Modified Nasoseptal Flap Technique to Prevent the Recurrence of Rathke's Cleft Cyst

Background

Rathke's cleft cysts (RCCs) are benign epithelial lesions arising from the Rathke's pouch remnants that fail to regress during embryogenesis. Some RCCs become symptomatic and require treatment. Cyst fenestration and drainage of its contents is the preferred procedure to treat symptomatic cases but carries a risk of recurrence. We propose the use of a novel modified nasoseptal flap technique to partially line the cyst wall to avoid recurrence.

Methods

This was a prospective, observational study that included all RCC patients admitted to the Department of Neurosurgery, Aster Medcity, from April 2015 to May 2018. The modified nasoseptal flap technique was performed in all patients. They underwent preoperative and postoperative ophthalmological, endocrine, endoscopic, and MRI evaluations to look for recurrence.

Results

Ten patients underwent the modified nasoseptal flap technique. The median follow-up was 36 months. Postoperatively, all patients were relieved from headaches. Moreover, their visual fields and pituitary functions normalized. None of the patients developed recurrence of RCC on follow-up brain MRI. On endoscopic examination, all patients had retained patency of the fenestra. The longest follow-up was 72 months.

Conclusions

The modified nasoseptal flap technique maintains patency and avoids recurrence of RCCs on long-term follow-up.

Intracranial nanomedicine-gel with deep brain-penetration for glioblastoma therapy

Glioblastoma Multiforme (GBM) is one of the challenging tumors to treat as it recurs, almost 100%, even after surgery, radiation, and chemotherapy. In many cases, recurrence happens within 2-3cm depth of the resected tumor margin, indicating the inefficacy of current anti-glioma drugs to penetrate deep into the brain tissue. Here, we report an injectable nanoparticle-gel system, capable of providing deep brain penetration of drug up to 4 cm, releasing in a sustained manner up to >15 days. The system consists of ∼222 nm sized PLGA nanoparticles (NP-222) loaded with an anti-glioma drug, Carmustine (BCNU), and coated with a thick layer of polyethylene glycol (PEG). Upon release of the drug from PLGA core, it will interact with the outer PEG-layer leading to the formation of PEG-BCNU nanocomplexes of size ∼33 nm (BCNU-NC-33), which could penetrate >4 cm deep into the brain tissue compared to the free drug (< 5 mm). In vitro drug release showed sustained release of drug for 15 days by BCNU-NP gel, and enhanced cytotoxicity by BCNU-NC-33 drug-nanocomplexes in glioma cell lines. Ex vivo goat-brain phantom studies showed drug diffusion up to 4 cm in tissue and in vivo brain-diffusion studies showed almost complete coverage within the rat brain (∼1.2 cm), with ∼55% drug retained in the tissue by day-15, compared to only ∼5% for free BCNU. Rat orthotopic glioma studies showed excellent anti-tumor efficacy by BCNU-NP gel compared to free drug, indicating the potential of the gel-system for anti-glioma therapy. In effect, we demonstrate a unique method of sustained release of drug in the brain using larger PLGA nanoparticles acting as a reservoir while deep-penetration of the released drug was achieved by in situ formation of drug-nanocomplexes of size <50 nm which is less than the native pore size of brain tissue (> 100 nm). This method will have a major impact on a challenging field of brain drug delivery.

Quality of life after resection of a meningioma—A cross-cultural comparison of Indian and Australian patients

Purpose

To compare health-related quality of life (HRQoL) and symptom burden following meningioma resection in patients from two samples from Australia and India. This will add to the body of data on the longer-term consequences of living with a meningioma in two socio-economically and culturally different countries.

Methods

The European Organisation for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30), Brain Neoplasm Module (QLQ-BN20) and the Hospital Anxiety and Depression Scale (HADS) were administered to 159 Australian and 92 Indian meningioma patients over 24 months postoperative. A linear mixed model analysis identified differences between groups over time.

Results

Australian patients reported better physical functioning in the early months after surgery (T1: mean diff: 19.8, p<0.001; T2: mean diff: 12.5, p = 0.016) whereas Indian patients reported better global HRQoL (mean: -20.3, p<0.001) and emotional functioning (mean diff:-15.6, p = 0.020) at 12–24 months. In general, Australian patients reported more sleep and fatigue symptoms while Indian patients reported more gastro-intestinal symptoms over the 2-year follow-up. Future uncertainty and symptoms common for brain tumour patients were consistently more commonly reported by patients in Australia than in India. No differences for depression and anxiety were identified.

