Complication Avoidance in Endonasal Endoscopic Pituitary Surgery.

Endoscopic endonasal surgery for pituitary tumors can be performed safely with a good outcome. Complications are uncommon and relate most often to nearby structures at risk. The authors detail the nuances, tips and tricks useful in avoiding complications and their early detection and management.

Endoscopic Management of Fourth Ventricle Neurocysticercosis: Description of the New Technique in a Case Series of 5 Cases and Review of the Literature.

BACKGROUND: Around 7%-33% of cases of neurocysticercosis (NCC) have intraventricular involvement, and the fourth ventricle is the most frequent site. Medical management and various surgical approaches have been described for treating this disease. The objective of this study was to describe technical modification for endoscopic fourth ventricular NCC removal in a series of 5 cases. METHODS: In this study (January 1, 2016, to December 31, 2017), all cases of fourth ventricular NCC which were treated with a special technique (endoscopic transcortical transforaminal transaqueductal approach) using a rigid endoscope system and 6-French infant feeding tube (IFT) were included in the study. The IFT was passed through the main channel, the cyst was engaged at the tip by applying gentle suction with a 20 cm3 syringe, and the cyst was removed along with the whole endoscopic assembly. Patient's clinical, radiologic, and follow-up data were retrieved from the department database records. RESULTS: Five patients (3 men, 2 women; mean age, 20 years; range, 11-27 years) were enrolled. All patients had features of raised intracranial pressure. Two patients also had drop attacks, and one presented with altered sensorium and one had upgaze palsy. Duration of symptoms ranged from 3 months to 3 years. All patients had isolated fourth ventricular NCC with obstructive hydrocephalus. Complete removal of the neurocysticercal cyst could be performed in all patients without any injury to the periaqueductal region or fornix. There was no intraoperative rupture of the neurocysticercal cyst. On follow-up (range, 12-28 months; mean, 19.4 months), all patients had relief of symptoms and imaging showed no cyst and hydrocephalus. CONCLUSIONS: We conclude that our endoscopic approach is safe, simple, cost-effective, and allows minimally invasive removal of the fourth ventricle cyst and treatment of hydrocephalus without any morbidity.

Cavernous malformations of central nervous system in pediatric patients: our single-centered experience in 50 patients and review of literature.

PURPOSE: Cavernous malformations (CMs) are rare developmental cerebrovascular malformations of the central nervous system with a childhood prevalence of 0.3 to 0.53%. Our purpose was to assess the clinical features and microsurgical outcome in pediatric central nervous system (CNS) CMs. MATERIAL AND METHODS: We retrospectively enrolled all the CM patients admitted to our institute from 1 January 2001 to 31 December 2014. Data was analyzed for their clinical features and surgical outcome. RESULTS: A total of 50 patients with CMs (30 supratentorial, 14 infratentorial, and 6 spinal) with a mean age of 14 years (3-18 years, SD ±4.64) were enrolled into the study. Most of these patients (78%) were male. Size varied from 1.2 to 6 cm. Three patients had multiple CMs. Symptoms of CMs were site specific. Seizure was the most common symptom (63.3%) of CMs at supratentorial location followed by headache (46%) and neurodeficiency (26%), while all brainstem and spinal CMs presented with neurodeficiencies. History of clinically significant acute hemorrhage was present in 19.2% of supratentorial (ST) superficial CMs, 50% of ST deep CMs, 25% of cerebellar CMs, 44.4% of brainstem CMs, and 50% of spinal CMs. Forty-five CMs in 44 patients were surgically excised. Their follow-up ranged from 6 to 162 months (mean 47.2 months, SD ±53). All supratentorial CM patients showed improvement in their symptoms. Patients with preoperative seizure showed good seizure control with Engel scale I in 16 (94.1%) and Engel scale II in 1 (5.9%). In infratentorial (IT) and spinal CM patients, 92.3 and 66.7% had improvement in their neurodeficiencies, respectively. There was no mortality in our series. CONCLUSION: Microsurgical excision of CNS CM results in excellent neurological outcome in pediatric patients. Early intervention is necessary in spinal CMs for better outcome.

Unusual cause of lumbar canal stenosis in 8th decade of life - Spinal epidural lipomatosis.

Spinal Epidural lipomatosis (SEL) is an uncommon condition, usually presents in young and middle aged patients, with male preponderance. Idiopathic SEL is rare, particularly in 8th decade of life. SEL should also be considered as a differential diagnosis in approach of elderly patient presenting with lumbar canal stenosis. Such a case of 77 year old man is presented here.

