Spontaneous resolution of a small extradural haematoma in a child.

We report the rapid spontaneous resolution of a small extradural haematoma (EDH) in a 19-month-old child. The haematoma was managed conservatively. The child went on to make a full recovery. The authors discuss the significance of this surprising clinical finding.

Alkaptonuria presenting with ochronotic spondyloarthropathy.

Alkaptonuria is a rare autosomal recessive metabolic disease that leads to the deposition of homogentisic acid. Ochronotic arthropathy is the articular manifestation of alkaptonuria with the most common clinical feature being severe spondyloarthropathy. We present the case of a 58-year-old woman with back pain. Radiographs and magnetic resonance imaging (MRI) revealed characteristic features of ochronotic spondyloarthropathy. The literature regarding management of alkaptonuria is reviewed.

Intraparenchymal pericatheter cyst following ventriculoperitoneal shunt insertion: does it always merit shunt revision?

Intraparenchymal pericatheter cyst is a rare complication of shunt surgery. It occurs as a consequence of increased CSF outflow resistance distal to a patent ventricular catheter. Treatment has traditionally consisted of shunt revision. We report on two such cases managed conservatively. The role of shunt revisions in cases with asymptomatic intraparenchymal pericatheter cyst is debatable.

Pelvic teratoma with extensive spinal involvement in a neonate: an important differential diagnosis.

A 6-week-old girl presented with an abdominal mass and spinal cord compression. Clinical and radiological features indicated a diagnosis of congenital neuroblastoma. Histology revealed a diagnosis of germ cell tumour after therapy for neuroblastoma had been commenced. This is, to the authors' knowledge, the first reported case of paediatric dumbbell retroperitoneal teratoma.

Anterior cervical foramenotomy for cervical radiculopathy.

Anterior cervical discectomy (ACD) is standard practice for cervical radiculopathy. Irrespective of the precise method used, it involves more or less complete disc removal with resultant anatomical and biomechanical derangements, and frequently the insertion of a bone or prosthetic graft. Anterior cervical foramenotomy is an alternative procedure that allows effective anterior decompression of the nerve root and lateral spinal cord, whilst conserving the native disc, preserving normal anatomy and movement, and protecting against later degeneration at adjacent spaces as far as possible. The aim of the study was to determine the safety and efficacy of anterior cervical foramenotomy in the treatment of cervical radiculopathy and took the form of a prospective study of 21 cases under the care of a single surgeon. All patients had a single level or two level anterior cervical foramenotomy. All had pre- and postoperative visual analogue scores for arm and neck pain, arm strength, sensation and overall use. A comparison between patients' perceptions and surgeon's observations was also made. Patients were followed up for between 10 and 36 months. Sixty-eight per cent completed full pre- and postoperative assessments. Twenty-eight per cent of the responders had complete arm pain resolution. There were statistically significant reductions in arm and neck pain, and overall disability. The surgeon's impression of improvement paralleled that of the patients. There was one complication with discitis. Anterior cervical foramenotomy is a safe and effective treatment for cervical radiculopathy caused by posterolateral cervical disc prolapse or uncovertebral osteophyte, and might also reduce adjacent segment degeneration.

Antenatal ultrasound and magnetic resonance imaging in localizing the level of lesion in spina bifida and correlation with postnatal outcome.

OBJECTIVE: To compare prenatal ultrasonography and magnetic resonance imaging (MRI) in the diagnosis of spina bifida with postnatal MRI/surgical findings and to study the postnatal outcome in relation to the level of lesion and head signs on antenatal imaging. METHODS: A retrospective study of babies referred to a tertiary neurosurgical unit with a diagnosis of spina bifida in the years 2000-2002 was performed. The levels of lesions and head signs diagnosed using antenatal ultrasonography and MRI were compared with postnatal MRI and operative findings. The levels of lesions and head signs diagnosed pre- and postnatally were used to study the correlation with neurological outcome at a mean follow-up period of 12 months. RESULTS: Twelve antenatally diagnosed and five postnatally diagnosed cases of spina bifida were seen. The level of lesion as identified by antenatal ultrasound correlated with that observed postnatally in 8/12 cases and the antenatal ultrasound diagnosis of ventriculomegaly was confirmed postnatally in all cases. The level of lesion as identified by antenatal MRI correlated with that observed postnatally in 4/8 cases (50%) and the antenatal MRI diagnosis of ventriculomegaly was confirmed postnatally in 5/8 (63%) cases. 12/17 babies were found to have residuals in the immediate postnatal urodynamic studies, of which 83% (n = 10) required intermittent catheterization of the bladder at 12 months of age. Low spinal lesions were associated with increased bladder morbidity when compared to high spinal lesions (8/10 vs. 4/7, P < 0.05) (odds ratio (OR) = 10.0; 95% CI, 1.05-95.01). The level of spinal lesion and the presence of ventriculomegaly did not have any statistically significant correlation with motor functions, morbidity and developmental milestones. CONCLUSIONS: Antenatal ultrasonography is a good tool in the diagnosis of spina bifida. We could not demonstrate any advantage of antenatal MRI over ultrasonography. There is better correlation of ultrasonography than MRI with postnatal MRI/operative findings in terms of level of lesion and head signs. Low spinal lesions appear to be associated with increased bladder morbidity.