Conclusion

This is the first cross cultural study to directly compare postoperative HRQoL in meningioma patients. Some differences in HRQoL domains and symptom burden may be explained by culturally intrinsic reporting of symptoms, as well as higher care support from family members in India. Although there were differences in some HRQoL domains, clinically meaningful differences between the two samples were less common than perhaps expected. This may be due to an Indian sample with high literacy and financial resources to afford surgery and follow up care.

Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction

We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored

Nocardia araoensis Causing Brain Abscess

Nocardial brain abscess is a rare central nervous system infection with high morbidity and mortality. Most of the human infections, i.e., about 90%, are due to Nocardia asteroides group comprising N. asteroides complex, Nocardia farcinica, and Nocardia nova. Other species rarely cause human infections. Here, we report a case of left parieto-occipital abscess caused by a rare species, Nocardia araoensis, its diagnosis, treatment options, and review of literature. A 73-year-old male, known case of diabetes mellitus, on prolonged oral corticosteroid for autoimmune hemolytic anemia presented with a 1-month history of memory deficit and gait imbalance. On examination, he had a right inferior quadrantanopia and hemiparesis. Magnetic resonance imaging showed a multiloculated ring-enhancing lesion in the left parieto-occipital region. Navigation-assisted biopsy was done. The organism isolated was N. araoensis. He was treated successfully with prolonged course of antibiotics which resulted in complete clinical and radiological resolution. N. araoensis is a rare cause of brain abscess and needs to be suspected in immunocompromised individuals. Early diagnosis and prolonged treatment can result in complete clinical and radiological resolution.

Persisting Embryonal Infundibular Recess Masquerading as a Nasal Mass

Persisting embryonal infundibular recess (PEIR) is a rare anomaly of the development of the posterior pituitary wherein there is a defect in the third ventricular floor. Earlier reports have found PEIR descending only up to the sella. However, this is the first case of PEIR presenting as a pulsatile nasal mass. A 35-year-old female presented to the otorhinolaryngologist with hyposmia. Diagnostic nasal endoscopy revealed a pulsatile nasal mass. Magnetic resonance imaging revealed a cystic lesion extending from the third ventricular floor to the nasal cavity. There was no associated hydrocephalus or empty sella. The case was successfully managed by the endoscopic endonasal transsphenoidal approach.

Profiling Cognitive Deficits in Intra-Axial and Extra-Axial Tumors Using Addenbrooke's Cognitive Examination as a Screening Tool: An Indian Experience

BACKGROUND

Tumors of the brain, whether intra- or extra-axial, results in cognitive deficits. The aim of the present study was to profile cognitive deficits using Addenbrooke's Cognitive Examination-Malayalam (ACE-M) as a screen and to determine the sensitivity and specificity of the same.

METHODS

Seventy-four drug naïve patients diagnosed to have brain tumors were assessed for cognitive functioning using ACE-M before surgery.

RESULTS

Patients with high-grade intra-axial tumors showed a significant association on the cognitive domains of registration (0.04), recall (0.01), and visuospatial functioning (0.02). Gender showed an association between registration (0.02) and verbal fluency (0.02) with females performing better while education was significantly associated with retrograde or remote memory (0.00) with college-educated sample performing better. Significance was assumed at P < 0.05. In extra-axial tumors, laterality had a single association with recall (0.02). Males showed a significant cognitive decline on the cognitive domains of attention (0.02), recall (0.05), naming (0.02), and language functions (0.01). College educated group performed better on registration (0.01), recall (0.09), naming (0.00), and visuospatial functioning (0.00). The area under the receiver operating characteristic curve was estimated as 0.75, which indicates fairly good discriminative ability with a cut off of 71/100; sensitivity at 77.3 and specificity fixed at 67.

CONCLUSIONS

ACE-M is capable of bringing out cognitive deficits along with a number of cognitive domains in patients with intra- and extra-axial tumors in the capacity of a screen, with fairly good levels of sensitivity and specificity.

