Retrospective Analysis of Transnasal Endoscopic CSF Rhinorrhea Repair in a Tertiary Care Centre.

To analyse the outcome of transnasal endoscopic repair of CSF Rhinorrhea in a tertiary care centre. This is a retrospective study conducted on 81 patients who underwent CSF Rhinorrhea repair in a tertiary care hospital for a period of 11 years. Following confirmation of diagnosis using bio-chemical and radiological investigations, all patients underwent transnasal endoscopic repair of CSF Rhinorrhea using a multilayer graft. Patients were followed up for 6 months. The most common etiology in our study was spontaneous CSF rhinorrhea (60.49%) and subjects with BMI > 25.5 kg/m2 were more prone to it. Cribriform plate was found to be the most frequent site of leak in our study (58.02%), followed by fovea ethmoidalis (12.35%). Overall success rate was 96.30%. Transnasal endoscopic approach for cerebrospinal fluid rhinorrhea repair shows good success rate and also offers the advantages of better visualization and identification of site of leak, less complications, rapid postoperative recovery, and low recurrence rate. Transnasal endoscopic CSF Rhinorrhea repair has shown good results in terms of low recurrence rates and high patient satisfaction among other advantages. Hence this approach should be commonly used for CSF rhinorrhea repair by surgeons.

Computed Tomography-Guided Catheter Aspiration and Thrombolysis of Hypertensive Basal Ganglionic Hematomas: Technique and Short-Term Outcome Comparison.

BACKGROUND: Minimally invasive techniques of hematoma evacuation with or without the use of thrombolytic agents to lyse the clots have shown promising outcomes compared to open surgical evacuation. However, there is a dearth of literature in developing nations. The objective in this study was to evacuate spontaneous hypertensive basal ganglionic hemorrhages using computed tomography (CT)-guided catheter insertion, hematoma aspiration, and lysis with thrombolytic agents and analyze the efficacy and outcomes. METHODS: Ten patients with spontaneous basal ganglionic hemorrhage underwent CT-guided clot catheter insertion, followed by aspiration of hematoma and clot lysis using 25,000 IU urokinase instilled every 12 hours. Details including symptoms, clinical and radiologic findings, efficacy of the technique, functional outcomes during follow-up, length of stay, and cost were recorded. Relevant details for 12 age- and sex-matched conservatively treated patients were compared. RESULTS: Functional outcome in the catheter group at 6 months was better than the medically managed group, with improved mean Glasgow Outcome Scale score (0.4 vs. 0.08), reduced modified Rankin scale score (-0.8 vs. -0.25), and reduced National Institutes of Health Stroke Scale score (-6.8 vs. -1.5 points). However, it was not statistically significant. Average hematoma volume reduction in the catheter group was 83.14%. In the medically managed group, 2 of 12 patients (16.6%) had hematoma expansion, 6 patients (50%) developed hydrocephalus, and 2 patients (16.6%) died. In the catheter group, 4 of 10 patients (40%) developed mild pneumocephalus that resolved. CONCLUSIONS: The evacuation of hypertensive basal ganglionic hematomas is feasible with basic neurosurgical instruments and existing resources (e.g., CT scan) with improved functional outcome compared with conservative treatment alone.

Evaluation of implant properties, safety profile and clinical efficacy of patient-specific acrylic prosthesis in cranioplasty using 3D binderjet printed cranium model: A pilot study.

There exists a significant demand to develop patient-specific prosthesis in reconstruction of cranial vaults after decompressive craniectomy. we report here, the outcomes of an unicentric pilot study on acrylic cranial prosthesis fabricated using a 3D printed cranium model with its clinically relevant mechanical properties. METHODS: The semi-crystalline polymethyl methacrylate (PMMA) implants, shaped to the cranial defects of 3D printed cranium model, were implanted in 10 patients (mean age, 40.8 ± 14.8 years). A binderjet 3D printer was used to create patient-specific mould and PMMA was casted to fabricate prosthesis which was analyzed for microstructure and properties. Patients were followed up for allergy, infection and cosmesis for a period of 6 months. RESULTS: As-cast PMMA flap exhibited hardness of 15.8 ± 0.24Hv, tensile strength of 30.7 ± 3.9 MPa and elastic modulus of 1.5 ± 0.1 GPa. 3D microstructure of the semi-crystalline acrylic implant revealed 2.5-15 µm spherical isolated pores. The mean area of the calvarial defect in craniectomy patients was 94.7 ± 17.4 cm2. We achieved a cranial index of symmetry (CIS -%) of 94.5 ± 3.9, while the average post-operative Glasgow outcome scale (GOS) score recorded was 4.2 ± 0.9. CONCLUSIONS: 3D printing based patient-specific design and fabrication of acrylic cranioplasty implant is safe and achieves acceptable cosmetic and clinical outcomes in patients with decompressive craniectomy. Our study ensured clinically acceptable structural and mechanical properties of implanted PMMA, suggesting that a low cost 3D printer based PMMA flap is an affordable option for cranioplasty in resource constrained settings.

