Posterior fossa tuberculosis: Unusual presentations of a common disease and literature review.

The burden of tuberculosis is very high in our country and though the number of deaths due to tuberculosis has drastically reduced, still the associated morbidities caused by the disease can be very debilitating.1 Central nervous system tuberculosis is a rare and serious presentation of tuberculosis, the general presentation being hydrocephalus, meningitis, and disseminated miliary lesions.2 More often than not tuberculosis is associated with immunocompromised status and central nervous system tuberculosis in immunocompetent young individuals with no evidence of systemic tuberculosis is very rare.3Association of tuberculosis with ocular manifestations and even blindness is not uncommon, the causes of blindness being causes like uveitis, retinitis, interstitial keratitis, ophthalmitis, and even orbital tuberculosis.4 Classical teaching in neurosurgery is that a posterior fossa lesion unless proven otherwise is a metastasis. Therefore, here we are discussing three cases of central nervous system tuberculosis in isolation, without any systemic involvement in immunocompetent adults in the posterior fossa region as well as a literature review of cases from across the globe of posterior fossa tuberculosis in immunocompetent adults. The first case is regarding a treatable cause like tuberculoma in an immunocompetent young adult causing blindness which is rare as well as unfortunate. The other two cases highlight the need to keep tuberculosis as a differential even when the clinical features, radiological features, and blood and other investigations are not suggestive.

A Case of Adult Orbital Intraconal Lymphangioma.

Orbital lymphangioma is an intra-orbital, nonencapsulated, congenital vascular tumor with a propensity for recurrent hemorrhage. It is a common vascular tumor in children below 10 years of age. Adult orbital intraconal lymphangiomas are very rare. The authors present a case of 68-year-old male patient presented with left eye symptoms of decreased vision, proptosis, restricted eye movement, and diplopia. The symptoms started following a trauma to the left eye 6 months back. Contrast magnetic resonance imaging scan showed a contrast enhancing well-defined 2.2 cm × 1.8 cm × 1.8 cm fairly rounded, slightly lobulated intraconal tumor in the retrobulbar region inferior to optic nerve. Patient underwent the left fronto-temporo-orbito-zygomatic (FTOZ) craniotomy. The tumor was moderately vascular, firm in consistency with lobulated surface. Few foci of hemorrhages were seen. Near total excision of the tumor was done. Histopathology and immunohistochemistry confirmed the diagnosis of orbital lymphangioma. Although rare, intraconal orbital lymphangioma should be kept in the differential diagnosis of orbital tumors presenting in adult patients following a trauma. It can radiologically mimic other intraorbital tumors. It is a surgical challenge and FTOZ craniotomy provides direct access to the orbital intraconal compartment.

Bedside Percutaneous Twist Drill Craniostomy of Chronic Subdural Hematoma-A Single-Center Study.

Background Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. Objectives This article studies the clinical and radiological outcomes in patients with CSDH who had undergone bedside percutaneous twist drill craniostomy (TDC). Patients and Methods A retrospective study was conducted in 80 patients who had undergone percutaneous TDC for CSDH between January 2017 and December 2018. Patients between 18 and 90 years of age were selected. CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, mixed density, and CSDH with hyperdense gravity-dependent fluid level were selected. CT evidence of multiple septations, recurrent CSDH, bilateral CSDH, and acute on CSDH were excluded. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline. The mass effect was determined by the effacement of the sulci, Sylvian fissure obscuration, or compression of lateral ventricles. Postoperative decrease in the signs and symptoms were considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Statistical Analysis Statistical analysis is done using Epi Info software. Results The mean age range was 67.78 years ± 12.03 standard deviation (SD). There were 49 (61.25%) males and 31 (38.75%) females. Thirty-eight (47.5%) CSDHs were on the right side and 42 (52.5%) on the left side. The locations were in the frontotemporoparietal region in 91.25% patients and in the frontoparietal region in 8.75% patients. The mean duration of symptoms was 4.62 days ± 5.20 SD. History of trauma was present in 58.75% patients. The mean duration of trauma was 45.78 days ± 28.32 SD. The most common symptoms were weakness of the limbs (68.75%), altered sensorium or decreased memory (52.5%), and headache (32.5%). The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 15 (mean 12.86 ± 2.98 SD). Limb motor weakness was noted in 75% patients. The maximum thickness of the CSDH (in millimeter) in axial CT scan was 8 to 32 (mean 23.22 ± 4.87 SD). All of the 80 patients had MLS. Postoperative GCS ranged from 3 to 15 (mean 14.1 ± 2.78 SD). Postoperative power was improved in 95% of affected limbs. Postoperative power was deteriorated (including patients of complications and death) in 5% patients. Clinical improvement was noted in 93.75% patients. Postoperative CT scan improvement was noted in 95% patients. Two patients (2.5%) had significant residue which required reoperation. Two patients (2.5%) developed extradural hematoma which was operated. Five (6.25%) patients developed complications, among which 4 (5%) patients died. The mean duration of stay in the hospital was 6.82 days ± 4.16 SD. Conclusions CSDH is a disease of elderly population. CSDH is more common in male population. The most common symptom is weakness of the limbs. High clinical and radiological improvement can be achieved with TDC. TDC should be considered as a safe and effective alternative to burr hole craniostomy.

