Fulminant Extra- And Intracranial Arteriovenous Thrombosis And Non-aneurysmal Subarachnoid Hemorrhage Following COVID-19 Infection.

PURPOSE: Coronavirus disease of 2019 (COVID-19) is associated with increased risk of stroke and intracranial hemorrhage. This first report of fulminant panvascular arteriovenous thrombosis with subarachnoid hemorrhage (SAH) in a post-COVID-19 infection is attributed to extensive arteriovenous inflammation leading to arterial rupture following vasculitis. CASE REPORT: We report a rare case of extensive extra- and intra-cranial cerebral arteriovenous thrombosis following COVID-19 infection, presenting as fatal non-aneurysmal subarachnoid hemorrhage. The clinical course, biochemical and radiological evaluation is discussed. The other possible etiological differentials which were analysed and ruled out during case management are also detailed. CONCLUSION: A high degree of suspicion for COVID-19 induced coagulopathy leading to extensive non- aneurysmal, non-hemispheric SAH and malignant intracranial hypertension should be entertained. Our experience and previous reports on non-aneurysmal SAH in such patients show a poor prognosis.

Endovascular management of V3 segment vertebro-vertebral fistula: case management and literature review.

Vertebro-vertebral fistula involving the V3 segment of the vertebral artery is a rare vascular pathology which is either spontaneous or traumatic in origin. We describe a post-operative traumatic vertebro-vertebral fistula in a 47-year old lady with NF-1. We review reported cases of V3 segment vertebrovertebral fistula for their incidence, aetiology, clinical presentation, treatment and outcomes using an illustrative case. Traumatic V3 segment vertebrovertebral fistula is predominantly managed with parent vessel occlusion. Per the algorithm presented, we suggest endovascular management of non-traumatic fistula be based on the anatomical variance of the contralateral vertebral artery.

Extensive anterior skull-base mesenchymal chondrosarcoma: unusual cause of multiple indolent masses on the forehead.

Primary intracranial occurrence of an extraskeletal mesenchymal chondrosarcoma (MC) is unusual. The commonly involved sites are the orbit, clivus and temporo-occipital junction. Occurrence of the lesion in the anterior skull-base (ASB) in an infiltrative manner and with extra-calvarial involvement, is anecdotal. We report the case of a 35-year-old woman who presented with two indolent swellings on the forehead for a duration of 1 year. Examination revealed impaired visual acuity and complete external ophthalmoplegia in the right eye and 5 × 6 cm and 2 × 3 cm sized hard masses on the forehead. CT and MRI revealed a large, intensely enhancing ASB mass with extensions into the right orbit, ethmoid sinus, nasal cavity, and anteriorly, into the subcutaneous tissue of the frontal scalp through erosions in the bone. At surgery via a right frontal recraniotomy, the lesion was found to be firm and very vascular. Owing to its extreme vascularity, decompression was limited to excision of the intracranial and extra-calvarial components of the lesion. Histopathology was consistent with the diagnosis of MC. The patient was advised a second stage surgery for excision of the residual lesion. She, however, opted for radiation therapy and was lost to follow-up. This report, with one of the most extensive ASB MCs described to date, adds to the list of rare differentials of indolent forehead masses in the diagnostic armamentarium of the neuropathologist.

A nondysraphic paraspinal mass and a ventricular septal defect: unusual components of diabetes-induced mesodermal derangement.

Solitary paraspinal masses in the pediatric age group commonly occur secondary to spinal dysraphism, chronic inflammatory conditions, and tumors. We describe the unusual case of a 10-year-old boy with a nondysraphic, paraspinal mass that had occurred secondary to congenital spinal epidural lipomatosis (SEL) in the setting of poorly controlled maternal type-I diabetes mellitus. The mass was picked up along with a ventricular septal defect (VSD) on an antenatal ultrasonogram. This is the first report in literature of SEL presenting as a solitary paraspinal mass at birth, and in the unusual setting of an antenatal mesodermal derangement that simultaneously engendered a VSD.

Validating the Efficacy of Two Burr-Hole Craniostomy over Mini-Craniotomy for Chronic Subdural Hematoma Drainage.