Fatal Superior Sagittal Sinus and Torcular Thrombosis After Vestibular Schwannoma Surgery: Report of a Rare Complication and Review of the Literature.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare condition with the potential to cause severe morbidity and mortality. CVST can also occur after vestibular schwannoma (VS) surgery with the thrombosis of transverse and sigmoid sinus. However, there is not a single report of superior sagittal sinus (SSS) thrombosis after VS surgery reported in the literature. CASE DESCRIPTION: A 45-year-old woman presented to our center with large left-sided solid cystic VS. On admission she was dehydrated, and after clinical stabilization, she underwent gross total excision of tumor through left retromastoid suboccipital craniotomy after cerebrospinal fluid drainage through an external ventricular drain. Surgery was uneventful, but postoperatively she had an episode of seizure. Immediate postoperative computed tomography (CT) brain scan was normal with good operative cavity. However, 24 hours later, she developed left-sided motor deficit, and a repeat CT scan showed right frontal parenchymal hemorrhage with intraventricular extension. On further evaluation, magnetic resonance venography showed entire SSS thrombosis, with patent bilateral transverse and sigmoid sinuses. She was not started on the anticoagulants in view of intracranial hemorrhage. Subsequently, she underwent right-sided decompressive craniectomy because there was progressive deterioration in her Glasgow Coma Scale, and she succumbed despite all efforts. Retrospectively, dehydration and intracranial hypotension could be likened to her sinus thrombosis. CONCLUSIONS: This case underscores the significance of adequate optimization of the patients prior to surgery, besides adequate operative skills to avoid this rare but serious complication of SSS and torcular thrombosis after VS surgery.

Endoscopic pituitary surgery: Techniques, tips and tricks, nuances, and complication avoidance.

Endoscopic pituitary surgery is useful in all micro- and macro-pituitary adenomas including those with suprasellar and cavernous sinus extension. The endoscope provides a panoramic close-up, a multi-angled view with excellent illumination and magnification, permitting complete excision of the tumor with preservation of normal pituitary. However, surgeons need to learn altogether different skills unique to endoscopy and the learning curve is steep. The learning curve can be shortened by proper selection of cases, gradual transition from the microscopic to the endoscopic approach, adequate sphenoethmoidal recess widening, identification of important landmarks during each stage of surgery, and use of neuronavigation. Results and long term outcomes can be improved with bimanual dynamic dissection and sequential tumor excision, preservation of normal pituitary, avoidance of arachnoidal tear and use of extended approach for tumors with large suprasellar extension. The gradual transition from microscopic to endoscopic approach, adherence to step by step technique and learning 'tips and tricks' of the endoscopic pituitary surgery reduce complications.

Acute Foramen Magnum Syndrome Following Single Diagnostic Lumbar Puncture: Consequence of a Small Posterior Fossa?

BACKGROUND: Type I Chiari malformation (CMI) is a rare complication of lumbar cerebrospinal fluid (CSF) drainage that is usually reported after lumbar drain or lumboperitoneal shunt placement. It usually remains asymptomatic; however, even if it becomes symptomatic, symptoms are usually mild. There are only a few reports of acute foramen magnum syndrome following continuous lumbar CSF drainage, and acute foramen magnum syndrome after a single diagnostic lumbar puncture (LP) has not been previously reported. We encountered this catastrophic complication in one of our patient. CASE DESCRIPTION: A 30-year-old woman with a large supratentorial meningioma and associated asymptomatic CMI presented with holocranial headache. She underwent successful and uneventful excision of the tumor. However, she developed quadriplegia and respiratory arrest 48 hours following a diagnostic LP performed on postoperative day 9. She underwent urgent posterior fossa decompression after magnetic resonance imaging showed increased tonsillar impaction and swelling along with cervicomedullary compression. Postoperatively, she steadily improved and regained normal power after 3 months. Retrospective quantitative analysis of magnetic resonance imaging (MRI) revealed a small posterior fossa. CONCLUSIONS: The association of intracranial tumors and lumbar CSF drainage with CMI is uncommon. The documentation of a small posterior fossa signifies the importance of both developmental (small posterior fossa) and acquired (intracranial tumor/lumbar CSF drainage) factors in pathogenesis of CMI. Although the extreme rarity of acute deterioration following a single LP does not warrant LP to be contraindicated in such patients, documentation of resolution of CMI with postoperative MRI before performing lumbar CSF drainage (whether therapeutic or diagnostic), might be helpful in avoiding this rare complication.

Surgical management of odontoid fractures at level one trauma center: a single-center series of 142 cases.

