Management of multiloculated hydrocephalus in children with emphasis on role of CT ventriculography.

OBJECTIVE: The authors performed a retrospective review of children diagnosed with multiloculated hydrocephalus (MLH) in our institute. The goal was to analyze the different diagnostic and therapeutic modalities used with special emphasis on CT ventriculography (CTV). METHODS: Male and female patients below the age of 18 years diagnosed with MLH were included. Cases of uniloculated hydrocephalus like entrapped temporal horn or isolated fourth ventricle were excluded. We used iohexol for CTV and gadodiamide for MR ventriculography. Neuroendoscopic procedures performed were endoscopic fenestration, endoscopic third ventriculostomy (ETV), endoscopic septostomy, endoscopic aqueductoplasty, or a combination of the above. The cohort was divided into two groups (endoscopic or shunt) based on initial surgical intervention. RESULTS: A total of 52 patients were included, with 43 boys and 9 girls. The average age of presentation was 7.7 months. The most common predisposing factor for MLH was neonatal meningitis seen in 30 patients. Mean duration of follow-up was 39 months. CTV was used in 26 patients and MR ventriculography in three patients. In one patient, the diagnosis of MLH was ruled out after ventriculography. Patients who underwent ETV only had the best outcome with 71.4% success rate. At the end of follow-up, 14 patients (27%) were shunt independent. CONCLUSIONS: The present study indicates that CTV helps to accurately define the anatomy of the ventricles and determine the site of physiological CSF obstruction. This helps in therapeutic planning and in avoiding misdiagnoses. Further, neuroendoscopy has the potential to lead to shunt independence in some patients.

Endoscopic Transcortical Transventricular Management of Cystic Craniopharyngioma: Outcome Analysis of 32 Cases at a Tertiary Care Center.

BACKGROUND: Microsurgical resection has been considered the gold standard treatment of craniopharyngioma, but lately, it has found less favor due to its morbidity and is being replaced by minimally invasive cyst drainage procedures. We present our experience of transventricular endoscopy and cyst drainage along with its technique and have analyzed its results. MATERIALS AND METHODS: Clinical and radiological data of all cystic craniopharyngioma patients treated by transventricular endoscopic cyst drainage and Ommaya placement were retrieved and analyzed. RESULTS: Thirty-two patients underwent endoscopic cyst drainage during the study period. All patients had immediate clinical and radiological improvement. No significant complications were seen. All patients underwent adjuvant radiotherapy and six patients (18.7%) showed recurrence. Three patients died in the follow-up period. CONCLUSIONS: Endoscopic transcortical transventricular cyst drainage with Ommaya reservoir along with adjuvant radiotherapy is a simple, safe, and effective treatment modality.

A Comparative Analysis Between Four-Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury.

OBJECTIVE: Primary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression. METHODS: A single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended. RESULTS: No significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome. CONCLUSIONS: FoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.

Primary Type I Cutaneous Meningioma of the Scalp: Cytohistological and Immunohistochemical Features of a Rare Neoplasm.

Primary cutaneous meningioma of scalp is a rare lesion and often clinically misdiagnosed. As clinical features are nonspecific, the diagnosis is often perplexing in this exceptional site. We report a case of a 7-year-old girl presenting with a nodule over occipital region of scalp since birth. No bony defect was noted on X-ray. On fine needle aspiration cytology, smears were cellular consisting mostly cohesive clusters of cells having pale pink granular cytoplasm, round to oval nuclei with unassuming nucleoli along with psammomatous calcification suggestive of cutaneous meningioma. Histology and immunohistochemistry with epithelial membrane antigen (EMA) confirmed the diagnosis. Histological sections revealed a proliferation of a spindle-shaped cell in the dermis, arranged in whorls or individually amid collagen fibers and psammoma bodies. Immunohistochemical study revealed positivity for EMA. A diagnosis of Type I cutaneous meningioma was finally rendered based on characteristic clinical, intraoperative, morphological, and immunohistochemical observations.

Spontaneous Umbilical CSF Fistula Due to Migration of the Peritoneal End of VP Shunt: A Case Report and Review of Pathogenesis.

