ABSTRACT
AIM: Acute onset spontaneous cerebellar hematoma (SCH) is a neurosurgical emergency with unpredictable natural history and outcome. Specific guidelines are available for management of small ( < 2.5 cm) and large sized (4.0 cm < ) SCH. But, literature is sparse for treatment of moderate sized SCH (2.5-4.0 cm). MATERIAL AND METHODS: In a retrospective analysis of 32 patients, with moderate sized acute SCH, external ventricular drainage (EVD) tube was inserted for evaluation of ICP and evacuation of cerebrospinal fluid. All patients with ICP > 25 mmHg underwent emergency SCH evacuation. Postoperatively, EVD was continued for 48-72 hours for ICP monitoring. Patients showing no improvement or persistent ventriculomegaly underwent ventriculoperitoneal shunt (VPS) insertion for the management of hydrocephalus. RESULTS: 29/32 patients needed operative intervention either in the form of hematoma evacuation or shunt placement. 10 patients improved to GOS 5 and 7 to GOS 4. Overall mortality was 25% (n=8). Despite SCH evacuation, none of the patients with ICP > 40 mmHg experienced good outcome (p < 0.0001). CONCLUSION: 47% of patients with moderate sized SCH need surgical evacuation. EVD insertion not only helps in ICP management but also includes the ability to gradually decompress ventricular system by varying the outflow pressure. Apart from radiologic findings, ICP measurement should be a guideline in management decisions.
Subject(s)
Cerebellar Diseases/surgery , Hematoma/surgery , Intracranial Hemorrhages/surgery , Monitoring, Physiologic , Adult , Aged , Decompression, Surgical/methods , Drainage/methods , Female , Humans , Hydrocephalus/etiology , Hydrocephalus/surgery , Intracranial Pressure , Male , Middle Aged , Retrospective StudiesABSTRACT
We report two cases of posterior third ventricular choroid plexus papilloma, one in an 8-month-old infant and another in a two-year-old child. These cases presented with features of obstructive hydrocephalus. Both these patients underwent a ventriculo-peritoneal (VP) shunt surgery prior to the tumor excision. Following the VP shunt surgery both patients developed ascitis requiring exteriorization of the abdominal end of the shunt. There was a clear proof of CSF overproduction: 1400-1500 ml/day in the eight-month-old infant and 900-1200 ml/day in the two-year-old child. In the former it was transient and could be treated with revision of the VP shunt whereas in the second case a ventriculo-arterial shunt had to be done. In the second case a staged reduction cranioplasty was also performed for an enormously enlarged head (head circumference--74 cm). Interesting clinical and radiological findings and useful management strategies are described.
Subject(s)
Cerebral Ventricle Neoplasms/pathology , Cerebral Ventricle Neoplasms/surgery , Hydrocephalus/etiology , Papilloma, Choroid Plexus/pathology , Papilloma, Choroid Plexus/surgery , Third Ventricle , Cerebral Ventricle Neoplasms/complications , Child, Preschool , Female , Humans , Hydrocephalus/surgery , Infant , Male , Papilloma, Choroid Plexus/complications , Ventriculoperitoneal ShuntABSTRACT
OBJECTIVE: To review the clinical profile, radiology and treatment of Pediatric posterior fossa extradural hematoma (PPFEDH) and evaluate the outcome. METHODS: Posterior fossa extradural hematoma (PFEDH) is an uncommon trauma sequel and in pediatric age group is still rare. This article discusses 18 cases of PPFEDH seen over a period of 8 years and review the pertinent medical literature. Only a few studies discuss PPFEDH and in most of them outcome has been good. Trauma has been subtle and fracture of occipital bone is seen in majority of cases. Treatment has been operative in majority of the cases. RESULTS: Most of the patients were diagnosed only on high index of suspicion with a history of trauma on the occipit, fracture of the occipital bone and persistent symptoms suggestive of increasing intracranial pressure and posterior fossa space occupying lesion. CT scanning was done liberally to confirm the suspicion and the patients with hematoma were treated aggressively by surgical evacuation with good recovery in most of them. CONCLUSION: Authors suggest an aggressive approach in the event of PPFEDH. However some patients can be managed conservatively but they should be closely observed for clinical manifestation and CT scan routinely to evaluate the progress of hematoma radiologically. A strict criterion should be followed in choosing such patients for conservative treatment as highlighted in the study.