Theranostic 3-Dimensional nano brain-implant for prolonged and localized treatment of recurrent glioma

Localized and controlled delivery of chemotherapeutics directly in brain-tumor for prolonged periods may radically improve the prognosis of recurrent glioblastoma. Here, we report a unique method of nanofiber by fiber controlled delivery of anti-cancer drug, Temozolomide, in orthotopic brain-tumor for one month using flexible polymeric nano-implant. A library of drug loaded (20 wt%) electrospun nanofiber of PLGA-PLA-PCL blends with distinct in vivo brain-release kinetics (hours to months) were numerically selected and a single nano-implant was formed by co-electrospinning of nano-fiber such that different set of fibres releases the drug for a specific periods from days to months by fiber-by-fiber switching. Orthotopic rat glioma implanted wafers showed constant drug release (116.6 μg/day) with negligible leakage into the peripheral blood (<100 ng) rendering ~1000 fold differential drug dosage in tumor versus peripheral blood. Most importantly, implant with one month release profile resulted in long-term (>4 month) survival of 85.7% animals whereas 07 day releasing implant showed tumor recurrence in 54.6% animals, rendering a median survival of only 74 days. In effect, we show that highly controlled drug delivery is possible for prolonged periods in orthotopic brain-tumor using combinatorial nanofibre libraries of bulk-eroding polymers, thereby controlling glioma recurrence.

Postoperative posterior ischemic optic neuropathy (PION) following right pterional meningioma surgery

Postoperative visual loss (POVL) is an unpredictable complication of nonocular surgeries. Posterior ischemic optic neuropathy (PION) is particularly feared in spinal surgeries in the prone position. We report a rare case of PION occurring after surgery for a pterional meningioma and discuss the various factors implicated in POVL.

Bilateral abducens and facial nerve palsies as a localizing sign due to reduction in intracranial pressure after fourth ventriculoperitoneal shunting

A trapped fourth ventricle often requires fourth ventriculoperitoneal shunting (4VP). Complications of this procedure include shunt blockage, infection, shunt migration, and overdrainage. Cranial nerve palsies are very rare after 4VP shunting and have been described with over drainage and brainstem distortion. We present an unusual case of bilateral abducens and facial nerve palsies after 4VP shunting after normalization of 4^th ventricular parameters. Measurement of various brainstem angles presented us with a plausible hypothesis to explain the cranial nerve dysfunction.

Extradural temporopolar approach for parahypothalamic hypothalamic hamartoma and use of posterior communicating artery as resection margin pointer

BACKGROUND

Hypothalamic hamartomas (HH) are malformations originating from the hypothalamus and are associated with seizures, hormonal and behavioral abnormalities.

METHOD

Most patients, especially those with a typical syndrome characterized by gelastic seizures, precocious puberty, cognitive decline, and behavior problems, are diagnosed in childhood. Pedunculated and parahypothalamic types of hamartomas are attached to the floor by a narrow or wide peduncle in the absence of distortion of the overlying hypothalamus. This location is most commonly associated with a clinical presentation of precocious puberty, and surgical removal has proved curative in small case series. Enthusiastic resection of hypothalamic lesions are known to produce severe hypothalamic disturbance while under resection might mean inadequate response to surgery.

CONCLUSIONS

In this article, the authors describe the use of extradural temporopolar approach to hypothalamic hamartoma as an improvisation to improve access with reduced morbidity and describe a surgical nuance of using posterior communicating artery to determine a safe but maximal resection margin.

Microsurgical management of aneurysms of the superior cerebellar artery - lessons learnt: An experience of 14 consecutive cases and review of the literature

Objective:

This is a retrospective study from January 2002 to December 2012 analyzing the results of microsurgical clipping for aneurysms arising from the superior cerebellar artery (SCA).

Materials and Methods:

All patients with SCA were evaluated with computerized tomography angiography and/or digital subtraction angiography (DSA) prior to surgery. All patients in our series underwent microsurgical clipping and postoperative DSA to assess the extent of aneurysm occlusion. The Glasgow outcome scale (GOS) and the modified Rankin's scale (mRS) were used to grade their postoperative neurological status at discharge and 6 months, respectively.

Results:

Fourteen patients had SCA aneurysms (ruptured-9, unruptured-5). There were 10 females and 4 males with the mean age of 47.2 years (median - 46 years, range = 24–66 years). Subarachnoid hemorrhage (SAH) was seen in 11 patients. The mean duration of symptoms was 2.5 days (range = 1–7 days). The WFNS score at presentation was as follows: Grade 1 in 10 cases, II in 2 cases, III in 1 case and IV in 1 case. In the 9 cases with ruptured SCA aneurysm, average size of the ruptured aneurysms was 7.3 mm (range = 2.5–27 mm, median = 4.9 mm). The subtemporal approach was used in the first 7 cases. The extradural temporopolar (EDTP) approach was used in the last 5 cases. Complications include vasospasm (n = 6), third nerve palsy (n = 5) and hydrocephalus (n = 3). Two patients died following surgery. At mean follow-up 33.8 months (median - 25 months, range = 19–96 months), no patient had a rebleed. At discharge 9 (64%), had a GOS of 4 or 5 and 3 (21%) had a GOS of 3. At 6 months follow-up, 10/14 (71%) patients had mRS of 0–2, and 2 (14%) had mRS of 5.

