Spectrum of Posterior Cerebral Artery Dissection: A Retrospective Observational Study and a Critical Review.

Background and Aims: Intracranial arterial dissections commonly involve the vertebrobasilar system leading to subarachnoid hemorrhage (SAH) or cerebral infarction attributable to a dissecting aneurysm of the vessel or occlusion of the lumen depending on the depth of dissection. However, isolated posterior cerebral artery dissections (PCADs) are rare and sparsely reported in the literature. Methodology: A retrospective multicentric observational study was carried out after collecting data from 14 patients admitted with PCAD in three hospitals of Kolkata, Jaipur, and Patna within the period of July 2021 to June 2022. Results: The median age of the population was 48.5 years, and 64.28% were females. SAH was the most common presentation with dissecting aneurysms in all patients barring one, who presented with a left occipital infarct consequent to ipsilateral PCAD. Among the 14 patients, three patients denied endovascular intervention and were lost to follow-up; one patient with an occipital infarct and another patient with a dissecting left P3 aneurysm, which underwent spontaneous thrombosis, were managed conservatively. Among the nine patients scheduled for endovascular coiling, one patient succumbed before intervention and one patient succumbed to sepsis in the postoperative period. A complete recovery was noted in six patients, whereas residual neurodeficits were present in three patients. Among the six patients who had an uneventful recovery at the end of 3 months, five patients had an endovascular intervention. Conclusion: PCAD may present with large-scale neurodeficits and is associated with high morbidity and mortality, hence necessitating prompt management. Conservative management is preferable for consequent infarcts, whereas endovascular management is desirable in cases of dissecting aneurysms, which usually tend to have a favorable outcome if intervened early.

Carotid cavernous fistula: Redefining the angioarchitecture.

OBJECTIVE: Numerous classification schemes have been used for carotid cavernous fistula (CCF), each describing some aspect of the disease process but none of them provides a complete description of the fistula including its clinical features, natural history, arterial and venous architecture. METHODS: Retrospective clinical and radiological review was done for all the patients diagnosed with CCF and treated at our institute. The CCF were classified according to the proposed API-ACE classification along with Barrow and Thomas classification. RESULTS: Overall 28 patients (M=21, F=7) were diagnosed and treated during the 6-year period. 89.2% of CCF developed following an episode of head injury. Orbital symptoms were the most common presenting complaints. Barrows type A was the most predominant subtype (n=24) and most of the patients (n=23) demonstrated decreased ipsilateral carotid filling. Combined anterior and posterior drainage pattern was the most common drainage pattern and anterior drainage was more commonly observed than posterior drainage. CONCLUSIONS: API-ACE classification helps to better understand and classify the angioarchitecture of CCF which could help better understand the clinical manifestations and guide in appropriate endovascular approach selection for treatment.

Clinico-radiological features of cerebral proliferative angiopathy: A large case series from India.

BACKGROUND: Based on angiographic features, a rare subgroup, different from classical brain AVMs, called cerebral proliferative angiopathy (CPA) was suggested by Lasjaunias et al. in 1989. There are only few reports of CPA described from Asia. Liu et al. has described 5 cases of CPA from China. The objective of study was to evaluate the clinico-radiological features of patients with CPA in our cohort and to find out the differences between our study and the study by Lasjaunias and Liu et al. METHODS: We retrospectively analysed cases of CPA from March 2012 to April 2020. All radiological images of the patients with AVMs were studied and findings suggestive of CPA were identified. We found 10 patients with CPA out of 272 cases of AVM (10/272) and described the various demographic and clinico-radiological features. RESULTS: The age of the patients with CPA in our series varied from 14 to 53 years and the mean age was 28.6 years. There was male preponderance (60%) with male to female ratio of 3:2. The most common presentation was seizure (70%). Intracranial haemorrhage was present in five patients. One patient had cerebral infarction. CONCLUSIONS: There were substantial differences in clinico-radiological profile of patients with CPA in our cohort as compared to the study by Lasjaunias et al. and Liu et al. in form of male dominance, higher rate of ICH and seizure. In our knowledge, this is the second largest series of CPA worldwide and the first largest series in Asia.

A rare case of cerebral proliferative angiopathy with acute cerebral infarction and facial capillary malformation.

We are describing a case of a 14-year-old girl who developed acute cerebral infarction which was documented on diffusion-weighted magnetic resonance imaging (DWI). On detailed evaluation, diagnosis of cerebral proliferative angiopathy (CPA) was made. Incidentally, she had capillary malformation on the forehead contralateral to cerebral vascular malformation. To our knowledge, this is the first case of CPA in the literature where DWI abnormality was due to acute cerebral infarction.

