Immediate postoperative resolution of syrinx post-C1/C2 fixation in an operated case of foramen magnum decompression for Chiari malformation: Is Goel's procedure a rescue surgery or a gold standard?

Chiari malformation (CM) is a common neurological disorder with foramen magnum decompression (FMD) as a commonly accepted treatment. The authors present a case of CM-1 wherein there was no radiological instability preoperatively and FMD was done as a treatment, after which the patient improved transiently only to deteriorate further. Atlantoaxial fixation was done as a second-stage procedure, after which the patient improved clinically and radiologically. The knowledge of this case and surgical entity should be borne in mind before the formulation of a treatment plan. It is important that the solution is to identify and treat the underlying pathology rather than to decompress and directly manipulate the tonsils.

Endoscopic Transnasal Navigation Guided Treatment of Clivus Abscess in Adult with Mucormycosis: A Rare Report.

Osteomyelitis and abscess of the clivus are rare conditions thought to arise from contiguous spread of infection from the paranasal sinuses. Clival osteomyelitis is a rare potentially life-threatening skull base infection which is generally challenging to diagnose and treat. It is typically seen in the pediatric population and is very rare in the adult population. The exact pathophysiology of osteomyelitis of the clivus is relatively uncertain. Here, we describe a case of a 32-year-old immunocompetent female with a primary complaint of headache, with no significant medical history of diabetes, hypertension or rhinosinusitis or SARS COV-2 for the past 18 months. This case report demonstrates an image-guided and endoscopic approach to surgical localization and treatment of abscesses in the clival area.

Epidermoid Cyst of the Brainstem in 3-Year-Old Child: A Rare Case Report.

Epidermoid cysts are infrequent lesions occupying the intracranial space, comprising approximately 1-2% of all intracranial tumors. Brainstem epidermoids are exceptionally uncommon in children; up until now, only a few scattered case reports have been documented in the literature regarding this unique location. These cysts commonly arise from the inclusion of ectodermal elements during neural tube closure. Complete excision of these cysts is challenging due to their close proximity and adherence to the brainstem, which makes it difficult to achieve. As a result, recurrence of the cysts is not uncommon. We have reported a rare case of a 3-year-old with a 5-month history of progressive headache, imbalance while walking and progressive weakness in his right upper limb and lower limb along with difficulty in swallowing. On MRI Brain imaging study he had a pre-pontine epidermoid with intra-axial extension in the pons. The patient underwent retro-sigmoid/suboccipital craniotomy and microsurgical excision of the tumor, including the tumor capsule. After completing the surgery, the cavity was irrigated using a solution containing hydrocortisone and Ringer lactate to prevent the occurrence of aseptic meningitis. In the postoperative, the patient recovered without any complications, as all symptoms showed immediate improvement, and the lower cranial nerves returned to normal functioning.

Pituitary Apoplexy Presenting with Isolated Third Nerve Palsy: A Rare Case Report.

A 46-year-old female came to neurosurgery outpatient department with sudden onset of drooping of RE upper eyelid and restriction of movements in adduction, depression and elevation in right eye. Patient was a known case of diabetes mellitus whose blood sugar levels were deranged. On examination, patient was diagnosed pituitary macroadenoma. Patient was treated for her uncontrolled diabetes mellitus following which she had underwent transsphenoidal pituitary macroadenoma removal. On treatment, patient's ptosis had subsided and restriction of movement has resolved.

A rare case of subependymal giant cell astrocytoma presenting with spontaneous intratumoral hemorrhage.

ABSTRACT: Subependymal giant cell astrocytomas (SEGAs) are low-grade gliomas usually arising in the periventricular regions near the foramen of Monro seen exclusively with tuberous sclerosis complex. Incidence of hemorrhage in SEGA is less than 1% with only 10 cases reported in English literature. We present a similar case of SEGA with spontaneous intratumoral hemorrhage in a 35-year-old male with cutaneous manifestations of tuberous sclerosis complex and acute onset headache with convulsion.

