Impact of Postoperative Infarcts in Determining Outcome after Clipping of Anterior Communicating Artery Aneurysms.

BACKGROUND: Development of cerebral infarcts following clipping of ruptured intracranial aneurysm is one of the major determinants of functional outcome in patients with subarachnoid hemorrhage (SAH). The aim of this study is to evaluate the factors affecting development of postoperative infarcts, its incidence, pattern, and functional outcome. MATERIAL AND METHODS: This study includes 118 patients of spontaneous SAH because of ruptured anterior communicating artery aneurysm, who underwent clipping. Relevant points in history, preoperative and intraoperative findings, and postoperative outcome are evaluated. RESULTS: 29 of 118 (24.5%) patients developed postoperative radiological infarcts. Approximately 37.9%, 17.2%, and 3.4% patients developed isolated infarcts, respectively, in anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) territory. About 20.7% patients developed infarcts in deep perforator territory. Nine of 29 (31.3%) patients developed multiple-vessel territory infarcts. Patients with poor preoperative neurologic status, prior history of seizure, and history of intraoperative rupture had higher chances of development of infarcts. Development of infarct was irrespective of temporary clipping (TC), duration of clipping, and elective versus rescue clipping. Development of infarcts adversely affected the outcome in significant proportions. Among patients with infarcts, unilateral ACA territory infarcts showed best prognosis, whereas all patients with multiple territory infarcts and PCA territory infarcts died. Age or sex of the patients did not affect the functional outcome. Timing of development of infarcts has no influence on functional recovery. CONCLUSION: Development of symptomatic infarct is the sole important predictor of functional outcome. A crowded neurovascular neighborhood and complex variations in local angioarchitecture make anterior communication (ACOM) territory predisposed to operative insults. Elective TC and aggressive management of cerebral vasospasm are recommended to prevent development of infarcts.

Long-term outcome in surviving patients after clipping of intracranial aneurysms.

OBJECTIVE: The quality of life and functional outcome may be significantly impaired in patients of aneurysmal subarachnoid hemorrhage. The purpose of the present study was to assess the status of patients undergoing surgical clipping of intracranial aneurysms in a long-term follow-up and to identify factors affecting outcome. METHODS: 494 patients who underwent clipping of their intracranial aneurysms with a minimum follow-up of 1 year after their discharge were studied. Preoperative factors such as age, Hunt and Hess grade, Fisher grade, time interval between ictus and surgery, and site of aneurysm were recorded. The long-term status was assessed using Glasgow Outcome Scale (GOS), Modified Rankin Scale (MRS), Barthel index (BI), and Mini-Mental State Examination (MMSE). RESULTS: Site of aneurysm and ictus-surgery interval did not have any effect on any parameter at long-term follow-up. Majority of patients who were discharged continued to improve as measured by GOS, Modified Rankin Scale, and Barthel index. However a significant proportion of patients had impaired MMSE at long-term follow-up. Multivariate analysis showed a significant effect of age on MMSE and also a positive correlation between number of aneurysms and GOS. CONCLUSIONS: Most patients who survived and were discharged continued to improve in the postoperative period even though the immediate postoperative outcome was not favorable in many. However, a substantial subset had impaired cognitive function.

Choroid plexus papilloma of the fourth ventricle in a septuagenarian.

Choroid plexus papillomas (CPP) are most commonly found in children and rarely in adult. A very few cases are reported in geriatric population. We present a case of 72-year-old man with posterior fossa lesion operated with provisional diagnosis of metastasis, but turn out to be CPP.

Primary calvarial Ewing's sarcoma presenting as a giant fungating skull tumour: a case report.

Giant calvarial Ewing's sarcoma is a rare entity. A 9-year-old girl presented with such a lesion, larger than her head and was fungating through the overlying skin. Surgical excision was done and the child was given chemotherapy. The child died after the second cycle. It is extremely uncommon to come across this disease in such an advanced stage.

Juxtapontine abscess around a retained wooden fragment following a penetrating eye injury: surgical management via a transtentorial approach.

Penetrating injury through the orbit with a retained intracranial wooden foreign body is rare. The authors report the case of a child with a juxtapontine brain abscess secondary to a retained foreign body. The pitfalls in diagnosis and the surgical management for removal of the wooden fragment and drainage of the abscess are discussed.

Posterior fossa vermian cystic schwannoma mimicking as pilocytic astrocytoma: a case report and literature review.

Intraparenchymal schwannomas are rare and most of the reported cases are in supratentorial region with frontal lobe being most common. Infratentorial location is very rare. We report a posterior fossa midline large cystic schwannoma with mural nodule mimicking as pilocytic astrocytoma. The pathogenesis and neuroradiological findings of intraparenchymal schwannomas are discussed with review of the related literature.

Decompressive craniectomy for malignant cerebral oedema of cortical venous thrombosis: an analysis of 13 patients.

OBJECTIVE: The study aims to define the role and indication of surgical intervention in cases of malignant cerebral edema in consequence to cortical venous thrombosis (CVT). METHODS: A retrospective study of 13 patients who underwent decompressive craniectomies for malignant CVT is presented. All patients had supra-tentorial cortical lesions attributable to CVT. The diagnosis was based on CT scan and MRI findings. Patients who presented in a poor clinical status with radiological evidence of malignant cerebral oedema as well as patients who worsened while on medical therapy underwent decompressive hemicraniectomies. Patients were followed up, and the outcome assessed as per Glasgow Outcome Scale (GOS) and Karnofsky Performance Status (KPS) scale. RESULTS: There were nine females and four males with a mean age of 29.2 years. Eleven patients survived with good outcome (GOs =5, n=5; GOS=4, n=6). At the last follow-up (median 35 months; mean 39 months), the KPS scale was 90 for five, 80 for four and 70 for two survivors. There were two deaths, both in patients with pre-operative Glasgow Coma Scale (GCS) <5. CONCLUSION: Timely recognition of failure of medical management and an appropriately timed surgical intervention may help to salvage CVT patients who develop malignant cerebral oedema.