Endovascular management of intracranial pseudoaneurysm: an institutional experience.

OBJECTIVE: Pseudoaneurysms (PSAs) of the internal carotid artery (ICA) and vertebral artery are rare entities but with varied treatment options. PSAs can be spontaneous or secondary to trauma, infections, malignancies or iatrogenic. To find out the efficacy of various endovascular interventions in the management of ICA and vertebral PSAs. METHODS: The study included 14 patients diagnosed with intracranial PSAs who underwent endovascular interventions in SMS Medical College, Jaipur (Rajasthan) between June 2015 to January 2019. The clinical and radiological findings (computed tomography angiography and digital subtraction angiography) were reviewed and the consequent endovascular intervention carried out and their results were analyzed. RESULTS: Total 14 patients were studied out of which 8 (57.1%) were anterior circulation PSAs and 6 (42.9%) were posterior circulation PSAs There were 10 (71.4%) females and 4 (28.5%) males between the age of 9 to 65 years. Only 2 patients with PSA had past history of trauma. Coiling was done in 8 patients (57.1%), stenting in 2 patients (14.2%), parent artery occlusion in 1 patient (7.1%), glue embolization in 1 patient (7.1%) while coiling with glue in 1 patient (7.1%) and flow diverter in 2 patients (14.2%). Immediate and complete occlusion was achieved in 11 (78.6%) patients while 3 (21.4%) patients had subtotal occlusion. 11 patients under follow up till June 2019 did not report recurrence or new neurological deficit. CONCLUSIONS: Endovascular interventions is minimally invasive and safe treatment strategy for intracranial PSAs. The ultimate choice of technique depends on clinical and imaging characteristics.

Curious Case of Atypical Hangman's Fracture: C2-C3 Listhesis without Pars Fracture.

Traumatic spondylolisthesis of axis or hangman's fracture is the second most common C2 vertebra injury. We present a report of a young man presenting with a history of fall from height with C2 to C3 spondylolisthesis without any evidence of injury to pars interarticularis but with associated injury to capsular ligament of facet joint along with posterior spinous ligamentous injury. The patient underwent intraoperative reduction in listhesis with posterior screw fixation. The patient showed uneventful postoperative course with neurological improvement at 6-week follow-up. Hangman's fracture refers to a diverse group of injury in which the soft tissue injury has an equally important part to play as the bone fracture.

Penetrating head injury due to angle grinder: an occupational hazard.

Penetrating head injury is a life threatening condition. In the workplace, these are mostly non missile type, low velocity civilian injuries caused by sharp objects. Angle grinders are used to cut stones, metal etc, and cause penetrating head injuries due to shattered rotating discs from the grinder at home and workplaces. We report a series of three cases of penetrating head injuries due to unsafe use of angle grinders. The relevant literature is reviewed and management of such cases is discussed.

Oyster Calcification of Infected Bone Flap: A Rare Complication.

An extremely rare case of chronic epidural empyema after cranioplasty is presented. It derives its extreme rareness from its association with calcification. This patient when presented to our department had a complaint of swelling with on and off discharging sinus for 2 months adjacent to old incision scar mark. The patient had a history of decompressive craniectomy and evacuation of acute subdural hematoma, in some other institution, 8 years back. Following that, the patient underwent cranioplasty with the exteriorized and preserved bone flap. In the meantime, he was asymptomatic. It is a unique interesting case of chronic epidural empyema with calcified walls after 8 years of long duration following cranioplasty.

Pseudo Primary Abscess of the Cavum Septum Pellucidum due to Pus Entrapment: A Rare Case Report.

The cavum septum pellucidum (CSP) is defined as a crevice-like space of variable width between the left and right transparent septum. In this report, a rare case of pseudo primary abscess formed in the CSP due to ventriculitis is presented.

Sinonasal teratocarcinosarcoma involving nasal cavity, nasopharynx, and all paranasal sinuses with bilateral orbital and intracranial extension: A rare case report.

Sinonasal teratocarcinosarcoma (SNTCS) is one of the rarest, aggressive malignant neoplasms of sinonasal tract, consisting of primitive neuroepithelial elements with various malignant epithelial and mesenchymal components. Previously described as teratoid carcinosarcoma, malignant teratoma, or blastoma, SNTCS constitutes less than 1% of all cancers and approximately 3% of all malignancies of head and neck region, which is mainly located in the nasal cavity and paranasal sinuses, although tumors occurring in other locations including the nasopharynx and oral cavity have been described. Here, we are presenting a 22-year-old patient with SNTCS involving the nasal cavity, nasopharynx, and all paranasal sinuses with bilateral orbital and intracranial extension treated with surgery followed by radiotherapy and chemotherapy.