Single-level ossified ligamentum flavum causing a holocord syrinx: illustrative case.

BACKGROUND: Syringomyelia is a neurological disorder that is caused by abnormal cerebrospinal fluid flow or circulation. It is an incidental finding in most cases, predominantly presenting with sensory symptoms of insensitivity to pain and temperature. Spinal ossified ligamentum flavum (OLF) leading to syringomyelia is one of the rare causes. The authors report an unusual case of syringomyelia due to a thoracic OLF. OBSERVATIONS: A 54-year-old female presented with backache, difficulty walking, spasticity in the bilateral lower limbs, tingling sensation in the bilateral lower limbs, and paraparesis for 5 years. Her radiological investigations were suggestive of an OLF causing a syrinx. She underwent laminectomy, and her syrinx resolved on subsequent follow-up. LESSONS: A syrinx due to a single-level OLF is rare, and this uncommon cause should be kept in mind while formulating treatment plans.

Unusual Presentation of Osteoid Osteoma of the Cervical Spine with Dysphagia: A Case Report.

It is uncommon for bony cervical spine lesions to cause dysphagia. Middle-aged female presented in the outpatient clinic with complaints of dysphagia of insidious onset. Patient's medical history, clinical manifestation and imaging studies guided the diagnosis of spinal osteoid osteoma. The presentation and surgical management are discussed in this report. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03835-w.

Post Mucormycosis Frontal Bone Osteonecrosis: "A Road Less Traveled During the Pandemic".

BACKGROUND: Osteonecrosis in mucormycosis is a rare phenomenon and has been reported usually following trauma or in immunocompromised individuals. Osteonecrosis of skull as a complication of mucormycosis is a rare presentation, which makes the study ever so rare and interesting. METHODS: Within 6 months, a total of 114 patients presented with mucormycosis as COVID-19 sequel, 60 of whom underwent form of endoscopic sinus debridement. Six of these 60 patients presented with frontal bone osteonecrosis and were included in the study. All 6 patients presented within a time period of 2-4 months' post FESS. RESULTS: One of the 6 patients succumbed to her illness. Another patient presented with local recurrence after 3 months, for which she underwent resurgery and debridement. The other 4 patients showed gradual recovery and are without symptoms or radiologic progression at 6-month follow-up. CONCLUSIONS: Osteonecrosis in mucormycosis is a rare phenomenon, and the 2 entities have rarely been reported together. The disease usually limits itself to the frontal bone only, and pathogenesis for spread is due to a vicious cycle of infection and ischemia. Prompt diagnosis via imaging, aggressive surgical debridement with a good antifungal cover, good patient compliance, and regular follow-up form the mainstay of treatment.

Cirsoid Aneurysm of Occipital Artery-Rare of the Rarest.

A case of 33 year old man diagnosed with a rare case of Cirsoid aneurysm of occipital artery was treated under general anaesthesia for surgical excision. An interdisciplinary approach of Neurosurgery and Oral and Maxillofacial team was made. Here we have discussed the clinical steps performed in the management of Cirsoid aneurysm of occipital artery. In-toto excision and thorough follow up has uneventfully lead to success in the outcome.

Giant Cell Tumour Of The Occipital Bone In A 13-Year Old Male.

Giant Cell Tumours (GCT) are usually found at the extremities of the long bones and their presence in the skull being less than 1%. In the skull, sphenoidal bone and temporal bone are the commonest sites. There have been very few reports of GCTs of the occipital bone. Total excision surgery is the ideal treatment of choice. If surgery poses a problem, then adjuvant radiotherapy can be administered too. We present a case of 13-year-old male child who was diagnosed with GCT of the occipital bone. He was successfully operated and is symptom free 6 months post his surgery till now.

Contrecoup Extradural Hematoma: When Hematomas Do Not Follow Rules.

