An institutional study on accuracy of freehand cervical C1 C2 screws placement by knock and drill technique in craniovertebral anomalous bony anatomy: An evaluation of more than 600 screws based on SGPGI screw accuracy criteria.

Purpose: To assess the accuracy of freehand cervical C1 C2 screws placement by knock and drill (K and D) technique in craniovertebral anomalous bony anatomy. Materials and Methods: From January 2017 to December 2022, 682 consecutive C1 C2 screws in 215 patients with craniovertebral junction (CVJ) anomalies were enrolled. All patients underwent posterior fixation with K and D technique without any fluoroscopic guidance. The patient's demographic details, clinical details, radiological details, major intraoperative events, and postoperative complications were noted. The screws malposition grades and direction on CT images in the axial and sagittal plane were defined as new per proposed "SGPGI accuracy criteria." All patients had a clinical evaluation at 3-month follow-up. Results: Total 682 C1, C2 screws were placed in 215 patients for CVJ anomalies using K and D technique. The accuracy of screws placement by freehand technique was 84.46% (576/682). So with technique explained the rate of malplacement in simple (16.35%) and complex (15.19%) groups were almost comparable and comparison difference was not significant (P = 0.7005). Conclusion: The freehand technique, as described, is effective in cases of anomalous bony anatomy, and it is mandatory in complex CVJ anomalies. The accuracy of screw placement and VA injury is comparable with major studies. This technique is supposedly cost-effective and less hazardous to both health-care workers and patients.

Stereotactic biopsy for brain lesions: Doing more with less.

Objectives: Stereotactic biopsy (STB) is a potential diagnostic tool considering its minimal invasiveness, high diagnostic yield, and minimal associated complications. Over the years, various frame-based instrument systems and frameless stereotactic biopsy systems have emerged to be employed in clinical use. With this study, we intend to get more by doing less in the form of STB for the patients of doubtful intracranial lesions treated over the past 5 years. We also want to highlight the technique of performing the procedure under scalp block, which can be used as a versatile tool in many clinical scenarios. Stereotactic biopsies may be planned even in rural district-level health facilities. One-time investment to procure instruments and avail existing imaging can lead to establishing definitive diagnoses in many doubtful cases. This will result in lesser cost and early establishment of treatment. Independent risk factors determining the outcome, such as deep-seated lesions, associated edema, and intraoperative hypertension, were studied. Establishing the diagnosis helped in prognosticating the disease, explaining the natural progression of symptoms, and starting adjuvant therapy. This tissue biopsy would also help secure samples for research and molecular analysis. Materials and Methods: Twenty patients underwent STBs at our institution between January 2018 and December 2022. We retrospectively analyzed patient characteristics, tumor pathology, surgical procedures, and outcomes, including the diagnostic value and surgery-related complications. These patients were followed up, and their progression-free and overall survival were analyzed. The need for adjuvant treatment was noted and analyzed. All procedures were performed using Cosman Roberts Wells® stereotactic frame. Pre-procedure magnetic resonance scans were performed at the time of admission. Contrast-enhanced computerized tomography (CT) scan after frame application was performed to identify targets and calculate the coordinates. A post-procedure CT scan was done to confirm the accessibility of the targeted lesion. Results: The most common location of the tumor was a deep-seated thalamic lesion. A definitive diagnosis was established in 19 patients (95%) at the first STB. The diagnoses were glioma in 55% of cases, primary central nervous system lymphoma, tuberculosis, and demyelinating disorders in 10% of each, and a metastatic brain tumor in 1 (5%). The post-operative complications were all transient except in one patient with deterioration of motor weakness. The follow-up was noted, and modes of adjuvant treatment needed in these patients were recorded. Conclusion: Stereotactic biopsy is a useful and effective method for achieving a definitive diagnosis and aiding in treating multifocal or small deep-seated lesions in or around eloquent regions.

Expanding the Horizons of Minimally Invasive Spine Surgery: Experience of the Destandau Technique for the Treatment of Multiple Spinal Diseases.