Concurrent multiple intracranial and intramedullary conus tuberculoma: A rare case report.

Central nervous system (CNS) tuberculosis commonly manifests as tubercular meningitis. CNS tuberculomas are more common intracranially and less frequently involve the spinal cord. Combination of intramedullary with intracranial tuberculomas is extremely rare. We report a case of concurrent occurrence of intramedullary tuberculoma with multiple intracranial tuberculomas in a young 16-year-old boy, who presented with two weeks history of paresthesias and weakness of the lower limbs and diminution of vision in left eye, who had been treated for pulmonary tuberculosis. Magnetic resonance imaging (MRI) spine showed a well-circumscribed lesion opposite L1, which was diagnosed as intramedullary tuberculoma. As for vision complaint, on cranial imaging, he was found to have multiple round contrast enhancing lesions, which were diagnosed as intracranial tuberculomas based on their typical MRI findings. He had complete recovery with conventional treatment of anti-tubercular therapy and steroids, without any surgical intervention. We suggest that MRI of the brain should be performed in all case of intramedullary spinal tuberculoma because of the possible presence of early asymptomatic/mild symptomatic intra-cranial tuberculomas.

Primary non-Hodgkin's lymphoma of the skull with extra and intracranial extension presenting with bulky scalp mass lesion.

Primary non-Hodgkin's lymphoma (NHL) of the cranium with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. These lesions are most of the time misdiagnosed because they mimic other conditions like meningioma. Here, we report a case presented with huge bulky scalp mass which on magnetic resonance imaging (MRI) brain showed involvement of scalp, cranial vault, meninges, and the brain parenchyma, mimicking a meningioma. After gross total resection, biopsy and CD marker study revealed primary non-Hodgkin's diffuse large B-cell lymphoma (DLBCL). Malignant NHL should be considered in differential diagnosis of bulky scalp mass lesion.

Tiger hide appearance: Impaction and prolapse of brain parenchyma through burr holes after evacuation of bilateral chronic subdural hematoma: A rare case report.

Burr hole evacuation of chronic subdural hematoma (SDH) with or without drainage system is the most common surgical method among various techniques. There are various complications of burr hole drainage evacuation of chronic SDH, but there is no case report regarding impaction and prolapse of brain parenchyma through burr hole as a complication. Herewith, we are reporting a case of bilateral chronic SDH with prolapse of brain parenchyma through burr holes. Magnetic resonance imaging (MRI) of brain showed a characteristic look and we named it "Tiger hide appearance". We failed to find such characteristic appearance in MRI brain on reviewing the available literature.

Nasofrontal dermoid with sinus tract upto the tip of the nose: A case report with review of the literature.

Nasofrontal dermoid with sinus tract extending to the nasal tip is rare in adults. It is unique in its embryological origin, presentation, and management. Pathogenesis involves the incomplete obliteration of the developing neuroectoderm. A sinus opening with intermittent oily discharge is characteristic. Associated intracranial extension may lead to meningitis and brain abscess. We present a case of a 21-year-old adult having a nasofrontal sinus tract with intracranial extension who presented with recurrent episodes of meningitis and discuss the physical findings with relevance to embryology, elaborating on the importance and means of addressing the intracranial as well as extracranial components for complete treatment.

Incidental frontal lobe mixed density epidermoid tumor in a patient of head injury: A rare case report.

The incidence of the epidermoid tumor is approximately 0.2-1.8% of all intracranial tumors. Epidermoid tumors are typically intradural, but extra-axial in location and only rarely found within the brain substance. We are reporting the first case of incidental mixed density frontal epidermoid tumor in a patient of head injury. Difficulty in the preoperative diagnosis and uncommon presentation of the intracranial epidermoid tumor prompted us to report this case.

Growing skull fracture with cerebrospinal fluid fistula: A rare case report and its management strategies.

The growing skull fracture (GSF) occurs in younger age group as a sequel of trauma. The most common site of these lesions is parietal region. Here we are presenting a case of GSF of posterior fossa with cerebrospinal fluid (CSF) fistula. As per literature, we have not found a single case of GSF in the posterior fossa with CSF fistula. The aim of this presentation is discussing the unusual presentation of GSF and its management.

Experiences and conceptualisation of spinal intramedullary tuberculoma management.

