Melanotic intracranial epidermoid: Case report and description of a new subtype.

Intracranial epidermoids are generally seen as hypodense nonenhancing lesions on computed tomography scans; and, as T1 hypointense and T2 hyperintense lesions on magnetic resonance imaging (MRI). Unusual radiological findings have been reported earlier. The authors present the case of a 54-year old male patient who had prior intracranial surgery. On MRI, there was a thick peripheral mantle of diffusion restriction with a central core of brilliant T1 hyperintensity and very black T2 hypointensity. The peripheral mantle showing diffusion restriction was heterogeneously T1 hypointense and T2 hyperintense. At surgery, there was a typical pearly white epidermoid peripherally with a greenish-brown centre. Pathology showed abundant extracellular melanin which was also found in the basal layer. The authors present the first case of a melanin pigmented intracranial epidermoid in literature, describing a new histological subtype.

Osteocutaneous bone flap - a useful variant of the osteoplastic flap in pediatric patients.

Traditional teaching describes two types of bone flaps in craniotomies - 'free bone flap' and osteoplastic craniotomies. While in the former, the entire bone flap devoid of soft tissue attachments is removed, in the latter the bone flap that is turned is hinged on a pedicle of temporalis muscle with the aim of retaining its vascular supply. We describe a variant of the latter in 13 pediatric patients in whom the lower margin of the craniotomy was above the attachment of the temporalis muscle and where the bone flap was lifted with all the layers of the scalp including the skin and galea, highlighting the thought process behind its performance and the advantages of the same.

Posterior listhesis of a lumbar vertebra in spinal tuberculosis.

The management of spinal tuberculosis, especially in children, is controversial. In children, vertebral destruction is more severe than adults because of the cartilaginous nature of their bone. Modern chemotherapy has significantly decreased mortality in spinal tuberculosis, but morbidity remains high. Without early surgery, patients can develop severe kyphosis leading to respiratory insufficiency, painful costopelvic impingement and paraplegia. Lumbar kyphosis results in early degenerative lumbar canal stenosis and is cosmetically unacceptable. We report a paediatric case of atypical spinal tuberculosis demonstrating the need for early surgical intervention to prevent significant spinal instability and neurologic deficit. A 12-year-old girl presented with increasing ambulatory difficulty and double incontinence 4 months after initiating treatment for pulmonary tuberculosis. There was no history of traumatic injury. Examination revealed severe lower limb neurologic deficit, with hypotonia, areflexia, marked sensory loss, and grade 0/5 power in both lower limbs. Plain radiographs and magnetic resonance imaging (MRI) demonstrated grade IV posterior listhesis of the L2 vertebral body over L3, cauda equina compression and bilateral psoas abscesses. Erosion of both the body and pedicle of L2 was observed. Both serology and pus drained from the psoas abscesses were negative for microorganisms. The patient underwent an L2 vertebrectomy via a left retroperitoneal approach. A titanium cage packed with autologous bone graft was inserted, and the spine was stabilized by fixation with screw and rods. Histopathology confirmed a diagnosis of tuberculosis. Eighteen months following the procedure, the patient has regained some power in her right leg and has completed her course of anti-tuberculous chemotherapy, but remains wheelchair-bound. To our knowledge, this is the first reported case of posterior listhesis secondary to spinal tuberculosis. Here, we discuss the possible management options in such a case, and the indications for surgery. As the global HIV/AIDS epidemic causes a resurgence in tuberculosis, increased awareness among the medical community regarding the atypical presentations of spinal tuberculosis is necessitated; both in the developing world where advanced clinical presentations are common, and in the developed world where spinal tuberculosis is an often-neglected diagnosis.

Posttraumatic retroclival acute subdural hematoma: report of two cases and review of literature.

Traumatic retroclival hematomas are uncommon lesions usually associated with significant trauma. Majority of the reported hematomas are epidural; and in the pediatric population. Retroclival acute subdural hematomas (RSDH) are very rare, with only two previous cases reported in English literature. An 18-year-old man presented with headache and no deficits following an accident. Computer tomography (CT) scan and magnetic resonance imaging (MRI) showed an acute RSDH extending into the spinal subdural space. He developed bilateral sixth nerve palsies, with symptoms of raised intracranial pressure within the next 24 hours. He underwent evacuation of hematoma with a good outcome. Another 19-year-old man presented with neck pain following a fall from a moving bus. He had no neurological deficits. CT scan showed a RSDH extending across the craniovertebral junction. He was managed conservatively with good outcome.

Complete posterior migration of intact vertebral body in spinal tuberculosis.

Spinal tuberculosis most commonly presents as a paradiscal lesion involving the disc space and adjacent vertebral bodies. Atypical forms of spinal tuberculosis have been described and are most often a result of posterior element involvement. The authors report a patient, who presented with complete posterior migration of an intact vertebral body, a complication of spinal tuberculosis that has not been reported till date. A 12-year-old girl with history of pulmonary tuberculosis presented with progressive paraparesis and back pain. Plain X-rays and MRI revealed that the L2 vertebral body had migrated posteriorly into the spinal canal, without significant movement of the posterior elements. The vertebral body was normal, with no erosion or bone loss. However, bilateral pedicle and facet joint involvement was seen. The neural elements were decompressed through an anterolateral retroperitoneal approach and the spine reconstructed. The authors present this rare manifestation of spinal tuberculosis and discuss the possible mechanisms of this presentation.

Intracranial Myoepithelioma: A Case Report and Review of Literature.

Intracranial myoepithelial tumors are extremely rare with <10 cases reported outside the sellar region. The authors describe a case of a 43-year-old male patient who presented with headache, numbness in the face, and a dumbbell-shaped lesion in the Meckel's cave clinically and radiologically suggestive of a Schwannoma. The histopathological and immunohistochemical evaluation led to a diagnosis of myoepithelioma. A review of literature reveals that this is only the ninth case of intracranial myoepithelial tumor reported, fifth benign case, and the first to be reported in the Meckel's cave region.

Cystic tuberculomas of the brain--two case reports.

A 19-year-old male presented with raised intracranial pressure and a peripherally enhanced multinodular lesion with a large subjacent cyst in the right medial frontal lobe. Surgery revealed a solid tuberculoma and an underlying cyst lined with normal brain tissue. A 22-year-old male with a history of tuberculous meningitis and hydrocephalus presented with an exophytic brain stem and a left temporal tuberculoma, which were excised in two stages. The temporal tuberculoma had a peripherally located cyst that was lined with tuberculous tissue. Intracranial tuberculomas are an important part of the differential diagnosis where tuberculosis is endemic and in immunocompromised patients. Cystic tuberculomas are uncommon. The cysts may be centrally or peripherally intralesional, or either subdural and extralesional, or occur between the lesion and the brain. The type of cyst is important to recognize preoperatively, so that adequate precautions can be taken during the excision of these lesions.