Endovascular Management of Falcine Dural Arteriovenous Fistula-A Case Report and Review of Literature.

Cranial dural arteriovenous (AV) fistulas are abnormal connections between the branches of dural arteries to dural veins or venous sinuses. They are most frequently located at the transverse sinus and cavernous sinus. They can occur at every cranial dural sinus. Dural AV fistula of falx cerebri is rare. A 62-year-old female presented with signs and symptoms of raised intracranial pressure. Radiological imaging revealed a dural AV fistula at the posterior one-third falx cerebri. She underwent transarterial embolization, and complete obliteration of the fistula was achieved. A detailed digital subtraction angiography study is warranted in patients with seemingly benign complaints like recurrent headaches, and falcine dural AV fistula should be identified and treated in the nick of time. We describe a very rare falcine dural AV fistula case and its management.

Carotid Endarterectomy and Carotid Artery Stenting for Symptomatic Carotid Stenosis: An Experience of a Hybrid Neurosurgeon in a Developing Nation.

Background: Stenosis of the ICA is an important cause of ischemic stroke and associated morbidity and mortality. Carotid artery stenting (CAS) and carotid endarterectomy (CEA) help to prevent impending or subsequent ischemic stroke in such patients. Aim and Objective: To study the outcome and adverse events associated with CEA and CAS. To determine the generalization of results obtained with multicentric trials such as CREST, etc., by comparing the results obtained by a single neurosurgeon in a community setting. Material and Methods: From Jan 2014-Dec 2017, 80 patients presented with symptomatic carotid stenosis. Out of these 80 patients, 65 underwent intervention; 34 patients underwent CEA and 31 patients underwent CAS. Pre-defined variables like age, sex, and degree of stenosis were assessed as potential risk factors, and the patients' clinical features, radiological imaging, and procedural complications were documented. Results: The primary outcome of procedure-related stroke, major adverse events (MAEs), and death at 30 days follow-up and long-term outcomes of restenosis at 1 year were analyzed. Peri-procedural stroke occurred in 2 cases (6.4%) of CAS; one suffered an ischemic stroke and other suffered a hemorrhagic stroke. Three cases of CEA suffered procedure-related events; one (2.9%) suffered TIA while the other two developed postoperative local hematoma without neurological deficit; one was treated conservatively while the other required re-exploration due to pressure symptoms. Restenosis occurred in one case that underwent CAS. Conclusion: CAS and CEA are complementary approaches in treating symptomatic carotid stenosis even when performed by a single hybrid neurosurgeon as results obtained are commensurable to major studies like CREST.

Life-threatening perforating brain injury by a rusty iron rod - A case report.

Background: When an object traverses through the cranium leaving behind both an entry and exit wound, it is called perforating brain injury. Perforating open brain injury is rare. A paucity of published literature on such cases and a lack of a standard management protocol pose significant challenges in managing such cases. Case Description: We present a case of a 24-year-old man who worked as a carpenter at the construction site. He slipped while working and fell from a height of 13 feet onto a rusty, vertically placed 3 feet iron rod located on the ground. Iron rod entered his body from the right upper chest, came out from the neck, and again re-entered through the right upper neck medial to the angle of the mandible and finally came out from the posterosuperior surface of the right side of the head. He presented to the emergency department in a conscious state, but his voice was heavy and slow-paced, and he showed signs of lower cranial nerve palsy on the right side. He underwent numerous radiological investigations. The iron rod was removed in the operation theater under strict aseptic precautions. On day 7 after surgery, he developed right lobar pneumonia, and on day 21, he developed an altered sensorium, followed by a loss of consciousness. He did not regain consciousness and, unfortunately, succumbed after 30 days of sustaining the injuries. Conclusion: Perforating open brain injuries are rare, especially in civilian society, and are usually associated with significant morbidity and mortality. Due to a lack of standard guidelines for managing such severe injuries and limited knowledge, many patients with these injuries do not survive. Although each case presents differently, certain management principles must be followed.

Ventral Craniovertebral Junction Arachnoid Cyst in an Elderly Patient-A Case Report of a Unique Occurrence at Extremes of Age.

BACKGROUND: Craniovertebral junction arachnoid cysts are uncommon. Among those reported, ventrally located arachnoid cysts at the extremes of age have been even rarer. We report a successfully managed case of a ventrally placed arachnoid cyst in an 88-year-old man using an unconventional surgical approach. CASE DESCRIPTION: An 88-year-old man presented to us with complaints of tingling and numbness in both upper and lower limbs. He had a weak handgrip on both sides. Spinal magnetic resonance imaging (MRI) showed a non-contrast-enhancing cystic lesion over the anterior lip of the foreman magnum that had displaced the cervicomedullary junction posteriorly. The lesion was homogenously hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI. The lesion was excised using a posterior approach. The cyst contents were drained, followed by complete wall excision. Complete improvement in clinical symptoms and an absence of neurological deficits were noted in the patient. CONCLUSION: Arachnoid cysts are congenital lesions and can present at the extremes of age. Ventrally placed small symptomatic arachnoid cysts can be managed successfully through the posterior approach, especially in the elderly population.

Concurrent Spinal Epidural Tubercular and Pyogenic Abscess of Cervical Spine without Bony Involvement.

Spinal epidural abscess (SEA) presents with vertebral body involvement. SEA is mostly pyogenic in developed countries, but in developing countries, tuberculosis is more common cause. Young female presented with fever, neck, and right upper limb pain for 1 month followed by acute onset weakness in the right upper limb. Magnetic resonance imaging study of cervical spine showed contrast-enhancing lesion in C2-C3 epidural region. Surgery-aided by initiation of antibacterial and antitubercular treatment based on culture and histopathological study of pus helped us to get good clinical outcome. One should always keep in mind possibility of tubercular abscess while treating cases of spinal epidural lesions, though it is rare in the absence of osseous involvement. Pyogenic and tubercular abscess can present concurrently and sending pus for culture and sensitivity is must as it plays important role in identifying dual organisms.