Post-craniotomy leptomeningeal cyst: a new presentation of an old problem.

Leptomeningeal cyst (LMC) is a known complication of pediatric head injury but has not been described following a craniotomy other than for craniosynostosis. We present the case of a 20-month-old boy who underwent craniotomy for a traumatic epidural hematoma. There was an inadvertent tear of the dura which was repaired with a pericranial patch and dural sealant. The patient presented with a progressive surgical site swelling 5 months post-surgery and a CT scan revealed an LMC with elevation of the bone flap. He underwent re-exploration with watertight repair of the dural defect and rigid fixation of the bone flap. This iatrogenic LMC provides an opportunity to compare and confirm the pathogenesis vis a vis the more common spontaneous post-traumatic LMC. Our report highlights the importance of proper dural closure and bone fixation after craniotomy in children whose skulls are still growing.

Tension Subdural Hygroma Following Resection of Posterior Fossa Tumour in a Child: A new clinico-radio-pathological entity.

Persistent hydrocephalus is common in children after resection of posterior fossa tumours. However, occurrence of subdural hygroma is very rare. We report the case of a 14-month-old child who presented at a paediatric neurology clinic in Muscat, Oman in 2021 who developed a tense subdural hygroma with stable hydrocephalus, in the early postoperative period, following posterior fossa tumour resection. We describe the distinctive clinical, radiological and pathological features associated with the development of a tense subdural hygroma. We also discuss the management by cerebrospinal fluid diversion, which includes either a ventriculoperitoneal or subduroperitoneal shunt. This unique condition is distinguished from external hydrocephalus by features that are critical to the management strategy.

Computed-tomography evaluation of parietal foramen topography in adults: a retrospective analysis.

BACKGROUND: The parietal foramen (PF) of the skull is a variable anatomic feature with important implications for venous drainage, infection, and injury. Its topography is clinically relevant for neurosurgeons for intracranial navigation and preoperative planning. METHODS: PF topography was investigated in a series of 440 head computed-tomography scans of Omani subjects at Sultan Qaboos University Hospital. The mean age of the patients was 52 ± 17 years and there were 160 males and 280 females. The topography features of the PF, including frequency, diameter, patency, and relative position in relation to the superior sagittal sinus (SSS), were recorded. Additionally, sex and laterality differences in PF parameters were analyzed using a Chi-square test. RESULTS: The overall prevalence of PF was 72.3% (318/440). The bilateral presence of PF was identified in 34% of skulls. Unilateral right-side prevalence was 18.2%, while left prevalence was 13.2% (p = 0.62). The prevalence of unilateral accessory PF on the right side was 1.8%, while it was 1.1% on the left (p = 0.69). PF within the sagittal suture/or intra-sutural PF was observed in 6.8% of skulls, with a frequency of 9.4% in men and 5.4% in women (p = 0.29). The diameter of the PF was 1.45 ± 0.74 mm on the right side, and 1.54 ± 0.99 mm on the left side (p = 0.96). There were 2% of incomplete PF. The PF was located over the SSS in 70.3% on the right side and 53.8% on the left side. No significant differences were observed between the PF topography parameters and sex or laterality. CONCLUSION: The present study for the first time reports the baseline data of PF topography in a large sample of CT scans in the Arab population. The geography and race influence the PF topography differences. PF may be used as a reliable landmark of SSS. The morphological characteristics and distribution of PF reported in this study have clinical implications for imaging diagnosis, intracranial navigation of vascular disorders, and treatment.

Spontaneous Near Fatal Hemorrhage into Neurofibromatosis Type 1 Lesion in the Scalp.

Neurofibromatosis type 1 (NF1) (von Recklinghausen's disease) is an autosomal dominant disorder characterized by café-au-lait spots, pigmented hamartomas of the iris, and multiple neurofibromas. Patients can present with hemorrhage secondary to trauma or rarely with spontaneous hemorrhage, both of which can be lethal and life-threatening. We report a 14-year-old girl with a rapidly expanding hematoma in a rare presentation of spontaneous bleed into the NF1 lesion in her scalp. Soon after presentation, she went into hemorrhagic shock. Emergency coiling of the left maxillary artery and branches successfully arrested the bleeding, while resuscitation reversed the hemorrhagic shock.

Prominent hemophagocytosis in cerebrospinal fluid in a patient with pneumococcal meningitis.

Hemophagocytosis is usually observed in bone marrow. But it can be an incidental finding in other body fluids in severe infections like cerebrospinal fluid in case of meningitis. Clinicians need to rule out primary type of hemophagocytic syndrome.

Extradural Hematoma Following Decompressive Craniectomy for Acute Subdural Hematoma: Two Case Reports Illustrating Different Mechanisms.

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.

Spontaneous Ventriculostomy into the Subdural Space in a Neonate with Congenital Hydrocephalus.

We report a case of spontaneous temporary resolution of congenital hydrocephalus due to drainage into the subdural space, which is not a physiological space for cerebrospinal fluid (CSF). This is the first report of spontaneous drainage of CSF into the subdural space, and we term it "ventriculosubdurostomy." We highlight the fact that spontaneous resolution of hydrocephalus due to drainage into a nonphysiological CSF space is temporary.

