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   2015| October-December  | Volume 10 | Issue 4  
    Online since August 13, 2015

 
 
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ORIGINAL ARTICLES
Volume change theory for syringomyelia: A new perspective
Survendra Kumar Rajdeo Rai, Pooja Survendra Kumar Rai
October-December 2015, 10(4):245-251
DOI:10.4103/1793-5482.162680  PMID:26425150
Background: The etiopathogenesis of syringomyelia is still an enigma. The authors present a novel theory based on fluid dynamics at the craniovertebral (CV) junction to explain the genesis of syringomyelia (SM). The changes in volume of spinal canal, spinal cord, central canal and spinal subarachnoid space (SSS) in relation to the posterior fossa have been analysed, specifically during postural movements of flexion and extension. The effect of fluctuations in volume of spinal canal and its contents associated with cerebrospinal fluid (CSF) flow dynamics at the CV junction have been postulated to cause the origin and propagation of the syringomyelia. The relevant literature on the subject has been reviewed and the author's theory has been discussed. Conclusion: Volume of spinal canal in flexion is always greater than that in extension. Flexion of spine causes narrowing of the ventral subarachnoid space (SAS) and widening of dorsal SAS while extension causes reverse changes leading to fluid movement in dorsal spinal SAS in flexion and ventral spinal SAS in extension. Cervical and lumbar spinal region with maximum bulk hence maximum area and volume undergo maximum deformation during postural changes. SSS CSF is the difference between the volume of spinal canal and spinal cord, varies in flexion and extension which is compensated by changes in posterior fossa (CSF) volume in normal circumstances. Blocked SAS at foramen magnum donot permit spinal SAS CSF exchange which during postural changes is compensated by cavitatory/cystic (syrinx) change at locations in cervical and lumbar spine with propensity for maximum deformation. Augmentation of posterior fossa volume by decompression helps by normalization of this CSF exchange dynamics but immobilizing the spinal movement theoretically will cease any dynamic volume changes thereby minimizing the destructive influence of the fluid exchange on the cord. Thus, this theory strengthens the rational of treating patients by either methodology.
  2,835 10,195 4
Outcome of revascularization in moyamoya disease: Evaluation of a new angiographic scoring system
Siddhartha Shankar Sahoo, Ashish Suri, Sumit Bansal, S Leve Joseph Devarajan, Bhawani Shankar Sharma
October-December 2015, 10(4):252-259
DOI:10.4103/1793-5482.162681  PMID:26425151
Background: Moyamoya disease (MMD) is a chronic progressive cerebrovascular occlusive disease affecting commonly the anterior circle of Willis. Matushima grade inadequately reflects the angiographic changes postrevascularization procedure. Aims: To analyze the clinical and angiographic outcome of revascularization procedures (direct [ST-middle cerebral artery (MCA) anastomosis] and indirect [encephalo-duro-arterio-myo-synangiosis (EDAMS)]) in MMD and validate a new angiographic scoring system. Materials and Methods: Retrospective study included symptomatic patients of MMD who underwent revascularization; both indirect and combined methods between January 2002 and April 2012. Follow-up angiography was done after at least 3 months. We devised a novel scoring system the "angiographic outcome score" (AOS) including reformation of distal MCA and anterior cerebral artery, regression of basal moyamoya vessels, leptomeningeal collaterals and overall perfusion. AOS was applied to the angiograms independently by a neuroradiologist and a neurosurgeon that were blinded toward its preoperative or postoperative status. Results: Totally 33 patients underwent 36 EDAMS and 4 combined procedures (EDAMS + ST-MCA bypass). The mean follow-up was 20 months. None had recurrent transient ischemic attack or fresh infarct. Postoperative AOS was significantly higher than preoperative AOS. The Spearman rho showed positive correlation between Matushima grade and postoperative AOS. Significant regression of basal moyamoya vessels and increase in number of loci of transdural collaterals was seen. Conclusions: EDAMS is a simple yet effective method of revascularization in both pediatric as well as adult age groups. AOS is a simple, precise and easily reproducible scoring system, which reflects the favorable angiographic changes after revascularization.
