Surgical Management of Moderate Sized Spontaneous Cerebellar Hematomas: Role of Intracranial Pressure Monitoring.

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.

Subgaleal migration of a ventriculoperitoneal shunt.

Blockage of a ventriculoperitoneal (VP) shunt is very common. Here, we describe an unusual case of shunt blockage in an infant. He was shunted for hydrocephalus associated with a Dandy-Walker malformation diagnosed at birth. At surgery, the entire VP shunt was found to have migrated into the subgaleal space, which clinically presented as shunt obstruction. We suggest techniques to avoid this rare, but preventable, complication of shunt surgery.

Angiolipoma of the right inferior colliculus: a rare central cause of hearing loss and limb ataxia.

Intracranial angiolipomas are rare entities and are infrequently symptomatic. These benign lesions are adherent to the surrounding neurovascular structures as they share the same blood supply, which limits their resectability, and impose a possibility of persistence of symptoms. However, due to recent advancements in the neuro-radiological fields and microneurosurgical techniques it has been possible to localise precisely and excise these lesions with low morbidity and mortality. The authors present an interesting rare case of intracranial angiolipoma of the right inferior colliculus situated in the quadrigeminal plate cistern. The patient had presented with ipsilateral hearing loss and upper limb ataxia. Interesting clinical findings, neuro-imaging studies and peroperative features are presented and discussed along with a brief review of the literature.

Intracranial migration of Foley catheter--an unusual complication.

Profuse nasal bleeding in cases of severe head injury is mostly associated with facial and skull base fractures and various methods have been tried to control such bleeding. Anterior nasal packing, producing a tamponade effect with a Foley catheter and other inflatable balloon devices are time proven methods. We describe a case of severe head injury with such fractures where a Foley catheter tamponade was attempted to control the severe nasal bleeding and the CT brain scan revealed inadvertent malposition of the catheter into the cranial cavity. This rare entity is described to highlight the potential danger associated with a proven method of controlling severe nasal bleeding and suggestions are outlined as to how to avoid such a mishap, along with a brief review of the literature.

Symptomatic cranial fibrous dysplasias: clinico-radiological analysis in a series of eight operative cases with follow-up results.

Cranial fibrous dysplasias are rare and comprise less than one percent of all primary bone lesions. These painless progressively expanding destructive bone swellings produce cosmetic deformities (commonest), sino-orbital and auditive complications (less common), peripheral compressive cranial neuropathies (uncommon) and compressive central neurological manifestations (rarest). Until recently some of the primary dysplastic skull base lesions were either treated expectantly or excised incompletely. In a significant percentage of cases, these lesions were considered inaccessible. However, with the development of modern neuro-imaging (CT and MRI) and the applications of current skull base approaches, the more aggressive and radical surgical procedures are being undertaken, with a significant improvement in overall outcome. We present a series of 8 cases of fibrous dysplasia in the age group of 10-33 years with a mean age of 19.75 years. Four cases each had monostotic type and polyostotic type. All patients presented with mild to moderate headaches, and seven cases with some form of cosmetic deformity. In 4 patients there was a unilateral proptosis, while only two had visual deterioration. One patient had anosmia and one hearing impairment. In one case fibrous dysplasia was hemicranial, and in another case the disease was pancranial. Neuro-imaging studies have well delineated the extent of the lesions. In two patients with unilateral fronto-orbital fibrous dysplasia, the removal of dysplastic bone, autoclaving and remodeling and replacement were performed. In two patients of sphenoidal wing fibrous dysplasia a total excision was possible. In the remaining four patients, a partial excision was performed. Overall outcome was good. There was no mortality. One patient had recurrent post-operative extradural haematomas. The authors present the results of an analysis of eight surgically treated cases of symptomatic cranial fibrous dysplasias along with their long-term outcome and the lessons learnt from this series.

Intracranial Salmonella infections: meningitis, subdural collections and brain abscess. A series of six surgically managed cases with follow-up results.

