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   Table of Contents - Current issue
Coverpage
July-September 2017
Volume 12 | Issue 3
Page Nos. 345-584

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COMMENTARY  

Psychiatric disorders in low backache patients: A neurosurgeon's nightmare!!! p. 345
Ashish Kumar
DOI:10.4103/1793-5482.175634  
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There is no evidence that laminoplasty results in improved outcomes compared with laminectomy in cervical spinal cord injury without instability p. 347
Shayan Abdollah Zadegan, Vafa Rahimi-Movaghar
DOI:10.4103/1793-5482.175640  
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Comments for radiological study of C3–C4 level surgical cases of cervical spondylosis p. 348
Mehmet Zileli
DOI:10.4103/1793-5482.175642  
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A case of early extraneural medulloblastoma metastases in a young adult p. 349
Abbas Amirjamshidi
DOI:10.4103/1793-5482.175647  
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Evidence-based evaluation of early versus late surgical decompression in cervical spinal cord injury p. 350
Mahdi Sharif-Alhoseini, Alexander Vaccaro, Vafa Rahimi-Movaghar
DOI:10.4103/1793-5482.165789  
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REVIEW ARTICLES Top

Primary intracranial dural-based Ewing sarcoma/peripheral primitive neuroectodermal tumor mimicking a meningioma: A rare tumor with review of literature p. 351
Vikul Kumar, Anshu Singh, Vivek Sharma, Mohan Kumar
DOI:10.4103/1793-5482.185060  
Ewing sarcoma/peripheral primitive neuroectodermal tumor (ES/pPNET) is a malignant small, round cell tumor arising from bone and soft tissue in children and young adults. It can occur at osseous and extraosseous sites. Its usual locations are diaphysis of long bones followed by pelvis, ribs, vertebrae, and rarely skull. We reviewed the literature and PubMed advanced search on ES/pPNET occurring at extraosseous sites, mainly involving the central nervous system (CNS). We reported a case of a 22-year-old male presenting with seizure finally diagnosed as a case of ES/pPNET. The challenges in management of this rare CNS tumor and its differential diagnosis are highlighted. We found that most cases of ES involving CNS represent secondary metastases from extracranial sites of ES/pPNET and there are rare case reports of primary intracranial ES-pPNET. Furthermore, among these intracranial tumors, most common tumors occupy an intraaxial location and only a handful of cases of dural-based or extraaxial tumors mimicking meningioma are reported. Differentiation of pPNET from central PNET (cPNET) is important as it has definitive therapeutic and prognostic implications. Awareness of this entity of ES/pPNET, its rare dural presentation, and differentiation from the more common cPNET is needed for appropriate patient management. Meningeal ES/pPNET has to be kept in mind in the differential diagnosis of meningeal tumors eroding bone.
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Sphenoid wing en plaque meningioma development following craniopharyngioma surgery and radiotherapy: Radiation-induced after three decades p. 358
Amol Raheja, Guru Dutta Satyarthee
DOI:10.4103/1793-5482.180946  
Radiation therapy is widely used as adjuvant or primary treatment modality of neoplastic lesions. Radiation therapy may cause an acute adverse effect such as brain edema, radiation necrosis, or delayed, for example, panhypopituitarism, vasculitis, and rare de-novo neoplasm development. However, radiation-induced meningioma (RIM) occurrence is extremely rare. A detailed PubMed and Medline search yielded only three isolated Case-reports of RIM development in craniopharyngioma cases receiving radiotherapy after surgery. All cases occurred in patients <13-year age, with male preponderance, detected after a mean interval of 23-year, the range being 2–44 years. Two had solitary while the third had multiple meningiomas. Authors report an 8-year-old female, who was operated for craniopharyngioma and received adjuvant therapy, was asymptomatic for next 30 years, met a road traffic accident and magnetic resonance imaging brain revealed incidental right sphenoid wing en plaque meningioma. She was planned for gamma-knife therapy as unwilling for surgical intervention. Management of RIM development after radiotherapy of craniopharyngioma along with pertinent literature is reviewed briefly.
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Newer insights to pathogenesis of traumatic brain injury p. 362
Sunil Munakomi, Iype Cherian
DOI:10.4103/1793-5482.180882  
Traumatic brain injury (TBI) is a silent epidemic and a global burden. However, when it comes to advancement in our quest to managing patients with head injuries, we seem to be making circles rather than moving forward. In this review paper,we focus on the current understandings in the pathogenesis of TBI that may aid us in providing newer avenues in management of the same.
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A systematic review about the position-related complications of acoustic neuroma surgery via suboccipital retrosigmoid approach: Sitting versus lateral p. 365
Mahdi Safdarian, Manouchehr Safdarian, Roger Chou, Seyed Mahmoud Ramak Hashemi, Vafa Rahimi-Movaghar
DOI:10.4103/1793-5482.185069  
This systematic review wasdesigned to compare the complications of acoustic neuroma surgery via the suboccipital retrosigmoid approach in the sitting versus lateral positions. Searches for randomized trials and observational studies about the complications of acoustic neuroma surgery were performed in five medical databases (though October 2015) including PubMed, MEDLINE (In-Process and Other Non-Indexed Citations), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO. Primary outcomes in this study were venous air emboli, neuropsychological defects, CSF leak, facial and abducens nerves palsy, postoperative deafness, hydrocephalus and mortality. Secondary outcomes were total tumor removal, facial and cochlear nerves preservation and ataxia. 843 abstracts and titles were reviewed and 10 studies (two non-randomized comparative studies and 8 non-comparative case series) were included for data extraction. Because of the heterogeneity of the studies, small number of participants and methodological shortcomings, findings were evaluated qualitatively. No impressive advantage was found in surgical or neurological outcomes for use of the sitting or lateral positions in patients with acoustic neuroma surgery. According to the available evidence, it seems that both sitting and lateral positions can be used with an equivalent safety for acoustic neuroma surgery via the retrosigmoid suboccipital approach. There seems a clear need for comparative studies to compare harms and other outcomes for these two positions.
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Genetic associations of intracranial aneurysm formation and sub-arachnoid hemorrhage p. 374
Christian B Theodotou, Brian M Snelling, Samir Sur, Diogo C Haussen, Eric C Peterson, Mohamed Samy Elhammady
DOI:10.4103/1793-5482.180972  
Risk factors for cerebral aneurysms typically include age, hypertension, smoking, and alcohol usage. However, the possible connection of aneurysms with genetic conditions such as Marfan's syndrome, polycystic kidney disease, and neurofibromatosis raises the question of possible genetic risk factors for aneurysm, and additionally, genetic risk factors for rupture. We conducted a literature review using the PubMed database for studies regarding genetic correlation with cerebral aneurysm formation as well as rupture from December 2008 to Jun 2015. Twenty-one studies related to IA formation and 10 concerning IA rupture that met our criteria were found and tabulated. The most studied gene and the strongest association was 9p21/CDKN2, which is involved in vessel wall remodelling. Other possible genes that may contribute to IA formation include EDNRA and SOX17; however, these factors were not studied as robustly as CDKN2. Multiple factors contribute to aneurysm formation and rupture and the contributions of blood flow dynamics and comorbidities as mentioned previously, cannot be ignored. While these elements are important to development and rupture of aneurysms, genetic influence may predispose certain patients to formation of aneurysms and eventual rupture.
