New-onset contralateral delayed extradural haematoma in an operated case of extradural haematoma: life-threatening if not diagnosed early.

Head trauma is still a leading cause of mortality in neurosurgical practice. Among various post-traumatic pathologies, extradural haematoma (EDH) is an acute condition that has good neurological outcomes if intervened promptly. New contralateral delayed EDH (DEDH) in an operated case of ipsilateral EDH is a very rare entity, which if not diagnosed timely may lead to devastating outcomes, sometimes even death. We present a case of newly found contralateral DEDH with significant mass effect and midline shift in the immediate postoperative scan, in an operated case of right frontoparietal EDH, which was not found in the initial preoperative scan. A high index of suspicion is needed in cases of unilateral EDH with contralateral skull fracture along with tense dura after the evacuation of EDH, to diagnose rare but life-threatening contralateral DEDH. Routine immediate postoperative CT scan will prevent devastating complications in these kinds of patients.

Vertebral arteriovenous fistula in neurofibromatosis type 1.

INTRODUCTION: Vertebral arterio-venous fistulas (VAVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. Among spontaneous cases, it is most commonly found to be associated with neurofibromatosis type 1 (NF1). EVIDENCE ACQUISITION: We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities and outcome of VAVFs associated with NF1. A literature search was performed by using databases PubMed Central, Embase, Cochrane Library, and Ovid MEDLINE. Also, the grey area search was done using the "Google Scholar" search engine. On screening of the original full-text English language articles, a total of 48 cases were considered suitable for inclusion in this review. EVIDENCE SYNTHESIS: VAVFs in NF1 commonly present between 3rd and 6th decade of life affecting females 2.4 times more than males. Left-sided fistulae were more common than the right side and most seen in the upper V2 segment of the vertebral artery. Most VAVFs in NF 1 patients were treated with constructive (occlusion of fistula only) endovascular therapy (N.=26) with a high success rate. Moreover, pooled proportion of the outcome data have shown significant difference between the endovascular constructive and destructive procedure. CONCLUSIONS: The spontaneous VAVF, commonly associated with NF-1, often requires treatment. Awareness of the coexistence between NF1 and VAVF is crucial to avoid diagnostic delays and unnecessary surgical intervention leading to disastrous outcomes. Endovascular treatment is the preferred treatment approach while open surgical treatment is required in some complex fistulae and failure of endovascular techniques.

Tailored Posterior-Only Approach for C2 Vertebral Body Lesions: Our Surgical Experience in 10 Patients.

BACKGROUND: C2 vertebral body (axis) lesions are often approached anteriorly and combined with posterior stabilization of the craniovertebral junction (CVJ). The anterior approach has its limitations. A posterolateral corridor is an alternative access to the C2 body lesions, and this alone may suffice in selected cases. We describe our experience with C2 body lesions, dealt primarily through a posterior approach, and propose an algorithm in the management of such cases. METHODS: Ten patients with axis lesions were operated through a midline posterior approach followed by posterior stabilization of the CVJ in the same sitting. Their preoperative and follow-up clinico-radiologic details were reviewed. RESULTS: The lesions included aneurysmal bone cysts (n = 2), fibrous dysplasia (n = 2), chordoma (n = 2), Ewing sarcoma (n = 1), metastases (n = 1), post-traumatic malunion (n = 1), and post-inflammatory deformity (n = 1). All patients presented with worsening neck pain. Five also had spastic quadriparesis. There were no perioperative complications. All showed clinical improvement at follow-up. Only 2 patients (chordoma: n = 1; aneurysmal bone cyst: n = 1) required an additional anterior procedure. CONCLUSIONS: Adequate debulking or total excision of lesion, neural decompression, and stabilization of the CVJ for axis body lesions can be achieved through a single midline posterior approach in most cases. If required, an anterior approach may be later added depending on the final histopathology.

Dural Artery from Supraclinoid Internal Carotid Artery to Anterior Clinoid Process: Origin, Course, and Clinical Implications.

BACKGROUND: Dura of the anterior clinoid process (ACP) is presumably supplied by the ophthalmic and external carotid artery branches. There is a less recognized artery described by Yasargil that arises directly from the supraclinoid internal carotid artery (ICA) and supplies the ACP dura. We studied the origin and course of this direct branch in patients in whom the carotid cistern was dissected for lesions not involving the carotid cistern and ACP dura. The management implications of this arterial twig have been described. METHODS: Thirty patients operated through the transsylvian route for suprasellar lesions were included. The arterial branch from the supraclinoid ICA to the clinoidal dura was dissected and studied under high magnification. RESULTS: A thin solitary artery could be delineated in 21 patients. In 14 patients, it originated from the dorsomedial surface of the ICA at its bifurcation close to the A1 origin. In the remaining 7, it was seen arising from the dorsomedial surface of the ICA, 2-4 mm proximal to bifurcation. The artery coursed from medial to lateral and pierced the clinoidal dura, 1-3 mm lateral to the entry of the carotid artery. The artery had no branches. CONCLUSIONS: The knowledge of this arterial twig to the clinoidal dura is important as this supply may be responsible for feeding the tumor arising from the dura arising from the anterior clinoid, making preoperative embolization impossible. In addition, the tumor may grow along with this vessel and infiltrate the adventitia of the ICA at the origin of this vessel.