Spinal aspergillosis in nonimmunocompromised host mimicking Pott's paraplegia.

The aim of this report is to highlight the less-known aspergillus spondylitis (AS) that may completely mimic Pott's paraplegia, leading to occasional but expensive diagnostic error, as the chemotherapeutic management of the two is different. A case of a patient with the diagnosis of Pott's paraplegia who turned out to have aspergillus spondylitis is described. Issues and difficulties regarding the differentiation between these two forms of spine infection and their therapeutic implications are discussed. We conclude that differential diagnosis of spinal tuberculosis (TB) should include aspergillus spondylitis, as cure of spinal aspergillosis, especially in early stages, is possible with surgery and/or antifungal agents, and morbidity and mortality are high in neglected cases.

Atypical forms of spinal tuberculosis: case report and review of the literature.

OBJECTIVE: The object of this report is to highlight some of the less known atypical features of spinal tuberculosis (TB) in the hope of facilitating early diagnosis. Pure neural arch and sacral TB is rare and the co-existence of these two as widely separated skip lesions in the same patient is even rarer. CLINICAL PRESENTATION: An unusual case of tuberculous process affecting the sacrum as well as the neural arches of upper cervical vertebrae is presented. Neither the clinical features nor the imaging techniques, including radiography, bone scintigraphy, computed tomography, and magnetic resonance imaging, were helpful in establishing the diagnosis. The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block. Development of this second destructive lesion involving the posterior spinal elements (the neural arch) led to a diagnosis of malignant spinal metastasis. The true diagnosis was only revealed by the histology of the solid tumor-like extradural mass in the upper cervical region and demonstration of acid-fast bacilli (AFB) in the lesion. Anti-TB chemotherapy resulted in complete resolution of sacral and cervical lesions as well as the neurologic deficits. CONCLUSION: Differential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases.

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.

Growing fracture of the orbital roof.

BACKGROUND: Growing fractures rarely arise in the skull base, and their pathogenesis and treatment are still debated. METHODS: The clinical and radiologic findings of a growing fracture involving the orbital roof in a 5-year-old boy are presented and the relevant literature is reviewed. RESULTS: The clinical picture of growing fracture of the orbital roof is dominated by ocular symptoms such as diplopia, eyelid swelling, and displaced eye globe. Computed tomography scan is excellent for demonstrating the bony defect in the orbital roof while magnetic resonance imaging is more sensitive in showing the intraorbital extension of the leptomeningeal cyst. Frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Craniotomy with direct repair of the dural and bone defects is the treatment of choice. CONCLUSION: Growing fracture of the orbital roof may complicate minor head injury and should be considered in the differentiated diagnosis in cases of persistent ocular symptoms.

Intracranial arachnoid cysts: Treatment alternatives and outcome in a series of 25 patients.

A series of 25 patients with intracranial arachnoid cysts is analyzed retrospectively. There were 14 males and 11 females ranging in age between a few days and 58 (mean 10) years. Seventy-six percent of patients were children below the age of 15 years. Most of the patients presented with symptoms and signs of long-standing raised intracranial pressure, while localizing signs were rather uncommon. The clinical manifestations were often mild relative to the large size of the cyst. Associated hydrocephalus was present in three patients: one with suprasellar cyst and two with posterior fossa cysts. Seven patients with mild symptoms and small cysts were treated conservatively, while the remaining 18 patients underwent surgical treatment. The initial surgical procedure consisted of craniotomy and fenestration of the cyst in three patients, and cystoperitoneal shunting in the other 15. Of the three patients who underwent craniotomy, one improved postoperatively, while the remaining two developed complications consisting of wound infection and postoperative epilepsy in one and permanent severe neurological deficit in the other. In contrast, six of the 15 cysts treated by shunting resolved completely, eight were smaller, and one remained unchanged. Radiological regression of the cyst after shunting was associated with various degrees of clinical improvement in 13 patients (87%). Two (13%) of 15 shunted patients developed complications in the early postoperative period, consisting of wound infection in one and early shunt failure in the other. Three patients (20%) with shunts had late complications during the follow-up period, consisting of recurrent shunt failure in the first, subdural hematoma in the second, and perforation of the peritoneal catheter into the hepatic bile ducts in the third. These findings, as well as recent data from the literature, suggest that in the management of intracranial arachnoid cysts, cystoperitoneal shunting was more effective and had fewer serious complications than craniotomy and cyst fenestration, and therefore, it is recommended as the treatment of first choice.

