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   2018| October-December  | Volume 13 | Issue 4  
    Online since October 23, 2018

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A comprehensive review of skull base osteomyelitis: Diagnostic and therapeutic challenges among various presentations
Muhammad Adnan Khan, Syed Abdul Qader Quadri, Abdulmuqueeth Syed Kazmi, Vishal Kwatra, Anirudh Ramachandran, Aaron Gustin, Mudassir Farooqui, Sajid Sattar Suriya, Atif Zafar
October-December 2018, 13(4):959-970
DOI:10.4103/ajns.AJNS_90_17  PMID:30459850
Skull base osteomyelitis (SBO) is a complex and fatal clinical entity that is often misdiagnosed for malignancy. SBO is commonly a direct complication of otogenic, sinogenic, odontogenic, and rhinogenic infections and can present as central, atypical, or pediatric clival SBO. This review describes the clinical profi le, investigational approach, and management techniques for these variants. A comprehensive literature review was performed in PubMed, MEDLINE, Research Gate, EMBASE, Wiley Online Library, and various Neurosurgical and Neurology journals with the keywords including: SBO, central or atypical SBO, fungal osteomyelitis, malignant otitis externa, temporal bone osteomyelitis, and clival osteomyelitis. Each manuscript's reference list was reviewed for potentially relevant articles. The search yielded a total of 153 articles. It was found that with early and aggressive culture guided long-term intravenous broad-spectrum antibiotic therapy decreases post-infection complications. In cases of widespread soft tissue involvement, an early aggressive surgical removal of infectious sequestra with preferentially Hyperbaric Oxygen (HBO) therapy is associated with better prognosis of disease, less neurologic sequelae and mortality rate. Complete resolution of the SBO cases may take several months. Since early treatment can improve mortality rates, it is paramount that the reporting radiologists and treating clinicians are aware of the cardinal diagnostic signs to improve clinical outcomes of the disease. It will decrease delayed diagnosis and under treatment of the condition. However, due to rarity of the condition, complete prognostic factors have not fully been analyzed and discussed in the literature.
  4,686 704 3
The role of medical treatment in chronic subdural hematoma
Amit Kumar Thotakura, Nageswara Rao Marabathina
October-December 2018, 13(4):976-983
DOI:10.4103/ajns.AJNS_13_17  PMID:30459852
Surgery is the standard treatment for chronic subdural hematoma (CSDH), one of the common problems in neurosurgical practice. Although medical treatment was used by some authors and found some positive results, it is not accepted by many authors. The aim of this review is to give overall view of the medical management of CSDH. Action of various drugs in the pathophysiological cascade of formation of CSDH was depicted. The review of literature is done under three headings – the primary medical treatment of CSDH, adjuvant medical treatment with surgery, and the treatment of the recurrence. Various classifications of CSDH and the factors influencing the outcome of medical treatment are discussed. There is a role of medical treatment in a selected group of patients with CSDH. Well-designed, multicenter, randomized controlled trials are required to define the indications and standard protocols for the medical treatment of CSDH.
  1,648 368 -
Role of hypertonic sodium lactate in traumatic brain injury management
Muhammad Reza Arifianto, Achmad Zuhro Ma'ruf, Arie Ibrahim, Abdul Hafid Bajamal
October-December 2018, 13(4):971-975
DOI:10.4103/ajns.AJNS_10_17  PMID:30459851
Traumatic brain injury (TBI) following increased intracranial pressure (ICP) is a neuroemergency case which should be managed promptly to prevent secondary brain injury. This will lead to a condition called cerebral energy dysfunction which is an important determinant factor toward worse outcome. Lactate, which was historically known as an end waste product, now is considered as an alternative cerebral energetic fuel. Hypertonic sodium lactate (HSL) is a promising hyperosmolar fluid which serves not only to decrease ICP but also to readily supply exogenous lactate to fulfill increased cerebral energy demand. Pioneer studies have shown the harmlessness and usefulness of HSL in treating pathological condition including TBI.
  1,395 323 -
Frequency of ischemic stroke subtypes based on toast classification at a tertiary care center in Pakistan
Faleha Zafar, Waseem Tariq, Raja Farhat Shoaib, Ahmed Shah, Maimoona Siddique, Abdullah Zaki, Salman Assad
October-December 2018, 13(4):984-989
DOI:10.4103/ajns.AJNS_365_16  PMID:30459853
Background: The purpose of this study was to determine the frequency of ischemic stroke subtypes based on Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification at a tertiary care center in Pakistan. Materials and Methods: Across-sectional study was conducted in Stroke Unit of Shifa International Hospital, Islamabad. We included 145 patients who presented to us from November 2015 to February 2016 with radiological confirmed neurological deficits consistent with ischemic stroke. The causes of ischemic stroke were classified according to TOAST criteria. Regression analysis and Chi-square test were used to compute P value. Results: Among the 145 patients diagnosed with ischemic stroke, there were 54.1% males and 45.9% females with a mean age of 65 ± 14 years. Nearly 62.7% patients had hypertension (HTN) as the most common risk factor, followed by 38.6% diabetes mellitus (DM), 27.5% heart failure, 19.3% valvular disease, 18.6% previous stroke, 16.4% smoking, 15.1% dyslipidemia, 13.7% ischemic heart disease, and 13.1% atrial fibrillation. HTN was significantly associated with large vessel disease (P = 0.028). DM was significantly associated with small vessel disease (P = 0.001). Smoking and atrial fibrillation both were associated with unknown etiology of stroke (P = 0.001 and P = 0.039, respectively). Most common etiology of stroke was cardioembolism (40%), and atrial fibrillation is found to be the most common cause of cardioembolic stroke with 30.6% incidence. Conclusion: Our study concludes that cardioembolic stroke is the most common cause of acute ischemic stroke in our stroke unit. Atrial fibrillation is found to be the most common cause of cardioembolic stroke.
  1,323 181 -
Spinal–epidural abscess presenting as an acute abdomen in a child: A case report and review of the literature
Fakhr Fakhouri, Ahmad Ghazal, Hasnaa Alnaeb, Rasha Hezan, Joudi Araj
October-December 2018, 13(4):1247-1249
DOI:10.4103/ajns.AJNS_177_17  PMID:30459907
Abdominal presentations in patients with spinal–epidural abscess (SEA) are not uncommon. However, it needs to be continually emphasized that the atypical presentations of these diseases could delay the timely diagnosis and consequently prompt management, which threatens spinal cord, leading to potential to paralysis or even death. We report a case of a young girl who presented with abdominal pain and fever. The diagnosis of SEA was unfortunately so delayed that the patient did not show any functional recovery postoperatively. This report aims to highlight the importance of high level of clinical suspicion to recognize an atypical presentation of the SEA. Moreover, the fully detailed history-taking and physical examination are of paramount importance. Spinal underlying pathologies should always be considered as a cause of abdominal pain, especially in children.
  1,343 83 -
Using of the chicken wing's bone in the microneusurgical training model for microdrilling
Cengiz Cokluk
October-December 2018, 13(4):990-994
DOI:10.4103/ajns.AJNS_372_16  PMID:30459854
Background and Objective: Repetitive practicing of microneurosurgical techniques in experimental laboratory using real surgical instruments on training models is extremely important before starting the real surgical interventions. The modeling of the surgical steps with creating of suitable laboratory models is also another important issue in the successfully gaining of microneurosurgical practice. Materials and Methods: In this experimental study, it was created a laboratory training model for microneurosurgical drilling of cranial bones including the close location with the neural and vascular structures. All steps of this study were performed under the operating microscope. Twenty-five fresh chicken wings obtained from supermarket were used for this study. The difficulty and suitability of the model was evaluated in terms of the usability in the training of microneruosurgical microdrilling. Difficulty of the procedure was divided as three degree (very easy, easy, and difficult). The objective criterion for the evaluation of the difficulty of the procedure was the protection of the neurovascular and muscular structures during the procedure. Results: The suitability of the procedure was also evaluated within three groups as bad, good, and perfect. In four (16%) chicken wing's bone, the difficulty of the microdirilling was evaluated as difficult. Fifteen (60%) of the chicken wing's bones were microsurgically drilled with easy procedure. The remaining six (24%) of the wing's bone microdrilling was evaluated as very easy procedure. The suitability of the model was evaluated as bad in three (12%) of the chicken wing's bone. The suitability was found as good in 16 (64%) of the bones. In the remaining three (24%) of the chicken wing's bone microdrilling, the suitability of the model was evaluated as perfect. Conclusion: Microsurgical drilling of the chicken wing's bone without any vascular and muscular injury is accepted as the indication of the successfully surgical microdrilling process. Consolidation of the surgical practice in a laboratory setting, grasping and using of microsurgical instruments, can be repeated in several times in this model. We believe that this model will contribute to the practical training of microneurosurgery.
  1,004 167 -
Intradural disc a diagnostic dilemma: Case series and review of literature
Ayush Sharma, Vijay Singh, Gururaj Sangondimath, Prashant Kamble
October-December 2018, 13(4):1033-1036
DOI:10.4103/ajns.AJNS_55_17  PMID:30459862
Introduction: We present a case series of six cases of intradural disc herniation at L4–L5 level diagnosed on the basis of intraoperative findings. Result: All our cases, on preoperative magnetic resonance imaging (MRI) were reported as having diffuse annular bulge with large posterocentral extrusion. Our study comprised patients in age group of 30–60 years. Four cases out of six presented with cauda equina syndrome. In three cases, cauda equina was associated with sudden deterioration in the power of lower limb muscle groups. Discussion: We suspect that intradural herniation of disc was synchronous with cauda equina syndrome in these cases, which was very well documented in one of the cases. On retrospective analysis, MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign were suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. The presence of hypointense structure inside the dura with no continuity with the adjacent intervertebral disc on MRI was highly suggestive of an intradural disc. Conclusion: Intradural disc prolapse remains a diagnostic dilemma as it is very difficult to diagnose all the cases preoperatively. The presence of above-mentioned radiological signs on MRI in patients having the large central disc on MRI, especially at L4–L5 levels, should raise suspicion of intradural herniation of disc.
  1,049 122 -
Comparison of phenytoin versus levetiracetam in early seizure prophylaxis after traumatic brain injury, at a tertiary care hospital in Karachi, Pakistan
Syed Muneeb Younus, Saqib Basar, Sheraz Ahmed Gauri, Ateeq Ahmed Khan, Muhammad Imran, Saadia Abubakar, Daniya Sheikh, Naila Shehbaz, Junaid Ashraf
October-December 2018, 13(4):1096-1100
DOI:10.4103/ajns.AJNS_125_17  PMID:30459875
Aims: The aim of the study was to compare the efficacy of phenytoin and levetiracetam for seizure prophylaxis in patients with severe traumatic brain injury (TBI). Subjects and Methods: A randomized controlled trial was conducted over a period of 6 months, at a tertiary health care center in Karachi, Pakistan. Patients with TBI were divided into two groups. Patients in Group A were given phenytoin, whereas Group B patients received levetiracetam. The first dose of the drugs was given within 24 h of injury and continued for 7 days. Data were collected using a predesigned pro forma. All the patients who were in a state of persistent coma, had altered mental status, or had clinical signs of seizures underwent a 1-h electroencephalographic (EEG) recording to observe the seizures, the first EEG was done on the 1st day posttrauma and a second one was done on day 7 of drug use, both the EEGs were compared for changes. We also analyzed the patients according to their duration of antiepileptic drug therapy, length of hospital stay, and complications during therapy. Results: One hundred and forty (117 males and 23 females) patients who presented with TBI having a mean age of 29.48 ± 16.24 years were part of the study. The most prevalent cause of brain injury was road traffic accidents in 72.85% patients. There was no significant relationship between the antiepileptic drug used with the initial EEG (P = 0.313) and seizure activity (P = 0.502). However, a significant correlation of the antiepileptic drug used was found with EEG (P = 0.002) and seizure activity (P = 0.014) on follow-up. Patients who took levetiracetam had decreased the incidence of abnormal EEG and seizure activity on follow-up. There was not any correlation between GCS both initially (P = 0.845) and on follow-up (P = 0.104) with the antiepileptic drug used. Conclusion: The incidence of abnormal EEGs and seizure activity in patients with TBI is the same for both levetiracetam and phenytoin for the initial 7 days post-TBI; however, the incidence of seizures is lower for patients who used levetiracetam on the subsequent follow-up.
