vision loss, headache, and features mimicking pituitary apoplexy. In this paper, we describe a case of OCC operated at our center. We carry out an updated review of literature depicting cases of OCC, their clinical presentation, management, and postoperative complications. We also propose a novel classification system based on lesion location and further analyze these cavernoma types with respect to the surgical approach used and visual outcome. A 30-year-old lady had presented with a 3-week history of progressive bilateral vision loss and headache. Based on imaging, she was suspected to have a cavernous angioma of the chiasma and left optic tract. Due to progressive vision deterioration, the lesion was surgically excised using pterional craniotomy. Postoperatively, her visual symptoms improved, but she developed diabetes insipidus. Clinical and radiological follow-up has been done for 18 months after surgery. A total of 81 cases have been described in the literature, including the present case. Chiasmal apoplexy is the most common presentation. Surgical excision is the standard of care. Our analysis based on lesion location shows the most appropriate surgical approach to be used for each cavernoma type. Visual outcome correlates with the preoperative visual status. Visual outcome is good in patients presenting with acute chiasmal apoplexy, and when complete surgical excision is performed. The endonasal endoscopic approach was found to provide the best visual outcome. In addition to preoperative visual status, complete surgical excision predicts favorable visual outcomes in OCC. Our proposed classification system guides the appropriate surgical approach required for a particular location of the cavernoma.

Arachnoid Welding-A Simple and Economical Method of Arachnoid Closure to Prevent Cerebrospinal Fluid Leak.

BACKGROUND: Collection of cerebrospinal fluid (CSF) in the subdural compartment is a major cause of postoperative morbidity, especially for posterior fossa surgeries. Arachnoid closure techniques, including suturing of the arachnoid and use of synthetic sealants, have been described in the literature. However, they are not always feasible or effective and have not been universally adopted. METHODS: We describe the technique of arachnoid welding for a case of brainstem cavernoma. This is a simple, cost-effective, and easily reproducible technique using readily available bipolar cautery kept at a low-current setting. At the end of surgery, the arachnoid leaflets are closely approximated, and bipolar cautery is used to seal the edges together. An illustrative video shows the technical nuances of this procedure. This technique can also be applied for arachnoid closure at other cranial and spinal sites. RESULTS: Arachnoid closure can act as an effective natural barrier to keep CSF in its physiological subarachnoid compartment. It provides an additional barrier to prevent CSF leak. It also prevents morbidity associated with adhesions and arachnoiditis. Proper closure of arachnoid makes durotomy during repeat surgery much easier and avoids injury to the underlying pia. A brief review of related literature shows the benefits of closing the arachnoid before dural closure and the different techniques that have been described so far. CONCLUSIONS: The arachnoid welding technique has a wide application, is easy to learn, and can be used especially for posterior fossa surgeries in which rates of CSF leak are the highest.

Virtual Reality in Preoperative Planning of Complex Cranial Surgery.

OBJECTIVE: Changing paradigms of neurosurgical training and limited operative exposure during the residency period have made it necessary to evaluate newer technologies for training. Virtual reality (VR) technology provides three-dimensional reconstruction of routine imaging, along with the ability to see as well as interact. The application of VR technology in operative planning, which is an important part of neurosurgical training, has been incompletely studied so far. METHODS: Sixteen final-year residents, post-M.Ch. (magister chirurgiae) residents, and fellows were included as study participants. They were divided into 2 groups based on their seniority for further analysis. Five complex cranial cases were selected and a multiple-choice question-based test was prepared by the authors, with 5 questions for each of the cases. The pretest score was determined based on performance on the test after participants accessed routine preoperative imaging. The posttest score was calculated after use of the VR system (ImmersiveTouch VR System, ImmersiveTouch Inc.). Analysis was performed by the investigators, who were blinded to the identity of the participant. Subanalysis based on the type of case and type of question was performed. Feedback was obtained from each participant regarding VR use. RESULTS: There was an overall improvement in scores from pretest to posttest, which was also noted in the analysis based on the participants' seniority. This improvement was noted to be more for the vascular cases (15.89%) compared with the tumor cases (7.84%). Participants also fared better in questions related to surgical anatomy and surgical approach, compared with questions based on the diagnosis. There was overall positive feedback from participants regarding VR use, and most participants wanted VR to become a routine part of operative planning. CONCLUSIONS: Our study shows that there is improvement in understanding of surgical aspects after use of this VR system.