Extradural hematoma (EDH) is a fairly common entity in neurosurgical practice but EDHt at a contrecoup site and crossing a cranial suture is rare. The authors present a case of EDH due to contrecoup injury in whom sutural diastases was noted and hematoma was seen to be crossing the adjacent suture. This was accompanied with subdural hematoma (SDH) at the coup site. According to the best of our knowledge, it makes the case only the 13th such to be reported in adults. A 27-year-old male patient was brought by relatives with a history of fall from a height resulting in head trauma over the left posterior parietal region. The patient presented with headache at the site of impact. Computed tomography (CT) scan of the brain revealed an undisplaced fracture of parietal bone on the left side (coup site) along with a small concavo-convex hyperdense lesion suggestive of a SDH. Scan also revealed a large biconvex, hyperdense lesion in the right frontoparietal region (contrecoup site). The hematoma was seen to be evidently crossing the coronal suture. Sutural diastases of coronal suture was suspected and the same was noticed intraoperatively. Approximately 80cc of clot was removed and hemostasis was achieved through coagulation of the middle meningeal artery and via dural hitch sutures. Contrecoup EDH across the adjacent suture with sutural diastases is rare as it does not follow the set rules of hematomas. A high index of suspicion is central in arriving at a rapid diagnosis and an early surgery to achieve a favorable outcome. The authors recommend a CT scan along all three planes along with a three-dimensional reconstruction for ready diagnosis. Contrecoup EDH with sutural diastases is a distinct and potentially dangerous entity and neurosurgeons should be aware of the same.

Neuro-Ophthalmic Manifestations of Intracranial Space Occupying Lesions in Adults.

Objectives: The purpose of this study is to evaluate the epidemiology, neuro-ophthalmic, and clinical characteristics of intracranial space occupying lesions (ICSOLs) in adult patients. Methods: All patients above 16 years presenting with brain tumors confirmed by magnetic resonance imaging and treated surgically in our institute were included in this study. Epidemiology of the patients along with neurological and ophthalmic manifestation was evaluated. Results: A total of 252 patients were included in the study ranging from 18 years to 79 years. Supratentorial location was more common than infratentorial location. The most common neurological symptom in our study was headache followed by seizures. Ophthalmic manifestations were present in (73.4%) of patients. The most common visual symptoms and signs were visual loss, strabismus, papilledema, and visual field defects. The most common histopathological diagnosis seen in our study was meningiomas followed by high-grade gliomas. Conclusion: Ocular signs and symptoms can be considered as a window to the brain through which ICSOLs can be detected. The most common neurological manifestation of ICSOL in our study was headache with or without true localizing signs and symptoms. More frequently, these patients present to an ophthalmologist before a neurosurgeon with related ocular manifestations. Hence, through our study, we emphasize the importance of a detailed ophthalmological examination in these patients which can aid in early diagnosis and prompt management of such lesions.

A Rare Case of Primary Pituitary Tubercular Abscess Mimicking a Pituitary Adenoma.

Primary pituitary tuberculosis (PTA) is a very rare disease. The clinical diagnosis is difficult as it is clinically radiologically indistinguishable from other sellar lesions. We present a case of PTA without any predisposing etiology and radiologically mimicking a pituitary macroadenoma. The patient underwent endoscopic transsphenoidal resection where pus admixed with mucoid was seen coming out of the lesion intraoperatively. Histology of the cyst wall was suspective of tuberculous etiology and QuantiFERON Tb Gold done for confirmation was positive. Postoperatively patient showed obvious improvement in visual symptoms. Patient developed diabetes insipidus and was put on desmopressin and was started with anti-tuberculosis medication for 18 months. Timely surgical intervention followed by anti-tubercular therapy and hormone replacement is the mainstay of treatment in these cases. For intraoperative management, we advise thorough wash with antibiotic and saline rather than curetting the walls of the abscess to decrease the postoperative incidence of endocrine abnormalities.

Neuroophthalmic Manifestations of Intracranial Tumours in Children.