  1,001 164 -
A randomized study comparing endoscopic third ventriculostomy versus ventriculoperitoneal shunt in the management of hydrocephalus due to tuberculous meningitis
Andrew Aranha, Ajay Choudhary, S Bhaskar, LN Gupta
October-December 2018, 13(4):1140-1147
DOI:10.4103/ajns.AJNS_107_18  PMID:30459883
Objectives: The objective of this study was to compare safety and efficacy of endoscopic third ventriculostomy (ETV) versus ventriculoperitoneal (VP) shunt in the treatment of hydrocephalus in tuberculous meningitis (TBM) and to assess clinical and radiological profiles of patients with TBM that would be better suited to either VP shunt or ETV. Methods: This study was a single-center randomized prospective study on 52 patients with TBM hydrocephalus in the pediatric age group (<18 years of age). Patients included in the study were randomized into undergo either VP shunt or ETV. Both groups were followed up for a minimum of 5 months and assessed for success and failure rates as well as procedural complications and neurologic sequelae. Results: Twenty-six patients underwent ETV with a success rate of 65.4% with six of nine failures occurring within the first 16 days after surgery (median time to failure – 3 days). In the VP shunt group, there was a success rate of 61.54% and a median time to failure of 50 days. Modified Vellore grading was found to be a significant factor in determining outcome in both ETV and VP shunt groups with high-grade TBM consistently associated with poor outcome (odds ratio = 4.2). Conclusions: ETV can be performed effectively in young children including infants, as well as those with communicating hydrocephalus, high cerebrospinal fluid (CSF) cell counts, and protein levels with a lower rate of failure than that of VP shunt. Hence, ETV should be attempted as the first-choice CSF diversion procedure in hydrocephalus secondary to TBM where technical expertise and experience with this procedure is available as it avoids the myriad of lifelong complications associated with shunts.
  1,009 138 1
Epidemiology of spinal injury in North East India: A retrospective study
Gyani Jail Singh Birua, Vishnu Singh Munda, Nagendra Nath Murmu
October-December 2018, 13(4):1084-1086
DOI:10.4103/ajns.AJNS_196_17  PMID:30459873
Aim: To find out the epidemiology of spinal injury in North East India. Material and Methods: This study is a retrospective hospital-based analysis of spine injury patients admitted to Central Referral Hospital, Sikkim Manipal University from July 2013 to June 2017July 2013 to June 2017. Results: During the study period 57 patients with spinal injury were admitted and treated. Out of the 57 patients, 46 (81%) were male and 11 (19%) were female. The most common mode of injury was fall from height (59.64%) followed by RTA (35.08%). Most common affected age group in this study was 20-39 years followed by 50-59 years age group. Cervical spine injury was the most common (52.63%) followed by thoracic (19.29%) spine. Most common injury found was fracture dislocation of C5-C6 level. Most common associated injury is head trauma (10.52 %) followed by chest injury and 82.45% cases had no associated trauma. Average period of hospital stay was 22.83 days with maximum period of stay was 111 days. During treatment period one patient died due to respiratory complications. Conclusion: The epidemiology of spinal injuries in Sikkim & North Eastern India is different from rest of the India and other developing countries. In present study most common cause of spine injury was fall from height followed by motor vehicle accidents. RTA was the main cause in younger age group and fall from height was more common in elderly group.
  1,021 114 1
Preemptive Effect of Intraurethral Instillation of Ketamine–lidocaine Gel on Postoperative Catheter-related Bladder Discomfort after Lumbar Spine Surgery
Farhad Etezadi, Yasamin Sajedi, Mohammad Reza Khajavi, Reza Shariat Moharari, Abbas Amirjamshidi
October-December 2018, 13(4):1057-1060
DOI:10.4103/ajns.AJNS_314_17  PMID:30459867
Background: Catheter-related bladder discomfort (CRBD) is one of the main reasons of agitation after surgery, leading to urgency and frequency during recovery. Ketamine has been used as an effective drug for reducing the signs and severity of this problem. We hypothesized that intraurethral instillation of ketamine–lidocaine gel before urinary catheterization can reduce the incidence of CRBD in the postoperative period. Materials and Methods: A total of 136 male patients, who underwent two-level laminectomy/discectomy were enrolled in this randomized clinical trial. Patients were randomized into the two groups before urinary catheterization. The ketamine group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL (100 mg) ketamine. Patients in control group received urethral lubrication with 5 mL xylocaine jelly (2%) in conjunction with 2 mL distilled water. The primary outcome was the incidence of CRBD. CRBD was assessed using four-stage criteria when arriving in the recovery room and at 1, 2, and 6 h after surgery. Postsurgical pain and the number of sedatives given and opioid requirement were also the secondary outcomes in this study. Results: Intraurethral instillation of ketamine–lidocaine gel reduced the incidence of CRBD at recovery (P < 0.001) along with a reduction in the severity of CRBD (P < 0.05) during the 1st and 2nd visit compared with control group. The mean pain intensity score (visual analog scale) and opioid requirement to relieve postsurgical pain were lower in the ketamine group during all the study timepoints from recovery and after transfer to the ward (P < 0.008). A higher rate of sedation (72% vs. 11%) also was seen at recovery period in the ketamine group (P < 0.008). Conclusion: Intraurethral instillation of ketamine–lidocaine gel before bladder catheterization is an effective technique for reducing the incidence and severity of postoperative CRBD.
  993 138 -
Cochlear implant device failure in the postoperative period: An institutional analysis
Simple Ravikumar Bhadania, Rajesh Vishwakarma, Amit Keshri
October-December 2018, 13(4):1066-1070
DOI:10.4103/ajns.AJNS_93_17  PMID:30459869
Introduction: As the cochlear implant (CI) surgeries are on rise, there is a compelling need to understand its long-term complications and revision surgery protocols. Our experience in the management of CI devices failure is shared in this paper. Aim: To review the experience in patients who underwent CI device manipulation/explanation in terms of failure rate, etiology, surgical considerations, and preoperative and postoperative auditory and speech outcome. Study Design: This was a retrospective study. Materials and Methods: A retrospective study of 250 patients (201 children and 49 adults) with normal cochlea at a tertiary care center from June 2004 to June 2014 was done. All cases were implanted multichannel devices via Veria technique of CI surgery. Preoperative assessment, surgical considerations, and postoperative auditory and speech outcomes were analyzed. Preoperative and postoperative auditory/speech outcomes were analyzed using Category of Auditory Perception (CAP) and Speech Intelligibility Rating (SIR) scores. Results: Reimplantation rate was 4%. The causes of revision CI surgery were hard device failure (n = 3), surgical site infection (n = 3), magnet displacement (n = 2), and electrode extrusion (n = 2). In one patient, recurrent cutaneous infection on the implanted site ultimately resulted in reimplantation in the opposite ear after multiple surgical interventions on the same side. The preoperative and postoperative CAP and SIR scores showed improvement in the postoperative period with P < 0.05 as compared with the paired t- test. Conclusions: Preoperative counseling for device failure should always be emphasized. The success rate is high in revision surgery with good performance in the postoperative audiological outcome. There is a compelling need for an agreed international definition of CI failure and the adoption of uniform reporting protocols.
  983 92 -
Evaluation of the correlation of magnetic resonance imaging and electrodiagnostic findings in chronic low backache patients
Roop Singh, Sushil Kumar Yadav, Sushma Sood, Rohtas Kumar Yadav, Ravi Rohilla
October-December 2018, 13(4):1078-1083
DOI:10.4103/ajns.AJNS_169_17  PMID:30459872
Background: Low back pain (LBP) is one of the most common medical complaints and leading cause of workforce loss in many countries. Magnetic resonance imaging (MRI) is a highly sensitive method for the detection of lesions in the spine because of its excellent imaging of anatomical detail. However, MRI does not provide information about physiological nerve function and has relatively low specificity. Electrodiagnostic (EDX) study, including needle electromyography (EMG), is a specific test to assess the physiological functions of nerve roots or peripheral nerves. The aim of the present study was to correlate the electrophysiological and MRI findings in chronic low backache patients. Materials and Methods: Fifty patients (26 males and 24 females) with mean age 33.54 ± 8.33 years with a history of LBP of minimum 3 consecutive months were evaluated with MRI and EDX (bilateral nerve conduction study of three nerves [tibial, peroneal, and sural nerve] and bilateral EMG of three muscles [paraspinal, tibialis anterior, vastus medialis]) studies. Results: Twenty-seven patients showed disc involvement on MRI and 23 MRI were normal. Mean conduction velocity was mildly decreased in tibial and sural nerves in all the patients either with normal MRI or disc involvement on MRI. In disc involvement conduction velocity, decrease was more as compared to normal MRI. About 39% patients with normal MRI and 78% patients with disc involvement showed abnormal EMG. This data represented statistically significant association of EDX study with MRI (P < 0.05). Conclusions: In patients with LBP, EDX studies are significantly more correlated with clinical data than MRI. Therefore, EMG may be a useful diagnostic tool to establish management protocols and prevent unnecessary interventions. EDX gives a better representation of physiological status of nerve and muscle, a supra added benefit which MRI lacks. However, MRI gives better visualization of anatomic parameters and structural details which may or may not be associated with chronic LBP.
  941 88 -
Controlled trial to compare therapeutic efficacy of endoscopic third ventriculostomy plus choroid plexus cauterization with ventriculoperitoneal shunt in infants with obstructive hydrocephalus
Amir Amini Navaei, Sara Hanaei, Zohreh Habibi, Morteza Faghih Jouibari, Vahid Heidari, Soheil Naderi, Farideh Nejat
October-December 2018, 13(4):1042-1047
DOI:10.4103/ajns.AJNS_63_17  PMID:30459864
Context: Ventriculoperitoneal (VP) shunt and endoscopic third ventriculostomy (ETV) are the established surgical treatments for obstructive hydrocephalus (HCP). Powerful evidence regarding the best therapeutic approach for infants with obstructive HCP is lacked. Aims: Comparison of the therapeutic efficacy of VP shunt and ETV/choroid plexus cauterization (CPC) in infants with obstructive HCP. Settings and Design: This was a randomized, active control, unblind, single-center, clinical trial. Methods: Infants with obstructive HCP were randomly allocated to each intervention group (ETV/CPC or VP shunt). They were monitored for at least 6 months for any sign of raised intracranial pressure (rICP). The recurrence of rICP signs requiring surgical intervention was considered as intervention failure. Statistical Analysis: The association between intervention group and outcome was tested with Chi-square test, and P = 0.05 or less was considered statistically significant. Results: Of the total fifty patients entering the study, 49 were included in the final analysis, 27 of them were in VP shunt and 22 in ETV/CPC group. Seventeen patients (34%) were female and 33 (66%) were male with mean age of 3.74 ± 3.1 months (range = 10 days – 11 months). Thirty-nine (79.6%) were under 6 months of age and the remaining were 6 months or older. The overall success rate in 36-month follow-up was 88.5% and 68.2% for VP shunt and ETV/CPC, respectively, with the difference being not statistically significant. Conclusion: The current study determined no inferiority of ETV/CPC compared to VP shunt, and therefore, it may become an efficient treatment for obstructive HCP in infants.
  913 81 1
Intramedullary glioblastoma multiforme of spine with intracranial supratentorial metastasis: Progressive disease with a multifocal picture
Abhishek Purkayastha, Neelam Sharma, Madakasira Sitaram Sridhar, Dwivedi Abhishek
October-December 2018, 13(4):1209-1212
DOI:10.4103/ajns.AJNS_67_17  PMID:30459896
Primary spinal glioblastoma multiforme (GBM) is very uncommon while an intramedullary spinal GBM with intracranial metastasis is rarely heard of. A 23-year-old male presented with bilateral paraplegia associated with bowel and bladder incontinence. Craniospinal radiograph showed an intramedullary spinal mass lesion, for which he underwent laminectomy and histopathology revealed GBM. He received local radiotherapy (RT) with temozolomide (TMZ). While on adjuvant TMZ, he developed severe headache and recurrent episodes of vomiting. Brain and spine imaging showed intracranial mass lesions associated with expansion of the entire cord. Biopsy from the intracranial lesion was confirmed as GBM on immunohistopathology. He was treated with palliative RT to the brain and was put on metronomic TMZ; however, he succumbed to his illness. Review of literature reveals that our case may be the fourth such case in the world and probably the first case reported in India where the intracranial metastatic GBM again presented with a reverse spinal dissemination.