Subject(s)
Cranial Fossa, Posterior/injuries , Craniocerebral Trauma/complications , Hematoma/therapy , Child , Child, Preschool , Cranial Fossa, Posterior/diagnostic imaging , Craniocerebral Trauma/diagnostic imaging , Craniocerebral Trauma/therapy , Female , Hematoma/diagnostic imaging , Hematoma/etiology , Humans , Male , Occipital Bone/injuries , Oman , Retrospective Studies , Skull Fractures/complications , Skull Fractures/diagnostic imaging , Skull Fractures/therapy , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
Patients with severe head injury with bilateral dilated unreactive pupils are considered to have a grave prognosis. Hence proper planning and aggressive management becomes mandatory for achieving good results. We present the outcome of consecutive 166 patients with severe head injury, admitted between January 1996 and December 2000 and analysed retrospectively. All the patients had an initial GCS of 8 or less and post resuscitation bilateral dilated unreactive pupils. Our aim was to analyze the long term outcome in these patients and identify the other significant prognostic factors. Of the 166 patients, 42 (25.30%) had a functional outcome (good recovery in 10.24%, moderate disability in 15.06%), and 124 (74.69%) had a poor outcome (death in 58.43% and severe disability in 16.26% of cases). There were 45 patients with polytrauma and 24 of these patients (53.33%) succumbed to the injuries. Obliteration of the basal cisterns and contusion were the common CT scan findings. Factors adversely affecting the survival included age of the patient, polytrauma with shock, initial GCS of 3 or 4, and compression of the basal cisterns on the initial CT scans. At follow up, most of the patients with a functional outcome showed a significant improvement in their motor function but continued to have neuro-behavioral and cognitive deficits.
Subject(s)
Craniocerebral Trauma/complications , Craniocerebral Trauma/physiopathology , Pupil Disorders/etiology , Adolescent , Adult , Child , Child, Preschool , Disability Evaluation , Female , Humans , Infant , Longitudinal Studies , Male , Trauma Severity IndicesABSTRACT
Fungal infections of the central nervous system (CNS) are fortunately rare but remain challenging problems occurring mostly in immunocompromised individuals, with protean manifestations, unpredictable course and unfavorable outcome in many cases despite aggressive neurosurgical intervention and recent antifungal drugs. Rhino-orbito-cerebral mucormycosis is a potentially lethal opportunistic fungal infection with rapid progression and high mortality. Its pathogenic nature becomes evident when the patient's general resistance is compromised. We present a case of an invasive rhino-orbito-cerebral mucormycosis in an apparently normal adult who initially developed mild paranasal sinusitis and later developed status epilepticus and despite an aggressive management died. Interesting clinical, neuroimaging and histological findings are described, and the possibility of fatal mucormycosis in an apparently normal host is highlighted.
Subject(s)
Brain Diseases/microbiology , Immunocompetence , Mucormycosis/pathology , Adult , Fatal Outcome , Humans , Male , Mucormycosis/immunology , Nose Diseases/microbiology , Orbital Diseases/microbiologyABSTRACT
Stabilisation of the fracture-dislocation of the cervical spine is achieved effectively by anterior or posterior or combined methods with attendant short and long term benefits, risks and complications associated with each procedure. Recently anterior methods have gained wider acceptance. A variety of preoperative and postoperative complications associated with anterior cervical fusion are well recognised. However, the delayed pharyngeal or oesophageal perforation is a rare, serious and life threatening complication of an anterior cervical internal fusion.The authors report a case of delayed pharyngeal perforation and spontaneous extrusion of the C2-C3 graft with its fixation device. After coughing out the entire gamet of the graft with the fixation pin, the patient was relieved of excruciating pain and dysphagia and had no significant morbidity thereafter over a 12-year follow up period. Relevant aspects are discussed with a review of the pertinent literature.
