Subdural Hematoma due to Dural Metastasis: A Systematic Review on Frequency, Clinical Characteristics, and Neurosurgical Management.

BACKGROUND: Subdural hematoma (SDH) occasionally accompanies dural metastasis and is associated with high recurrence rate, significantly impacting patient morbidity and mortality. This systematic review aims to evaluate the characteristics, management options, and outcomes of patients with SDH associated with dural metastasis. METHODS: A comprehensive search of the PubMed and Cochrane databases was conducted for English-language studies published from inception to March 20, 2023, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors reviewed cases of histopathologically confirmed SDH with non-central nervous system (non-CNS) tumor metastasis, focusing on therapeutic management of SDH. Statistical analysis was performed using SPSS software, with a significance level set at 0.05. RESULTS: This review included 32 studies comprising 37 patients with 43 SDH cases associated with dural metastasis. Chronic SDH was the most frequently observed presentation (n = 28, 65.12%). The systemic malignancies most commonly associated with SDH due to dural metastasis were prostate carcinoma (n = 9, 24.32%) and gastric carcinoma (n = 5, 13.51%). A statistically significant association was found between metastatic melanoma and subacute SDH (p = 0.010). The majority of patients were treated with burr holes (n = 15, 40.54%) or craniotomies (n = 14, 37.84%), with no statistically significant difference in mortality rates between the two techniques (p = 0.390). Adjuvant therapy was administered to a limited number of patients (n = 5, 13.51%), including chemotherapy (n = 2, 5.41%), whole brain radiotherapy (n = 1, 2.70%), a combination of chemotherapy and whole brain radiotherapy (n = 1, 2.70%), and transcatheter arterial chemoembolization (n = 1, 2.70%). The overall recurrence rate was 45.95% (n = 17), with burr holes being the most common management approach (n = 4, 10.81%). Within a median of 8 days, 67.57% (n = 25) of patients succumbed, primarily due to rebleeding (n = 3, 8.11%), disseminated intravascular coagulation (n = 3, 8.11%), and pneumonia (n = 3, 8.11%). CONCLUSION: This review highlights the need for improving existing neurosurgical options and exploring novel treatment methods. It also emphasizes the importance of dural biopsy in patients with suspected metastasis to rule out a neoplastic etiology.

Trampoline-Associated Cranial and Spinal Injuries: A 10-Year Study in a Pediatric Neurosurgery Center.

OBJECTIVE:  There has been an increasing use of trampolines for recreation by children in recent years. Many studies have explored the different types of injuries sustained due to falls from trampolines, but so far none have focused specifically on cranial and spinal injuries. In this study, we describe the pattern of cranial and spinal injuries sustained by pediatric patients that were associated with the use of trampolines and their management in a tertiary pediatric neurosurgery unit over a period of 10 years. METHODS:  This is a retrospective study of all children less than 16 years of age with suspected or confirmed trampoline-associated cranial or spinal injuries, managed by a tertiary pediatric neurosurgery unit from 2010 to 2020. Data collected included the patient's age at the time of injury, gender, neurological deficits, radiological findings, management, and clinical outcome. The data were analyzed to highlight any trends in the pattern of injuries. RESULTS:  A total of 44 patients with a mean age of 8 years (ranging from one year and five months to 15 years and five months) were identified. 52% patients were male. 10 patients (23%) had a reduced Glasgow Coma Scale (GCS) score. In terms of imaging findings, 19 patients (43%) had a radiologically positive head injury, nine (20%) had a craniovertebral junction (CVJ) injury, including the first (C1) and second (C2) cervical vertebrae, and six (14%) had an injury involving other parts of the spine. No patient sustained concurrent head and spinal injuries. Eight (18%) patients had normal radiological findings. Two (5%) had incidental findings on radiology that required subsequent surgery. A total of 31 patients (70%) were managed conservatively. 11 patients (25%) underwent surgery for their trauma, of which seven were cranial. Two further patients underwent surgery for their incidental intracranial diagnoses. One child died from an acute subdural hemorrhage. CONCLUSIONS:  This study is the first to focus on trampoline-associated neurosurgical trauma and report the pattern and severity of cranial and spinal injuries. Younger children (less than five years of age) are more likely to develop a head injury, whereas older children (more than 11 years of age) are more likely to develop a spinal injury following the use of a trampoline. Although uncommon, some injuries are severe and require surgical intervention. Therefore, trampolines should be used prudently with the appropriate safety precautions and measures.

Metastatic Lesions of the Clivus: A Systematic Review.