  935 58 -
Study of fatigue and associated factors in traumatic brain injury and its correlation with insomnia and depression
Sachin Tomar, Achal Sharma, Akhilesh Jain, Virendra Deo Sinha, Ishwar Dayal Gupta
October-December 2018, 13(4):1061-1065
DOI:10.4103/ajns.AJNS_89_17  PMID:30459868
Introduction: Fatigue has been cited as a common problem associated with traumatic brain injury. A positive association of fatigue has been suggested with insomnia and depression which are also considered to be significantly associated with traumatic brain injury. Aims and Objectives: The present study in post-traumatic brain injury patients is planned to assess the prevalence of fatigue, depression and insomnia, the correlation of fatigue with depression and insomnia and the risk factors associated with fatigue. Material and Methodology: Total 100 patients were recruited in the present study. Interview was focused on assessment of severity of traumatic brain injury, fatigue, insomnia and depression using Glasgow Coma Scale, Fatigue Severity Scale, Insomnia Severity Index and Patients Health Questionnaire(PHQ-9) respectively. Results: Prevalence of depression was found 84% while that of fatigue and insomnia was 50% and 49% respectively. All patients with fatigue had depression whereas those patients without fatigue were also found to have depression (68%) and this correlation was found statistically significant. Similarly, insomnia was reported in 70% of patients who were fatigued against 28% of patients with no fatigue. This was also found statistically significant (P <0.0002). Conclusion: Fatigue in common in post TBI patients. Insomnia and depression are closely associated with fatigue. Clinical and research investigations of fatigue in post-traumatic brain injury should include concomitant screening for treatable depressive symptoms and sleep disorders.
  908 81 -
Early surgical outcome of endoscopic third ventriculostomy in the management of obstructive hydrocephalus: A randomized control trial
Mohammad Mahfuzur Rahman, Mohammad Abdus Salam, Kalim Uddin, Mohammad Mizanur Rahman, Mohammad Rafiqul Islam, Mohammad Ashraful Haque, Ahmed Riyad Hussain, Mohammad Abdullah Yusuf
October-December 2018, 13(4):1001-1004
DOI:10.4103/ajns.AJNS_376_16  PMID:30459856
Background: Management of obstructive hydrocephalus is an important issue for the reduction of mortality and morbidity. Objectives: The aim of the present study was to assess the early surgical outcome of endoscopic third ventriculostomy (ETV) in the management of obstructive hydrocephalus. Methodology: This randomized controlled trial was conducted at the Department of Neurosurgery at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from April 2009 to September 2010 for 1½ years. All patients presenting with obstructive hydrocephalus with the obstruction at or distal to the third ventricle and age 6 months and above were included in the study population. All the patients were divided into two groups named as Group A (experimental group) who were treated with ETV and Group B (control group) who were treated with ventriculoperitoneal shunt (VPS). The early surgical outcome was defined as outcomes within 1 month following surgical interventions. Pre- and post-operative outcomes of this study were measured. Results: A total number of sixty patients were recruited from which thirty patients were in Group A and the rest thirty patients were in Group B. The mean postoperative head circumference was 43.4 ± 7.1 cm and 47.8 ± 5.6 cm in VPS and ETV surgery, respectively (P ≤ 0.01). Postoperative vomiting was improved 24 (92.3%) in Group A and 23 (88.5%) in Group B (P < 0.05). Postoperative infection occurred in 1 (3.3%) case in Group A and 8 (26.7%) cases in Group B (P < 0.05). The success of the operation in Group A and Group B included 25 (83.3%) cases and 12 (40%) cases, respectively (P < 0.05). Conclusion: Early surgical outcome following ETV is better than VPS surgery in patients with obstructive hydrocephalus.
  888 90 1
Clinical characteristics of cerebellar infarction due to arterial dissection
Joji Inamasu, Shunsuke Nakae, Yoko Kato, Yuichi Hirose
October-December 2018, 13(4):995-1000
DOI:10.4103/ajns.AJNS_373_16  PMID:30459855
Objectives and Background: Arterial dissection (AD) of the vertebral artery (VA) or its branches may cause ischemic stroke of the posterior circulation. However, clinical and radiological characteristics of patients with AD-related cerebellar infarction (CI) have rarely been reported. Methods: Forty-nine patients with CI admitted to our department from April 2008 to March 2015 were identified from our database. After dichotomization into the AD and non-AD group, their demographics and presenting symptoms were compared. Subsequently, a multivariate regression analysis was performed to identify variables that correlated with AD. Results: During the 7-year period, 14 and 35 patients were identified in the AD and non-AD group, respectively. The AD group was significantly younger than the non-AD group (55.0 ± 16.3 vs. 69.7 ± 10.7 years, P = 0.001) and was also more likely to experience acute pain at onset (86% vs. 17%, P < 0.001). Using a multivariate regression analysis, these two variables and the male sex were found to correlate with AD. AD was located in extracranial VA (n = 3); intracranial VA (n = 8); posterior inferior cerebellar artery (PICA) (n = 3); and superior cerebellar artery (n = 1). Identification of AD was delayed in one patient with an extracranial VA and one patient with a PICA dissection. Conclusions: AD was responsible for approximately 30% of CI in our cohort. Pain at onset may be a useful symptom to identify patients with AD-related CI. While intracranial VA was the most common location of AD, physicians should be aware of the possibility of extracranial VA or PICA dissection in patients with seemingly unremarkable radiological findings.
  890 88 -
Congenital hydrocephalus, corpus callosum agenesis, and prosencephalic cyst with supernumerary nostril: A neurocristopathy
Rahul Gupta, Dinesh Kumar Barolia, Manisha Goyal
October-December 2018, 13(4):1239-1243
DOI:10.4103/ajns.AJNS_128_17  PMID:30459905
A 3-month-old-male infant presented with enlargement of head since birth. Clinical and radiological evaluation revealed congenital hydrocephalus, corpus callosum agenesis, prosencephalic cyst, and cranial vault deficiency with supernumerary nostril on the left side. Right ventriculoperitoneal shunt (Chhabra shunt) surgery was performed. The patient did well postoperatively. Parents of the patient have been counseled for repair of supernumerary nostril. Congenital hydrocephalus with corpus callosum agenesis is rare. Furthermore, supernumerary nostril is a very rare anomaly with <40 cases reported in the literature till date. To the best of our knowledge, congenital hydrocephalus, corpus callosum agenesis, prosencephalic cyst, and cranial vault deficiency associated with supernumerary nostril have not been reported till date. We herein briefly review the pertinent literature and describe the embryopathogenesis of this rare association. We propose that this association is a neurocristopathy.
  893 81 -
Moulded osteomyofascial pedicled split (MOPS) craniotomy flap in reconstruction of anterior cranial fossa defects: Pilot study of a novel technique
Vinu Venu Gopal, Lekshmi S Bhooshan, Alfred Michael, Philip Issac, Shaju Mathew, Tinu Ravi Abraham, PK Balakrishnan
October-December 2018, 13(4):1011-1017
DOI:10.4103/ajns.AJNS_23_17  PMID:30459859
Introduction: Anterior cranial fossa (ACF) defects still remains a reconstructive challenge to neurosurgeons due to the difficult location, inaccessibility, and unfavorable vascular anatomy. Usual reconstructive methods reported complications such as recurrent cerebrospinal fluid leak due to bone resorption and tissue breakdown. This is mainly due to the avascularity of the bone graft and inability to provide bony structural support for the skull base. An ideal reconstructive modality should provide a rigid bony support to prevent brain herniation as well as ensure a water tight barrier between sinonasal tract and intracranial compartment. Methodology: Hence, we thought of a novel technique of taking the outer table of the primary craniotomy flap with its intact myofascial pedicle and moulded it with multiple osteotomies (moulded osteomyofascial pedicled split (MOPS) craniotomy flap) to fit into uneven ACF defects. Advantages of our flap include (1) It is a pedicled vascularized bone flap. (2) It is taken from primary craniotomy flap; hence, no separate craniotomy is required. (3) The inner table is intact and leaves no secondary calvarial bone defect on the donor site. (4) Osteoplastic flap is moulded to fit into the defect, thus providing good contour. Results: MOPS flap was used in five patients with ACF defects due to varied etiologies such as encephalocele defect, frontal mucocele, skull base meningioma, and complex naso ethmoid fracture. Age of the patients included in the study varied from 21 to 60 years. Male:female ratio was 4:1. ACF defects were reconstructed using MOPS flap in all cases. There were no postoperative complications and 1-month postoperative computerized tomography scan showed no evidence of bone resorption with acceptable cosmesis. Conclusion: MOPS craniotomy flap provides a novel, easily mastered, and cost-effective technique with minimal complication in reconstruction of complex ACF defects with acceptable esthetic and functional outcome.
  868 104 -
Spinal cord-derived neural precursor cells as a preventive therapy for spinal cord injury
Seyed Mojtaba Hosseini, Ali Sharafkhah, Seyyed Mohyeddin Ziaee
October-December 2018, 13(4):1101-1107
DOI:10.4103/ajns.AJNS_140_17  PMID:30459876
Background: Spinal cord injury (SCI) as one of the most important diseases of central nervous system (CNS) without any definite treatment is still growing in incidence. In addition to trauma, some surgeries such as cardiac and thoracic aorta surgery may result in SCI as a complication. In last years, a promising approach has shed light on this CNS injury thanks to stem cell technology. Stem cell therapy could be considered as a good candidate for transplantation and enhancing neural regeneration in SCI. In this study, we identified the effects of spinal cord-derived neural precursor cells (NPCs) transplantation on SCI in after and before injury injection. Materials and Methods: NPCs were isolated from the adult rat spinal cord and cultured in vitro using complete culture media. After neurosphere formation, the cells were differentiated to neurons, oligodendrocytes, and astrocyte. The cells were transplanted to the rat model of SCI in 1 day before and 1 day after injury. The animals were followed for 12 weeks to assess their neurological performance. In addition, histological study and inflammatory cytokines levels have been studied. Results: Our results indicate that NPCs infusion both pre- and post-SCI could decrease the level of inflammatory cytokines. In addition, the neurological performance and histologic studies showed recovery after this type of injury using NPCs, and it might be due to inflammation modulatory effects on neural stem cells. Conclusion: NPCs therapy for SCI in both two-time points (before and after SCI) could be beneficial and make a neurological recovery. In other words, NPCs therapy could be considered as a therapeutic and also preventive approach for SCI.
  861 109 -
Type I spinal arteriovenous fistula with ventral intradural venous drainage: A proposal of a modified classification
Nimer Adeeb, Justin M Moore, Abdulrahman Y Alturki, Ketan R Bulsara, Christoph J Griessenauer, Apar S Patel, Raghav Gupta, R Shane Tubbs, Christopher S Ogilvy, Ajith J Thomas
October-December 2018, 13(4):1048-1052
DOI:10.4103/ajns.AJNS_100_17  PMID:30459865
Objectives: Spinal arteriovenous fistula (AVF) is the most common spinal vascular lesion and constitutes an abnormal communication between a feeder artery and a draining vein. Arterialization of the venous plexus leads to venous hypertension; consequent edema and congestion of the spinal cord are associated with progressive neurological decline. Patients and Methods: In this report, we describe two unique cases of type I cervical spinal AVF, in which a radiculomeningeal artery forms an intradural fistula that drains into the ventral venous plexus. Results: Both patients underwent surgical obliteration of the fistula with complete occlusion confirmed on postoperative angiography. Conclusion: Both cases do not fit into the current classification scheme. A modified classification is proposed.
  878 74 -
Outcome of decompressive craniectomy in traumatic closed head injury
Altaf Ali Laghari, Muhammad Ehsan Bari, Muhammad Waqas, Syed Ijlal Ahmed, Karim Rizwan Nathani, Wardah Moazzam
October-December 2018, 13(4):1053-1056
DOI:10.4103/ajns.AJNS_195_17  PMID:30459866
Objective: The aim of the current study was to observe functional outcomes of patients undergoing decompressive craniectomy (DC) for raised intracranial pressure (ICP) after blunt head injury and to assess possible predictive factors. Methodology: This study was a prospective cohort study which was conducted at Aga Khan University Hospital, Karachi over a period of 2 years (January 2015–December 2016). Adult patients, aged between 15 and 65 years of both genders undergoing DC during the study period were selected. Outcomes of DC were assessed at an interval of 3 months following injury using the Glasgow outcome score. The data were analyzed on IBM statistics SPSS version 21. Results: Seventy-two patients underwent DC for raised and refractory ICP. Glasgow Outcome Scale (GOS) at discharge, 1-month and 3-month follow-up were reported. GOS at 3-month follow-up showed 21 patients (29.2%) patients had a good recovery, moderate disability was reported in 16 patients (22.2%), and severe disability in 12 patients (16.7%), persistent vegetative state was seen in five patients (6.9%). Eighteen patients had in hospital mortality (25.0%). Tracheostomy and sphenoid fractures were found to be negative predictors of good functional outcome. Conclusions: DC is associated with an in hospital mortality of 25.0%. Favorable outcomes were seen in 51.4% patients. Tracheostomy and sphenoid fractures were negative predictors of good functional outcome. The results are comparable to international literature.