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Surgical treatment of large and giant cavernous carotid aneurysms p. 382
Kitiporn Sriamornrattanakul, Ittichai Sakarunchai, Kei Yamashiro, Yasuhiro Yamada, Daisuke Suyama, Tsukasa Kawase, Yoko Kato
DOI:10.4103/1793-5482.180930  
Cavernous carotid aneurysms (CCAs) are uncommon pathologic entities. Extradural place and the skull base location make this type of an aneurysm different in clinical features and treatment techniques. Direct aneurysm clipping is technically difficult and results in a significant postoperative neurological deficit. Therefore, several techniques of indirect surgical treatment were developed with different surgical outcomes, such as proximal occlusion of internal carotid artery (ICA) or trapping with or without bypass (superficial temporal artery-middle cerebral artery bypass or high-flow bypass). High-flow bypass with proximal ICA occlusion seems to be the most appropriate surgical treatment for CCA because of the high rate of symptom improvement, aneurysm thrombosis, and minimal postoperative complications. However, in cases of CCA presented with direct carotid-cavernous fistula, the appropriate surgical treatment is high-flow bypass with aneurysm trapping, which the fistula can be obliterated immediately after surgery.
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ORIGINAL ARTICLES Top

Outcomes following surgical management of cervical chordoma: A review of published case reports and case series p. 389
My Pham, Mohammed Awad
DOI:10.4103/1793-5482.185066  
Aim: This review aimed to summarize the clinical outcomes in relation to tumor resection margins of cervical chordomas. Methods: Studies that described any surgical intervention for cervical chordoma were identified. Cervical chordomas with cranial or spinal extension, purely retropharyngeal chordomas or where resection type was not reported, were excluded from the study. Results: Seventy-six articles were obtained and these reported a total of 195 patients. Seventy-six percent cervical chordoma patients had intralesional resection with adjuvant radiotherapy. Ninety-two percent chordoma recurrences and all chordoma metastases occurred in patients with intralesional resection. En bloc surgeries were longer (900 min vs. 619 min) and staged surgeries. Intralesional surgeries (2899 ml vs. 2661 ml) had greater intraoperative blood loss. Vertebral artery and nerve root sacrifice were greater in en bloc patients (35%, 39%) compared to intralesional patients (17%, 10%). Postoperative complications were more common in en bloc (54%) than in intralesional patients (11%). Conclusions: En bloc resection cervical chordomas are associated with less recurrence and no metastasis compared to intralesional resection. En bloc is possible through wide exposure of the vertebrae via a multidisciplinary team approach and utilization of particular surgical equipment. The higher rate of complications associated with en bloc surgeries may be acceptable, particularly when there is a chance of cure of disease.
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Microsurgical management of benign lesions interior to the cavernous sinus: A case series p. 398
Forhad Hossain Chowdhury, Mohammod Raziul Haque
DOI:10.4103/1793-5482.180892  
Background: Benign lesion interior to the cavernous sinus (CS) is very rare. Objective: In this series we found nonneoplastic lymphatic aggregation and osteoclastoma inside the CS which is very rare and probably not reported in literature. One interesting postoperative complaint of feeling of tickling down of warm water under the skin forehead was found in the patient of inflammatory disease of CS which is not reported in literature. Here we also describe our experiences of microsurgical management of series of benign lesions inside the CS. Materials and Methods: Benign mass originated from the content of CS or inner side of walls of CS, confirmed peroperatively were included in this series. Prospectively recorded data of microsurgical management was retrogradely studied. Results: Total number of patient was 12. Patient's age range was 30–60 years. Follow-up range was 60 months to 19 months. Three was nonneoplastic lesion (tuberculosis, inflammatory and nonneoplastic lymphoid infiltration). Among the 9 neoplastic lesions, two hemangiomas, two meningiomas, three 6th nerve schwannomas, one osteoclastoma and one epidermoid tumor. Middle cranial fossa-subtemporal extradural approach was used in 9 cases and in two cases extended middle fossa zygomatic approach. New postoperative 3rd nerve palsy developed in 5 cases all recovered completely except one. In seven patients 6th nerve palsy developed after operation; only one recovered. Postoperatively simultaneous 3rd, 4th and 6th nerve palsy developed in four cases. One interesting postoperative complaint of feeling of tickling down of warm water under the skin of left sided forehead was found in the patient of inflammatory disease of CS. Mortality was nil. Total resection was done in 9 cases. There was no recurrence till last follow-up. Conclusion: Though decision for microsurgical removal of such lesions is not straight forward. Probably microsurgery is the best option in treating such benign lesions though it may associate with some permanent cranial nerve palsy.
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COMMENTARY Top

Commentary p. 407
Silky Chotai
DOI:10.4103/1793-5482.180885  
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ORIGINAL ARTICLES Top

Surgical management of giant skull osteomas p. 408
Farid Yudoyono, Roland Sidabutar, Rully Hanafi Dahlan, Arwinder Singh Gill, Sevline Estethia Ompusunggu, Muhammad Zafrullah Arifin
DOI:10.4103/1793-5482.154873  
Objective: Surgical management of giant skull osteomas Osteomas are benign, generally slow growing, bone forming tumors limited to the craniofacial and jaw bones. Materials and Methods: A retrospective review of all cases of osteoma diagnosed from 2009 to 2013 treated in our hospital. The data collected included age at diagnosis, gender, lesion location, size, presenting and duration of symptoms, treatment, complication and outcome. Results: During our study period there were 15 cases that were treated surgically. Their mean age was 42 years (range: 15–65 years) and all of our patients were female. The average duration of symptoms was 3 years and size varying from 4 cm to 12 cm. Eight patients complained of headache, whereas 6 patients complained about esthetics, and 1 patient presented with proptosis. The tumor was excised by cutting the base of the tumor and then residual tumor was grinded using a round head cutting bar. Osteoma was removed with esthetically acceptable appearance. Conclusion: There were no major complications during operative and postoperative period. Although osteomas are usually slow growing but surgery is usually performed due to esthetic reasons. It is important to plan an appropriate surgical approach that minimizes any damage to the adjacent structures.