Technical Nuances and Complication Avoidance in Surgery for Medullary Hemangioblastoma.

Hemangioblastomas are benign World Health Organization grade 1 tumors that are relatively rare.1 They may be sporadic or found in association with von Hippel-Lindau disease. Posterior fossa hemangioblastomas arise in the cerebellar hemisphere and, less commonly, at other sites such as medullary hemangioblastomas.2-4 Their characteristic radiologic features including solid-cystic morphology and prominent vessels aid in the preoperative diagnosis.5 In this operative video, we discuss the technical nuances and steps to avoid complications while operating on a large medullary hemangioblastoma. A 19-year-old lady presented with headache, vomiting, and visual deterioration of 2 months' duration. On examination, she had visual acuity of 4/60 right side, 6/60 left side, bilateral papilledema, and truncal and gait ataxia. Since she had presented in altered sensorium and a computed tomography head scan showed hydrocephalus, a ventriculoperitoneal shunt was placed on an emergency basis. Proper radiologic workup was done. On the basis of radiologic findings, she was provisionally diagnosed to have hemangioblastoma and surgery was planned. Preoperative angiogram showed an intense tumoral blush, but embolization was deemed infeasible since the tumor had multiple feeding vessels. Definitive surgery for tumor excision was performed 5 days after the shunt surgery. The patient's family consented to the procedure and the use of images and clinical data for publication. Video 1 highlights the tumor location, its prominent blood supply and venous drainage, use of intraoperative neuromonitoring, and the technical nuances for an en bloc excision. The patient had a left lateral gaze (sixth nerve) palsy in the immediate postoperative period, which resolved over the next 3 months. Postoperative and follow-up imaging confirmed complete tumor excision. Modern microsurgical techniques and a thorough understanding of the tumor vasculature help in performing safe and complete excision of such tumors.1,2 En bloc excision remains the mainstay of surgery for hemangioblastomas.

Mucous Extractor for Tumor Tissue Sampling in Neurosurgery.

Objective Collection of sample for histopathological analysis is highly important during any surgical procedure. The histopathology report helps determine the diagnosis, prognosis further management, and follow-up plan. The use of a reliable sample collection technique is doubly important in neurosurgical procedures because lesions are often deep-seated and difficult to access. Materials and Methods Conventional techniques of sample collection, such as use of tumor-grasping forceps and collection of material from the ultrasonic aspirator device suffer from limitations of access and unreliability. We propose a novel technique of sample collection using readily available mucous aspirator device. Results This device is economical, sterile, and disposable. It can be used even in low-resource settings because it is easily available. It can also be connected to suction cannula and the negative pressure settings can be adjusted as required. Conclusion The use of this device for neurosurgical procedures has been tried in the transcranial and transnasal neurosurgical procedures and found to be effective. The sample collected in the canister of the mucous aspirator can be directly sent to the laboratory for histopathological analysis.

The Yin and Yang of Operating on a Posterior Fossa Meningioma: The Schmahmann Syndrome.

The cerebellum is classically linked with control of motor function, such as coordination, balance, and regulation of movement. There is an increasing awareness, now, of the non-motor functions of the cerebellum, and the occurrence of behavioral anomalies with cerebellar disorders. We present the first report of Schmahmann syndrome (cerebellar cognitive affective syndrome [CCAS]) occurring secondary to posterior fossa meningioma excision. A 35-year-old lady with a posterior fossa meningioma developed an infarct of the right posterosuperior cerebellar hemisphere and ipsilateral superior vermis, following suboccipital craniotomy and tumor resection. Few days after the surgery, she presented with aggressive and emotional behavior, irrelevant talk, and emotional lability. The CCAS scale was administered, and she scored poorly on almost all parameters. A neuropsychological evaluation was also done. The occurrence of CCAS, posterior fossa syndrome (PFS), and behavioral abnormalities like abnormal pathological laughter/crying provides further clinical evidence of the "affective" functions of the cerebellum, modulated mainly by the posterior lobe and vermis of the cerebellum.

