Brain Injuries and Facial Fractures: A Prospective Study of Incidence of Head Injury Associated with Maxillofacial Trauma.

BACKGROUND: Presence of head injuries in patients with maxillofacial trauma is a lifethreatening condition. Prompt determination of head injury in these patients is crucial for improving patient survival and recovery. Hence, the need to know about the incidence of head injuries associated with maxillofacial trauma becomes an important aspect. MATERIALS AND METHODS: A total of 100 patients were included in the study. Patient with head injuries associated with maxillofacial fractures was accounted to determine the incidence and pattern of head injuries accompanying maxillofacial trauma. They were evaluated for epidemiological demographic and clinical characteristics. RESULTS: The present study had 91% predominance of male patients with age ranging from 1 to 75 years. 91% cases were as a result of RTA. The most frequent maxillofacial injury represented was the fractured mandible. The incidence of head injuries associated with maxillofacial trauma was 67 %. Among all the patterns of head injuries, concussion was the most common head injury associated with maxillofacial trauma. CONCLUSION: In our study, the risk of head injury increased significantly as the Glasgow Coma Scale score decreased and with increase in the number of facial fractures. There was association between head injury and maxillofacial trauma.

Noncontiguous Double Spinal Lipoma with Tethered Cord and Polydactyly: Two Different Embryological Events in One Patient.

Lumbosacral lipoma is reported to occur in 4-8 of 100,000 patients. Sixty-six percent of lipomyelomeningocele in young patients have accompanied by hypertrophic filum terminale. It is rare to find two isolated spinal lipomas simultaneously. Embryological origin of dorsal and filar lipomas is different from each other and hence rarer to find them together. Radical resection is now being preferred for better long-term progression-free survival. We report an interesting case of spinal dysraphism in a 4-month-old female child with protruding, nontender, soft, subcutaneous 5 cm × 7 cm mass of the lumbosacral area that had been present since birth. Other anomalies included polydactyly of left hand. Magnetic resonance imaging demonstrated two isolated spinal lipomas, a transitional type and a terminal type filum lipoma with an interval of normal filum between the two. The findings were confirmed at surgery and detethering done along the white plane with neural placode reconstruction as described by Dachling Pang. The child had an uneventful postoperative recovery.

A rare case of infantile cerebellar pilocytic astrocytoma and thrombocytopenia presenting with intratumoral hemorrhage.

Incidence of gliomas presenting with hemorrhage is around 3.7-7.2%. Low-grade gliomas account for <1% tumor with hemorrhage. Infants presenting with cerebellar pilocytic astrocytomas (PAs) and hemorrhage with thrombocytopenia have not been reported. We report an interesting case of a 9-month-old infant who presented to the emergency department in a drowsy state with recurrent vomiting. Laboratory investigations showed anemia, thrombocytopenia, and coagulopathy. Radiological evaluation showed a large PA with bleed. The patient was treated with retromastoid suboccipital craniotomy and tumor excision and improved postoperatively. Cerebellar PA with bleed and coagulopathy in infants has not been reported in literature till date. Their presentation seems to be acute in nature, and high index of suspicion is required for the diagnosis of these posterior fossa tumors, which can deteriorate rapidly in infants.

Morphological Patterns of Intracranial Lesions in a Tertiary Care Hospital in North Karnataka: A Clinicopathological and Immunohistochemical Study.