Neural arch tuberculosis: radiological features and their correlation with surgical findings.

Radiological features of 17 cases of neural arch tuberculosis (NAT), treated surgically by the authors, are reviewed and correlated with the operative and histopathological findings. The diagnostic accuracy of different imaging modalities in the evaluation of this rare, atypical form of spinal tuberculosis was found to be very low. Thus, the initial diagnosis was in error in 15 out of 17 of our cases. Recognition of the radiological diagnostic features of NAT is important, not only because they may mimic primary or metastatic spinal neoplasms, but also because of the surgical implications. Computed tomography (CT) and magnetic resonance imaging (MRI) features correlated most closely with the surgical findings, whereas plain spinal radiographs and myelograms were found to be non-specific and non-diagnostic.

Pharyngo-cutaneous fistula following anterior cervical fusion.

A 26-year-old man who underwent anterior cervical fusion for a compressed fracture of the C5 vertebra developed postoperatively partial extrusion of the bone graft, followed by progressive dysphagia and retropharyngeal emphysema. Although no definite perforation of the oesophagus or pharynx was detected at reoperation, an extensive pharyngocutaneous fistula formed subsequently through the operative wound. Open drainage in association with broad spectrum antibiotics, continuous nasopharyngeal suctioning, stopping of oral intake and gastrostomy feeding resulted in closure of the fistula. However, the fistula recurred twice soon after resumption of the oral feeding. The diagnostic difficulties in determining when the healing of a pharyngo-cutaneous fistula is complete are underlined. In addition, the importance of continued treatment for 4-6 weeks after first radiological evidence of closure of the fistula is emphasized.

Orbito-cranial injury caused by penetrating metallic foreign bodies: report of two cases.

Two cases of orbito-cranial injury caused by foreign bodies (FBs) penetrating the lateral wall and roof of the orbit are described. In the first patient, a long rusted nail acted as a missile and was only detected by X-rays and CT scan. The nail penetrated the orbit, the eyeball, the lateral orbital wall, and the temporal lobe of the brain. Lodged partly in the orbit and partly in the brain, this nail caused leakage of cerebrospinal fluid (CSF) through eye and led to orbital cellulitis and localized meningitis. The foreign body (FB) was removed through an extradural pterional approach with rapid resolution of orbital cellulitis and meningitis. In the second patient, large metallic FB, having penetrated the orbital roof was lodged intracranially above the chiasma. This was removed via frontal craniotomy. Mechanism of such injuries and appropriate surgical approaches are described as well.

Acute spontaneous spinal epidural hematoma: the influence of magnetic resonance imaging on diagnosis and treatment.

BACKGROUND: Acute spontaneous spinal epidural hematoma (ASSEDH) is rare and its treatment standard were set prior to the era of magnetic resonance imaging (MRI). Recent data provided by this new technique necessitate a critical review of these standards. METHODS: A case of ASSEDH diagnosed by MRI and confirmed at surgery is presented. In addition, all cases of ASSEDH reported in the pertinent literature since 1987 were reviewed and compared with those cases described earlier. RESULTS: Since the introduction of MRI, the mean incidence of ASSEDH cases reported in the literature has increased from 2.2 to 6.4 new cases per year, with a remarkable rise in the percentage of those cases that did not require surgical treatment from 1.5% before the era of MRI to 29% thereafter. CONCLUSION: ASSEDH runs a benign course more often than previously estimated and, therefore, the choice of the treatment should be decided for each case individually. Urgent surgical decompression remains the treatment method of choice for patients with ASSEDH presenting with disabling neurologic deficit.

Intestinal obstruction caused by extraperitoneal cerebrospinal fluid collection.

External compression caused by a massive extraperitoneal cerebrospinal fluid collection lead to intestinal obstruction in a 3-year-old child who had previously had a ventriculoperitoneal shunt for treatment of hydrocephalus. Radiological findings and ways of preventing this situation are discussed. A useful diagnostic radiological sign, the "coiling sign', indicating shunt misplacement at the peritoneal level, is also described.

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.