  2,502 2,041 4
CASE REPORTS
A rare case of neurofibromatosis - type 1
Prithvi Varghese, Muhammed Jasim Abdul Jalal
October-December 2015, 10(4):344-347
DOI:10.4103/1793-5482.162728  PMID:26425173
Neurofibromatosis type 1 (NF1), also known as von Recklinghausen disease, is an autosomal dominant familial tumor syndrome. Glioblastoma is a malignant brain tumor but is a rare occurrence in patients with NF1. Here, we report a rare occurrence of glioblastoma in a 60-year-old man with NF1, who presented with headache, neck pain, and gait unsteadiness of 3 days duration. He also had postural hypotension. Motor examination revealed left hemiparesis. Multiple subcutaneous soft swellings and multiple cafι-au-lait spots were seen all over his body. He also had inguinal and axillary freckling. Abdominal imaging revealed a right suprarenal mass suggestive of cystic pheochromocytoma. Brain imaging revealed a predominantly cystic intra-axial right frontal space occupying lesion (SOL) with enhancing solid component, perilesional edema, and mass effect. The patient underwent laparoscopic removal of right adrenal mass after being adequately "blocked" by an alpha blocker-prazosin. Thereafter, he underwent right frontal craniotomy and gross total excision of right frontal infiltrative SOL. The postoperative period was uneventful. Patient underwent adjuvant radiotherapy and chemotherapy.
  3,107 172 2
ORIGINAL ARTICLES
Imaging characteristics of supratentorial ependymomas: Study on a large single institutional cohort with histopathological correlation
Sandhya Mangalore, Saritha Aryan, Chandrajit Prasad, Vani Santosh
October-December 2015, 10(4):276-281
DOI:10.4103/1793-5482.162702  PMID:26425155
Background: Supratentorial ependymoma (STE) is a tumor whose unique clinical and imaging characteristics have not been studied. Histopathologically, they resemble ependymoma elsewhere. We retrospectively reviewed the imaging findings with clinicopathological correlation in a large number of patients with STE to identify these characteristics. Materials and Methods: Computed tomography (CT) magnetic resonance images (MRI), pathology reports, and clinical information from 41 patients with pathology-confirmed STE from a single institution were retrospectively reviewed. CT and MRI findings including location, size, signal intensity, hemorrhage, and enhancement pattern were tabulated and described separately in intraventricular and intraparenchymal forms. Results: STE was more common in pediatric age group and intraparenchymal was more common than intraventricular form. The most common presentation was features of raised intracranial tension. There were equal numbers of Grade II and Grade III tumors. The imaging characteristics in adult and pediatric age group were similar. The tumor was large and had both solid and cystic components. Advanced imaging such as diffusion, perfusion, and spectroscopy were suggestive of high-grade tumor. Only differentiating factor between Grade II and Grade III was the presence of calcification. 1234 rule and periwinkle sign which we have described in this article may help characterize this tumor on imaging. Conclusion: This series expands the clinical and imaging spectrum of STE and identifies characteristics that should suggest consideration of this uncommon diagnosis.
  2,780 424 9
Attention and executive functions in microsurgically treated patients after subarachnoid hemorrhage
Maida Koso, Kemal Dizdarevic
October-December 2015, 10(4):260-265
DOI:10.4103/1793-5482.162683  PMID:26425152
Objectives: This research aimed to assess attention and executive functions in subarachnoid hemorrhage (SAH) patients. Methods: The prospective, controlled, longitudinal study was conducted. There were two groups of patients (SAH and lumbar microdiscectomy groups), and all of them were operated on by a single neurosurgeon (KD) in the same institution. Preoperatively, SAH patients were in the Hunt-Hess Grade I and II. They did not develop any focal neurological deficit or hydrocephalus postoperatively. The patients were tested in 2-time points: 15 and 45 days after microsurgery with a battery of tests and questioners consisting of the Trail Making Test, the Sustained Attention to Response Task, the Hayling Sentence Completion Test, The Attention/Concentration test of Attention, the Wechsler Adult Intelligence Scale (verbal part). Results between groups were compared (sex, age; years of education and verbal IQ). Results: It was found the presence of lower attention and executive function test scores in the SAH group of patients with a trend of improving during the time. Conclusion: The detailed neuropsychological assessment of operated patients who sustained SAH and were without the focal neurological deficit postoperatively, showed declination in their attention and executive function with a trend of cognitive recovery as time passes by.