Congenital spinal dermal sinuses: poor awareness leads to delayed treatment.

OBJECTIVE: Congenital spinal dermal sinuses are relatively uncommon congenital abnormalities that result from abnormal neurulation. Lack of awareness about this problem, especially at the primary care level, results in these patients not being managed appropriately. This issue is highlighted in this case series of nine patients. MATERIALS AND METHODS: The nine patients--six males and three females--were treated over a 3-year period in two centres in the UK and India. The age varied from 212 months to 19 years. Clinical presentations included meningitis or neurological deficits. One was asymptomatic. MRI was done in all cases and showed the sinus tracts in all cases. In five cases, there were intramedullary dermoids and in the others the sinus tract ended either on the dura or blindly. All cases were treated surgically by excision of the sinus and tumour if any. In terms of the neurological status, one became normal, four improved and four remained the same. Of the four who remained the same, two had had normal neurological examination preoperatively. The mean duration from first assessment by a medical practitioner to correct diagnosis and referral to a neurosurgeon was 5 years (range 2 months to 18 years). Proper diagnosis and appropriate management was delayed in these cases because professionals were not aware of this condition. CONCLUSIONS: Primary care physicians should be made more aware about congenital spinal dermal sinuses. This will facilitate early diagnosis and referral to specialist services.

Combined diastematomyelia and hemivertebra: a review of the management at a single centre.

A combination of hemivertebrae and diastematomyelia is rare. We have identified 12 such patients seen during a period of 11 years in the orthopaedic, spinal and neurosurgical units in Nottingham and analysed their treatment and outcome.

Lumboperitoneal shunts: are the complications acceptable?

BACKGROUND: Lumboperitoneal shunts have long been used in the treatment of benign intracranial hypertension, postoperative pseudomeningocele, CSF leak and communicating hydrocephalus. Although they can provide a rapid and effective resolution of the symptoms there are major disadvantages associated with their use. METHOD: We retrospectively analyzed the records of 21 patients who underwent LP shunt insertion in our institution during the study period. FINDINGS: Eighteen patients (85.7%) underwent at least one shunt revision with a total of 63 revisions. Shunt related infections were observed in 7 cases and 7 patients developed Chiari malformation, 2 (9%) of these requiring further treatment. CONCLUSIONS: Despite the symptomatic control achieved with lumboperitoneal shunts we find the complication and revision rates unacceptably high. The technique should be re-evaluated and other treatment strategies considered.

Temozolomide as first-line agent in treating high-grade gliomas: phase II study.

UNLABELLED: Temozolomide a recent, oral, second generation alkylating agent is a chemotherapeutic with demonstrated efficacy for the treatment of high-grade gliomas; its efficacy has been demonstrated in both pre-clinical and phase I and II studies. The goal of this study is to determine the activity and safety of temozolomide in improving overall survival (OS), progression-free survival (PFS) and health-related quality of life (HQL) in patient with malignant gliomas. Forty-two patients with newly diagnosed glioblastoma, anaplastic astrocytoma and anaplastic oligodendroglioma were studied. The mean follow-up period was 12 months. The overall response rate (only responsive patient) for all histological groups was 40%, 10 patients (24%) showed a stabilization of disease. The median PFS and OS was respectively 8.35 and 14.1 months: time to progression was 34 week ranging from 21 to 47. In all patients, treatment with temozolomide was associated with improvement of performance status including the patient showing disease progression: Karnofski score improved in all patients by a minimum of 10, with a median of 20 at 6 months. No patient stopped the treatment due to side-effects, no major adverse events were recorded. CONCLUSION: Temozolomide appears to be an ideal, first-line, single-agent, with a safe profile and demonstrated HQL benefits in patients with high-grade gliomas.

The role of neuroendoscopy in the management of brain tumours.