INTRODUCTION: An "Intra-cranial space occupying lesion" (ICSOL)is defined as a mass lesion in the cranial cavity with a diverse aetiology like benign or malignant neoplasm, inflammatory or parasitic lesion, haematoma, or arterio-venous malformation. Central nervous system neoplasms represent a unique, heterogenous population of neoplasms constituting 1.9% of all malignant tumours in India. A broad spectrum of non-neoplastic conditions can mimic a brain tumour, both clinically and radiologically and these patients undergo biopsy. In such cases, the pathologist can readily differentiate between neoplastic and non-neoplastic imitators. AIM: The present study attempts to provide preliminary data on morphological patterns of intracranial lesions in North Karnataka region and to study clinicopathological spectrum with correlation of radiological findings of ICSOL. Special emphasis is made on the utility of special stains and IHC markers in CNS tumours. MATERIALS AND METHODS: This retrospective and prospective descriptive study was performed on biopsy specimen of ICSOL received from Departmnet of Neurosurgery, Basaveshwar Teaching Hospital, Kalaburgi. The study period was from January 2012 to June 2013 retrospectively and July 2013 to June 2015 prospectively. All specimens were preserved in 10% formalin and allowed to fix for 24 hours. The haematoxylin and eosin stained sections of the CNS lesions were obtained by routine processing and paraffin embedding. Special stains and IHC were done wherever appropriate. RESULTS: Sixty two cases of CNS lesions were studied, of which 12 (19.4%) cases were non neoplastic with six (50%) being cystic lesions and four (33.4%) were cerebral abscess. The neoplastic lesions comprised of 50 (80.6%) cases, which included 48 (96%) primary and two (4%) metastatic lesions. Among primary tumours, gliomas constituted the largest category of 24 (50%) cases with 16.7% being Glioblastoma Multiforme (GBM) and pilocytic astrocytomas each, followed by schwannomas (14%) and meningothelial tumours (12%). Majority were Grade I among gliomas and tumour of meninges with 37.5% and 87.5% respectively. Mean age of the patients was 26.72±11.2 (range: 0.4 to 80) years. Male to female ratio was 1:1.14. GFAP was demonstrated in astrocytomas, mixed gliomas and gliosarcoma. CONCLUSION: The surgical pathologist plays an important role in accurate diagnosis of various lesions of CNS which will be of immense help for patient prognosis and treatment. Immunohistochemistry is currently being employed to assist in the diagnosis of brain tumours.

Pediatric encephaloceles: A series of 20 cases over a period of 3 years.

BACKGROUND: Encephalocele is the protrusion of the cranial contents beyond the normal confines of the skull through a defect in the calvarium and is far less common than spinal dysraphism. The exact worldwide frequency is not known. AIMS AND OBJECTIVES: To determine the epidemiological features, patterns of encephalocele, and its postsurgical results. MATERIALS AND METHODS: The study was carried from year July 2012 to June 2015. Patients with encephalocele were evaluated for epidemiological characteristics, clinical features, imaging characteristics, and surgical results. RESULTS: 20 encephaloceles patients were treated during the study period. Out of these 12 (60%) were male and 8 (40%) female. Age range was 1 day to 6 years. The most common type of encephalocele was occipital 12 (60%), occipito-cervical 4 (20%), parietal 2 (10%), fronto-nasal 1 (5%), and fronto-naso-ethmoidal 1 (5%). One patient had a double encephalocele (one atretic and other was occipital) with dermal sinus tract and limited dermal myeloschisis. Other associations: Chiari 3 malformation (2), meningomyeloceles (4), and syrinx (4). Three patients presented with rupture two of whom succumbed to meningitis and shock. Seventeen patients treated surgically did well with no immediate surgical mortality (except a case of Chiari 3 malformation who succumbed 6 months postsurgery to unrelated causes). Shunt was performed in 4 cases. CONCLUSION: The most common type of encephalocele is occipital in our set up. Early surgical management of encephalocele is not only for cosmetic reasons but also to prevent tethering, rupture, and future neurological deficits.

Extended costotransversectomy to achieve circumferential fusion for pathologies causing thoracic instability.