Abdominal complications after ventriculoperitoneal (VP) shunt surgery for hydrocephalus have been known to occur. The more common complications include peritoneal pseudocyst, obstruction of the lower end, and shunt infection. Perforations of the intra-abdominal hollow viscera leading to spontaneous extrusions of the peritoneal catheter via the natural orifices have also been reported. A rarer phenomenon still is the migration of the lower end of the VP shunt through the anterior abdominal wall, leading to the formation of a spontaneous umbilical fistula at a site unrelated to the surgical site. Eight cases have been described in the literature so far with various causes elucidated. We report this condition in a child 4.5 years after his shunt surgery and postulate different mechanisms for both early and late presentations of this condition.

A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage.

CONTEXT: Spontaneous intracerebral haemorrhage (ICH) accounts for 4-14% of all strokes and has a high mortality rate of 30-50% during the first month. Management of large hematomas is controversial, with some advocating medical management while others favoring surgical evacuation. AIM: This study was undertaken to compare the outcome of patients with a spontaneous supratentorial intracerebral hemorrhage (SSICH) managed with or without surgical evacuation. SETTINGS AND DESIGN: Four hundred and eighty-two SSICH patients admitted from September 2013 to August 2015 were evaluated based on the inclusion and exclusion criteria. MATERIALS AND METHODS: Among a total of 61 patients with Glasgow Coma Scale (GCS) of 4-14 and hematoma volume of> 30 ml, 27 were randomized to receive medical management (MM) alone and the remaining 34 were randomized to combined surgical as well as medical management (SM). Primary and secondary outcomes were mortality and dependency at 3 months, respectively. STATISTICAL ANALYSIS USED: Student's t-test and X2 test were used for univariate analysis, and logistic regression analysis was employed for multiple variables. RESULTS: On univariate analysis, mortality was significantly lower in the SM group (n = 21,61.8%) compared to the MM group (n = 23,85.2%) (P = 0.043); however, the groups showed no significant difference in dependency at 3 months. Further subgroup analysis showed that a hematoma volume of 30-60 ml, a deeply located hematoma, associated intraventricular hemorrhage, and a Glasgow Coma Scale (GCS) of 4-8 had a significantly lesser mortality in the SM group (P < 0.05). On multivariate analysis, a significant association was found between the mortality and the treatment arm (P = 0.006). CONCLUSIONS: In patients with SSICH, mortality was found to be significantly associated with the treatment arm and the results were in favour of SM among the patients presenting with GCS 4-8, hematoma volume 31-60 ml, midline shift of more than 5 mm, and intraventricular extension of the hematoma.

Isolated cysticercosis involving the anterior abdominal wall: a rare case report.

Isolated cysticercosis of anterior abdominal wall without parasitosis of central nervous system is very rare and may mimic a tumor leading to diagnostic and therapeutic dilemma. Histopathological examination plays an important role in making a definitive diagnosis. Here we report a case of a 13-year old Muslim girl presenting with swelling and pain in left lower abdomen which was clinically diagnosed as lipoma. On histopathological examination cysticercus with surrounding inflammation was seen. Since cysticercosis is a preventable disease, early and accurate diagnosis is necessary for the reduction of disease burden in the endemic areas.

Transdural herniated lumbar disc disease with muscle patch for closure of durotomy - A Brief review of literature.

PURPOSE: Intradural migration of disc (IDMD) is a rare clinical entity accounting for 0.27-0.33% of all herniated disc diseases. Flimsy or dense adhesion between the ventral dural surface and the opposing posterior longitudinal ligament (PLL) is the principal pathology for intradural migrated disc. The most commonly affected lumbar segments are L4-5 (55%), L3-4 (16%), L5-S1 (10%) and less commonly L2L3 and L1L2. No imaging feature is characteristic and the management protocol of durotomy via an endoscopic method is unclear. METHODS: An L5S1 disc disease was operated by endoscopic method. Difficulty in separating the dural sac from PLL, dense adhesions prompting sharp dissection at this location and a calcified disc are the earliest evidence of intradural migration. MRI features of an intradural location are loss of continuity of posterior longitudinal ligament, beak-like appearance also known as "Hawk-beak sign", peripheral enhancement around an intradural disc, fluid-filled intradural cyst. Magnification either by Microscope or Endoscope is of importance when dissecting the intradural disc so as to avoid the nerve root injury. Liberal use of fibrin glue and augmentation with muscle patch was performed. RESULTS: Ambulated by 48h and discharged by 5th day. Two and 9 months follow up showed no evidence of pseudomeningocoele. CONCLUSION: Autologous muscle patch with fibrin glue for dural rent closure is a simple and effective method which can be performed by endoscopic or minimally invasive approaches. Suturing the dura, being a tedious and cumbersome procedure can be avoided.