A Case of Multiloculated Hydrocephalus.

Multiloculated hydrocephalus (MLH) is a disease in which no single treatment has shown to be superior to others. The authors report a pediatric case of postmeningitic MLH diagnosed at the age of 3 months. It was treated with antibiotics and right ventriculoperitoneal (VP) shunt. At 10 months of age, the patient again presented with gross MLH and non-functioning shunt tube. Patient underwent endoscopic fenestration of the multiple cysts along with endoscopic-guided left VP shunt. At 1 year of age, the patient again presented with MLH with large right-sided cyst. Patient again underwent right VP shunt. The child improved in postoperative period and hence discharged. Pediatric MLH is a neurosurgical challenge. The prognosis is guarded and it is not possible to assure the parents regarding the cure of the disease. Decision of treatment options is difficult since there is no end to the treatment of many such cases. Neuroendoscopy has a definite role in MLH.

Analysis of the Surgical Technique and Outcome of the Thoracic and Lumbar Intradural Spinal Tumor Excision Using Minimally Invasive Tubular Retractor System.

BACKGROUND: Conventionally, intradural spinal tumor excision requires longer skin incision, bilateral subperiosteal muscle stripping, and total laminectomy, thereby decreasing the stability of the spine and increasing the morbidity. Minimally invasive surgery (MIS) for intradural spinal tumor excision preserves the posterior supporting structures of the spine in the midline and on the contralateral side and decreases morbidity and achieves the resection of the tumor. AIMS: The aim is to analyze the surgical technique and outcome of the thoracic and lumbar intradural spinal tumor excision using minimally invasive tubular retractor system. PATIENTS AND METHODS: A retrospective study was conducted in patients admitted with thoracic and lumbar intradural spinal tumors who had undergone tumor excision using minimally invasive tubular retractor system and satisfied the inclusion and exclusion criteria. Intradural tumors involving one or two vertebral levels were included in the study. Intramedullary spinal tumor, intradural tumor extending into intervertebral foramen, and intradural tumor involving more than two vertebral levels were excluded from the study. The study included the data of the 13 patients, who were operated between January 2017 and October 2018. The age and sex of the patients were noted. Gadolinium-enhanced magnetic resonance imaging scan and X-ray of the spine were taken in all the patients. The pre- and postoperative data analyzed include pain using visual analog scale (VAS), power using Medical Research Council (MRC) grading, myelopathy using Nurick's grade, sensory changes, and bowel and bladder symptoms. The steps involved in the surgical technique, extent of resection, intraoperative blood loss, duration of surgery, postoperative complications, duration of stay after the surgery, and postoperative X-ray were analyzed. RESULTS: Out of 13 patients, one case of dorsally placed meningioma was converted to open laminectomy and excision due to nonvisualization of the spinal cord and increased bleeding from the tumor. Hence, data of the remaining 12 patients were analyzed. The histopathology of these cases was meningioma (6), schwannoma (5), and neurenteric cyst (1). There were 5 men and 7 women with age group of 27-70 years (mean: 48 years). There were 8 thoracic and 4 lumbar tumors. The duration of symptoms was 2 days to 72 months (mean: 35 months). Eight cases were predominantly occupying on the right side and 4 cases on the left side within the spinal canal. The skin incision length was 25 mm to 35 mm (mean: 28 mm). We used tubular retractors with diameter ranging from 22 mm to 30 mm (mean: 24 mm). Expandable retractors were used in 9 cases (75%) and nonexpandable in 3 cases (25%). Tubular retractor of company Jayon (India) was used in 5 cases and PITKAR (India) in 7 cases. We have not found any significant difference in the usage of both the systems. The tumor size (craniocaudal) was ranging from 9.5 mm to 38 mm (mean: 19 mm). Intraoperative blood loss was 75-200 ml (mean: 115 ml). Gross total resection was achieved in 8 cases and near-total resection in 4 cases. Dura was sutured primarily in all the cases. The dural closure was done with continuous sutures in 6 (50%) cases and interrupted in 6 (50%) cases. Polypropylene suture was used in 10 cases and polyglactin suture in 2 cases of dural closure. The authors found it easy to suture the dura using 7-0 polypropylene. Fibrin sealant was used in 9 (75%) cases. The duration of the surgery was ranging from 160 min to 390 min (mean: 260 min). Cerebrospinal fluid leak and pseudomeningocele were noted in one case. One patient developed suture site infection. VAS for pain, sensory symptoms, Nurick's grade for myelopathy, and MRC grading for power were improved in all the affected patients. Out of two patients with constipation, one patient improved and the other developed incontinence, which was recovered on follow-up after 2 weeks. Out of the 4 patients with urinary symptoms, 3 were improved. Another patient of preoperative normal micturition developed urinary retention due to exacerbation of benign prostatic hypertrophy. Postoperative X-ray showed preserved spinous process and facet joints in all cases. The duration of the hospital stay was ranging from 2 days to 11 days (mean: 6 days). CONCLUSION: Anteriorly or laterally placed intradural spinal tumors confined to the spinal canal can be excised safely and effectively using tubular retractor system, with adding the advantages of the MIS surgery. When in doubt, always convert the MIS to open surgery to avoid injury to vital structures.

