Aim: The aim was to correlate the clinical profile and neurological outcome with findings of imaging modalities in acute spinal cord injury (SCI) patients. Subjects and Methods: Imaging (radiographs, computed tomography [CT], and magnetic resonance imaging [MRI]) features of 25 patients of acute SCI were analyzed prospectively and correlated with clinical and neurology outcome at presentation, 3, 6 and 12 months. Results: Average initial sagittal index, Gardner’s index, and regional kyphosis were 8.12 ± 3.90, 15.68 ± 4.09, 16.44 ± 2.53, respectively; and at 1-year were 4.8 ± 3.03, 12.24 ± 4.36, 12.44 ± 2.26, respectively. At presentation patients with complete SCI had significantly more compression percentage (CP) (P < 0.001), maximum canal compromise (P < 0.001), maximum spinal cord compression (P < 0.001), in comparison to incomplete SCI patients. Qualitative MRI findings; hemorrhage, cord swelling, stenosis showed a predilection toward complete SCI. Improvement in canal dimensions (P = 0.001), beck index (P = 0.008), spinal cord edema (P = 0.010) and stenosis (P = 0.001) was more significant in patients managed operatively; but it was not associated with improved neurological outcome. Cord edema was found more in incomplete SCI patients. Patients presenting with complete SCI improved neurologically to a lesser extent. Conclusions: The present study concludes that imaging modalities in spinal cord injuries have a major role in diagnosis, directing management and predicting prognosis. Imaging findings of severe kyphotic deformities, higher canal and cord compression, lesion length, hemorrhage, and cord swelling are associated with poor initial neurological status and recovery. Quantitative and qualitative parameters measured on MRI have a significant role in predicting initial severity of neurological status and outcome. Operative intervention helps in improving few of these imaging parameters, but not ultimate neurological outcome. MRI is an excellent modality to evaluate acute SCI, and MR images obtained in the acute period significantly and usefully predict neurological outcome.

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Background: Spinal intradural extramedullary teratoma is a rare condition, more common in children than in adults often with a history of spinal dysraphism. Method: We reviewed the literature and Pubmed advanced search showed nine results of intradural extramedullary teratoma in adults which included five independent case reports and three cases in a case series. We reported a rare case of intradural extramedullary teratoma in an adult located opposite L4 vertebra with neither spinal dysraphism nor any history of the prior spinal procedure. Results: The occurrence of teratomas in the spine is extremely rare. Further, spinal intradural extramedullary teratoma is more common in children but a rare entity in adults. Conclusion: Although uncommon, spinal cord neoplasm should be considered in the differential diagnosis of backache or radicular pain associated with neurological deficits even in absence of spinal dysraphism or any spinal procedure.

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Background: Gliosarcoma (GS), a subtype of glioblastoma (GBM), is a rare primary neoplasm of the central nervous system. Certain features like temporal lobe affinity, tendency for extraneural metastasis and poorer outcome compared to GBM indicate that GS may indeed be a separate clinicopathologic entity. This led us to revisit this entity in our settings. Materials and Methods: Between 2009 and 2014, 16 cases of histologically proven GSs (14 primary, two secondary) were treated. Patient data were retrieved retrospectively. Statistical analysis was performed with? Statistical Package for Social Sciences, version 17.0. (Chicago, Illinois, USA). Survival was analyzed by Kaplan–Meier method. Results: GS predominantly affected males in their fifth decade of life. Raised intracranial pressure was the most common mode of clinical presentation. Temporal lobe was the most commonly affected part of the brain and majority of primary and all of secondary GBM were located peripherally. In 7 (43.8%) patients, tumor was radiologically well-demarcated and enhanced strongly and homogenously on contrast as compared to 9 (56.2%) patients where the tumor was ill-defined and showed heterogenous patchy or ring enhancement. Extent of excision was total in seven patients (43.8%), near total in 4 (25%) and subtotal in five patients (31.2%). Median survival was 6 months. Patients with well-demarcated, enhancing mass on imaging intraoperatively had firm tumors with a good plane of cleavage and had a better survival (8 months) compared to those in whom the tumor radiologically and intraoperatively mimicked GBM (2 months). Conclusion: GS is associated with poor survival (median survival 6 months). Radiological and intraoperative findings help categorize these tumors into GBM like GS and meningioma like GS. While the former histologically mimics GBM and has very poor survival (2 months), GS with meningioma like feature tends to have better survival (8 months).

