Management of a rare case of intraventricular ruptured dermoid cyst and chemical meningitis.

INTRODUCTION: Intraventricular dermoid cyst are very rare benign tumour. Due to benign nature, it may go un-noticed for years and might present with sudden rupture. Ruptured cyst can cause chemical meningitis, hydrocephalus, seizures etc. Due to lack of data, there are no defined guidelines about its management. We are reporting an interesting case of ruptured intraventricular dermoid cyst and chemical meningitis, who was managed successfully and will review the literature. CASE REPORT: A 48 years male patient was brought with complaint of sudden mental deterioration, irritability, headache, vomiting for 3 days. He had history of seizures for 1 year. On examination, his higher mental functions were deteriorated, had neck rigidity and left lower limb weakness. CT/MRI brain confirmed diagnosis of right frontal horn ruptured dermoid cyst with scattered fat droplets, hydrocephalus and ventriculitis. Excision of cyst was done via right trans-sulcal (superior frontal sulcus) approach. Patient recovered well. DISCUSSION: Intraventricular dermoid cyst are a rare benign lesion. Due to potential of rupture, it must be surgically treated. Steroids should be used to treat chemical meningitis. Various individual case reports have shown good outcome after surgical management. CONCLUSION: We recommend early surgery, thorough ventricular wash with ringer lactate, post-operative extraventricular drain and steroid cover to manage ruptured cyst and chemical meningitis.

Extensive titanium mesh invasive cranial fibrous dysplasia.

BACKGROUND: Craniofacial fibrous dysplasia (FD) is a benign lesion. It presents as bony swelling. Even after complete excision, it has a tendency to recur due to some residual lesion in normal bone. Recurrence at same site is common, but it recurs in bone. We are reporting a rare case of recurrent FD engulfing titanium mesh. CASE DESCRIPTION: A 22-year-old girl, who underwent frontal FD excision and reconstruction using titanium mesh surgery 2 years back, came with complaint of progressive bony swelling at same site for 1 year. CT head confirmed bony lesion involving mesh, frontal air sinus. She underwent complete excision of lesion and cranioplasty using bony cement. Biopsy confirmed recurrence of FD and invasion of titanium mesh. CONCLUSION: Recurrence of FD, involving cranioplasty titanium mesh, is extremely rare. It suggests local invasiveness of lesion. Recurrence can be prevented by excision of lesion with free bony margins.

A Rare Case of Intramedullary Lipoma of Brainstem to Thoracic Cord--What to Do?

INTRODUCTION: Intramedullary lipomas are rare, representing 1% of spinal cord tumors. There are less than 25 case reports about cord lipoma extending into brain. Due to paucity of literature, etiology and management are not well established. CASE REPORT: A 14-month-old baby girl was brought with complaints of torticollis toward right side, left upper limb monoplegia, and swallowing difficulty for 6 months. Magnetic resonance imaging brain and spine confirmed the diagnosis of cervicothoracic intramedullary lipoma extending till pontomedullary junction, invading subcutaneous fat. She underwent partial resection of lesion along with decompression. The recovery was good. CONCLUSION: Such lipoma needs extensive pre-, intra-, and postoperative planning. The goal should be decompression, rather than excision. Outcome is good with partial resection.

A Worst-Case Scenario-Undiagnosed Ruptured Arteriovenous Malformation Managed with Limited Resources.

BACKGROUND: Treatment of arteriovenous malformations (AVMs) is currently performed at specialized neurosurgical centers well equipped with microscopes with green filters, neurosurgical catheterization laboratories, and experienced neurosurgical teams. Patients in whom AVMs are diagnosed at smaller hospitals should be referred to such specialized centers. This case report describes the unavoidable worst-case scenario of an emergency unplanned surgical excision of an undiagnosed ruptured AVM with large hematoma. CASE DESCRIPTION: A 26-year-old man was brought to the emergency department with episodes of seizures and sudden loss of consciousness. His Glasgow Coma Scale score was 5. He had anisocoria. Computed tomography of the head showed right occipital hematoma with mass effect and herniation. Suspected diagnosis was spontaneous tumor or hypertensive bleed. Emergency surgery was performed. Intraoperatively, ruptured AVM was found. After explaining to family members about nonavailability of conventional instruments (i.e., microscope, clips, indocyanine green), we planned for excision of AVM with available resources. CONCLUSIONS: Postoperatively the patient recovered satisfactorily with right-side vision loss. He underwent cranioplasty after 6 weeks. In such a worst-case scenario, remaining calm, following basic surgical steps, using blood transfusion, and employing lateral thinking regarding using available resources can result in satisfactory management of the patient.