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Role of routine repeat computed tomography of brain in patients with mild and moderate traumatic brain injury: A prospective study p. 412
Jayun M Shah, Kairav S Shah, Jinendra Kumar, Ponraj K Sundaram
DOI:10.4103/1793-5482.180968  
Background: Computed tomography (CT) has become the primary investigative modality for traumatic brain injury (TBI) and there are established guidelines for the initial CT (CT-1). There are no specific guidelines for scheduling repeat CT in TBI. This study was carried out to compare the usefulness of unscheduled repeat CT (UCT-2) with scheduled repeat CT (SCT-2) in the presence or absence of neurological deterioration and to identify risk factors associated with radiological worsening (RW). Methods: This prospective study comprised admitted patients with mild and moderate TBI between February and May, 2014 and all patients were subjected to repeat CT brain. Patients with penetrating brain injuries and surgical conditions after CT-1, and age <5 years were excluded. Positive yield after the second CT (SCT-2 and UCT-2) leading to modification of management were compared between the two groups. Results: In this study, 214 patients (214/222) underwent SCT-2 and 8 underwent UCT-2 (8/222). Surgery was required in 2 (0.9%) from the first group and 7 (87.5%) in the latter. UCT-2 was more likely to show RW warranting surgery as compared to SCT-2 (P < 0.05). In the SCT-2 group, CT-1 had been done within 2 h after trauma in 30 patients and 8 (8/30; 26.7%) showed RW and; after 2 h in the remaining 184 (184/214) with RW seen in 23 (23/184; 12.5%). RW was more common when the CT-1 was within 2 h from trauma (P < 0.05). In our study, the age of the patient and admission Glasgow Coma Scores did not significantly affect the findings in repeat CT. Conclusion: Repeating CT brain is costly besides needing significant logistical support to shift an injured and often unstable patient. SCT-2 is more likely to show RW when CT-1 is done within 2 h after trauma. UCT-2 is more likely to show RW and findings warranting surgery as compared to SCT-2. Hence, a repeat CT may be preferred only in the presence of clinical worsening and when CT-1 is done within 2 h after trauma.
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Factors affecting outcome of acute cervical spine injury: A prospective study p. 416
Bhavanam Hanuma Srinivas, Alugolu Rajesh, AK Purohit
DOI:10.4103/1793-5482.180942  
Background: Injury to the spine and spinal cord is one of the common cause of disability and death. Several factors affect the outcome; but which are these factors (alone and in combination), are determining the outcomes are still unknown. The aim of the study was to evaluate the factors influencing the outcome following acute cervical spine injury. Materials and Methods: A prospective observational study at single-center with all patients with cervical spinal cord injury (SCI), attending our hospital within a week of injury during a period of October 2011 to July 2013 was included for analysis. Demographic factors such as age, gender, etiology of injury, preoperative American Spinal Injury Association (ASIA) grade, upper (C2-C4) versus lower (C5-C7) cervical level of injury, imageological factors on magnetic resonance imaging (MRI), and timing of intervention were studied. Change in neurological status by one or more ASIA grade from the date of admission to 6 months follow-up was taken as an improvement. Functional grading was assessed using the functional independence measure (FIM) scale at 6 months follow-up. Results: A total of 39 patients with an acute cervical spine injury, managed surgically were included in this study. Follow-up was available for 38 patients at 6 months. No improvement was noted in patients with ASIA Grade A. Maximum improvement was noted in ASIA Grade D group (83.3%). The improvement was more significant in lower cervical region injuries. Patient with cord contusion showed no improvement as opposed to those with just edema wherein; the improvement was seen in 62.5% patients. Percentage of improvement in cord edema ≤3 segments (75%) was significantly higher than edema with >3 segments (42.9%). Maximum improvement in FIM score was noted in ASIA Grade C and patients who had edema (especially ≤3 segments) in MRI cervical spine. Conclusions: Complete cervical SCI, upper-level cervical cord injury, patients showing MRI contusion, edema >3 segments group have worst improvement in neurological status at 6 months follow-up.
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Comparison of postoperative clinical outcome after repairing surgery for lumbar spinal stenosis between diabetic and nondiabetic patients p. 424
Tahmineh Afsharian, Shirzad Azhari, Babak Mostafazadeh
DOI:10.4103/1793-5482.175623  
Background: Poorer postoperative outcome is suggested after repairing surgery in diabetic patients with lumbar spinal stenosis in comparison with nondiabetic patients. The present study aimed to compare the clinical outcome of surgery for lumbar spinal stenosis and diabetic and nondiabetic patients to highlight the effect of diabetes on prognosis of this surgical procedure. Methods: This prospective cohort study is conducted on 25 diabetic patients with lumbar spinal stenosis who were candidate for surgical treatment. A gender, age, and body mass index-matched group including 30 nondiabetic patients with lumbar spinal stenosis was considered as the control. The clinical condition of the patients was assessed based on oswestry disability index (ODI) before and immediately after surgery. Results: There was no difference in baseline ODI index between diabetes and diabetes group (73.68 ± 18.89 vs. 71.20 ± 18.27, P = 0.625), whereas postprocedure ODI was significantly higher in diabetic patients than in nondiabetic group (54.32 ± 19.03 vs. 29.47 ± 18.75, P < 0.001). The multivariable logistic regression analysis could show a difference in postoperative ODI between diabetic and nondiabetic patients with the presence of baseline variables as the confounders (beta = −24.509, P < 0.001). Conclusion: Lower improvement in physical ability is expected in diabetic patients after surgery for lumbar spinal stenosis when compared to nondiabetes patients.
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Computed tomographic study of posterior cranial fossa, foramen magnum, and its surgical implications in Chiari malformations p. 428
Showkathali Iqbal, Ambooken P Robert, Dominic Mathew
DOI:10.4103/1793-5482.175627  
Objective: The aim of this study is to measure the height and volume of the bony part of the posterior cranial fossa (PCF) and the surface area of the foramen magnum (FM) using computed tomography (CT) scans and to correlate our clinical findings with the available current literature. Materials and Methods: This cross-sectional study was conducted in a tertiary care referral hospital in the Southern part of India during the period from January 2015 to August 2015. A total of 100 CT scans of the suspected head injury patients were collected retrospectively form the basis for this study. The height, volume of PCF and the anteroposterior (AP), transverse diameter, and surface area of the FM were measured. The values of all parameters were subjected to statistical analysis using SPSS version 16. Results: The age of the patients were ranged between 18 and 70 years with the mean age of 41.22 ± 13.93 years. The dimensions of the posterior fossa and FM were larger in males compared to females. The mean height of the posterior fossa was 38.08 (±4.718) mm (P = 0.0001), and the mean volume of the posterior fossa was 157.23 (±6.700) mm3 (P = 0.0001). The mean AP, transverse diameter, and the surface area of the FM were 33.13 (± 3.286) mm, 29.01 (± 3.081) mm, and 763.803 (±138.276) mm2, respectively. Conclusion: The normal dimensions of the posterior fossa and FM were less in females than males and were useful to radiologists and neurosurgeons to better their diagnostic inferences, as well as to determine the proper treatment options in Chiari malformation type I (CMI) and other posterior fossa anomalies. The posterior fossa tissue volume can be reliably measured in patients with CMI using our method. More studies were required because there were variations in dimensions among individuals of different races in different regions of the world.