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Unilateral oculomotor nerve palsy is a rare and challenging condition for both emergency department (ED) physicians and neurosurgeons. In this report, we present you a case of head trauma with oculomotor nerve palsy whose initial neuroimaging findings were normal. A 50-year-old female presented to our ED due to head trauma secondary to fall from height. On her physical examination, ptosis, minimal lateral deviation, and dilated pupilla unresponsive to the light were determined in the left eye. A computed tomography and magnetic resonance imaging were performed and both were found to be normal. Patient was consulted with an ophthalmologist and any sign of direct trauma to the eye was not determined. Then, the patient was consulted with a neurosurgeon and hospitalized. In some rare instances, minor traumas to the head may result in isolated oculomotor nerve palsy without accompanying findings. Neurosurgeons and ED physicians must be careful about this rare condition.

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Objective and Background: The objective of this study is to evaluate how the neurological outcome in patients operated for cervical spinal cord injury (SCI) is influenced by surgical timing, admission American Spinal Injury Association (ASIA) grading system, and age. Materials and Methods: From January 2004 to December 2011, we operated 110 patients with cervical SCI. Fifty-seven of them (44 males and 13 females) with preoperative neurological deficit, were included in this study with a complete follow-up. Age, sex, associated comorbidities (evaluated with Charlson comorbidity index [CCI]), mechanism of trauma, preoperative and follow-up ASIA score, time elapsed from injury to surgical treatment, preoperative cervical computed tomography scan or magnetic resonance imaging, type of fractures, and surgical procedure were evaluated for each patient. The patient population was divided into two groups related to the timing of surgery: Ultra-early surgery group (within 12 h from the trauma, 27 patients) and early surgery (within 12–72 h from the trauma, 30 patients). Statistical Analysis Used: The univariate analysis of data was carried out by the Chi-square test for discrete variables, the t-test for the continuous ones. Logistic regression was used for the multivariate analysis. Results: Neurological outcome was statistically better in ultra-early surgery group (<12 h) than in patient underwent surgery within 12–72 h (82.14% vs. 31%, multivariate analysis P = 0.005). The neurological improvement was also correlated with the age and the ASIA grade at admission in the univariate analysis (P = 0.006 and P = 0.017 respectively) and in the multivariate 1 (P = 0.037 and P = 0.006 respectively) while the CCI was correlated with the improvement only in the univariate analysis (P = 0.007). Conclusion: Nowadays, in patients with cervical SCI early surgery could be associated with improved outcome, most in case of young people with mild neurological impairment.

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An aneurysmal bone cyst (ABC) is a benign, locally proliferative vascular disorder of non-neoplastic osseous lesions in children and young adults. Seventy-five percent of ABCs occur before the age of 20 years. They comprise 1.4% of all primary bone tumors, and commonly occur in the long bones. Spinal ABCs are much rarer. We present to you one such rare case of ABC involving the lumbar spine which was successfully treated with surgery. The clinical pathological and radiological features are described. The treatment options available are discussed.

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Shunt calcification is a rare complication of ventriculoperitoneal shunting that occurs years later after the initial operation this condition is rarely reported in literature. Two patients with shunt calcifications were described. The first patient was 17-year-old lady who had congenital hydrocephalus and shunted in the early infancy, she was presented recently complaining of itching of the skin along the shunt track and limitation of neck movement. The patient was then operated with removal of the old peritoneal catheter and replacing it with a new one. The second patient was 17-year-old boy originally was a case of posterior fossa pilocytic astrocytoma associated with obstructive hydrocephalus, he was operated with both shunting for the hydrocephalus and tumor removal, 6 years later he presented with shunt exposure. Calcification of the shunt tube was discovered intraoperatively upon shunt removal. Shunt calcification has been observed mainly in barium-impregnated catheters. Introducing plain silicone-coated shunt tubing may reduce the rate of this condition. The usual complaints of the patients suffering from this condition are pain in the neck and chest wall along the shunt pathway and limitation of the neck movement due to shunt tube tethering, but features of shunt dysfunction and skin irritation above the shunt may be present. In this review, plain X-ray and operative findings showed that the most extensive calcification is present in the neck, where the catheters were subject to heavy mechanical stress. Disturbed calcium and phosphate metabolisms may be involved in this condition. Shunt calcification is a rare condition that occurs due to material aging presenting with features of shunt tethering, dysfunction or overlying skin irritation. Plain X-ray is needed to detect calcification while shunt removal, replacement or endoscopic third ventriculostomy may carry solution for this condition.

