Indocyanine green as an adjunct for resection of insular gliomas.

OBJECTIVE: Many controversies exist regarding the extent of resection for insular gliomas and the timing of resection. Several techniques and adjuncts are used to maximize safety during resection of these tumors. We describe the use of indocyanine green (ICG) to identify the branches of the middle cerebral artery and discuss its utility to increase safety for resection for insular gliomas. MATERIALS AND METHODS: Five patients with insular gliomas were surgically treated by the authors from June 2013 to June 2014. The patients presented with complaints of either a headache or recurring episodes of convulsions. All the patients were operated with the aid of neuronavigation and tractography. The long perforating branches of the middle cerebral artery course through the insula and pass onward to supply the corona radiata. It is essential to preserve these vessels to prevent postoperative neurological deficits. ICG (Aurogreen) was used to identify and preserve the long perforating arteries of the middle cerebral artery. RESULTS: ICG dye correctly identified the long perforating branches of the middle cerebral artery and easily distinguished these vessels from the short perforating branches. All the branches of the middle cerebral artery that coursed through the tumor and had an onward course were preserved in all the patients. Only one patient developed a transient right sided hemiparesis that had improved at follow-up. CONCLUSIONS: Surgery for insular gliomas is challenging due to its location adjacent to eloquent areas, important white fiber tracts and the course of the middle cerebral artery within it. ICG is useful to identify and preserve the long perforating branches of the middle cerebral artery that course through the tumor and traverse onward to supply the corona radiata.

Supratentorial endodermal cysts - Report of two cases.

We describe two rare cases of frontal cystic lesions presenting with symptoms and signs of raised intracranial pressure. Both had a preoperative diagnosis of an arachnoid cyst and were subjected to a craniotomy with marsupialization of the cyst. However, the histology confirmed them to be an endodermal cyst (EC) on both occasions. Both the patients have been closely followed with no recurrence of symptoms. ECs of the central nervous system are usually reported in the spinal canal, mid-line posterior fossa, and the suprasellar regions. Supratentorial and non-midline ECs are rare, with only about 22 cases previously reported in literature. We discuss both the cases and review the relevant literature.

Successful management of a cervical fracture in a patient with ankylosing spondylitis by a posterior approach.

Patients with ankylosing spondylitis (AS) are at an increased risk of spinal fractures due to the altered spinal biomechanics. Moreover, it is difficult to treat these fractures due to the combination of ankylosis and osteoporosis. We report successful management of a C6-C7 vertebral fracture in a patient with AS. The patient improved in his neurological status and a good fusion was seen at a follow-up of 24 months.

Brain Herniation in Neurofibromatosis with Dysplasia of Occipital Bone and Posterior Skull Base.

A 22-year-old female, a known case of neurofibromatosis 1 (NF1), presented with a congenital swelling in the left occipital region. She had developed recent onset dysphagia and localized occipital headache. Neuroradiology revealed a left occipital meningoencephalocele and a left parapharyngeal meningocele. This was associated with ventriculomegaly. She was advised on cranioplasty along with duraplasty which she denied. She agreed to a lumbar-peritoneal shunt. She described a dramatic improvement in her symptoms following the lumbar-peritoneal shunt. Occipital dysplasias, though uncommon, have been reported in the literature. We review this case and its management and discuss relevant literature on occipital dysplasias in NF1.

Is Only Stabilization the Ideal Treatment for Ossified Posterior Longitudinal Ligament? Report of Early Results with a Preliminary Experience in 14 Patients.

BACKGROUND AND OBJECTIVE: Surgical treatment of ossified posterior longitudinal ligament (OPLL) continues to be wrought with confusion, debate, and arguments. We report our experience with an alternative form of treatment that involves only fixation of the involved spinal segments. We report and put on record our remarkably gratifying clinical experience in 13 of 14 patients having OPLL after surgery that involved only facetal fixation and aimed at arthrodesis of involved spinal segments. No direct bone, ligament, or disc resection was done for decompression of the spinal dural tube or root canal. The OPLL was not directly handled during the surgical procedure. The rationale of the proposed treatment is discussed. METHODS: During the period June 2012 to August 2014, 14 patients having OPLL were treated by facetal transarticular screw fixation technique. The Japanese Orthopaedic Association score, visual analogue scale, and Odom's criteria were used as indices to monitor the clinical status. RESULTS: The procedure resulted in firm stabilization and fixation of the spinal segments and provided a ground for arthrodesis. During an average follow-up period of 17 months, there was immediate postoperative and progressive recovery in symptoms in 13 patients. There were no surgery or implant-related mechanical or infective complications. CONCLUSIONS: Instability could be the defining phenomenon in pathogenesis of clinical symptoms related to OPLL. The clinical outcome in our patients suggests that only fixation of the spinal segments can be a simple, safe, and rationale form of treatment for the complex pathology of OPLL.

Lower motor neuron facial palsy after ventriculoperitoneal shunt surgery.

A 40-year-old woman underwent marsupialisation of a symptomatic retrocerebellar cyst. She developed pseudomeningocoele after the procedure. CT of the brain showed hydrocephalus. Therefore, a right-sided ventriculoperitoneal shunt procedure was performed. Unfortunately, the patient developed lower motor neuron-type facial paralysis immediately after the surgery. We localised the site of injury in the distal fallopian canal probably during tunnelling of the subcutaneous tract for passage of the shunt. We discuss the steps to be followed to avoid such mishaps with a brief review of the literature.

Meningioma of foramen magnum causing drop attacks.

A 52-year-old female presented with frequent episodes of falls without loss of consciousness. These episodes lasted for brief period followed by full neurological recovery. Magnetic resonance imaging (MRI) of the brain showed foramen magnum meningioma encasing left vertebral artery. The patient had dramatic improvement after excision of the tumor.

Epidermoid causing ischemic stroke in the brainstem.

Intracranial tumors may rarely cause stroke. We report an epidermoid cyst causing stroke in a pediatric patient. We have also reviewed the literature and pathogenesis of stroke caused by intracranial tumors.

Traumatic cervical epidural hematoma in an infant.

An 8-month-old male infant had presented with a history of a fall from the crib a fortnight ago. He had developed progressive weakness of both lower limbs. On examination, the infant had spastic paraplegia. Magnetic resonance (MR) imaging of the cervical spine showed an epidural hematoma extending from the fourth cervical (C4) to the first dorsal (D1) vertebral level with cord compression. The patient had no bleeding disorder on investigation. He underwent cervical laminoplasty at C6 and C7 levels. The epidural hematoma was evacuated. The cervical cord started pulsating immediately. Postoperatively, the patient's paraplegia improved dramatically in 48 hours. According to the author's literature search, only seven cases of post-traumatic epidural hematoma have been reported in pediatric patients, and our patient is the youngest. The present case report discusses the etiopathology, presentation, and management of this rare case.