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Safety and efficacy of spinal loop rectangle and sublaminar wires for osteoporotic vertebral compression fracture fixation p. 436
Sanganagouda Shivanagouda Patil, Shekhar Yashwant Bhojaraj, Abhay Madhusudan Nene
DOI:10.4103/1793-5482.175648  
Background: Natural history of osteoporotic vertebral compression fractures (OVCFs), that is, collapse, loads the rigid pedicle screw rod construct in the absence of anterior column reconstruction, often leading to implant back outs. Semi rigid spinal loop rectangle and sublaminar wire construct allows controlled axial collapse and does not require anterior column reconstruction. Materials and Methods: This is a retrospective study of 50 consecutive patients of OVCFs. The immediate and final follow-up safety (neurologic deficit, implant failure/back out, revision surgeries, and infection) and efficacy (visual analog scale [VAS] score, axial collapse of the fracture, fracture union and retaining, and the attempted segmental deformity correction) parameters were compared to describe the utility of spinal loop rectangle and sublaminar wiring as a novel, low cost modality of spinal instrumentation for treating OVCFs. Results: All the twelve patients with Frankel grade D neurologic deficit improved to Frankel grade E and six patients (out of 8) with Frankel grade C improved to Frankel grade E (and remaining two patients improved to Frankel grade D), following surgery. The average preoperative VAS score of 8.98 (ranging from 5 to 10) improved to 2.76 (ranging from 1 to 10) at final follow-up. Controlled collapse of anterior column, union of OVCF nonunion, and retaining of attempted deformity correction by sublaminar wire anchors cephalad and caudal to the transpedicular decompression was seen in each patient at the final follow-up. Conclusion: Spinal loop rectangle and sublaminar wiring construct are viable alternative options for stabilizing OVCFs.
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Outcome and management of spinal tuberculosis according to severity at a tertiary referral center p. 441
Prasad Chandramouliswara Bodapati, Ramesh Chandra Venkata Vemula, Ameen Abdul Mohammad, Alladi Mohan
DOI:10.4103/1793-5482.180924  
Objective: Anti-tuberculosis (TB) treatment remains the mainstay of treatment of spinal TB. There is a lack of consensus regarding the timing of interventional procedures and surgery in the patients with spinal TB. This study aims to prospectively study the clinical outcome and management in patients presenting with spinal TB at our tertiary referral center and teaching hospital. Methods: Data were collected prospectively from 48 patients treated for spinal TB presenting to us from August 2011 to December 2012. All the patients were followed-up for the duration of anti-TB treatment. Results: The categorization of patients into different management groups was based on the clinical and radiological findings at the time of diagnosis. The patients with mild disease (n = 23) were successfully managed with anti-TB treatment alone. The other 25 patients needed an intervention either in the form of pigtail catheter drainage of the paravertebral collection (n = 18) or an extensive surgical debridement followed by the fusion techniques (n = 7). All the patients responded well to the treatment, and there were no significant complications in any of the patients. It had been observed that various stages of spinal TB demand different approaches for the treatment in the form of either chemotherapy alone, chemotherapy with pigtail drainage of the paravertebral collection, or surgery in conjunction with chemotherapy. Conclusions: Judicious use of pigtail drainage and surgical intervention in addition to anti TB treatment can be rewarding in the patients with spinal TB.
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The use of event-related potential (P300) and neuropsychological testing to evaluate cognitive impairment in mild traumatic brain injury patients p. 447
Puneet Nandrajog, Zamzuri Idris, Wan Nor Azlen, Alwani Liyana, Jafri Malin Abdullah
DOI:10.4103/1793-5482.180921  
Background: The aim of the study is to compare the amplitude and latency of the P300 event-related potential (ERP) component between a control group and patients after mild traumatic brain injury (mTBI) during 1–7 days (short duration) and 2–3 months (long duration), and to compare the outcome of neuropsychological tests between the long duration postinjury and control study groups. Materials and Methods: We studied responses to auditory stimulation in two main and one subgroups, namely the control healthy group (19 patients, both ERP and neuropsychology test done), the mTBI 1 group (17 patients, only ERP done within 7 days after injury), and the mTBI 2 subgroup (the 17 mTBI 1 patients in whom a repeated ERP together with neuropsychological testing was done at 2–3 months postinjury). Auditory evoked responses were studied with two different stimuli (standard and target stimuli), where the P300 amplitude and latency were recorded from three midline sites and results were compared between the groups, as were the neuropsychological test results. Results: There was a significant prolongation of the target P300 latency values shown by the MBI 1 group measured at the central electrode when compared to the control group, which was also seen when the mTBI 1 and mTBI 2 groups were compared. The results of the P300 amplitude values measured at the frontal electrode showed the control group to have higher readings during the presentation of standard tones when compared to the mTBI 1 group. The mTBI 2 group performed better on some neuropsychological tests. Conclusion: The latency of P300 was significantly prolonged in early mTBI patients who improved over time, and the neuropsychological testing on mTBI 2 patients showed them to be comparable to the control group. The study indicates that ERP should be used as an additional modality of investigation in mTBI patients.
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Selective dorsal rhizotomy: A multidisciplinary approach to treating spastic diplegia p. 454
Hussam Abou Al-Shaar, Muhammad Tariq Imtiaz, Hazem Alhalabi, Shara M Alsubaie, Abdulrahman J Sabbagh
DOI:10.4103/1793-5482.175625  
Background: Spasticity is a motor disorder that interferes with mobility and affects the quality of life. Different approaches have been utilized to address patients with spastic diplegia, among which is selective dorsal rhizotomy (SDR). Although SDR has been shown to be efficacious in treating spastic patients, many neurologists and neurosurgeons are not well aware of the procedure, its indications, and expected outcomes due to the limited number of centers performing this procedure. Objectives: The aim of this study is to describe the collaborative multidisciplinary approach between neurosurgeons, neurophysiologists, and physiotherapists in performing SDR. In addition, we delineate three illustrative cases in which SDR was performed in our patients. Materials and Methods: A retrospective review and analysis of the clinical records of our three patients who underwent SDR was conducted and reported. Patients' outcomes were evaluated and compared to preoperative measurements based on clinical examination of power, tone (Ashworth scale), gait, and range of motion, as well as subjective functional assessment, gross motor function classification system, and gross motor function measure with follow-up at 6, 12, and 24 months postoperatively. A detailed description of our neurosurgical technique in performing SDR in collaboration with neurophysiology and physiotherapy monitoring is provided. Results: The three patients who underwent SDR using our multidisciplinary approach improved both functionally and objectively after the procedure. No intraoperative or postoperative complications were encountered. All patients were doing well over a long postoperative follow-up period. Conclusion: A multidisciplinary approach to treating spastic diplegia with SDR can provide good short-term and long-term outcomes in select patients suffering from spastic diplegia.
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The minipterional approach for ruptured and unruptured anterior circulation aneurysms: Our initial experience p. 466
Kenan A Alkhalili, Jack R Hannallah, Gasser H Alshyal, Mohab M Nageeb, Khaled M Abdel Aziz
DOI:10.4103/1793-5482.180951  
Objective: To report our experience with the minipterional (MPT) craniotomy approach for anterior circulation aneurysms and to discuss the clinical outcomes as well as to evaluate the advantages of this unique approach. Materials and Methods: Single-center retrospective review of 57 cases involving anterior circulation aneurysms both ruptured and unruptured aneurysms treated with the MPT. We analyzed the clinical and patient demographic data, aneurysm characteristics, surgical outcomes, and complications in these individuals. Results: Between July 2008 and March 2014, of the 57 patients reviewed: 45 had middle cerebral artery (MCA), 6 had internal carotid artery terminus, and 7 had posterior communicating artery aneurysms. 20 of the 57 patients presented with a ruptured aneurysm. The average aneurysm size was 5.8 mm. The length of hospitalization for unruptured aneurysm cases ranged between 3 and 5 days. The average follow-up for all cases was 21.5 months. Successful clipping of the aneurysms was obtained in all patients. None of the cases required additional skin incisions or craniotomy extensions. The overall surgical outcomes were favorable. There was no postoperative facial nerve damage, temporalis muscle wasting, or symptoms of paresthesias around the incision line. Two patients developed a postoperative stroke manifested as symptoms of unilateral arm and facial weakness, receptive aphasia, and dysarthria. Conclusion: The MPT provides a reliable and less invasive alternative to the standard pterional craniotomy. Furthermore, ruptured and unruptured anterior circulation aneurysms can safely and effectively be treated with limited bone removal which provides better cosmetic outcomes and excellent postoperative temporalis muscle function.
