Clival Tuberculosis: A Case Report.

A 39-year-old female presented with complaints of occipital headaches, diplopia, numbness over left half of face and deviation of face to the right. On examination she had hypoesthesia over left half of face, associated with bilateral abductor and left facial palsy. Neuroradiology showed a well-defined lytic lesion involving the clivus and adjacent sphenoid sinus and sella. The patient underwent an endoscopic transnasal decompression of the clival lesion. Intraoperative squash preparation was reported to show tuberculous granulation, which was confirmed on postoperative histology. The patient was advised anti-tubercular therapy. At 12 months follow up neuroradiology showed a near total resolution of the clival lesion. The patient had completely recovered from her cranial nerve deficits. Tuberculous involvement of spheno-clival region is rare and the authors' literature search has yielded only three previous similar case reports. A surgical decompression followed by anti-tubercular therapy is the recommended approach for management of clival tuberculosis. The relevant literature on the subject is presented.

Analysis of Factors Influencing Outcome of Depressed Fracture of Skull.

CONTEXT: The outcome of patients with depressed fracture varies and depends on multiple factors. There has been no previous study on the significance of these factors on the outcome of depressed fracture of the skull and hence this study. Aims: The primary aim of our study is to find the factors affecting the outcome in cases of depressed skull fracture (DSF). This will help us improve outcomes and give more accurate prediction of long-term outcomes. SETTINGS AND DESIGN: Prospective observational study. SUBJECTS AND METHODS: Institutional Ethics Committee approval was taken for doing this observational study. This was conducted in a tertiary care institute by collecting data of fifty cases of DSFs in 2 years, between January 2012 and December 2013. The study included patients who were diagnosed with DSFs admitted to our tertiary care public hospital. Patients with comorbidity involving injury to other organs or medical disorders and pediatric patients were excluded from our study. STATISTICAL ANALYSIS USED: Chi-square test and Fisher exact test. Results: There was a statistically significant impact on age, sex, Glasgow Coma Scale (GCS) score at presentation, type of DSF, and site of DSF in the long-term outcome of patients. The patients with GCS score of 13 or more fared well with good long-term outcome as against those with GCS score below it. Any additional brain injury in the form of hematomas, etc., has a significant negative impact on long-term outcome of the patient and warrant urgent surgical intervention. Complications such as dural tear, cerebral contusions, wound infections, and seizures have adverse effect on the recovery. CONCLUSIONS: Our observation suggests that patients brought to hospital with minimal delay, with GCS score between 13 and 15, with simple DSF and normal brain parenchyma without dural tear, have the best outcome.

Transthoracic approach for ventrally situated paraspinal extradural hydatid cyst of the dorsal spine.

A 40-year-old female presented with back pain without any neurological deficits. Radiological investigations revealed a ventrally situated paraspinal lesion causing widening of the right D4 neural foramen. She underwent a right posterolateral thoracotomy and excision of the lesion in toto, which was reported as a hydatid cyst on histology. Ventrally situated paraspinal extradural hydatid cysts are rare. A Transthoracic surgical exposure offers a direct approach for complete excision of the lesion, minimizing the chances of rupture and spillage.

Coexistent intracerebral metastatic melanoma and meningioma.

Coexistence of multifocal neural crest tumors, namely meningioma, melanoma, and nerve sheath tumors, is termed as neurocristopathy. Neurofibromatosis is the commonest form of neurocristopathy. We report a rare case of frontal lobe metastatic melanoma coexistent with a parietal lobe meningioma, in the absence of any stigmata of neurofibromatosis.

Transthoracic approach for lesions involving the anterior dorsal spine: A multidisciplinary approach with good outcomes.

INTRODUCTION: Anterior approach provides excellent visualization and access to the anterior thoracic spine. It may be used alone, in combination with a posterior midline approach or in a staged or sequential fashion. AIMS: To analyse our institutional experience in transthoracic approaches and to determine the safety and benefit of this approach in our patient series. MATERIALS AND METHODS: A total of 16 patients were operated for varying lesions of body of dorsal vertebra by the transthoracic approach. The study was for a period of 5 years from January 2011 to December 2015. Patients age ranged from 25 to 61 years with an average of 36.4 yrs. There were 7 males and 9 females. In our series 9 patients had Kochs spine, 4 patients were traumatic fracture spine and 3 had neoplastic lesion. Majority of patients had multiple symptoms with backache being present in all patients. RESULTS: There was one post operative mortality which was unrelated to surgery. One patient had post operative delayed kyphosis. Remaining patients improved in their symptoms following surgery. CONCLUSION: With careful coordination by thoracic surgeons, neurospinal surgeons and anaesthetists, the anterior spine approach for dorsal spine is safe and effective. Adequate preoperative evaluation should stratify the risk and institute measures to reduce it. Accurate surgical planning and careful surgical technique are the key to yield a good outcome and to reduce the risk of complications.

Outcome Analysis in Cases of Spinal Conus Cauda Ependymoma.