  1,727 1,289 -
The AOSpine thoracolumbar spine injury classification system: A reliability and agreement study
Parisa Azimi, Hassan Reza Mohammadi, Shirzad Azhari, Pooyan Alizadeh, Ali Montazeri
October-December 2015, 10(4):282-285
DOI:10.4103/1793-5482.162703  PMID:26425156
Aim: Recently, AOSpine trauma knowledge forum proposed the AOSpine thoracolumbar injury classification (AOSTLIC) system and suggested that it was reliable. However, reliability data from additional institutions for the AOSTLIC system are not available. This study was to examine the reliability of the AOSTLIC system in patients with thoracolumbar (TL) fractures. Materials and Methods: Between August 2009 and June 2012, 56 patients with 74 levels traumatic TL spinal injuries were recruited. Two classifiers, consisting of two spine surgeons, assessed clinical and imaging data. Initially, one surgeon reviewed the data in order to classify and calculate injury severity score according to the AOSTSIC system. This process was repeated on a 5-week interval by another surgeon. Then we analyzed data for intra-observer and inter-observer reliability using the kappa statistic (k). Finally, validity was assessed using the known-groups comparison. Results: The mean age of patients was 59.5 ± 11.5 years. The k values for the AOSTSIC system for intra-observer and inter-observer reliability ranged from 0.83 to 0.89, indicating nearly perfect agreement agreements. Known-groups analysis showed satisfactory results. The AOSTSIC system discriminated well between sub-groups of patients who differed in Oswestry disability index. Conclusion: The findings showed that the morphologic classification in AOSTSIC system appears to be reliable and reproducible classification.
  2,233 369 7
CASE REPORTS
Giant hydatid cyst in the posterior fossa of a child
Fakhr Fakhouri, Abdelwahed Ghajar, Nihad Mahli, Nihad Shoumal
October-December 2015, 10(4):322-324
DOI:10.4103/1793-5482.162719  PMID:26425166
The hydatid cyst (HC) is endemic in Mediterranean region including Syria. The central nervous system is involved in 2-3% of cases. HC in cerebellum is very rare. We report a case that presented as an emergency for high intracranial pressure and deteriorating Glascow coma scale. Close monitoring and precise surgical management using Dowling's technique resulted in very good outcome with full recovery. We highlight the need for very careful surgical treatment because cyst rupture and secondary hydatidosis due to spillage of the cyst contents can dramatically worsen the outcome. HC should be taken into consideration in countries where hydatid infestation is endemic.
  2,349 180 2
ORIGINAL ARTICLES
Safe and accurate placement of thoracic and thoracolumbar percutaneous pedicle screws without image-navigation
Shahid M Nimjee, Isaac O Karikari, AB Carolyn A. Hardin, Jonathan Choi, Ciaran J Powers, Christopher R Brown, Robert E Isaacs
October-December 2015, 10(4):272-275
DOI:10.4103/1793-5482.162700  PMID:26425154
Background: Percutaneous pedicle screw placement is now commonly used to treat spinal instability. It is imperative, especially at thoracic levels, to avoid damage to adjacent neurovascular structures. Although more technically demanding when compared with the lumbar spine, we believe that the percutaneous placement of thoracic pedicle screws can be performed safely without image-navigation. Purpose: The purpose was to evaluate the safety of percutaneous pedicle screw placement in the thoracic and thoracolumbar spine without image-navigation. Study Design / Setting: A retrospective study at a single institution. Patient Sample: Patients over the age of 18 years who presented with degenerative disease, trauma or tumor that required surgical stabilization. Outcome Measures: Our outcomes included postoperative plain film X-rays and computerized tomography (CT). Materials and Methods: We performed a retrospective study of patients who underwent percutaneous pedicle screw placement without image-navigation between T2 and L2. Results: Between 2005 and 2011, a total of 507 pedicle screws were placed in 120 patients. The indications included trauma (17%), tumor (8%), and degenerative conditions (75%). The mean age was 61.3 years (range: 20-81 years). Fifty-seven percent were male, and 43% were female. The mean blood loss was 297 ± 40 ml. All patients underwent postoperative anterior-posterior and lateral films that showed safe placement of pedicle screws. Moreover, 57% of patients underwent postoperative CT imaging. There was 1 (0.4%) medial breach and 13 (5%) lateral breaches of the pedicle screw patients who underwent CT imaging as read by an independent neuroradiologist. None of the breaches resulted in adverse neurological sequelae either immediately after or at most recent follow-up. Conclusion: Thoracic and thoracolumbar percutaneous pedicle screw placement can be performed safely and accurately without image-navigation.
