Factors affecting the outcome of foetal hydrocephaly.

In this study, the authors attempt to provide an account of the factors that affect the outcome of hydrocephaly in 26 foetuses. The hydrocephalus was related to a myelomeningocele in 35% of patients. Sixty-two percent of foetuses showed intra-uterine progression of their hydrocephalus and 50% were shunted postnatally. At a mean follow up of 2 years, the outcome was considered "fair" in 54% of patients. Our findings demonstrate that in foetal hydrocephaly a more favourable outcome is expected in patients with hydrocephalus which does not progress in utero, in whom the labour is not induced before 36 weeks of gestation, who are delivered vaginally weighing more than 2.5 kg and have a head circumference below the 95th centile and a CT cortical mantle thickness of 2 cm and more and who are treated by CSF shunting. The diagnosis of the foetal hydrocephaly at or before 28 weeks of gestation and the presence of a myelomeningocele did not affect the outcome significantly. Neurosurgeons are reminded to keep an open mind for infants with foetal hydrocephaly and to offer active treatment to patients with a potentially favourable outcome.

Primary midline cranial vault lymphoma simulating a parasagittal meningioma: the role of angiography in preoperative diagnosis.

Primary non-Hodgkin's lymphoma (NHL) of the skull with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. Up to date, only nine such cases have been reported in the literature and in none was the lesion located in the midline. The authors report a unique case of a primary NHL involving the midline of the cranium. The lesion presented as a slowly growing scalp swelling mimicking a parasagittal meningioma. The angiographic findings of mild vascularity in the periphery of the tumor and downward displacement of a patent superior sagittal sinus indicated that the lesion was unlikely to be a meningioma. Neurosurgeons must maintain a broad differential diagnosis in any patient with a scalp mass eroding through the skull and associated neurological symptoms or signs. An intraoperative frozen section is recommended since the identification of a lymphoma is likely to influence the neurosurgeon's decision about the extent of the surgical excision.

Low rate of shunt revision in tumoural obstructive hydrocephalus.

The authors calculated the shunt revision rate for 77 consecutive patients with tumoural obstructive hydrocephalus. At a mean follow up of 23.7 months, the annual revision rate was 0.06 which is significantly lower than the annual revision rate of 0.39 for other hydrocephalic patients treated during the same period. Shunted patients who had total excision of their lesions had a significantly lower revision rate than patients who had a partial excision or a biopsy. It is therefore, suggested that cases with tumoural obstructive hydrocephalus may represent a subset of hydrocephalic patients who are associated with a relatively low risk of shunt complications. The observation has to be addressed when the role of endoscopic third ventriculostomy in these patients is being considered.

Intraventricular and leptomeningeal dissemination of a pilocytic cerebellar astrocytoma in a child with a ventriculoperitoneal shunt: case report.

Dissemination of a pilocytic cerebellar astrocytoma is a very rare occurrence. So far only eight cases have been reported in the literature and in only one of these cases had the tumour spread into the ventricles. We report a case of a child who presented with communicating hydrocephalus and a small cerebellar lesion. The patient was initially treated by a ventriculoperitoneal (VP) shunt and the lesion was followed-up. Two years later, intraventricular and leptomeningeal dissemination of the tumour which proved to be a pilocytic astrocytoma was documented. The role of the VP shunt in diverting metastasizing tumour cells into the ventricles is discussed.

The difference in the outcome of surgery for traumatic extradural hematoma between patients who are admitted directly to the neurosurgical unit and those referred from another hospital.

In this study of 120 cases that had surgery for traumatic extradural hematoma (EDH) at Frenchay Hospital, England, between 1975 and 1987, the author attempts to outline the influence on the outcome of surgery for EDH of whether the patient is admitted directly to the neurosurgical unit or via another hospital. Only 15% of the patients were admitted directly, while 85% were referred. The results show that although the directly admitted patients included significantly more unconscious patients exhibiting clinical signs of herniation, their outcome was not significantly worse. Therefore, in support of previous reports, it is recommended that all head injured patients be admitted to the primary care of neurosurgeons.

Arteriovenous malformations of the brain: Indications and outcome of microsurgical excision.

