Endovascular repositioning and resizing of the distal catheter of a ventriculoatrial shunt.

Ventriculoatrial (VA) shunts are an effective alternative to ventriculoperitoneal shunts for diversion of cerebrospinal fluid in patients with hydrocephalus. Accurate placement of the distal end of a VA shunt in the right atrium is imperative for appropriate drainage and can be technically challenging. Misplaced or dislodged shunt catheter needs urgent repositioning, which can be performed by endovascular techniques. We present a case of VA shunt placement related complication, in which the dislodged distal fragment was retrieved by endovascular techniques. The remaining distal catheter, found to be in the internal jugular vein, was not only repositioned, but also resized for accurate placement in the right atrium.

Intraconal optic sheath schwannoma: report of two cases.

Optic sheath schwannoma is extremely rare. We discuss two cases of intraorbital intraconal optic sheath schwannoma. Vision significantly improved in both patients following the surgery. We have briefly described the surgical technique & discussed the relevant literature.

Cystic Chordoma of the Cavernous Sinus.

Chordomas are the tumors commonly involving base of skull which are predominantly solid in consistency. A cystic chordoma of the cavernous sinus is an extremely rare entity and has never been reported. We report a 26-year-old male presenting with gradually progressive right-sided sixth nerve palsy and headache. Computed tomography and magnetic resonance imaging of the brain showed a cystic lesion in the right cavernous sinus. The patient was successfully treated using a transnasal endoscopic transsphenoidal approach. Histopathological examination of the lesion revealed chordoma. Our case is the first report of such a condition. Chordoma should be considered in the differential diagnosis of cystic lesions in the parasellar location. We briefly review the radiology, the pathology and management dilemmas of such lesions.

Polytetrafluoroethylene sponge syringosubarachnoid shunt.

Syringomyelia is condition in which a cyst or cavity forms inside the spinal cavity. Its management always remains a difficult. A variety of surgical techniques have been used in management of syringomyelia. Syringosubarachnoid shunt remains an effective method in management of syringomyelia. Shunt tube obstruction remains an important complication of shunt procedure. We describe a novel technique of use of polytetrafluoroethylene sponge shunt for syringosubarachnoid shunt in patient with large syrinx and Chiari 1 malformation. Polytetrafluoroethylene sponge is a non irritant material with multiple porosities that is less susceptible to blockages or kinking. It could provide a good alternative technique in syringosubarachnoid shunting.

Giant ventral midline schwannoma of cervical spine : agonies and nuances.

Pure ventral midline giant schwannoma is an extremely rare entity. Spinal intradural extramedullary schwannomas commonly occur posterolateral or anterolateral to the spinal cord. A case of a pure midline ventrally situated giant pan cervical extramedullary schwannoma in an 18-year-old male patient with compressive myelopathy and sphincter involvement is presented. Spinal MR imaging showed a midline ventrally situated extramedullary tumor with severe spinal cord compression extending from clivus to C7 vertebra. It was resected through a posterolateral approach. Histology was consistent with a schwannoma. Post operative MR imaging showed no evidence of the tumor. The radiological features, pathogenesis and surgical strategies in management of these difficult tumors are discussed and the relevant literature is briefly reviewed.

Complete recovery of visual loss following surgical treatment of mucopyocele of the anterior clinoid process.

A mucocele is a collection of mucus, which is lined by the mucus-secreting epithelium of a paranasal sinus. Paranasal sinus mucoceles occur as a result of inflammation, tumor, trauma or surgical manipulation. The anterior clinoid process may be pneumatized by an extension of the sphenoid paranasal sinus air space during normal development. Mucocele of the anterior clinoid process is rare. We report a patient with mucopyocele of the anterior clinoid process that resulted in rapid monocular visual loss. The left optic canal was exposed extradurally via a supraorbital craniotomy and the mucopyocele was totally excised. The optic canal was decompressed by drilling the superior, lateral and medial rims, to achieve circumferential decompression of the optic nerve. The patient's vision improved postoperatively.

Trigeminal neurinomas with extracranial extension: analysis of 28 surgically treated cases.