INTRODUCTION: One half of all central nervous system ependymomas, arise within the spinal canal and about 40% of these arise from filum terminale. The myxopapillary variant of spinal ependymoma almost exclusively occurs in the lumbosacral region and they are histologically designated as Grade I. Long term control is best achieved by gross total removal at the initial operation. There is as yet no consensus on the management of incompletely excised tumour. Opinions regarding radiotherapy are controversial and the indications are empirical. AIM: In the present study, we investigated the clinical characteristics and long-term outcomes in patients with conus cauda ependymoma that were managed at our center with baseline comparison of our findings with those reported in literature. MATERIALS AND METHODS: A retrospective analysis of 44 cases of conus cauda ependymoma tumours treated at the Department of Neurosurgery at a tertiary care centre from January 2001 to December 2015 was done. Detailed scrutiny and analysis of the patient's data with respect to the demographic features, clinical findings, investigative procedures, extent of surgical resection, intra and postoperative complications, efficacy of adjuvant therapy, postoperative results and long term follow-up were done. RESULTS: The analysis was done in 44 patients with conus cauda ependymoma over a period of 15 years. The mean age of presentation was 31 years. Incidence of male predominance was noted. Average duration of presenting features was 10 months. Back pain and motor weakness in the lower limbs were the commonest clinical findings. Total excision of the tumour was possible in 89% cases. Myxopapillary ependymoma was the commonest variant. Radiotherapy was only given in patients with near total to subtotal excision of tumour. Back pain and motor weakness improved in majority of patients after surgery. There is limited role of radiotherapy in cases with total tumour excision. CONCLUSION: Conus cauda ependymomas are relatively benign tumours. The long term prognosis is excellent with respect to recurrence and functional outcome in cases with complete tumour excision. Early diagnosis and surgery will prevent occurrence of permanent neurological deficits. Radiotherapy can be given in cases of subtotal excision but there is limited role of radiotherapy in cases with total tumour excision.

Spontaneous Resolution of Non Traumatic Chronic Subdural Haematoma Despite Continued Antiplatelet Therapy: A Case Report.

Spontaneous resolution of traumatic chronic subdural haematoma (CSDH) has been reported in literature. However, those with non traumatic CSDH are exceedingly rare and none reported with continued antiplatelet therapy where it itself is an aetiological agent for development of non traumatic CSDH. A 50-year-old male presented to us with a non haemorrhagic cerebellar infarct with a concomitant CSDH without history of any trauma. Patient's PT/INR, Bleeding time and Clotting time were normal. Patient was started on antiplatelet therapy (Tablet Aspirin 150 mg OD) for the acute infarct. MR Brain at 1 month showed an increased size of CSDH. However patient denied surgical evacuation hence we continued conservative line of management, however we continued anti-platelet therapy with close neurological and coagulation profile monitoring that remained within normal range throughout the period of observation. CT at 5(th) month showed complete resolution of CSDH. Patient was on antiplatelet drugs throughout the period of observation. Our case argues about the role of antiplatelet therapy in patients with CSDH with contrary lesions requiring anticoagulation.

Giant parietal lobe infantile gliosarcoma in a 5-year-old child.

The relative frequency of pediatric gliosarcoma (GSM) is 1.9% among glioblastomas and 0.5% among pediatric central nervous system tumors. A 5-year-old female child came to us with history of fever and loss of appetite since 2 weeks and right sided weakness since 4 days. Magnetic resonance imaging showed a large heterogeneously enhancing space occupying lesion in the left parieto-occipital region. A parieto-occipital craniotomy with radical excision of tumor was performed. The patient was given adjuvant therapy following surgery and survived until 9 months following surgery. The etiopathogenesis, treatment modalities and prognosis of GSM is discussed.

Cavernoma of the conus medullaris mimicking transverse myelitis.

We present an interesting case of conus medullaris cavernoma that was initially treated as transverse myelitis. Haemorrhagic lumbar puncture led us to perform magnetic resonance (MR) imaging, which showed the presence of a cavernous angioma at the D12-L1 level. The total excision of the lesion was followed by dramatic improvement. We suggest that MR imaging be performed early in all suspected cases of transverse myelitis so that emergency surgical intervention can be offered before the development of permanent neurological deficits.

Grave's disease with transverse and sigmoid sinus thrombosis needing surgical intervention.

Thrombosis of venous sinuses associated with thyrotoxicosis is rare, and isolated transverse and sigmoid sinus thrombosis is rarer and reported only once previously. We present a case of Graves disease, who suffered unilateral sigmoid and transverse sinus thrombosis with intracranial hemorrhage. A 42-year-old female, a diagnosed case of Graves disease, presented to us with headache, drowsiness, and hemiparesis. Computed Tomography revealed a large right temporo-parieto-occipital venous infarct. The patient needed surgical intervention in the form of decompressive craniotomy following which she improved, and on follow-up is having no deficits. Thrombophilia profile showed a low Protein S and Anti thrombin III (AT III) levels. Deranged thrombophilia profile in combination with the hypercoagulable state in thyrotoxicosis, most likely precipitated the thrombotic event. Timely surgical intervention can be offered in selective cases with a good clinical outcome.