Poor-grade subarachnoid hemorrhage: is surgical clipping worthwhile?

BACKGROUND: Management of patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) is difficult and the protocols followed differ from center to center. MATERIAL AND METHODS: In this report, we present our experience with aneurysmal clipping in patients with poor-grade SAH. Patients with poor Hunt and Hess (H and H) grade (Grade IV and Grade V) were offered surgery after stabilization of their hemodynamic and metabolic parameters. The status was recorded as favorable (good recovery, mild to moderate disability but independent), unfavorable (severe disability, vegetative) and dead. RESULTS: Out of a total of 1196 patients who underwent aneurysmal clipping, 165(13.8%) were in poor grade. Of the 165 patients, 99 (60%) were in H and H Grade IV and 66 (40%) were in Grade V. More than half of the patients (58%) were operated within 24 h of admission. There was an overall mortality of 50.9%. In the long term, of the survivors who were followed up, about 72% achieved a favorable outcome. CONCLUSIONS: With an aggressive approach aimed at early clipping, the chances of rebleed are reduced and vasospasm can be managed more aggressively. This protocol resulted in survival in a significant proportion of patients who would have otherwise died. In the long-term follow-up, the surviving patients showed significant improvement from the status at discharge.

Ruptured posterior cerebral artery aneurysm in association with neurofibromatosis type 2--a case report.

Intracranial aneurysms have been described in patients with Neurofibromatosis (NF)- 1, but not with NF-2 apart from one instance of a middle meningeal artery aneurysm (Louis DN, Ramesh V, Gusella JF. Neuropathology and molecular genetics of neurofibromatosis 2 and related tumors. We report a case of NF-2 and ruptured posterior cerebral artery aneurysm.

Atypical teratoid/rhabdoid tumour of the central nervous system in adult: case report.

Atypical teratoid/rhabdoid tumours (AT/RT) are aggressive neoplasms of the central nervous system occurring mainly in the paediatric population. We reported a 32-year-old male patient who was admitted in emergency in unconscious state. The neoplasm was localised in the left frontal region and was totally excised. The histological and immunohistochemical report revealed AT/RT. This unusual presentation underlines the necessity of considering this devastating neoplasm in the differential diagnosis of malignant brain tumours of adults.

Contrasting behavior of glio-ependymal cysts: a report of two cases and literature review.

Cystic lesions of the brain may present with seizures or headache due to raised intracranial pressure. These cysts when associated with developmental brain anomalies may turn out to be pathologic surprises. In the present communication, two patients with glio-ependymal cysts were described with contrasting symptomatologies and surgical management. Non-enhancing cystic lesions of the brain, without mural nodule, may turn out to be glio-ependymal cysts, requiring total surgical excision or marsupilization.

Vertebral body hyperostosis as a presentation of Pott's disease: a report of two cases and literature review.

Vertebral body tuberculosis has numerous forms of presentations. We present two patients of Pott's disease, in whom vertebral body hyperostosis was the radiological presentation. Both the patients had massive hyperostosis of vertebral bodies leading to the obliteration of the spinal canal and neurological deficits. The first case had associated lupus vulgaris, while the second patient had milliary mottling of lungs and calcified bilateral psoas muscles. Surgical decompression, followed by full-dose chemotherapy, remains the hallmark of management of this disease.

Intracerebral infarcts following clipping of intracranial aneurysms: incidence, clinical correlation and outcome.

Subarachnoid hemorrhage (SAH) is a significant health care problem. One of the major determinants of outcome following surgery of intracranial aneurysms is development of intracranial infarcts. All patients underwent clipping for aneurysms in one year in the department of neurosurgery, PGIMER, Chandigarh were studied. Data regarding age, sex, date of ictus, date of admission, any co-morbidity, clinical grades at presentation, CT findings, infarcts, intraoperative rupture, and clinical status in the postoperative period were recorded. Outcome at discharge was assessed by Glasgow outcome scale (GOS). First, 174 patients were included in the study. Radiological cerebral infarctions occurred in 69 patients (39%). The most frequent location of infarct was deep perforator infarct followed by ACA territory infarct. 69.58% of patients developed infarct on the same side of aneurysm and 20.28% of patients developed infarct on opposite side, whereas 11% developed bilateral infarcts. Infarcts that occur early after surgery may be related to surgical factors whereas the late infarcts were probably as results of delayed ischemic deficits. Anatomical distribution of infarcts also showed two different patterns, infarcts limited to one vascular territory (more commonly seen in early onset infarcts) or multiple, cortical, bilateral infarcts (more commonly seen in late onset infarct). Patients with poor H&H grade, higher Fisher's grade, intraoperative rupture and prolonged temporary clipping had more chances of developing an intracranial infarct.

Giant intraparenchymal neurocysticercosis: report of surgical aspects two cases.

Giant parenchymal cysticercosis is a relatively rare condition and surgical treatment may be required when it is associated with elevated intracranial pressure. We report two patients with giant parenchymal cysticercosis who were treated surgically for the elevated intracranial pressure. In both the patients the preoperative diagnosis was of a cystic glioma. Total excision of the lesions was achieved in both the patients. In countries endemic to neurocysticercosis gaint parenchymal cysticercosis should be considered in the differential diagnosis of cystic enhancing mass lesion. Surgical excision may be indicated when it is associated with elevated intracranial pressure.