Background There is an increasing incidence of chronic subdural hematoma due to extended life expectancy and associated trauma and fall risk. This retrospective study evaluates the efficacy of two burr-hole craniotomy over mini-craniotomy. Methods Sixty-five patients were recruited over 2 years, of which 56 were male and 9 were females. A patient with a chronic subdural hematoma either underwent burr-hole craniostomy or mini-craniotomy for hematoma evacuation. Glasgow coma scale (GCS) and modified Rankin score were used to assess the neurological status and interventional outcome at discharge and follow-up, respectively. A head CT scan was performed at 3 week and 3 month follow-up. Statistical Analysis Categorical data are presented as frequency and percentage, while non-categorical data are represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using the chi-square test and p -value less than 0.05 was considered statistically significant. Results The mean age of patients was 55.6 years. Headache (35 cases), hemiparesis, and altered sensorium were seen in 20 patients, each with the main presenting symptoms. Trauma history was noted in 69.2% of patients. One (3.7%) hematoma recurrence in the burr-hole group and four (8.3%) in the mini-craniotomy group was recorded. The mean operative time was longer in the minicraniotomy group (124.2 min vs. 75.4 min; p < 0.001). A higher incidence of recurrence was noted in the craniotomy group (8.3%) than the burr-hole group (3.7%). No statistical difference in the recurrence rate, duration of hospital stay, GCS at discharge, modified Rankin score between the two study groups at discharge was noted. Conclusion Two burr-hole craniostomy is a safe and effective surgical option to treat chronic subdural hematoma. It is also validated in patients on anticoagulants and antiplatelet medications with adequate pre-surgical correction of coagulation parameters.

Assessing efficacy of instructor based orientation to donning doffing protocols and modifications to doffing area infrastructure in reducing SARS-CoV-2 infection among Doctors assigned to COVID-19 patient care.

Background: We assess the efficacy of orientation programmes for doctors of proper donning, doffing techniques for personal protective equipment (PPE) and safe practices inside the COVID-19 hospital in reducing the COVID-19 infection rate among doctors. Methods: A total of 767 resident doctors and 197 faculty visits on weekly rotation were recorded over a six month period. Doctors were guided through orientation sessions before their entry into the COVID-19 hospital from 1 August 2020. The infection rate among doctors was used to study the efficacy of the programme. McNemars Chi-square test was used to compare the infection rate in the two groups before and after orientation sessions were commenced. Discussion: A statistically significant reduction in SARS-CoV-2 infection was seen among resident doctors after orientation programmes and infrastructure modification (3% vs 7.4%, P=0.03). Twenty-eight of 32 (87.5%) doctors who tested positive developed asymptomatic to mild infection. The infection rate was 3.65% and 2.1% among residents and faculty respectively. There was no mortality recorded. Conclusion: Orientation programme for healthcare workers for PPE donning and doffing protocols with practical demonstration and trial of PPE usage can significantly reduce COVID-19 infection. Such sessions should be mandatory for all workers on deputation in designated area for Infectious Diseases and in pandemic situations.

A clinicopathological study of diagnostically challenging meningioma mimics.

The occurrence of neoplastic and nonneoplastic dural based masses that mimic meningiomas is infrequent and may not be considered during radiological and intraoperative analysis. We describe single institute study of 20 such rare cases. This study included total of 20 cases of meningioma mimics. The clinical, radiological and histopathological findings were evaluated. Tissue fixed in 10% formalin was routinely processed and 5 µ thick sections were cut and stained with hematoxylin & eosin. Histochemistry and immunohistochemistry using avidin-biotin complex immunoperoxidase method was done wherever indicated. In the present study group, 15 were male and 5 female with a male: female ratio of 3:1. The age ranged from 14 to 78 years. Radiologically all these lesions were extra-axial in location, predominantly hypointense on T2W, isointense on T1W images and showed intense homogenous enhancement on contrast administration. Four cases were in pediatric age group with histopathological diagnosis of Rosai Dorfman disease, medulloblastoma, hemangiopericytoma and malignant melanoma. In the adult population, the histopathological diagnoses were hemangiopericytoma, undifferentiated sarcoma, extraskeletal osteosarcoma, Rosai Dorfman disease, medulloblastoma, and metastases from systemic malignancies. Of the total 6 cases of metastases 1 was nonseminomatous germ cell tumor from a primary in testis, 1 was adenocarcinoma from an unknown primary, and 4 were adenocarcinoma from lung. There was a single case of dural based frontal lobe malignant melanoma with congenital hairy nevi on anterior chest wall, scalp, anterior abdominal wall and inguinal region. As the management and biologic behaviour of many of the MM are different, it is essential to familiarize ourselves to them.