  1,946 582 1
Multiple glioblastomas: Are they different from their solitary counterparts?
Gajendra Singh, Anant Mehrotra, Jayesh Sardhara, Kuntal K Das, Janmejay Jamdar, Lily Pal, Arun K Srivastava, Rabi N Sahu, Awadhesh K Jaiswal, Sanjay Behari
October-December 2015, 10(4):266-271
DOI:10.4103/1793-5482.162685  PMID:26425153
Context: Multiple glioblastomas (GBMs) have a reported incidence of 2-20%. Aims: We intend to study these subsets of GBMs to know whether these are similar to their solitary counterparts. Setting and Design: A retrospective study. Materials and Methods: We analyzed 7 cases of biopsy-proven multiple GBMs. Multiple GBMs were described if there were >1 lesion which was at least 1 cm apart. The clinical data, radiological features, histopathological and immunohistochemical analysis and follow-up were recorded. Results: The mean age was 45 years (range 17-69 years). All cases presented with features of raised intracranial pressure (ICP). Totally, 3 cases presented with hemiparesis and 2 cases with altered sensorium and generalized tonic clonic seizures each. The median Karnofsky performance status (KPS) was 50. Mean duration of symptoms was 40 days. All lesions were contrast enhancing (2 with homogenous enhancement and 5 had ring enhancement). Total excision of the lesion causing mass effect was done in all cases. Histopathologically, small cells were significantly present in 4 cases, and satellitosis was seen in 5 cases. Glial fibrillary acidic protein (GFAP) was absent in all cases in which small cells were significant. In these 4 cases, the proliferation index ranged from 40% to 95%. Totally, 3 patients died within 2 months of surgery, whereas remaining 4 patients underwent chemo-radiotherapy. Conclusions: We conclude that the cases usually present with features of raised ICP and poor KPS. Histopathologically these lesions show significant small cell population, satellitosis, and GFAP negativity.
  1,714 399 4
Spinal tumors: Trends from Northern India
Rajnish Kumar Arora, Raj Kumar
October-December 2015, 10(4):291-297
DOI:10.4103/1793-5482.162707  PMID:26425159
Introduction and Methods: We retrospectively analyzed 111 patients with spinal tumors operated over a period of 9 years to observe the relative frequency of different lesions, their clinical profile, functional outcome and prognostic factors. 30/111 (27%) were extradural, 40/111 (36.1%) were intradural extramedullary (IDEM) and 41/111 (36.9%) were intramedullary spinal cord tumors (IMSCTs). Mean age at surgery was 30.81 years (range 1-73 years). The average preoperative duration of symptoms was 16.17 months (15 days to 15 years). Major diagnoses were ependymomas and astrocytomas in IMSCT group, schwanommas and neurofibromas in IDEM group, and metastasis, lymphoma in extradural group. The common clinical features were motor weakness in 78/111 (70.27%), sensory loss in 55/111 (49.54%), pain 46/111 (41.44%), and sphincter involvement in 47/111 (42.43%) cases. Results: Totally, 88/111 (79.27%) patients had improvement in their functional status, 17/111 (15.31%) remained same, and 6/111 (5.4%) were worse at time of their last follow-up. The mean follow-up was 15.64 months (1.5 m−10 years). Totally, 59 out of 79 patients, who were dependent initially, were ambulatory with or without the aid. Most common complication was persistent pain in 10/111 (9%) patients and nonimprovement of bladder/bowel symptoms in 7/111 (6.3%). One patient died 3 months after surgery. Conclusions: (1) Congenital malformative tumors like epidermoids/dermoids (unrelated to spina bifida) occur more frequently, whereas the incidence of spinal meningioma is less in developing countries than western populations. (2) The incidence of intramedullary tumors approaches to that of IDEM tumors. Intramedullary tumors present at a younger age in developing countries. (3) Rare histological variants like primitive neuroectodermal tumors should also be considered for histological differential diagnosis of spinal tumors. (4) Preoperative neurologic status is the most important factor related to outcome in spinal tumors.
