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   Table of Contents - Current issue
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April-June 2017
Volume 12 | Issue 2
Page Nos. 153-343

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ORIGINAL ARTICLES  

Cerebrospinal fluid dynamics study in communicating hydrocephalus p. 153
Vengalathur Ganesan Ramesh, Vidhya Narasimhan, Chandramouli Balasubramanian
DOI:10.4103/1793-5482.145110  
Context: Communicating hydrocephalus often poses a challenge in diagnosis and management decisions. Aims: The objective of this study is to measure the opening pressure (Po), pressure volume index (PVI), and cerebrospinal fluid outflow resistance (Rout), in patients with communicating hydrocephalus using bolus lumbar injection method and to evaluate its diagnostic and prognostic value. Materials and Methods: The study was conducted in 50 patients with communicating hydrocephalus, including normal pressure hydrocephalus (NPH) (19), post-meningitic hydrocephalus (23) and post-traumatic hydrocephalus (8). An improvised bolus lumbar injection method [the Madras Institute of Neurology (MIN) method] was used. Results: In the NPH Group, the CSF dynamics studies correlated well with the clinico-radiological classification. The prediction of shunt responsiveness by CSF dynamics studies correlated with good outcome in 87.5%. In the post-meningitic hydrocephalus group, the value of CSF dynamics studies in predicting patients needing shunt was 89.5%. The CSF dynamics studies detected patients who needed shunt earlier than clinical or radiological indications. In the post-traumatic hydrocephalus group, 62.5% of patients improved with the treatment based on CSF dynamics studies. Conclusions: The improvised bolus lumbar injection method (MIN method) is a very simple test with fairly reliable and reproducible results. Study of CSF dynamics is a valuable tool in communicating hydrocephalus for confirmation of diagnosis and predicting shunt responsiveness. This is the first time that the value of CSF dynamics has been studied in patients with post-meningitic hydrocephalus. It was also useful for early selection of cases for shunting and for identifying patients with atrophic ventriculomegaly, thereby avoiding unnecessary shunt.
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Radiosurgery in treatment of cerebral arteriovenous malformation: Mid-term results of 388 cases from a single center p. 159
Mohammad Ali Bitaraf, Ramon Katoozpour, Mazyar Azar, Mohsen Nouri, Seyed Abolghasem Mortazavi, Abbas Amirjamshidi
DOI:10.4103/1793-5482.145121  
Background and Objectives: The purpose of this study is to evaluate the outcome and risks of radiosurgery for patients with arteriovenous malformations (AVM) of the brain all treated in a single center in the 3rd world with all its limitations. Materials and Methods: We performed a retrospective analysis of 388 patients with AVM treated with radiosurgery during an 8-year period. Factors associated with increased chance of AVM obliteration or hemorrhages during the follow-up period were analyzed. Results: Among 388 cases included in our series, 74 were Spetzler-Martin (SM) grade IV or V. Forty-four patients (11.3%) experienced post-radiosurgery hemorrhage in their follow-up period. The number of feeders (one/multiple) and deep location of the AVM did not alter the chance of bleeding (P < 0.05). Higher SM grading of the AVM was associated with increased chance of hemorrhage and decreased obliteration rate (P > 0.05) in the mid-term follow up. Conclusions: Our case series showed that radiosurgery can be considered a viable alternative in the treatment of even large AVMs which might not be considered good candidates for surgery or endovascular treatment. Further data including large size lesions are warranted to further support our findings.
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Vertex epidural hematoma: An analysis of a large series p. 167
Vengalathur Ganesan Ramesh, Marappan Kodeeswaran, Kunjithapatham Deiveegan, Venkataraman Sundar, Kuchalambal Sriram
DOI:10.4103/1793-5482.145555  
Context: Vertex epidural hematoma (VEDH) is uncommon. A high index of suspicion is required to suspect and diagnose this condition, and the surgical management is a challenge to neurosurgeons. There are only isolated case reports or small series of VEDH in the literature. Aims: We have tried to analyze a large series of VEDH seen in our institute. Settings and Design: Retrospective observational study. Subjects and Methods: This is an analysis of case records of patients with VEDH during 17 years period from 1995 to 2012. Statistical Analysis Used: Nil. Results: Twenty nine cases of VEDH encountered over a period of 17 years have been analyzed, including 26 males and 3 females. Majority were due to road accidents. Headache, papilledema and lower limb weakness have been the major presenting features in these cases. The diagnosis was by direct coronal computerized tomography (CT) scan in most of them. Majority were managed conservatively with observation and serial imaging. Four patients who had large VEDH with altered sensorium were managed surgically. The source of bleeding was mainly from superior sagittal sinus. Conclusions: VEDH has to be suspected when a patient presents with impact over the vertex and features of raised intracranial pressure. Direct coronal CT or magnetic resonance imaging is useful in the diagnosis. Surgery is required when the patient develops progressive deterioration in sensorium and/or with the hematoma volume more than 30 ml. The present series of 29 cases is the largest reported so far.
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Invasive aspergillus sinusitis with orbitocranial extension p. 172
Saleh S Baeesa, Rakan F Bokhari, Khalid B Alghamdi, Hisham B Alem, Jaudah A Al-Maghrabi, Tariq A Madani
DOI:10.4103/1793-5482.144188  
Context: Invasive sinonasal aspergillosis is a silently progressive disease that, left untreated, may invade the adjacent intracranial and intra-orbital compartments incurring serious morbidity. Aim: To evaluate our results of a collaborative surgical management plans for patients with invasive sinonasal aspergillosis with orbitocranial extension. Setting and Design: Retrospective study. Materials and Methods: Between the years 2000 and 2012, 12 patients with Aspergillus sinusitis with orbitocranial extension were treated at our institution. Preoperative CT and MRI scans were done in all cases and cerebral angiography in two patients with subarachnoid hemorrhage (SAH). Surgical combined transcranial and endonasal approaches to the skull base were considered in all patients. Adjuvant antifungals were administered postoperatively with regular clinical and radiologic follow up. Results: All cases had a long history of headache and nasal obstruction (n = 12). Five presented with unilateral proptosis, one with meningitis, one with epilepsy, two with SAH, and one patient presented with trigeminal neuralgia. Craniotomy alone was chosen for the patients with isolated sphenoiditis (n = 2) while a combined cranial and endonasal approach was elected for the other patients (n = 10). Adjuvant antifungal therapy was used for 3-12 months. Patients were followed up clinically and radiologically for an average 36-month period (range = 12-50 months) with disease eradication achieved in eight patients (67%). Two died as consequence to SAH. Follow up also showed that three patients (25%) had sinunasal recurrence requiring evacuation through an endonasal approach. Conclusions: Surgical intervention, with adjuvant antifungal therapy, aiming for safe total removal of the fungal burden, whenever feasible, has a major role in the management of invasive sinonasal aspergillosis with orbitocranial extension with minimal morbidity and good outcomes.