OBJECTIVE: Minimally invasive spine surgery is rapidly gaining popularity because of its versatile nature. Traditionally, prolapsed disc has been the most common disease targeted using this technique. However, its usefulness for various other diseases has also been shown in studies. We present our experience of using this technique for various spinal diseases apart from prolapsed discs. METHODS: This is a retrospective study in which patients operated on by a single surgeon from January 2019 to April 2023 were included. Cases that required conversion to open technique were excluded. Intraoperative findings and postoperative courses were obtained from patient records. RESULTS: A total of 47 patients were included in the study, of whom 29 were male and 18 were female. The various diseases treated comprised intradural extramedullary (IDEM) tumors (n = 23), hypertrophied/ossified ligamentum flavum (n = 9), arachnoid cysts (n = 6), dermoid/epidermoid cysts (n = 4), detethering of cord (n = 3), and posterior cervical decompression for an ossified posterior longitudinal ligament (n = 2). The average duration of surgery was 2.1 ± 1.2 hours and the mean intraoperative blood loss was 138.4 ± 59.1 mL. The mean length of hospital stay was 2.3 ± 0.9 days. Two patients had superficial wound infection and none of the operated patients had cerebrospinal fluid leakage. Re-exploration was not required in any of the operated patients. CONCLUSIONS: Minimally invasive techniques for dealing with multiple diseases involving the spine are as good as traditional open techniques, with some additional advantages of lesser tissue trauma, early return to work, and so on. However, one must overcome the steep learning curve before adopting them in day-to-day practice.

Clip Reconstruction of Fusiform A1 Segment Aneurysm Using Lateral Supraorbital Approach.

Fusiform aneurysms of the anterior cerebral artery are a surgical rarity encountered only occasionally by a neurosurgeon.1,2 Seen most commonly in the vertebrobasilar territory, these aneurysms differ in pathophysiology and clinical presentation from their saccular counterparts. Arterial dissections and atherosclerosis are the leading causes of these aneurysms in young and elderly patients, respectively.3 Patients can present with symptoms related to mass effect/compression of adjacent structures or with ischemic symptoms apart from aneurysm rupture. Management of these aneurysms remains challenging owing to the lack of a distinct neck. Surgical options include clip reconstruction, parent vessel occlusion, or aneurysm trapping with4 and without1 bypass using a branch of the superficial temporal artery. Clipping techniques used for these aneurysms include the use of fenestrated clips, vessel wall reconstruction, and wrapping.5,6 However, due to enormous variations in aneurysm morphology, each case presents a unique challenge; hence neurosurgeons need to be aware of this important entity. Endovascular techniques including parent vessel occlusion or vessel-preserving techniques using coil or flow diverters have also been described,3 but clipping remains the preferred choice for most surgeons worldwide. In Video 1, we present a case of fusiform A1 segment aneurysm in a 34-year-old gentleman and demonstrate how the aneurysm was clipped using a lateral supraorbital approach. He made an uneventful recovery with subtle right lower limb weakness. This video shows the technique and utility of a minimally invasive skull base approach for dealing with a fusiform anterior circulation aneurysm.

Factors predicting seizure outcome after surgical excision of meningioma: SOLID-C guideline for prophylactic AED.

BACKGROUND: Seizures are commonly seen among meningioma patients and may cause impaired quality of life. These patients can be effectively treated with surgery. Still, many patients have persistent seizure episodes after surgery. The factors which are associated with worsening of seizure episodes remain critical in improving the quality of life for such patients. In this study, we aim to analyze the clinical and histopathological factors to predict the post excision seizure-outcome in meningioma and need of antiepileptic prophylaxis for these patients. METHODS: Adult patients who underwent primary resection of meningioma at our institute between 2007 and 2020 were included in the study. Eligibility criteria were as follows: (i) Surgery for newly-diagnosed biopsy proven meningioma, (ii) Presence of pre-operative seizure (iii) A follow-up period ≥ 12 months. RESULTS: Of the 1145 patients in this series, 333 patients were recruited in study. The major determinants of prophylactic anti-epileptic were tumour size (S), Oedema (O), location (L), inclusion body (I), antiepileptic drugs (D) and surgical complication (C). The factors independently associated with poor seizure control after surgical resection were presence of brain parenchyma invasion (p < 0.001), pre-operative use of > 2 antiepileptics (p = 0.016) and presence of intranuclear inclusion bodies (p = 0.001). CONCLUSIONS: The identification and consideration of factors associated with prolonged seizure control after surgery may help us to guide treatment strategies aimed at improving the quality of life for patients with meningiomas. Authors have proposed a SOLID-C guideline to avoid the blanket approach of prophylactic AED in patients undergoing for meningioma resection.

Cerebellopontine Angle Epidermoids: Comparative Results of Microscopic and Endoscopic Excision Using the Retromastoid Approach".