  1,780 267 1
Clinical profile and outcomes in brainstem glioma: An institutional experience
Pavan Kumar Lachi, Monica Irrakula, Syed Fayaz Ahmed, Deepa Joseph, Suresh Pamidighantam, Kotiyala V Jagannath Rao Naidu
October-December 2015, 10(4):298-302
DOI:10.4103/1793-5482.162709  PMID:26425160
Aim of the Study: This study was to analyze the clinical outcomes of brain stem glioma treated with radiation therapy (RT) in our institution. Material and Methods: Records of 48 patients with brainstem glioma treated between January 2007 and January 2013 were reviewed. Demographic variables, clinical variables, radiological findings and treatment details with respect to age, sex, location of tumor ( pontine Vs non pontine ), signs and symptoms, RT dose, follow up period and outcomes were recorded. Patients were subdivided into two groups based on their age, age <15 years (Group I) and age >=15 yrs (Group II). Results: The median age at diagnosis was 10 years (range 4-50). Male to female ratio was 11:10. Of the 48 cases analyzed, 27 patients (56%) were in group I and 21 (44%) were in group II. Radiologically, 90.5% had involvement of pons. 10 (21%) patients received RT dose >60 Gy and 38 (79 %) patients received RT dose of 54-60 Gy. Median overall survival was 7months (range 3-44 months). Median overall survival in Group I and Group II was 4 months and 10 months respectively (P = 0.042). Conclusions: Brain stem glioma in pediatric age group is associated with worse outcomes than in adults.
  1,676 229 7
CASE REPORTS
Spinal neural fibrolipoma: A case report and review of the literature
Cigdem Tokyol, Adem Aslan, Güler Senyildiz Hastürk, Emre Kacar, Mehmet Gazi Boyaci
October-December 2015, 10(4):341-343
DOI:10.4103/1793-5482.162727  PMID:26425172
Neural fibrolipoma is characterized by infiltration of the epineurium by adipose and fibrous tissue. Intradural spinal cases are extremely rare. We report an unusual case of spinal neural fibrolipoma. A 31-year-old pregnant woman presented due to weakness of right leg (muscle strength 2/5). Magnetic resonance (MR) evaluation of the spine revealed an extramedullary intradural mass at the T1-T4 level. MR findings were suggesting a dermoid cyst or a lipoma. Subtotal surgical excision of the tumor was done. Histopathological examination showed enlarged nerve bundles infiltrated by fibroadipose tissue. Thus, the diagnosis of neural fibrolipoma was established. One month after surgery, lumbar MR showed residual tumor tissue, but successful decompression of the spinal cord. Six months after surgery, the neurological examination, muscle strength 4/5 evaluated. Neural fibrolipoma is characterized by infiltration of the epineurium by adipose and fibrous tissue. The tissue grows between and around nerve bundles thereby causing enlargement of the affected nerve. Neural fibrolipoma is a benign lesion with no effective therapy. Surgical excision usually causes severe damage of the involved nerve. Although spinal cases are extremely rare, it should be included in the differential diagnosis of extramedullary intradural masses.
  1,574 201 2
Enigmatic intracranial cyst causing diplopia and trigeminal neuralgia
Pavan Kumar Pelluru, Alugolu Rajesh
October-December 2015, 10(4):316-318
DOI:10.4103/1793-5482.162717  PMID:26425164
Chronic compression by intracranial cystic lesions can cause cranial nerve palsies and bony changes. With the advent of imaging techniques, grossly accurate diagnosis is possible. However, few cases do surprise the clinicians both intra, and postoperatively. A 27-year-old male presented to us with complaints of double vision for 4 months followed by sharp, shooting pain in the left V1 and V2 distribution for 1-month duration, on examination, he had left lateral palsy and decreased pin prick and temperature sensation in V1 distribution. On computed tomography scan, a cystic lesion noted which is isodense in the middle cranial fossa with erosion of the underlying bone. On magnetic resonance imaging lesion was iso to hyperintense on T1-Weighted and hyperintense on T2-Weighted, brilliantly enhancing on contrast administration. Provisional diagnosis was trigeminal schwannoma, left temporal craniotomy and total excision of the cyst done. Histopathological examination showed cyst wall lined with collagen. Postoperatively patient neuralgic pain subsided with persisting sixth nerve palsy.