INTRODUCTION: Odontoid fractures constitute 9-20% of all adult cervical spine fractures. The present study was carried out to focus on the nuances involved in the surgical management of odontoid fractures. MATERIALS AND METHODS: Patients with an odontoid fracture, admitted for surgical stabilization, between January 2008 and March 2014, were included in the study. RESULTS: Among 142 patients [127 male and 15 female patients; median age: 28 years range 4-75 years], type II odontoid fractures were present in 111, type IIA fractures in 8, and type III fractures in 23 patients. 58.5% patients had been involved in a motor vehicular accident while 38.7% had sustained a fall. Eighty-five patients (59.9%) with a well-reduced fracture and an intact transverse ligament underwent anterior odontoid screw (OS) placement; the other 57 patients (40.1%) underwent posterior fixation (PF). The mean follow-up duration was 22 months (range: 6 months-5.4 years). OS placement was successful in 82 patients (96.5%) with a fusion rate of 95% (95.8% in type II, 100% in type III, and 75% in type IIA odontoid fractures). The procedure-related morbidity was 11.7%. One patient died of sub-arachnoid hemorrhage (SAH) that occurred during OS placement. The PF procedures had a better fusion rate (96.5%). The latter patients, however, had significant restriction of their neck movements and an overall morbidity of 8.7%. The revision surgery rates after OS placement and PF fixation were 7% and 3.5%, respectively. CONCLUSIONS: Anterior OS fixation shows excellent fusion rates and should be the first-line management in reduced/non-displaced acute type II (including type IIA) and high type III odontoid fractures as it preserves cervical motion. PF, that has also been associated with an excellent fusion rate, should be reserved for patients where OS fixation has either failed or has not been feasible.

Quantitative analysis of variable extent of anterior clinoidectomy with intradural and extradural approaches: 3-dimensional analysis and cadaver dissection.

BACKGROUND: Drilling of the anterior clinoid process (ACP) is an integral component of surgical approaches for central and paracentral skull base lesions. The technique to drill ACP has evolved from pure intradural to extradural and combined techniques. OBJECTIVE: To describe the computerized morphometric evaluation of exposure of optic nerve and internal carotid artery with proposed tailored intradural (IDAC) and complete extradural (EDAC) anterior clinoidectomy. METHODS: We describe a morphometric subdivision of ACP into 4 quadrangles and 1 triangle on the basis of fixed bony landmarks. Computerized volumetric analysis with 3-dimensional laser scanning of dry-drilled bones for respective tailored IDAC and EDAC was performed. Both approaches were compared for the area and length of the optic nerve and internal carotid artery. Five cadaver heads were dissected on alternate sides with intradural and extradural techniques to evaluate exposure, surgical freedom, and angulation of approach. RESULTS: Complete anterior clinoidectomy provides a 2.5-times larger area and 2.7-times larger volume of ACP. Complete clinoidectomy deroofed the optic nerve to an equal extent as by proposed the partial tailored clinoidectomy approach. Tailored IDAC exposes only the distal dural ring, whereas complete EDAC exposes both the proximal and distal dural rings with complete exposure of the carotid cave. CONCLUSION: Quantitative comparative evaluation provides details of exposure and surgical ease with both techniques. We promote hybrid/EDAC technique for vascular pathologies because of better anatomic orientation. Extradural clinoidectomy is the preferred technique for midline cranial neoplasia. An awareness of different variations of clinoidectomy can prevent dependency on any particular approach and facilitate flexibility.

Outcome after decompressive craniectomy in patients with dominant middle cerebral artery infarction: A preliminary report.

INTRODUCTION: Life-threatening, space occupying, infarction develops in 10-15% of patients after middle cerebral artery infarction (MCAI). Though decompressive craniectomy (DC) is now standard of care in patients with non-dominant stroke, its role in dominant MCAI (DMCAI) is largely undefined. This may reflect the ethical dilemma of saving life of a patient who may then remain hemiplegic and dysphasic. This study specifically addresses this issue. MATERIALS AND METHODS: This retrospective analysis studied patients with DMCAI undergoing DC. Patient records, operation notes, radiology, and out-patient files were scrutinized to collate data. Glasgow outcome scale (GOS), Barthel index (BI) and improvement in language and motor function were evaluated to determine functional outcome. RESULTS: Eighteen patients between 22 years and 72 years of age were included. 6 week, 3 month, 6 month and overall survival rates were 66.6% (12/18), 64% (11/17), 62.5% (10/16) and 62.5% (10/16) respectively. Amongst ten surviving patients with long-term follow-up, 60% showed improvement in GOS, 70% achieved BI score >60 while 30% achieved full functional independence. In this group, motor power and language function improved in 9 and 8 patients respectively. At last follow-up, 8 of 10 surviving patients were ambulatory with (3/8) or without (5/8) support. Age <50 years corresponded with better functional outcome amongst survivors (P value -0.0068). CONCLUSION: Language and motor outcomes after DC in patients with DMCAI are not as dismal as commonly perceived. Perhaps young patients (<50 years) with DMCAI should be treated with the same aggressiveness that non-DMCAI is currently dealt with.