OBJECT: The object of this paper was to review the authors' experience with 28 cases of trigeminal neurinomas having an extracranial extension. METHODS: The authors analyzed 28 cases of trigeminal neurinoma in which there was an extracranial extension of the tumor. All patients were treated in their department between the years 1989 and 2009. RESULTS: There was tumor extension along the ophthalmic division of the nerve in 4 cases, along the maxillary division in 5, and along the mandibular division in 13. In 6 tumors there was diffuse extracranial extension and the exact extracranial division of nerve involvement could not be ascertained. In 10 cases, the tumor had a multicompartmental location--in the posterior fossa, the middle fossa, and the extracranial compartment. Tingling paraesthesiae, numbness, and diffuse pain in the distribution of the trigeminal nerve were common symptoms and were present in 90% of patients. The extracranial component had a well-defined perineural/meningeal membrane cover that was continuous with the middle fossa dura mater and isolated the tumor tissue from the adjoining critical structures. In 7 out of 10 cases, even the posterior fossa component of the tumor was entirely "interdural" (within the confines of the dura). The maximum dimension of the tumor was > 4 cm in 22 cases. A limited "transcranial" approach with (12 cases) or without (16 cases) zygomatic osteotomy was found suitable for resection of these tumors. In 4 cases a lateral orbitotomy was performed. Total tumor resection was performed in 20 cases and partial resection in 8. The duration of follow-up ranged from 6 months to 19 years. Two patients required additional surgery for symptomatic recurrence. CONCLUSIONS: Extracranial extensions of trigeminal neurinomas have a well-defined meningeal covering. In most cases resection was performed via a minimally invasive cranial avenue (a "reverse skull base approach"). Radical resection was associated with an excellent long-term outcome.

Seeding metastases of a benign intraventricular meningioma along the surgical track.

Seeding metastases of a benign intraventricular meningioma along the surgical track is rare. We report a patient with a benign fibroblastic intraventricular meningioma that had spread along the path of previous surgery; the recurrences as well as the primary tumor were benign.

Pure ventral midline long segment schwannoma of the cervicodorsal spine: a case report.

Spinal intradural extramedullary schwannomas commonly occur posterolateral or anterolateral to the spinal cord. A case of a pure midline ventrally situated cervicodorsal extramedullary schwannoma in a 33-year-old female patient with subacute cord compression and sphincteric involvement is presented. Spinal MR imaging showed a C2-D3 midline ventrally situated extramedullary tumor with severe spinal cord compression. It was resected through a posterolateral approach. Histology was consistent with a schwannoma. There was a gradual improvement in left-sided spasticity but the patient had mild diaphragmatic paresis. MR imaging showed no evidence of the tumor at followup after 6 months. The radiological features, pathogenesis and surgical strategies in management of these difficult tumors are discussed and the relevant literature is briefly reviewed.

A massive cervicomedullary intramedullary spinal cord lipoma.

We present a large cervicomedullary intramedullary lipoma in a 17-year-old boy, who presented with spastic quadriparesis and exaggerated reflexes. MRI revealed an intramedullary lipoma extending from the craniovertebral junction to the sixth cervical vertebra. There was no spinal dysraphism. Subtotal excision with primary dural closure was performed, which produced an improvement in the patient's condition. The technique we used is discussed.

Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients.

OBJECT: This study is a retrospective analysis of 60 surgically treated patients with 64 peripheral nerve sheath tumors (PNSTs) at the second cervical (C-2) nerve root. The anatomical subtleties of these tumors and their implications for surgical strategy when compared with other spinal PNSTs and other tumors in the foramen magnum region are reviewed. METHODS: Sixty patients with C-2 PNSTs treated surgically in the Department of Neurosurgery at King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College between 1992 and 2006 were studied. All patients underwent magnetic resonance imaging. Tumors were divided into 3 groups depending on their anatomical location identified during surgery. Those tumors located within or extending into the spinal dural tube were called Type A, those located within the dural tube of the C-2 ganglion were labeled as Type B, and tumors extending laterally into the paraspinal region were labeled as Type C. Follow-up durations ranged from 6 months to 15 years (mean 64 months). RESULTS: There were 38 male and 22 female patients in the study, who ranged in age from 6 to 62 years (mean 28 years). Nine patients had clinical features indicative of neurofibromatosis (NF). The mean duration of symptoms at the time of presentation was 27 months (range 4 days-5 years). Two patients had no specific symptoms related to the C-2 PNST, 6 patients had only local symptoms such as neck pain or stiffness, and 52 patients had symptoms of varying degrees of myelopathy. There were 5 solely Type A tumors, 7 Type A + B tumors, 31 Type B tumors, and 21 Type B + C tumors. All Type A, A + B, and B tumors were totally resected. Seven of 21 Type B + C tumors were partially resected, and the remainder were completely resected. All patients postoperatively reported varying improvement in their preoperative symptoms. Except for patients with NF who were disabled by other tumors, the rest of the patients resumed their normal life style. There have been no cases of symptomatic tumor recurrence. CONCLUSIONS: The majority of PNSTs located at the C-2 level in these patients probably arose from the large C-2 ganglion and are limited within the dural confines or are interdural in location. In contrast to other spinal PNSTs, the location of C-2 PNSTs is in most cases posterior to the lateral mass of the atlas and axis and the atlantoaxial joint and is exposed to the posterior without any bone cover. Radical tumor resection is safe, resolution of clinical symptoms is rapid, and recurrence rates are extremely low. In a selected number of cases, bone work for tumor exposure and resection can be entirely avoided.