BACKGROUND: All children between 0 and 16 years presenting with brain tumours confirmed by Magnetic Resonance Imaging (MRI) and treated surgically in our institute were included in this study. OBJECTIVE: The aim of this study is to evaluate the neuroophthalmic and clinical characteristics of intracranial space occupying lesions in children. METHODS: Neuroophthalmic manifestations along with location of the tumour by contrast-enhanced MRI, type of surgical intervention, and postoperative histopathological diagnosis were evaluated. RESULTS: In pediatric brain tumours, male preponderance was seen and supratentorial location was more common in general, while in older children, infratentorial tumours were more common than supratentorial tumours. Headache, vomiting, and cerebellar signs were the commonest neurological features. Diminution of vision, diplopia, and strabismus were the commonest ophthalmic symptoms. Papilledema, ophthalmoparesis, and nystagmus were the most frequent ophthalmological signs. Neurological manifestations of seizures, altered sensorium and motor deficits were more frequently seen in supratentorial tumours, while cranial nerve involvement and ataxia were seen in infratentorial tumours. Ophthalmological manifestations including diplopia, strabismus, ophthalmoparesis, and nystagmus were more frequently seen in infratentorial tumours. Astrocytoma was the most frequent histopathological diagnosis followed by medulloblastoma. CONCLUSION: Diagnosis of pediatric intracranial tumours is complex and requires a multidisciplinary approach for prompt management. An ophthalmologist should have a high index of suspicion for brain tumours especially in patients presenting with common ocular symptoms like diminution of vision, diplopia, and strabismus without any neurological symptoms.

Sinking Skin Flap Syndrome following Posttraumatic Hydrocephalus.

INTRODUCTION: Complications following craniotomy are not uncommon and Sinking Skin Flap Syndrome (SSFS) constitutes a rare entity that may present after a large Decompressive Craniectomy. Although the entity is widely reported, the literature mostly consists of case reports. Authors present a case series of three patients with review of literature highlighting the various factors which can prove therapeutic and can help in avoidance of complications. MATERIALS AND METHODS: The study was conducted over a period of 3 years, from 2016 to 2019, and included 212 patients who underwent unilateral Decompressive Craniectomy (DC) for trauma in our institute. All 212 patients underwent a similar DC following a strict institutional protocol and the craniectomies were performed by the same surgical team. At total of 160 patients survived and elective cranioplasty was planned at a 3-month interval. Out of a total of 160 patients who survived, 38 developed hydrocephalus, 3 patients presented with hydrocephalus acutely and had to be shunted before cranioplasty and underwent ventriculoperitoneal (VP) shunting on the opposite side of craniectomy. All 3 of these patients developed SSFS and were the focus of this case series wherein review of literature was done with emphasis being laid on the salient features towards management of SSFS in such precranioplasty shunted patients. These 3 patients were treated via rehydration using normal saline (NS) till the Central Venous Pressure (CVP) equaled 8-10 cm of water, nursing in Trendelenburg position and shunt occlusion using silk 3-0 round bodied suture tied over a "C"-loop of VP shunt tube over clavicle. This was followed by cranioplasty within 2 days of presentation using a flattened, nonconvex artificial Polymethyl Methacrylate (PMMA) bone flap with central hitch suture taken across the bone flap and release of shunt tie in immediate postoperative period. The PMMA bone flap was made intraoperatively after measuring the defect size accurately after exposure of defect. 3D printing option was not availed by any patient considering the high cost and patients' poor socioeconomic status. RESULTS: Out of a total of 212 patients, thirty-eight patients (19%) developed posttraumatic hydrocephalus and out of 38, three presented with SSFS over the course of time. Two patients presented with hemiparesis of the side opposite to sunken flap while 1 other patient was brought by relatives in stuporous state. All 3 were subjected to VP shunt tie, rehydration, and cranioplasty using flattened artificial bone flap and showed gradual recovery in postoperative period without any complications. CONCLUSION: Various factors like nursing in Trendelenburg position, adequate rehydration, early cranioplasty after resolution of oedema, preoperative tying of VP shunt and its subsequent release in immediate postoperative period, use of flattened PMMA bone flaps, placement of a central dural hitch suture across the bone, and a preoperative central burr hole in the bone flap may accelerate healing and, in most cases, reversal of sensory-motor deficits along with reduction in complication rates.