"Rabbit ear" scalp deformity caused by massive subdural effusion in infant following bilateral bur-hole drainage failure: successfully managed with subduro-peritoneal shunt.

INTRODUCTION: Subdural effusion in an infant is a rare clinical scenario which may be secondary to a variety of etiologies. Massive subdural effusion is an extremely rare complication of head injury. CASE REPORT: Authors report a rare case of progressive massive subdural effusion which, despite bilateral bur-hole placement and drainage, failed and presented with visual deterioration and massive bulge of the scalp at bur-hole sites, producing a rabbit ear appearance in a 10-month-old infant. Ultimately, cystoperitoneal shunt was carried out in a desperate attempt to prevent impending rupture of scalp sutures at sites of previous bur-hole placement. This was followed by not only complete resolution of hygroma but also visual recovery. The patient is doing well at 6 months following shunt, regaining normal vision and appropriate developmental milestones. A MRI scan of the brain was carried out at last follow-up, which revealed mild ventriculomegaly with the rest of the brain being unremarkable, and subduro-peritoneal shunt in situ. Such a case has not been reported in the literature till date. DISCUSSION: Subdural effusion usually runs a self-limiting course. Though neurosurgical intervention is occasionally needed, different methods of surgical procedure for management include bur hole alone, bur holes with subdural drain placement, twist drill craniotomy with drain, and even craniotomy. Various methods of management are discussed along with a review of pertinent literature.

Giant intradiploic pseudomeningocele of occipital bone.

The management of intradiploic CSF collection is controversial. Although it is a benign lesion, even then delay in diagnosis and treatment may lead to significant morbidity. The authors report a very rare case of giant posttraumatic intradiploic pseudomeningocele involving the occipital bone, occipital condyles, and clivus. The pathogenesis and management of intradiploic CSF collection are discussed. This 16-year-old boy presented with a history of enlarging swelling in the suboccipital region associated with headache, lower cranial nerve palsy, and features of high cervical compressive myelopathy. Investigations revealed a giant intradiploic lesion involving the occipital bone, condyles, and clivus associated with secondary basilar invagination, hydrocephalus, and syringomyelia. Intrathecal contrast administration did not reveal communication of intradiploic space with the subarachnoid space. A large occipital craniotomy was performed. A linear fracture and dural defect in the midline was identified, which was closed with fascial graft after removing the inner table of the skull. Cranioplasty was performed using the expanded calvarial bone. Ventriculoperitoneal shunt insertion was performed for hydrocephalus, and the patient improved remarkably. Posttraumatic intradiploic CSF collection, although a benign condition, may present with severe complications if treatment is delayed. Early diagnosis and treatment is essential. The authors suggest that this condition should be treated early, as for growing skull fractures.

Outcome after hemorrhage following Gamma Knife surgery for cerebral arteriovenous malformations.

OBJECT: Although the effects of Gamma Knife surgery (GKS) on the risk of hemorrhage are poorly understood, a certain subset of patients does suffer bleeding after GKS. This study was undertaken to analyze the outcome of patients sustaining hemorrhage after GKS; it is the most feared complication of radiosurgical management of cerebral arteriovenous malformations (AVMs). METHODS: Between May 1997 and June 2006, 494 cerebral AVMs in 489 patients were treated using a Leksell Gamma Knife Model B, and follow-up evaluations were conducted until June 2007 at the All India Institute of Medical Sciences in New Delhi. Fourteen patients who sustained a hemorrhage after GKS formed the study group. In most of these patients conservative management was chosen. RESULTS: The mortality rate was 0% and there was a 7% risk of sustaining a severe deficit following rebleeding after GKS. None of the patients sustained rebleeding after complete obliteration. Patients with Spetzler-Martin Grade III or less had increased chances of hemorrhage after GKS (p < 0.002). The presence of deep venous drainage, aneurysm, venous hypertension, or periventricular location on angiography was common in patients with hemorrhage after GKS. CONCLUSIONS: The risk of hemorrhage that remains following GKS for cerebral AVMs is highest in the 1st year after treatment. The present study showed a relatively good outcome even in cases with hemorrhage following GKS, with no deaths and minimal morbidity, further substantiating the safety and efficacy of the procedure.