  843 105 -
Therapeutic evaluation of tumor necrosis factor-alpha antagonist etanercept against traumatic brain injury in rats: Ultrastructural, pathological, and biochemical analyses
Askin Esen Hasturk, Emre Cemal Gokce, Erdal Resit Yilmaz, Bahriye Horasanli, Oya Evirgen, Nazli Hayirli, Hilal Gokturk, Imge Erguder, Belgin Can
October-December 2018, 13(4):1018-1025
DOI:10.4103/ajns.AJNS_29_17  PMID:30459860
Purpose: The aim of the present study was to investigate the effect of etanercept (ETA) on histopathological and biochemical changes after traumatic brain injury (TBI) in rats. Materials and Methods: Thirty-six male Wistar albino rats were distributed into three groups (n = 12 each). Control group rats were not subjected to trauma. Trauma group rats were subjected to TBI only. ETA group rats were subjected to TBI plus ETA (5 mg/kg intraperitoneal [i.p.]). The groups were further subdivided into those sacrificed in the hyperacute stage (1 h after TBI) (control-1, trauma-1, and ETA-1 groups) and the acute stage (6 h after TBI) (control-6, trauma-6, and ETA-6 groups). Tissue levels of tumour necrosis factor-alpha, interleukin-1 beta, malondialdehyde, catalase, glutathione peroxidase, and superoxide dismutase were analyzed. Histopathological and ultrastructural evaluations were also performed. Results: i.p. administration of ETA at 1 and 6 h significantly reduced inflammatory cytokine expression, attenuated oxidative stress and lipid peroxidation, prevented apoptosis, and increased antioxidant defense mechanism activity in comparison to trauma group. Histopathological and ultrastructural abnormalities were significantly reduced in ETA-treated rats compared to closed head injury trauma groups. Conclusions: ETA significantly improves neural function and prevents post-TBI histopathological damage in rats.
  821 101 2
Comparative study of derangement of coagulation profile between adult and pediatric population in moderate to severe traumatic brain injury: A prospective study in a tertiary care trauma center
Ashish Kumar Dwivedi, Achal Sharma, Virendra Deo Sinha
October-December 2018, 13(4):1123-1127
DOI:10.4103/ajns.AJNS_16_17  PMID:30459880
Object: Coagulopathy is a common occurrence following traumatic brain injury (TBI). There are various studies showing incidence and risk factors of coagulopathy and their correlation with poor outcome in adult as well as paediatric age groups. Exact incidence, associated risk factors, treatment guideline for coagulopathy and its impact on outcome are still lacking. In our study we compared the adults and paediatric age groups TBI patients for incidence and risk factors of coagulopathy and its impact on outcome. Methods: Prospective study of 200 patients including 152 adult patients (age > 18 years) and 48 paediatric (Age < 18 years) patients of TBI admitted in intensive care unit of trauma centre of a tertiary care centre was performed from august 2015 to march 2016. Both population were further subdivided into moderate TBI and severe TBI as per Glasgow coma score (GCS). Patient with long bone injury, chest injury and abdominal injuries, coagulation disorder, liver disease, medical disease like diabetes mellitus and hypertension were excluded from study. Coagulation profile were compared in the both groups (Adult and paediatric) and correlated with the outcome. Chi- Square test, student t test and Odds ratios were used for statistical analysis. Results: Mean age among the adult and paediatric population were 37.89 ± 11.88 years and 11.41 ± 5.90, respectively. Among the patient with moderate TBI, coagulopathy was seen in 30% patients of adult TBI whereas it was 12.5% among the paediatric TBI (P = 0.185). Among the severe TBI group coagulopathy was observed in 68.03% and 37.5% of adult and paediatric age group respectively (P = 0.0016). There was significant correlation found between midline shift and coagulopathy in the paediatric age group (P = 0.022; OR - 4.58). E. There was significant association of coagulopathy and contusion on CT scan among the adult population (P = 0.007; OR - 3.487) found whereas no such correlation were observed in paediatric population. Conclusion: Coagulopathy was significantly higher among the adult patient with severe TBI as compare to paediatric patient with severe TBI. There was no statistically significant difference in mortality among patients of both the age groups with coagulopathy.
  831 79 -
Clinical and radiological outcomes of day-care posterior foraminotomy and decompression of the cervical spine
Manoj Dayalal Singrakhia, Nikhil Ramdas Malewar, Sonal Deshmukh, Shivaji Deshmukh
October-December 2018, 13(4):1118-1122
DOI:10.4103/ajns.AJNS_14_17  PMID:30459879
Purpose: Anterior cervical procedures are associated with many intra- and post-operative complications leading to long-term patient morbidity. In this study, we have evaluated the clinical and radiological Outcome of day care posterior cervical foraminotomy in patients with single-level cervical radiculopathy with or without neurodeficit. Materials and Methods: Seventeen patients underwent single-level posterior cervical foraminotomy for radicular symptoms were studied between June 2011 and May 2016. Clinical outcome was studied by visual analog scale (VAS) score, neck disability index (NDI), and Odom's criteria. Adjacent segment degeneration was evaluated on lateral cervical radiograph at every follow-up by calculating the focal and global angulation of the cervical spine and disc height at the operated level and adjacent segments. Dynamic lateral cervical spine radiograph was done to evaluate segmental instability. Results: After a mean follow-up duration of 30.64 months, 13 patients had excellent, three patients had good, and one patient had fair outcome as per Odom's criteria. The mean VAS score for radicular pain, neck pain, and NDI was significantly reduced postoperatively (P < 0.001). The mean focal angulation, mean global angulation, the disc height at operated and adjacent level were not changed significantly (P > 0.05). There was no instability noted postoperatively on lateral dynamic cervical spine radiographs. There was no complication in our study. Conclusion: Posterior cervical foraminotomy is an effective surgical method for treatment of patients with single-level cervical radiculopathy and helps to achieve good clinical and radiological outcome, prevents postoperative adjacent segment degeneration and instability with minimal complications.
  820 82 1
Diprosopus a rare craniofacial malformation
Mrinal Bhuyan, Inamul Haque
October-December 2018, 13(4):1257-1259
DOI:10.4103/ajns.AJNS_202_17  PMID:30459911
Diprosopus is an extremely rare form of craniofacial malformation seen in newborns where there is duplication of face which may be partial or complete. The baby usually has a single trunk and normal limbs. We report a case of diprosopus admitted in our institute and analyze the anomalies and clinical problems and outcome of the case.
  847 44 -
Assessment of primary brain lymphoma using multimodal magnetic resonance imaging and proton magnetic resonance spectroscopy
Abdelkhalek Housni, Saïd Boujraf, Badreddine Alami, Mohammed Benzagmout, Mustapha Maaroufi
October-December 2018, 13(4):1205-1208
DOI:10.4103/ajns.AJNS_137_17  PMID:30459895
Objectives: The primary lymphoma of the central nervous system is a cancer rare. The diagnosis of this tumoral entity must be considered as an emergency considering the therapeutical involved. Therefore, we report this entity while reporting diagnostic challenges. Patients and Methods: Unfortunately, the conventional clinical and imaging signs can be confusing and might contribute to delay the diagnosis process of potentially curable pathological entity. The diagnosis confirmation in immunocompetent patients is based on a stereotaxic biopsy. Results and Conclusion: In this paper, we report a case illustrating the contribution of multimodal imaging including diffusion-weighted magnetic resonance imaging (MRI), diffusion tensor MRI, perfusion MRI, and proton MR spectroscopy to the diagnostic approach of the atypical primary lymphoma of the central nervous system.
  802 88 -
Chronic unilateral temporo-occipital headache attributed to unilateral C3 radiculopathy
Hak-cheol Ko, Byung-chul Son
October-December 2018, 13(4):1229-1232
DOI:10.4103/ajns.AJNS_197_17  PMID:30459902
Although C1–C3 upper cervical radiculopathy can cause a headache, most case reports are occipital neuralgia (ON), not headache. Here, we report a unique case of chronic temporo-occipital headache due to C3 radiculopathy. A 62-year-old male presented with a chronic left-sided temporo-occipital headache with duration of 4 years. The headache was aching and pressure like in nature. It had a typical radiating pattern on every occasion. It started in the posterior temporal area above the ear. It then extended to retroauricular area, then suboccipital area, and lateral neck. No hypesthesia, allodynia, or limitation in neck motion was noted. Myelographic computed tomography revealed a left-sided C2/C3 foraminal stenosis. Subsequent foraminotomy and decompression of the left C3 completely alleviated the chronic left-sided temporo-occipital headache. Unilateral C3 radiculopathy can cause chronic temporo-occipital headache besides ON. The present case might be a typical example of “headache attributed to upper cervical radiculopathy” (A11.2.4) rather than cervicogenic headache according to the International Classification of Headache Disorders, 3rd edition (beta version).
  818 64 -
Angiocentric glioma: Report of a rare case presenting with psychosis
Jayashri Popat Chaudhari, Kanchan Snehal Kothari, Tejal Pratin Pandya, Naina Atul Goel
October-December 2018, 13(4):1186-1192
DOI:10.4103/ajns.AJNS_371_16  PMID:30459891
Angiocentric glioma (AG), first described in 2005, was included as a distinct entity in the 2007 World Health Organization Classification of Tumors of the Central Nervous System. It is a very rare cerebrocortical tumor mainly affecting children and young adults with a history of intractable partial seizures. The histopathological features of this entity are perivascular arrangement of monomorphic, bipolar spindled cells with subpial aggregation of tumor cells and variable neuroparenchymal colonization. Of uncertain histogenesis, this is a stable/slowly growing tumor. Prognosis following total surgical resection is favorable. We describe an AG in a 16-year-old, intellectually disabled, male patient, with psychosis. This is a rare presentation with only one such case in literature. Patient's symptoms ameliorated following surgery.
  816 62 -
Pediatric intracranial tumors over a 5-year period in a tertiary care center of North Kerala, India: A retrospective analysis
Aparna Govindan, Rajeev Mandaka Parambil, Jacob Paul Alapatt
October-December 2018, 13(4):1112-1117
DOI:10.4103/ajns.AJNS_251_17  PMID:30459878
Background: Pediatric brain tumors are unique in terms of distribution, clinical presentation, pathologic types, management, and prognosis. There are not many studies from India which have looked into the epidemiology of pediatric brain tumors. Aims: This study aimed to analyze the epidemiology of pediatric brain tumors in North Kerala and compare it with data from the rest of India and other countries. Materials and Methods: This is a retrospective study of 5-year data of pediatric brain tumors which were operated in a tertiary referral center in North Kerala, India, from 2009 to 2013. The data were procured from the departments of neurosurgery and pathology of the institution. The data were tabulated and analyzed using SPSS software. Results: A total of 71 children had histologically proven brain tumors during the 5-year period. There were 34 boys and 37 girls. Distribution in different age groups was as follows: infancy –5 (7%), 1–5 years –22 (31%), 6–10 years – 21 (29.6%), and 11–18 years – 23 (32.4%). The most common tumors were primitive neuroectodermal tumors (PNETs). In infancy, the number of high-grade tumors was more, whereas in the 11–18 years' age group, there were a significantly higher number of low-grade tumors (P = 0.04). Discussion: Pediatric brain tumors were distributed almost equally in both sexes. PNET was the most common. We could not get statistical significance in many of our values due to small sample size. Conclusion: This study highlights the need for diligent collection of data and maintenance of a registry for brain tumors to study the disease in the Indian population.
  802 68 -
Extradural hematoma following decompressive craniectomy for acute subdural hematoma: Two case reports illustrating different mechanisms
Mahesh Krishna Pillai, Rajeev Kariyattil, Venkatesh Govindaraju, Koshy Kochummen, Rajinder Kumar
October-December 2018, 13(4):1213-1215
DOI:10.4103/ajns.AJNS_87_17  PMID:30459897
The occurrence of extradural hematoma (EDH) after decompressive craniectomy (DC) for traumatic brain injury is uncommon. We report two cases, one developing ipsilateral EDH and another developing contralateral simultaneous EDH and subdural hematoma after DC. The strategies to anticipate the occurrence of such concurrent hematomas (CH) are highlighted. We propose a subclassification of CH into “immediate” and “delayed,” based on their difference in clinical presentation, image findings, pathogenesis, and surgical management.