Neuroendoscopic Management of Lateral Ventricular Neurocysticercosis Presenting as Brun's Syndrome.

Background: Brun's syndrome is a phenomenon characterized by sudden onset of severe headache, vomiting associated to a vestibular syndrome triggered by an abrupt movement of the head. Case Presentation: We present a case of a 12-year-old female patient with headache, vertigo, and vomiting; magnetic resonance imaging (MRI) was suggestive of a cystic intraventricular mass in the frontal horn of the left lateral ventricle. The patient underwent endoscopic exploration for the excision of cyst with complete postoperative recovery and histopathology suggestive of intraventricular neurocysticercosis. Discussion: Brun's syndrome is caused by a mobile deformable intraventricular mass leading to an episodic obstructive hydrocephalus resulting from an intermittent or positional CSF obstruction with elevation of intracranial pressure due to the ball valve mechanism. Treatment is mainly surgical, preferably by the neuroendoscopic technique as it has an advantage of performing septostomies and third ventriculostomies in addition to cyst removal, making this procedure practical for most cases of ventricular cysticercosis even in emergencies.

A Rare Case of an Aneurysmal Bone Cyst of the Temporal Bone.

Aneurysmal bone cysts (ABCs) are benign bone lesions mainly occurring at the metaphyseal end of long bones and are a rarity in the calvarium. The reported incidence of this lesion in the skull is 1% of all the ABC. It is a benign condition that may extend intracranially. We report here a case of a 3½-year-old male child who presented with a bony hard, painless, and gradually enlarging swelling over his right temporal region. Radiological investigations and histology revealed that the lesion was an ABC. A total surgical excision was achieved despite its intracranial extension along with the involvement of dura. Prognosis is excellent with total removal as a total surgical removal of the lesion is considered curative. The rarity of the lesion along with a good surgical result despite an intracranial extension with dural involvement prompted this report.

A Rare Chronic Presentation of Schwannoma with Hemorrhage.

Spinal schwannomas are slow-growing benign tumors arising from the nerves. In the spinal cord, they arise most commonly from cervical and lumbar levels. They are mostly intradural extramedullary (IDEM) accounting for 30% of intradural tumors showing a female preponderance. They are seen occurring between 25 and 50 years of age. Most of these cases show acute presentation as hemorrhage within the tumor with weakness. This is a rare presentation by itself reported by only 12 cases world over. It is even rarer to see them show chronic presentation. We are reporting one such case of a 61-year-old female who presented to us with chronic low backache for 3 years with radicular symptoms in the bilateral lower limbs following a fall on her back. Magnetic resonance imaging was done which showed a well-defined IDEM lesion from L3 to L5 vertebral level which was isointense on T1 and hyperintense on T2 with a peripheral rim and short inversion time inversion-recovery showed fluid-fluid level within. Gradient-recalled echo showed blooming with no suppression on fat-sat and no diffusion restriction. A computed tomography angiography was done which ruled out vascular malformation. Intraoperatively, a large feeding vessel with a tumor was visualized after laminectomy was done for the corresponding levels. Postoperatively, the patient showed a significant decrease in radicular symptoms and was discharged after 2 weeks with an uneventful postoperative period. HPE of the lesion showed sheets of fascicles of elongated spindle cells arranged in loose myxoid matrix with hyperchromatic nuclei and scanty hemorrhage and lymphocytic infiltrates suggestive of schwannoma with myxoid degeneration. Immunohistochemistry also confirmed a diagnosis of schwannoma. From this case, it is seen that the diagnosis of a spinal schwnnoma showing delayed presentation with atypical imaging findings is a challenge and must needs a high index of suspicion and appropriate surgical planning.

Microendoscopic discectomy for lumbar disc herniations.