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Objectives: Our main objective was to evaluate whether serum hypocalcaemia (defined as <2.1 mmol/L [8.5 mg/dL]) and ionized serum calcium (defined as <1.10 mmol/L [4.5 mg/dL]) is a prognostic factor for mortality and morbidity (defined as Glasgow outcome score [GOS] ≤3) in early moderate and severe traumatic brain injury (TBI). Materials and Methods: We developed a retrospective study and evaluated clinical profiles from included patients from January 2004 to December 2012. Patients were between 16 and 87 years old and had a Glasgow coma scale of 3–13 points following TBI, with demonstrable intracranial lesions in cranial computed tomography. Results: We found a significant statistical difference (P < 0.008) in the ionized serum calcium levels on the 3^rd day of admission between the groups: GOS ≤3 and >3 (disability/death). According with the receiving operative curves analysis, we found that the best level of higher sensitivity (83.76%) and specificity (66.66%) of hypocalcaemia of serum ionized calcium on 3^rd day was the value of 1.11 mmol/L, with an odds ratio value of 6.45 (confidence intervals 95%: 2.02–20.55). Conclusions: The serum levels of ionized calcium on day 3 could be useful for the prediction of mortality and disability in patients with moderate and severe TBI.

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Split cord malformation (SCM) is a rare congenital anomaly in which the cord is split over a portion of its length to form double dural tubes (SCM type I) or two hemicords in a single dural sheath (SCM type II). Dachling Pang classified SCM into 2 types with type I SCM consisting of two hemicords, each contained within its own dural sheath and separated by rigid osseocartilaginous median septum. We report a rare case of SCM type 1 c in which there was a single dural sheath.

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We report a case of a median nerve schwannoma, a rare type of a benign tumor of Schwann cells that presents as a palpable and painful mass on the flexor aspect of the forearm. Schwannomas of the median nerve make up 0.1–0.3% of all hand tumors. Symptoms are caused by an entrapment syndrome resulting from the growing tumor. Pain is the most common complaint of schwannomas. Imaging studies include computed tomography and magnetic resonance imaging and ultrasound. It is difficult to differentiate schwanommas from neurofibromas solely on the basis of a radiological investigation. Tumors of the median nerve are diagnostically challenging and median nerve schwannomas are rare. Diagnostic pearls are described to facilitate a more accurate and timely diagnosis. These characteristics include mobility, Tinel’s sign, S-100 histological staining, and Antoni patterns. With a correct diagnosis, the tumor can be extirpated with preservation of nerve function and a low risk of recurrence.

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Arteriovenous malformation (AVM) of the scalp is an uncommon entity. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complications. The etiology of scalp AVMs that is, cirsoid aneurysm may be spontaneous or traumatic. Clinical symptoms frequently include pulsatile mass, headache, local pain, tinnitus; and less frequently, hemorrhage and necrosis. Selective angiography is the most common diagnosis method. Surgical excision is especially effective in AVMs and the most frequently used treatment method. Here, we present one such case where staged embolization, excision, and subsequent grafting was done.