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A study of partial pressure of arterial carbon dioxide and end-tidal carbon dioxide correlation in intraoperative and postoperative period in neurosurgical patients p. 475
Pallavi Gaur, Minal Harde, Pinakin Gujjar, Devanand Deosarkar, Rakesh Bhadade
DOI:10.4103/1793-5482.180959  
Background and Aim: Monitoring carbon dioxide (CO2) is of utmost importance in neurosurgical patients. It is measured by partial pressure of arterial CO2 (PaCO2) and end-tidal CO2 (ETCO2). We aimed to study the correlation between PaCO2and ETCO2in neurosurgical patients in the intraoperative and postoperative period on mechanical ventilation in Postanesthesia Care Unit (PACU). Methodology: This was prospective observational study done at tertiary care teaching public hospital over a period of 1 year. We studied 30 patients undergoing elective craniotomy intraoperatively and in the postoperative period on mechanical ventilation for 24 h. Serial measurement of ETCO2and PaCO2at baseline, hourly intraoperatively and every 6 hourly in the PACU were studied. Data analysis was done using SPSS software version 20. Results: The mean PaCO2–ETCO2gradient intraoperatively over 4 h is 3.331 ± 2.856 and postoperatively over 24 h is 2.779 ± 2.932 and lies in 95% confidence interval. There was statistically significant correlation between PaCO2and ETCO2intraoperatively baseline, 1 h, 2 h, 3 h, and 4 h with Pearson's correlation coefficients of 0.799, 0.522, 0582, 0.439, and 0.547, respectively (P < 0.05). In PACU at baseline, 6 h, 12 h, 18 h, and 24 h Pearson's correlation coefficients were. 534, −0.032, 0.522, 0.242, 0.592, and 0.547, respectively, which are highly significant at three instances (P < 0.01). Conclusion: ETCO2correlates PaCO2with acceptable accuracy in neurosurgical patients in the intraoperative and postoperative period on mechanical ventilation in Intensive Care Unit. Thus, continuous and noninvasive ETCO2can be used as a reliable guide to estimate arterial PCO2during neurosurgical procedures and in PACU.
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The benefits of navigated neuroendoscopy in children with multiloculated hydrocephalus p. 483
Sergei Afanasievich Kim, German Vladimirovich Letyagin, Vasiliy Evgenievich Danilin, Anna Alekseevna Sysoeva, Jamil Afetovich Rzaev, Galina Ivanovna Moisak
DOI:10.4103/1793-5482.165799  
Context: Multiloculated hydrocephalus remains one of the most challenging neurosurgical problems. In this study, we use frameless navigation during endoscopic interventions to improve the efficiency of operations. Subjects and Methods: Nine navigated endoscopic procedures were performed in 8 children with various forms of multiloculated hydrocephalus from March 2013 to June 2014. Preoperatively, the optimal entry point for fenestration of several cysts was determined on the basis of magnetic resonance data. During surgery, rigid endoscope was registered in neuronavigation system for making the connection between separated ventricles and cysts. The final stage of the operation was to conduct a stent through the working channel of the endoscope for implantation of a shunt. Results: Number of compartments interconnected by an operation ranged from 3 to 5. Seven interventions were performed simultaneously with the shunt implantation. The follow-up period ranged from 9 to 15 months. The clinical improvement as a result of the operation was achieved in all children. The follow-up included clinical examination and evaluation of magnetic resonance imaging. Additional surgery was necessary in two patients: The first 5 months later, the second 1-year after endoscopic intervention. Conclusion: Application of frameless navigated neuroendoscopy makes this kind of operations the most efficient and safe for the patient.
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COMMENTARY Top

Multiloculated hydrocephalus p. 488
Farideh Nejat
DOI:10.4103/1793-5482.175617  
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ORIGINAL ARTICLES Top

Severity of anemia and hemostatic parameters are strong predictors of outcome in postoperative neurosurgical patients p. 489
Mrinalini Kotru, Satya Shiv Munjal, Deepti Mutreja, Guresh Kumar, Manmohan Singh, Tullika Seth, Hara Prasad Pati
DOI:10.4103/1793-5482.180940  
Objective: Post-operative neurosurgical patients are commonly associated with haemostatic derangements; many a times leading to development of overt disseminated intravascular coagulation (DIC) and eventually death in some of them. The present study has analysed the factors that would predict the outcome in post operative neurosurgical patients with deranged haemostatic parameters. Methods: This is a prospective, descriptive study over a period of 15 months on 115 post operative neurosurgical patients who were clinically suspected to have DIC and investigated for the haemostatic parameters. Patients with at least one parameter abnormal were included in the study and complete data was available in 85 patients was analysed. Results: Majority of deaths (22/33, 66.7%) were related to bleeding and end organ failure attributed to DIC. The most common haemostatic abnormalities found were thrombocytopenia with prolonged Prothrombin time (PT) in 48/115 (42.7%) patients. The parameters found significantly different between those who survived and those died were age, post-operative development of chest infections, severe anemia, and renal function abnormalities. Also, patient outcome correlated strongly with marked prolongation of prothrombin time (PT) and Partial thromboplastin time (PTT). However, presence of ≥3 coagulation abnormalities, presence of significant drop in haemoglobin post operatively and /or development of chest infection predicted death in postoperative neurosurgical patients with accuracy of 80.4% and this was highly significant (P = 0.000). Conclusion: Presence of ≥3 coagulation abnormalities, significant drop in hemoglobin post operatively and /or development of chest infection post-operatively were strong predictors of death in postoperative neurosurgical patients.
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Contribution of the xenograft bone plate-screw system in lumbar transpedicular stabilization: An in vivo study in dogs p. 494
Sani Sarigul, Hakan Salci, Huseyin Lekesiz, Seref Dogan, Resat Ozcan, Osman Sacit Gorgul, Kaya Aksoy
DOI:10.4103/1793-5482.185061  
Objectives: Xenograft bone plate-screws (XBPSs) can be alternative tools in lumbar transpedicular stabilization (TS). The aim of this study was to show biomechanical and histopathological contribution of the XBPSs system in lumbar TS. Materials and Methods: Fifteen (n = 15) hybrid dog and ten (n = 10) L2-4cadaveric specimens were included in the study. The dogs were separated according to surgical techniques: L3laminectomy and bilateral facetectomy (LBF) in Group I (experimental group [EG I] (n = 5), L3LBF plus TS with metal plate-screws (MPSs) in Group II (EG II) (n = 5), and L3LBF plus TS with XBPSs in Group III (EG III) (n = 5). The cadaveric specimens were separated to L2-4intact in Group I (CG I), (n = 5), and L3LBF in Group II (CG II), (n = 5). The dogs were sacrificed at the end of 3rd month, and their L2-4spinal segments were en bloc removed and prepared as in control groups. Flexion, extension, left-right bending, rotation, and compression tests were applied to all segments. Stiffness values were calculated and analyzed statistically. All dog segments were evaluated histopathologically. Results: XBPS system showed a higher average stiffness values for left bending, extension, flexion, and compression compared to MPS, but these differences were not statistically meaningful. XBPS system had superiority to the fusion formation, as well. Conclusions: XBPSs provide stability and help the fusion formation, but this system does not have a biomechanical advantage over MPS system in TS.
