A large cirsoid aneurysm of the scalp with multiple arterial supply: illustrative case.

BACKGROUND: Cirsoid aneurysm of the scalp is a rare arteriovenous fistula having a traumatic, congenital, iatrogenic, or idiopathic etiology. Its presentation can range from a small swelling to a large pulsatile mass with tinnitus, headache, and scalp necrosis. OBSERVATIONS: A 67-year-old female presented with a gradually increasing swelling on her forehead and head since childhood and no history of trauma. Examination revealed 12 × 5 cm tortuous midline swelling. Computed tomography angiography revealed a mass of tortuous vessels in the right frontoparietal region of the scalp with no bony defect or intracranial extension. Contrast-enhanced computed tomography of the head showed no intracranial pathology. The diagnosis of cirsoid aneurysm was made, and surgery was planned. A bicoronal incision was made. The feeding arteries were dissected and ligated. The nidus was carefully separated, cauterized, and excised in toto. Inadvertently, a buttonhole in the skin was created while dissecting the nidus, which was sutured. The patient developed a small area of scalp necrosis on the 10th postoperative day, which was debrided and sutured. At the 6-month follow-up, no signs of recurrence were present. LESSONS: A large cirsoid aneurysm of the scalp with multiple arterial supplies can be treated successfully with surgery. Meticulous dissection and hemostasis are warranted to avoid perioperative complications.

Resection of a large multisegmental filum terminale ependymoma through a multisegmental hemilaminectomy.

This video demonstrates a gross-total resection of a multisegmental intradural extramedullary tumor using only multisegmental hemilaminectomy. The patient is a 21-year-old woman presenting with only backache. MRI of the lumbar spine demonstrates a large multisegmental heterogeneously enhancing intradural extramedullary tumor extending down from the eleventh dorsal vertebrae down to the fifth lumbar vertebrae. The surgical video demonstrates the technique of multisegmental hemilaminectomy and microsurgical resection of the tumor without posterior spinal instrumentation. Postoperatively, the patient had no neurological deficit and was discharged on postoperative day 5. Three-month postoperative MRI shows no residual disease or spinal deformity.

"Stealth cranioplasty:" A novel endeavor for symptomatic adult Chiari I patients with syringomyelia: Technical note, appraisal, and philosophical considerations.

AIM AND OBJECTIVE: In this article, we describe a novel technique of reconstruction of posterior fossa by cranioplasty with use of preshaped titanium mesh following posterior fossa decompression (PFD) for Chiari malformation type I (CMI) with syringomyelia (SM) in symptomatic adults. MATERIALS AND METHODS: Eleven patients underwent limited PFD and expansive cranioplasty with preshaped titanium mesh, what we term as "Stealth Cranioplasty" (SCP), following arachnoid preserving duraplasty (APD) and hexagonal tenting of the duraplasty with the cranioplasty (HTDC) for the management of symptomatic adult CMI with SM. All these patients had syringes extending from 3 to >10 vertebral levels. RESULTS: Seven male and four female symptomatic CMI adult patients, between age ranges of 22 and 44 years (mean 29.45 years), presented with different neurological symptoms related to CMI and SM for 6-84 months (mean 37.09 months). All the patients underwent PFD, APD followed by SCP and HTDC and were followed up for 7-54 months (mean 35.90 months). Of 11 patients, 8 patients improved according to the Chicago Chiari Outcome Scale (CCOS) with score of 13-15 while 3 patients remained unchanged with CCOS of 12, and there was no worsening. There was no complication related to Chiari surgery in any of the patients. All the patients had good reestablishment of cisterna magna. Two patients had marked reduction of syrinx while eight patients had moderate-to-mild reduction and one patient had no change of syrinx. None of the patients needed redo surgery. CONCLUSION: SCP is an effective, fruitful, and cost-effective technique for the management of symptomatic adult CMI with SM. This technique has the advantages of preventing complications and recurrences in addition to the improvement of symptoms by addressing the basic pathology.

Was Cavum Septum Pellucidum the Cause of Intractable Seizure in a 17-Year-Old Boy with Wilson Disease?