OBJECTIVE: Spinal intramedullary tuberculoma (SIMT) is rare, accounting for 2/100,000 cases of tuberculosis and only 0.2% of all cases of central nervous system(CNS) tuberculosis. We share our experiences of 11 cases of this entity for improving diagnosis and conceptualize the management of this rare disease. METHODS: The clinical profile, radiological data and management of 11 cases of SIMT which were managed either conservatively or by surgical intervention during last 27 years (1987-2014) were analysed. RESULTS: Male:female ratio was 1.75:1. Five cases had associated pulmonary Koch's. Most common site was thoracic cord. Two cases had concurrent multiple intracranial tuberculoma. Most common presentation was paraparesis. X-ray myelography was performed in two patients in the initial period of study suggesting intramedullary pathology. In the subsequent nine cases who had magnetic resonance imaging (MRI), seven showed typical "target sign" and conglomerate ring lesion. Out of 8 surgically managed patients, 6 cases improved rapidly and in 2 patients gradual improvement was seen in follow-up. Most common indication of surgical excision was rapid neurological deterioration followed by diagnosis in doubt. Histopathology confirmed tuberculous etiology of the intramedullary lesion in all. Clinical and radiological improvement was seen in all 3 conservatively managed patients in follow-up. CONCLUSION: MRI findings of SIMT were specific and proven histologically correct. Surgical intervention may be indicated if there is no response to chemotherapy, the diagnosis is in doubt, or there is a rapid deterioration in neurological function because surgical outcome is good in these circumstances.

Bilateral cerebellopontine arachnoid cyst: A rare entity.

Bilateral cerebellopontine angle (CPA) arachnoid cysts (ACs) are very rare: only one case is reported in literature. Pathogenesis of those cysts is unknown; they are thought to be congenital. The presenting symptoms of CPA AC are frequently nonspecific or otological. The management of ACs of the CPA is controversial. We are reporting two cases of bilateral CPA AC with their pathophysiology and review of literature.

Neuroendocrine dysfunction in acute phase of moderate-to-severe traumatic brain injury: a prospective study.

OBJECTIVES: Most of the retrospective studies have demonstrated that traumatic brain injury mediated hypopituitarism could be more frequent than previously known. Therefore, this study has prospectively investigated pituitary function and their correlation with severity, pressure effect and Glasgow Outcome Scale in the acute phase of moderate-to-severe traumatic brain injury. PATIENTS AND METHODS: One hundred consecutive moderate-to-severe traumatic brain injury patients from August 2012 to November 2013 formed the study group. Apart from clinical assessment, non-contrast computed tomography of the head was performed on all patients on admission. The hormonal analysis (fT3, fT4, TSH, GH, Cortisol, Prolactin) was performed within 24 hours of traumatic brain injury and was repeated on the 7th day amongst the patients who survived. RESULTS: Growth hormone was the most common hormone to decrease. Cortisol was the most common hormone to increase. Risk of pituitary insufficiency was increased in patients with severe traumatic brain injury, patients with increased intracranial pressure and who had low Glasgow Outcome Scale. CONCLUSION: Neuroendocrine dysfunction occurs often in the acute phase of moderate-to-severe traumatic brain injury, more commonly in patients with severe traumatic brain injury, patients with pressure effects and low Glasgow Outcome Scale. Hormonal analysis should be considered in patients with moderate-to-severe traumatic brain injury, so that appropriate hormonal replacement can be done to optimize the clinical outcome.

Occipital post-traumatic intradiploic arachnoid cyst converted to pseudomeningocele after re-trauma: a rare complication of rare pathology.

BACKGROUND: Growing skull fracture (GSF)/pseudomeningocele is a rare complication of head injury in children. Post-traumatic intradiploic arachnoid cyst (PTIAC) is a variant but it is extremely rare. PTIACs are usually asymptomatic or with mild symptoms like headache. The rupture of PTIAC due to re-trauma leading to pseudomeningocele formation has not been seen or reported before. PATIENT AND METHOD: We present a case of occipital PTIAC where pseudomeningocele developed after re-trauma, and discuss the pathogenesis and management. RESULT: En masse removal of the ruptured PTIAC was performed along with dural-defect repair. The post-operative recovery was good. CONCLUSION: PTIAC is an extremely rare occurrence as a variant of GSF. It is usually asymptomatic, but it may rupture with trivial trauma due to a thinned-out outer table and then converts into pseudomengocele. En masse excision with dural-defect repair gives good results in cases of ruptured PTIAC due to re-trauma.