Background Densely packed neurovascular structures, often times inseparable capsular adhesions and sometimes a multicompartmental tumor extension, make surgical excision of cerebellopontine angle epidermoids (CPEs) a challenging task. A simultaneous or an exclusive endoscopic visualization has added a new dimension to the classical microscopic approaches to these tumors recently. Methods Eighty-six patients (age: 31.6 ± 11.7 years, M:F = 1:1) were included. Nineteen patients (22.1%) had a multicompartmental tumor. Tumor extension was classified into five subtypes. Sixty-two patients underwent a pure microscopic approach (72%) out of which 10 patients (16%) underwent an endoscope-assisted surgery (11.6%) and 24 patients (28%) underwent an endoscope-controlled excision. Surgical outcomes were retrospectively analyzed. Results Headache (53.4%), hearing loss (46.5%), and trigeminal neuralgia (41.8%) were the leading symptoms. Interestingly, 21% of the patients had at least one preexisting cranial nerve deficit. Endoscopic assistance helped in removing an unseen tumor lobule in 3 of 10 patients (30%). Pure endoscopic approach significantly reduced the hospital stay from 9.2 to 7.3 days ( p = 0.012), and had a statistically insignificant yet a clearly noticeable lesser incidence of subtotal tumor excision (0 vs. 10%, p = 0.18) with comparable cranial nerve deficits but with a higher postoperative cerebrospinal fluid (CSF) leak rate (29% vs. 4.8%, p = 0.004). Conclusion Endoscope assistance in CPE surgery is a useful addition to conventional microscopic retromastoid approach. Pure endoscopic excision in CPE is feasible, associated with a lesser duration of hospital stay, better extent of excision in selected cases, and it has a comparable cranial nerve morbidity profile albeit with a higher rate of CSF leak.

Non-aneurysmal subarachnoid hemorrhage: Is the deep venous system the hidden culprit?

AIM: The exact cause of bleeding in non-aneurysmal sub-arachnoid hemorrhage (SAH) is yet to be established. The present study intends to evaluate the morphological variants of deep cerebral venous drainage, especially basal veins of Rosenthal (BVR), and to correlate if such a venous anomaly is associated with increased incidence of non-aneurysmal SAH. METHODS: A prospective analysis of all the patients of age more than 12 years with spontaneous non-aneurysmal SAH and undergone 4-vessel DSA for the diagnosis of the source of bleeding was included in the study (n = 59). The anatomy of the basal venous distribution was evaluated and was divided into 3 different types, namely normal (Type A), normal variant (Type B), and primitive (Type C), based on DSA findings. The follow-up of these cases was noted. The three groups were compared with one another. RESULTS: The median age of presentation was 51 years with slight male predominance (52%). Primitive venous drainage was associated with a poorer grade at presentation (p = 0.002), more severe bleed (p = 0.001), vasospasm (p = 0.045), and a poorer outcome at 6 months (p = 0.019). Hydrocephalous and vasospasm were seen in patients with primitive venous drainage. On multivariate regression analysis for poorer outcome, it was observed that a worse grade at presentation, extensive bleed, primitive venous drainage are independent predictors of an adverse outcome. CONCLUSION: The presence of primitive venous drainage has a linear relationship with the development of non-aneurysmal SAH with multi-cisternal hemorrhage, worse grade at presentation, and unfavorable outcome.

A new comprehensive grading for giant pituitary adenomas: SLAP grading.

AimGiant pituitary adenomas are difficult to resect due to multicompartmental extension. We developed a new grading system for giant pituitary adenomas (GPAs) considering possible extension in superior, lateral, anterior, and posterior (SLAP) directions. We also related the degree of resection to the SLAP grading.MethodsA review of case files and radiological images of patients with the GPAs defined as pituitary adenomas with a size of more than 4 cm in any dimension was done. The extent of the tumour was noted and scored as per the SLAP system. The maximum total score is 10 and represents a large tumour with maximum extensions in all directions. The subtotal resection (STR) was defined as a residual tumour volume of more than 10%. The association between individual and total score on the degree of resection was determined.ResultsA total of 103 cases of GPAs were analyzed. All patients had a suprasellar (S) extension. The lateral (L) extension was seen in 97.3% of cases. The anterior (A) extension was seen in 28 (27.2%) cases. The posterior (P) extension was seen in 45 (43.7%). Forty-eight (46.6%) had a total score of 5 or more. The STR was achieved in 64 (62.2%) cases. On regression analysis, a total score of ≥5 was associated with odds of 5.02 (1.69-14.93), p-value 0.004 for STR.ConclusionThe SLAP grading is a comprehensive grading system that can be applied easily to the GPAs and gives a complete picture of the extension of the tumour.

