Brain abscess in a non-penetrating traumatic intracerebral hematoma: case report and review of literature.

We report a 57-year-old man who presented one month after sustaining a traumatic right temporal intracerebral hematoma with history of headache, left hemiparesis and altered sensorium of two days duration. A diagnosis of right temporal resolving hematoma was made on computed tomography scan. However, his sensorium progressively deteriorated and he underwent craniotomy and partial excision of an abscess. He was treated with appropriate antibiotics for six weeks despite of which he did not improve and died nine months later. We conclude that there should be a high index of suspicion for brain abscess in patients with traumatic intracerebral hemorrhage if the clinical and radiological picture is different from the expected course of a resolving hematoma.

Chondromyxoid fibroma of the seventh cervical vertebra.

Chondromyxoid fibroma is a rare benign bone tumor representing less than 0.5% of all bone tumors. It commonly involves the long tubular bones. Involvement of the spine is rare. A 35-year-old man presented with history of neck pain, restriction of neck movements, pain and numbness along the medial aspect of the left forearm and weakness with wasting of the left hand. A presumptive diagnosis of a bony tumor such as an aneurysmal bone cyst or a giant cell tumor involving the seventh vertebral body was made on plain X-rays, MRI and bone scan. He underwent C7 central corpectomy, incomplete intralesional curettage with iliac bone grafting and C6 to T1 interspinous wiring. The histological diagnosis was chondromyxoid fibroma. On eight years' follow-up, CT scan showed no progression of the tumor with good alignment and fusion of the graft at the site of the corpectomy. The authors conclude that corpectomy and iliac bone grafting for chondromyxoid fibroma has a good outcome on long-term follow-up.

Surgical management of intracranial fungal masses.

Background: Intracranial fungal masses (IFMs, granulomas and abscesses) are uncommon lesions, infrequently encountered by neurosurgeons. There is no conclusive evidence on the ideal surgical management of these lesions. Aims: To summarize the recent literature on the prevalence, presentation, surgical management and outcome of patients with IFMs. Materials and Methods: The recent published literature was searched using standard search engines (PubMed and Google) for articles reporting on the databases and surgical management of IFMs. A special effort was made to include publications from Indian centers. Results: Intracranial fungal masses were rarely seen even in major neurosurgical centers in India with a prevalence of around one to two per year. While most patients with IFM have immunosuppressed states, nearly 50% of patients with IFMs (especially in India) have no obvious predisposing causes and are apparently immunocompetent. The clinical presentation could be categorized into three groups: 1. Involvement of the cranial nerves 1 to 6 with orbital and nasal symptoms. 2. Focal neurological deficits due to involvement of any part of the neuraxis; and 3. "Stroke-like" presentation with sudden onset of hemiparesis. Based on the presence or absence of radiological evidence of paranasal sinus disease, IFMs were classified into two types: 1. Rhinocerebral type; 2. Purely intracranial type that was further divided into a. intracerebral or b. extracerebral forms. Aspergillus species was the commonest fungal organism causing IFMs but a number of other fungi have been reported to cause IFMs. Surgery for IFMs can be of different types, namely 1. Stereotactic procedures; 2. Craniotomy; 3. Shunt surgery; and 4. Treatment of fungal aneurysms. Generally, radical surgery is advocated for IFMs but there is no unanimity regarding the radicality of the excision especially for the rhinocerebral form of the disease. Surgery should always be followed by antifungal therapy for prolonged periods. Mortality and morbidity in patients with IFMs is very high and ranges from 40-92%. Immunosuppressed patients with IFMs and those in whom the diagnosis is delayed have the highest mortality rates, with immunocompetent patients with the rhinocerebral form of the disease having the best outcome. Conclusions: There should be a high index of suspicion for IFMs not only in patients with known risk factors for the development of fungal infections but also in immunocompetent patients in India. Intraoperative pathological diagnosis should be obtained in any patient suspected to have an IFM and tissue should be processed for fungal cultures. Prompt diagnosis, radical and safe surgery and aggressive and prolonged treatment with anti-fungal agents may lead to a better outcome especially in immunocompetent patients.

Unusual presentation of the "syndrome of the trephined".

A 45-year-old lady underwent right fronto-parietal craniotomy and subtotal excision of a parasagittal meningioma. Bone flap was not replaced as it was infiltrated by the tumor. In the postoperative period she developed episodes of altered sensorium associated with worsening of left hemiparesis and a sunken scalp at the site of bone defect. Computed tomography (CT) of brain showed sunken scalp flap in the right fronto-parietal region with compression of the underlying brain. A diagnosis of syndrome of the trephined was considered and her symptoms improved with cranioplasty. Pathophysiology of the syndrome of the trephined is discussed.

Glioblastoma multiforme in a child with acute lymphoblastic leukemia: case report and review of literature.

An 11-year-old boy with acute lymphoblastic leukemia had received prophylactic cranial irradiation (1800 cGy /10 fractions) and intrathecal methotrexate. Five years later, he developed a glioblastoma multiforme in the right frontal region while the leukemia was in remission. It is possible that the glioma may have been induced by radiation and /or chemotherapy.

Alveolar soft-part sarcoma presenting with multiple intracranial metastases.

A 28-year-old man presented with history of raised intracranial pressure and one episode of generalized tonic clonic seizures. Computed Tomogram revealed multiple contrast enhancing intracranial lesions. Biopsy of one of the lesions was reported as metastatic alveolar soft part sarcoma. He was advised whole brain radiotherapy.

New solitary cysticercus granulomas causing recurrent symptoms in patients with resolved solitary granulomas.

Recurrence of symptoms in a patient with a resolved solitary cerebral cysticercus granuloma (SCCG) is uncommon. Recurrent seizures in these patients are generally attributed to an epileptogenic scar or calcific residue of the granuloma. We report two patients with recurrent seizures and one patient with headache; all three patients were previously diagnosed to have SCCG and had complete resolution of the granuloma on follow-up imaging. Computed tomography (CT) at the time of recurrent symptoms showed a SCCG at a site different from the initial lesion, but in the same cerebral hemisphere in all the three patients. Since a new lesion can cause recurrent symptoms in patients with a resolved SCCG, repeat imaging should be performed in all these patients. We also postulate that recurrent cysticercal lesions in patients who have previously had a SCCG, tend to be solitary.