  801 67 -
Extensive paraspinal tuberculosis masquerading malignant tumor in an elderly male
Veldurti Ananta Kiran Kumar, Vissa Shanthi, Yashwanth Sandeep, Veda Dhruthy Samudrala, Amit Agrawal
October-December 2018, 13(4):1202-1204
DOI:10.4103/ajns.AJNS_2_17  PMID:30459894
Paraspinal tuberculosis is an uncommon manifestation of extrapulmonary tuberculosis, and in rare cases, these lesions can mimic malignant lesions. We report a case of an elderly man where imaging showed extensive left paraspinal lesion which was mimicking malignant neoplasm. The patient underwent L3–L4 unilateral partial laminotomy, there was grayish, relatively avascular lesion in the left paraspinal region, involving the left psoas muscle and going into the neural foramina, and a subtotal resection of the lesion could be performed. However, after biopsy, it turned out to be tuberculoma, and the patient was on antitubercular therapy and doing well. The present case illustrates that extensive involvement of the paraspinal soft tissue and adjacent bony structures on imaging in tuberculosis can mimic malignant tumors. Conservative surgical excision will help in preserving the bony elements and in establishing the diagnosis.
  805 60 -
Adult thoracic intradural exophytic mature teratoma: Case report and literature review
Aaron P Danison, Dinesh Ramanathan, Mahan Matin, Kee Kim, Ripul R Panchal
October-December 2018, 13(4):1182-1185
DOI:10.4103/ajns.AJNS_370_16  PMID:30459890
Mature thoracic intraspinal teratomas are rare tumors in adults. In this case study, we present a case of intradural, extramedullary teratoma, which was surgically resected. A 50 year old man presented with progressive bilateral leg pain, severe myelopathy and weakness. Magnetic Resonance Imaging (MRI) revealed a cystic mass lesion in the T11-12 region region. Microsurgical resection of the tumor using CO2 laser with neuromonitoring was performed. Postoperatively, the patient had a remarkable clinical improvement. Mature spinal teratomas are rare, slow growing spinal tumors. Surgical resection provides excellent recovery, and recurrence rates are low.
  786 75 -
Gamma knife management of skull base chordomas: Is it a choice?
Wael K Zakaria, Raef F Hafez, Ahmed N Taha
October-December 2018, 13(4):1037-1041
DOI:10.4103/ajns.AJNS_61_17  PMID:30459863
Background: Skull base chordomas are locally invasive tumors which able to extend in different directions with skull base invasion. Although they are histologically benign, they have invasive nature makes total resection virtually impossible to achieve in most cases and this lead to residual tumors after surgery. To decrease postoperative surgical resection morbidity of these tumors, gamma knife radiosurgery (GKRS) was performed as alternative management for these residual chordomas to evaluate its safety and efficacy. Materials and Methods: A retrospective study was made on eight residual skull base chordomas treated with GKRS between 2011 and 2015. The mean patient age was 49 years (range 30–73 years). Four patients harboring chordoma were male, and four patients were females with 1:1 ratio. All patients had undergone one prior surgery. Patients were treated with peripheral dose ranged between 12–15 gray (Gy) (mean 13.75 Gy) usually at 35% to 50% isodose curve (mean 38.8%). The maximum dose to the adjacent brain stem area ranged between 10 and 12 Gy. All patients were followed up from 8 to 39 months (mean 18 months). Results: The tumor control rate was 50% and 25% after 18 and 36 months, respectively, but we found that their wasdeclined in the tumor control rate with long follow-up time. Four tumors were stable in their size just for 18 months, and then there two of these tumors were progressed in their size, the other four patients showed progression in their tumors in their 1st year of treatment without sign of central tumor necrosis. Conclusion: Skull base chordoma patients complained from symptoms due to tumor mass effect which were not prospected to respond to GKRS alone as the aim of this type of treatment was the local tumor control, the tumor control rate declined with long follow-up time and this correlated with radioresistant nature of skull base chordoma. We advise a gross total resection to decrease the tumor volume, and this making gamma knife a reasonable treatment modality.
  797 62 1
Role of diffusion-weighted imaging in detecting early ischemic brain injury following aneurysmal subarachnoid hemorrhage
Varun Aggarwal, Achal Sharma, VD Sinha
October-December 2018, 13(4):1074-1077
DOI:10.4103/ajns.AJNS_73_17  PMID:30459871
Background: Aneurysmal SAH is the significant cause of morbidity and mortality in stroke patients. Early brain injury and delayed cerebral ischemia are the two main responsible pathophysiologic processes. Cerebral ischemia needs to be detected early so that early aggressive therapy could be started. Although Diffusion weighted imaging (DWI) has often been utilized for the measurement of acute ischemic strokes, its role in the detection of early cerebral ischemia due to aneurysmal subarachnoid hemorrhage has not been extensively investigated. This study is being carried out to describe the role of DWI in detecting early ischemic brain injury and outcome after aneurysmal SAH. Aim: Efficacy of DWI in detecting ischemic injury and predicting outcome after aneurysmal SAH. Material and Methods: In this prospective study 44 consecutive patients who had aneurysmal SAH; admitted within 7 days of their ictus were included. Hunt and Hess grade on admission and modified Fisher grade of SAH were noted. Plain CT brain and MR DWI was done on day before surgery. Diffusion restriction on DWI was correlated with postoperative neurological deficit, postoperative CT finding and outcome of the patient at 1 month follow-up. Results: DWI revealed restricted diffusion in 12 patients, out of which 1 patient was having infarction in preoperative CT scan, 6 patients were having postoperative deficit in the form of disorientation, hemiparesis and aphasia, and all patients were having infarction in postoperative CT scan. When DWI findings were compared on the basis of postoperative neurological deficit, postoperative CT finding and modified Rankin outcome score at 1month follow-up, results were statistically significant. Conclusion: DWI shows cerebral ischemia much earlier than CT scan in cases of aneurysmal SAH. It has significant correlation with postoperative neurological status and outcome of the patient.
  778 80 -
Pilocytic astrocytoma with gangliocytic differentiation to pilomyxoid astrocytoma-expanding the morphological spectrum: Case report and literature review
Kirti Gupta, Manoj Kumar Tewari, Pravin Salunke
October-December 2018, 13(4):1193-1196
DOI:10.4103/ajns.AJNS_247_17  PMID:30459892
We present a rare case of pilocytic astrocytoma (PA) with gangliocytic differentiation arising in the suprasellar/chiasmatic region in a young boy that showed a rapid regrowth after the 1st subtotal resection and “differentiated” into pilomyxoid astrocytoma (PMA) in subsequent recurrences. The clinical course, imaging, and histological features have been described with a review of the literature. While PA is well-circumscribed, biphasic tumors with bipolar piloid cells, those arising in the diencephalic region often contain myxoid stroma, angiocentric pattern, and “intermediate” features between PA and PMA. Examples of PMA “maturing” to PA are also on record; however, PA with gangliocytic component differentiating to PMA has not been described in the literature to the best of our knowledge.
  793 56 -
Adverse event with the use of carmustine wafers and postoperative radiochemotherapy for the treatment of high-grade glioma
Federico Salle, Wissem Lahiani, Edgardo Spagnuolo, Stéphane Palfi
October-December 2018, 13(4):1171-1174
DOI:10.4103/ajns.AJNS_235_16  PMID:30459887
Randomized, controlled trials have shown significant improvement of survival after implantation of 1,3-bis(2-Chloroethyl)-1-nitrosourea (BCNU) wafers for patients suffering from high-grade glioma. A combination of local chemotherapy with BCNU and concomitant radiochemotherapy with temozolomide (TMZ) appears to be attractive to enhance the overall survival, even though these treatments may potentially cumulate their toxicity.We report a clinical case of a patient submitted to this combined treatment protocol. Severe brain edema and a cystic formation in the surgical cavity rapidly developed. Data supporting the use of Gliadel® combined with TMZ comes from small retrospective studies, and some series have shown a very high rate of adverse events (AEs) when this multimodality treatment is applied. Combined protocols of local and systemic chemotherapy might provide survival benefits, although AEs seem currently underestimated.
  775 70 -
Peroneal nerve palsy due to subparaneurial ganglion cyst, a rare variant of intraneural ganglion cyst
Dongbin Kim, Jin-Gyu Choi, Byung-Chul Son
October-December 2018, 13(4):1225-1228
DOI:10.4103/ajns.AJNS_6_17  PMID:30459901
Intraneural ganglion cysts are rare mucinous cysts originating within the epineurium of peripheral nerves. Although ganglion cysts are the most frequent tumors of the upper and lower extremities, ganglion cysts rarely result in peripheral nerve compression. We report a case of a 30-year-old patient who presented with foot drop due to subparaneurial ganglion cyst, a variant of an intraneural ganglion cyst. Characteristic magnetic resonance imaging findings were essential in the preoperative diagnosis of intraneural ganglion cyst. The common peroneal nerve and its branches were recognized and traced to its bifurcation during the operation. The articular branches were addressed. The mucious content of the ganglion was typically found to be located within the subparaneurial compartment. Incision of the subparaneurial ganglion cyst was performed, and mucinous content was evacuated. At 2 months after the surgery, paralyzed peroneal nerve was recovered completely. Therefore, early diagnosis of intraneural ganglion, precise identification of the pathology, and proper treatment of the articular branch with atraumatic dissection of ganglion cyst are essential in the successful management of this rare lesion.
  778 67 1
An unusual cause of posterior reversible encephalopathy syndrome
Biplab Das, Gaurav Goel, Anshu Mahajan, Atma Ram Bansal, Harsh Sapra, Ajaya Nanda Jha
October-December 2018, 13(4):1254-1256
DOI:10.4103/ajns.AJNS_188_17  PMID:30459910
Posterior reversible encephalopathy syndrome (PRES) is a clinical radiographic diagnosis of heterogeneous etiologies. The pathogenesis of PRES remains unclear, but may be related to impaired cerebral autoregulation and endothelial dysfunction. We present a case of intravascular nonionic contrast-induced PRES observed after cerebral angiography. The index patient was a follow-up case of large vertebrobasilar artery-dissecting aneurysm for which endovascular coiling was done 6 months back. She improved completely within a week. Contrast-induced PRES is a reversible benign condition, knowledge of which is crucial for appropriate management.
  775 70 -
P53 and Ki-67 expression in primary pediatric brain tumors: Does it correlate with presentation, histological grade, and outcome?
Vikas Sharma, Yawar Shoaib, Laxmi Narayan Gupta, Amit Dagar
October-December 2018, 13(4):1026-1032
DOI:10.4103/ajns.AJNS_69_17  PMID:30459861
Context: Pediatric brain tumors are a vexing problem for the neurosurgeon due to the fragile patient cohort. We attempt to find parameters which can help us to treat and prognosticate these patients in a better way. Aims: This study aims to correlate clinical presentation, outcome, and histological grade with P53 and Ki-67 expression in primary pediatric brain tumors. Setting Design: This was a prospective, observational study. Patients and Methods: Forty-seven patients with primary brain tumors in the age group 0–18 years were included in this study. Clinical presentation was noted. Patients were operated, and specimen was sent for histopathological and immunohistochemistry examination for p53 and Ki-67. The WHO classification of 2007 was used to grade the tumors. Follow-up was done at 3 and 6 months with Glasgow outcome score. Expression of p53 and Ki-67 in different tumors was correlated with clinical presentation, tumor grade and outcome. Analysis Method: Statistical Package for Social Science version 17. P < 0.05 was considered statistically significant. Results: There was statistically significant correlation between high tumor grade and high Ki-67 levels (P = 0.000). On post hoc analysis, there was a significant difference between p53 levels in Grade 1 and Grade 4 tumors. There was statistically significant correlation between neurological deficit and higher p53 levels (P = 0.040). There was statistically significant correlation between poor outcome and higher p53 (P = 0.034) and Ki-67 (P = 0.000) levels at 3 months follow-up which continued at 6 months. Conclusions: From this study, we conclude that p53 and Ki-67 expression in pediatric brain tumors is associated with poor outcome and correlates with tumor grade. Moreover, p53 expression correlates with neurological deficit.
  774 70 -
Left deep frontal cavernous angioma mimicking a glioma in an adult patient
Andrea Boschi, Arturo Consoli, Annamaria Buccoliero, Giovanni Barbagli, Salvatore Mangiafico, Franco Ammannati
October-December 2018, 13(4):1233-1235
DOI:10.4103/ajns.AJNS_124_17  PMID:30459903
Cerebral cavernous angiomas are vascular malformations characterized by large adjacent vessels. Usually, these lesions are smaller than 3 cm, the mean age at presentation occurs between 20 and 40 years, and the neuroradiological findings are well described, especially for magnetic resonance imaging, where the “popcorn balls” appearance is due to the presence of locules containing blood. Among these, the giant cavernous angiomas are very rare, particularly in adults. We collected clinical and neuroradiological data from clinical file and hospital diagnostic archive. A comprehensive review of similar cases was performed. We describe the clinical, diagnostic, and surgical management of a giant cerebral cavernous angioma located in the left deep frontal lobe mimicking a high-grade glioma in an adult Chinese patient. Giant cerebral cavernous angioma may be misdiagnosed and should be considered as differential diagnosis.