Subject(s)
Pharynx/injuries , Postoperative Complications/diagnostic imaging , Spinal Fractures/surgery , Spinal Fusion/adverse effects , Adult , Bone Nails/adverse effects , Bone Screws/adverse effects , Cervical Vertebrae/injuries , Cervical Vertebrae/surgery , Deglutition Disorders/etiology , Female , Humans , RadiographyABSTRACT
Spinal abscess due to Aspergillus is rare. A young boy with chronic granulomatous disease and aspergillosis of the rib had been treated with antifungal treatment 3 months earlier. The patient presented with a brief history of progressive paraparesis. Imaging showed D9--11 vertebral involvement and destruction of the D10 vertebral body with angulation and a large dorsally placed, multiloculated epidural abscess extending from D6 to L2. There was also extensive granulation anterior to and on either side of the vertebrae. The patient underwent extensive laminectomy and decompression of all the loculi and partial removal of the granulation tissue. Aggressive medical treatment was started. The authors recommend an aggressive surgical and medical approach in such cases of disseminated invasive aspergillosis, even though the result may not be very satisfactory. This report discusses the full clinical profile and management of Aspergillus spinal epidural abscess and emphasizes the need to follow up these cases to detect recurrence and new lesions, even if the patients are on adequate medical treatment. In spite of all efforts, high morbidity and mortality is common in such patients.
Subject(s)
Aspergillosis/microbiology , Aspergillus niger/isolation & purification , Epidural Abscess/microbiology , Thoracic Vertebrae/microbiology , Antifungal Agents/therapeutic use , Child , Combined Modality Therapy , Epidural Abscess/diagnosis , Epidural Abscess/therapy , Granulomatous Disease, Chronic/diagnosis , Granulomatous Disease, Chronic/surgery , Humans , Itraconazole/therapeutic use , Laminectomy/methods , Magnetic Resonance Imaging , Male , Thoracic Vertebrae/diagnostic imaging , Thoracic Vertebrae/pathology , Thoracic Vertebrae/surgery , Tomography, X-Ray ComputedABSTRACT
Diffuse idiopathic skeletal hyperostosis (DISH) has long been regarded as a benign asymptomatic clinical entity with an innocuous clinical course. Precise information is lacking in the world literature. Authors report the results of a retrospective analysis of 74 cases of DISH. Eleven patients presented with progressive spinal cord or cauda equina compression. In nine cases ossified posterior longitudinal ligament (OPLL) and in two cases ossified ligamentum flavum (OLF) were primarily responsible. Surgically treated patients (eight) had far better outcome as compared to the patients managed conservatively, as they had refused surgery. 'DISH' is neither a benign condition, nor it always runs a innocuous clinical course. In fact, in about 15% of the cases, serious neurological manifestations occur, which may require a major neurosurgical intervention.
Subject(s)
Cauda Equina , Hyperostosis, Diffuse Idiopathic Skeletal/complications , Nerve Compression Syndromes/etiology , Spinal Cord Compression/etiology , Aged , Aged, 80 and over , Humans , Ligamentum Flavum , Male , Middle Aged , Ossification of Posterior Longitudinal Ligament/etiology , Ossification, Heterotopic/etiology , Retrospective StudiesABSTRACT
We report on two patients with haemangiomas of the temporalis muscle, one congenital and one of late onset, which were diagnosed on computed tomography. Both were resected successfully and both patients are well with no signs of recurrence 3(1/2) years and 18 months later, respectively.
Subject(s)
Hemangioma/pathology , Muscle Neoplasms/pathology , Temporal Muscle/pathology , Adult , Child, Preschool , Female , Hemangioma/congenital , Hemangioma/diagnostic imaging , Humans , Male , Muscle Neoplasms/congenital , Muscle Neoplasms/diagnostic imaging , Radiography , Temporal Muscle/diagnostic imagingABSTRACT
Yolk sac tumours are rare conditions among the germ cell tumours. Intracerebral germ cell tumours are exceedingly rare. A 15 year old girl presenting with a one week history of raised intracranial pressure is described. She had bilateral papilloedema and a right 6th nerve palsy. CT scan showed an intra-parenchymatous right frontal ring enhancing lesion of 2 cms diameter. The patient underwent microsurgical total excision of the tumour, followed by chemotherapy. She was asymptomatic at three years following surgery.
Subject(s)
Brain Neoplasms/diagnostic imaging , Brain Neoplasms/surgery , Endodermal Sinus Tumor/diagnostic imaging , Endodermal Sinus Tumor/surgery , Frontal Lobe , Adolescent , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Bleomycin/therapeutic use , Brain Neoplasms/drug therapy , Brain Neoplasms/pathology , Cisplatin/therapeutic use , Combined Modality Therapy , Endodermal Sinus Tumor/drug therapy , Endodermal Sinus Tumor/pathology , Female , Humans , Microsurgery , Tomography, X-Ray Computed , Vinblastine/therapeutic useABSTRACT
A nineteen year old man with intrasacral meningocele is reported, who presented with long standing episodic gluteal pain and progressive muscle wasting. Magnetic resonance imaging established the diagnosis. Surgical excision relieved the pain but muscle wasting persisted. Pertinent literature is reviewed.