Comparative Study of Single Burr-Hole Craniostomy versus Twist-Drill Craniostomy in Patients with Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly. On accounting its risk-to-benefit ratio, there was always controversy regarding the management of the CSDH as to which procedure is superior. AIMS: The aim is to compare the clinical and radiological outcomes in patients of CSDH who have undergone single burr-hole craniostomy (BHC) versus twist-drill craniostomy (TDC). PATIENTS AND METHODS: A retrospective study was conducted in patients admitted with CSDH who had undergone single BHC or TDC between January 2014 and December 2016. Patients between 18 and 90 years of age were selected. Patients with CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, and mixed density were selected. CT scan findings of CSDH with hyperdense gravity-dependent fluid level were also selected. Patients with CT evidence of multiple septations were excluded from the study. Recurrent CSDH, bilateral CSDH, and CSDH with secondary acute bleed were also excluded. Diagnosis was done using noncontrast CT scan. The maximum thickness of the CSDH was measured in the axial film of CT scan. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline in axial CT film. The mass effect was determined by the effacement of the sulci, sylvian fissure obscuration, or compression of lateral ventricles. The decrease in the signs and symptoms in postoperative period was considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of the MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan. Patients with significant residue underwent reoperation. RESULTS: There were 63 patients in BHC group and 46 patients in TDC group. The mean age in BHC and TDC groups was 61.39 ± 13.21 standard deviation (SD) and 73.36 ± 10.82 SD, respectively. There were 48 (76.19%) male and 15 (23.81%) female in BHC group. There were 32 (69.57%) male and 14 (30.43%) female in TDC group. In BHC group, 41.27% were on the right side and 58.73% on the left side. In TDC group, 50% were on the right side and 50% on the left side. In BHC group, 82.54% were in the frontotemporoparietal region, 9.52% in the frontoparietal region, 6.35% in the temporoparietal region and 1.58% in the parietooccipital region. In TDC group, 86.95% were in the frontotemporoparietal region, 8.69% in the frontoparietal region, 2.17% in the temporoparietal region, and 2.17% in the parietooccipital region. There was no significant difference in duration of symptoms and history of trauma in both the groups. The symptoms of the patients in BHC versus TDC include weakness of the limbs (44.44% vs. 73.91%), headache (50.79% vs. 32.60%), altered sensorium or decreased memory (44.44% vs. 54.4%), vomiting (19.04% vs. 6.52%), speech abnormalities (15.87% vs. 19.56%), urinary incontinence (25.39% vs. 15.21%), seizure (1.58% vs. 4.34%), and diplopia (4.76% vs. 0%). The mean preoperative Glasgow Coma Scale (GCS) score in BHC versus TDC was 13.44 ± 2.23 SD versus 12.47 ± 2.95 SD limb weakness was noted in 52.38% BHC group and 82.60% TDC group. There was significantly decreased GCS score in TDC group. The number of the patients with limb weakness on affected side was significantly more in TDC group. The mean maximum thickness of the CSDH (in millimeter) in axial CT scan was 17.22 ± 4.29 SD in BHC group and 22.21 ± 4.52 SD in TDC group. The number of patients with MLS was 59 (93.65%) in BHC group and 45 (97.82%) in TDC group. There was significant difference in thickness of CSDH in both the groups. However, there was no significant difference in MLS in both the groups. There was no significant difference in prothrombin time, International Normalized Ratio, and activated partial thromboplastin time values of both the groups. There was significant difference in platelet counts of both the groups. The mean duration of procedure (in minutes) in BHC versus TDC was 79.20 ± 26.76 SD versus 27.47 ± 4.80 SD. The duration of procedure was significantly more in BHC compared to TDC. In postoperative assessment, there was no significant difference in the GCS score, power improvement, power deterioration, clinical improvement, and improvement in CT scans of both the groups. Postoperative CSDH residue requiring reoperation was significantly more in TDC group against the BHC group (13.04% vs. 1.58%). There was no significant difference in the development of acute subdural hematoma (SDH) (4.76% vs. 8.6%), reoperation rate (6.35% vs. 17.39%), complications (9.52% vs. 15.21%), and death (4.76% vs. 10.87%) in BHC group vs. TDC group. There was no significant difference in the period of hospital stay (days) in BHC (8.90 ± 5.89 SD) and TDC groups (7 ± 4.24 SD). CONCLUSION: The duration of procedure was significantly more in BHC than in TDC. In postoperative outcome, there was no significant difference in the GCS score, motor power improvement, motor power deterioration, overall clinical improvement, and improvement in CT scans of both the groups. Postoperative residue requiring reoperation was significantly more in TDC group. There was no significant difference in the development acute SDH, reoperation rate, complications, death, and hospital stay in both the groups. Avoiding the complications of general anesthesia and giving the equal postoperative improvement and complications of BHC, the TDC is considered as an effective alternative to the BHC in the surgical management of CSDH.