Primary intracranial peripheral PNET"--a case report and review.

The site of origin of primitive neuroectodermal tumors (PNETs) is quite varied and has significant influence on the prognosis. We report a case of intracranial peripheral PNET/Ewing's sarcoma arising from the superior tentorial surface in a 13-year-old girl. Gross total excision of the tumor was done. We have discussed the distinction between central nervous system PNET (CNS PNET) and Intracranial Peripheral PNET (pPNET/ES) as their treatment and prognosis varies radically. A review of literature shows that prognosis is better in intracranial pPNET/ES.

Idiopathic Intracranial Hypertension - Challenges and Pearls.

Idiopathic intracranial hypertension (IIH) is defined as a syndrome of raised intracranial pressure with normal imaging of the brain and cerebrospinal fluid (CSF) composition. There is a rising incidence and prevalence of this disease related to the increased prevalence of obesity. It typically affects women of working age, and headache is the predominant morbidity in over 90%. The disease is also more prevalent in young males. There are many controversies and myths that surround IIH. There are currently few treatment options for IIH, management is typically medical with those experiencing progressive visual loss undergoing surgical procedures. Weight loss and venous sinus stenting are a few therapies directed at the etiology.

Factors affecting outcome of acute cervical spine injury: A prospective study.

BACKGROUND: Injury to the spine and spinal cord is one of the common cause of disability and death. Several factors affect the outcome; but which are these factors (alone and in combination), are determining the outcomes are still unknown. The aim of the study was to evaluate the factors influencing the outcome following acute cervical spine injury. MATERIALS AND METHODS: A prospective observational study at single-center with all patients with cervical spinal cord injury (SCI), attending our hospital within a week of injury during a period of October 2011 to July 2013 was included for analysis. Demographic factors such as age, gender, etiology of injury, preoperative American Spinal Injury Association (ASIA) grade, upper (C2-C4) versus lower (C5-C7) cervical level of injury, imageological factors on magnetic resonance imaging (MRI), and timing of intervention were studied. Change in neurological status by one or more ASIA grade from the date of admission to 6 months follow-up was taken as an improvement. Functional grading was assessed using the functional independence measure (FIM) scale at 6 months follow-up. RESULTS: A total of 39 patients with an acute cervical spine injury, managed surgically were included in this study. Follow-up was available for 38 patients at 6 months. No improvement was noted in patients with ASIA Grade A. Maximum improvement was noted in ASIA Grade D group (83.3%). The improvement was more significant in lower cervical region injuries. Patient with cord contusion showed no improvement as opposed to those with just edema wherein; the improvement was seen in 62.5% patients. Percentage of improvement in cord edema ≤3 segments (75%) was significantly higher than edema with >3 segments (42.9%). Maximum improvement in FIM score was noted in ASIA Grade C and patients who had edema (especially ≤3 segments) in MRI cervical spine. CONCLUSIONS: Complete cervical SCI, upper-level cervical cord injury, patients showing MRI contusion, edema >3 segments group have worst improvement in neurological status at 6 months follow-up.

A rare case of congenital glioblastoma with atypical presentation in an eleven month-old infant: Case report with review of literature.

Glioblastoma multiforme (GBM) is the most common and malignant primary brain tumor in adults. The occurrence of this entity in infants is a rarity and portends a uniform dismal prognosis and survival in spite of all the latest available management options. The authors herein report a case of a GBM in an 11 month-old infant with tumor involving predominantly the left temporal and frontal regions who expired 10 weeks after tumor decompression. Literature and available management options have been reviewed in the context of the presented case.

Primary CNS vasculitis masquerading as glioblastoma: A case report and review.

Isolated angitis of the central nervous system (IACNS)/primary angitis of central nervous system vasculitis (PACNS) is an uncommon vascular disease, sparingly presenting as an isolated inflammatory lesion on magnetic resonance imaging (MRI). The disease usually manifests as a long-drawn and progressive ischemic event. Delay in diagnosis due to focal nature of the lesion also contributes to the poor prognosis as the dismal natural history and immunosuppressive therapy. To date, only a few cases with tumor-like isolated angitis of CNS have been reported with clear and definitive diagnostic workup.

Paradoxical response in spinal tuberculosis: Lessons learnt.

