Unusual vascular anatomical variant leads to spontaneous hemorrhage in a cavum septum pellucidum in an adolescent: A case report and literature review.

Background: Hemorrhagic lesions of the septum pellucidum are rare and usually occur in neonates. They can be due to a number of etiologies. Here, we report a rare case of adolescent nontraumatic septum pellucidum hemorrhage with a review of literature. Case Description: A 16-year-old girl presented with a 1-month history of gradual visual deterioration in the left eye, intermittent headache, and vomiting. Brain imaging showed hematoma located between the leaflets of the septum pellucidum with obstructive hydrocephalus. Transcallosal resection of interventricular mass was done. The patient was discharged with improved neurological symptoms; however, the left eye vision did not recover. Imaging demonstrated a unique anatomical variant in deep vascular structures. Conclusion: Cavum septum pellucidum hemorrhage is rare in adults. Many theories were constructed to explain its etiology. Bleeding due a vascular anatomical variant was not previously encountered. Understanding the embryological origin and anatomical details are important for proper clinical assessment and management of these patients.

Effect of cranioplasty timing on the functional neurological outcome and postoperative complications.

BACKGROUND: The optimal timing for performing cranioplasty and its effect on functional outcome remains debatable. Multiple confounding factors may come into role; including the material used, surgical technique, cognitive assessment tools, and the overall complications. The aim of this study is to assess the neurological outcome and postoperative complications in patients who underwent early versus late cranioplasty. METHODS: A retrospective cohort study was conducted to investigate the neurological outcome and postoperative complications in patients who underwent cranioplasty between 2005 and 2018 at a Level l trauma center. Early and late cranioplasties were defined as surgeries performed within and more than 90 days of decompressive craniectomy, respectively. The Glasgow Outcome Score (GOS) and modified Rankin scale (mRS), recorded within 1 week of cranioplasty, were used to assess the neurological outcome. RESULTS: A total of 101 cases of cranioplasty were included in the study. The mean age of the patients was 31.4 ± 13.9 years. Most patients (n = 86; 85.1%) were male. The mean GOS for all patients was 4.0 ± 1.0. The mean mRS was 2.2 ± 1.78. Hydrocephalus was noted in 18 patients (early, n = 6; late, n = 12; P = 0.48). Seizures developed in 28 patients (early, n = 12; late, n = 16; P = 0.77). CONCLUSION: The neurological outcome in patients who underwent early versus late cranioplasty is almost identical. The differences in the rates of overall postoperative complications between early versus late cranioplasty were statistically insignificant. The optimal timing for performing cranioplasty is mainly dependent on the resolution of cerebral swelling.

Tension Pneumoventricle Secondary to Cutaneous-Ventricular Fistula: Case Report and Literature Review.

BACKGROUND: Tension pneumoventricle (TPV) is a subtype of tension pneumocephalus in which the air is trapped inside the ventricles through a one-way osteodural defect, causing an increase in intracranial pressure. TPV secondary to cutaneous-ventricular fistula has been reported only twice in the literature. CASE DESCRIPTION: Herein, we report the third case in a 53-year-old woman who developed TPV with decreased level of consciousness after removal of a posterior fossa meningioma while she was on external ventricular drainage. There was no identifiable bony defect on neuroimaging. The drain was changed urgently, and the fistula located at the drain tunneling site was sealed. CONCLUSIONS: This case report highlights the importance of suspecting and treating cutaneous-ventricular fistulas in TPV urgently in patients without skull base defects or those who showed no improvements with external ventricular drainage.

Sinus Pericranii Complicated by Hydrocephalus: Case Report and Literature Review.

BACKGROUND: Sinus pericranii (SP) is a rare vascular condition that results when abnormal communication between the intracranial and extracranial venous systems is present. Here we report a rare case of hydrocephalus revealed through a SP scalp mass with a review of literature. CASE DESCRIPTION: A 13-year-old girl presented with a history of bulging left eye, bilateral gradual deterioration of vision, nausea, and progressive headaches. The family reported the sudden appearance of a scalp mass prior to these symptoms. Brain imaging showed supra- and infratentorial communicating hydrocephalus and subcutaneous vascular collaterals from the midportion of the superior sagittal sinus. After ventriculoperitoneal shunt insertion, interval reduction of the ventricular size and disappearance of extracranial veins without associated intra- or extracranial vascular anomalies was observed. CONCLUSIONS: SP is divided into two main types: (1) Spontaneous type, in which lesions are formed due to acquired causes without a syndromic association or other vascular anomalies or stenosis. The most commonly reported cause is trauma in which SP may develop at the trauma site rather than the midline. (2) Congenital type, in which case the most commonly reported association is craniosynostosis. It can also be seen with vein of Galen hypoplasia, vein of Galen malformations, dural sinus malformations, solitary developmental venous anomalies, and intraosseous arteriovenous malformations. We are reporting the first case of idiopathic SP with hydrocephalus without a congenital association or acquired cause, including trauma. The sudden change in SP size can indicate a change in intracranial pressure and the development of hydrocephalus.

Spinal Pilomyxoid Astrocytoma.

Pilomyxoid astrocytoma (PMA) is a rare brain tumour generally located in the chiasmatic-hypothalamic region. In comparison to pilocytic astrocytoma, PMA has distinct histopathological features, aggressive clinical behaviour, a high recurrence rate, and early cerebrospinal fluid dissemination. Only 14 cases of PMA have been reported in the spinal cord since its pathological description in 1999. Here, we report the 15th case in a 3-year-old girl who was treated with chemoradiotherapy and followed up for 5 years. In this report, we also present a review of spinal PMA including treatment options and prognosis.