  1,608 152 -
"Giant" terminal myelocystocele: A rare variant of spinal dysraphism
Sumit Bansal, Ashok Kumar Mahapatra
October-December 2015, 10(4):350-352
DOI:10.4103/1793-5482.162730  PMID:26425175
Terminal myelocystocele (TMC) is a rare form of spinal dysraphism. They constitute approximately 5% of skin covered lumbosacral masses. The TMC is composed of a low-lying conus medullaris with cystic dilatation of caudal central canal and a surrounding meningocele that extends from the conus to the skin. A 2-year-old female child presented with a large lumbosacral mass and weakness of both lower limbs since birth. Magnetic resonance imaging revealed a giant TMC. The child was operated on successfully. This is an interesting and rare case of "giant" TMC with partial sacral agenesis.
  1,537 178 2
Rare occurrence of intracranial epidermoid tumor in an unusual location with atypical radiological features
Hrishikesh Sarkar, G Vijaya, Suresh Mitta
October-December 2015, 10(4):319-321
DOI:10.4103/1793-5482.162718  PMID:26425165
Intracranial epidermoid tumors are benign rare tumors that arise due to dysembryogenesis. Thought rare, they have characteristic radiological features such as their magnetic resonance imaging signal intensities and a typical location. We present a rare case of intracranial epidermoid tumor in a young female patient that was unusually located within the left frontal lobe and had certain atypical radiological findings. Preoperatively, this lesion was erroneously presumed to be a low grade glioma or a dermoid. Therefore, this case report prompts us to include atypical epidermoid cyst in the list of differential diagnosis for nonenhancing lobar tumors.
  1,507 165 1
Ruptured concomitant dermoid cysts of conus medullaris and cervico medullary junction
Adhithyan Rajendran, Babupeter Sathyanathan, Vanitha Krishnamoorthy, Balaji Ayyam Perumal, Iyengaran Srihari
October-December 2015, 10(4):313-315
DOI:10.4103/1793-5482.162716  PMID:26425163
Cranio spinal dermoid tumors are rare, benign, slow growing congenital, cystic uni or multi locular tumors, which arise from the inclusion of epithelial tissue within the neural grove during embryonic development . [1] In this case report, we present an uncommon presentation, of a case of concomitant dermoid cysts at conus medullaris and cervico medullary junction that ruptured into the central canal.
  1,489 141 -
ORIGINAL ARTICLES
The long-term efficacy of pedicular screw fixation at patients suffering from thoracolumbar burst fractures without neurological deficit
Seyed Amirhossein Javadi, Fereshteh Naderi
October-December 2015, 10(4):286-289
DOI:10.4103/1793-5482.162704  PMID:26425157
Objectives: Treatment of choice at stable burst fracture is still a matter of debate. The aim of this study is assessment of health-related quality of life (HRQOL) regarding short form-36 (SF-36) and its correlation with kyphosis in patients affected by thoracolumbar burst fracture without neurological deficit undergoing posterior short segment pedicular screw fixation. Materials and Methods: Twenty patients with thoracolumbar burst fractures without neurological deficits, meeting our criteria were enrolled in this study. The patients underwent short segment pedicular screw fixation. After 2 years of follow-up, the outcome assessment was performed with evaluating HRQOL; SF-36. The mean ± standard deviation was measured at each eight category of SF-36 and compared with normative values of Iran. The correlation of Cobb angle and body pain was analyzed by linear regression. Results: The study detected reduced quality of life (QOL), with total mean of 49.7 ± 14 and physical function grade of 61.2 ± 22 which was significantly lower than Iran normative reported as 85.9 ± 19. Fifty percent still suffered from moderate to severe pain and Cobb angle had no statistically significant correlation with body pain. Conclusions: It seems that surgical treatment could not improve pain related disability of patients with stable thoracolumbar burst fracture at long term follow up.