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Background: The objective was to determine the predictors of posttraumatic psychiatric disorders (PTPD) during the first 6 months following traumatic brain injury (TBI) focusing on neuroimaging, clinical and neuropsychological appraisements during acute and discharge phase of TBI. Materials and Methods: We designed a prospective, longitudinal study in which 150 eligible TBI patients were entered. Postresuscitation brain injury severity and discharged functional outcome were evaluated by standard clinical scales. First neuroimaging was done at a maximum of 24 h after head trauma. Early posttraumatic (PT) neuropsychological outcomes were assessed using Persian neuropsychological tasks at discharge. The standardized psychiatric assessments were carefully implemented 6 months postinjury. A total of 133 patients returned for follow-up assessment at 6 months. They were divided into two groups according to the presence of PTPD. Results: Apparently, aggression was the most prevalent type of PTPD (31.48%). There was no significant difference between groups regarding functional outcome at discharge. Diffuse axonal injury (12.96%) and hemorrhages (40.74%) within the cortex (42.59%) and sub-cortex (33.33) significantly occurred more prevalent in PTPD group than non-PTPD ones. Primary postresuscitation TBI severity, early PT lingual deficit and subcortical lesion on first scan were able to predict PTPD at 6 months follow-up. Conclusion: Almost certainly, the expansive dissociation risk of cortical and subcortical pathways related to linguistic deficits due to severe intracranial lesions over a period of time can augment possibility of subsequent conscious cognitive-emotional processing deficit, which probably contributes to latter PTPD. Hence, early combined therapeutic supplies including neuroprotective pharmacotherapy and neurofeedback for neural function reorganization can dampen the lesion expansion and latter PTPD.

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Objective: Homonymous hemianopia due to damage to the optic radiations or visual cortex is a possible consequence of tumor resection involving the temporal or occipital lobes. The purpose of this review is to present and analyze a series of studies regarding the use of awake craniotomy (AC) to decrease visual field deficits following neurosurgery. Materials and Methods: A literature search was performed using the Medline and PubMed databases from 1970 and 2014 that compared various uses of AC other than intraoperative motor/somatosensory/language mapping with a focus on visual field mapping. Results: For the 17 patients analyzed in this study, 14 surgeries resulted in quadrantanopia, 1 in hemianopia, and 2 without visual deficits. Overall, patient satisfaction with AC was high, and AC was a means to reduce surgery-related complications and cost related with the procedure. Conclusion: AC is a safe and tolerable procedure that can be used effectively to map optic radiations and the visual cortices in order to preserve visual function during resection of tumors infiltrating the temporal and occipital lobes. In the majority of cases, a homonymous hemianopia was prevented and patients were left with a quadrantanopia that did not interfere with daily function.

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Ganglioneuroma is a rare, benign, slow-growing, well-differentiated tumor consisting ganglion cells and Schwann cells. Ganglioneuromas originate from neural crest cells and can affect any part of the sympathetic tissue from the skull base to the pelvis. However, ganglioneuroma occurring in the nerve root is extremely rare. We describe a 44-year-old man with ganglioneuroma involving the right fifth lumbar nerve root.

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Right lower quadrant pain after a lumbar discectomy is a rare condition. We report on a 29-year-old man who developed right lower quadrant pain 12 h after lumbar discectomy due to the formation and rupture of a right iliac artery pseudoaneurysm. The diagnostic laparoscopy was done under the impression of acute appendicitis but showed a retroperitoneal hematoma. An emergency abdominal computed tomography confirmed a right iliac artery pseudoaneurysm rupture. We performed a transarterial embolization with multiple metallic coils in the aneurysm cavity and connected the proximal and distal right internal iliac artery because his hemodynamics became progressively unstable. In this article, in addition to presenting the clinical course of an unusual case, we also wanted to emphasize that patients with right lower quadrant pain could be presenting an early sign of pseudoaneurysm formation and rupture after a lumbar discectomy.

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The syndrome of spontaneous intracranial hypotension is often difficult to treat. Unfortunately, cerebrospinal fluid leaks are often numerous and difficult to detect radiologically. Multiple entries to the spinal epidural space, in an effort to alleviate symptoms, are therefore sometimes necessary. This case report details two patients treated successfully with a single lumbar entry point and the administration of a continuous multi-site epidural blood patch via a mobile catheter and their subsequent follow-up. These procedures are based on that first published by Ohtonari et al. in 2012. It is, to our knowledge, the first undertaken in Australasia.