Paraclinoid Segment Aneurysms of the Internal Carotid Artery: Surgical Clipping.

BACKGROUND: Paraclinoid segment aneurysms arise from the internal carotid artery (ICA) between the distal dural ring and the origin of the posterior communicating (PComm) artery. OBJECTIVE: This pictorial study presents videos showing clipping of paraclinoid segment aneurysms. MATERIALS AND METHODS: The various subtypes of these aneurysms, the nuances in the technique of clinoidectomy, and methods of proximal control are presented. RESULTS: Cavernous ICA is designated as C4, clinoidal segment (between the proximal and distal dural rings) as C5, and supraclinoid segment (between the distal dural ring up to the PComm artery as C6 segment. The techniques used for clipping various aneurysms are based upon their subtypes and location. In the first case, in a giant superior hypophyseal artery aneurysm directed toward the suprasellar region, an intradural clinoidectomy helped in accessing the neck of the aneurysm encroaching into the clinoidal segment of ICA. In the second case, concurrent bilateral "kissing" paraclinoid segment aneurysms were clipped using a unilateral approach. In the third case, clipping of a dissecting paraclinoid segment aneurysm is demonstrated. CONCLUSIONS: Surgery still represents the most definitive form of treatment. It may also be used to evacuate an intracerebral hematoma, with an extremely tortuous proximal vessel or in an aneurysm with complex anatomy, with blister aneurysms, or following aneurysm regrowth following a failed endovascular procedure. Assessing the three-dimensional anatomy of various segments of ICA is an important step.

Endoscopic Keyhole Approach for Intracranial Epidermoid.

Objective In contemporary neurosurgical practice, keyhole endoscopic approach has established its role in various neurosurgical pathologies. Intracranial epidermoid is an ideal pathology for endoscopic keyhole approach as epidermoid is well encapsulated, extra-axial, avascular, and easily suckable. The objective of this study is to share our experience of endoscopic keyhole approach for intracranial epidermoids at various locations as a new minimally invasive neurosurgical approach to deal with these lesions. Materials and Methods We conducted a retrospective study on 26 patients who underwent keyhole pure endoscopic excision of intracranial epidermoid between July 2015 and December 2019. Patient's demographics, clinical features, radiological imaging, and postoperative complications were noted. Follow-up outcome of preoperative symptoms and postoperative complications were also analyzed. Results The mean age of the study population was 30.5 years with a mean follow-up of 30 months. The common presenting features were headache, hearing loss, and trigeminal neuralgic pain. Gross total resection was achieved in 73.1% cases, while near total resection and subtotal resection were achieved in 19.2 and 7.7% cases, respectively. In the follow-up, maximal improvement was seen in trigeminal neuralgic pain (83%) and headache (66.7%). Major postoperative complications were facial nerve paresis, lower cranial nerve paresis, and transient facial hypoesthesia, most of which improved over time. None of the patients required resurgery till date. Statistical Analysis Patients' data were analyzed using SPSS software version 23 (Statistical Package for Social Sciences, IBM, Chicago, United States). Conclusion This study demonstrates that with careful patient selection, endoscopic keyhole excision of epidermoid is a good alternative to conventional microsurgical excision with comparable surgical and functional outcomes.

Seizure Outcome after Lesionectomy With or Without Concomitant Anteromedial Temporal Lobectomy for Low-Grade Gliomas of the Medial Temporal Lobe.