Acute Hydrocephalus in a Case of Mumps Meningoencephalitis: A Rare Occurrence.

Mumps is an acute viral illness, which presents with glandular and/or nervous system involvement. The most common central nervous system manifestations of mumps include aseptic meningitis and meningoencephalitis. Mumps meningoencephalitis, which is characterized by fever, vomiting, nuchal rigidity, and altered sensorium, usually develops at least 3-10 days after mumps parotitis. Acute hydrocephalus secondary to mumps meningoencephalitis is rare. Here we report a child who developed acute hydrocephalus following mumps meningoencephalitis and who was treated with external ventricular drainage following which he showed exceptional recovery.

Supraorbital Craniotomy for Large Anterior Skull Base Meningiomas: A Technical Note.

BACKGROUND: Supraorbital craniotomy (SOC) has brought a paradigm shift in approaching anterior skull base lesions. With better understanding of relevant anatomy, the indications are being stretched from highly selected, small-to-moderate-sized tumors to large and complex anterior skull base lesions. OBJECTIVE: We share our experience and discuss the nuances of surgery for large anterior skull base meningiomas using the SOC. METHODS: This is a single institute study using prospectively collected retrospective data from seven cases of large anterior skull base meningiomas (>3 cm) using the SOC. We reviewed the indications, safety, and procedural complications in these cases. RESULTS: Simpson's Grade 2 excision was achieved in all these seven cases, with faster postoperative recovery. Follow-up clinical outcome and cosmesis were satisfactory. CONCLUSION: SOC is a safe alternative for the standard skull base approaches in treating large anterior skull base meningiomas. The SOC can be effectively used to treat selected large anterior skull base meningiomas.

Rare manifestation of common disease with an unique method of minimally invasive spine stabilization: Cervical 2-3 facet lesion.

Cervical granulomatous infections of the posterior elements are very rare, it is often difficult to diagnose due to rarity and variable presentation of symptoms. Any cervical surgical procedure carries a certain morbid risk to the patient. We present a case of cervical 2-3 facet joint lesion which was managed by a minimally invasive technique with a favorable outcome.

Minimally Invasive Augmented Fixation for Anatomical Reduction of Grade 2 and Grade 3 Listhesis in Patients with Osteoporosis.

STUDY DESIGN: A retrospective study. PURPOSE: To study the efficacy of augmented fixation for anatomical reduction of grade 2 and grade 3 listhesis in patients with osteoporosis. OVERVIEW OF LITERATURE: Spondylolisthesis in osteoporotic patients requiring spinal fixation are associated with complications such as loss of surgical construct stability, screw pulling out, and screw loosening. Augmented fixation is a novel strategy to achieve necessary construct integrity. METHODS: Thirteen consecutive patients with grade 2 or grade 3 listhesis, with proven osteoporosis on dual energy X-ray absorptiometry (DEXA) scan, and who underwent augmented fixation for reduction of listhesis were retrospectively analyzed. In all patients, surgical access was achieved with a fixed 22 mm tubular retractor. A modified technique of bilateral, sequential, transforaminal decompression and discectomy, followed by reduction of listhesis using unilaterally placed augmented screws was employed in all the cases. Patients were followed up with plain X-rays at regular intervals to assess for implant stability and fusion status. All patients were started on medical treatment for osteoporosis. RESULTS: The mean age of the patients was 52.46 years, with 12 females and one male. The median T-score on DEXA scan was -3.0. Of the 13 patients, listhesis was at L4-L5 in five and at L5-S1 in eight. Nine patients had grade 2 listhesis, while four patients had grade 3 listhesis. Complete reduction was achieved in 10 patients. The median duration of follow-up was 18 months. Postoperative outcomes were satisfactory in all cases. CONCLUSIONS: Augmented fixation is a useful technique for achieving anatomical reduction of listhesis in patients with osteoporosis.

Extrapontine Myelinolysis and Reversible Parkinsonism After Hyponatremia Correction in a Case of Pituitary Adenoma: Hypopituitarism as a Predisposition for Osmotic Demyelination.