Focal intracranial infections due to Salmonella are rare. So far, around 80 cases have been reported in the world literature. The authors present their experience of 6 cases of intracranial Salmonella infections, mainly subdural empyema in 5 and effusion in 1. In 1 case, subdural empyema was bilateral, and in another case, there was an associated brain abscess. Positive blood cultures and positive Widal tests were noticed in 2 patients each. Early diagnosis and prompt evacuation of subdural collections and brain abscess and antibiotic therapy lead to satisfactory results. This study suggests that a high index of suspicion, early diagnosis and quick evacuation lead to success; this point is highlighted with the help of a review of the literature.

Rathke's cleft cyst presenting as pituitary apoplexy.

Sellar lesions mainly constitute pituitary adenomas, craniopharyngiomas and benign cysts. Rathke's pouch cyst is a developmental sellar and/or suprasellar cystic lesion lined by a single layer of ciliated cuboidal or columnar epithelium, which rarely be comes symptomatic. The authors present an interesting case of intrasellar Rathke's pouch cyst, with a presenting feature of acute pituitary apoplexy. This was a 19 year old healthy male who had developed sudden headache and visual disturbance. Neuro-radiological imaging revealed a mass in the sella. Via transsphenoidal approach a haemorrhagic intrasellar cystic lesion was removed and was confirmed as a haemorrhagic Rathke's cleft cyst by histopathological examination. Interesting clinical presentations and the neuroimaging findings are described and discussed.

Congenital intra-extracranial dumbbell schwannoma of temporal fossa unassociated with any major cranial nerve.

Intracranial schwannomas commonly arise from the vestibular nerve and less commonly from other cranial nerves. On rare occasions, they may be intraparenchymatous, intraventricularor intrasellar. However, the occurrence of a congenital solitary intracranial extradural schwannoma unrelated to any cranial nerve in the absence of von Recklinghausan's syndrome is exceptional. The authors report a unique, heretofore unreported case of a congenital temporal extradural schwannoma, unassociated with any known cranial nerve and with a transcranial extension presenting as a temporal fossa mass since birth in a 16-year-old female patient. Total resection of this tumour was uncomplicated. A brief review of the relevant literature is presented.

Craniospinal giant cell tumors: clinicoradiological analysis in a series of 11 cases.

Primary craniospinal giant cell tumors are rare (5-15% of all giant cell tumors), locally destructive bone lesions which are generally not associated with Paget's disease. Clinical behavior of the craniospinal giant cell tumor (GCT) is unpredictable but often very aggressive and therefore optimal management of the lesions remains controversial. Wide resection of the involved bone is required, preferably with a wide margin of normal tissue, which may be difficult to achieve in the craniospinal region. The authors analysed a series of 11 patients, which included five cases of cranial and six cases of spinal GCTs. Their ages ranged from 12 to 46 years with a male preponderance. In the five cranial cases, all the tumors involved the skull base, three involved the spheno - ethmoidal region and in two cases the petroclival region was involved. Common presenting symptoms were frontotemporal swelling, epistaxis, local pain and neurological deficits attributable to the neurovascular compression. Proptosis, visual loss, nasal mass and cranial nerve involvement were the common findings. In the six patients with spinal lesions (one cervical, four thoracic and one thoracolumbar), local pain, progressive sensory motor deficits and bladder involvement were common presentations. Neuroimaging studies were performed in various combinations for preoperative evaluation and surgical planning. In cranial cases, multidisciplinary approaches were used to perform a near total or a total excision. In the spinal GCTs, only a partial excision was possible. Postoperative radiotherapy was delivered in ten patients. Histopathological studies were diagnostic. All patients were followed up for periods ranging from one to 10 years, with a mean of 2 years and 3 months. No significant increase in the residual tumor or recurrences, as seen on periodic neuroimaging studies, were noted during their follow-up period.