This study is based on a retrospective analysis of 30 consecutive patients with previously untreated cerebral arteriovenous malformations (AVMs), who were seen at King Khalid University Hospital between 1987 and 1994. There were 17 males and 13 females, ranging in age between nine and 52 years. Twenty patients presented with intracranial hemorrhage, while the remaining 10 complained of epilepsy. The lesions were located as follows: 15 at the convexity, seven interhemispheric, four central, three basal, and one cerebellar. Nineteen patients (63%) underwent microsurgical excision, which was complete in 16 and incomplete in three. There were no postoperative deaths. Fifteen patients had no additional postoperative neurological deficit, while four patients sustained neurological deterioration, which was severe one. Two patients refused surgical treatment and the risk of surgery was considered too high in nine patients. Our result suggest that the local neurosurgical management standard of selected AVMs is quite satisfactory. However, for a more comprehensive therapeutic approach to these difficult lesions, national expertise in other therapeutic modalities, such embolization techiques and radiosurgery, is urgently needed.

Short course antimicrobial therapy in intracranial abscess.

In this study, the author attempts to question the necessity of prolonged antimicrobial treatment for intracranial abscess. The C reactive protein (CRP) was measured serially in 26 patients with intracranial abscess. All patients had undergone surgery and were treated with antimicrobial therapy. The CRP was elevated in 20 (77%) patients and its return to normal after treatment correlated with a good recovery. In 3 (12%) patients a persistently high CRP level postoperatively coincided with reformation of the abscess. A transient rise in the CRP value during decrease to normal was due to deep venous thrombosis in 2 (8%) patients. The return of the CRP to normal in conjunction with improvement of the patient's clinical condition and evidence of resolution of the abscess on CT scan were used as a guideline to stop antibiotics early. The antimicrobial therapy of the patients in this series ranged from 11-30 (mean 20) days and the follow up from 6-36 (median 21) months; there have been no recurrences.

Multiloculated hydrocephalus related to cerebrospinal fluid shunt infection.

This study is an attempt to establish that CSF shunt infection has a role in the aetiology of multiloculated hydrocephalus. The authors carried out a review of 12 cases of multiloculated hydrocephalus who were treated at King Khalid University Hospital between 1988-1994. The multiloculation appears to have developed following the shunt infection in all cases. The hydrocephalus was related to an intraventricular haemorrhage (IVH) in 9 patients and was congenital in 2 patients and post-meningitic in 1 patient. The shunt infection was caused by a gram-negative organism in 8 patients and duration of external ventricular drainage ranged from 9-24 (median 13) days. The diagnosis of multiloculated hydrocephalus was made on average 2 months after the shunt infection. In three patients endoscopic fenestration of intraventricular septations was attempted but was effective in only one case. The other patients were managed by two shunts (9 patients) and three shunts (2 patients). At a mean follow-up of 15 months, the shunt revision rate of the patients was 0.4/year. One patient died of multiple brain abscesses and 6 patients remain severely disabled. The poor outcome may also be related to the original IVH as well as the multiloculated hydrocephalus. The study also shows that patients with post-haemorrhagic hydrocephalus, who develop a shunt infection due to gram-negative organisms and in whom the CSF fails to be cleared of the infection following 12 days of external drainage appear to be at risk of developing multiloculated hydrocephalus.

Cerebro-vasculopathy and malignancy: catastrophic complications of radiotherapy for optic nerve glioma in a von Recklinghausen neurofibromatosis patient.

The authors report a unique case of a patient with intraorbital optic nerve glioma and von Recklinghausen neurofibromatosis who developed cerebro-vasculopathy and malignant transformation in the orbit 18 months after radiotherapy treatment. The case is an important reminder of the possibly increased susceptibility of von Recklinghausen neurofibromatosis patients to the complications of radiotherapy.

Trigeminal neuralgia related to cerebellopontine angle tumors.

A review of 30 cases with cerebellopontine angle tumors was carried out to identify patients with trigeminal neuralgia (TN) at presentation and to compare them with patients without TN. The study shows that dermoid tumors and the presence of tumor at the apex of petrous bone on CT are associated with a significantly higher incidence of TN, while the incidence did not appear to be influenced by age, sex, or size of tumor. In all patients but one (with medulloblastoma) that had surgery, there the TN disappeared following total or subtotal excision of the tumor, providing the trigeminal nerve was well decompressed. Patients with TN should be investigated carefully by CT or MRI irrespective of their age or the absence of neurological signs.