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Spinal injury resulting from car accident: Focus to prevention p. 180
Esmaeil Fakharian, Mahdi Mohammadzadeh, Hamid Reza Saberi, Mohammad Reza Fazel, Mohsen Rejali, Hossein Akbari, Azadeh Sadat Mirzadeh, Javad Mohammadzadeh
DOI:10.4103/1793-5482.152110  
Aim: To determine and compare the patterns of spinal injury in car occupants. Materials and Methods: Retrospective cross-sectional study enrolling all patients with spinal fracture after car accidents, who were admitted to hospital more than 24 h during 2004–2009. Results: The lumbosacral spine was the most commonly involved region (64.8). Six patients had spinal cord injury (6.6%). The majority of the victims were drivers of the vehicle (86.8%) and remaining were passengers. There was a significant difference in lumbar anatomic region (P = 0.05) and place of accident (P = 0.05) in car occupants' position (P = 0.05). Car rollover was the most common mechanism of spinal fractures. There was a significant difference in lumbar anatomic region (P = 0.05), and two or more associated organ injuries (P ≤ 0.05) in car accident mechanism (P = 0.05). Conclusion: The chance of sustaining serious spine and associated multiple injuries in car accidents is quite high in our today's society. This may be due to the low level of standards for car manufacturing, absence or inadequacy of appropriate safety measures in cars, and poorly designed roads and problems in quality of driving to mention some reasons. Therefore, these victims are prone to significant morbidity and even mortality and need more specific prehospital supportive interventions.
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Effect of radiation on brain tissue endothelin-1 level and tumor development p. 185
Metin Kaplan, Ahmet Kılınç, Sait Ozturk, Nevin Ilhan, Simay Gurocak, Murat Gonen
DOI:10.4103/1793-5482.145575  
Background: Radiotherapy causes injury in the endothelial cells of blood vessels and the production of vasoactive amines such as endothelin-1 (ET-1). ET-1 is an important peptide in cancer development. In this study, the effects of radiation on brain tissue ET-1 level were evaluated. Is it possible to suggest a mechanism using ET-1 level in the production of this adverse effect? In this paper, the relationship between the development of brain tumors and the ET-1 level has been discussed. Materials and Methods: Twenty-eight adult Sprague Dawley rats were used in the experiments. The rats were divided into four groups (n = 7) as follows: control group: radiation was not applied during the experiment; Group 1: Decapitated on the 1st day following radiation; Group 2: Decapitated on the 7th day following radiation; and Group 3: Decapitated on the 30th day following radiation. ET-1 levels were measured with enzyme-linked immunosorbent assay (ELISA) method. The t-test, variance analysis, and Tukey honestly significant difference (HSD) tests were used in the statistical analysis. A value of P < 0.05 was accepted as significant. Results: No statistical differences were observed in the tissue ET-1 levels between the control group and other groups. According to the variance analysis and Tukey test, the differences between the groups were not significant. Conclusion: We observed in this study that the effects of radiation on brain tumor development or malignant transformation are not mediated by ET-1 levels. In addition, these results support the hypothesis of the fact that medical treatment with ET-1 antagonists in clinical cases receiving radiotheraphy is unnecessary.
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Extradural anterior clinoidectomy: Technical nuances from a learner's perspective p. 189
Shashwat Mishra, Baltazar Leão, Diego Mendez Rosito
DOI:10.4103/1793-5482.145544  
Background: Extradural removal of the anterior clinoid process (ACP) is a crucial step in the proper surgical exposure of various pathologies in and around the central skull base. Since the pioneering description by Dolenc, the technique of extradural clinoidectomy has undergone several refinements in the light of improved understanding of microsurgical anatomy and maturation of neurosurgical techniques. Mastery of the surgical nuances involved in performing this surgical exercise will allow the young neurosurgeon to execute this step without undue reluctance and trepidation. Objective: This paper is an attempt to describe in detail, from a learner's viewpoint, the sequence of maneuvers involved in extradural removal of the ACP. Materials and Methods: The standard pterional approach and extradural anterior clinoidectomy was performed on four sides of two formalin fixed and latex injected cadaver heads. Important steps were photographed through the surgical microscope. Conclusion: An accurate understanding of the microsurgical anatomy of this region and the surgical nuances relevant to extradural clinoidectomy helps simplify the complexity of this surgical step.
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Secondary communicating hydrocephalus management by implantation of external ventricular shunt and minimal gradual increase of cerebrospinal fluid pressure p. 194
Keyvan Mostofi, Madjid Samii
DOI:10.4103/ajns.AJNS_320_16  
Background: This paper presents a new management strategy explaining the process used by implantation of external ventricular drainage (EVD) and very gradual increase of intracranial pressure for treatment of acute hydrocephalus. During the last 30 years' experience in professional practice, the senior author (M.S.) discovered that there are some options of regulations between cerebral spinal fluid (CSF) production and resorption. This theory shows that minimal continuous increase of the CSF pressure as long as the patient general neurological condition is unchanged and appears as normal can lead to definitive treatment of hydrocephalus without needing to set a shunt. Gradual weaning from EVD is used in some neurosurgical centers related to aneurismal subarachnoid hemorrhage only in a way to treat hydrocephalus in the acute phase, but not as an alternative curative treatment for hydrocephalus, and as far as we know this procedure has not been presented to date in medical literature in this form and this purpose. Materials and Methods: Between July 2000 and November 2012, 16 patients suffering from acute secondary hydrocephalus were treated by the method described in the International Neurosciences Institute in Hannover (Germany). Results: The causes of hydrocephalus were brain tumors (12), arteriovenous malformations (2), one cavernoma, and one polytrauma. In 11 patients (68.75%), the procedure led to a complete cure and surgical treatment has been excluded after EVD removal without any risk to the patients. Conclusions: Minimal gradual increase of CSF pressure by EVD implantation for the treatment of secondary acute communicating hydrocephalus used by senior author as an option is a safe alternative treatment of hydrocephalus and may obviate the need for surgical procedures.