Complex congenital atlantoaxial dislocation in an infant: case report.

The authors report the case of congenital atlantoaxial dislocation in a 9-month-old female infant, who presented with progressive quadriparesis and respiratory failure. The problems in management due to such an early age of presentation, including atypical clinical presentation, unique radiological findings, limited management options, and variable clinical outcomes discussed. This is the youngest case of non-syndromic congenital atlantoaxial dislocation, reported to date, and is a unique combination of lateral, rotatory, and antero-posterior atlantoaxial dislocation.

Spontaneous evacuation of hyperacute extradural hematoma: two illustrative case reports.

Spontaneous drainage of extradural hematoma (EDH) through a skull fracture is rare, with only 14 cases reported to date. Five of these belong to pediatric age group. The authors report two cases of spontaneous evacuation of acute EDH, in children, with two differing types of skull fractures, one being an elevated fracture. The context, in which the terminologies of "spontaneous evacuation" and "spontaneous resolution" to be used, is clarified.

Delayed transient post-traumatic quadriplegia.

Transient neurological deficit following cervical trauma have been reported following sports injuries, and has been referred to as cervical cord neurapraxia. The so-called "whiplash injuries" following minor motor vehicle collisions usually do not produce any neurological deficit. Here we report the case of a whiplash type of injury presenting with a delayed onset neurological deficit, which was followed by rapid and complete recovery. The patient, an otherwise healthy 34-year-old male, attended the emergency department of Sultan Qaboos University Hospital following a rear-end motor vehicle collision. We present images showing degenerative disc disease causing spinal canal narrowing and mild cord compression in the patient, but no spinal instability. Differential diagnoses are also discussed.

Cerebellar mutism following closed head injury in a child.

Cerebellar mutism is a rare occurrence following paediatric trauma. Although it is quite common after posterior fossa surgery in children, this phenomenon has rarely been reported following other insults, such as trauma, and its pathophysiology remains poorly understood. We report a seven-year-old child who presented to the casualty department of Sultan Qaboos University Hospital in Muscat, Oman, in May 2013 with a traumatic right cerebellar contusion. The child presented with clinical features of cerebellar mutism but underwent a rapid and spontaneous recovery. The possible mechanism of this occurrence is discussed.

Primary Extradural Meningioma Presenting as Frontal Sinusitis with Extensive Bony Changes: Case report.

Primary extradural meningiomas are rare tumours and calvarial meningiomas with extensive bony changes and frontal sinusitis are rarer still. We report a 40-year-old female patient who presented to the otorhinolaryngologist at the Sultan Qaboos University Hospital in Muscat, Oman, in October 2013 with headaches and frontal swelling. She was diagnosed with frontal sinusitis complicated by osteomyelitis. Further clinical examination and imaging revealed a left frontal calvarial meningioma with extensive bony changes and extracalvarial extension into the frontal sinus. She underwent a left frontal craniotomy during which the tumour was removed. The postoperative period was uneventful and a follow-up computed tomography scan after three months showed only postoperative changes. This report discusses the radiological differential diagnosis and management of this type of lesion.

Fungal Granuloma following Endoscopic Third Ventriculostomy for Infantile Hydrocephalus.

Endoscopic third ventriculostomy (ETV) is increasingly being used in the treatment of hydrocephalus in infancy. Infective complications rarely occur following ETV and fungal infections or granulomas have not been reported so far. The authors report the occurrence and management of a fungal granuloma incidentally detected during a repeat ventriculoscopy for a non-functioning ETV.

Scissoring of a Cobalt Alloy Aneurysm Clip causing Slippage during Cerebral Aneurysm Surgery: Case report and review of literature.

Clip slippage is a rare occurrence, and the scissoring or torsional failure of aneurysm clips is rarer still. Titanium clips have been implicated in a few such reported cases. The authors report its occurrence while using a fenestrated cobalt alloy clip for an internal carotid artery aneurysm which was identified by intraoperative angiography and rectified by re-applying a non-fenestrated cobalt alloy clip. The possible mechanism of this complication, and measures that may prevent its occurrence, including meticulous dissection, decompression when possible, proper clip selection, and intraoperative angiogram are described.

Traumatic Acute Brain Herniation through the Ear in a Child: Concealed compound fracture.

A seven-year-old girl presented to Sultan Qaboos University Hospital, Oman, with a history of having been hit by a motor vehicle. After this, she had right-sided cerebrospinal fluid otorrhoea, and a week later, brain matter extruded through the right ear. A computed tomography scan of the brain demonstrated a tegmen fracture communicating with the external auditory canal. There was no hearing or facial nerve impairment and an otoscopic examination showed an intact tympanic membrane. She underwent a transcranial repair of the middle cranial fossa base, which revealed a wide dural and bony defect of the tegmen with herniation of the temporal lobe. Repair was made with an intradural patch of artificial dura. The rarity of this type of presentation of temporal bone fracture and its management are discussed.

Choroid plexus cyst of the third ventricle presenting as acute triventriculomegaly.