BACKGROUND: Osmotic demyelination syndrome commonly follows rapid correction of hyponatremia. Although pons is a common location, extrapontine locations, such as striatum and thalamus, have been reported. CASE DESCRIPTION: A 48-year-old woman presented with masked facies, shuffling gait, and pill-rolling tremors suggestive of acute-onset parkinsonism. Hyponatremia was diagnosed following a bout of diarrhea, which was corrected with hypertonic saline. Magnetic resonance imaging of the brain showed a giant pituitary adenoma. Hyperintensities on T2-weighted imaging were also seen at the level of pons and bilateral striatum. Central pontine myelinolysis and extrapontine myelinolysis were diagnosed. Hormonal assay showed hypocortisolism, secondary hypothyroidism, and hypogonadism. The patient was started on levodopa-carbidopa, steroids, and thyroxine. She underwent transnasal pituitary adenoma excision. At 6 months postoperatively, she had recovered completely with normal gait. Repeat imaging showed complete resolution of myelinolysis. At 36 months, she continued to have hypocortisolism and hypothyroidism requiring replacement. CONCLUSIONS: Extrapontine myelinolysis with parkinsonism and asymptomatic central pontine myelinolysis is rare with few cases described in the literature. Our patient had a pituitary adenoma with hyponatremia requiring sodium correction, and we believe that hypopituitarism might have predisposed her to osmotic demyelination. We reviewed relevant literature on extrapontine myelinolysis in suprasellar tumors and the pathophysiology. Hypopituitarism is an underrecognized cause of hyponatremia. When treating a patient with hyponatremia, knowing the pituitary function status is a prerequisite for the physician to prevent osmotic demyelination syndrome.

Clinical and radiological assessment of cerebral hemodynamics after cranioplasty for decompressive craniectomy - A Clinical study.

OBJECTIVES: To find the correlation between radiologically proven improvement in cerebral hemodynamics with clinical improvement in patients undergoing cranioplasty. MATERIAL AND METHODS: The study is a prospective observational study of 10 cases, in M S Ramaiah Institute of Neurosciences, involving patients treated by a decompressive craniectomy for intractable intra cranial hypertension either due to trauma or stroke and afterwards underwent cranioplasty. RESULTS: Of the 10 patients, 70% patients showing significant improvement in motor functions on Barthel index scale, 60% patients showed improvement in speech, mean duration from date of decompressive craniectomy to cranioplasty being 122.4days. Cerebral perfusion was remarkably better after cranioplasty, as demonstrated decrease in the Pulsatility index on the ipsilateral side of decompression on Trans cranial Doppler (<0.73 mean). This data also favored improved cerebral blood flow and permeability on the CT perfusion with increase in cerebral blood flow (CBF), Cerebral Blood Volume (CBV) and decrease in Time to Peak (TTP) and a positive outcome when correlated with Barthel index with P-values of 0.093, 0.017 and 0.001 respectively. CONCLUSION: Cranioplasty influences the cerebral hemodynamics after cranioplasty and has a positive correlation on the functional outcome and cerebral blood flow in the MCA territory.

Giant posterior fossa dural cavernoma in a child.

PURPOSE: Extra-axial (dural) cavernomas are rare and constitutes 5% of all cavernomas. They are thought to arise from the venous plexus of the dura. They can reach large sizes before diagnosis and can have an aggressive presentation. METHODS: The authors report a rare case of giant cavernoma based on the posterior fossa dura adjacent to the sigmoid sinus (sino-dural angle) in an 8-year-old boy which was excised with good outcome. The authors describe its clinico-radiological profile and outcome characteristics along with a comprehensive review of relevant literature. RESULTS: This child underwent retromastiod craniectomy and complete excision of the dural cavernoma. The dural attachment was coagulated. Histopathological examination confirmed the diagnosis. CONCLUSION: We report cavernoma needs to be considered in the differential diagnosis of a dural-based posterior fossa lesion in paediatric population as complete excision is possible.

Angioglioma of the Spinal Cord.

BACKGROUND: Angiogliomas are rare low-grade glial tumors with significant vascular components. These tumors are usually seen in the brain, and spinal cord angiogliomas have not been reported in the literature until now. CASE DESCRIPTION: We report the case of a 15-year-old boy with an angioglioma of the medulla and cervicodorsal spine, which was completely excised through a combined suboccipital craniotomy and cervicodorsal laminotomy. The patient experienced excellent clinical recovery after the surgery, and follow-up contrast magnetic resonance imaging showed complete excision of the tumor. CONCLUSION: The fact that increased vascularity in a glioma does not always indicate a higher grade is confirmed by the unique histology of angiogliomas. These tumors can present with intratumoral bleeding. Awareness of these entities is extremely important. Complete excision can be attempted, and the postoperative prognosis is very good.