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Introduction: The association between ABO blood groups and intracranial aneurysms is not well-known. Many co-morbid factors are associated with intracranial aneurysms. Our objective was to assess the prevalence of different blood group in patients with intracranial aneurysm and to look for associations between risk factors and these groups. Materials and Methods: This retrospective study includes 1,491 cases who underwent surgical operations for intracranial aneurysms from 1993-2014. We have evaluated the information related to clinical history, ABO blood groups and associated risk factors in the patients both ruptured and unruptured intracranial aneurysms by chart review of the cases. Results: In our study, out of 1,491 cases, the most common ABO blood groups were group O (668 cases, 44.80%) and Group A (603 cases, 40.44%), and Rh(+) in 1,319 (88.4%) and Rh(-) in 147 (11.6%). Blood Group A (43% vs. 36%) and Group B (16.2% vs. 8.6%) were significantly higher in Caucasian and African Americans respectively. However, in general population, there was no significant difference in blood groups between Caucasians and African Americans. Rh(-) factor was significantly higher in Caucasians compared to African Americans. Incidence of smoking was significantly higher in aneurysm patients with O group compared to others. In addition, incidence of hypercholesterolemia was significantly higher in aneurysm patients with A group compared to others. Conclusion: The racial disparity in the distribution of blood groups, and risk factor association with blood groups in the development of intracranial aneurysm needs to be considered. The findings from our study may be useful in identifying patients at increased risk. Further study may be required to establish the risks from multiple centers studies around the world.

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Aims: This study was done with the aim to compare the clinical outcome and patients’ quality of life between early versus delayed surgically treated patients of acute subaxial cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute subaxial cervical spinal cord trauma is safe and is associated with improved outcome as compared to delayed surgical decompression. Materials and Methods: A total of 69 patients were recruited and divided into early decompression surgery Group A (operated within 48 h of trauma; n = 23) and late/delayed decompression surgery Group B (operated between 48 h and 7 days of trauma; n = 46). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion. Results: The early surgery group spent lesser days in the intensive care unit and hospital (Group A 28.6 vs. Group B 35 days) had lesser postoperative complications (Group A 43% vs. Group B 61%) and a reduced mortality (Group A 30% vs. Group B 45%). In Group A, 38% patients had 1 American Spinal Injury Association (ASIA) grade improvement while 31% experienced >2 ASIA grade improvement. In Group B, the neurological improvement was 27% and 32%, respectively (P = 0.7). There was a significant improvement in the postoperative quality of life scores in both groups. Conclusion: Early surgery in patients with acute subaxial cervical spine injury should be considered strongly in view of the lesser complications, early discharge, and reduced mortality.

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Introduction: Decompressive craniectomy as a surgical treatment for brain edema has been performed for many years and for several different pathophysiologies, including malignant middle cerebral artery (MCA) infarct. The purpose of this article was to share author’s experience with decompressive craniectomy in malignant MCA infarct with special emphasis on patients older than 60 years and those operated outside 48 h after onset of stroke. Materials and Methods: Totally, 53 patients who underwent decompressive craniectomy after malignant MCA infarction between January 2012 and May 2014 at tertiary care hospital were analyzed for preoperative clinical condition, timing of surgery, cause of infarction, and location and extension of infarction. The outcome was assessed in terms of mortality and scores like modified Rankin scale (mRS). Results: Totally, 53 patients aged between 22 and 80 years (mean age was 54.92 ± 11.8 years) were analyzed in this study. Approximately, 60% patients were older than 60 years. Approximately, 74% patients operated within 48 h (25 patients) had mRS 0–3 at discharge while 56% patients operated after 48 h had mRS 0–3 at discharge which is not significant statistically. 78% patients aged below 60 years had mRS 0–3 at discharge while only 38% patients aged above 60 years had mRS 0–3 at discharge which was statistically significant (P < 0.008). Conclusion: Decompressive craniectomy has reduced morbidity and mortality especially in people aged below 60 years and those operated within 48 h of malignant MCA stroke though those operated outside 48 h of stroke also fare well neurologically, there is no reason these patients should be denied surgery.

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The growing skull fracture (GSF) occurs in younger age group as a sequel of trauma. The most common site of these lesions is parietal region. Here we are presenting a case of GSF of posterior fossa with cerebrospinal fluid (CSF) fistula. As per literature, we have not found a single case of GSF in the posterior fossa with CSF fistula. The aim of this presentation is discussing the unusual presentation of GSF and its management.