Conclusions:

Aneurysms of the SCA are uncommon and tend to rupture even when the aneurysm size is small (<7 mm). They commonly present with SAH. The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.

Trichosporon asahii infection presenting as chronic meningo-ventriculitis and intra ventricular fungal ball: a case report and literature review

Central nervous system trichosporonosis is a rare clinical entity and so far only six cases including three each of brain abscess and meningitis has been on record. We report a rare case of chronic meningo-ventriculitis and intraventricular fungal ball due to Trichosporon asahii in an 18-year-old immunocompetent male from Burundi, east Africa. Neuroendoscopy showed multiple nodules and a fungal ball within the ventricle, which on culture grew T. asahii. He was initially empirically treated with liposomal amphotericin B. However, the antifungal susceptibility testing of T. asahii isolate revealed high minimum inhibitory concentration for amphotericin B (2 μg ml⁻¹), flucytosine (16 μg ml⁻¹) and caspofungin (2 μg ml⁻¹) but exhibited potent activity for voriconazole, posaconazole, itraconazole and fluconazole. The patient rapidly succumbed to cardiac arrest before antifungal therapy could be changed. Although disseminated trichosporonosis has been increasingly reported the diagnosis represents a challenge especially in rare clinical settings such as intraventricular fungal ball in the present case, which has not been described previously.

Role of endoscopy in recalcitrant intraventricular tuberculoma-innovative novel treatment adjunct

INTRODUCTION

Intraventricular tuberculomas are rare entities. To the best of our knowledge, only 14 cases have been reported in English literature. Medical management of cerebral tuberculomas is well accepted. Intraventricular tuberculomas may be recalcitrant for unclear reasons. An effective management protocol for this entity is unclear. To the best of our knowledge, the definitive indication, timing, and possible role of surgery in these lesions have not been discussed in literature.

MATERIALS AND METHODS

A 27-year-old nursing professional who was undergoing treatment for miliary tuberculosis at another center presented to us in 2008 with right hemiparesis, deteriorating vision, and progressive decline in consciousness. In addition to antituberculous therapy (ATT), she underwent multiple CSF diversion procedures for the obstructive hydrocephalus secondary to a recalcitrant third ventricular tuberculoma. Finally, she underwent endoscopic decompression of the lesion with a very good clinical response at 1-year follow-up.

DISCUSSION

We discuss a patient with recalcitrant intraventricular tuberculoma managed using neuroendoscopy along with the standard antituberculous therapy. We also discuss in detail the technique we utilized for endoscopic management of this lesion.

CONCLUSION

Being a rare entity, a consensus for management of these lesions is not possible, but we have demonstrated that neuroendoscopic management of these rare entities is an option giving the advantage of definitive diagnosis when required, hastening the resolution, and clearing the CSF pathway.

Nocardia farcinica brain abscess: epidemiology, pathophysiology, and literature review

BACKGROUND

Infections caused by Nocardia farcinica are potentially lethal because of the organism's tendency to disseminate and resist antibiotics. Central nervous system involvement has been documented in 30% of infections caused N. farcinica.

METHODS

Case report and review of the literature.

RESULTS

A case of primary brain abscess caused by N. farcinica, identified by 16SrRNA sequencing, is presented, and 39 cases reported previously in the literature are reviewed. Our patient underwent a neuronavigation-guided right frontal craniotomy and was treated with trimethoprim/sulfamethoxazole and amoxicillin-clavulanic acid for 12 mo. He showed marginal improvement in his prior left hemiparesis at the last review 14 months later.

CONCLUSION

Cases of N. farcinica infections are being reported increasingly because of recent changes in taxonomy and diagnostic methodology. This change in epidemiology has implications for therapy because of the organism's pathogenicity and natural resistance to multiple antimicrobial agents, including third-generation cephalosporins. Any delay in starting appropriate antibiotic therapy can have adverse consequences.