Minimally invasive atlantoaxial fusion: cadaveric study and report of 5 clinical cases.

OBJECTIVE Minimally invasive techniques are being increasingly used to treat disorders of the cervical spine. They have a potential to reduce the postoperative neck discomfort subsequent to extensive muscle dissection associated with conventional atlantoaxial fusion procedures. The aim of this paper was to elaborate on the technique and results of minimally invasive atlantoaxial fusion. MATERIALS Minimally invasive atlantoaxial fusion was done initially in 4 fresh-frozen cadavers and subsequently in 5 clinical cases. Clinical cases included patients with reducible atlantoaxial instability and undisplaced or minimally displaced odontoid fractures. The surgical technique is illustrated in detail. RESULTS Among the cadaveric specimens, all C-1 lateral mass screws were in the correct position and 2 of the 8 C-2 screws had a vertebral canal breach. Among clinical cases, all C-1 lateral mass screws were in the correct position. Only one C-2 screw had a Grade 2 vertebral canal breach, which was clinically insignificant. None of the patients experienced neurological worsening or implant-related complications at follow-up. Evidence of rib graft fusion or C1-2 joint fusion was successfully demonstrated in 4 cases, and flexion-extension radiographs done at follow-up did not show mobility in any case. CONCLUSIONS Minimally invasive atlantoaxial fusion is a safe and effective alternative to the conventional approach in selected cases. Larger series with direct comparison to the conventional approach will be required to demonstrate clinical benefit presumed to be associated with a minimally invasive approach.

The vanishing shunt valve.

PURPOSE: Ventriculoperitoneal (VP) shunt is one of the most commonly performed procedures by a neurosurgeon. It is occasionally fraught with the most bizarre complications. Understanding the pathophysiology of these complications can help us make the procedure safe and more effective. METHODS: The authors report a case of 8-year-old boy, previously operated for lumbar myelomeningocele and hydrocephalus with an intra diploic migration of shunt tube and shunt dysfunction, and discuss the pathophysiology, diagnosis, and surgical strategy. RESULTS: After diagnosis of shunt malfunction, shunt revision was done with placement of new system and removal of the old apparatus. Patient had a remarkable recovery after the surgery. CONCLUSION: Intradiploic migration is an extremely rare cause of shunt malfunction and has never been reported in literature before. Possible mechanism is that prolonged pressure on the valve due to recumbent head position in a paraplegic child might have led to new bone formation and subsequent intradiploic migration of the valve. Careful planning the position of shunt valve in relation to head position, especially in children who are recumbent due to paraplegia might avoid this untoward complication.

Occipital dermal sinus with a vermian dermoid.

Congenital occipital dermal sinus with an underlying dermoid is a rare, benign lesion of embryological origin and may occur anywhere along the neuraxis. We present a case of a 15-year-old girl with a vermian dermoid and an occipital dermal sinus. Gross total resection of the lesion was done and post-operative period was uneventful. A detailed review of the literature is also covered.

Pediatric infratentorial subdural empyema: analysis of 14 cases.

OBJECT: Pediatric cases of infratentorial subdural empyema (SDE) are both rare and associated with high rates of morbidity and mortality. The goal of this study was to report patient characteristics, treatment, and outcome in an exclusively pediatric series of SDE cases. METHODS: A series of 14 pediatric cases of infratentorial SDE was retrospectively analyzed. All patients were treated between 1994 and 2004. Sixty-four percent of the patients were boys; the majority of cases occurred during the summer months. Clinical features included headache, fever, vomiting, meningism, and otorrhea. Cerebellar signs were found only in 21% of patients. In 85.7% of the cases, the patients presented with a depressed level of consciousness (Glasgow Coma Scale Scores 11-15). In 79.6%, pus collection was seen over the cerebellar convexity; interhemispheric and tentorial collections were also observed in some cases. Hydrocephalus was present in 92.9% of patients. Five patients required external ventricular drainage during surgery or postoperatively. Shunt placement was required in 21% of cases. All patients were treated with antibiotic therapy and surgery (bur holes in 21% of the cases, craniectomy in 79%). Pus cultures demonstrated microbial infection in 71.4%, and polymicrobial infection in 21%. Four patients required repeated surgery for reaccumulation of pus. Minor postoperative complications developed in three patients. All 14 patients survived. At follow up, the Glasgow Outcome Scale scores were 4 or 5 in all cases. CONCLUSIONS: Early diagnosis and prompt surgical treatment are crucial in cases of SDE. With appropriate surgery, antibiotic therapy, and management of hydrocephalus, good outcome can be expected.