INTRODUCTION: Lumbar disc herniation is one of the main causes of discogenic low back pain and reported to affect 60%-80% of people during their lifetime. The two main surgical modalities for intervertebral disc surgery are standard open discectomy and minimally invasive discectomy which include percutaneous endoscopic lumbar discectomy and microendoscopic discectomy (MED). We report our experience with the same technique of MED to evaluate the efficacy of MED for lumbar disc pathology. AIMS AND OBJECTIVES: The aims and objectives were to study the efficacy, advantages, and associated limitations and complications of MED in lumbar disc herniations. MATERIALS AND METHODS: This study was carried out on 300 patients who had single-level herniated disc. The procedure was done by Microscopic Endoscopic Tubular Retraction System. Preoperative assessment of Visual Analog Scale (VAS) and modified Suezawa and Schreiber (MSS) clinical scoring system was documented 1 day prior to surgery. Postoperative results were determined to be excellent, good, fair, or poor according to MacNab criteria and also evaluated by MSS clinical scoring system on postoperative day 7 and after 6 months. RESULTS: A total of 187 patients were males and 113 patients were females and a majority of patients were in the age group of 31-40 years. A total of 192 patients had disc herniations at L4-L5 level. The mean operative time was 82 min and the mean hospital stay was 5.3 days. Eighteen cases (6%) developed postoperative complications including discitis, dysesthesia, recurrent prolapsed intervertebral disc, residual disc, dural tear, and nerve root injury. Mean preoperative VAS score was 8.7 and the mean postoperative VAS scores at postoperative day 7 and at 6 months were 2.25 and 1.12, respectively. The mean preoperative MSS score was 3.27 and the MSS scores at postoperative day 7 and at 6 months were 7.42 and 8.2, respectively. The overall successful outcome of the endoscopic discectomy after 6-month follow-up on the basis of VAS improvement percentage was 87.6%, MSS scoring percentage was 91.6%, and MacNab scoring percentage was 92.67%. CONCLUSION: MED is a safe and effective technique. It offers decreased blood loss, shorter operative time, shorter in-hospital stay, decreased need for pain medication, decreased rate of infection, and a shorter return to work time. Limitations of this technique include a learning curve which is related to surgery time, complications, conversion to open procedures, and recurrent disc herniation.

Abnormal Migration and Extrusion of Abdominal End of Ventriculoperitoneal Shunt: An Experience of Eight Cases.

BACKGROUND: Ventriculoperitoneal (VP) shunt is commonly used in the treatment of hydrocephalus. Migration and extrusion of the distal end of the VP shunt are relatively rarely occurring complications. AIM: To retrospectively analyze patients with extrusion of the abdominal end of ventriculoperitoneal shunts and evaluate the possible etiology and outcome. SETTINGS AND DESIGN: All patients presenting with extrusion of lower end of the shunt were included. The variables collected were age, sex, site of extrusion, time duration of extrusion, presence of local infection, meningitis, shunt dependency, and treatment received. Contrast-enhanced computed tomography of brain was carried out in all patients to rule out retrograde migration of infection in the cranial cavity. MATERIALS AND METHODS: Eight patients of abnormal migration and extrusion of lower end of VP shunt were included. RESULTS: The distal end of VP shunt was extruded from the anus (n = 3), vagina (n = 2), and anterior abdominal wall (n = 3). In five of these patients, shunt catheter was draining cerebrospinal fluid (CSF), the children were afebrile and CSF was sterile. In three children with extrusion of the shunt through the abdominal wall, the shunt tract was infected. Two of these patients had abscess in the shunt tract, which required incision and drainage. Both these patients had meningitis with a growth of Streptococcus species from CSF. Seven patients required further CSF diversion such as endoscopic third ventriculostomy (n = 3) or placement of VP shunt (n = 4). CONCLUSION: Distal tip migration of VP shunt may prove to have potentially serious complications such as meningitis. A prompt and aggressive protocol of management is recommended.