Massive spontaneous hemothorax, giant intrathoracic meningocele, and kyphoscoliosis in neurofibromatosis type 1

Neurofibromatosis type 1 (NF-1) is a heterogeneous autosomal dominant disease with an incidence ranging from 1 in 2500 to 1 in 3000. Rare intrathoracic vascular disorders resulting in massive spontaneous hemothorax with fatal consequences may occur in these patients, so also are various types of skeletal dysplasia which may result in dramatic presentations, posing management challenges to the attending physicians. We report the case of a 43-year-old woman with NF-1 who developed spontaneous massive hemothorax and was discovered to have a concurrent giant intrathoracic meningocele and thoracic kyphoscoliosis with severe vertebral dysplastic changes. Surgical treatment via a right thoracotomy with primary repair of the meningocele and spinal fusion with fibula graft resulted in good outcome. This case represents an extreme manifestation of this otherwise indolent disease in clinical practice.

Fungal Granuloma following Endoscopic Third Ventriculostomy for Infantile Hydrocephalus

Endoscopic third ventriculostomy (ETV) is increasingly being used in the treatment of hydrocephalus in infancy. Infective complications rarely occur following ETV and fungal infections or granulomas have not been reported so far. The authors report the occurrence and management of a fungal granuloma incidentally detected during a repeat ventriculoscopy for a non-functioning ETV.

Scissoring of a Cobalt Alloy Aneurysm Clip causing Slippage during Cerebral Aneurysm Surgery: Case report and review of literature

Clip slippage is a rare occurrence, and the scissoring or torsional failure of aneurysm clips is rarer still. Titanium clips have been implicated in a few such reported cases. The authors report its occurrence while using a fenestrated cobalt alloy clip for an internal carotid artery aneurysm which was identified by intraoperative angiography and rectified by re-applying a non-fenestrated cobalt alloy clip. The possible mechanism of this complication, and measures that may prevent its occurrence, including meticulous dissection, decompression when possible, proper clip selection, and intraoperative angiogram are described.

Dilemmas and challenges in the management of a neonate with Adams-Oliver syndrome with infected giant aplasia cutis lesion and exsanguination: a case-based update

BACKGROUND

Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with a variable extent of defective formation of the scalp. Adams-Oliver syndrome is a condition mainly characterized by the congenital absence of skin, known as "aplasia cutis" which is usually limited to the vertex scalp and transverse limb defects.

CASE REPORT

A 17-day-old term female neonate was referred to us with an infected scalp lesion of the vertex. The lesion which is about 10 × 9 cm had signs of infection with necrotic eschar. We started the neonate on systemic parenteral antibiotics with local dressings. On day 3 of conservative management, the neonate had exsanguination due to bleeding from the midline with severe hemodynamic compromise requiring cardiopulmonary resuscitation. After controlling the bleeding with local tamponade and resuscitating the child, she was taken for early surgery. Debridement and bipedicled rotation flap of the scalp to cover the raw area was performed. On day 18, the flap started showing signs of necrosis. The neonate was taken up for debridement, and subsequently, maternal allograft of split-thickness skin was placed as a temporary wound cover. Meanwhile, the wound showed progressive epithelialization. At 1 year, the patient continued to have a non-healing area, which was later successfully covered with a split-thickness skin graft. We plan to revaluate the need for cranioplasty at around 3-4 years of age.

DISCUSSION

We discuss the dilemmas and challenges involved in the successful management of a neonate with Adams-Oliver syndrome with infected aplasia cutis and an episode of life-threatening exsanguination.

CONCLUSION

Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with defective formation of the scalp to a varying extent and severity, requiring various timely strategies.

Intraventricular chordoid meningioma in a child: fever of unknown origin, clinical course, and response to treatment

The authors present the case of an 11-year-old boy with an intraventricular chordoid meningioma, which is a rare presentation of prolonged fever of unknown origin due to a rare tumor in a rare location. The fever resolved after excision of the lesion. Subsequent imaging revealed recurrence at 1 year. After a repeat excision and fractionated radiotherapy, the patient has remained disease free 5 years after the first surgery. Very few cases of intraventricular chordoid meningioma have been reported to date. The pathological features and clinical course are described. A review of the literature describing management options for this tumor type, recently found to have a higher recurrence rate, is described herein.

Postulating the concept of compensated trapped fourth ventricle: a case-based demonstration with long-term clinicoradiological follow-up

BACKGROUND

A trapped fourth ventricle (TFV) is diagnosed when the inlet and outlets of the fourth ventricle are obstructed with a resultant dilated fourth ventricle.