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Neglected knowledge: Asymmetric features of lumbar disc disease p. 199
Ayhan Kanat, Ugur Yazar, Bulent Ozdemir, Hizir Kazdal, Mehmet Sabri Balik
DOI:10.4103/1793-5482.145573  
Background: Lumbar disc herniations have been extensively studied in the literature. Asymmetric trunk muscle anatomy could affect the development of this entity which has never been quantitatively studied previously. The purpose of this manuscript was to analyze the operated sides of herniated lumbar disc. Materials and Methods: Data files of patients with lumbar disc herniation operated in author's hospital between January 2007 and March 2009 were analyzed. Results: In operated side analysis, discectomy side was 53% on the left side, 40% on the right side, the difference between two sides was statistically significant. Conclusion: The asymmetric distribution may be a significant factor in the development and surgical treatment of lumbar disc herniations.
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CASE REPORTS Top

Spontaneous resolution of colloid cyst of the third ventricle: Implications for management p. 203
Mazda Keki Turel, Walter Kucharczyk, Fred Gentili
DOI:10.4103/1793-5482.181138  
While there is little controversy regarding the treatment of symptomatic colloid cysts, the optimal management of “incidentally” detected and asymptomatic colloid cyst remains unclear. The age of the patient, duration and significance of symptoms related to the cyst, size and radiological characteristics of the cyst and the presence of hydrocephalus are all factors to be considered before considering surgery. While surgery most often provides good results in the majority of patients, complications do occur. Despite growing literature about the natural history of this condition, to date, only three cases of spontaneous resolution of colloid cyst <10 mm have been reported. We report the case of spontaneous resolution of a colloid cyst larger than 10 mm, initially managed with close observation and serial neuroimaging. This case highlights the possible role for a conservative approach even in larger-sized cysts.
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Progression in size of an arterio-venous malformation p. 207
Abhidha Shah, Neeraj Patni, Raghvendra Ramdasi, Atul Goel
DOI:10.4103/1793-5482.145150  
We report a case of a young girl who was admitted with history of sudden onset left hemiplegia, when she was 5 years old. Investigations revealed no vascular malformation or abnormality. On conservative treatment, she progressively improved and had residual hemiparesis. She continued to have intermittent episodes of generalized and focal convulsions. For persistent convulsions, she was investigated again with MRI and angiography after 5 years of first presentation. Investigations at this time revealed a large arteriovenous malformation in the left posterior frontal region. The arteriovenous malformation was resected by surgery. Following surgery, the episodes of convulsions reduced. Arteriovenous malformations are generally considered to be congenital lesions and their size and physical architecture generally remains constant. The presented case clearly demonstrated de novo appearance or growth of the size of the arteriovenous malformation. Such a pattern of development and growth of a arteriovenous malformation is rare and only infrequently reported.
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Gossypiboma complicated with paraspinal abscess and lumbar sinus: An uncommon complication of posterior lumbar spinal surgery p. 211
Ranjan Kumar Sahoo, Pradipta Tripathy, Pulin Bihari Das, Debahuti Mohapatra
DOI:10.4103/1793-5482.148804  
A 42-year-old female presented with the complaint of purulent discharging sinus over posterior lumbar area following one month of lumbar spinal surgery for prolapsed intervertebral disc. Gossypiboma complicated with paraspinal abscess and sinus track formation over posterior lumbar area was diagnosed in magnetic resonance imaging which was confirmed in re- exploration of lumbar spinal operative site.
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Acute pulmonary edema and thrombocytopenia following venous air embolism during sitting position neurosurgery p. 214
Deepti Saigal, Pragati Ganjoo, Madhumita Tetarway, Kiranlata Kiro
DOI:10.4103/1793-5482.150223  
Venous air embolism (VAE) is a well-known complication of sitting position neurosurgery which most characteristically manifests as mild to severe hemodynamic alterations. Development of pulmonary edema is a known, though infrequent, manifestation of VAE. We report here the occurrence of acute pulmonary edema without accompanying hemodynamic changes in a patient undergoing retromastoid craniotomy and tumor decompression in the sitting position. The patient required supportive treatment and elective ventilation for 11 days before the edema resolved. He also developed significant postoperative thrombocytopenia which though, was self-limiting. Thus, VAE may manifest with atypical manifestations like pulmonary edema and thrombocytopenia that can significantly contribute to postoperative patient morbidity.
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Hydrocephalus associated with spinal intramedullary pilocytic astrocytoma p. 217
Sumit Bansal, Sachin A Borkar, Ashok K Mahapatra
DOI:10.4103/1793-5482.144174  
Hydrocephalus secondary to intraspinal tumors is a well-known but rare condition. We report a case of holocord intramedullary pilocytic astrocytoma associated with hydrocephalus in a 29-year-old male patient. He underwent ventriculoperitoneal shunt followed by subtotal resection of the tumor.