Neuroendoscopy is increasingly used in the management of brain tumours and tumour related hydrocephalus and this study reviews the efficacy of neuroendoscopic interventions in this unit in patients with brain tumours. A series of 87 neuroendoscopic operations carried out in 77 patients with brain tumours over a 6-year period is reported. The age range of the patients was from 5 months to 70 years (median 13 years). In 56 cases (64%) presentation was with a newly-diagnosed tumour and hydrocephalus. The majority of the remaining patients had varying degrees of worsening hydrocephalus on the background of a previously diagnosed tumour. Neuroendoscopic third ventriculostomy (NTV) was successful in relieving hydrocephalus in the short term in 63/66 cases (95%) and in the longer term in 55/66 cases (83%). Neuroendoscopic tumour biopsies were successful in providing a tissue diagnosis in 17/28 cases (61%) and four extensive and three partial resections of tumour were carried out. There were two deaths within 30 days of the procedure with only one of these, secondary to intraventricular haemorrhage, directly related to neuroendoscopy. Few significant complications were noted otherwise. For selected intraventricular and paraventricular tumours neuroendoscopy offers the opportunity to combine relief of hydrocephalus with tumour biopsy and sampling of CSF in a single procedure.

Treatment of Chiari malformation, syringomyelia and hydrocephalus by neuroendoscopic third ventriculostomy.

This short paper illustrates a case with cervical myelomeningocoele, a Chiari malformation (CM), hydrocephalus (HC) and cervical syringomyelia treated by neuroendoscopic third ventriculostomy (NTV) with resolution of both the hydrocephalus and the syrinx. Two similar cases are discussed. The technique is advocated for the treatment of such complex dysraphic conditions.

Anterior sacral meningocoele presenting as a peri-anal abscess.

Anterior sacral meningoceole is a rare occurrence and presentation as a perianal abscess has not been previously reported. The case is presented and the condition discussed. The potential risks of failing to establish the diagnosis, prior to surgery, are outlined.

Heparin treatment of atrial thrombus in ventriculo-atrial shunts.

This short report details the management of two cases of atrial thrombus on ventriculoatrial shunts, treated non-surgically by simple anticoagulation. While this is extremely simple it appears not to have been reported before.

Changes in third ventricular size with neuroendoscopic third ventriculostomy: a blinded study.

The objective was to study the relation between changes in cerebral ventricular size and clinical outcome after neuroendoscopic third ventriculostomy (NTV) in both primary (no previous surgery) and secondary (previous CSF diversion for hydrocephalus) NTV. Changes in ventricular size were related to the need for further surgery for CSF diversion. A blinded retrospective study of the pre-NTV and post-NTV sizes of the ventricles in an unselected series of patients undergoing this procedure was done. A decrease in third ventricular size was seen in significantly more patients in the primary group than in the secondary group. Median change in third ventricle width for those who did not require further CSF diversion was significantly greater than those with no clinical benefit (p=0.01). Positive predictive power for successful outcome was highest for measures of the third ventricle; 73% and 68% for third ventricle width and height respectively, 88% for anterior to posterior commissure distance. In conclusion, third ventricular size reduces after NTV. The use of such a change as an arbiter of success in this procedure is questionable as clinically successful cases can have no change in ventricular size. It is considered that clinical outcome is the most important guide to success or failure as reduction in ventricular size is by no means guaranteed. Radiological outcomes alone may be misleading and reliance on them should be avoided.

The effectiveness of neuroendoscopic interventions in children with brain tumours.

OBJECT: The purpose of this study was to review the efficacy of neuroendoscopic interventions in children with brain tumours and tumour-related hydrocephalus. METHODS: In all, 61 consecutive neuroendoscopic operations carried out in 53 children with brain tumours over a 6-year period were reviewed. The patients ranged in age from 5 months to 18 years (median 9 years). Forty of 61 presentations were with a newly diagnosed tumour and hydrocephalus - the remainder predominantly had a known tumour and worsening hydrocephalus. CONCLUSIONS: Neuroendoscopic third ventriculostomy (NTV) successfully relieved hydrocephalus in the short term in 45 of 47 cases and in the longer term in 39 of 47 cases. Neuroendoscopic biopsy provided definitive tissue diagnosis in 10 of 16 cases and 5 tumours were resected. There was 1 postoperative death, which not directly related to the neuroendoscopy and few significant complications otherwise. Neuroendoscopic methods allow effective immediate and longer term control of hydrocephalus as well as the opportunity for CSF sampling and tumour biopsy in selected cases.

Sildenafil (Viagra)-induced spontaneous intracerebral haemorrhage.

Sildenafil (Viagra) has been developed as a drug to help male impotence. It has a direct effect on the vasculature of the corpus cavernosum. A case of spontaneous intracerebral haemorrhage (ICH) following the illicit use of Viagra is reported. A discussion of drug-induced ICH is included.

Third ventricular plasma-cell lesion with delayed intraventricular transudation of contrast medium.

We report a patient presenting with hydrocephalus secondary to a posterior third ventricular plasma-cell lesion which exhibited delayed transudation of contrast medium into the adjacent aqueduct and fourth ventricle.