Neglected Case of Primary Intraorbital Hydatid Cyst.

Background: Hydatid cyst is a parasitic infection caused by Echinococcus granulosus and human is an accidental host. Liver and lungs are the most widely recognized organ of association but relatively low in other organs. Orbital involvement of the hydatid cyst is rare. Case Description: The case was a 47-year-old lady presented in the late stage of disease when corneal ulcer had developed and with complete vision loss along with headache, proptosis, and pain in the left eye. Cystic lesion in the retro-orbital region of the left eye was revealed by Computed tomography scan and magnetic resonance imaging. The patient underwent surgery. Hundreds of daughter cysts were seen intraoperatively and cyst wall sent for histopathological examination to confirm the diagnosis. The patient was further treated with albendazole for 3 months. Conclusion: Although hydatid cyst is uncommon, it ought to be considered in the differential diagnosis of cystic lesion of orbital locale, more so in the endemic territories.

Post-Traumatic Diploic Leptomeningeal Cyst with Bilateral Posterior Cranial Fossa Epidural Hygroma: A Management Dilemma?

BACKGROUND: Post-traumatic diploic leptomeningeal cyst with bilateral posterior cranial fossa epidural hygroma is a rare complication after calvarial fracture. Very few cases have been reported to date; hence, there are no specific guidelines for the management of these cases. CASE DESCRIPTION: A 4-year-old boy was brought to the emergency department after suffering from head trauma caused by a fall from a rooftop where he was treated conservatively at a local hospital. Later, he developed swelling in the occipital region and was brought to the department of neurosurgery where he was operated on. After the first surgery, recurrence of swelling was seen after a postoperative period of 2 months, and computed tomography scan reported persistent epidural hygroma with extension into the subcutaneous space. The second surgery was performed, and 12-month follow-up did not show any recurrence of swelling in the patient. CONCLUSIONS: Post-traumatic leptomeningeal cyst is commonly associated with occipital injury. The causes are as follows: the dura is very loosely attached to the intracranial lamina in young children, injury to the skull results in potential epidural space, and any tear or breach in the meninges leads to accumulation of cerebrospinal fluid in these spaces giving rise to cystic swelling. Watertight duroplasty with trials of duro-periosteal hitching has been described in the management of these cases.

Peripheral nerve stimulation: black, white and shades of grey.

Unbearable chronic neuropathic pain, which can often not be resolved by conservative pain management techniques, calls for peripheral nerve stimulation. The technique, based on the Gate control hypothesis, uses low intensity current to block depolarization and conduction of neuronal membrane. Conditions such as intractable migraine, occipital and trigeminal neuralgia, burn injury pain, transformed migraine, among others, which cause intense pain can be treated by PNS, especially when the pain is localised and can be traced back to a specific nerve. Complication rates in PNS vary from 5% in some cases to 43% in others. Common complications include lead breakage, electrode migration, etc., meanwhile complications associated with every surgery like risks of anaesthesia, bleeding etc., are also present. PNS shows great potential in the treatment of intractable pain, and with its less invasiveness, high success rate, and development of advanced technologies like BION and SAINT, it is bound to become a standard procedure in the future for neuropathic pain management.

Elevated Skull Fractures - Too Rare to Care for, Yet too Common to Ignore.

Elevated skull fractures form a rare subset of compound skull fractures owing to the paucity of cases studied and reported. In this article, we present 17 cases of elevated skull fracture in a mixed population of adult and pediatric age groups which were operated over a period of 5 years (2012-2017) at our institute. We have discussed the mode of injury, clinical presentation, clinicoradiological findings, and treatment options highlighting the appropriate management strategies opted. Although elevated fractures are rare; issuing definite treatment protocol can reduce the morbidity and mortality of the patients.

The autoimmune basis of hypopituitarism in traumatic brain injury: fiction or reality?

Post-traumatic hypopituitarism has remained as an obscured cause of worsening morbidity and mortality in head injury patients. Researchers have for decades been puzzled by the mechanism of pituitary dysfunction in these cases. Amongst other causes like direct injury, vascular injury etc, an immunological basis of hypopituitarism has been suggested in some animal studies as well as human research. In this article, we have reviewed the latest articles and compiled the evidence which suggests for or against the role of autoimmunity in post-traumatic hypopituitarism or which defines the strength to which autoimmunity has been established as a cause of head-injury induced pituitary dysfunction.

Depressed Fractures of Skull: An Institutional Series of 453 Patients and Brief Review of Literature.