BACKGROUND CONTEXT: Conventional circumferential stabilization for pathologies causing instability of the thoracic spine requires a two or even a three-staged procedure. The authors present their tertiary care center experience of single-staged procedure to establish a circumferential fusion through an extended costotransversectomy approach. OBJECTIVE: To demonstrate neural canal decompression, removal of the pathology, achieve circumferential fusion, and correcting the deformity through a single procedure. STUDY DESIGN: Prospective and observational. PATIENT SAMPLE: Forty-six patients with pan thoracic column instability due to various pathologies. OUTCOME MEASURES: Neurologic condition was evaluated using American Spinal Injury Association and Eastern Cooperative Oncology Group grading systems. Outcome was evaluated with regard to the decompression of neural canal, correction of deformity, and neurologic improvement. All patients were evaluated for neural canal compromise and degree of kyphosis preoperatively, early, and late postoperatively. METHODS: All patients had severe spinal canal compromise (mean, 59%±9%) and loss of vertebral body height (mean, 55%±10%). A single-stage circumferential fusion was performed (four-level pedicle screw fixation along with a ventral cage fixation after a vertebrectomy or corpectomy) through an extended costotransversectomy approach. RESULTS: The pathologies included trauma (21), tuberculosis (18), hemangioma (2), aneurysmal bone cyst (1), recurrent hemangioendothelioma (1), solitary metastasis (1) and plasmacytoma (1), and neurofibromatosis (1). Thirty-five of 46 patients (76%) demonstrated improvement in the performance status. The major complications included pneumonitis (3), pneumothorax (3) and neurologic deterioration (3; improved in two), deep venous thrombosis (2), and recurrent hemoptysis (1). No implant failures were noted on last radiology follow-up. There were two mortalities; one because of myocardial infarction and another because of respiratory complications. CONCLUSIONS: The following study demonstrated that extended costotrasversectomy approach is a good option for achieving single-staged circumferential fusion for correcting unstable thoracic spine due to both traumatic and nontraumatic pathologies.

A rare case of split pons with double encephalocoele, dermal sinus tract, and lipomeningomyelocele: a case report and review of literature.

INTRODUCTION: Multiple neural tube defects and pontine anomalies are relatively rare. Cases of split pons and double encephalocoeles in combination with other spinal anomalies are even rarer. CASE REPORT: Here, we present a very rare case of split pons, twin encephalocoeles (one of which was atretic), lumbar dermal sinus tract, lumbosacral lipomeningomyelocele, thickened filum, and syringomyelia that was managed successfully at our institute. CONCLUSION: Cases of split pons and double encephalocoeles in combination with other spinal anomalies are very rare, and to the best of author's knowledge, this is the first case report of these multiple anomalies in world literature.

A rare case of giant terminal lipomyelocystocele with partial sacral agenesis.

Terminal myelocystoceles (TMCs) are a rare form of occult spinal dysraphism. They constitute approximately 5% of skin covered lumbosacral masses. The TMC is composed of a low-lying conus medullaris with cystic dilatation of caudal central canal, a surrounding meningocele and a lipoma that extends from the conus to a subcutaneous fat collection. A 6-month-old female child presented with a large lumbosacral mass (14 cm × 12 cm × 10 cm) and weakness at the ankle joints since birth. Magnetic resonance imaging and computed tomography scan revealed a low-lying terminal lipomyelocystocele with holocord syrinx and partial sacral agenesis. The child was operated on successfully. This is an interesting and rare case of giant terminal lipomyelocystocoele with syrinx and a partial sacral agenesis. Terminal lipomyelocystocele should be included in the differential diagnosis of congenital lesions presenting as a lumbosacral mass and operated early.

Calvarial tuberculosis: Uncommon manifestation of common disease--a series of 21 cases.

OBJECTIVE: Tuberculosis is an endemic disease in developing countries like India. It can involve almost any part of human body. One such, albeit rare, is the extra pulmonary manifestation - tuberculosis of calvaria. There have been many isolated case reports and short series published on this unusual presentation. The aim of this presentation is to acquaint the reader with the varied presentation; to emphasise the role of prompt surgical debridement; as also to stress the role of complete anti-tubercular drug therapy in the management of this rare disease. METHODS: A retrospective analysis of a total of 21 patients over a period of 10 years period (July 1995 to June 2005). All patients were screened for the evidence of primary pulmonary tuberculosis. As part of their radiological workup, they were subjected to either a CT scan-head or MRI-brain. All patients were surgically managed at the institute. ATT was prescribed for 18 months. Follow-up period ranged from 6 months to 8 years. RESULTS: All patients improved following the completion of therapy with no evidence of recurrence. CONCLUSION: Calvarial tuberculosis is endemic in developing countries. This disease mainly affects the young population. With the rising incidence of AIDS, neurosurgeons all over the world are more likely to be exposed to this disease. CT-head and MRI-brain is the mainstay for radiological diagnosis. Definitive diagnosis rests on a biopsy report. Surgical debridement followed by anti-tubercular therapy for 18 months is the mainstay of the management of this unusual presentation.

