Idiopathic hypertrophic cranial pachymeningitis.

Idiopathic hypertrophic cranial pachymeningitis is a rare form of fibrosing chronic inflammatory process of unknown etiology, which causes thickening of the intracranial dura mater. We present four patients with hypertrophic cranial pachymeningitis who presented with chronic headache and cranial nerve palsies. The diagnosis of idiopathic hypertrophic cranial pachymeningitis was based on neuroimaging findings of thickened enhancing dura, exclusion of known causes and histopathologic findings compatible with nonspecific inflammation in the meningeal biopsies. Corticosteroid therapy was effective in all cases in inducing a complete or partial remission of the neurologic symptoms and signs. We describe the clinical, radiological and pathological features of idiopathic hypertrophic cranial pachymeningitis and discuss the relationship of this entity with other inflammatory fibrosclerotic disorders to explain the pathogenesis. A high index of suspicion, prompt confirmation of the diagnosis by meningeal biopsy, and early institution and long-term maintenance of steroid therapy may help to prevent irreversible neurologic sequelae, especially blindness.

Selection of ideal candidates for epilepsy surgery in developing countries.

In order to become cost-effective, epilepsy surgery centers in developing countries will have to achieve excellent results by selecting candidates destined to have a seizure-free outcome using locally available limited technology and expertise, without compromising on patient safety. Our experience illustrates that this goal can be accomplished by selecting patients, whose epileptogenic zone can be unquestionably established, based on history, magnetic resonance imaging, and interictal and ictal scalp electroencephalogram findings. Patients with mesial temporal lobe epilepsy, and those with circumscribed potentially epileptogenic lesions belong to this category. A stepwise approach by reserving more difficult to treat patients to later date as experience develops, or by referring them to a better-equipped center, will help each center to understand its capabilities and limitations and to move forward. It would be essential to work with and educate the local public and professionals, if the epilepsy surgery program in a developing region were to have a lasting impact, It is encouraging to note that, despite major challenges, in the last one-decade, several epilepsy centers in the developing world have not only successfully implemented epilepsy surgery programs, but also have produced results comparable to that from developed countries at a fractional cost.

Brainstem abscess complicating tetralogy of Fallot successfully treated with antibiotics alone.

Medically treated brainstem abscess in a 11 year old boy with tetralogy of Fallot is reported. There was a complete resolution of the lesion without any neurologic sequelae during parenteral antibiotic therapy with crystalline penicillin, chloramphenicol and metronidazole. The pathogenesis and management of cardiogenic brain abscesses in general and brainstem abscess in particular has been reviewed.