  1,371 244 1
CASE REPORTS
The unusual angiographic course of intracranial pseudoaneurysms
Mario Zanaty, Nohra Chalouhi, Pascal Jabbour, Robert M Starke, David Hasan
October-December 2015, 10(4):327-330
DOI:10.4103/1793-5482.162721  PMID:26425168
Although rare, traumatic intracranial pseudoaneurysms remain one of the most difficult vascular lesions to diagnose and treat. A 55-year-old male patient underwent endoscopic endonasal transphenoidal resection for a pituitary macroadenoma. The operation was complicated by an arterial bleed. The initial angiogram revealed pseudoaneurysm of the anterior choroidal artery. Although the pseudoaneurysm completely disappeared on the second angiogram, it was surprisingly found to have enlarged on the third angiogram. The lesion was successfully treated with flow-diversion using a pipeline embolization device. The present case demonstrates that the natural history of iatrogenic pseudoaneurysms may be unpredictable and misleading. Traumatic pseudoaneurysms should, therefore, be carefully followed when conservative treatment is elected or when the lesion seems to have spontaneously regressed. Flow-diversion seems to be a reasonable treatment option.
  1,450 149 5
Multiple meningiomas consisting of fibrous meningioma, transitional meningioma, and meningotheliomatous meningioma in one adult patient
Farid Yudoyono, Roland Sidabutar, Muhammad Zafrullah Arifin, Ahmad Faried
October-December 2015, 10(4):348-349
DOI:10.4103/1793-5482.162729  PMID:26425174
Multiple histopathology of meningioma is a condition in which the patient has more than one histopathology feature of meningioma in different intracranial locations, with or without sign of neurofibromatosis. Meningiomas are the most common, non-glial, primitive intracranial tumors; their prevalence among operated tumors is around 13-19%. They may occur at any age, but have a peak incidence around 45 years of age. The incidence of multiple intracranial meningiomas varies from 1% to 10% in different series, and the frequency of multiple meningiomas without neurofibromatosis was reported to be <3%.
  1,403 195 2
Enchondroma of the cervical spine in young woman: A rare case report
Dong Mun Jeong, Sung Hwa Paeng
October-December 2015, 10(4):334-337
DOI:10.4103/1793-5482.162725  PMID:26425170
Enchondroma is a type of benign cartilaginous bone tumor. Enchondroma of the spine is very rare. There are only a few cases of enchondromas located in the lamina of the cervical spine have been reported. Therefore, we report a case of enchondroma in the cervical spine. A 24-year-old female patient presented with a history of neck pain, restriction of neck movement, pain and numbness along the right scapula, and weakness accompanied by wasting of the right hand. Presumptive diagnoses included bony tumors such as an aneurysmal bone cyst or a giant cell tumor. Radiologic examinations revealed a round tumor in the right lamina of C4 with extracortical extension and foramen of C4-5. C4 right hemilaminectomy and facetectomy were performed with near complete removal of the tumor. On histological examination, the tumor was confirmed to be an enchondroma. At the 6-month follow-up, a computed tomography scan showed no recurrence with good alignment.
  1,442 148 2
ORIGINAL ARTICLES
Extracranial to intracranial by-pass anastomosis: Review of our preliminary experience from a low volume center in Egypt
Arundhati Biswas, A EL Samadoni, Ahmed Elbassiouny, Khaled Sobh, Ahmed Hegazy
October-December 2015, 10(4):303-309
DOI:10.4103/1793-5482.162711  PMID:26425161
Background: Cerebral revascularization is a useful microsurgical technique for the treatment of steno-occlusive intracranial ischemic disease, complex intracranial aneurysms that require deliberate occlusion of a parent artery and invasive skull base tumors. We describe our preliminary experience with extracranial-to-intracranial by-passes at a low volume center; and discuss clinical indications and microsurgical techniques, challenges in comparison to large advanced referral centers. Materials and Methods: Twenty-seven patients with hemodynamic ischemia or complex aneurysms or skull base tumors were operated at Cairo University Hospitals in the period between May 2009 and June 2014. All patients operated by a low flow by-pass were operated through a superficial temporal artery to middle cerebral artery (MCA) anastomosis. All patients chosen for a high flow by-pass were operated using a radial artery graft interposed between the MCAs distally and the common or the external carotid artery proximally. Patency was confirmed at the end of surgery using appearance on the table and confirmed after surgery by transcranial color-coded duplex or computed tomography angiography. All patient data were prospectively collected and retrospectively analyzed at the end of surgery. Results: Nineteen patients (70.4%) were operated upon for flow augmentation and eight patients (29.6%) were operated upon for flow replacement. A total of 30 anastomoses were performed. All except one were patent which gives a patency rate of 96.3%. There was one death in the present series resulting from a hyperperfusion syndrome. 89.5% of patients with hemodynamic ischemia stopped having symptoms after surgery. All but one patient operated for hemodynamic ischemia showed a considerable cognitive improvement after surgery. None of the patients operated upon for flow replacement showed improvement of oculomotor nerve function in spite of adequate intraoperative decompression. All patients treated for flow replacement showed the absence of recurrence on follow-up. Conclusion: Our initial results for both low and high flow by-pass procedures in our low volume center indicate that such complex surgical procedures are possible with results comparable to those obtained in other larger referral centers throughout the world. This procedure not only represents a more definitive treatment when compared to other endovascular or radiation treatments but is also much less costly when compared to other treatment modalities.