BACKGROUND: Metastatic lesions of the clivus are extremely rare, having previously been estimated as representing 0.02% of all intracranial tumors. Owing to its close intracranial relationship with the clivus before entering the cavernous sinus, clinical palsies of the sixth cranial nerve have been classically associated with destructive lesions of this structure. METHODS: A comprehensive search of PubMed was conducted for studies of patients with metastasis to the clivus from primary cancer at any site. Studies reported in English in the past 20 years from our last search on April 12, 2021 were included. The data collected included patient age, sex, symptoms at presentation, histopathology and treatment timeline of the primary tumor, treatment, follow-up, and mortality. RESULTS: After the literature review, 46 studies reporting on 58 patients with clivus metastasis were included in the final analysis. The mean age of the patients was 57.5 years, and 39 were male (67.2%). The most common sites of the primary tumor were the prostate (22%), gastrointestinal tract (15%), lung (13%), and kidney (11%). In 43% of patients, symptoms of clivus metastasis had presented before the diagnosis of primary cancer was known, and 71% of the patients had presented with sixth nerve palsy. Of the 58 patients, 53% had undergone surgery, and 37% had received adjuvant radiotherapy. Of the 58 patients, 25% had received radiotherapy alone. The endoscopic transsphenoidal approach to the clivus was almost uniquely used for surgical management. Survival data were available for 31 patients. Death had occurred at a mean of 9.4 months after the presentation of clivus metastasis. A strong correlation was found between the interval from primary cancer to the presentation of clivus metastasis and mortality. CONCLUSIONS: Although an extremely rare occurrence, clivus metastasis should be considered in patients with a history of malignancy, in particular, prostate malignancy, presenting with new-onset isolated sixth nerve palsy.

A case report of Vagus nerve stimulation for intractable hiccups.

INTRODUCTION: Intractable hiccups frequently result from an underlying pathology and can cause considerable illness in the patients. Initial remedies such as drinking cold water, induction of emesis, carotid sinus massage or Valsalva manoeuvre all seem to work by over stimulating the Vagus nerve. Pharmacotherapy with baclofen, gabapentin and other centrally and peripherally acting agents such as chlorpromazine and metoclopramide are reserved as second line treatment. Medical refractory cases even indulge in unconventional therapies such as hypnosis, massages and acupuncture. Surgical intervention, although undertaken very rarely, predominantly revolves around phrenic nerve crushing, blockade or pacing. A novel surgical strategy is emerging in the form of Vagus nerve stimulator (VNS) placement with three cases cited in literature to date with varying degrees of success. Here the authors report a case of VNS placement for intractable hiccups with partial success, in accordance with SCARE-2018 guidelines. PRESENTATION OF THE CASE: An 85-year-old gentleman with a 9-year history of intractable hiccups secondary to pneumonia came to our hospital. The hiccups were symptomatic causing anorexia, insomnia, irritability, depression, exhaustion, muscle wasting and weight loss. The patient underwent countless medical evaluations. All examinations and investigations yielded normal results. The patient underwent aggressive pharmacotherapy, home remedies and unconventional therapies for intractable hiccups but to no avail. He also underwent left phrenic nerve blocking and resection without therapeutic success. The patient presented to our hospital and decision for VNS insertion was taken for compassionate reasons considering patient morbidity. The patient demonstrated significant improvement in his symptoms following VNS insertion. DISCUSSION: A temporary hiccup is an occasional happening experienced by everyone. However, intractable hiccups are associated with significant morbidity and often mortality. Several medical, pharmacological, surgical and novel treatment options are available for intractable hiccups. CONCLUSION: VNS insertion is a novel surgical option for the treatment of intractable hiccups.

Atlantoaxial limited dorsal myeloschisis: A report of two cases and review of literature.

Introduction: Limited dorsal myeloschisis (LDM) is a rare form of spinal dysraphism that is characterised by a distinctive fibroneural stalk connecting the spinal cord to the overlying skin lesion. The skin lesions associated with LDM can appear benign clinically and careful evaluation with an MRI scan is essential for diagnosing LDM and to differentiate this entity from other forms of spinal dysraphism and benign causes of skin lesions. Research question: There is a lack of reported atlantoaxial LDM in the literature. We sought to report the clinical presentation, radiological features and surgical management of the first two reported atlantoaxial LDM. Material and methods: Clinical findings and radiological images of the two cases of atlantoaxial LDM that underwent surgical intervention at our institution were retrieved from the medical notes, operative records and imaging system. Results: Both cases of atlantoaxial LDM (C0-1 and C1-2 respectively) underwent successful resection of the overlying cutaneous lesions and stalks to release the tethered spinal cords. Discussion: The surgical management of LDM have been associated with good outcomes and consists of resecting the fibroneural stalk close to the underlying cord, releasing the tethered spinal cord and removing the overlying cutaneous lesion. Conclusion: These are the first two reported cases of atlantoaxial LDM in the literature. We aim to raise awareness of this pathological entity and highlight the importance of establishing the correct diagnosis to guide definitive management, and report the favourable neurological outcome in these cases despite the rostral location.