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Tuberculosis (TB) is a well-known endemic in developing countries. However calvarial TB is quiet rare even in such endemic areas. The most common sites affected are the frontal and parietal bones with destruction of both the inner and outer table. We hereby report a young male presenting to us with scalp swelling in the right temporal region with pus discharging sinus after an episode of tooth extraction for dental infection. Radiology revealed a loculated swelling within the right temporalis muscle and an associated bony defect in the right parietal bone. The patient was operated upon and the biopsy was suggestive of tubercular pathology. The patient improved on antitubercular therapy. The rare presentation of calvarial TB occurring secondary to dental infection along with relevant literature is discussed here.

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Lumbosacral perineural cysts (Tarlov’s cysts) are nerve root cysts, which are usually asymptomatic and are detected incidentally on imaging. These cysts are rare with an incidence of 4.6%. We report three cases of Lumbosacral Tarlov’s cysts, which presented with cauda equina syndrome and radicular pain syndrome. Two of our patients had symptoms of cauda equina syndrome, and one had acute sciatica. Complete excision of the cyst was achieved in two patients and marsupialization of the cyst was done in another patient due to its large size and dense adherence to the sacral nerve roots. All the patients were relieved of the radicular pain with no new neurological deficit following surgery. Symptomatic lumbosacral Tarlov’s cyst is a rare lesion, and the presentation can be low back pain, cauda equina syndrome or sciatica. Therefore, this entity should be kept in the differential diagnosis of patients presenting with these symptoms. Complete Surgical excision of these symptomatic cysts is the treatment of choice to achieve a cure.

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Hereditary angioedema is an autosomal dominant disorder following a genetic defect of C1 inhibitor gene on chromosome 11. This rare condition presents itself as a recurrent attack of submucosal swelling mostly involving skin, gastrointestinal tract and upper respiratory airway and exacerbates with any physical and emotional stress. Prompt diagnosis and prevention of an acute attack with early recognition and effective treatment can protect the patient from potential laryngeal edema and fatality.

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Cerebral proliferative angiopathy (CPA) is a unique and rare vascular malformation with distinct clinico-radiological features. CPA is associated with low risk of hemorrhage as compared to classical cerebral arteriovenous malformations (AVMs). Infratentorial location of diffuse nidus is also an uncommon presentation. Infratentorial hemorrhagic presentation of CPA is a rare co-occurrence. Herein, we report a case of an elderly old male, who presented with acute onset severe headache, recurrent vomiting, vertigo and swaying toward left side while walking. Cerebellar signs in the form of scanning speech, nystagmus, impaired finger-to-nose incoordination test, dysdiadochokinesia, and limb ataxia on the left side were present. Magnetic resonance imaging (MRI) brain revealed diffuse vascular network with intermingled normal brain parenchyma and hemorrhage in the left cerebellum. Digital subtraction angiography (DSA) revealed diffuse, ill-defined, nidus in left posterior fossa involving the left posterior inferior cerebellar, anterior inferior cerebellar and posterior cerebral arterial territories. There were no definite arterial feeders. DSA showed scattered “puddling” appearance of contrast material in the widespread nidus and drained into the multiple ill-defined posterior fossa veins. The MRI brain and DSA findings were consistent with the diagnosis of the CPA. Treatment in our case was limited to supportive medical therapy because selective embolization was not feasible due to nonidentifiable arterial feeders. He was asymptomatic at 1-year follow-up. This case highlights a rare entity called CPAs, which have different clinical presentations, angiographic features, treatment options and patient outcome as compared to classical cerebral AVMs.

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Introduction: Intraoperative neurophysiological monitoring (IOM) during neurosurgical procedures has become the standard of care at tertiary care medical centers. While prospective data regarding the clinical utility of IOM are conspicuously lacking, retrospective analyses continue to provide useful information regarding surgeon responses to reported waveform changes. Methods: Data regarding clinical presentation, operative course, IOM, and postoperative neurological examination were compiled from a database of 1014 cranial and spinal surgical cases at a tertiary care medical center from 2005 to 2011. IOM modalities utilized included somatosensory evoked potentials, transcranial motor evoked potentials, pedicle screw stimulation, and electromyography. Surgeon responses to changes in IOM waveforms were recorded. Results: Changes in IOM waveforms indicating potential injury were present in 87 of 1014 cases (8.6%). In 23 of the 87 cases (26.4%), the surgeon responded by repositioning the patient (n = 12), repositioning retractors (n = 1) or implanted instrumentation (n = 9), or by stopping surgery (n = 1). Loss of IOM waveforms predicted postoperative neurological deficit in 10 cases (11.5% of cases with IOM changes). Conclusions: In the largest IOM series to date, we report that the surgeon responded by appropriate interventions in over 25% of cases during which there were IOM indicators of potential harm to neural structures. Prospective studies remain to be undertaken to adequately evaluate the utility of IOM in changing surgeon behavior. Our data is in agreement with previous observations in indicating a trend that supports the continued use of IOM.