BACKGROUND: Mesial temporal lobe epilepsy attributed to low-grade glioma is known for intractable seizures and choice of surgery range from lesionectomy (Lo) to lesionectomy with anteromesial temporal resection (L0 + AMTR) is still debatable. We intend to analyze the seizure outcome after lesionectomy alone or with AMTR. SUBJECTS AND METHODS: Retrospective analyses of patients operated for medial low-grade temporal lobe tumors with seizures were included in the study. Preoperative records include video-electroencephalographic, magnetic resonance imaging (epilepsy protocol), and neuropsychological evaluation for language, memory, and dominance were assessed. Two groups (Lo [Group I] and Lo + AMTR [Group II]) were assessed after surgery by the international league against epilepsy (ILAE) seizure outcome scale. RESULTS: A total of 39 patients underwent Lo (n = 20) and Lo + AMTR (n = 19) with a mean age of 26.92 ± 12.96 months, and mean duration of seizures was 36.87 46.76 months. A total of 23 patients had long-term intractable seizures for >1 year despite >2 drugs(Group I [n = 10], Group II [n = 13]); remaining 16 had frequent seizures of <1-year duration. In the postoperative period, on a mean follow-up of 49.72 ± 34.10 months, the ILAE outcome scale shown a significant difference (P = 0.05) in seizure outcome between two groups. Four (40%) patients out of 10 having refractory seizures in Group I and 8 (80%) from the Group II out of 10 patients could achieved ILAE Class 1 outcome after surgery. Histopathology analysis includes low-grade astrocytoma (n = 29) and in two patients there were associated CA1 neuronal loss in hippocampus, one patient had mesial temporal sclerosis from Group II attributed to its intractability in seizures. CONCLUSION: For the mesial temporal low-grade glioma presenting with seizures, the seizure outcome by lesionectomy with AMTR is superior than lesionectomy only.

"Extra-cranial proximal pica aneurysm - a rare and surreptious cause of posterior fossa sah: case report and review of literature".

BACKGROUND: Extra-cranial posterior inferior cerebellar artery (PICA) aneurysms are rare with only 22 cases been reported so far. Intra-dural type of extra-cranial PICA aneurysm is even rarer with few case reports available. We report a previously unreported type of proximal PICA aneurysm in which the PICA aneurysm had intra-dural location at the C2 vertebral level. CASE DESCRIPTION: A 51 year old gentleman presented with sub-arachnoid haemorrhage and intra-ventricular haemorrhage, predominantly involving the fourth ventricle and had no focal neurological deficit. CT angiogram was negative however a dedicated four vessel angiogram demonstrated an abnormal extracranial origin of right PICA at C1-C2 level, with associated aneurysm in its proximal segment. A C1 posterior arch excision with partial C2 laminectomy and clipping of the aneurysm was done. CONCLUSION: Aneurysm associated with extracranial intra-dural PICA origin is a rare cause of SAH, and may not be detected with CT angiography. Such cases often require dedicated four vessel angiography, with careful study for any possibility of extra-cranial aneurysm. This variant has important surgical implication and requires preservation of the Lateral spinal artery (LSA-PICA communication), and that such aneurysm approached only with posterior cervical exposure without the need of a craniotomy. Such cases remind us the need to have an in-depth understanding of the variations of the posterior circulation.

C3 segmental vertebral artery and its surgical implication in craniovertebral junction anomalies: Insights from two cases.

A spectrum of vertebral artery (VA) anomalies have been described with or without an associated congenital craniovertebral junction (CVJ) anomalies. C3 segmental VA, where the VA enters the dura at the level of C2/3 intervertebral foramen is an extremely rare anomaly. We report two cases of congenital CVJ anomaly (irreducible in one with C2/3 fusion and reducible in the other; without any subaxial fusion but with articular agenesis at C2/3 joint on the anomalous artery side). Computed tomographic angiography revealed intraspinal intradural entry of VA through the C2/3 intervertebral foramen on the right side with the contralateral artery found crossing the atlanto-axial joint. Both the patients underwent posterior approach and C2 was spared from instrumentation in both cases. Postoperatively, the patient with irreducible dislocation recovered well while the patient with reducible dislocation expired, possibly secondary to the thrombosis of the dominant VA from C2/3 foraminal encroachment. C3 segmental VA may be advantageous in aggressively exposing the C1/2 joint but instrumentation of C2 or C3 needs caution in view of the possibility of VA injury. Our experience shows that VA may be endangered even while exposing and protecting the artery. For such cases, we recommend posterior decompression of the C2/3 neural foramen during instrumentation in the absence of associated C2/3 fusion, as an abnormal joint morphology of C2/3 indicates a C2/3 instability.

Unusual Complication of a Neglected Growing Skull Fracture.

INTRODUCTION: The growing skull fracture (GSF) is a rare complication seen after head injury in infants and young children. It occurs due to a wide skull defect with underlying dural defect and changes in pressure gradients within skull cavity. Neglected cases may develop progressive neurological deficits and complications after second head trauma. Case Discussion: We present a 14-year-old child who developed sudden-onset, diffuse, soft, fluctuant, circumferential swelling of the head after a road traffic accident. He had sustained a head injury at the age of 3-months leading to an asymptomatic soft swelling over the skull which was left untreated. Present CT scan of the brain showed a bony defect with ragged edges and cerebrospinal fluid (CSF) collection in subgaleal space circumferentially. He underwent exploration, duroplasty, and cranioplasty and had a good outcome. CONCLUSION: Neglected GSF can rupture and cause diffuse subgaleal CSF collection. It should be managed with dural repair and cranioplasty.