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The role of tranexamic acid in prevention of hemorrhage in major spinal surgeries p. 501
Afsoun Seddighi, Amir Nikouei, Amir Saeid Seddighi, Alireza Zali, Seyed Mahmood Tabatabaei, Fatemeh Yourdkhani, Shoeib Naimian, Iman Razavian
DOI:10.4103/1793-5482.165791  
Background: Blood loss that necessitates blood transfusion is one of the most frequent complications of major spinal surgeries. This study has been designed to evaluate the efficacy and safety of prophylactic tranexamic acid (TA) in decreasing perioperative blood loss. Materials and Methods: From January to August 2011, all the patients who needed major spinal surgeries and aged between 18 and 60-year-old were divided into two groups randomly, the experimental group received 10 mg/kg of TA 20 min after inducing the anesthesia as loading dose followed by 0.5 mg/kg/h until skin closure and the control group received equal amounts of normal saline as placebo. Intraoperative blood loss was recorded by estimating blood with the suction tube plus the number of bloody gasses. The amounts compared between the 2 groups and analyzed. Results: Forty patients were enrolled in this study in the first group intraoperative, the 1st and 2nd postoperative days, the mean blood loss were 574 ml, 80.5 ml, and 669.5 ml while in the second group were 797 ml, 124 ml, and 921.5 ml. Conclusion: TA seems to be safe and can be considered in spinal surgeries with significant excepted blood loss especially in female patients and instrumental procedures. We suggest further studies on TAs efficacy and safety in larger scales.
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Skull base bony lesions: Management nuances; a retrospective analysis from a Tertiary Care Centre p. 506
Amit Kumar Singh, Arun Kumar Srivastava, Jayesh Sardhara, Kamlesh Singh Bhaisora, Kuntal Kanti Das, Anant Mehrotra, Rabi Narayan Sahu, Awadhesh Kumar Jaiswal, Sanjay Behari
DOI:10.4103/1793-5482.185068  
Background: Skull base lesions are not uncommon, but their management has been challenging for surgeons. There is large no of bony tumors at the skull base which has not been studied in detail as a group. These tumors are difficult not only because of their location but also due to their variability in the involvement of important local structure. Through this retrospective analysis from a Tertiary Care Centre, we are summarizing the details of skull base bony lesions and its management nuances. Materials and Methods: The histopathologically, radiologically, and surgically proven cases of skull base bony tumors or lesions involving bone were analyzed from the neurosurgery, neuropathology record of our Tertiary Care Institute from January 2009 to January 2014. All available preoperative and postoperative details were noted from their case files. The extent of excision was ascertained from operation records and postoperative magnetic resonance imaging if available. Results: We have surgically managed 41 cases of skull base bony tumors. It includes 11 patients of anterior skull base, 13 middle skull base, and 17 posterior skull base bony tumors. The most common bony tumor was chordoma 15 (36.6%), followed by fibrous dysplasia 5 (12.2%), chondrosarcoma (12.2%), and ewings sarcoma-peripheral primitive neuroectodermal tumor (EWS-pPNET) five cases (12.2%) each. There were more malignant lesions (n = 29, 70.7%) at skull base than benign (n = 12, 29.3%) lesions. The surgical approach employed depended on location of tumor and pathology. Total mortality was 8 (20%) of whom 5 patients were of histological proven EWS-pPNET. Conclusions: Bony skull base lesion consists of wide variety of lesions, and requires multispecialty management. The complex lesions required tailored approaches surgery of these lesions. With the advent of microsurgical and endoscopic techniques, and use of navigation better outcomes are being seen, but these lesions require further study for development of proper management plan.
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Outcome following surgical resection of craniopharyngiomas: A case series p. 514
KC Bidur, Devkota Upendra Prasad
DOI:10.4103/1793-5482.150228  
Introduction: Debate continues as to the optimum treatment for craniopharyngioma; radical surgical resection or partial resection followed by radiotherapy. Radical surgical resection may be complicated by intraoperative injury to surrounding structures and stormy postoperative hormonal problem. This study aims to examine the result of safe maximal surgical resection. Materials and Methods: Retrospective study of all histopathologically proven craniopharyngiomas who had undergone surgical resection over an almost 8 year period was included. Data were collected reviewing demography, clinical presentation, hormonal dysfunction, extent of resection and visual deterioration. Outcome was measured in terms of Glasgow outcome scale and recurrence. Results: Of 25 patients, 68% were male, and 32% were female. Age of patients ranged from 7 to 58 years with a mean of 30.12 ± 16.42 years. Patients presented with visual deterioration were 76% and with a headache were 68%. Mean duration of symptoms was 10.64 ± 14.28 months. Gross total resection was done in 21 (84%), while subtotal resection in 4 (16%) who also received subsequent adjuvant radiotherapy. During the postoperative period, diabetes insipidus developed in 84% patients, but none had it permanently. Favorable outcome was found in 88% patients. However, there were 4% operative mortality with overall mortality of 8% and tumor recurrence in 8% patients. Conclusion: Gross total excision if judiciously decided intraoperatively has a favorable outcome with acceptable morbidity.
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Efficacy of superficial temporal artery-middle cerebral artery bypass in cerebrovascular steno-occlusive diseases: Hemodynamics assessed by perfusion computed tomography p. 519
Woo-Keun Kwon, Taek-Hyun Kwon, Dong-Hyuk Park, Joo-Han Kim, Sung-Kon Ha
DOI:10.4103/1793-5482.153497  
Objectives: Our purpose of this study was to assess the cerebral hemodynamic improvement with perfusion computed tomography (CT), before and after superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery in patients with cerebrovascular steno-occlusive diseases including both moyamoya disease and nonmoyamoya steno-occlusions. Materials and Methods: Twenty-four STA-MCA bypasses were performed to 22 patients with symptomatic cerebrovascular steno-occlusive diseases, including both moyamoya disease and nonmoyamoya steno-occlusive diseases. Brain perfusion CT images were obtained before and after the bypass surgery. The relative parameters such as cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) derived from the perfusion CT were collected and analyzed to assess the efficacy of STA-MCA bypass. Results: The CBF increased, and MTT decreased after the bypass surgery in both moyamoya group and nonmoyamoya group. The increase of CBF in nonmoyamoya group and the decrease of MTT delay in moyamoya group, overall group were statistically significant (P < 0.05). No significant postoperative change in CBV was noted. During the postoperative follow-up period, none of the 22 patients experienced any repeated ischemic/hemorrhagic attacks nor any newly developed neurologic deficits. Conclusion: The STA-MCA bypass is an effective surgical management for patients with cerebrovascular steno-occlusive diseases, such as moyamoya disease and internal carotid artery/MCA steno-occlusion. And perfusion CT can be used as an effective quantitative modality to assess the cerebral perfusion before and after the STA-MCA bypass surgery.