CASE REPORT

A 3-month-old male child had a ventriculoperitoneal shunt for post-infectious hydrocephalus. At the age of 9 years, he became symptomatic with altered sensorium. He had a CT head which showed enlarged ventricles with a large fourth ventricle. A subsequent ventriculogram revealed dilated lateral ventricles with an aqueductal obstruction in association with an enlarged fourth ventricle. Although diagnosed as a TFV radiologically, his lateral ventricle shunt was revised with a diagnosis of shunt malfunction as there was a simultaneous dilatation of the lateral ventricle. He was never treated for the TFV. At his latest follow-up at 25 years of age, his MRI brain showed well-decompressed lateral ventricles with a large fourth ventricle. On clinical examination, he had truncal ataxia noticed only during turning which, according to the mother, "was always there". His MR flow study showed obstruction at the level of the aqueduct with some evidence of bidirectional flow at the foramen of Magendie.

DISCUSSION

The concept of compensated hydrocephalus represents a stage where a previously active hydrocephalus attains a nonprogressive state clinically and radiologically. We postulate the concept of a "compensated" TFV with a long-term clinical and radiological follow-up.

CONCLUSION

We demonstrate and describe a compensated TFV and reiterate that a TFV is a functional concept with imaging being at most only corroboratory.

Brevibacterium casei as a cause of brain abscess in an immunocompetent patient

Coryneform bacteria belonging to the genus Brevibacterium have emerged as opportunistic pathogens. Of the nine known species of Brevibacterium isolated from human clinical samples, Brevibacterium casei is the most frequently reported species from clinical specimens. We report the first case of B. casei brain abscess in an immunocompetent patient successfully treated by surgery and antimicrobial therapy.

Isolated intracranial Rosai Dorfman disease

Rosai Dorfman disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy, is a benign histiocytic proliferative disorder mainly affecting the lymph nodes. Although several cases of extra-nodal involvement have been reported previously, central nervous system involvement, particularly in the absence of nodal disease is extremely rare. We report a case of isolated intracranial RDD occurring in a relatively elder patient, which was shown by histological examination to have a dura-based involvement.

Long-term stability of effects of subthalamic stimulation in Parkinson's disease: Indian Experience

Reports of long-term effects of subthalamic (STN) stimulation for Parkinson's disease (PD) are few, mostly open-label evaluations and from Western centers. We used single-blind and open-label motor, cognitive and quality of life (QOL) evaluations to study the effects of bilateral STN stimulation in 45 patients over 5 years. Our patients showed a stable and substantial reduction in the cardinal signs of PD, motor fluctuations, and dyskinesias but less so for axial signs. The reduction in medications and the intensity of electrical stimulation needed also remained stable during follow up. Although the total QOL and its parkinsonism and social components showed sustained benefits till 5 years, the gains in emotional and systemic subsets were short lasting. Global scores for mood and cognition did not show significant worsening. Benefits of STN stimulation on the cardinal signs, motor complications, and QOL of advanced PD were substantial and sustained till 5 years. The initial benefits in axial motor signs and emotional and psychological aspects of QOL did not show similar stability. In general, the procedure had insignificant impact on cognition and mood. This is the first report of STN stimulation in Asian patients with PD.

Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction

We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored.

Temporal fossa arachnoid cyst presenting with bilateral subdural hematoma following trauma: two case reports

INTRODUCTION

Intracranial arachnoid cysts are considered to be congenital malformations with a predilection for the temporal fossa. They are often asymptomatic but can sometimes be symptomatic due to enlargement or hemorrhage. There are multiple case reports of arachnoid cysts becoming symptomatic with hemorrhagic complications following head trauma. In such cases, the bleeding is often confined to the side ipsilateral to the arachnoid cyst. Occurrence of contralateral subdural hematomas in patients with temporal fossa arachnoid cysts has rarely been observed and is reported less frequently in the medical literature.

CASE PRESENTATION

We report two cases of people (a 23-year-old man and a 41-year-old man) with temporal fossa arachnoid cysts complicated by a subdural hematoma following head injury. Both patients developed a subdural hematoma contralateral to the side of a temporal fossa arachnoid cyst. It is likely that lack of adequate intracranial cushioning in the presence of an intracranial arachnoid cyst may result in injury not only to ipsilateral but also to contralateral bridging veins, following head trauma.

