Postoperative hematoma involving brainstem, peduncles, cerebellum, deep subcortical white matter, cerebral hemispheres following chronic subdural hematoma evacuation.

Among the intracranial hematomas, chronic subdural hematomas (CSDH) are the most benign with a mortality rate of 0.5-4.0%. The elderly and alcoholics are commonly affected by CSDH. Even though high percentage of CSDH patients improves after the evacuation, there are some unexpected potential complications altering the postoperative course with neurological deterioration. Poor outcome in postoperative period is due to complications like failure of brain to re-expand, recurrence of hematoma and tension pneumocephalus. We present a case report with multiple intraparenchymal hemorrhages in various locations like brainstem, cerebral and cerebellar peduncles, right cerebellar hemisphere, right thalamus, right capsulo-ganglionic region, right corona radiata and cerebral hemispheres after CSDH evacuation. Awareness of this potential problem and the immediate use of imaging if the patient does not awake from anesthesia or if he develops new onset focal neurological deficits, are the most important concerns to the early diagnosis of this rare complication.

Tuberculum sellae meningiomas: A series of 41 cases; surgical and ophthalmological outcomes with proposal of a new prognostic scoring system.

CONTEXT: Tuberculum sellae meningiomas have proved difficult to treat, partly because of their intimate association with the optic nerves and chiasma, hypothalamus, and internal carotid arteries. AIMS: The aim of this study is to analyze the degree of influence of various prognostic factors affecting visual outcome; the pattern of visual recovery and develop a scoring system for prognostication. SETTINGS AND DESIGN: This is a retrospective study carried out from January 2004 till June 2011. MATERIALS AND METHODS: Patients were analyzed on the basis of clinical, radiological, and surgical factors that appeared to affect the outcome. A special scoring system (according to the guidelines of the German Ophthalmological Society) was adopted to quantify the extent of ophthalmological disturbances. STATISTICAL ANALYSIS USED: Comparison of categorical variables between the two was performed using chi-square test and a P value of ≤ 0.05 was considered significant. Logistic regression was used when multivariate analysis was required. RESULTS: Vision improved in 27% and deteriorated in 7.3%. A prognostic scoring system (score 4-13) was developed depending on the degree of influence of significant prognostic factors. The patients with a score of ≤6 had improved vision postoperatively (44%), whereas none of those with a score > 6 improved. Completeness of visual recovery was perceived in 100% of patients within 3 months. Complete resectability was achieved in 73% of patients. CONCLUSIONS: The proposed scoring system is very useful in prognosticating the visual outcome of these patients. The patients with a score of ≤6 have the best visual outcome postoperatively. Complete resectability is better achieved with extended bifrontal and unilateral frontal approaches. Short-term postoperative visual outcome is a strong indicator of permanent visual outcome after surgery.

A 10-year retrospective study of hemangioblastomas of the central nervous system with reference to von Hippel-Lindau (VHL) disease.

We aimed to analyze the clinical, radiological, surgicopathological and clinical outcome data of patients who underwent surgery for central nervous system (CNS) hemangioblastoma (HBL) with or without von Hippel-Lindau (VHL) disease. The clinico pathological and radiological findings, management and clinical outcome of patients with CNS HBL (operated between 2000 and 2009) were analyzed retrospectively. The differences between sporadic and VHL-associated HBL were analyzed. Forty-nine patients (28 male, 21 female) underwent surgery for CNS hemangioblastoma. Thirty-nine patients (80%) harbored sporadic HBL whereas 10 (20%) had VHL disease. The mean age at diagnosis for VHL-associated HBL was 32 years when compared to 40 years in sporadic HBL. The lesions were solitary in 41 patients and multiple in eight. The cerebellum was the most common site of HBL (35/49, 71%). Six patients with sporadic and two with VHL disease had spinal lesions. On imaging (available in 43/49 patients), a cyst with a mural nodule was the most common finding, seen in 16 patients (37.2%) whereas nine patients (21%) had solid and cystic lesions. Clinical presentation, radiological features, and histomorphology of HBL with or without VHL disease were similar. Multiple cysts in the pancreas, kidney, broad ligament, epididymis, clear cell renal cell carcinoma, phaeochromocytoma and retinal angiomas were the visceral manifestations seen in patients with VHL disease. Of all patients with VHL disease, three required multiple surgeries for new lesions and one died of renal failure and sepsis. Among the patients with sporadic disease (31/39), two died of surgical complications, one died of postoperative sepsis, three were lost to follow-up and the remainder had resolution of symptoms at 1year following surgery. We concluded that the diagnosis of VHL disease is important as management is more difficult and lifelong follow-up and counseling are required in these patients and for their at-risk relatives.