Response of cavernous sinus hemangioma to radiotherapy: a case report.

The author reports a case of a histologically proven cavernous hemangioma of the cavernous sinus and middle fossa, which was treated by radiotherapy. This very rare lesion represents a formidable challenge to the neurosurgeon and its excision has been associated with a considerable mortality rate. The significant reduction in the size of tumor of our patient after radiotherapy and the corresponding improvement in her clinical condition provide further evidence in support of the use of radiotherapy as the first line treatment modality after the histological confirmation of a cavernous sinus hemangioma. Surgery should be reserved for tumors that fail to respond to radiotherapy or recur after an initial good response to radiotherapy.

Intracranial mycotic infections in neurosurgical practice.

Intracranial mycotic infections requiring neurosurgical intervention are being diagnosed more frequently. This study is a review of 17 cases of intracranial mycotic infections that were treated in a neurosurgical unit in Saudi Arabia over an 8-year period. A primary focus of infection was identified in 41% of patients while 18% of patients had a predisposing factor. Forty-seven percent of patients presented with a brain abscess (solitary 29%, multiple 18%) while 35% had a granuloma. 18% meningitis and ventriculitis and 12% hydrocephalus. The Aspergillus species and Ramichloridium machenziei were the commonest pathogens. Following the appropriate surgical and antimicrobial treatment, the mortality rate was 41% and there was evidence of residual disease at follow-up in 18%. The reason for a fatal outcome was failure to consider a fungal aetiology and to obtain a tissue diagnosis early-because of late referral (2 cases), as well as failure to respond to antimycotic therapy (4 cases) and rupture of the internal carotid artery due to Aspergillus arteritis (one case). It is concluded that an early tissue diagnosis is crucial in the management of intracranial mycotic infection so that the appropriate surgical and antimycotic treatment can be started early.

Actinomycotic brain abscess successfully treated by burr hole aspiration and short course antimicrobial therapy.

Three cases of brain abscess caused by Actinomyces israelii are reported which were successfully treated by burr hole aspiration and a short course of antibiotics (3-4 weeks). The clinical response of the patients, as well as the serial serum C-reactive protein levels and CT findings were used as a guideline for stopping antimicrobial therapy relatively early.

Systemic metastasis of medulloblastoma through ventriculoperitoneal shunt: report of a case and critical analysis of the literature.

An unusual case of medulloblastoma metastasizing through a ventriculoperitoneal shunt to the scrotum in a child with a hydrocele is presented. A review of the literature disclosed 160 cases of medulloblastoma with systemic metastases, 30 (18.7%) of them having undergone systemic shunts. Analysis of the distribution patterns of the metastases in relation to the shunt type revealed that shunts had probably provided the route of systemic spread in no more than 11 cases (6.9%). Only one of these cases had no intracranial tumor at autopsy, suggesting that the outcome was probably worsened by the systemic metastases through the shunt. In contrast, five patients had intraaxial tumor recurrence that largely determined the outcome. In the remaining five cases, information concerning the tumor within the central nervous system was not available, and it remains speculative whether these patients could have survived longer without the shunts. It is concluded that the chance of medulloblastoma metastasizing through cerebrospinal fluid shunt is quite small and has an even smaller chance of adversely affecting the final outcome of the medulloblastoma patient. Consequently, in our opinion there should be no contraindication to precraniotomy shunting if required in such patients.

Intracranial xanthogranuloma of the dura in Hand-Schüller-Christian disease. Case report.

The authors describe a 37-year-old man with the classic clinical features of Hand-Schüller-Christian disease. He presented with symptoms of increased intracranial pressure due to obstructive hydrocephalus secondary to a huge xanthogranuloma involving falx cerebri and tentorium cerebelli. Immunohistochemical and ultrastructural studies failed to demonstrate Langerhans histiocytes, however. The implication of this finding is discussed in light of the recent relevant literature.

A variant of the syndrome of spinal arachnoid cysts with multiple congenital defects.

We report an apparently unique case of multiple spinal intradural arachnoid cysts in association with distichiasis, late onset lower limb lymphoedema, and previously unrecognized features of associated bilateral megaureters, Arnold Chiari malformation with hydrocephalus and syringomyelia. The literature on this unusual group of congenital malformations is reviewed.