Magnetic resonance imaging evaluation of subarachnoid hemorrhage in rats and the effects of intracisternal injection of papaverine and nitroglycerine in the management of cerebral vasospasm.

BACKGROUND: Cerebral vasospasm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). It usually occurs about 3-9 days after SAH. The pathogenesis involves the release of endogenous spasmogens. Though various treatment modalities are available, none are really effective. AIMS AND OBJECTIVES: The aim of the study was to develop an effective animal model for the study of SAH and vasospasm as well as to study the efficacy of vasodilators, namely nitroglycerine and papaverine, on SAH-induced vasospasm using magnetic resonance angiography. MATERIALS AND METHODS: Fifteen Wistar albino rats, weighing around 150-200 gm were used for the study. Five rats served as controls of SAH-induced vasospasm, while five rats each were used to study the efficacy of intracisternal injection of papaverine or nitroglycerine. RESULTS: Rats demonstrate vasospasm in a manner similar to humans. The maximal vasospasm is seen in the basilar artery. Statistical analysis demonstrates an improvement in vasospasm after instillation of intracisternal papaverine at the end of 2 hours in basilar and left internal cerebral artery. However, nitroglycerine does not produce any significant amelioration of vasospasm. Thus, it can be deduced that the pathogenesis of the vasospasm is more due to the action of cGMPase enzyme rather than inhibition of nitric oxide (NO) synthetase by the spasmogens. The present study is the first study in the English literature to compare the effects of single bolus doses of nitroglycerine and papaverine using magnetic resonance angiography. CONCLUSION: Rats can be used to create an effective model for SAH-induced vasospasm as the pattern resembles human SAH. Papaverine is an effective drug for ameliorating SAH-induced vasospasm. Short-acting NO donors are not as effective in ameliorating vasospasm.

Spinal intramedullary tuberculosis: a series of 15 cases.

OBJECTIVES: Spinal intramedullary tuberculosis is a rare disease. This study aims to acquaint readers with its clinicoradiological features and emphasizes the importance of early treatment in intramedullary spinal tuberculosis. MATERIALS AND METHODS: Retrospective analysis was conducted from 1985 to 2006 over a period of 21 years and data were retrieved from patient records at our institute (single centre study). Clinicoradiological and pathological data were reviewed along with final outcome at discharge and analyzed. RESULTS: Fifteen patients were analyzed. Mean age of presentation was 31 years (range: 18-45 years), with average duration at presentation being 11 months (2-24 months). Common locations: dorsal region: 7 cases, cervical: 5 cases, cervicodorsal: 2 cases and dorsolumbar region: 1 case. Sensori-motor involvement was noted in fourteen patients. Bowel and bladder involvement was seen in ten patients while one patient had respiratory distress. Only 40% of patients had secondary involvement of spine while the rest of the cases were having primary spinal intramedullary tuberculosis. Three patients had previous history of tubercular meningitis, while one patient had old pulmonary tuberculosis. There were one case each of cervical node involvement and intracranial granuloma. Twelve patients underwent surgery while others were conservatively managed, all patients received antitubercular therapy for 18 months. Nine of the twelve operated patients showed improvement in motor power, while two of the conservatively managed patients improved. Patients presenting late had a poorer outcome. CONCLUSION: Spinal intramedullary tuberculosis is a non-malignant, treatable lesion giving a good outcome on management. Surgically managed patients showed a better outcome.

Giant terminal lipomyelocystocele.

Terminal myelocystocele is a rare form of occult spinal dysraphism in which the hydromyelic caudal spinal cord and the subarachnoid space are herniated through a posterior spina bifida. A 1-year-old female child presented with a large lumbosacral mass (30 x 20 x 10 cm), flaccid paraplegia and urinary incontinence since birth. Magnetic resonance imaging revealed a low-lying conus (with associated conus lipoma) and a dilated central canal surrounded by a meningocele suggestive of terminal lipomyelocystocele and was operated on successfully. In our experience, this was a giant terminal lipomyelocystocele and such a large lesion has not been reported in the literature before. Terminal myelocystocele should be included in the differential diagnosis of congenital lesions presenting as a lumbosacral mass and operated early.