Mixed schwannoma with meningioma - report on 2 cases of unusual tumor with review of literature.

We present 2 rare cases of mixed schwannoma with meningioma. The first case was sporadic, in a 38-year-old female in cervical spine (C2). The second case was a 24-year-old female, associated with NF-2, involving bilateral cerebellopontine angle with extension into the left cavernous sinus, sellar region with erosion of the petrous ridge and multiple intradural extramedullary lesions in the spinal cord suggestive of neurofibromas. To date only 12 cases of such tumors are documented in the literature. To the best of our knowledge this is the first case of sporadic mixed schwannoma with meningioma in cervical spine (C2).

Management of oculomotor nerve schwannomas in two different locations: surgical nuances and comprehensive review.

Rare tumors with anecdotal reportage, oculomotor schwannomas are most often seen in the oculomotor cistern close to the anterior clinoidal region. Adding to the small series of reported cases of this unusual lesion, we report two male patients in their second decade who presented with different degrees of oculomotor palsy. The location of the lesion was caverno-cisternal in one case and orbito-cavernous in the other. Intricate neurovascular relationships of this lesion, especially in non-cavernous locations, are discussed. The risk of damage to nerve rootlets enmeshed within the lesion is high with attempts at near-total excision, rendering the anatomical preservation of the nerve an arduous exercise. The authors review literature pertaining to this unusual lesion and elucidate surgical nuances which may have a bearing on outcome.

Fatal leptomeningeal melanoma in neurocutaneous melanosis.

We report an unusual occurrence of a primary dural-based malignant melanoma in a 13-year-old boy with neurocutaneous melanosis. The lesion presented with rapid-onset symptoms characterized by raised intracranial pressure and seizures, had an aggressive clinical course, and proved to be fatal despite two surgeries and adjuvant therapy. There should be a high index of suspicion for the occurrence of such a malignant leptomeningeal tumor in patients with congenital melanocytic nevi presenting with neurological symptoms of recent onset.

Atypical presentation of pediatric mixed germ cell tumors in the sellar-suprasellar region.

Intracranial germ cell tumors constitute a unique group of tumors, more often reported from the Asian region. Amongst them, the non-germinomatous variety occurs with a lesser frequency than the germinomatous variety. We report two children with mixed germ cell tumors with unusual clinical presentations: Central diabetes insipidus and recent-onset oculomotor palsy mimicking pituitary apoplexy. Unlike in adults, suprasellar lesions with a pituitary apoplexy-like picture in the pediatric age group may suggest a possibility of a mixed germ cell tumor.

Management of Frontal Bone Fracture in a Tertiary Neurosurgical Care Center-A Retrospective Study.

Objective We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures. Methodology A retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose. Results A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant ( p < 0.001). Conclusion Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.

Computed Tomography-Guided Catheter Aspiration and Thrombolysis of Hypertensive Basal Ganglionic Hematomas: Technique and Short-Term Outcome Comparison.

BACKGROUND: Minimally invasive techniques of hematoma evacuation with or without the use of thrombolytic agents to lyse the clots have shown promising outcomes compared to open surgical evacuation. However, there is a dearth of literature in developing nations. The objective in this study was to evacuate spontaneous hypertensive basal ganglionic hemorrhages using computed tomography (CT)-guided catheter insertion, hematoma aspiration, and lysis with thrombolytic agents and analyze the efficacy and outcomes. METHODS: Ten patients with spontaneous basal ganglionic hemorrhage underwent CT-guided clot catheter insertion, followed by aspiration of hematoma and clot lysis using 25,000 IU urokinase instilled every 12 hours. Details including symptoms, clinical and radiologic findings, efficacy of the technique, functional outcomes during follow-up, length of stay, and cost were recorded. Relevant details for 12 age- and sex-matched conservatively treated patients were compared. RESULTS: Functional outcome in the catheter group at 6 months was better than the medically managed group, with improved mean Glasgow Outcome Scale score (0.4 vs. 0.08), reduced modified Rankin scale score (-0.8 vs. -0.25), and reduced National Institutes of Health Stroke Scale score (-6.8 vs. -1.5 points). However, it was not statistically significant. Average hematoma volume reduction in the catheter group was 83.14%. In the medically managed group, 2 of 12 patients (16.6%) had hematoma expansion, 6 patients (50%) developed hydrocephalus, and 2 patients (16.6%) died. In the catheter group, 4 of 10 patients (40%) developed mild pneumocephalus that resolved. CONCLUSIONS: The evacuation of hypertensive basal ganglionic hematomas is feasible with basic neurosurgical instruments and existing resources (e.g., CT scan) with improved functional outcome compared with conservative treatment alone.