  784 59 -
Armored brain associated with secondary craniostenosis development at 7-year following ventriculoperitoneal shunt surgery during infancy: Extremely unusual association and review
Guru Dutta Satyarthee, Sanjeev Lalwani
October-December 2018, 13(4):1175-1178
DOI:10.4103/ajns.AJNS_263_16  PMID:30459888
Calcification is uncommon in chronic subdural hematoma and popularly known as calcified chronic subdural hematoma (CSSDH), and about hundred cases are reported in the form of isolated cases report. The calcified inner membrane of chronic subdural hematoma gets adherent to underlying cerebral cortex preventing re-expansion of the brain and producing mass effect. Calcification can develop in chronic subdural hematoma of traumatic origin or postmeningitic effusion or extremely rarely after shunt surgery. CCSDH is also known as armored brain or Matrioska head and those related to cerebrospinal fluid diversion ventriculoperitoneal (VP) shunt surgery, constitute one of the rare complications of shunt, and development is attributed to overdrainage of shunt. Authors report a unique case with bilateral calcified chronic subdural hematoma in an 8-year-old boy, who had VP shunt surgery for obstructive hydrocephalus at the age of 1 year of life, presented with feature of nonlocalized raised intracranial pressure; a diagnosis of suspected VP shunt malfunction was also considered; however, cranial computed tomography scan on current admission revealed the presence of bilateral calcified chronic subdural hematoma with secondary craniostenosis and managed successfully with burr-hole craniostomy and drainage of CCSDH. In a detailed PubMed and Medline search, authors could not get any publication regarding CSSDH associated with secondary craniostenosis developing following VP shunt surgery in infancy. The current case represents the first case in the Western literature developing secondary craniostenosis-associated CCSDH following shunt surgery in infancy, requiring surgical management. The clinical features, neuroimaging, and management of such rare case along with pertinent literature are reviewed briefly.
  775 61 -
A rare case of dumbbell-shaped primary intraspinal peripheral primitive neuroectodermal tumor involving thoracic spinal epidural space
Anu Cheppanalil Thomas, Rajeev Rajashekharan
October-December 2018, 13(4):1216-1218
DOI:10.4103/ajns.AJNS_91_17  PMID:30459898
Primary intraspinal primitive neuroectodermal tumor (PNET) is a type of round cell malignant tumor which is reported only above 100 in literature. We report a case of epidural thoracic peripheral PNET, discuss its pathological features, radiology, and treatment options.
  772 53 -
Embolization with NBCA for ruptured aneurysm located in the moyamoya-like collateral network associated with isolated middle cerebral artery occlusion
Cheol Young Lee
October-December 2018, 13(4):1236-1238
DOI:10.4103/ajns.AJNS_127_17  PMID:30459904
Collateral vessel formation in moyamoya disease is a well-described phenomenon. However, the occurrence of unusual anastomosis pattern (moyamoya-like) associated with isolated middle cerebral artery (MCA) stenosis or occlusion has been reported very rarely and is not well known the relationship with aneurysm. We report a case of ruptured aneurysm treated with N-butyl cyanoacrylate (NBCA) located in moyamoya like collateral network with isolated MCA occlusion.
  742 80 1
Unravelling hitherto unreported masses camouflaged as pituitary macro adenomas
Vernon Velho, Amrita Guha, Harish Naik, Laxmikant Bhople, Nimesh Jain
October-December 2018, 13(4):1005-1007
DOI:10.4103/ajns.AJNS_17_17  PMID:30459857
Background: Lesions of the pituitary gland and the juxtasellar region are quite frequently encountered in daily practise of a neurologist/neurosurgeon. While the differentials of sellar masses are quite large and form an extensive list and the management protocol varies in each case, the onus of properly categorizing and diagnosing the pituitary mass often falls on the reporting radiologist. We hereby present two such unusual masses in the sellar-suprasellar region which were masquerading as pituitary macro adenomas. Materials and Methods: Two cases of sellar-suprasellar masses which were preoperatively diagnosed as pituitary macro-adenomas on radiological imaging proved out to be pituitary natural killer cell lymphoma and lepromatous abscess. Results: The first one is a rare case of pituitary abscess seen in a lepromatous patient which is not yet reported in the literature. The second case is of primary pituitary natural killer cell lymphoma which is almost entirely unknown, with only two such cases being reported worldwide till date. Conclusion: It is important to realize that all enhancing pituitary lesions are not macro adenomas and it is necessary to have a high index of suspicion in such cases. The clinical implications of such an error and steps that can be taken to prevent misinterpretations of unusual sellar masses camouflaging as pituitary macro adenomas have been briefly outlined.
  760 62 -
Outcome of posttraumatic delayed intracerebral tension pneumatocele: Prospective study of four cases: Single institutional experience
Vivek Kumar Kankane, Tarun Kumar Gupta
October-December 2018, 13(4):1087-1095
DOI:10.4103/ajns.AJNS_226_17  PMID:30459874
Aim: Delayed intracerebral tension pneumatocele (DITP) is an uncommon cause of raised intracranial pressure following trauma. However, it can cause herniation syndrome due to a sudden increase in intracranial pressure which requires emergent intervention. Pneumocephalus is a complication of head injury in 3.9%–9.7% of the cases. The accumulation of intracranial air can be acute (<72 h) or delayed (≥72 h). Method: When intracranial air causes intracranial hypertension and has a mass effect with neurological deterioration, it is called tension pneumocephalus. In our case series, we demonstrated four cases of DITP in adult patients from January 2012 to January 2017 in the Department of Neurosurgery at R. N. T. Medical College and M. B. Hospital, Udaipur, Rajasthan. Result: During this period, a total number of patients admitted of head injury are 1768 and hence, the incidence of DITP in our series is 0.226% which is very less as compared to previous literature. All patients are male; age ranging from 17 years to 55 years (mean age was 31.75 years). All patients have a history of head injury, and mode of injury had road traffic accidents. Glasgow Coma Score (GCS) at readmission were 12–13 (mean GCS 12.75). Duration of developed DITP 1 month to 2½ months (mean 1.375 months), all patients had gone to surgical intervention, and outcome assessed using Glasgow outcome score. All patients had a good outcome and average follow-up was 12.5 months. Conclusion: long term observation of patients with simple pneumocephalus following trauma is beneficial as there is an expected risk of developing delayed tension pneumocephalus which may manifest with raised intracranial pressure.
  754 58 1
Ruptured posterior circulation aneurysms with bilateral internal carotid artery occlusion: Surgical nuance
Nitin Narayan Dange, Amit Mahore, Ashwini Kumar Patil, Juhi Kawale
October-December 2018, 13(4):1008-1010
DOI:10.4103/ajns.AJNS_19_17  PMID:30459858
Background: Craniotomy and surgical clipping is the standard modality of treatment in patients of cerebral aneurysms. However, the surgical clipping of aneurysm may pose serious difficulties in the case of a bilateral carotid artery occlusion. The endovascular treatment has shown promising results in this disease. Methods: A retrospective study of all patients of posterior circulation aneurysms in the background of carotid occlusive disease at our department was performed. The aim of this study was to describe the clinical, radiological characteristics, and the treatment of this rare entity. Results: Four patients were treated from January 2009 to October 2015. The mean age of our patients was 34 years with ages that ranged from 17 to 45 without any gender predominance. The mean period between onset of symptoms and diagnosis was 6 weeks. Angiographic localization of the disease was observed in all patients. All patients were treated by endovascular techniques. The postoperative course has been satisfactory with a complete neurological recovery in all patients. Conclusions: Rupture of posterior circulation aneurysms in the setting of bilateral internal carotid artery occlusion is extremely rare. Treatment is exclusively endovascular intervention. The functional outcome of ruptured posterior circulation aneurysms in setting of bilateral carotid occlusive disease is particularly favorable with good neurological recovery.
  744 64 -
Multimodality techniques in microsurgical clipping as the gold standard treatment in the management of basilar tip aneurysm: A case series
Liew Boon Seng, Yasuhiro Yamada, Niranjana Rajagopal, Ameen Abdul Mohammad, Takao Teranishi, Kyosuke Miyatani, Tsukasa Kawase, Yoko Kato
October-December 2018, 13(4):1148-1157
DOI:10.4103/ajns.AJNS_159_18  PMID:30459884
Introduction: Basilar aneurysms represent 5%–7% of all intracranial aneurysms. The main goal of open surgery is to achieve complete obliteration of the aneurysmal sac using minimal invasive technique while emphasizing on avoidance of complication. Materials and Methods: We performed a retrospective cohort study of nine cases of unruptured basilar tip aneurysm referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Japan. The objective of the study was to analyze the surgical outcomes of unruptured basilar tip aneurysm. Results: Nine patients with unruptured basilar tip aneurysm were referred to our hospital between 2015 and 2017. The median size of the aneurysm and age were 4.00 mm (interquartile range [IQR] = 3.25–6.75 mm) and 58 years (IQR = 54–70 years), respectively. Five patients (55.6%) were presented with multiple intracranial aneurysms. Surgical adjuncts such as intraoperative neuromonitoring, intraoperative indocyanine green (ICG) angiography with dual-image videoangiography (DIVA), and neuroendoscope were used. Two patients developed transient postoperative oculomotor nerve palsy which resolved spontaneously. The median duration of surgery and days of hospitalization were 292 min (IQR = 237.5–350.5 min) and 12 days (IQR = 12–25 days), respectively. There was no mortality recorded in this case series. Conclusion: Microsurgical clipping of basilar tip aneurysm is safe in unruptured basilar tip aneurysm with a low risk of postoperative mortality or morbidity. All complications reported in this case series were transient with no long-term sequalae. The improved safety profile of microsurgical technique is due to the availability of intraoperative neuromonitoring, neuroendoscope, ICG, and DIVA. The application of multimodality technique in neurovascular surgery has also helped to achieve complication avoidance. The obliteration of the aneurysmal sac helps to restore the laminar blood flow in the bifurcation and distal blood vessels and improves the brain perfusion.
  704 101 1
Endoluminal shuntscope-guided ventricular catheter placement: Early experience
Vivek Agrawal, Rajendra B Aher
October-December 2018, 13(4):1071-1073
DOI:10.4103/ajns.AJNS_98_17  PMID:30459870
Background: Placement of ventricular catheter (VC) in an optimal position is the most important factor in determining the outcome of shunt surgery. VC obstruction due to shunt tube placement in brain parenchyma, across the septa, tangled in the choroid plexuses and clogging of VC due to brain matter or other debris are common reasons resulting in shunt complete or partial dysfunction. To resolve these hurdles, many technical advancements have been made including navigation, stereotaxy, sonography, and ventriculoscope-guided VC placement. Objective: To report early experience, technique, and result of placing VC with shuntscope. Methods: We are publishing our experience of shuntscope-guided ventriculoperitoneal shunt in 9 cases done from June 2015 to April 2016. Shuntscope is a 1 mm outer diameter semi-rigid scope from Karl Storz with 10000 pixel of magnification. It has a fiber optic lens system with camera and light source attachment away from the scope to make it light weight and easily maneuverable. Results: In all cases, VC was placed in the ipsilateral frontal horn away from choroid plexuses, septae, or membranes. Septum pellucidum perforation and placement to opposite side of ventricle was identified with shunt scope assistance and corrected. Conclusion: Although our initial results are encouraging, larger case series would be helpful. Complications and cost due to shunt dysfunction can thus be reduced to a great extent with shuntscope.
  741 58 -
Bilateral orbital cavernous hemangioma
Aslam Hentati, Nidhal Matar, Hadhemi Dridi, Soufien Bouali, Hafedh Jemel
October-December 2018, 13(4):1222-1224
DOI:10.4103/ajns.AJNS_96_17  PMID:30459900
Cavernous hemangioma of the orbit (CHO) is a benign slow-growing lesion of intracanal space. Bilateral orbital cavernous hemangiomas are extremely rare, so that only a few cases have been reported in scientific literature. A 54-year-old patient presented a 1-year history of impaired visual acuity of the left eye. Physical examination showed a left axial propotosis. Orbital magnetic resonance imaging showed a 28 mm diameter intraconal space mass of the left orbit, as well as another 11 mm diameter lesion in the right eye, in the superomedial extraconal space. A superior wall left orbitotomy was performed with a total removal of the tumor. The right lesion was respected. Histopathological examination confirmed the diagnosis of CHO. Bilateral cavernous hemangiomas are extremely rare. Orbital imaging guides the diagnosis. The neurosurgeons prefer craniotomy while ophthalmologists favor various modifications of orbitotomies.