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Orbito-zygomatic craniotomy is a widely accepted skull-based technique, but osteotomy at the malar eminence (ME) is complicated. We have developed a safe fronto-orbito-zygomatic (FOZ) osteotomy by creating small guide burr holes in the superior and lateral parts of the orbital wall and cutting the bone using a diamond-coated threadwire saw. This method involves standard two-piece osteotomy by creating small superior and lateral guide orbital burr holes instead of sectioning into the superior and inferior orbital fissures. The guide burr holes are connected using a diamond-coated threadwire saw to create the FOZ bar. This method was applied to the treatment of four patients with skull-based tumors or internal carotid and basilar artery aneurysms. Postoperative three-dimensional bone density computed tomography showed minimum bone gap in the ME. No craniotomy-related complication has occurred. FOZ osteotomy by creating guide burr holes in the orbital wall and cutting the bone using a diamond-coated threadwire saw is safe and results in minimum bone gap in the ME.

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Different surgical procedures have been used in the management of chronic subdural hematoma (CSDH). Nowadays treatment with burr hole is more preferable than craniotomy in most clinics. We present two cases of CSDH, which caused neurological deficits. In both cases cortical membranectomy was performed following craniotomy. After this procedure, significant improvement was observed in patients neurological deficits. We recommend that craniotomy and subtotal membranectomy may be a more adequate choice in such cases. This report underlined that craniotomy is still an acceptable, safe, efficient and even a better procedure in selected patients with CSDH.

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A 9-year-old boy admitted to the neurosurgical hospital complaining of headache, vomiting, abdominal pain, and weakness in the arms and legs, urinary retention. Previously, the patient had a treatment of pediatricians. He was examined, magnetic resonance imaging revealed the tumor of the conus medullaris and cauda equina. The surgery was performed with removal myxopapillary ependymoma (ME). Postoperative neurological symptoms regressed; he has received radiotherapy postoperatively. This case illustrates a rare clinical presentation of ME, which simulated intracranial, thoracic, and caudal pathology. We presented features of the clinical presentation, diagnostics, and treatment options of this ependymoma.

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Cerebellar anaplastic astrocytoma is infrequently encountered even nowadays, and drop metastasis with progression into spinal glioblastoma is not reported in the English literature. We report a case of cerebellar anaplastic astrocytoma receiving operation and subsequent concurrent chemoradiotherapy. One year later, progressive weakness of both lower limbs and unsteady gait occurred. Spine magnetic resonance imaging showed cervical and thoracic spine intramedullary tumor. We then performed laminectomy and tumor biopsy. The histopathological report demonstrated primary spinal cord glioblastoma multiforme with positive glial fibrillary acidic protein, high MIB-1 labeling index and negative staining of isocitrate dehydrogenase-1 mutation. After reviewing the English literature to date, most metastatic spinal glioblastoma resulted from previous intracranial glioblastoma, and there are few studies mentioning spinal glioblastoma originating from intracranial low-grade gliomas. Over time, improvement in local control of the primary tumor has raised patient risk of the possibility of spinal metastasis, and clinical physicians should be aware of this aspect so that quicker diagnosis and management will be accomplished, even in patients with lower grade of intracranial gliomas.