Occipital Interhemispheric Transtentorial Approach for Tumors of Posterior Third Ventricular Region: Review of Surgical Results.

Background: Controversies exist regarding the ideal surgical approach for tumors in posterior third ventricular region (PTV). Objective: To evaluate the results of occipital interhemispheric transtentorial (OITT) approach for tumors in PTV. Materials And Methods: Thirty-three patients underwent surgery via OITT approach for PTV tumors at Sri Sathya Sai Institute of Higher Medical Sciences during the study period of 5 years (June 2011-May 2016). Ideal trajectory for OITT approach was determined by neuronavigation. Endoscope was used for removing any residual lesion at the blind spots. Results: Postoperative magnetic resonance imaging (MRI) performed in all the patients revealed gross total or near-total (>95%) excision of tumor in 31 patients (93.9%). Preoperative neurological deficits improved either completely or significantly following excision of the tumor in 73.3% (11/15) of the patients. Outcome was good (modified Rankin scale ≤2) at discharge in 93.9% (31/33) and at a final follow-up of 3 months or more in 96.8% (30/31) of the patients. None of the patients died during the postoperative period. Complications included upgaze palsy (transient- 6.1% [2/33], persisting- 3% [1/33]), visual field defects (transient- 3% [1/33], persisting- 3% [1/33]), transient third nerve paresis (1/33-3%), transient hemiparesis (1/33-3%), operative site hematoma (1/33-3%), small posterior cerebral artery (PCA) territory infarct (1/33-3%), and small venous infarct (1/33-3%). At least one follow-up MRI could be performed in 23 patients. Final follow-up MRI revealed no recurrence or increase in the size of the residual lesion compared to postoperative images in 20 patients (20/23-87%) and large recurrence in 3 patients (3/23-13%) with high-grade lesions. Conclusion: Gross total/near-total excision can be performed in majority of the PTV tumors through OITT approach with minimal morbidity and mortality.

Isolated sellar tuberculoma presenting with panhypopituitarism: clinical, diagnostic considerations and literature review.

Tuberculosis, a common cause for chronic intracranial infections can mimic varied intracranial pathologies including tumours. Pituitary tuberculomas are rare lesions and are often diagnosed pre-operatively as pituitary tumours. We report a case of a 31-year-old lady with a sellar-suprasellar lesion who presented with panhypopituitarism. The patient underwent a trans-nasal, trans-sphenoidal surgical decompression of the lesion. Histopathology revealed a tuberculous lesion in the pituitary. The characteristic radiological features of sellar tuberculomas are discussed along with a review of literature. Atypical sellar radiology in the presence of a thickened pituitary stalk could point to pathology other than pituitary adenoma, possibly a chronic inflammatory condition like tuberculoma.

Fibro-osseous lesion of the pineal region resembling osteoblastoma: a case report.

A case of unusual fibro-osseous lesion resembling osteoblastoma of the pineal region is reported, in a 50-year-old man. The patient presented with a history of headache, vomiting and generalized tonic-clonic seizures. CT scan showed a hyperdense lesion in the posterior third ventricle with obstructive hydrocephalus. On histopathology the lesion showed cellular areas with oval to polygonal cells showing clear to eosinophilic cytoplasm along with focal anastomosing network of osetoid-like extracellular material lined by similar cells. The extracellular material was seen densely calcified at places with cement lines and Haversian canal formation. The cells were strongly immunoreactive for epithelial membrane antigen and focally for S-100 protein and negative for glial fibrillary acidic protein.

Cervical spine instability following resection of benign intradural extramedullary tumours in children.