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Association of brain abscess with a mycotic aneurysm of the contralateral internal carotid artery in a patient of cyanotic heart disease p. 220
Sumit Bansal, Sachin A Borkar, Ashok K Mahapatra
DOI:10.4103/1793-5482.144171  
Congenital cyanotic heart disease can lead to intra-cranial involvement. Authors report a very rare case of right intra-cerebral abscess diagnosed on computerized tomography (CT) scan and simultaneous presence of an aneurysm of the left internal carotid artery diagnosed on CT angiogram in a 15-year-old child with congenital cyanotic heart disease with recent onset left hemiparesis. Right cerebral abscess was tapped and left internal carotid aneurysm was planned to be followed up by giving antibiotics and serial angiograms, but he could not survive and died due to non-cranial cause. We conclude that cerebral angiography is necessary to diagnose cerebro-vascular complications, including infectious aneurysms, in cases presenting with unusual findings on neuroimaging study. Patient must undergo serial angiography while being on intravenous antibiotics. Intervention (either surgical or endovascular) should be considered if there are no signs of regression of size of aneurysm or in the presence of aneurysm rupture. We have not been able to find a similar case in the English literature.
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Dorsally exophytic glioblastoma arising from the medulla oblongata in an adult presenting as 4th ventricular mass p. 224
Kuntal Kanti Das, Guru Prasad Bettaswamy, Anant Mehrotra, Sushila Jaiswal, Awadhesh Kumar Jaiswal, Sanjay Behari
DOI:10.4103/1793-5482.144151  
Brainstem gliomas are relatively rare in adults (<2% of all gliomas). Exophytic gliomas are focal brainstem lesions, which project into the 4th ventricle or cerebellopontine angles. These exophytic lesions are usually of low-grade histology (pilocytic astrocytoma or ganglioglioma) and have a relatively better outcome compared with brainstem gliomas as a whole. Glioblastoma is the commonest primary glial cell neoplasm and mostly occurs in the supratentorial compartment. It is rather uncommon in the brainstem and seldom has been described as having an exophytic growth pattern. Here we describe an exophytic brainstem glioblastoma arising from the medulla oblongata in a 55-year-old lady who presented with a 4th ventricular mass, and present a brief review of the literature. Till now, six cases of glioblastoma arising from the medulla oblongata have been reported. So, ours is the seventh such report. To the best of our knowledge, it also happens to be the sixth reported case of dorsally exophytic brainstem glioblastoma till date.
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Moyamoya disease presenting as bilateral acute subdural hematomas without deficits p. 228
Mudumba Vijayasaradhi, Vangala B Prasad
DOI:10.4103/1793-5482.149997  
We report a patient presenting with imageological features of bilateral acute subdural hematomas and subarachnoid hemorrhage, who was subsequently diagnosed as a case of moyamoya disease. Imageological features, source of hemorrhage, literature review, and management are discussed. We report this case in view of its rarity in presentation with these imageological features.
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Sinonasal teratocarcinosarcoma involving nasal cavity, nasopharynx, and all paranasal sinuses with bilateral orbital and intracranial extension: A rare case report p. 232
Dhruba Jyoti Kurmi, Radhey Shyam Mittal, Achal Sharma, Ashok Gandhi, Shashi Singhvi
DOI:10.4103/1793-5482.145559  
Sinonasal teratocarcinosarcoma (SNTCS) is one of the rarest, aggressive malignant neoplasms of sinonasal tract, consisting of primitive neuroepithelial elements with various malignant epithelial and mesenchymal components. Previously described as teratoid carcinosarcoma, malignant teratoma, or blastoma, SNTCS constitutes less than 1% of all cancers and approximately 3% of all malignancies of head and neck region, which is mainly located in the nasal cavity and paranasal sinuses, although tumors occurring in other locations including the nasopharynx and oral cavity have been described. Here, we are presenting a 22-year-old patient with SNTCS involving the nasal cavity, nasopharynx, and all paranasal sinuses with bilateral orbital and intracranial extension treated with surgery followed by radiotherapy and chemotherapy.
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A common case with an unusual association: Chiari I malformation with holocord syrinx p. 241
Sumit Bansal, Sachin A Borkar, Ashok K Mahapatra
DOI:10.4103/1793-5482.144169  
Authors are presenting a common case of Chiari malformation but with a very unusual associated finding, holocord syringomyelia, which responded to posterior fossa decompression. An 11-year-old male patient presented with progressive left hemiparesis and numbness on left half of the body for 4 years. Magnetic resonance imaging of the spine revealed peg-shaped herniation of tonsils 8 mm below the foramen magnum and holocord syringomyelia. No focal intraspinal mass was seen. Chiari I malformation with holocord syrinx was diagnosed. The patient underwent posterior fossa decompression with subpial resection of both tonsils with augmentation duraplasty. Post-operatively, patient improved clinically as well as radiologically.
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Bilateral platysma dystonia p. 244
Achmad Fahmi, Ayako Mandai, Tetsuryu Mitsuyama, Shinichi Goto, Takaomi Taira
DOI:10.4103/1793-5482.144152  
Platysma dystonia is an involuntary movement of platysma muscle. It is a rare form of dystonia. In this case report, we would like to report a good result of peripheral nerve denervation for bilateral platysma dystonia case. A 58-years-old woman presented with an 8-years history of involuntary jerking movement of her bilateral platysma muscles. Oral medication was not effective. Microsurgical denervation of the facial nerves and its terminal branches to the platysma muscles were performed. Immediately after surgery, the patient showed considerable improvement. There were no complications. Selective peripheral denervation is useful for dystonia of the platysma muscles.
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Incidental bleeding meningioma p. 247
Robert Sinurat, Jusuf D Banjarnahor
DOI:10.4103/1793-5482.144195  
The authors present the case of a 46-year-old woman who was admitted to their institution after suffering acute intratumoral hemorrhage. There was no history and evidence of neoplasms, trauma, seizures and coagulopathy in the patient. Surgery was performed for evacuation of the hematoma and tumor excision after brain CT scan. Post operative results her neurologic function recovered completely. The pathology reports revealed angioblastic meningioma. The key to make an early and accurate diagnosis is good radiological examination, and definitive surgery can bring a more favorable outcome, lowering the morbidity and mortality rate.