  1,412 171 3
CASE REPORTS
A case of early extraneural medulloblastoma metastases in a young adult
Slavomir Iliev Kondoff, Milko Dimitrov Milev, Lili Naskova Laleva, Christo Christov Tzekov, Christina Petrova Kostadinova, Galina Ivanova Kirova-Nedyalkova, Polina Danailova Dakova
October-December 2015, 10(4):331-333
DOI:10.4103/1793-5482.162723  PMID:26425169
Extraneural metastases are a relatively rare manifestation of the primary brain tumors, and a major part of the cases has been associated with initial medulloblastoma. Herein, we present the case of a young female adult diagnosed and operated for medulloblastoma. The patient developed extraneural metastases in the first postoperative year. The condition exhibited an aggressive course of development, and the applied treatment approaches were unable to halt its progression. A short literature review identifies the predictive factors determining both prognosis and treatability of the condition; the current limitations and future perspectives of the treatment options are discussed.
  1,398 172 5
Incidental frontal lobe mixed density epidermoid tumor in a patient of head injury: A rare case report
Pankaj Gupta, Radheyshyam Mittal, Ashok Gandhi, Achal Sharma, Sapna Gandhi
October-December 2015, 10(4):338-340
DOI:10.4103/1793-5482.162726  PMID:26425171
The incidence of the epidermoid tumor is approximately 0.2-1.8% of all intracranial tumors. Epidermoid tumors are typically intradural, but extra-axial in location and only rarely found within the brain substance. We are reporting the first case of incidental mixed density frontal epidermoid tumor in a patient of head injury. Difficulty in the preoperative diagnosis and uncommon presentation of the intracranial epidermoid tumor prompted us to report this case.
  1,375 168 -
Treatment of arteriovenous malformation with high-flow fistula and bilateral transverse-sigmoid sinuses stenosis resulting diffuse cortical vein engorgement and symptoms resembling carotid-cavernous fistula
Kuo-Wei Chen, I-Chang Su, Jing-Er Lee, Hon-Man Liu
October-December 2015, 10(4):310-312
DOI:10.4103/1793-5482.162715  PMID:26425162
Patients harboring arteriovenous malformations (AVMs) may present with focal neurological deficit, seizures, hemorrhage or be completely asymptomatic. This diversity in manifestation of AVM is related to the individual characteristics of AVMs such as size, location, configuration of feeding arteries, and drainage veins. Treating the AVMs with high-flow fistula and downstream sinuses occlusion is challenging. The authors reported their experience of treating this kind of AVM. The high venous pressure caused diffuse cortical venous regurgitation and engorgement of left superior ophthalmic vein and symptoms resembling carotid-venous fistula. To avoid possible reflux of embolization materials to cortical veins and facilitate surgical treatment, the bilateral transverse sinuses were re-canalized first. The venous pressure was measured through left transverse sinus, and it decreased significantly from 50 mmHg to 20 mmHg after bilateral sinus stenting. The AVM was then embolized and excised uneventfully.
  1,345 195 3
LETTER TO EDITOR
Rhabdoid meningioma in the petroclival region: An atypical meningioma in an atypical site
KA Kawsar, MR Haque, FH Chowdhury
October-December 2015, 10(4):325-326
DOI:10.4103/1793-5482.162720  PMID:26425167
  1,074 122 -
ORIGINAL ARTICLES
Commentary
A Amirjamshidi
October-December 2015, 10(4):289-290
  857 69 -
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