  732 62 -
Coil embolisation of post traumatic giant supraclinoid pseudoaneurysm presenting as carotid cavernous fistula
Dange Nitin Narayan, Singh Vikas Jayprakash, Dhar Arjun, Gupta Achal
October-December 2018, 13(4):1244-1246
DOI:10.4103/ajns.AJNS_161_17  PMID:30459906
This report documents the occurrence, diagnosis and treatment of a 29 year-old male patient who presented with progressive swelling of the left eye with associated progressive loss of vision, three months after sustaining a closed head injury in a road traffic accident. Magnetic resonance imaging (MRI) showed a large, ill-defined lesion in the left supraclinoid and paraclinoid region with variable contrast enhancement. A four vessel Digital Subtraction Angiography (DSA) showed a large, supra-clinoid pseudoaneurysm which had ruptured inferiorly into the roof of cavernous sinus, forming direct carotid cavernous fistula (CCF) which lead to dilatation of the superior ophthalmic vein and subsequent peri-orbital oedema and chemosis of conjunctiva. Complete obliteration of the indirect CCF was achieved by coiling of the aneurysm alone. During follow up, patient reported a significant improvement in vision and follow up DSA after one year shows no recurrence with this technique.
  736 55 -
Sellar embryonal tumor: A case report and review of the literature
Fatih Yakar, İhsan Doğan, Cem Meco, Aylin Okcu Heper, Gokmen Kahilogullari
October-December 2018, 13(4):1197-1201
DOI:10.4103/ajns.AJNS_30_17  PMID:30459893
Primitive neuroectodermal tumors (PNETs) are aggressive, poorly differentiated tumors in children and young adults. However, the embryonal tumor group did not include the central nervous system (CNS) PNET title and ependymoblastoma subtitle in the 2016 World Health Organization CNS tumor classification. Here, we report the case of a 6-year-old boy with a sellar embryonal tumor and present a review of the related literature. To the best of our knowledge, this is the first case of an endoscopically operated sellar embryonal tumor in the pediatric age group.
  724 67 -
Endoscopic endonasal resection of the odontoid process in a patient with chronic injury of the C1 transverse ligament
Andrey Grin, Ivan Lvov, Ivan Godkov, Aleksey Sytnik, Anton Kordonskiy, Vladimir Smirnov
October-December 2018, 13(4):1179-1181
DOI:10.4103/ajns.AJNS_366_16  PMID:30459889
Atlas dislocation after transverse ligament injury is one of the most rare types of trauma to the upper cervical level. If magnetic resonance imaging of the craniovertebral junction reveals the Kassam line passing through the cervix of the odontoid process, a transnasal approach can be used for surgical treatment. Here, we present a case in which an endoscopic endonasal approach was used to treat chronic traumatic transligamentous atlas dislocation. A 26-year-old male underwent two-stage surgical treatment; during the first stage, posterior decompression and fixation were performed under halo immobilization. In the second stage, a transnasal endoscopic approach to the odontoid process was used. A transnasal approach permitted complete decompression of the medulla oblongata and facilitated early extubation of the patient without any postoperative complications such as respiratory or pharyngopalatine deficiency. The patient was discharged in good condition 9 days after the surgery.
  728 62 -
Two-level spontaneous pedicle fracture above a degenerative spondylolisthesis and minimally invasive treatment
Daniel Carr, Richard Floyd Cook, Matthew Bahoura, Doris Tong, Teck Soo
October-December 2018, 13(4):1279-1281
DOI:10.4103/ajns.AJNS_109_18  PMID:30459917
This is a case report and literature review. The objectives of the study are to describe minimally invasive treatment of pedicle fractures, to show contralateral pedicle changes with pedicle fracture treatment, and to review literature on incidence and mechanism of neural arch fractures. After conservative therapy, there are several options for the treatment of pedicle fractures including pediculoplasty, osteosynthesis, or fusion. As patients' age increases, the incidence of pedicle fracture may rise and minimally invasive pedicle screw treatment represents a good motion-preserving option to stabilize without fusion. We report a patient with spontaneous pedicle fractures above a degenerative spondylolisthesis and evidence of contralateral pedicle changes at L2 and L3. After minimally invasive pedicle screw placement, postoperative imaging demonstrated trabeculation across both L2 and L3 fractures with a resolution of contralateral pedicle sclerotic changes and healing of incompletely fracture contralateral pedicle at L2. Pedicle fractures lead to contralateral pedicle sclerotic changes and potential fracture and may cause significant back pain. Stabilization and healing of the neural arch can be achieved with minimally invasive placement of pedicle screws without need for fusion.
  686 96 -
Proposal of treatment strategies for bilateral chronic subdural hematoma based on laterality of treated hematoma
Satoru Takahashi, Takahiro Yamauchi, Toshihiro Yamamura, Takahiro Ogishima, Toshinari Arai
October-December 2018, 13(4):1134-1139
DOI:10.4103/ajns.AJNS_124_18  PMID:30459882
Background: Chronic subdural hematoma (CSDH) is a disorder that is commonly seen in routine neurosurgery. Although risk factors for recurrence have been studied, the findings are inconsistent. Furthermore, bilateral CSDHs are operated unilaterally or bilaterally depending on symptoms or hematoma volume. Although there are cases in which hematomas on nonoperated side in unilaterally operated bilateral CSDHs requiring for additional operation, little have been studied on the effect of the surgical selection. The purpose of this study is to identify risk factors for recurrence in operated hematomas and additional operation in nonoperated hematomas and improve surgical strategy. Materials and Methods: We retrospectively reviewed patients who underwent surgery in our facility for bilateral CSDHs between January 2011 and December 2016. Univariate and multivariate analyses were performed to examine the relationship between recurrence or requirement for additional operation and clinical and radiological variables. Results: Recurrence was observed significantly more frequent for operated hematomas when hematoma type was separated type as reported previously. In unilaterally operated bilateral CSDHs, there were 22 hematomas on nonoperated side, and five hematomas required an additional operation after the first hospitalization. Increased volume of hematoma on the nonoperated side was the risk factors for additional operation (P = 0.022). Receiver operating characteristic (ROC) curve revealed that requirement for additional operation significantly increased when hematoma volume enlarged to approximately 44 cm3 or greater 1 day after operation. Conclusions: In unilaterally operated bilateral CSDHs, when hematoma volume on nonoperated side increased 1 day after the last operation, additional operation in the early stage is considerable to prevent re-hospitalization and deterioration of activities of daily living.
  677 98 1
Posterior fossa arteriovenous malformation with multiple pedicle aneurysms and recruitment of meningeal supply
Senshu Nonaka, Hidenori Oishi, Satoshi Tsutsumi, Hisato Ishii
October-December 2018, 13(4):1250-1251
DOI:10.4103/ajns.AJNS_180_17  PMID:30459908
Cerebral aneurysms arising on the peripheral posterior inferior cerebellar artery (PICA) are rare. Here, we present a unique case of arteriovenous malformation (AVM) with pedicle aneurysms arising on the peripheral PICA and recruited by meningeal supply. A 67-year-old woman presented with subarachnoid hemorrhage. Cerebral angiography revealed two saccular aneurysms on the peripheral PICA, which formed an abnormal arteriovenous shunt adjacent to the transverse sinus. The shunt was also fed by the ipsilateral superior cerebellar and contralateral posterior meningeal arteries. The proximal aneurysm was larger and deep seated while the distal aneurysm was smaller and located superficially. The patient underwent coil embolization of the proximal aneurysm followed by microsurgical trap of the distal aneurysm and resection of the arteriovenous shunt lying superficially in the cerebellar hemisphere. The shunt was histologically verified as AVM. Staged approach with coil embolization and open microsurgery can be a treatment option for multiple PICA aneurysms associated with an AVM.
  710 64 -
Does age affects the surgical outcome in patients with unruptured cerebral aneurysms? A 2-year retrospective study from a single center in Japan
Shyam Duvuru, Treepob Sae-Ngow, Yoko Kato, Tsukasa Kawase, Yasuhiro Yamada, Riki Tanaka
October-December 2018, 13(4):1108-1111
DOI:10.4103/ajns.AJNS_151_17  PMID:30459877
Background: The management of unruptured cerebral aneurysms (UCA) in elderly population is a challenge. With a very high life expectancy and high risk of rupture in Japan, the need for identifying the best treatment modality is essential to help the patients in decision-making. Methods: This was a 2-year single-center retrospective comparative analysis of the outcomes of surgical clipping (SC) in patients aged above 75 and <75 years. The modified Rankin score was used to stratify the patients and to analyze the functional outcome. Functional status at discharge was the primary end point. Results: There were 224 patients with 239 aneurysms. About 12.5% of the patients were more than 75 years with a mean age of 77.85. The mean age of patients <75 years was 60.96, and it was statistically significant. The overall male-to-female ratio was 1:3.3. The most common location was the middle cerebral artery followed by internal carotid artery at the posterior communicating and ophthalmic segments, and 22 patients had aneurysms of the posterior circulation. Nearly 77% of the aneurysms were <6 mm. There was no significant difference in size of the aneurysm as the age increased to more than 75 years. There were complications in 6 patients, and there was no mortality in the study population. There was no statistically significant difference in the outcome between the groups. Conclusions: SC can be considered a safe option for UCA in the aging population.
  701 59 -
Airway management in case of diffuse idiopathic skeletal hyperostosis
Kundan Gosavi, Paulomi Dey, Sachin Swami
October-December 2018, 13(4):1260-1263
DOI:10.4103/ajns.AJNS_235_17  PMID:30459912
Diffuse idiopathic skeletal hyperostosis (DISH) is associated with abnormal ossification of spinal and extraspinal appendages. Incidence of DISH is high in old age with predilection for males. Cervical hyperostosis can make intubation difficult in multiple ways. Here, we report a case of DISH bridging the cervical spine from C2 to C7 vertebrae managed using awake fiberoptic technique and a small-sized endotracheal tube.
  692 64 -
Secondary arachnoid cyst – A late complication of craniotomy: A case report and review of literature
Mostafa Osman, Ahmed Diraz
October-December 2018, 13(4):1273-1275
DOI:10.4103/ajns.AJNS_68_18  PMID:30459915
Arachnoid cyst can be defined as cerebral-spinal fluid entrapment within the central nervous system. It may occur primarily as a congenital malformation or secondary as a complication following trauma, infection, bleeding, or surgical manipulation. Congenital arachnoid cyst usually asymptomatic and cause no pressure symptoms. No treatment is needed unless size increase and cause pressure symptoms and increased intracranial pressure. We report a case presented to the hospital with neurological signs of increased intracranial pressure, 3 years Post aborted craniotomy for meningioma resection. Radiological imaging showed postoperative newly developed arachnoid cyst with mass effect. He underwent the urgent cerebral spinal fluid diversionary procedure with cystoperitoneal shunt.
  702 54 -
The optimal operative timing of traumatic intracranial acute subdural hematoma correlated with outcome
Worawach Karnjanasavitree, Nakornchai Phuenpathom, Thara Tunthanathip
October-December 2018, 13(4):1158-1164
DOI:10.4103/ajns.AJNS_199_18  PMID:30459885
Objective: Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH. Materials and Methods: The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups. Results: The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome. Conclusions: The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.
  667 78 -
Persisting embryonal infundibular recess masquerading as a nasal mass
Shejoy Joshua, Shyamsundar Sreedhar, Vineeth Viswam, Dilip Panikar
October-December 2018, 13(4):1219-1221
DOI:10.4103/ajns.AJNS_92_17  PMID:30459899
Persisting embryonal infundibular recess (PEIR) is a rare anomaly of the development of the posterior pituitary wherein there is a defect in the third ventricular floor. Earlier reports have found PEIR descending only up to the sella. However, this is the first case of PEIR presenting as a pulsatile nasal mass. A 35-year-old female presented to the otorhinolaryngologist with hyposmia. Diagnostic nasal endoscopy revealed a pulsatile nasal mass. Magnetic resonance imaging revealed a cystic lesion extending from the third ventricular floor to the nasal cavity. There was no associated hydrocephalus or empty sella. The case was successfully managed by the endoscopic endonasal transsphenoidal approach.
  700 41 -
Laminectomy versus laminoplasty in the surgical management of long-segment intradural spinal tumors: Any difference in neurological outcomes?
