Extra-Axial Third Ventriculostomy Through Lamina Terminalis with Multiple Cisternostomies - Rescue Surgery for Patients with Failed Shunt Surgeries and Hydrocephalus.

Background and Aim: Contemporary management of hydrocephalus involves various modes of cerebrospinal fluid (CSF) diversion, including shunt surgery and endoscopic ventriculostomy. However, there are times when either of these procedures have either failed or are not feasible. Highly invasive procedures aimed at internal CSF have been described previously, which, with the aid of modern microsurgical techniques, can be attempted in cases with very limited options. Our aim was to study the utility of extra-axial third ventriculostomy via lamina terminalis fenestration with multiple cisternostomies in the treatment of failed hydrocephalus. Materials and Methods: Forty-five patients with hydrocephalus were operated for extra-axial trans-lamina terminalis third ventriculostomy with multiple cisternostomies from January 2017 to January 2019. A minimally invasive supraorbital craniotomy was performed with subfrontal fenestration of the lamina terminalis and trans-lamina terminalis fenestration of the floor of the third ventricle with multiple cisternostomies including the optico-carotid cistern and opening of the Liliequist membrane. Results: Tuberculous meningitis was the most common etiology in the series, and multiple shunt procedures and incompatible CSF profiles were the most common reasons that necessitated this alternate rescue procedure. At a mean follow-up of 6 months, no patient required a revision shunt surgery. There was one death due to cardiac failure with anasarca, unrelated to the procedure. Conclusions: Extra-axial trans-lamina terminalis ventriculostomy with cisternostomies can safely be performed using minimally invasive micro-neurosurgical techniques, adding to the armamentarium of neurosurgeons in the management of complex cases of hydrocephalus.

Management Strategies of Cranial Encephaloceles: A Neurosurgical Challenge.

BACKGROUND: Encephalocele is defined as herniation of cranial contents beyond the normal confines of the skull through a defect in the calvarium either along the midline or at the base of skull. These anomalies should be repaired in the first few months of life to prevent neurological deficits and facial disfigurement. The aim of the surgery is water tight dural closure at the level of internal defect, closure of skull defect, and reconstruction of external bony deformity. MATERIALS AND METHODS: Fifty-four cases of encephalocoeles were studied in our hospital over a 6-year period from 2010 to 2016. Computed tomography (CT) and magnetic resonance imaging (MRI) brain were performed to delineate the bony defect and associated anomalies. Reconstruction of the bony defect was done using autologous calvarial bone graft, Osteopore polycaprolactone (PCL) bone scaffold filler and titanium mesh. RESULTS: In our study, 54 patients (34 boys and 20 girls) whose age varied between 2 months and 14 years were evaluated. Frontoethmoidal (44.5%) and occipital encephaloceles (25.9%) were the most frequently seen varieties. Repair of the dural defect either primarily or using pericranium was done in all cases. Closure of the bony defect was done using autologous calvarial bone graft in 12 (22.22%) patients. Titanium mesh was used in eight and Osteopore PCL bone scaffold filler in four children. Cranioplasty was not done in remaining thirty children because of the small bone defect. Overall, 80% had no postoperative problem and were discharged between 7 and 10 days of surgery. Cerebrospinal fluid leak was the most frequent postoperative complication, noted in five patients. Re-exploration with repair was done in one and remaining four were managed conservatively. Overall, cosmetic results were acceptably good, with parents judging the cosmetic outcome as good to excellent in 70%, satisfactory in 18%, and poor in 3% at the last follow-up. CONCLUSION: Our study demonstrated that encephaloceles are associated with complex deformities and pose a technical challenge to the neurosurgeon. A multidisciplinary approach is necessary to manage these cases. MRI brain and three dimensional CT aids in evaluating the deformity better and surgical correction should be performed as soon as possible to prevent a further neurological deficit. Repair of dural defect and reconstruction of the skull defect results in a good long-term outcome. We present our experience on 54 cases of cranial encephaloceles managed surgically over a period of only 6 years which is one of the largest series reported from Asia.

Tectal Tuberculoma: An Unusual Cause of Parinaud's Syndrome.

INTRODUCTION: Parinaud's Syndrome is an inability to move the eyes upwards which is caused by damage to the tectal plate of midbrain. Commonest causes implicated are the Pineal tumors in children, Multiple Sclerosis in adults and stroke in elderly patients. We present a rare case of Tectal plate tuberculoma leading to Parinaud's Syndrome. DISCUSSION: Parinaud's syndrome is caused by damage to the tectal plate or posterior commissure of midbrain. Our patient presented with upward gaze paresis and was diagnosed to have tuberculoma involving the midbrain region. He was managed conservatively and responded to the treatment. CONCLUSION: Tectal plate tuberculoma though a rare possibility, warrants proper diagnostic workup in order to prevent unnecessary brainstem surgery.