Subject(s)
Buttocks/pathology , Meningocele/pathology , Neuralgia/pathology , Sacrum/pathology , Adult , Humans , Magnetic Resonance Imaging , Male , Meningocele/surgery , Muscle, Skeletal/pathology , Muscular Atrophy/pathology , Neuralgia/surgeryABSTRACT
Primary Ewing's sarcoma is an uncommon lethal tumour of the long bones and pelvic girdle mainly affecting children and young adults. An origin in the cranial bones is extremely rare. We report a unique case of primary involvement of the greater wing of sphenoid bone in a 16-year-old patient. Aggressive management using microsurgical resection, radiotherapy and chemotherapy was curative. Localized, primary Ewing's sarcoma of the cranial bones should be considered as a distinct clinicopathological entity with an extremely low rate of dural penetration and metastases, and with a relatively better prognosis as compared with those of long bones and pelvic girdle. In neurosurgical practice, primary Ewing's sarcoma of the cranial bones requires early aggressive management to achieve adequate long-term prognosis and cure.
Subject(s)
Sarcoma, Ewing/surgery , Skull Neoplasms/surgery , Sphenoid Bone/surgery , Adolescent , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Female , Humans , Microsurgery/methods , Prognosis , Sarcoma, Ewing/drug therapy , Sarcoma, Ewing/radiotherapy , Skull Neoplasms/drug therapy , Skull Neoplasms/radiotherapyABSTRACT
Primary intraosseous cranial hemangiomas are rare benign tumors comprising 0.2% of all osseous neoplasms. Symptomatic cranial cryptic hemangiomas are extremely rare. We report the case of a 43-year-old man with a cryptic hemangioma of the superior orbital rim. Radiological investigations revealed it to be an intraosseous cryptic mass which was totally excised and the supraorbital nerve was decompressed, relieving the patient of his symptoms. Histopathology showed features of an intraosseous hemangioma.
Subject(s)
Facial Pain/etiology , Hemangioma/diagnosis , Nerve Compression Syndromes/etiology , Orbital Neoplasms/diagnosis , Adult , Decompression, Surgical , Diagnosis, Differential , Hemangioma/complications , Hemangioma/diagnostic imaging , Hemangioma/surgery , Humans , Male , Orbital Neoplasms/complications , Orbital Neoplasms/diagnostic imaging , Orbital Neoplasms/surgery , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
Shunt migration into the cranial ventricle is a rare complication of shunt surgery. We encountered this complication in an infant within three weeks of insertion. The shunt tube was removed and replaced by another tube with a reservoir, following which the child did well.
Subject(s)
Cerebral Ventricles , Cerebrospinal Fluid Shunts/adverse effects , Foreign-Body Migration/etiology , Hydrocephalus/surgery , Female , Foreign-Body Migration/surgery , Humans , Infant, NewbornABSTRACT
In the National Neurosurgical Centre in the Sultanate of Oman, four patients with cranio-facial actinomycosis were seen over a 5-year period. All patients had osteomyelitis and intracranial granulomata and the diagnosis was confirmed with histopathology. In two cases the organisms were cultured. In three patients the cranial spread was by contiguity from the scalp and face while one case had the extradural granuloma following a dental extraction. With medication there was gross reduction of proptosis and intracranial lesion in one patient and in two there was marked reduction in the size of the intracranial lesion as seen on serial computerized tomographic scanning of the head (CT head). Three patients are now asymptomatic and are being followed up while one expired with subarachnoid haemorrhage. Although eradication of the disease is difficult, with adequate medication and appropriate surgical intervention, three of these patients continue to remain relatively symptom-free for long periods of time.
Subject(s)
Actinomycosis, Cervicofacial/therapy , Actinomycosis, Cervicofacial/diagnostic imaging , Actinomycosis, Cervicofacial/pathology , Adult , Biopsy , Female , Humans , Male , Tomography, X-Ray ComputedABSTRACT
A rare case of an extradural brucellosis granuloma in the thoracic region is presented. Medical treatment delayed surgical intervention and led to total paraplegia with sphincteric disturbance despite improving serum antibody titres. However, delayed neurosurgical intervention resulted in near-total clinical recovery. Early surgical intervention in cases of significant spinal cord compression due to an extradural brucellosis granuloma with a progressive neurological deficit is recommended.