Transient Complete Unilateral Oculomotor Nerve Palsy following Clipping of Ruptured Anterior Communicating Artery Aneurysm: An Abstruse Phenomenon.

BACKGROUND: Aneurysmal subarachnoid hemorrhage may be associated with different cranial nerve palsies, with oculomotor nerve palsy (ONP) being the most common. ONP is especially associated with posterior communicating artery aneurysms, due to the anatomical proximity of the nerve to the aneurysmal wall. Anterior communicating artery (Acom) aneurysms are very unlikely to produce ONP due to the widely separated anatomical locations of Acom and oculomotor nerve. CASE DESCRIPTION: Here we describe the case of a 60-year-old nondiabetic lady who presented with Acom aneurysmal subarachnoid hemorrhage having a World Federation of Neurosurgical Societies (WFNS) grade I. She underwent an uneventful right pterional craniotomy and clipping of the aneurysm, except for a short period of controlled rupture of the aneurysm. Postoperatively she developed complete ONP on the right side, though her sensorium was preserved. Computed Tomogram and Magnetic Resonance Imaging scans of the brain did not yield any useful information regarding its etiology. She was conservatively managed and kept on regular follow-up. She had a gradual recovery of ONP in the following order: pupillary reaction, ocular movements, and finally ptosis. On postoperative day 61, she had complete recovery from ONP. CONCLUSION: We describe a very unusual case of complete ONP following Acom aneurysm clipping and its management by masterly inactivity.

Pediatric Suprasellar Atypical Teratoid Rhabdoid Tumor Arising from the Third Ventricle: A Rare Tumor at a Very Rare Location.

Atypical teratoid rhabdoid tumor (ATRT) is a rare, highly malignant tumor of the central nervous system, commonly affecting children below 3 years of age, with around 300 cases reported in the literature. Suprasellar area is a very rare location for such tumor in the pediatric population, with technical difficulties in complete excision. Third ventricular ATRT is very rare. Here, we report the case of a 2-year-old male child who presented with lethargy and vomiting. He had features of raised intracranial pressure with reduced vision in both eyes. Magnetic resonance imaging of the brain revealed a heterogeneously enhancing lobulated giant lesion in the suprasellar location, occupying the third ventricle and hypothalamus with encasement of both carotids. He underwent pericoronal parasagittal craniotomy, interhemispheric transcallosal interforniceal approach and gross total excision of the lesion. Postoperatively, the child had altered sensorium and diabetes insipidus, both of which recovered over a span of 10 days. Histopathological examination of the specimen was consistent with the diagnosis of World Health Organization Grade IV ATRT. In spite of all our efforts, he succumbed to his illness 5 months postoperatively.

Bone Wax in Neurosurgery: A Review.

It has been 125 years since the so-called initial use of bone wax (BW) by Sir Victor Horsley, and a review of this age-old hemostatic agent seems appropriate. The first use of BW for hemostasis occurred in the eighteenth century, when modeling or candle wax was used for hemostasis. Although the pioneers in the use of BW in craniofacial surgeries were Jean Louis Belloq, Khristian Khristianovich Salomon, and François Magendie, the first successful use in neurosurgery was demonstrated by Henri Ferdinand Dolbeau in 1864 after extirpation of a frontal osteoma. This technique was further popularized by Sir Victor Alexander Haden Horsley, the father of British neurosurgery, who is often incorrectly mentioned as the inventor of BW. Originally derived from beeswax, the currently available commercial preparation also contains paraffin wax and isopropyl palmitate. The main action being mechanical tamponade, BW has found several other uses in neurosurgery, other than being a hemostatic agent. Although it is cost-effective, the use of BW is associated with several complications also, including ineffective bone healing and infection. Several alternatives are being developed, but none are yet a full replacement for "Horsley's wax."

Pediatric dural venous sinus thrombosis following closed head injury: an easily overlooked diagnosis with devastating consequences.

Dural venous sinus thrombosis (DVST) is an uncommon finding after traumatic brain injury. The diagnosis can often be initially missed, particularly if not associated with an overlying fracture. Pediatric DVST following closed head injury and without an overlying fracture is very rare, with only 20 cases reported in the literature to date. Here we present the case of a 19-month-old boy who presented with a history of trivial fall and an episode of fever. On presentation, the pediatric Glasgow Coma Scale (pGCS) score was E3V4M6, and initial brain computed tomography (CT) was normal. He was initially conservatively managed. However, subsequent CT, taken following an episode of seizure, revealed right tentorial subarachnoid hemorrhage and falx hematoma. Conservative management was continued till he started developing recurrent seizures with a decrease in pGCS scores. Repeat CT revealed sinus thrombosis that involved the posterior aspect of the superior sagittal sinus with a massive brain edema. The coagulation profile was normal, and no fracture overlying the sinus was observed. Although he underwent emergency bifrontal decompressive craniotomy, he did not recover. This study emphasizes on the importance of not missing the diagnosis of sinus thrombosis and the devastating consequences that can occur if it is overlooked.