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A rare case of recurrence of primary spinal neurocysticercosis mimicking an arachnoid cyst p. 250
Anirban Pal, Chaitali Biswas, Tirtha R Ghosh, Pulak Deb
DOI:10.4103/1793-5482.144176  
Neurocysticercosis (NCC) is a common parasitic infection of the central nervous system but isolated primary spinal NCC is of very rare occurrence. The authors report a case of 44-year-old male, a postoperative case of multiple spinal NCC lesion excision 2 years ago, who presented with cauda equina syndrome and magnetic resonance imaging revealed a lesion mimicking an arachnoid cyst in the D1-9 region of the spinal cord. On intraoperative surgical exposure multiple cysts were found and excised. The suspicion of recurrence of NCC was confirmed by histopathology. Postoperatively there was significant improvement in neurological symptoms of the patient. Recurrence of primary spinal NCC should be considered in differential diagnosis of an arachnoid cyst if there is a definitive past history.
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Bilateral posterior fossa and temporo-occipital extra-dural hematomas: A simple novel technique p. 253
Ashish Aggarwal, Pravin Salunke, Sameer Futane, Harsimrat Bir Sodhi
DOI:10.4103/1793-5482.150008  
Posterior fossa extra-dural hematoma is rare and early diagnosis and management is associated with good outcome. Twenty four year male presented with somnolence and soft tissue swelling of occipital region following road traffic accident. CT scan revealed bilateral posterior fossa with bilateral temporo-occipital Extradural Hematoma (EDH) with mass effect. He was operated through a trifoliate incision and craniotomies leaving a strip of bone over the transverse and occipital sinus. The blood loss with such technique was minimal and the control of sinus tear was easier as the dura on either sides of the sinus can to tied to each other to hitch the sinus up to the bone thereby, providing a good tamponade. Early diagnosis of posterior fossa EDH and prompt surgical evacuation especially in patients with mass effect provide excellent recovery. However, the surgery may be associated with significant blood loss due to venous sinus injury increasing the morbidity and mortality. We have described a novel technique that minimizes the blood loss for patients with PFEDH straddling across the venous sinuses.
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Post-burn spontaneous brain fungation caused by infiltrating Marjolin's ulcer of scalp p. 256
Vishal Bhasme, Manish Agrawal, NC Poonia, H Bagaria, Pranay Chakotiya
DOI:10.4103/1793-5482.150220  
Marjolin's ulcer is a well-recognized, rare, long-term complication of post-burn scar and other chronically irritating local skin conditions. Its infiltration into the skull bones and the underlying dura causing complete destruction is very rare and quiet exceptional. We present an unusual case of spontaneous brain fungation through the scar tissue present over the scalp as a result of flame burn 18 years back. Patient was treated surgically, but expired after 10 days. Though we were not able to save the patient, its presentation was so unique that we want to report this case.
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Postoperative hematoma involving brainstem, peduncles, cerebellum, deep subcortical white matter, cerebral hemispheres following chronic subdural hematoma evacuation p. 259
Mohana Rao Patibandla, Amit K Thotakura, Dinesh Shukla, Anirudh K Purohit, Gokul Chowdary Addagada, Manisha Nukavarapu
DOI:10.4103/1793-5482.144163  
Among the intracranial hematomas, chronic subdural hematomas (CSDH) are the most benign with a mortality rate of 0.5-4.0%. The elderly and alcoholics are commonly affected by CSDH. Even though high percentage of CSDH patients improves after the evacuation, there are some unexpected potential complications altering the postoperative course with neurological deterioration. Poor outcome in postoperative period is due to complications like failure of brain to re-expand, recurrence of hematoma and tension pneumocephalus. We present a case report with multiple intraparenchymal hemorrhages in various locations like brainstem, cerebral and cerebellar peduncles, right cerebellar hemisphere, right thalamus, right capsulo-ganglionic region, right corona radiata and cerebral hemispheres after CSDH evacuation. Awareness of this potential problem and the immediate use of imaging if the patient does not awake from anesthesia or if he develops new onset focal neurological deficits, are the most important concerns to the early diagnosis of this rare complication.
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Solitary giant diffuse neurofibroma of the scalp with calvarial defect p. 263
Sanjeev Kumar, Pramod Chaurasia, Daljit Singh, Vineeta V Batra, Rajendra Aher
DOI:10.4103/1793-5482.144199  
Neurofibromas of the scalp can have protean presentations. Most of the swellings are small, solitary and are easily diagnosed clinically. Diffuse swellings on the other hand are rare and are commonly seen in adults. The skull defects with these swellings are also rarely reported in the absence of neurofibromatosis. There is only one report of child having diffuse neurofibroma with skull defect. We report a second case in literature in a child with progressive, painful, diffuse neurofibroma along with calvarial defect.
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Intra-axial chondroblastoma: A bony tumor in the cerebral hemisphere – A case report and review of literature p. 266
Mayur Sharma, Shadma W Khan, Vernon Velho, Rahul Mally
DOI:10.4103/1793-5482.144168  
This case highlights a rare possibility of occurrence of chondroblastoma, a bony tumor, at an uncommon location. Extraosseous, soft tissue location of this bony tumor is rare and more so for intracranial intra-axial location. We report a case of an intra-axial frontal lobe lesion, histologically proven to be an extraosseous chondroblastoma. A 23-year-old male presented with a history of headache and vomiting of 1 month duration. Imaging was suggestive of left frontal lobe intra-axial calcified lesion suggestive of oligodendroglioma. Patient was operated upon by left frontal craniotomy with complete excision of the lesion. The patient recovered well postoperatively. Left sixth nerve paresis improved and ataxia decreased.Intra-axial chondroblastomas are extremely rare tumors. Differential diagnosis should be kept in mind, especially in cases of calcified lesions. Complete excision should be the aim to achieve cure.
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Thoracic psammomatous spinal meningioma with osseous metaplasia: A very rare case report p. 270
Akhil Prakash, Shashank Mishra, Ruchi Tyagi, Prakash C Attri, Amit Bhatnagar, Sandeep Kansal
DOI:10.4103/1793-5482.150222  
Thoracic spinal psammomatous meningioma is a rare subtype of meningioma. Among diverse types of mesenchymal differentiation, osseous metaplasia is found to be still rarer. We are presenting a new case of thoracic psammomatous spinal meningioma with osseous metaplasia in a middle aged female which that gives a sense of cancellous bone in the spinal canal. To conclude, meningiomas with osseous metaplasia are very rare tumors that complicate the surgical removal in certain cases. Ossification, if predicted prior to operation with computed tomography reconstruction, makes planning of removal easier. In our case, maintained cerebrospinal fluid spaces despite hard consistency of tumor made its removal easier once cerebrospinal fluid was drained. We have submitted this article because it is very rare and curable pathology and preoperative diagnosis helps in prevention of neurological injury during its excision.
