Persistent Craniopharyngeal Canal: A Rare Cause for Recurrent Meningitis in Pediatric Population.

We present the case of a 5-year-old girl who had six episodes of meningitis. She also had panhypopituitarism and was found to have a persistent craniopharyngeal canal (CPC) as the cause of her recurrent meningitis. Role of neuroradiology and a high index of suspicion by the clinical team are highlighted here. Persistent CPC is a rare cause of recurrent meningitis. We discuss the approach to the child with recurrent meningitis.

Middle ear rhabdomyosarcoma infiltrating the petrous with diffuse leptomeningeal spread in a child.

We present a case of middle ear rhabdomyosarcoma with intracranial erosion and later presented with diffuse leptomeningeal spread. Such lesions are difficult to eradicate and have a poor prognosis.

Delayed-onset bilateral abducens paresis after head trauma.

Bilateral sixth nerve paresis following closed head injury, though rare, is a known entity. However, delayed-onset post-traumatic bilateral abducens paresis is extremely rare. We present two cases. The first patient had onset of bilateral abducens paresis 2 weeks after closed head injury and the second patient after 3 days. The cause in the former was detected to be chronic subdural hematoma and in the latter is speculated to be edema/ischemia due to injury to soft tissue structures housing these nerves. The delayed onset of bilateral abducens paresis following head injury may vary according to the cause. There may be another mechanism of injury apart from direct trauma. Though rare, it needs to be evaluated and may have a treatable cause like elevated intracranial pressure.

Ventral compression in adult patients with Chiari 1 malformation sans basilar invagination: cause and management.

BACKGROUND: A small subset of patients with adult Chiari I malformation without basilar invagination (BI) and instability show ventral cervicomedullary distortion/compression and have symptoms pertaining to that. The cause of this ventral compression remains speculative. Additionally, it is unclear if these patients would require ventral decompression with posterior fusion or only posterior decompression would suffice. METHODS: Sixteen adult patients with Chiari I malformation with significant ventral cervicomedullary compression, in the absence of BI, were included in the study. Atlantoaxial dislocation (AAD) was excluded in these patients by flexion-extension craniovertebral junction X-rays and computed tomography (CT). Their clinical profile, especially symptoms pertaining to cervicomedullary compression, i.e. dysphagia, dysarthria and spasticity, were graded. The ventral cervicomedullary compression (VCMC) was quantified using pBC2 (maximum perpendicular distance to the basion-infero posterior point of the C2 body) on sagittal magnetic resonance imaging (MRI) and only those patients with pBC2 ≥9 mm were included. Furthermore, retroversion of dens and retro odonotid tissue thickness was calculated in each patient. Fifteen patients underwent posterior decompression alone and one refused surgery. Follow-up was done every 3 months. Repeat MRI was done at 1 year following surgery to look for pBC2. RESULTS: The mean pBC2 was 11 ± 0.2 mm. Retroversion of dens was responsible for VCMC in three patients and periodontoid crown in 13. There was no correlation between the tonsillar descent, age and the pBC2. All patients improved in symptoms of cervicomedullary compression following surgery. One patient worsened 6 months after initial improvement. The pBC2 did not change, as seen on follow-up MRI done in five patients. CONCLUSIONS: VCMC in adult patients with Chiari I malformation in the absence of BI and/or AAD is due to periodontoid tissue (crown) or retroverted dens. Though a long-term study is required, it appears that all patients with Chiari I malformation, irrespective of the VCMC, can be given a chance with posterior decompression alone. Transoral decompression with posterior fusion may be required in a small subset of patients who fail to improve or worsen following posterior decompression only.

An exophytic brain stem glioblastoma in an elderly presenting as a cerebellopontine angle syndrome.

Exophytic brain stem gliomas are rare and are generally seen in paediatric population. These are usually low grade gliomas. We report a case of brainstem glioblastoma in an elderly patient presenting as a cerebellopontine mass.

Extra-axial ependymoma mimicking a parasagittal meningioma.

Supratentorial ependymomas are more often found in adults than in children and are usually intra-axial. We report an extra-axial supratentorial ependymoma which mimicked the presentation of a parasagittal meningioma. The diagnosis and management of this unusual tumor is detailed.

Preoperative diffuse leptomeningeal spread in a medulloblastoma: Paraplegia following surgery for posterior fossa and call for newer management protocols.

Management of patients with medulloblastoma presenting with multiple metastasis in subarachnoid space preoperatively is unclear. An 11-year-old boy presented with vermian medulloblastoma with an unusually long segment cervico-dorsal lesion and suprasellar lesion. The child underwent a posterior fossa craniotomy (prone position) and excision of vermian mass. He developed paraplegia in the immediate postoperative period, the possible causes for which are being discussed. Besides, treatment options for patients presenting with disseminated disease preoperatively have been highlighted. Preoperative chemotherapy to downstage such lesions may be tried and such complications could be avoided.