Fungal rhinosinusitis: a clinicopathological study from South India.

Fungal rhinosinusitis (FRS) is uncommon and accounts for 6-12% of culture or histologically proven chronic sinusitis. FRS may be acute or chronic. The aim of this paper was to study the histological features that contribute to the diagnosis and sub typing of FRS, using a retrospective review of all paranasal sinus mucosal biopsies from January 2005 to December 2008. The clinical features, predisposing conditions, imaging findings, and extent of the lesion were noted. The slides were reviewed with hematoxylin and eosin, Gomori's methenamine silver, and periodic acid Schiff stains. Culture reports were obtained wherever material was subjected to culture. There were 63 biopsies diagnosed as FRS (45.7%) out of 138 biopsies of chronic sinusitis in the study period. The FRS was classified as allergic in 15 (23.8%), chronic non-invasive (sinus mycetoma) in 1 (1.6%), chronic invasive in 10 (15.87%), granulomatous invasive in 19 (30%), and acute fulminant in 18 (28.5%) biopsies or surgical resections. Predisposing conditions were identified in 19 patients with diabetes mellitus as the commonest. Seventeen of the 18 patients with acute fulminant FRS had predisposing conditions. As per the results, the characteristic histological features were allergic mucin in allergic, fungal ball in chronic non-invasive, sparse inflammation and numerous hyphae in chronic invasive, non caseating granulomas with dense fibrosis in granulomatous invasive, and infarction with suppuration in acute fulminant FRS. Aspergillus sp. was the commonest etiologic agent. To conclude, predisposing risk factors were more common in invasive FRS than in non-invasive sinusitis and Aspergillus species was the most common etiologic agent.

Isolated cerebral Aspergillus granuloma with no obvious source of infection.

BACKGROUND: Intracranial fungal granulomas occur by extension from contiguous structures or by hematogenous dissemination from lungs. Isolated granulomas without any obvious source of infection are extremely uncommon. OBJECTIVE: To describe isolated intracerebral Aspergillus spp. granuloma without any obvious source of infection. MATERIALS AND METHODS: We analyzed clinical, radiological and pathological features of isolated intracerebral aspergillus granulomas diagnosed in our institution between 1986 and 2006. The chest X-ray and paranasal sinus (PNS) X-rays were reviewed. Fungal stainings were done on histological sections. RESULTS: We identified eight patients with Aspergillus spp. intracerebral granulomas (six males, two females). There were no predisposing risk factors. The chest and PNS X-rays were normal. On computerized tomography all were heterogeneously enhancing lesions with perilesional edema. Pre or perioperative diagnosis was never made. Histological studies revealed granulomas with minimal fibrosis and giant cells and septate hyphae of Aspergillus spp. on fungal stains. Two patients died of postoperative complications and two patients relapsed. CONCLUSION: Isolated intracerebral aspergillus granulomas are rare and pose a diagnostic challenge. Fungal granulomas should be considered in the differential diagnosis of intracerebral inflammatory pathologies.

Giant mycotic aneurysm of the vertebral artery: a case report.

Giant mycotic pseudoaneurysms of the vertebral artery are extremely rare. Their management is technically challenging because of the distorted anatomy and intimate relation to the lower cranial nerves. We present a rare case of a 7-year-old boy referred to us by a pediatrician who was treating him for bacterial endocarditis. The pulsatile swelling measured 10 x 5 cm and was located in the left suboccipital triangle. The skin over the swelling was tethered to the underlying pulsatile swelling, suggesting prerupture syndrome. A contrast angiogram revealed a pseudoaneurysm from the third part of the left vertebral artery. Vegetations were seen on the tricuspid valve on echocardiography. Two-step surgery was performed under the cover of antibiotics. Excision of the aneurysm was done after ligation of the third part of the vertebral artery. The postoperative period was uneventful, and there was no neurologic deficit. Repeat magnetic resonance angiogram revealed no residual pseudoaneurysm. The histopathologic examination of the specimen was suggestive of mycotic aneurysm of left vertebral artery.