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Distal posterior cerebral artery revascularization for a fusiform PCA aneurysm: A lesson learned p. 273
Gavin W Britz, Ali Zomorodi, Ciaran J Powers
DOI:10.4103/1793-5482.144186  
The need for revascularization with proximal posterior cerebral artery occlusion in the treatment of giant and fusiform aneurysms is unclear. While early series demonstrated only about a 10% chance of infarction following posterior cerebral artery occlusion, recently several authors have advocated a bypass prior to parent vessel sacrifice in all cases. We present the case of an adult man with a fusiform aneurysm of the right posterior cerebral artery at the P2-P3 junction. He clinically failed a balloon test occlusion preoperatively and therefore underwent an occipital artery to distal posterior cerebral artery bypass with subsequent endovascular occlusion of the parent vessel and aneurysm. Despite the fact that the immediate and 6 month follow up cerebral angiography confirmed a patent bypass, the patient still developed a posterior cerebral artery territory stroke. We believe this case demonstrates that successful distal revascularization in the setting of proximal posterior cerebral artery occlusion does not guarantee against cerebral ischemia and infarction even in those patients that fail a test occlusion.
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Self inflicted stab with a knife: An unusual mode of penetrating brain injury p. 276
Zeeshan Qazi, Bal Krishna Ojha, Anil Chandra, Sunil Kumar Singh, Chhitij Srivastava, Nishant Verma, Tushar B Patil
DOI:10.4103/1793-5482.149994  
Self-inflicted penetrating injuries have been very rarely described in the medical literature. We describe a middle-aged woman, who had driven a long knife inside her skull with the help of a brick. She had done this to get relief from chronic headache, which was troubling her for 10 years. Patient was hemodynamically stable and had Glassgow Coma scale score of 15. She was immediately operated to remove the knife and evacuate the acute subdural hematoma. Patient made a steady postoperative recovery. Psychiatric and neurological evaluation in the postoperative period revealed features of mixed anxiety and depressive disorder with migraine, for which she was started on treatment. Management of such cases needs a team approach with inputs from neurosurgeon, neurophysician and psychiatrist.
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Isolated lumbar intradural extra medullary spinal cysticercosis simulating tarlov cyst p. 279
Sumit Bansal, Ashish Suri, Mehar Chand Sharma, Aanchal Kakkar
DOI:10.4103/1793-5482.150225  
Spinal cysticercosis is a very uncommon manifestation of neurocysticercosis, which is caused by the larvae of Taenia solium. Here, we present a rare case of isolated lumbar intradural extramedullary neurocysticercosis, initially thought to be Tarlov cyst. A 40-year-old man, presented with low backache for 1-year with radiation of pain to right leg for 3 months. The patient was treated successfully with the surgical removal of the cyst, followed by medical treatment. Spinal neurocysticercosis should be considered in the differential diagnosis in high-risk populations, with new symptoms suggestive of a spinal mass lesion.
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Granulomatous hypophysitis caused by Rathke's cleft cyst mimicking a growth hormone-secreting pituitary adenoma p. 283
Masato Hojo, Ryota Ishibashi, Hiroshi Arai, Susumu Miyamoto
DOI:10.4103/1793-5482.146390  
We report a case of granulomatous hypophysitis caused by Rathke's cleft cyst (RCC) mimicking a growth hormone (GH)-secreting pituitary adenoma. Neuroradiological and endocrinological evaluations showed abnormal findings consistent with acromegaly: Magnetic resonance imaging demonstrated a pituitary mass lesion, and GH and insulin-like growth factor I levels were markedly elevated, and GH levels were not suppressed in oral glucose tolerance test. Transsphenoidal surgery was performed, but no adenomatous tissue could be detected. Histological examination revealed RCC and concurrent granulomatous giant cell inflammatory reaction of the anterior hypophysis. To the authors' knowledge, this is the first documented case of granulomatous hypophysitis caused by RCC mimicking a GH-secreting pituitary adenoma.
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A rare case of dural arteriovenous fistula presenting as primary intraventricular hemorrhage p. 287
Trilochan Srivastava, Raghavendra Bakki Sannegowda, VD Sinha, RS Jain, Rahul Jain, Tarun Mathur
DOI:10.4103/1793-5482.146399  
Primary intraventricular haemorrhage (PIVH) is rare. Dural arteriovenous fistula causing PIVH is extremely rare. We report a case of a 17 year old boy who presented with left hemiparesis, left lower motor neuron facial palsy and ataxia. His computed tomography head revealed primary intraventricular hemorrhage. Catheter super selective angiography revealed a dural arterio venous fistula with arterial feeder arising from the middle meningeal artery as well as from the inferior marginal tentorial artery. Glue injection led to successful disappearance of the fistula and eventual clinical recovery.
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A rare case of solid calcified intramedullary neurenteric cyst: Case report and technical note p. 290
Krishna Chaitanya Joshi, Daljit Singh, Sudhir Suggala, Tushit Mewada
DOI:10.4103/1793-5482.145557  
Neurenteric cysts are rare lesions of the spinal cord, constituting less than 1.3% of all spinal cord tumors. Approximately 90% of neurenteric cysts are located in the intradural extramedullary compartment, while the remaining 10% are divided between an intradural intramedullary or extradural location. They are usually extramedullary and found in the lower cervical and thoracic spine. We report a case of 8 year old child with totally solid calcified intramedullary cyst which has hitherto not been reported in literature. We discuss the challenges faced in the diagnosis and surgical management of such lesions and a brief review of pertinent literature.