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Prognostication in cervical spondylotic myelopathy: Proposal for a new simple practical scoring system p. 525
Vengalathur Ganesan Ramesh, Manianandan Ganapathi Vel Kannan, Kuchalmbal Sriram, Chandramouli Balasubramanian
DOI:10.4103/1793-5482.146391  
Context: The ability to preoperatively predict the outcome in cervical spondylotic myelopathy (CSM) helps in planning management and counseling the patient and family. Aims: A simple prognostic scale, namely, the Madras Institute of Neurology Prognostic Scale (MINPS) for CSM has been proposed. Settings and Design: Six well-known prognostic factors, namely, age, duration of symptoms, neurological disability (Nurick's grade), number of levels of compression, effective canal diameter, and intrinsic cord changes, have been taken into account. Each factor has been divided into three subgroups and allotted a score. The total score in this scale ranges from a maximum of 18 to a minimum of 6. Materials and Methods: This scale has been evaluated in a group of 85 patients operated for CSM. Statistical Analysis Used: The usefulness of MINPS was statistically assessed using ANOVA test. Results: It has been found that majority of patients with a score of 14 or more improved; those with a score of 9 or less deteriorated; those with a score between 10 and 13 remained static. Conclusions: The MINPS for CSM is a very practical scale which can be applied easily with the available clinical and radiological data, with good accuracy of outcome prediction. This is the first scale of its kind.
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Brain metastases in cancer patients attending a Gamma Knife Center: A study from a single institute in Iran p. 529
Parisa Azimi, Sohrab Shahzadi, Mohammad Ali Bitaraf, Maziar Azar, Mazdak Alikhani, Alireza Zali, Sohrab Sadeghi, Ali Montazeri
DOI:10.4103/1793-5482.145564  
Background: This study was aimed to explore data on brain metastases in cancer patients attending the Iranian Gamma Knife Center. Meterials and Methods: This was a retrospective study. In all 5216 case records of patients who referred to the Iranian Gamma Knife Center for treatment of brain tumors during year 2003-2011 were reviewed. Data were explored to identify patients who developed brain metastases due to cancer and assessed the information as applied to cancer patients including survival analysis. Results: Two hundred and twenty patients were identified as having brain metastases due to cancer. The mean age of patients was 54.0 (standard deviation [SD] =12.7) years. Patients were followed for an average of 7 months after treatment with gamma-knife. The median survival time for different the Graded Prognostic Assessment (GPA) was: GPA: 0-1, 4.0 ± 0.4 months; GPA: 1.5-2.5, 6.0 ± 0.7 months; GPA: 3, 9.0 ± 0.9 months; and GPA: 3.5-4.0, 12.0 ± 1.8 months and the overall median survival was 7.0 (SD = 0.6) months. Conclusion: The findings suggest that many cancer patients in Iran might develop brain metastasis. Although, this is not a very high incidence compared with the existing statistics from other countries, there is an urgent need to explore the issue further.
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Endoscopic carpal tunnel decompression: Comparison of mid- and long-term outcomes of 30 endoscopic and 30 standard procedure carpal tunnel decompression operations p. 534
Umit Eroglu, Onur Ozgural, Fatih Yakar, Gökmen Kahiloğulları
DOI:10.4103/1793-5482.210002  
Background: Carpal tunnel syndrome is the most frequently seen trap neuropathy leads to pain, paresis, and weakness of hands. Methods: Totally, 60 patients who underwent endoscopic or standard CTS surgery in İbni Sina Hospital, Medical Faculty of Ankara university in the period of 2009 and 2012 were enrolled in this prospective study. Results: During 36 months, 60 patients had undergone hand surgery. Totally, 14 male and 46 female patients of this serial had an average age of 51.24 (22-74) years. A number of 26 patients (43%) had left and 34 had (57%) right hand surgery. Complete relief of nocturnal paresis and pain has been shown in the 6th, 12th, and 24th month analyses of endoscopic surgery group results. Two patients in open surgery group underwent second operation due to relapse. The patients in the endoscopic group reported higher satisfaction cosmetically. Conclusion: Endoscopic carpal tunnel syndrome treatment is alternative and considerable option against standard open methods and due to low morbidity rates its performance is highly prevalent in recent years.
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CASE REPORTS Top

Recurrent intracranial Rosai-Dorfman disease: Management of a challenging case p. 537
Sudeep Das, Ahitagni Biswas, Soumyajit Roy, Mukund N Sable, Daljit Singh, Manisha Jana, Mehar Chand Sharma, Pramod Kumar Julka
DOI:10.4103/1793-5482.209994  
Rosai-Dorfman disease (RDD) is a rare, idiopathic, benign histioproliferative disorder. Extranodal involvement is seen in around 25–40% of patients. Central nervous system manifestation of RDD is uncommon and suprasellar location of the lesion is a distinct rarity. Surgery is the cornerstone of management of intracranial RDD. However, tumor recurrence or regrowth is a potential problem. Hence, low dose conformal radiotherapy (RT) should be considered in patients undergoing sub-total resection or having unresectable recurrent disease. Though cranial RT usually leads to satisfactory improvement of symptoms and long-term disease stabilization or regression, in few patients there may be an eventual progression of disease for which systemic chemotherapy may be considered. We have highlighted the salient features of this enigmatic disease by citing a case of a 50-year-old male patient with suprasellar RDD treated by maximal safe surgery and deferred radiation therapy on progression.
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Extensive intracranial calcification of pseudo-TORCH syndrome with features of Dandy–Walker malformation p. 541
Ashis Patnaik, Sudhansu Sekhar Mishra, Srikanta Das
DOI:10.4103/1793-5482.145162  
Pseudo-TORCH syndrome or congenital infection-like syndrome is a group of conditions which resemble congenital infections such as those caused by toxoplasmosis, rubella, cytomegalovirus (CMV), herpes (TORCH) group of organisms, clinico-radiologically, but serological tests are negative for the organisms. One of the variety shows features such as microcephaly, extensive intracranial calcification showing gross resemblance to congenital CMV infection, making its other name as microcephaly intracranial calcification syndrome (MICS). Dandy–Walker malformation (DWM), in addition to posterior fossa large cyst, cerebellar vermis hypoplasia, and hydrocephalus is often associated with agenesis of the corpus callosum and callosal lipomas, dysplasia of the brainstem, and cerebellar hypoplasia or dysgenesis. But radiological features of DWM with microcephaly and intracranial calcification are very unusual and have been rarely reported in the literature.[1] We report a case of infant showing clinical features suggestive of congenital CMV infection with negative serology and radiological imaging suggestive of DWM with extensive intracranial calcification. Pseudo-TORCH syndrome with radiological features of DWM is a congenital developmental abnormality. Inspite of hydrocephalus, it does not require cerebrospinal fluid (CSF) diversionary procedure due to lack of increased intracranial pressure. Conservative management for seizure disorder is the optimal therapy.