Microsurgical Treatment of Sporadic and von Hippel-Lindau Disease Associated Spinal Hemangioblastomas: A Single-Institution Experience.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To examine the clinical profile and surgical complications in patients with spinal hemangioblastomas and to evaluate the long-term outcome in them. OVERVIEW OF LITERATURE: Although considered to be histologically benign, hemangioblastomas may cause significant neurological deficits. The proportion of spinal hemangioblastomas associated with von Hippel-Lindau (VHL) disease has been estimated be 13%-59%. Preoperative neurological function correlates with postoperative neurological status. Studies have shown no difference in outcomes between sporadic and VHL-associated spinal hemangioblastomas. METHODS: This retrospective study included 14 consecutive patients treated for spinal hemangioblastomas at our institute between January 2000 and June 2013. The mean follow-up period was 5 years. Magnetic resonance imaging of the complete neuraxis was performed in all cases, and preoperative embolization was performed in two cases. RESULTS: In total, 14 patients underwent 18 surgeries, of which 15 were for spinal hemangioblastomas. Of all the patients, 86% had motor weakness and 79% presented with sensory disturbances. Preoperative McCormick functional grades were grade I in 7 (50%), grade II in 3 (21%), and grade III in 4 (29%) patients; 50% patients were diagnosed with VHL disease. All patients underwent complete resection of the tumor. Eight patients experienced deterioration in their neurological status in the immediate postoperative period; among them, five had gradual improvement. At 5-year follow-up, 11 (78.57%) patients showed good functional outcomes. CONCLUSIONS: Microsurgical excision of spinal hemangioblastomas can cause postoperative morbidity, mainly in the form of neurological deterioration. Almost half of our patients had deterioration in the McCormick grade in the immediate postoperative period. However, a complete microsurgical excision can result in good long-term functional outcomes, as most of the immediate postoperative neurological deterioration in our patients was reversible. There was no difference in the long-term functional outcomes between sporadic and VHL-associated spinal hemangioblastomas.

Total Excision of a Giant Ventral Midline Cervical Spinal Intradural Schwannoma via Posterior Approach.

Schwannomas are the most common intradural extramedullary tumors of the spine. They usually occupy a posterolateral or lateral position in relation to the cord. The ventral midline is a very rare location for the origin of a spinal schwannoma. A giant one in such a location causes technical difficulties in excision. Here, we present a giant cervical spinal schwannoma, located ventral to the cord, in a 38-year-old lady who presented with features of myelopathy and bladder involvement. Magnetic resonance imaging was suggestive of an intradural extramedullary lesion extending from cervico-medullary junction to the third dorsal vertebral level with severe cord compression. The same was excised totally via a posterior approach after midline suboccipital craniectomy and C2-C6 laminoplasty. Postoperatively, she made a good recovery and was ambulant without support. Postoperative magnetic resonance imaging showed complete excision of the tumor. Histopathology was suggestive of schwannoma.

Incidental diagnosis of two intracranial aneurysms following surgical evacuation of chronic subdural hematoma.

The development of subarachnoid hemorrhage (SAH) following evacuation of chronic subdural hematoma (CSDH) is a very rare phenomenon. SAH in this context occurring secondary to intracranial aneurysm rupture is still rare. We report a case of an elderly lady who presented with right hemiplegia and altered sensorium. Computed tomography (CT) scan of the brain revealed a left fronto-temporoparietal CSDH with midline shift, which was promptly evacuated surgically via a single burr-hole. Postoperatively, her level of consciousness deteriorated and there was increased the amount of drain. Emergency CT of the brain revealed diffuse SAH. CT cerebral angiogram revealed one aneurysm each in the right internal carotid artery and anterior communicating artery. Meanwhile, her consciousness level improved on conservative management. The relatives were not keen for further follow-up.

Penetrating brain injury with a bike key: a case report.

Penetrating brain injury (PBI) may be caused by low-velocity or high-velocity objects. Several objects are known to cause such injury ranging from knives to rooster pecks. However, an assault with the key of a bike causing PBI has not been reported in the literature. The objective of this study was to report the case of a 21-year-old male patient, who presented after an assault with a bike key. The key was impacted in the left parietal region. Left parietal craniotomy was done and the key was removed. There was an underlying parenchymal contusion, which was excised. On post-operative day two, the patient developed motor aphasia, which subsided in subsequent days with antiedema measures. At the first month follow-up, the patient was having normal speech and consciousness. Prompt treatment of penetrating brain injury is important and angiography is not always necessary for PBI.