BACKGROUND: Benign intradural extramedullary (IDEM) tumours in children are usually neural sheath derivatives or are dura based. Total resection of these benign tumours is the primary surgical goal. A management issue related to their occurrence in the growing paediatric spine is a higher propensity for the development of postlaminectomy kyphosis, especially in the upper cervical spine, than what is seen in adults. METHODS: A retrospective study was performed on 22 patients to analyse the incidence, presentation and management of postoperative kyphotic deformities in children who underwent laminotomy and tumour excision for benign cervical IDEM tumours. RESULTS: The incidence of postoperative kyphosis was 13%. All these patients underwent subsequent posterior fusion following reduction of the deformity with good results. CONCLUSION: Following excision of cervical intradural lesions, paediatric patients need to be followed up regularly to rule out the development of postsurgical deformities especially in the upper cervical spine region. Various biomechanical, surgical and tumour-related factors which influence the development of deformities are reviewed.

Metachronous occurrence of a temporal ganglioglioma and a bifrontal anaplastic ependymoma: coincidence or an explainable pathological curiosity?

In this first-of-its-kind report, we describe an unusual case of a 32-year-old man who harboured two biologically distinct metachronous brain tumours. He presented with features of raised intracranial pressure 8 years after total excision of a right temporal ganglioglioma. Imaging showed a heterogenously contrast enhancing bifrontal lesion with ventricular extension. Histopathological examination revealed an anaplastic ependymoma. While a co-incidental occurrence is a possibility, there could be possible mechanisms to explain this pathological oddity.

Surgical Outcome of Encephaloduroarteriomyosynangiosis for Moyamoya Disease.

OBJECTIVE: Indirect bypass surgeries for moyamoya disease have included modifications of procedures involving placement of the superficial temporal artery on the brain pial surface. We evaluate the functional and angiographic outcomes of patients treated with encephaloduroarteriomyosynangiosis (indirect) revascularization and examine the outcome in relation to demographic and radiological factors. MATERIALS AND METHODS: Patients treated surgically for moyamoya disease over a 14-year period were identified. Demographics, clinical presentation, and radiology were analyzed to assign a stage for the disease (Suzuki staging) and the extent of revascularization (Matsushima grade) at the last follow-up. A modified Rankin score was used to assess the clinical status at presentation and the functional outcome at follow-up. RESULTS: There were 46 patients operated on by a single surgeon over a 14-year period. A higher incidence of motor deficits, seizures, and speech deficits was seen in the pediatric population. Age, sex, preoperative Suzuki disease stage, and hemispheric involvement had no bearing on angiographic outcome at last follow-up. Three of 46 patients (6.5%) developed immediate postoperative complications. Among 43 patients on follow-up, 39 had stable disease or showed improvement in clinical symptoms with 90% event-free status at last follow-up. CONCLUSIONS: Indirect revascularization procedures are an effective alternative to direct cerebral revascularizations in the early or advanced stages of moyamoya disease. This is effective in a predominant ischemic presentation as noted in our series.

Contemporary Management of Distal Anterior Cerebral Artery Aneurysms: A Dual-Trained Neurosurgeon's Perspective.

Objectives Distal anterior cerebral artery (DACA) aneurysms are a subset of aneurysms located in the anterior circulation but away from the circle of Willis. We analyze the clinical presentation and outcomes of two treatment groups-surgical and endovascular-for DACA aneurysms managed by a dual-trained neurosurgeon. Material and Methods A retrospective evaluation of radiological and operative/interventional data of 34 patients with 35 DACA aneurysms over a 12-year period was analyzed. Twenty-seven patients underwent surgery, whereas seven underwent endovascular coiling of the aneurysms. Modified Fisher grade and World Federation of Neurosurgical Societies scale (WFNS) were used to note the subarachnoid hemorrhage (SAH) severity. Statistical Analysis Categorical data were presented as frequency and percentage, while noncategorical data were represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using Chi-square test, and p < 0.05 was considered statistically significant. Results Of 34 patients, 33 presented with a bleed and 23.5% patients were noted to have another aneurysm in addition to the DACA aneurysm. Patients who underwent clipping for another aneurysm along with the DACA aneurysm in a single surgical exercise had a poor outcome compared with those who underwent surgery for the lone DACA aneurysm (7 vs. 20, p = 0.015). Most patients in both surgical (70.37%) and endovascular (85.71%) groups had good outcome (mRS ≤ 2). Conclusions A good outcome can be achieved with either surgery or endovascular coiling in the management of DACA aneurysms. In patients with multiple aneurysms, SAH with aneurysmal rupture of DACA should be managed first; the other unruptured aneurysm may be operated after an interval to avoid morbidity.