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Anterior cervical discectomy/corpectomy and fusion is performed in degenerative, traumatic and neoplastic etiologies of the cervical spine. This procedure is highly successful and associated with fewer complications. The rates of early and late postoperative infection have been reported to be between 0.1% and 1.6%, the late infections are being very rare. We report a rare case of a 30-year-old HIV negative, non-diabetic male who developed a late prevertebral cervical abscess with discharging sinus over posterior triangle of neck 3 years after an anterior cervical C6 corpectomy with fibular grafting and buttress screw fixation performed elsewhere for traumatic fracture C6 vertebra. The abscess was drained using radical neck dissection approach with complete excision of sinus track and removal of the infected implant. On culture, the organism was found to be beta-hemolytic streptococci, for which appropriate antibiotics were administered postoperatively. The sinus tract completely healed in 3 months time. Late infection as a complication of anterior cervical spine surgeries is rare and is associated with esophageal perforation, implant migration, seeding of the deep prevertebral space with oropharyngeal flora, or from surgical site/bacteremia or with Zenker’s diverticulum. Few cases have been reported till date, but none have presented with a sinus tract. We present a case of delayed prevertebral abscess after cervical spine instrumentation that followed abnormal path causing sinus track to be developed in the site (the posterior triangle of the neck) other than previous incision site. Exploring both triangles of the neck using radical neck dissection approach was essential for complete excision of sinus track, removal of screw and debridement.

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Aim: Abnormal motor response in the form of decerebration signifies either injury or compression of brain stem. The presence of decerebrate rigidity following head injury is a grave prognostic sign. Mortality may increase up to 70% in patients showing signs of decerebration. Although many studies have identified the prognostic factors in severe head injuries, few studies have focused on the operated patients with decerebration in predicting the long-term outcome. This study was planned to determine the outcome in this group of patients for prognostication and to help plan further line of management. Materials and Methods: All the patients admitted with severe head injury with decerebration (M2 motor response) admitted in neurosurgery department from September 2009 to January 2011 were included in the study. All the patients had operable supratentorial mass lesions with no direct evidence of brain stem damage. Patients with penetrating injury and diffuse injury with no operative mass lesions were excluded from the study. Clinical and computerized tomography (CT) data were correlated with outcome retrospectively. Glasgow outcome scale (GOS) was used as a measure of functional outcome. Results: The patients admitted with decerebration (M2 motor response) comprised 8% of the total head injury related operative procedures performed at our institute during the period. Of the 72 patients, 14 (19%) patients were more than 60 years old and 21% (15) were females. The surgical mass lesions comprised extradural hematoma in 27 (38%), cerebral contusions in 19 (26%), acute Subdural Hematoma alone in 7 (10%), and acute Subdural Hematoma (SDH) with cerebral contusion in 19 (26%) of the patients. Of the 72 patients, 36(50%) were operated within 24 hours of injury Follow-up of all, but 2 (3%) was obtained. Favorable outcome (GOS 4 and 5) was obtained in 14% (n = 10) of the patients with 83% (n = 60) mortality rate. The favorable outcome rate among the patients operated for Extradural Hematoma was 26% and for cerebral contusions was 11%. Only 5% of the patients operated for acute SDH survived. Conclusion: Radiological diagnosis (type of lesion), followed by duration of decerebration and age of the patient are the most important prognostic factors determining the outcome of surgery in decerebrating patients. Our results confirm that despite the poor prognosis in decerebrate patients, a significant number of patients may still survive and have a good outcome.

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Objective: Patients with head injury who are not identified at admission are a challenge to manage and in this backdrop we decided to analyze our data of such pediatric patients for their outcome. Materials and Methods: It was a retrospective study conducted at the level-I trauma center. A total of 12 consecutive pediatric (<20 years) age group patients whose identities were not known at the time of admission were included in the study. Results: All 12 patients were male. The road traffic accident was the most common cause of injury (8, 67%). Mean age of the patients were 16.75 ± 4.45 years. Computerized tomography (CT) scan showed cerebral contusion in four (33%) patients. Six (50%) patients needed surgery and others were treated conservatively. During the course of hospital treatment, one (8%) patient died, two (16%) had good recovery, and four (33%) were moderately disabled. Among the 12 patients identity, eight (67%) could be ascertained. Seven (58%) patients were sent home with their relatives, one (8%) was referred to a district hospital and three (25%) remained as unknown and were referred to destitute home for rehabilitation. Conclusion: Unidentified patients of pediatric age group have better outcome if proper care is provided in time.

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