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Neurosarcoidosis presenting as an incidental solitary cranial ring-enhancing lesion p. 544
Michael Thambuswamy, Ashish H Shah, Mai Tran, Joanne T Thambuswamy, Amade Bregy, Michael D Norenberg, Ricardo J Komotar
DOI:10.4103/1793-5482.146389  
Isolated neurosarcoidosis without prior systemic symptoms is extremely rare, occurring in approximately 2% of patients with neurosarcoidosis. Due to its rarity, mistakes in diagnosis and treatment occur commonly. We present a case of a 47-year-old female who was found to have an incidentally discovered solitary intracranial lesion that mimicked a high-grade neoplasm, but was later confirmed to be neurosarcoidosis. Incidental solitary neurosarcoid granulomas are difficult to diagnose due to its nonspecific clinical and imaging presentations. Early diagnosis by biopsy in these rare incidental cases remains paramount for adequate treatment.
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Post-traumatic fibrous dysplasia of the parietal bone: A rare entity p. 547
Muhammad Sohail Umerani, Saqib Kamran Bakhshi, Asad Abbas, Salman Sharif, Sidra Arshad
DOI:10.4103/1793-5482.148800  
Fibrous dysplasia (FD) is a rare fibro-osseous lesion in which normal bone is replaced by abnormal fibrous tissue. Although a congenital disorder, a single case report of traumatic etiology had been described in the literature. We report a case of monostotic FD of the parietal calvarium in a 21-year-old female patient who presented to us with a single swelling in the parietal region been noticed after head injury sustained at the age of 7 years. After imaging investigations, the lesion was excised via craniotomy followed by cranioplasty in the same sitting. The histopathological evidence was suggestive of FD. To the best of our knowledge, this is the second case of a posttraumatic cranial FD and the first case describing the growing mass in the parietal bone secondary to head injury.
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Recurrent intraventricular meningioma with malignant transformation p. 551
Jasmit Singh, Hrushikesh Kharosekar, Vernon Velho
DOI:10.4103/1793-5482.149996  
Benign meningioma undergoing a malignant transformation (to a chondrosarcoma) in intraventricular location is very rare and this is first case report to best of our knowledge. Herein, we report a rare case of malignant transformation of a benign intraventricular meningioma with relevant literature.
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Spinal capillary hemangiomas: Two cases reports and review of the literature p. 556
Thara Tunthanathip, Sanguansin Rattanalert, Thakul Oearsakul, Kanet Kanjanapradit
DOI:10.4103/1793-5482.148793  
Hemangiomas have rarely been found in the spinal cord. A few cases of spinal capillary hemangioma have been reported since 1987. The authors reported the two cases of capillary hemangioma including the tumor at conus medullaris and the another mimicked von Hippel-Lindau disease. A 15-year-old man was presented with coccydynia and left leg pain. A magnetic resonance imaging (MRI) revealed an intradural extramedullary enhancing mass at conus medullaris. Another case, a 31-year-old man was presented with a history of familial history of brain tumor, retinal hemangioma both eyes, multiple pancreatic cyst and syringobulbia with syringohydromyelia. On MRI, a well-circumscribed intramedullary nodule was detected at C5-6 level and multiple subpial nodule along cervicothoracic spinal cord. All patients underwent surgery, and the histological diagnosis confirmed capillary hemangioma. Although rare and indistinguishable from other tumors, capillary hemangioma should be in the differential diagnosis of the spinal cord tumor.
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Removal of a low clival chordoma in a teenager by dorsolateral suboccipital transcondylar approach p. 563
Deepal Attanayake, Buddhika Dias
DOI:10.4103/1793-5482.145549  
Chordomas are rare midline tumors of the central nervous system which arise from the remnants of the primitive notochord and have unique diagnostic and management challenges. Although recommended treatment for chordoma is radical resection, this may require extended skull base approaches. We report a case of low clival chordoma in a teenage patient which was successfully treated by dorsolateral suboccipital transcondylar approach.
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Primary pleomorphic xanthoastrocytoma of the spinal cord: A case report and review of literature p. 566
Mayur Sharma, Vernon Velho, Rachana Binayake, Hrushikesh Kharosekar
DOI:10.4103/1793-5482.145547  
Primary pleomorphic xanthoastrocytoma (PXA) of the spinal cord is a rare slow growing tumor. To our knowledge, only five such cases have been reported in the literature till date. We report the clinical, radiological, and histopathological features of a spinal PXA in a 23-year-old female previously operated 5 years back for a spinal tumor, presented with weakness in lower limbs, sphincter incontinence and low back pain. Magnetic resonance imaging scan with contrast reveals an intramedullary lesion in the spinal cord from D8-D10 level. The patient was operated with reexploration of the previous incision, and gross total excision was achieved. Histopathology confirmed the diagnosis of PXA. Clinical and radiological follow-up is required to detect early recurrence. Adjunct radiotherapy or and chemotherapy should be considered only when there is postoperative residual or recurrence, however there are no definite guidelines in view of the rarity of this condition.
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Spontaneous resolution of ruptured dissecting anterior inferior cerebellar artery aneurysm: A rare case report p. 570
Sumeet Singh, RS Mittal, Devendra Purohit, Jetendra Shekhawat
DOI:10.4103/1793-5482.145561  
Dissecting anterior inferior cerebellar artery (AICA) aneurysms are extremely rare, and only nine cases are reported till date. We are reporting a case of ruptured dissecting distal AICA aneurysm with spontaneous resolution; first of its kind in the indexed literature.
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Plasmacytoma of the clivus p. 573
R Amita, S Sandhyamani, Suresh Nair, TR Kapilamoorthy
DOI:10.4103/1793-5482.148788  
We report a case of solitary plasmacytoma of the clivus in a 55 year old male.
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CASE REPORT WITH REVIEW OF LITERATURE Top

Intracranial en-plaque tuberculoma impersonating en-plaque meningioma: Case report and brief review of literature p. 576
Jayendra Kumar, Jeevesh Mallik, Ben A Strickland, Viraat Harsh, Anil Kumar
DOI:10.4103/1793-5482.175619  
Background: Tuberculosis of the central nervous system continues to be a major health hazard in developing countries like India. There are various manifestations of central nervous system tuberculosis including meningitis and space occupying lesions. We present a case of tuberculoma en-plaque which is often initially confused with a meningioma on presentation. We also review the literature relevant to this unusual entity. Methods: A search of PubMed, PubMed Central, the Cochrane Library, and MEDLINE were performed to identify all English language reports of intracranial en-plaque tuberculomas. The combinations of text strings “tuberculoma,” “en*,” and “plaque” were used to perform the query on PubMed. Only the studies reporting intracranial en-plaque tuberculomas were included. Results: Literature review revealed six reports on en-plaque tuberculomas including seven patients. The mean age at presentation was 40.5 years, and no sex predilection was seen. Five of the six reported studies used anti-tuberculous therapy with or without surgical excision of the mass. Most of the patients in reported cases recovered fully. Conclusion: It is imperative to consider tuberculoma as an important differential when encountering intracranial en-plaque masses as en-plaque tuberculomas can be effectively treated with a combination of anti-tuberculosis therapy and surgical resection, yet consequences of a missed or late diagnosis can prove fatal.
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