Posterior fossa involvement in a recurrent gliosarcoma.

Gliosarcoma (GSM) is a WHO grade 4 tumor and a variant of glioblastoma multiforme with predilection for the temporal lobe. We record, perhaps the first case in literature, of a temporal lobe GSM with recurrence involving the posterior fossa. A 50-year-old man presented to us with headache, vomiting, and lethargy of relatively recent onset. Magnetic resonance imaging revealed a well-circumscribed lesion in the left temporal lobe for which left temporal craniotomy with radical excision of the tumor was performed. Histopathology was suggestive of GSM. He presented to us within a month of the first surgery with a large recurrence involving the temporal lobe. He underwent a second surgery with radical excision of the tumor. Histopathology was confirmatory of GSM. He was administered concomitant chemotherapy and radiotherapy. Within a fortnight of starting adjuvant therapy, the bone flap started bulging and a repeat computed tomography scan revealed a large recurrence extending into the posterior fossa. The patient's relatives refused consent for third surgery and he finally succumbed on postoperative day 21. GSMs are aggressive tumors that have a temporal lobe predilection, but they may present anywhere in the brain. Detailed studies on larger cohort of cases are needed to understand the true nature of these biphasic tumors.

Everted skull fracture.

OBJECTIVE: Skull bone fractures are common in trauma. They are usually linear undisplaced or depressed; however, a distinct possibility of elevated fracture remains. We describe an entity of everted fracture skull in which the fracture segment is totally everted. The nature of trauma, management, and complications of this unique case are discussed. CASE REPORT: A 21-year-old woman involved in a railway accident presented to us with a primary dressing on her wound. Investigations revealed an everted fracture skull. She underwent surgery with good results. CONCLUSION: We would like to add everted fracture skull to the nomenclature describing skull fractures in addition to elevated compound fracture skull as a new entity.

Intramedullary enterogenous cyst of the conus medullaris presenting as lower limb pain.

Enterogenous cysts account for 0.7-1.3% of spinal axis tumors. Cervical and thoracic segments are most often affected and they are rare in the lumbar region. Intramedullary variant which comprises less than 5% of enterogenous cysts are densely adherent to the surrounding tissue and preclude total excision. Partial excision is associated with recurrence and is the most common unfavorable outcome in these cysts. Hence, such patients need follow-up with serial imaging. We describe a case of conus medullaris enterogenous cyst presenting as lower limb pain. Due to dense adhesion of the cyst to the surrounding neural tissue, subtotal excision was done. The patient is symptom and tumor free at one year interval. We describe our case, discuss its uniqueness and review the literature on this rare but difficult to cure tumor.

Giant primary ossified cavernous hemangioma of the skull in an adult: A rare calvarial tumor.

Primary intraosseous cavernous hemangiomas (PICHs) of the cranium are rare benign vascular tumors that account for about 0.2 % of all bone tumors and 10 % of benign skull tumors. They generally present as osteolytic lesions with honeycomb pattern of calcification. Completely ossified cavernous hemangioma of the calvarium in an adult has not been reported previously. A 28-year-old female presented to us with a large right parietal skull mass that had been present since the last 15 years. Total resection of the lesion was performed. Pathological examination was suggestive of cavernous hemangioma of the skull bone. Cavernous hemangioma should be considered as one of the differential diagnosis in any case of bony swelling of the calvarium so that adequate preoperative planning can be made to minimize blood loss and subsequent morbidity.

Langerhans' cell histiocytosis involving posterior elements of the dorsal spine: An unusual cause of extradural spinal mass in an adult.

Langerhans cell histiocytosis (LCH) is a clonal proliferation of Langerhans cells occurring as an isolated lesion or as part of a systemic proliferation. It is commoner in children younger than 10 years of age with sparing of the posterior elements in more than 95% of cases. We describe a case of LCH in an adult female presenting with paraplegia. MRI revealed a well-defined extradural contrast enhancing mass at D2-D4 vertebral level involving the posterior elements of spine. D2-5 laminectomy with excision of lesion was performed which lead to marked improvement of patients neurological status. Histopathology was suggestive of eosinophilic granuloma. We describe the case, discuss its uniqueness and review the literature on this rare tumor presentation.

Primary calcified hydatid cyst of the brain.

Cerebral hydatid disease is very rare, and in non-endemic areas like India, the occurrence is as low as 0.2% of all intracranial space occupying lesions. Calcification of the cyst wall indicates an even rarer subvariety, i.e., alveolar echinococcosis (AE). AE has hitherto been unreported in the Indian subcontinent. We report such a case in a 25-year-old male, a shepherd by occupation, who presented to us with intractable seizures and headache. He had no gross lesion in the liver. Craniotomy with total excision of the lesion was performed, followed by antiparasitic treatment. The radiological presentation, differential diagnosis and treatment modalities are discussed in relation to our case.