CONCLUSION

It is important to identify and report such rare complications with intracranial arachnoid cysts, so that asymptomatic patients with an intracranial arachnoid cyst can be counseled about such possibilities following head trauma.

Ventriculosubgaleal shunts in the management of infective hydrocephalus

INTRODUCTION

Temporary diversion of cerebrospinal fluid (CSF) is often required due to patient and CSF related factors, of which infection is a significant one. The various methods available have significant disadvantages. Ventriculosubgaleal shunts (VSG) have been earlier demonstrated to be useful in a variety of circumstances.

MATERIALS AND METHODS

Hospital charts of 21 consecutive children during a 4-year period were analyzed retrospectively. Infection was defined based on a positive CSF culture or a history of recently treated meningitis with abnormal CSF findings. The conversion to a permanent shunt was based on normalization of CSF values in a functioning VSG shunt or when the VSG shunt is ineffective. The end point was control of raised intracranial pressure (ICP) features and infection.

RESULTS

The ages ranged from 1 month to 7 years with a median age of 2 months. Five (23.8%) were born premature. Twelve children (57.1%) had a previously untreated hydrocephalus, whereas nine (42.8%) had undergone some procedure. A positive CSF culture was obtained in ten (47.6%). Repeat VSG shunts were required in five children (23.8%). Seventeen (80.9%) of these children underwent conversion to a ventriculoperitoneal (VP) shunt. Of the remaining four, one did well without any further procedure, two died due to their primary problems, and one refused any further procedure due to poor neurological status. There were two wound complications-one CSF leak and one shunt migration.

CONCLUSION

VSG shunts are a simple and efficient way of managing infective hydrocephalus.

Choroid plexus cyst of the third ventricle presenting as acute triventriculomegaly

INTRODUCTION

Cystic lesions in and around the third ventricle have been known to cause intermittent and acute obstruction of the foramen of Monroe with rapid onset symptoms. Most of these lesions are seen on routine investigations, whereas some are not so obvious resulting in mistaken diagnosis. Symptomatic choroids plexus cysts have only been infrequently reported, predominantly in the lateral ventricle.

CASE REPORT

A 3-year-old female child presented with rapid loss of consciousness for the first time. Computed tomography and magnetic resonance imaging scans only showed triventriculomegaly. Endoscopy revealed a cyst of the third ventricle, which was excised, leading to good recovery. Biopsy of the wall revealed a choroid plexus cyst.

CONCLUSION

Choroid plexus cysts are rare causes for symptomatic obstruction of the third ventricle and may be difficult to detect on routine investigations and may lead to the wrong choice of treatment. Endoscopic fenestration or excision is a good option to manage such lesions.

An unusual parasagittal tumour with acute blindness and response to cerebrospinal fluid shunting

We report a seven-year-old girl who presented with a sudden tumor apoplexy due to a parasagittal hemangiopericytoma. Following tumor excision, the child was noted to have bilateral optic nerve dysfunction and progressive papilledema, despite rapid overall neurological improvement. Based on the clinical features, we feel that this case represents an unusual form of visual deterioration related to impaired CSF absorption somehow precipitated by the acute tumour apoplexy. This unusual case of blindness responded significantly to CSF shunting. Several reports exist describing raised intracranial pressure with papilledema caused by nonthrombotic sinus occlusion due to tumors in proximity to the posterior superior sagittal sinus, torcular herophili and the jugular outlet. Communicating hydrocephalus, pseudotumor syndrome or intracranial venous sinus obstruction should be considered when otherwise inexplicable visual loss coexists with optic nerve dysfunction and papilledema. We emphasize the importance of a thorough search for the cause of visual loss.

Decompressive hemicraniectomy in malignant middle cerebral artery infarction: an analysis of long-term outcome and factors in patient selection

Object

Middle cerebral artery infarction often occurs at a younger age than other strokes and is associated with significant rates of mortality and morbidity. After a period of pessimism regarding decompressive hemicraniectomy in the management of acute stroke, the method has reemerged in the past decade. The present study was undertaken to assess the immediate and long-term outcome of this intervention and to help better define the selection criteria for surgery.

Methods

The authors conducted a nonrandomized prospective study using decompressive hemicraniectomy with duraplasty in patients at various stages of clinical deterioration due to a space-occupying middle cerebral artery infarct. Patients were assessed at 6 and 12 months postinfarction by using functional scales. Subjective reconsideration was assessed using a questionnaire.