Pretruncal Nonaneurysmal Subarachnoid Hemorrhage with Underlying Hemophilia C.

BACKGROUND: Pretruncal nonaneurysmal subarachnoid hemorrhage (PNSAH) accounts for 15%-12% of all case of subarachnoid hemorrhage. Its precise etiology is not yet established. Multiple theories and risk factors have been investigated to address the possible cause of this type of hemorrhage including basilar tip dissecting aneurysms, high spinal arteriovenous fistula, venous stenosis/hypertension or venous bleeding. Hereditary coagulopathies and hemophilias have rarely been reported in the literature as a potential cause of PNSAH. CASE DESCRIPTION: Here, we reported a rare case of PNSAH with negative angiogram and magnetic resonance imaging who was also found to have hemophilia C (factor XI deficiency) confirmed by laboratory investigation. We also included a literature review of hereditary coagulopathies and their role as a possible cause of PNSAH. CONCLUSIONS: Detailed medical history and physical examination of patients with PNSAH may lead to further hematologic evaluation for this group of patients, as in this case, and may reveal more cases of mild coagulopathy that require treatment.

Supratentorial Craniotomies with or without Dural Closure-A Comparison.

BACKGROUND: Dural closure is a routine surgical step in neurosurgery. The benefit of suturing the dura to achieve watertight closure-with or without the use of dural substitutes-has been questioned in supratentorial craniotomy. We performed a retrospective study to examine the possible benefits and harms of suturing the dura compared with no dural closure and the occurrence of postoperative infection, cerebrospinal fluid (CSF) leak, and postcraniotomy headaches. METHODS: We performed a retrospective study to compare the incidence of CSF leak, infection, surgical site swelling, and postcraniotomy headaches between patients with watertight dural closure (closed group) and patients without watertight dural closure (open group). Any method used to close the dura and to achieve watertight closure was included, whether primary or secondary closure (with or without using suturable dural substitute). RESULTS: Overall, 216 patients were included in the present study, with 112 patients in the open group and 114 in the closed group. The open group experienced a greater incidence of infection and CSF leak (6 in the open group vs. 2 in the closed group), but without statistical significance (P = 0.15). We found no difference in surgical site swelling (P = 0.29). However, the closed group showed a greater association with the development of postcraniotomy headaches (P = 0.001). CONCLUSION: We found no difference in the occurrence of CSF leak, infection, or surgical site swelling between the closed and open groups. The incidence of postcraniotomy headaches was greater in the closed group, and the difference was statistically significant.

Canalis basalis medianus with cerebrospinal fluid leak: rare presentation and literature review.

Canalis Basalis Medianus is a rare congenital normal anatomically variant of the clivus .We report a very rare case of cerebrospinal fluid leak from a canalis basilaris medianus in a 22-year-old male, who presented to our hospital with frontal headache and running nose two weeks after an elective septoplasty.

Lhermitte-Duclos Disease with Cervical Arteriovenous Fistula.

Lhermitte-Duclos disease is a rare condition with less than 250 cases reported in the literature. It was considered a neoplastic or hamartomatous growth in the cerebellum. It commonly presents with symptoms of high intracranial pressure or obstructive hydrocephalus. Surgical resection is often curative. The lesion is associated with PTEN gene mutation, and it is considered to be one of the diagnostic criteria of Cowden's syndrome. Vascular tumors are reported in this syndrome, including glioblastomas and meningiomas. Furthermore, central nervous system vascular lesions were also reported in Lhermitte-Duclos disease, such as deep venous anomalies and brain arteriovenous fistulas. A report of an asymptomatic spinal cervical AVF in a patient with Lhermitte-Duclos disease was published in 2006. We present the second case of Lhermitte-Duclos disease associated with an asymptomatic spinal cervical AVF in a 17-year-old young woman with literature review of central nervous system vascular lesions in Lhermitte-Duclos disease.

Minimally Invasive Brain Port Approach for Accessing Deep-Seated Lesions Using Simple Syringe.

BACKGROUND: Retraction-related injury is a recognized complication in neurosurgery. Use of tubular retractors that distribute the pressure on brain tissue was introduced to minimize brain injury. We developed a modified technique using a simple plastic syringe with a Foley catheter to achieve atraumatic cannulation in accessing deep lesions. METHODS: A retrospective pilot study was conducted to assess safety of the syringe transtubular technique for accessing deep lesions as a cost-effective substitute for commercial brain port methods and to identify retraction-related injury using diffusion-weighted magnetic resonance imaging postoperatively. Nine patients were operated on using the syringe technique. Lesions selected were intraparenchymal, deeply located in the supratentorial compartment. Lesions were located in the insula (n = 2), thalamus or basal ganglia (n = 5), subcortical frontoparietal (n = 1) lobe, and right temporal lobe (n = 1). Patients with hematomas, intraventricular lesions, superficially located lesions; pediatric patients less than 12 years old; and patients undergoing redo surgeries were excluded. RESULTS: Surgical goals were achieved in 8 patients. Three patients had transient deficits; one patient had significant morbidity, which was diagnosed postoperatively as toxoplasmosis. Diffusion restriction was noted in all patients at the surgical cavity but not in the cannulation path. CONCLUSIONS: Transtubular approaches have a good safety profile and can help achieve surgical goals. Larger studies are needed to compare this approach with other methods, including its effect on hospital stay and survival. The syringe technique is an alternative safe method that can be used in certain neurosurgical centers where commercial tube systems are unavailable.