BACKGROUND: There has been a substantial increase in the number of cases with head injuries in the past two decades which has simultaneously led to increase in the annual incidence of depressed fractures of skull. Most of these skull fractures are associated with considerable morbidity and mortality of patients and an unavoidable financial burden on the family members. However, many changes have been undertaken directed toward improved management of patients with head injuries and skull fractures in the past 20 years. OBJECTIVE: To study and compare the patterns of occurrence of the depressed fractures of skull and examine the factors which may influence the surgical outcome of patients with reference to similar case series from the past literature. PATIENTS AND METHODS: We reviewed patient records of 453 patients admitted with depressed skull fractures in Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India, during the period of March 2004 through July 2009. RESULTS: The incidence of depressed skull fracture was highest (56%) in the age group of 16-45 years. There was a predominance of male cases over females with a ratio of 7:1. The most common mode of injury was noted to be alleged assault (36%) and the parietal region (34%) being the most common site. Most cases had mild injury (62%) with Glasgow Coma Scale score of 13-15. The percentage of pure depressed fractures was 57% and the rest 42% were associated with intracranial lesion, of which the most common was contusion (25%). Superficial wound infection was observed in 38% of the patients. Of all the 453 patients, 91% were operated and most of them were operated within 24 h with overall mortality rate of 17%. CONCLUSIONS: Our study revealed the increased incidence of mortality in the age group of 16-45 years, which can guide our focus of management on them with strategic planning at individual as well as community level. Primary surgical repair of depressed skull fractures is safe, feasible, and associated with good outcomes. There was no significant association between tear in dura and an increase in the complications and, also, no substantial data to support the use of prophylactic antibiotics in patients to reduce chances of infection with it.

Vertex Extradural Hematoma: A Diagnostic Dilemma.

Extradural hematomas (EDHs) of vertex are rarely seen and form a small percentage of all EDH. Usual cause of an EDH located at the vertex is tearing of the superior sagittal sinus. A 35-year-old male patient was admitted to our department, with history of fall and lucid interval. Imaging studies showed contusion in the right frontal region with midline shift and bilateral EDH located at vertex which was misinterpreted as artifact or subdural hematoma. We present this rare case and briefly review the literature regarding its etiopathology and associated clinico-radiological findings. The principles of management of this rare entity are also discussed.

Intracranial en-plaque tuberculoma impersonating en-plaque meningioma: Case report and brief review of literature.

BACKGROUND: Tuberculosis of the central nervous system continues to be a major health hazard in developing countries like India. There are various manifestations of central nervous system tuberculosis including meningitis and space occupying lesions. We present a case of tuberculoma en-plaque which is often initially confused with a meningioma on presentation. We also review the literature relevant to this unusual entity. METHODS: A search of PubMed, PubMed Central, the Cochrane Library, and MEDLINE were performed to identify all English language reports of intracranial en-plaque tuberculomas. The combinations of text strings "tuberculoma," "en*," and "plaque" were used to perform the query on PubMed. Only the studies reporting intracranial en-plaque tuberculomas were included. RESULTS: Literature review revealed six reports on en-plaque tuberculomas including seven patients. The mean age at presentation was 40.5 years, and no sex predilection was seen. Five of the six reported studies used anti-tuberculous therapy with or without surgical excision of the mass. Most of the patients in reported cases recovered fully. CONCLUSION: It is imperative to consider tuberculoma as an important differential when encountering intracranial en-plaque masses as en-plaque tuberculomas can be effectively treated with a combination of anti-tuberculosis therapy and surgical resection, yet consequences of a missed or late diagnosis can prove fatal.

Giant bilateral keloids of the ear lobule: Case report and brief review of literature.

Keloids are abnormal tissue response to cutaneous injury. They are benign fibrocollagenous growth that rise above the skin surface and extend beyond the borders of the original wound. They may also rarely regress spontaneously and show a high level of recurrence after treatment. They usually arise after cutaneous insult, but idiopathic spontaneous etiology is also reported. Their high recurrence creates nuisance not only for the patient but also for the doctors. Bilateral keloids of ear lobules are rare. We report one such case of giant keloids of bilateral ear lobules in a 42-year-old male patient. Keloids have known to be notorious for their poor response to treatment owing to complex and ill-deciphered pathophysiology. Recent studies indicate that transforming growth factor beta and platelet-derived growth factor play an integral role in the formation of keloids. In this article, we have reviewed the available literature to discuss the pathophysiology and treatment modalities that may be used to prevent the recurrence of keloids.

Transpedicular surgical approach for the management of thoracic osteophyte-induced intracranial hypotension refractory to non-operative modalities: case report and review of literature.