Twenty-six patients were included in the study. The mean age was 48.4 ± 11.2 years, and the mean preoperative Glasgow Coma Scale score was 9.9 ± 3.2. The median time from ictus to surgery was 54 hours (range 13–288 hours). The rate of survival at 1 year postsurgery was 73%. Among survivors, 33.3% were independent (Barthel Index [BI] > 95) and 55.6% were partially dependent (BI 60–95) at 1 year postsurgery, with 72% attaining the ability to walk independently by 1 year postsurgery. No patient remained in a vegetative state. The 1-year BI score was inversely related to patient age (r = − 0.47, p = 0.048).

Conclusions

Survival after decompressive hemicraniectomy was better than previously reported using medical management alone. A vegetative state was avoided and functional independence was possible, especially in younger patients. Increasing age was a statistically significant predictor of disability and long-term functional dependence.

Dural arteriovenous fistula coexisting with a lumbar lipomeningocele

✓ The authors describe the case of a 44-year-old woman who presented with recent onset of progressive paraparesis and bladder involvement; she had an asymptomatic lumbosacral lipomatous swelling that was present since birth. Magnetic resonance imaging confirmed the diagnosis of a lipomeningocele. It also revealed intramedullary hyperintensity on T2-weighted images and serpiginous flow voids suggestive of a dural arteriovenous fistula (DAVF) at the same level; the lesion was confirmed by spinal angiography. Both lesions were surgically managed, and the patient subsequently experienced neurological improvement. The coexistence of a DAVF and a lipomeningocele at the same level is unusual and can lead to treatment failure if missed.

Deep brain stimulation for Parkinson's disease

Dopaminergic replacement therapy with levodopa/carbidopa is still the cornerstone for the treatment of Parkinson's disease (PD). However, the medical management of PD is complicated by the appearance of disabling motor response fluctuations, levodopa-induced dyskinesias and psychosis. Since the early 1990s, surgical therapies have made a rapid reentry into the therapeutic armamentarium for PD and deep brain stimulation (DBS) of the globus pallidus interna or subthalamic nuclei is currently the most promising of such interventions. Recognition of the physiological changes in basal ganglia circuits in animal models of PD has provided the much-needed theoretic basis for targeting these areas. DBS of these areas has proven to be a safe procedure and effective against all the major motor symptoms of PD. Though not curative it can substantially reduce motor response fluctuations, levodopa-induced dyskinesias, and improve the quality of life of these patients. DBS is an expensive treatment and hardware-related complications are not rare. The results of the procedure are dependent on careful patient selection and the experience of the performing team. An update on the principles, methods and results of such procedures is essential to raise the awareness of this new therapeutic modality and to provide guidelines to the referring physicians.

Evidence of functional somatotopy in GPi from results of pallidotomy

The objective of this study was to explore the functional anatomy of the globus pallidus internus (GPi) by studying the effects of unilateral pallidotomy on parkinsonian 'off' signs and levodopa-induced dyskinesias (LID). We found significant positive correlations between the preoperative levodopa responsiveness of motor signs and the levodopa responsiveness of scores in timed tests (Core Assessment Program for Intracerebral Transplantations) in the contralateral limbs and the improvement in these scores after surgery, whereas there was no correlation with the improvement in LID. We also found a highly significant correlation (P: < 0.0001, r = 0.8) between the volume of the ventral lesion in the GPi and the improvement in LID in the contralateral limbs, whereas there was no correlation between the ventral volume and the improvement in parkinsonian 'off' signs. The volumes of the total lesion cylinder and the dorsal lesion did not correlate with the outcome of either dyskinesias or parkinsonian 'off' signs. The differential predictive value of levodopa responsiveness for the outcome of parkinsonian 'off' signs and LID and the different correlations of ventral lesion volume with dyskinesias and parkinsonian 'off' signs indicate that different anatomical or pathophysiological substrates may be responsible for the generation of parkinsonian 'off' signs and dyskinesias. Whereas cells in a wider area of the GPi may be implicated in parkinsonism, the ventral GPi seems to be crucial for the manifestation of LID. We suggest that our observations are additional proof of the functional somatotopy of the systems within the GPi that mediate parkinsonism and dyskinesias, especially along the dorsoventral trajectory used in pallidotomy. The outcome of pallidotomy in which the lesion involves the ventral and dorsal GPi could be the net effect of alteration in the activity of pathways which mediate different symptoms, and hence could be variable.