BACKGROUND: Patients with spinal tuberculosis started on antituberculous treatment (ATT) empirically and showing increasing size of the lesion on follow-up are a treatment challenge. We describe our experience in managing such cases. MATERIALS AND METHODS: We treated 80 patients with spinal tuberculosis at our institute from January 2012 to June 2014. Of these, 50 were managed by surgical intervention and the rest 30 were managed conservatively only on anti-tubercular drugs. Six patients out of these 30 patients, showed a paradoxical increase in the size of lesion without any neurological deficits after 3 months of starting ATT. Surgical intervention was done in three cases, whereas other three were managed by ultrasound-guided tapping of the lesion with continuation of ATT. RESULTS: There was an improvement in the symptoms with weight gain and normalcy of appetite. However, all these patients had lymphopenia on differential leukocyte counts at the outset which normalized at 3 months. CONCLUSION: The mainstay of management of paradoxical response in spinal tuberculosis should be conservative with drainage or aspiration of abscesses along with the continuation of ATT. Surgical decompression and stabilization may be necessary in few cases who develop new neurological deficits or deformity or instability.

Calvarial tubercular osteomyelitic abscess in an elderly.

Tuberculous osteomyelitis of skull is very rare, even in areas where tuberculosis is endemic. We herein describe an elderly woman who was apparently immunocompetent and presented with left frontal scalp swelling and right cervical lymphadenopathy. CT scan showed irregular bony destruction of the frontal bone. MRI revealed a large extradural, multiseptate, solid-cystic lesion with peripheral enhancement. FNAC from the lesion showed granulomas with caseation suggestive of tuberculosis. The lesion was debrided and she was started on anti-tubercular therapy. Deterioration of liver parameters led to change from primary drugs to liver-friendly, anti-tubercular agents. Though anti-tubercular therapy is the mainstay of calvarial tuberculosis, surgical debridement reduces the bacterial burden and probably hastens recovery.

Enigmatic intracranial cyst causing diplopia and trigeminal neuralgia.

Chronic compression by intracranial cystic lesions can cause cranial nerve palsies and bony changes. With the advent of imaging techniques, grossly accurate diagnosis is possible. However, few cases do surprise the clinicians both intra, and postoperatively. A 27-year-old male presented to us with complaints of double vision for 4 months followed by sharp, shooting pain in the left V1 and V2 distribution for 1-month duration, on examination, he had left lateral palsy and decreased pin prick and temperature sensation in V1 distribution. On computed tomography scan, a cystic lesion noted which is isodense in the middle cranial fossa with erosion of the underlying bone. On magnetic resonance imaging lesion was iso to hyperintense on T1-Weighted and hyperintense on T2-Weighted, brilliantly enhancing on contrast administration. Provisional diagnosis was trigeminal schwannoma, left temporal craniotomy and total excision of the cyst done. Histopathological examination showed cyst wall lined with collagen. Postoperatively patient neuralgic pain subsided with persisting sixth nerve palsy.

"NIMS technique" for minimally invasive spinal fixation using non-fenestrated pedicle screws: A technical note.

STUDY DESIGN: Case series. OBJECTIVE: To reduce the cost of minimally invasive spinal fixation. BACKGROUND: Minimally invasive spine (MIS) surgery is an upcoming modality of managing a multitude of spinal pathologies. However, in a resource-limited situations, using fenestrated screws (FSs) may prove very costly for patients with poor affordability. We here in describe the Nizam's Institute of Medical Sciences (NIMS) experience of using routine non-FSs (NFSs) for transpedicular fixation by the minimally invasive way to bridge the economic gap. MATERIALS AND METHODS: A total of 7 patients underwent NFS-minimally invasive spine (MIS) surgery. Male to female distribution was 6:1. The average blood loss was 50 ml and the mean operating time was 2 and 1/2 h. All patients were mobilized the very next day after confirming the position of implants on X-ray/computed tomography. RESULTS: All 7 patients are doing well in follow-up with no complaints of a backache or fresh neurological deficits. There was no case with pedicle breach or screw pullout. The average cost of a single level fixation by FS and NFS was ₹1, 30,000/patient and ₹32,000/patient respectively ('2166 and '530, respectively). At the end of 1-year follow-up, we had two cases of screw cap loosening and with a displacement of the rod cranio-caudally in one case which was revised through the same incisions. CONCLUSIONS: Transpedicular fixation by using NFS for thoracolumbar spinal pathologies is a cost-effective extension of MIS surgery. This may extend the benefits to a lower socioeconomic group who cannot afford the cost of fenestrated screw (FS).