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Clear-cell meningioma: Intraoperative diagnosis by squash cytology: Case report and review of the literature p. 293
Vaishali Walke, Shantilal M Sisodia, Sanjay Bijwe, Purwa Patil
DOI:10.4103/1793-5482.146392  
Clear-cell meningioma (CCM), an unusual subset of meningioma has prominent, clear-cell morphology. It is a wolf in sheep's clothing characterized by benign histologic attributes, but tendency for recurrence (61%) and metastasis. Therefore, WHO has classified it as grade II meningioma. Fine-needle aspiration cytology diagnosis is simple, rapid, cost-effective and reliable procedure primarily aimed at preoperative diagnosis of advanced and metastatic extracranial tumor. Preoperative and/or intraoperative cytodiagnosis of CCM demand expertise in the evaluation of cytology smears. However in case of intra operative evaluation of squash smears there is a time constraint and a very small tissue material obtained by stereotactic biopsy are available for interpretation. Knowledge of clinical features including age, anatomical locations, neuroimaging findings and cytomorphologic features, are prerequisites for arriving at definitive cytodiagnosis. We describe intra operative squash cytology of CCM in a 16-year-old female, located in cerebello-pontine angle. The diagnosis of CCM offered on squash cytology was subsequently confirmed on histopathology and immunohistochemistry. It typically showed pattern less sheets and groups of polyhedral, clear cells with monomorphic, round nuclei having a bland chromatin and inconspicuous nucleoli. Separation of CCM from other tumors having clear -cell morphology and variants of meningioma is important because of its high recurrence rate and mortality.
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Corpus callosum dermoid cyst: A rare entity p. 296
Sunita Singh, Promil Jain, Hemant Yadav, Ishwar Singh, Rajeev Sen
DOI:10.4103/1793-5482.148796  
Dermoid cyst is a congenital lesion that arises due to embryogenic impairment. It accounts for less than 0.3% of all intracranial masses. Herein we report a 30-year-old male who presented with a short history of headache and behavioral disorder. Physical and radiological examination diagnosed it to be a lipoma/epidermoid arising from corpus callosum. The lesion was removed endoscopically and histopathologic examination was performed which confirmed it to be a dermoid cyst. Rarity of the lesion and difficulty in pre-operative diagnosis prompted us to bring forward this case report.
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Parieto-temporal pleomorphic xanthoastrocytoma in a black African child p. 298
Aaron Musara, Kazadi K Kalangu, Maximillan N Dzowa, Wilfred Muteweye, Rudo Mutasa
DOI:10.4103/1793-5482.145535  
Pleomorphic xanthoastrocytoma (PXA) is a rare cerebral tumor, accounting for <1% of all astrocytic neoplasms. PXA, usually, has a favorable prognosis in spite of what might be suggested from the ominous microscopic appearance. There is no literature immediately available on the black population for this tumor. Management is by surgical resection. The ideal is gross total resection, which offers an excellent prognosis. This disease condition has not been reported in the black population. The following is a presentation of a case report in a black African girl, followed by a review of the literature.
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Exophytic pontine glioblastoma multiforme presenting as cerebellopontine angle mass p. 302
Sukhdeep Singh Jhawar, Garewal Singh Sarvpreet, TN Shadangi
DOI:10.4103/1793-5482.148801  
Exophytic pontine glioblastoma multiforme (GBM) is a highly malignant tumor of posterior fossa, which is quite rare and such tumor presenting as cerebellopontine (CP) angle mass is even rarer. Here, we describe a 12-year-old boy who presented with imbalance on walking and facial nerve paresis. Magnetic resonance imaging of the brain revealed an irregular ring enhancing mass lesion of the CP angle, which was initially thought to be a tuberculoma, but was later confirmed to be a GBM. Clinical and radiological differentiation of uncommon lesions of CP angle in children is discussed with brief review of pertaining literature.
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A unique case of split cord malformation type 1 with three different types of bony spurs p. 305
Kanwaljeet Garg, Vivek Tandon, Ashok Kumar Mahapatra
DOI:10.4103/1793-5482.149981  
Split cord malformation (SCM) is a rare congenital anomaly. The presence of bony spurs seen in type 1 SCM are usually partial and unequivocally are found attached to the dorsal surface of the vertebral body. We present here a unique case of SCM where the bony spur was found attached to the ventral aspect of the posterior arch and there were three different types of spurs (Type 1A, 1B and 1C) in the same patient.
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Tranexamic acid may be beneficial for difficult hemostasis following tumor resection in neurosurgical patients: A personal experience p. 309
Hemant Bhagat, Bhupesh Kumar, Neha Garg, Rajesh Chhabra
DOI:10.4103/1793-5482.145542  
Neurosurgeons may find themself in a precarious situation, while unable to secure hemostasis following tumor resection. Use of tranexamic acid was helpful in our patient to secure complete hemostasis in one such event of uncontrollable bleeding.
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Giant convexity chondroma with dural involvement: Case report and review of literature p. 311
Venkatesh Raju, Raju Raman, Balamurugan Shanmugasundaram, Indunesh Kochikaran
DOI:10.4103/1793-5482.145574  
Intracranial chondromas are rare benign cartilaginous tumors arising usually from the skull base. We present a case of giant chondroma with dural attachment. Imaging modalities and management pearls are discussed. A brief review of literature is also presented.
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Primary hydatid cyst of pineal region of brain: A case report from Saudi Arabia p. 314
Ahmed Bakhsh, Khalid Mukarram Ali Siddiqui, Suad Taraif
DOI:10.4103/1793-5482.146397  
Preoperative diagnosis of cerebral echinococcosis in an unusual location is always difficult. Nonetheless, this possibility should be kept in mind in all cystic lesions of the brain. Although total excision of the cyst without rupture is a time - tested treatment, but in order to prevent recurrence, adjuvant medical treatment should also be started. Albendazole, mebenadazole and praziquental are commonly used drugs. Albendazole is a drug of choice. Its usual dose for adults is 400 mg twice daily. Exact duration of treatment is still uncertain, but it should not be <6 months. This case report shows primary presentation of hydatid cyst in the pineal region which later disseminated intracranially. However complete excision of the cyst at site of recurrence, combined with medical treatment, proved quite successful. Patient was found recurrence free 3 years after surgery. Last but not least, endoscopic third ventriculostomy and biopsy should be performed very carefully in cystic lesions of posterior third ventricular region.