PURPOSE: In this article, we aim to describe the presentation and management of a case of spontaneous intracranial hypotension caused by a dural tear from a ventral thoracic osteophyte at the T12 level that was refractory to non-surgical treatment modalities. A review of the literature has been performed. Also a proposal of diagnostic and treatment algorithm is presented. Intracranial hypotension and CSF leak as a result of dural tear is a common phenomenon. However, the detection of the source of CSF leak from a thoracic spinal osteophyte has rarely been reported. METHODS: Diagnostic workup including MRI and CT Myelogram as well as application of epidural blood patches and surgical technique of hemilaminectomy and osteophytectomy by transpedicular approach have been described. Literature review was conducted using relevant search terms in PubMed. RESULTS: The patient's spontaneous intracranial hypotension symptoms resolved and this persisted on follow up visits. Review our experience as well as similar cases in the literature pointed us towards a diagnostic and treatment algorithm. CONCLUSIONS: Spontaneous resolution is the norm for intracranial hypotension of most etiologies and management of all such cases begins with fluid resuscitation coupled with bed rest. On failure of conservative therapy, autologous epidural blood patches into the spinal epidural space should be tried, which often produce an immediate relief of symptoms. Osteophyte-induced dural tear and consequent intracranial hypotension may require surgical intervention if the symptoms are refractory to conservative treatment. Under all circumstances a careful step-wise approach for diagnosis and treatment of spontaneous intracranial hypotension needs to be followed, as we have proposed in our article.

Elevated fracture of skull in pediatric age group: A series of five patients with review of literature.

Elevated fractures of skull in pediatric age group are rarely reported in the literature. In view of rarity, we present a series of five cases of elevated skull fracture in pediatric age group. Over a period of 1-year, we operated on five such cases. In this article, we have discussed the mode, mechanism and extent of injury, its clinico-radiological findings, course of the disease, and the management outcome. Four out of five cases improved after surgery and did not suffer any complications. Early recognition and appropriate management of compound elevated fracture in pediatric age group comes with good outcome and prevents unwanted morbidity and mortality.

A curious case of spontaneously resolving closed "jigsaw" depressed skull fracture in an adolescent.

Spontaneously resolving depressed skull fractures have been previously reported in the pediatric age group, however they are very rare in adolescents. We report a case of spontaneously elevating depressed fracture in a 13 year old boy. Depressed skull fractures in this age group might resolve on its own but may also complicate during its course of non-operative self elevation. In the reported case, the child developed gliosis and suffered seizures two years after the trauma. Repeat scans showed almost normal skull topography with underlying gliotic changes. Although all depressed skull fractures won't complicate as such, patients without neurological deficits should also be operated to prevent any delayed complications.

Posttraumatic Bilateral Epidural Hygroma of the Posterior Cranial Fossa: Case Report and Brief Review of Literature.

BACKGROUND: Posttraumatic posterior fossa epidural hygroma is a rare entity, and a clear management has not been established in the medical literature. We present 1 case and review the literature relevant to this unusual entity. The mechanism of formation and management of posterior cranial fossa epidural hygroma are also outlined. CASE DESCRIPTION: A 2-year-old child presented after a rooftop fall injury with symptoms of headache, drowsiness, vomiting, and brief loss of consciousness. Computed tomography scan demonstrated swelling in the left occipital region and epidural hygroma. After conservative management failed, surgical repair of the dura mater was performed. The child was discharged postoperative day 11 in stable condition with marked improvement in occipital swelling. CONCLUSIONS: It is imperative to consider epidural hygroma in very small children presenting with occipital injury. As a result of loose adhesion of dura mater and internal cranial lamina layers in younger pediatric patients, potential epidural space may be easily created secondary to injury, and small breaches in meningeal integrity near the cisterna magna may favor cerebrospinal fluid leak. During surgery, if watertight repair of a visible dural tear is performed, duro-periosteal hitching or vacuum drain placement may not be required.

Reliability of treating asymptomatic traumatic type II dens fractures in patients over age 80: A retrospective series.