BACKGROUND: Cavum septum pellucidum (CSP), which is often found incidentally in a few populations, occasionally becomes symptomatic if enlarged significantly. Wilson disease (WD) is an uncommon autosomal recessive inborn defect in copper metabolism characterized by abnormal accumulation of copper in various tissues, particularly in the liver and the brain. Seizure disorder, although rare both in CSP and WD, may happen in a few patients with either of the conditions. CASE DESCRIPTION: We report a case of 17-year-old boy, a patient with known WD, who developed intractable seizure for a year, which was not controlled with a large amount of antiepileptics. Magnetic resonance imaging showed enlargement of his preexisting CSP, which was small and asymptomatic at the time of diagnosis of WD. His WD was in a state of remission when he developed the seizure disorder. On endoscopic cyst fenestration, he was relieved of the seizure. CONCLUSIONS: Symptomatic CSP is a rare disorder, but the coexistence of WD is even rarer. Endoscopic cyst fenestration is a novel procedure that can be successful in properly selected cases. To the best of our knowledge, CSP associated with WD has not been reported in any English literature. We present this case for its rarity along with a relevant literature review.

Primary Ewing's sarcoma of the skull.

Ewing's sarcoma, a highly malignant bone tumour, typically affects the pelvis and the long bones of the lower extremities in children and young adults and primary involvement of the skull is rare. Here, we present a case of primary Ewing's sarcoma of the skull with localised swelling in a young adult that involved the frontoparietal region of the skull and was very aggressive in nature. Even with aggressive surgery, the patient had multiple recurrences within 1 month of surgery and ultimately the patient died.

Double migration of a schwannoma of thoracic spine.

Mobile intraspinal tumours have rarely been reported. In most cases, mobile tumours such as schwannomas or ependymomas were located in the cauda equina. Perusal of the literature revealed only two reports of mobile schwannomas in the cervical and thoracic regions. We report a case of thoracic schwannoma which migrated twice in successive operations resulting in negative exploration in the expected area. The aim of this report is to remind the surgeons about the possibility of migration of intradural-extramedullary tumour.

Contiguous haemangioblastomas of the brain and spine in a patient of Von Hippel-Lindau disease.

Von Hippel-Lindau (VHL) disease is an inherited, autosomal-dominant syndrome caused by heterozygous germline mutations in the VHL gene, and predisposing to the development of benign and malignant tumours and cysts in multiple organ systems involving eyes, kidneys, pancreas, liver and central nervous system. The responsible tumour suppressor gene for VHL disease is in chromosome 3p25. We are presenting a case of a patient with both cerebellar as well as spinal haemangioblastoma in addition to polycystic pancreas. We operated on both the spinal and the cerebellar haemangioblastomas and the patient had made a very good recovery. We present this case for its rarity along with the literature review.

Spinal extradural cavernous haemangioma in an elderly man.

Cavernous haemangiomas are vascular malformations that may affect any part of the central nervous system. Epidural haemangiomas are rare and constitute ~4% of all epidural tumours and 12% of all intraspinal haemangiomas. These tumours enlarge slowly and produce symptoms of progressive myelopathy or radiculopathy or both. History, clinical examination, routine radiographs, MRI and histopathological studies are the aids for a definitive diagnosis. Surgery can give a very beneficial result with good functional and neurological improvement. Chance of recurrence is less after a good surgical removal. Here we present a case of spinal extradural cavernous haemangioma in a 65- year-old man who had a good functional and neurological recovery after surgery. At 9 months postoperative follow-up, he did well without any new problems with regard to recurrence. We report this case for its rarity.

Solitary osteochondroma of the atlas causing spinal cord compression: a case report and literature review.

Solitary osteochondroma (SOC) of the spine is very rare, though OC is the commonest benign tumour of the bone. Only about 1-4% of SOCs occur in the spine. And solitary ostechondroma of spine causing cord compression is even rarer. These tumours slowly enlarge, creating insidious but progressive symptoms of myelopathy or radiculopathy or both. Clinical histories, routine radiographs, CT studies, MRI studies and histopathological studies are the adjuncts for a definitive diagnosis. Surgical intervention can lead to functional and neurologic improvement with very little chance of recurrence. The authors present a case of a C1 posterior arch intraspinal SOC with cord compression who recovered very well after surgery and was doing well without recurrence after 1 year of surgery. The authors are reporting this case with English language medical literature review as it is quite rare among the SOCs of the cervical spine.

Calcified chronic subdural haematoma.

Chronic subdural haematoma (CSH) is a well-known disease entity; however, calcified CSH (CCSH) is quite rare. Here the authors report on a 65-year-old man who developed gradual left hemiparesis and had gradually deteriorating level of consciousness for 1 month. CT scan revealed a huge right-sided CCSH. He underwent surgery and the CCSH was excised totally. The patient recovered well and was able to do his daily activities by himself. Surgical treatment for CCSH results in good neurological outcome.