Orbital tuberculosis with coexisting fungal (Aspergillus flavus) infection.

BACKGROUND: A coexisting invasive fungal and tubercular involvement of the skull base is a rare event. Co-infection has been reported with involvement of paranasal sinuses and middle ear cleft. CASE DESCRIPTION: We herein report a case of an elderly male diabetic patient who presented with gradually progressive visual loss, which on imaging showed an orbital lesion. Surgical decompression and microbiological evaluation showed growth of Mycobacterium tuberculosis and Aspergillus flavus. CONCLUSION: Rare combinations of such infections do exist and should be treated aggressively to achieve good outcomes in a losing battle with fastidious organisms in the backdrop of compromised immunity.

Neglected primary Ewing's sarcoma of ethmoid presenting as surgical emergency.

We present a male child with primary Ewing's sarcoma arising from ethmoid sinuses with intradural and extracranial extension (bilateral nasal cavities, orbits, and maxillary sinuses). This is a rare condition. He presented with recurrent episodes of epistaxis for 2 years, sudden onset rapidly progressive bilateral proptosis, with painful restriction of extraocular movements, and decreased visual acuity for 4 days. Sudden complete loss of vision following admission demanded emergency tumor decompression.

Novel magnetic resonance imaging scoring system for diagnosis of spinal tuberculosis: A preliminary report.

BACKGROUND: There exists a lot of ambiguity in the preoperative diagnosis of the various vertebral lesions. Mostly in these patients tuberculosis of spine (TB) is suspected due to endemicity of the disease in the Indian subcontinent. However, no definite guidelines are available to diagnose tuberculous (TB) vertebral lesions in the current literature. STUDY DESIGN: This prospective study was conducted in the Department of Neurosurgery, Nizam's Institute of Medical Sciences, from August 2009 to March 2012. AIM OF THE STUDY: To formulate non invasive methods to diagnose tuberculous vertebral lesions confidently so that the dependency on histopathologic diagnosis can be reduced. MATERIAL AND METHODS: Spinal MRI images of 45 patients suspected of having tuberculosis aetiology were included in the study prospectively. RESULTS: A total of 64 patients were analysed and 19 patients were excluded due to lack of regular follow up or histological proof. The patients were divided into two groups; those with TB of the spine and those with some other condition affecting the spine (non TB spine) based on the final diagnosis. Of the 45 patients males were 30 (66.6%) and females were 15 (33.3%). There was no significant difference in the mean age of presentation. For TB patients this was 41 ± 15.56 years and in Non TB was 43 ± 18.27 years. All patients presented with backache in either group. There was epiphyseal involvement (100%), disc height reduction (71.42%) and pedicle destruction (42.82%) in plain X-rays in the TB group. Lumbar spine was the most common affected region in our study (26.31% in non TB and 34.6% in TB group of patients). Significant P value and the Odds Ratio was found for T1 hypo intensity, T2 hyper intensity, epiphyseal involvement, disc involvement, pedicle involvement, anterior subligamentous extension, paraspinal extension and no spinous process involvement (eight parameters). The eight parameters were tested among both the groups and it was noted that scores ≥ 6 favored a tuberculous pathology whereas ≤4 were suggestive of non tuberculous etiology. CONCLUSIONS: The eight point MRI criteria of the vertebral lesions are likely to enhance the diagnostic ability of tuberculous and non tuberculous pathologies thereby reducing the dependency on histopathologic diagnosis or invasive method for early initiation of therapy.

Lumbar extradural dumbbell cavernous hemangioma: A rare lesion.

A 52-year-old female presented with slowly progressive left lower limb polyradiculopathy. MRI of the lumbar region revealed an extradural dumbbell mass at L3 vertebral level, isointense on T1W and hyperintense on T2W images with homogenous contrast enhancement and extending into paraspinal region through left L3/4 foramen. L2 to L 4 left hemilaminectomy and excision of intraspinal part of tumor was performed. Histopathological examination revealed presence of cavernous hemangioma. This case is reported because of its rarity, unusual dumbbell shape of lesion and difficulty in making a preoperative diagnosis without a coexisting bone lesion.