Does negative pressure wound therapy with saline instillation improve wound healing compared to conventional negative pressure wound therapy? - A randomized controlled trial in patients with extremity ulcers.

BACKGROUND: Wounds are important health problems that cause significant financial burden and loss of time to work, more so in low and lower middle income countries. Negative pressure wound therapy (NPWT) is widely established in managing acute and chronic extremity wounds. We studied the effects of addition of normal saline instillation to NPWT in terms of changes in granulation tissue, bacterial-burden and overall wound healing using readily available means and materials including wall suction for negative pressure, sponge and adhesive transparent sheet for dressing and normal saline for irrigation. METHODS: All patients with extremity ulcers initially underwent surgical debridement. They were then allotted into two groups, group 1 (NPWT with normal saline instillation- NPWTi) including 25 patients and group 2 (NPWT) including 23 patients. Tissue-bit samples taken on day1 and day 10 were used for bacteriology and for assessing histology. The wound surface-area was measured using the software ImageJ on day 1 and day 10. RESULTS: Median log difference in colony-count between day1 and day10 was 0.6 (0.2-1.4) in group1 and 0.13 (0.04-0.6) in group 2 (p < 0.05). Mean percentage reduction in wound size was 28.82 and 19.80 in group 1 and group 2 respectively (p < 0.05). Histological parameters of wound healing assessed as surface epithelium, granulation, inflammatory cells, proliferative blood-vessels and fibroblasts were significantly better in group1. A drawback observed with NPWTi was skin maceration around the ulcer which was successfully managed. CONCLUSION: Our findings suggest that wound healing is significantly better when saline instillation is combined with NPWT. It can aid in complex extremity ulcers management by reducing the size of the wound with healthier looking granulation tissue.

Giant skull vault defect in a child caused by Langerhans cell histiocytosis: the "calvaria-eating disease".

Langerhans cell histiocytosis (LCH) is a rare disease of young children that can be difficult to diagnose and treat. Clinical manifestations can sometimes be quite unusual, and bony lesions can reach a large size before treatment is sought. We present a unique case of a 3-year-old male child with a painless giant calvarial defect and cystic swelling. Complete removal of the cyst with curettage of the involved bone margins and cranioplasty was done using bone cement (polymethyl methacrylate, PMMA). However, there was a flare up of the disease due to abnormal inflammatory reaction to PMMA, and cranioplasty bone flap had to be removed. The child did well after PMMA bone flap removal.LCH should be suspected in a male child presenting with a large calvarial defect and no history of trauma. The use of materials, viz., hydroxyapatite, poly-DL-lactide (PDLLA), and PMMA for cranioplasty in LCH, may cause reactivation of the disease process and therefore must be used cautiously in these patients.

Portal Annular Pancreas: Case Report of a Rare Anomaly.

Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic parenchyma. It is an asymptomatic condition and is usually an incidental finding. It is, however, important to a surgeon because the postoperative pancreatic fistula (POPF) rates following pancreatic resection are higher in patients with this anomaly. A 47-year-old male presented with features of obstructive jaundice. He was diagnosed to have periampullary carcinoma, and pancreatoduodenectomy was planned. During surgery, uncinate process was seen extending posterior to the portal vein and was communicating with the body of pancreas to the left of the portal vein. After transection, there were two pancreatic stumps. The pancreatic duct was identified in the stump anterior to the portal vein. No duct was present in the posterior pancreatic stump. We closed the posterior pancreatic stump with interrupted polypropylene sutures and performed a duct to mucosa pancreaticojejunostomy in the anterior stump. On reviewing the preoperative computed tomography (CT) scan, we were able to identify the pancreatic tissue encasing the portal vein superior to the splenic vein. Circumportal pancreas is classified based on the orientation of pancreatic duct to the portal vein and the relationship of the aberrant pancreatic tissue with the splenoportal confluence. Following pancreatoduodenectomy, the surgeon has to manage two pancreatic stumps, one anterior and the other posterior to the portal vein. No standardised technique has been described for management of the pancreatic stumps. Every surgeon planning pancreatic surgery should be aware of this rare anomaly, and look for the same in the preoperative CT scan so that appropriate plan can be made regarding the type of pancreatic anastomosis.