Chiazor U Onyia, Sajesh K Menon
October-December 2018, 13(4):1128-1133
DOI:10.4103/ajns.AJNS_67_18  PMID:30459881
Background: Previous comparative studies have shown that apart from lack of any significant difference in neurologic outcomes between laminoplasty and laminectomy following resection of intradural spinal tumours, spinal column issues such as postoperative deformities, malalignment, and adjacent level disease have also been clearly demonstrated to be quite similar for both techniques. However, there is no study yet that describes any difference in neurologic outcomes for long-segment intradural lesions as a rare subset of these lesions (in terms of number of spinal segments involved) following surgical management between these two techniques. Materials and Methods: This is a retrospective review of surgical treatment with either laminectomy or laminoplasty done for patients with long-segment intradural tumors at a tertiary health-care institution in India. Results: Out of over 167 patients surgically treated for intradural tumors during the study period, a total of 60 patients were included in the evaluation. The long-segment tumors were intramedullary in 22 (36.7%) patients and intradural-extramedullary in the remaining 38 (63.3%) patients. No patient in both cohorts had any revisional surgery after initial resection or any serious complications. The incidence of neurologic function remaining unchanged at the end of follow-up was similar between laminoplasty and laminectomy (12.5% vs. 11.1%). There was no significant correlation between the preoperative McCormick score and postoperative McCormick score (P > 0.05 at 95% degree of confidence; Spearman's rho = 0.028), suggesting that functional outcomes were not dependent on the initial neurologic status. Multivariate logistic regression analysis showed that : the two independent variables (Extent of surgery and Choice of procedure) were not significant predictors of the dependent variable (Functional outcome following surgery) (odds ratio = 3.836; p = 0.071). Conclusion: This retrospective evaluation demonstrates laminoplasty not to be more or less likely to have any better functional outcome or need for revision compared to laminectomy in the resection of long-segment intradural lesions. A quality randomized controlled study on a much larger scale will be required to validate this finding.
  649 85 -
Is transposition of deep brain stimulation device a solution in patients with recurrent skin erosions?
Domenico Servello, Christian Saleh, Edvin Zekaj
October-December 2018, 13(4):1252-1253
DOI:10.4103/ajns.AJNS_184_17  PMID:30459909
Skin erosion and infection are common but serious problems in deep brain stimulation (DBS). They can lead to the removal of the entire DBS device and consequently stop the entire treatment. Of critical importance, therefore, is to find surgical solutions that allow to leave the complex DBS device in place when medical treatment fails in repeated skin complications, to allow continuing treatment in otherwise pharmacological refractory patients. We present a patient with repeated retro-auricular skin erosions, who failed to respond to surgical revisions and antibiotic treatment. However, instead of removing the DBS device as it would be general practice we succeeded with a right to left transposition of connecting cables to save the entire DBS system. There is lack of data on therapeutic surgical options in repeated skin complications. We propose the transposition of DBS device as possible solution for multiple skin erosions in DBS surgery.
  673 51 -
Surgical strategies for ruptured complex aneurysms using skull base technique and revascularization surgeries
Naoki Otani, Kojiro Wada, Terushige Toyooka, Satoru Takeuchi, Arata Tomiyama, Kentaro Mori
October-December 2018, 13(4):1165-1170
DOI:10.4103/ajns.AJNS_176_18  PMID:30459886
Object: Surgical clipping of paraclinoid aneurysm, thrombosed large aneurysm, and/or vertebral-basilar dissecting aneurysms can be very difficult and has relatively high morbidity. We describe our experience using skull base and bypass technique and discuss the advantages and its pitfalls. Patients and Methods: We retrospectively reviewed medical charts of 22 consecutive patients with complex aneurysmal lesions underwent skull base and/or bypass techniques between March 2012 and April 2017. Results: There were 5 patients with paraclinoid or internal carotid artery (ICA) aneurysm underwent modified extradural temporopolar approach with mini-peeling of the dura propria with suction decompression, 3 patients with ICA aneurysm underwent intradural anterior clinoidectomy, 12 patients with vertebral dissecting aneurysm through transcondylar fossa approach (6 patients underwent occipital artery-posterior inferior cerebellar artery [OA-PICA] bypass), 1 patients with vertebral artery dissection underwent superficial temporal artery-superior cerebellar artery and OA-PICA bypass through posterior transpetrosal approach, 1 patient with arteriovenous fistula at the ventral side of the craniovertebral junction through extremely far lateral approach. Surgical outcome was good recovery in 10 patients, moderate disability in 4, severe disability in 4, vegetative state in 2, and dead is 2 patients. The favorable outcome was 63.6%, and poor outcome was 36.4%, which showed poor grade subarachnoid hemorrhagic patients. No patient suffered any complication related to re-rupture and/or incomplete clipping. Conclusion: Skull base technique, which can create a wide and shallow operative space, allowed us to improve surgical outcome and to reduce the risk of intraoperative neurovascular injury for surgical treatment of deeply located complex aneurysms.
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A giant tumefactive perivascular space: A rare cause of obstructive hydrocephalus and monoparesis
Peter Yat-Ming Woo, Eric Cheung, James Ting-Fong Zhuang, Hoi-Tung Wong, Kwong-Yau Chan
October-December 2018, 13(4):1295-1300
DOI:10.4103/ajns.AJNS_108_18  PMID:30459922
Cerebral perivascular spaces (PVSs), otherwise known as Virchow-Robin spaces, are interstitial fluid-filled channels, <2 mm in diameter that form around arterial perforators as they course from the cortex into the brain parenchyma. In contrast, a giant tumefactive PVS is a rare entity comprising of clusters of such channels larger than 15mm resembling a neoplastic process as the name suggests. We report a 55-year-old male who presented with unsteady gait, cognitive decline, and left lower limb weakness for 6 months. Magnetic resonance imaging revealed a noncontrast enhancing multicystic intraaxial lesion of the right mesencephalon-diencephalon junction extending into the anterior third ventricle causing obstructive hydrocephalus. A ventriculoperitoneal shunt was inserted with a complete reversal of his neurological symptoms. Such PVSs can easily be misidentified for a cystic tumor, and their unique radiological features are discussed to prevent unnecessary surgery. We also demonstrate that when they cause hydrocephalus and midbrain compression symptoms cerebrospinal fluid shunting alone can result in excellent outcomes.
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Sporadic cisternal oculomotor nerve schwannoma: A rare case with review of literature
Raghavendra Marutirao, Suyash Singh, Kamlesh Singh Bhasiora, Satyadeo Pandey, Jayesh Sardhara, Kuntal Kanti Das, Arun Kumar Srivastava, Sushila Jaiswal, Sanjay Behari
October-December 2018, 13(4):1269-1272
DOI:10.4103/ajns.AJNS_104_18  PMID:30459914
Cranial nerve schwannomas usually arise from sensory nerve and the occurrence of schwannoma in a motor nerve is rare, especially in sporadic cases. Oculomotor nerve schwannomas (ONS) are rare and they are unique as they arise from motor nerve. ONS palsy may or may not be the presenting feature of oculomotor schwannoma. We present the case of a young male with ONS, presenting with oculomotor nerve palsy along with features of raised intracranial pressure. Oculomotor schwannoma is described in literature only as case reports, and oculomotor nerve is also a rare site for schwannoma as being a motor nerve. In this article, we describe a case of cisternal ONS with review of pertinent literature.
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Unfolding the Truth; the Way Towards Painfree Spine Surgery
Salman Sharif, Afifa Afsar
October-December 2018, 13(4):1303-1304
DOI:10.4103/ajns.AJNS_68_17  PMID:30459924
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Pituitary apoplexy producing internal carotid and basilar artery compression: A rare case report
Pramod Vaijnath Nagure, Vasudha Ravindra Nikam, Amit Sambhaji Garud
October-December 2018, 13(4):1264-1268
DOI:10.4103/ajns.AJNS_90_18  PMID:30459913
Pituitary apoplexy is a rare disease followed by ischemic or hemorrhagic process within the pituitary adenoma. Here, we report two cases of pituitary apoplexy with a history of sudden onset of headache, vomiting, and diminished vision. Our aim is to share our experience and discuss these cases as follows: the first one to know the compression of basilar artery along with the compression of basilar part of pons and in both the cases with compression of an internal carotid artery leading to cerebral infarcts.
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Isolated intraventricular Rosai–Dorfman disease
Pranav Pramod Patwardhan, Naina Atul Goel
October-December 2018, 13(4):1285-1287
DOI:10.4103/ajns.AJNS_134_18  PMID:30459919
Rosai–Dorfman disease (RDD) is a benign histioproliferative disorder characterized by generalized lymphadenopathy, weakness, anemia, and rarely extranodal involvement. The disease affects the central nervous system (CNS) very rarely and at a relatively older age. Isolated intracranial involvement is very rare. RDD tends to present as dural masses mimicking meningioma, though very rare case reports describe isolated parenchymal involvement in the CNS. Only one case of intraventricular RDD has been described so far to the best of our knowledge. We present a very rare presentation of this disease as an isolated intraventricular presentation in the region of the atria of the lateral ventricles.
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Surgical management of intracranial giant epidermoid cysts in adult: A case-based update
Antonella Mangraviti, Edoardo Mazzucchi, Alessandro Izzo, Cosimo Sturdà, Alessio Albanese, Enrico Marchese, Alessandro Olivi, Alfredo Puca, Carmelo Lucio Sturiale
October-December 2018, 13(4):1288-1291
DOI:10.4103/ajns.AJNS_91_18  PMID:30459920
Epidermoid cysts (ECs) are benign and slow-growing lesions that account for about 0.2%–2% of all intracranial tumors. Symptoms appear slowly and tumors may have already grown to giant proportions when patients receive their first diagnosis. The optimal treatment for ECs is surgical removal, which includes the total resection of the entire capsule of the lesion in order to minimize the risk of malignant transformation associated with partial removal. However, considering the giant size that the ECs can reach at the time of the diagnosis, and their adherence to the surrounding structures, the risks and benefits of total versus subtotal resections in the short- and long-term patients' outcome are still under debate. Here, we report a case of an extensive giant EC and offer a discussion of its characteristics, surgical management, and postoperative outcome, taking a cue to argue about the recent literature based in the latest case studies.
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Ipsa scientia potestas est: Regional epidemiological studies lead to regional strategies for stroke prevention
Pouria Moshayedi
October-December 2018, 13(4):1301-1302
DOI:10.4103/ajns.AJNS_72_17  PMID:30459923
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Venous infarct after sacrifice of single cortical vein during deep-brain stimulation surgery
Edvin Zekaj, Christian Saleh, Andrea Ciuffi, Andrea Franzini, Domenico Servello
October-December 2018, 13(4):1276-1278
DOI:10.4103/ajns.AJNS_126_18  PMID:30459916
Intracerebral hemorrhage (ICH) is the most feared and dreadful complication related to deep-brain stimulation (DBS). Bleeding may originate from arterial or venous damage. Commonly, hemorrhage is detected by postoperative imaging performed to assess lead positioning in asymptomatic patients. Rarely, hemorrhage leads to stroke, coma, or even death. We present the case of a patient who suffered a severe ICH of venous origins after bilateral DBS. Deep-brain hemorrhages are the most difficult to be predicted and to be prevented because they are caused by small vessels. As superficial hemorrhages are secondary to venous coagulation or sulcal hemorrhage, neurosurgeons must drive all efforts to minimize their occurrence.
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Intramedullary spinal cord lipoma mimicking a late subacute hematoma
Ivan Pasalic, Klara Brgic, Jakob Nemir, Danijela Kolenc, Niko Njiric, Goran Mrak
October-December 2018, 13(4):1282-1284
DOI:10.4103/ajns.AJNS_112_18  PMID:30459918
Spinal cord lipomas are rare and benign tumors which may cause progressive neurological deficits due to their local expansion. We present the case of a 59-year-old male patient with severe lumbosacral pain and slowly progressive paresis of the right leg, misdiagnosed with degenerative spine disease. Repeated magnetic resonance (MR) T1-weighted images of the thoracic spine suggested a subacute intramedullary hematoma. Due to progression of the neurological deficit, the patient was referred to a neurosurgeon, who indicated surgical evacuation of the hematoma. The intraoperative finding revealed an intramedullary spinal cord lipoma, which was later confirmed by histological analysis. Since subacute intramedullary hematomas and intramedullary spinal cord lipomas present with similar clinical and radiological features, diffusion-weighted MR imaging should be used to distinguish these entities.
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Retrobulbar lymphangioma: A rare case report
Anil Kumar, Lokesh Nehete, Jitender Chaturvedi, Nighat Hussain
October-December 2018, 13(4):1292-1294
DOI:10.4103/ajns.AJNS_165_18  PMID:30459921
We report a case of biopsy-proven retrobulbar lymphangioma in a 14-year-old girl. She presented with chief complaints of swelling in the left eye for 2 months. The patient underwent imaging evaluation and it was diagnosed as cavernous hemangioma, radiologically. However, later on, the patient underwent surgery, and the specimen was sent for histopathology which revealed it to be a lymphangioma.
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