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Hydatid cysts in the right temporalis muscle: An exceptional clinical scenario p. 318
Sanjeev Attry, Raghavendra Nayak, SK Saha, SN Ghosh
DOI:10.4103/1793-5482.150229  
Hydatid diseases is a parasitic infestation of human and herbivorous animals caused by a cestode, Echinococcus granulosus, which resides in the intestine of definitive hosts like dogs and some wild carnivores like foxes. Liver and lung are commonly involved organs and involvement of muscles and bones is very unusual. Hydatid cyst of the temporalis muscle is extremely rare, even in the countries where echinococcal infestation is endemic. We report a case of 23-year-old female patient with a cystic swelling in the right temporalis muscle which turned out to be hydatid cysts. Surgical excision formed the main modality of treatment.
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Multiple spinal extradural arachnoidal cysts: An uncommon cause of thoracic cord compression p. 321
Raghavendra Nayak, Anupkumar Chaudhuri, Shahid Sadique, Sanjeev Attry
DOI:10.4103/1793-5482.150004  
Spinal extradural arachnoid cysts are one of the rare causes of symptomatic spinal cord compression. Among them, occurrence of multiple cysts at the same spinal segment is rarely described in the literature. They appear to be extradural outpouchings of arachnoid that communicate with the intraspinal sub-arachnoid space through a small defect in the dura, filled by cerebrospinal fluid. Pathogenesis of these lesions is still unclear. Surgical excision is considered as the gold standard treatment. We present a 7-year-old female child who presented with spastic paraparesis. Her magnetic resonance imaging showed a thoracic posterior extradural arachnoid cyst, whereas, intraoperatively we found multiple cysts, which were excised completely. Neurological symptoms gradually recovered after surgical decompression.
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Unusual presentation of an intraventricular hydatid cyst as a bleeding cystic tumor: A case report and brief review p. 324
Sumyra Khurshid Qadri, Nissar Hussain Hamdani, Abdul Rashid Bhat, Mohammad Iqbal Lone
DOI:10.4103/1793-5482.145541  
Hydatid cysts constitute only 2% of all intracranial masses, commonly involve parenchyma and very rarely ventricles. Here, we report an unusual case of a primary, isolated intraventricular hydatid cyst that mimicked a tumor and presented as intraventricular hemorrhage with hydrocephalus in a boy, causing a diagnostic dilemma. Although, preoperative modalities like computed tomography, magnetic resonance image and serology generally help in establishing the diagnosis, but hydatid cysts with unusual localizations and atypical imaging findings may complicate the diagnosis and need be considered in the differential diagnosis of all cystic masses in all anatomic locations, especially in endemic areas, so as to reduce the patient morbidity and mortality.
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Clival defect causing primary spontaneous rhinorrhea p. 328
Vivek Tandon, Kanwaljeet Garg, Ashish Suri, Ajay Garg
DOI:10.4103/1793-5482.144202  
Primary cerebrospinal fluid (CSF) rhinorrhea due to a defect in clivus is an extremely rare entity, till date only four such cases are reported in the world literature. We present a case of 55-year-old female who presented with primary spontaneous CSF rhinorrhea, for which endonasal surgery was performed about 9 years back. Patient developed recurrent CSF leak with a history of meningitis. Repeat imaging showed clival defect causing CSF leak. Transsphenoidal repair was performed under neuronavigation. In this paper, we discuss the possible mechanism of fistula formation and literature is reviewed.
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Concurrent multiple intracranial and intramedullary conus tuberculoma: A rare case report p. 331
Manish Jaiswal, Ashok Gandhi, Devendra Purohit, Radhey Shyam Mittal
DOI:10.4103/1793-5482.143461  
Central nervous system (CNS) tuberculosis commonly manifests as tubercular meningitis. CNS tuberculomas are more common intracranially and less frequently involve the spinal cord. Combination of intramedullary with intracranial tuberculomas is extremely rare. We report a case of concurrent occurrence of intramedullary tuberculoma with multiple intracranial tuberculomas in a young 16-year-old boy, who presented with two weeks history of paresthesias and weakness of the lower limbs and diminution of vision in left eye, who had been treated for pulmonary tuberculosis. Magnetic resonance imaging (MRI) spine showed a well-circumscribed lesion opposite L1, which was diagnosed as intramedullary tuberculoma. As for vision complaint, on cranial imaging, he was found to have multiple round contrast enhancing lesions, which were diagnosed as intracranial tuberculomas based on their typical MRI findings. He had complete recovery with conventional treatment of anti-tubercular therapy and steroids, without any surgical intervention. We suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intra-cranial tuberculomas.
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LETTERS TO EDITOR Top

Hunter's syndrome and the airway: Implications for the anesthesiologist - A correspondence p. 334
Nilay Chatterjee, Josemine Davis, Arimanickam Ganesamoorthi
DOI:10.4103/1793-5482.145534  
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Gliomatosis cerebri in a 10-year-old male patient p. 336
Atahualpa Strapasson, Ápio Cláudio Martins Antunes, Francine Oliveira, Paulo P Oppitz
DOI:10.4103/1793-5482.150230  
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Management of intracranial epidermoid tumor p. 338
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/1793-5482.145545  
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Valsalva maneuver aided adherent ventriculoperitoneal shunt removal p. 339
Rudrashish Haldar, Ratnadip Bose, Sukhen Samanta, Kuntal K Das
DOI:10.4103/1793-5482.145536  
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HIV-associated lymphoma presenting with painful ophthalmoplegia p. 341
Satoru Takeuchi, Shotaro Hagiwara, Hiroshi Nawashiro, Katsuji Shima
DOI:10.4103/1793-5482.145108  
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Neurosurgery under siege – Stories from Aleppo and the Syrian war: A narrative article p. 342
Fakhr Fakhouri
DOI:10.4103/ajns.AJNS_59_17  
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