Occipital condyle syndrome in a case of rotatory atlantoaxial subluxation (type II) with craniovertebral junction tuberculosis: Should we operate on "active tuberculosis?"

Tuberculosis of the craniovertebral junction is rare as well as intriguing. We present a unique amalgamation of three rare entities: craniovertebral tuberculosis, occipital condyle syndrome, and nontraumatic type II rotatory atlantoaxial dislocation in one patient. We reviewed the limited literature available and the underlying pathophysiology to highlight the pattern of the disease presentation, progression, and response to management options. A 13-year-old girl presented with neck pain, torticollis, and right hypoglossal weakness following a fall from stairs 10 months back. Radiological investigation suggested right occipital condylar destruction with right-sided neck tilt and rotatory atlantoaxial dislocation. The contrast magnetic resonance imaging was suggestive of craniovertebral tuberculosis with primary foci in the right lung (apical cavitary lesion). In view of an intact neurological condition, she was started on antitubercular treatment and she continues to do well during the follow-up. It remains debatable if an anticipation of this problem calls for a surgical addressal at the acute stage of the disease as a delayed correction is likely to be more complex. While a halo device is preferable in these cases, it remains cumbersome and less preferred in comparison to the Philadelphia collar.

Predicting the Ideal Ventricular Freehand Pass Trajectory Using Osirix Software and the Role of Occipital Shape Variations.

BACKGROUND: Cannulation of lateral ventricles via a posterior approach is a common neurosurgical procedure. It is often believed that a single entry and fiducial point applies to all. No importance is given to skull shape variations, which can lead to wrong shunt positions and revisions. OBJECTIVE: A virtual-reality study was conducted to find the ideal entry point, ideal forehead fiducial point, and ideal angulation of the ventricular catheter and variations in these with changes in skull shapes. METHODS: Fifty human cadaveric skulls were used to measure anteroposterior (AP) diameter and width and to classify shape of skulls into 4 types. Hydrocephalus (100 cases) and normal magnetic resonance images (50 cases) were studied from a PACS (Picture Archiving and Communication System) database. An Osirix DICOM Viewer (3.9.4) was used to reconstruct the images and estimate the ideal, 90°, and midline shunt trajectory and correlate the same with AP/width ratios and skull shapes. RESULTS: Contrary to popular practice, the vertical distance from the inion for ideal trajectory placement was <6 cm and >4 cm in all shapes and ratio groups for hydrocephalus and nonhydrocephalus cases, respectively. As the AP/width ratio increases, the fiducial needs to be placed at a higher distance from the nasion and the distance of the entry point also increased from the inion. A rounder or more dolichocephalic skull dictates a 90° approach to be better, especially as the first pass. CONCLUSIONS: No magical external entry point uniformly applicable for all cases exists. Hence, there is a need to classify skulls according to shapes/ratios and to use a tailored approach for a freehand pass to cannulate the ventricles.

Uncommon Presentation of Isolated Jejunal Lymphoma Masquerading as Crohn's Disease.

Primary gastrointestinal lymphoma is a rare entity, commonly involving stomach, small bowel, and colorectum. The usual location for small bowel B cell lymphoma is distal ileum due to abundant lymphoid tissue. We are reporting the case of a 53-year-old lady presumptively diagnosed as Crohn's disease on clinical and radiological grounds but histopathologically proven to be an unusual variant of isolated primary non-Hodgkin's lymphoma.

Gangrenous Appendicitis: A Rare Presentation of Pericecal Hernia; Case Report and Review of the Literature.

Intra-abdominal Hernias are rare conditions usually secondary to congenital defects, with pericecal hernias accounting for a minority of them. They can be difficult to diagnose due to non-specific presentations but may lead to strangulation and thus require early management. We herein report a rare case of pericecal hernia with gangrenous appendicitis in an 88 year-old lady presenting with features of acute intestinal obstruction and right iliac fossa lump, which on exploration was found to be a pericecal hernia with knotting, strangulation, and gangrenous changes of appendix. This case highlights the need of a high index of suspicion for internal hernias and that of prompt operative intervention to avoid enterectomies and to improve outcome.