INTRODUCTION: Cystic lesions in and around the third ventricle have been known to cause intermittent and acute obstruction of the foramen of Monroe with rapid onset symptoms. Most of these lesions are seen on routine investigations, whereas some are not so obvious resulting in mistaken diagnosis. Symptomatic choroids plexus cysts have only been infrequently reported, predominantly in the lateral ventricle. CASE REPORT: A 3-year-old female child presented with rapid loss of consciousness for the first time. Computed tomography and magnetic resonance imaging scans only showed triventriculomegaly. Endoscopy revealed a cyst of the third ventricle, which was excised, leading to good recovery. Biopsy of the wall revealed a choroid plexus cyst. CONCLUSION: Choroid plexus cysts are rare causes for symptomatic obstruction of the third ventricle and may be difficult to detect on routine investigations and may lead to the wrong choice of treatment. Endoscopic fenestration or excision is a good option to manage such lesions.

Ventriculosubgaleal shunts in the management of infective hydrocephalus.

INTRODUCTION: Temporary diversion of cerebrospinal fluid (CSF) is often required due to patient and CSF related factors, of which infection is a significant one. The various methods available have significant disadvantages. Ventriculosubgaleal shunts (VSG) have been earlier demonstrated to be useful in a variety of circumstances. MATERIALS AND METHODS: Hospital charts of 21 consecutive children during a 4-year period were analyzed retrospectively. Infection was defined based on a positive CSF culture or a history of recently treated meningitis with abnormal CSF findings. The conversion to a permanent shunt was based on normalization of CSF values in a functioning VSG shunt or when the VSG shunt is ineffective. The end point was control of raised intracranial pressure (ICP) features and infection. RESULTS: The ages ranged from 1 month to 7 years with a median age of 2 months. Five (23.8%) were born premature. Twelve children (57.1%) had a previously untreated hydrocephalus, whereas nine (42.8%) had undergone some procedure. A positive CSF culture was obtained in ten (47.6%). Repeat VSG shunts were required in five children (23.8%). Seventeen (80.9%) of these children underwent conversion to a ventriculoperitoneal (VP) shunt. Of the remaining four, one did well without any further procedure, two died due to their primary problems, and one refused any further procedure due to poor neurological status. There were two wound complications-one CSF leak and one shunt migration. CONCLUSION: VSG shunts are a simple and efficient way of managing infective hydrocephalus.

Comparison of section of filum terminale and non-neurosurgical management for urinary incontinence in patients with normal conus position and possible occult tethered cord syndrome.

OBJECTIVE: Patients with persistent urinary incontinence and a normal location of the conus on magnetic resonance imaging scans may have occult tethered cord syndrome (OTCS). We compare outcomes in such patients after filum section versus nonoperative treatment. METHODS: We performed a retrospective analysis of a consecutive series of children with refractory urinary incontinence and normal location of the conus who were offered section of the filum for treatment of possible OTCS. RESULTS: Eight children, aged 4.4 to 9.8 years, underwent filum section, with one child undergoing two such operations. Clinical urological improvement occurred in seven children at a mean follow-up period of 3.1 years, with improved urodynamic findings in four of the seven children tested postoperatively. Other non-urological back or lower limb abnormalities improved in five out of six children with such findings. None of the patients underwent additional urological operations after filum section. Seven children, aged 3.1 to 13.5 years, all of whom had abnormal urodynamic findings, did not undergo filum section. At a mean follow-up period of 3.3 years, two patients had urological improvement and three patients had undergone bilateral ureteric reimplantations. Other non-urological back and/or lower limb abnormalities were present in five patients and did not improve. One patient had the filum cut after 8 years and improved thereafter. CONCLUSION: Section of the filum in children with refractory urinary incontinence and OTCS may produce better urological outcomes than continued medical management. A definitive answer to the question of whether section of the filum is better than non-neurosurgical medical management for children with OTCS awaits the conclusion of a randomized controlled trial.

Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme.

OBJECT: Ascites and abdominal pseudocysts are two complications that can occur following placement of a ventriculoperitoneal (VP) shunt. Although various factors have been implicated, the exact pathogenesis of the two conditions remains elusive. To the authors' knowledge, there are no studies in which these two obviously related conditions have been compared. METHODS: The authors retrospectively reviewed the cases of children with abdominal complications caused by a VP shunt. There were 15 patients who developed a pseudocyst and five patients who developed ascites. The cases were analyzed to identify common and distinguishing factors that may help in identifying the mechanism involved. Abdominal symptoms were the mode of presentation for patients with ascites, whereas shunt malfunction was the mode of presentation in 60% of those with pseudocysts. Culture-proven infection, abdominal surgery, and the number of revisions seemed to be more common in cases with pseudocysts than in ascites. The fluid in ascites was found to be a transudate irrespective of the origin of hydrocephalus. Alternative drainage sites were required in the treatment of patients with ascites, and reimplantation in the peritoneum was possible in 66.7% of those with pseudocysts. In the long-term, however, peritoneal reimplantation was possible in three of the five patients with ascites. CONCLUSIONS: Abdominal pseudocysts and ascites, after VP shunt treatment, are distinct conditions with different modes of presentation and findings during examination of fluid, and therefore they require different management strategies.