BACKGROUND: Management of type II odontoid fractures in elderly remains controversial to whether surgical treatment is favored over conservative one. This is a study of geriatric patients with asymptomatic type II dens fractures who after sustaining a fall were initially evaluated at community hospitals. They were placed in a rigid collar and were followed up in a spine clinic. PURPOSE: To assess the reliability of treating very old patients with type II dens fracture conservatively and whether surgical intervention if needed would affect the clinical outcome. STUDY DESIGN: Retrospective study with the literature review. PATIENT SAMPLE: Consecutive patients above 80 years of age, who sustained a clinically asymptomatic type II dens fracture and were observed after a conservative treatment plan, was initiated. OUTCOME MEASURES: Outcome measures included self-reported worsening neck pain, neurological function, and radiographic measures over the follow-up period. MATERIALS AND METHODS: A retrospective clinical analysis of 5 active geriatric patients with type II asymptomatic dens fracture. After evaluating them, treatment options were discussed with patients and their family members. The decision was to continue to follow them with a rigid collar very closely since they were reluctant to undergo any surgical procedure. RESULTS: Patients were followed for an average of 29 months. They were observed for any worsening neck pain, neurological deficit, or deterioration of fracture on follow-up imaging studies. At last follow-up, 2 of 5 patients continued to be asymptomatic, the 3(rd) died of unrelated causes while 2 others required surgeries at least 1-year post injury. CONCLUSIONS: Treatment of type II dens fractures in the elderly is controversial. Independent elderly patients who are asymptomatic at presentation may be safe to be followed up very closely with a neck brace and serial X-ray. Converting to surgical treatment can be done safely when needed without affecting the overall clinical out.

Factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma.

OBJECT: Spinal metastases account for the majority of bone metastases from thyroid cancer. The objective of the current study was to analyze a series of consecutive patients undergoing spinal surgery for thyroid cancer metastases in order to identify factors that influence overall survival. METHODS: The authors retrospectively reviewed the records of all patients who underwent surgery for spinal metastases from thyroid cancer between 1993 and 2010 at the University of Texas MD Anderson Cancer Center. RESULTS: Forty-three patients met the study criteria. Median overall survival was 15.4 months (95% CI 2.8-27.9 months) based on the Kaplan-Meier method. The median follow-up duration for the 4 patients who were alive at the end of the study was 39.4 months (range 1.7-62.6 months). On the multivariate Cox analysis, progressive systemic disease at spine surgery and postoperative complications were associated with worse overall survival (HR 8.98 [95% CI 3.46-23.30], p < 0.001; and HR 2.86 [95% CI 1.30-6.31], p = 0.009, respectively). Additionally, preoperative neurological deficit was significantly associated with worse overall survival on the multivariate analysis (HR 3.01 [95% CI 1.34-6.79], p = 0.008). Conversely, preoperative embolization was significantly associated with improved overall survival on the multivariate analysis (HR 0.43 [95% CI 0.20-0.94], p = 0.04). Preoperative embolization and longer posterior construct length were significantly associated with fewer and greater complications, respectively, on the univariate analysis (OR 0.24 [95% CI 0.06-0.93] p = 0.04; and OR 1.24 [95% CI 1.02-1.52], p = 0.03), but not the multivariate analysis. CONCLUSIONS: Progressive systemic disease, postoperative complications, and preoperative neurological deficits were significantly associated with worse overall survival, while preoperative spinal embolization was associated with improved overall survival. These factors should be taken into consideration when considering such patients for surgery. Preoperative embolization and posterior construct length significantly influenced the incidence of postoperative complications only on the univariate analysis.

Traumatic intracerebellar haematoma: To operate or not to operate?

BACKGROUND: Pure cerebellar haematoma of traumatic etiology, without associated posterior fossa sub- or epi-dural haematomas is a rare entity and has been reported to have a poor outcome. We report 23 patients with traumatic intracerebellar haematoma. We sought to study the pattern of such presentations and assess the factors which could be associated with their outcome. METHODS: A retrospective review of prospectively collected data for all patients who were admitted for the management of traumatic intracerebellar haematoma at Rajendra Institute of Medical Sciences, Ranchi, India provided data for the 23 consecutive patients admitted for aforesaid over a seven-year study period. Medical records, diagnostic imaging and operative notes were reviewed for all patients. We divided the patient pool in to two groups based on their GCS score at the time of presentation - Group A (GCS > 7) and Group B (GCS ≤ 7). The association of different allied factors was studied and statistically analyzed. The relevant medical literature was also reviewed. RESULTS: Most Group B patients were found to be associated with poor outcome at hospital discharge. The overall incidence of poor outcome in our study was 69.56%. GCS score at time of admission, allied supratentorial lesions, advanced age, condition of fourth ventricle and chest infection were found to be important factors which could be associated with poor outcome. CONCLUSION: Surgery in patients with the mentioned risk factors remains debatable and should be approached cautiously. Larger multi-institutional and meta-analytic studies are required to study and statistically establish the factors which might be associated with poor outcome in these patients. An algorithm which may be used in the management of traumatic intracerebellar haematoma patients is proposed.