Amey Savardekar

Incidence, risk factors, and outcome of postoperative pneumonia after microsurgical clipping of ruptured intracranial aneurysms.

Background: Occurrence of pneumonia challenges the medical management of patients who have undergone surgery for aneurysmal subarachnoid hemorrhage, and is associated with significant mortality and morbidity. There are very few studies evaluating the incidence and outcome of postoperative pneumonia in patients undergoing microsurgical clipping of ruptured intracranial aneurysms. The aim of this study was to determine the incidence, risk factors, and outcome of postoperative pneumonia in patients undergoing surgery for ruptured intracranial aneurysms. Methods: All patients operated for intracranial aneurysms, over a period of 9 months, were included prospectively. They were studied for risk factors predisposing them to pneumonia and their outcomes were noted at discharge. Patients with predisposing chronic lung disease, preexisting pneumonia, and chronic smoking habits were excluded. Results: One hundred and three patients [Mean age: 46.01 years; M:F – 58:45] underwent microsurgical clipping of aneurysm during the study period. Of these, 28 patients (27.2%) developed postoperative pneumonia. The variables associated with postoperative pneumonia were: [Preoperative] age >50 years, Glasgow Coma Scale (GCS) at presentation <15 and Hunt and Hess grade before surgery >2; [postoperative] duration of surgery >3 hours, GCS <15 after complete reversal from anesthesia, duration of intubation in the postoperative period >48 hours, tracheostomy, postoperative ventilation, intensive care unit (ICU) stay >5 days. Predictive factors for postoperative pneumonia by multivariate analysis were: Postoperative endotracheal intubation >48 hours, tracheostomy and ICU stay >5 days. Conclusions: There is a high incidence of postoperative pneumonia and mortality associated with pneumonia (27.2% and 9.7%, respectively in our study) in patients of ruptured intracranial aneurysms undergoing microsurgical clipping at our center, with Acinetobacter species being the predominant causative organism.

Delayed-onset bilateral abducens paresis after head trauma

Bilateral sixth nerve paresis following closed head injury, though rare, is a known entity. However, delayed-onset post-traumatic bilateral abducens paresis is extremely rare. We present two cases. The first patient had onset of bilateral abducens paresis 2 weeks after closed head injury and the second patient after 3 days. The cause in the former was detected to be chronic subdural hematoma and in the latter is speculated to be edema/ischemia due to injury to soft tissue structures housing these nerves. The delayed onset of bilateral abducens paresis following head injury may vary according to the cause. There may be another mechanism of injury apart from direct trauma. Though rare, it needs to be evaluated and may have a treatable cause like elevated intracranial pressure.

Importance of an intact dura in management of compound elevated fractures; a short series and literature review.

Purpose: To describe compound elevated fractures (CEFs) of the skull vault, with radiological pictures, management problems and prognosticative factors. Method: The authors describe three cases of CEFs of the cranium, their mode of injury, clinical findings, radiological images and management problems. The authors have reviewed the existing literature regarding epidemiological data, neurological status, dural breech, methods of management and final outcome, in respect of CEFs. Results: The first case had no dural breech, the second case had completely shattered dura, with extruding brain matter from the wound, while the third case had an elevated bone flap in consequence to large extradural haematoma. The patients with intact dura had relatively favourable outcome, when compared to patients with shattered dura. Three cases are added to the existing 10 such cases described in English literature. The major cause of unfavourable outcome remains sepsis and the presence of intact dura places these cases in the relatively safe category, regarding infective complications. Conclusion: The authors attempt at highlighting the importance of intact dura with such an injury. The review of literature supports favourable outcomes in patients having no dural breech.

Primary osteosarcoma of clivus: A short report

Abstract Next to multiple myeloma, osteosarcoma is the commonest primary malignant neoplasm of skeletal system. These are aggressive tumours, composed of spindle cells producing osteoid and rarely occur in calvaria. The authors report a 55-year-male harbouring clival osteosarcoma, his clinical presentation, radiological findings, management and outcome.

Isolated tumorous Langerhans cell histiocytosis of the brainstem: a diagnostic and therapeutic challenge

Langerhans cell histiocytosis (LCH) of the CNS is a rare entity, known to involve primarily the hypothalamicpituitary region, with the clinical hallmark of diabetes insipidus. There have been a few reports of CNS LCH involving the brainstem as intraparenchymal enhancing lesions, but this has never been the presenting complaint of LCH. The authors report on a 7-year-old boy who presented with right cerebellopontine syndrome, in whom a well-defined, solid, enhancing lesion in the brainstem was diagnosed. Clinicoradiological differential diagnosis included glioma and tuberculosis. Biopsy revealed atypical histiocytes positive for CD68, CD1a, and S100 protein; these are the diagnostic features of LCH on histopathological examination. The rapid growth of the lesion was controlled with a chemotherapeutic regimen of cladribine.

Solid variant of aneurysmal bone cyst presenting as a giant cervical mass: A clinical, radiological, histopathological dilemma.

Background: Typical aneurysmal bone cysts (ABCs) are osteolytic, multicystic lesions with parietal sclerosis and blood-filled cysts. In rare instances, the cystic components may be completely absent. Such solid variants in ABC (s-ABC) exhibit a solid architecture; making the clinical, radiological, and histological differentiation from other solid bone tumors like osteosarcoma (especially giant cell rich osteosarcoma) and giant cell tumor, a difficult task. Case Report: We report the case of a 45–year-old male presenting with a giant solid cervical spine lesion. Histopathology revealed solid variant of ABC, even though the radiological and fine needle aspiration cytology studies pointed toward a giant cell tumor. Conclusion: We aim to discuss the clinical, radiological, and histological findings of solid ABC (a rare benign entity) vis-à-vis the common neoplastic entities of osteosarcoma and giant cell tumor. The histopathological nuisances in making the diagnosis of s-ABC are put forth, along with its impact on management of such giant bony spinal lesions.

Preservation of Labyrinthine Structures While Drilling the Posterior Wall of the Internal Auditory Canal in Surgery of Vestibular Schwannomas via the Retrosigmoid Suboccipital Approach

OBJECTIVE To describe a new technique for safe drilling of the posterior wall of the internal auditory canal (IAC), in which the intact posterior lip of the internal auditory meatus is used as a fixed intraoperative reference point to preserve the integrity of labyrinthine structures. METHODS The retrosigmoid suboccipital approach was used to operate on 6 cases of vestibular schwannomas (Koos grade I and II), with preserved hearing. On a preoperative high-resolution computed tomography scan, a line starting 2 cm lateral to the lateral edge of the sigmoid sinus on the dura mater and directed tangential to the posterior semicircular canal or common crus was identified to intersect the posterior wall of the IAC. Drilling was carried out at a measured angle to the posterior petrous wall for meticulously measured distances, taking the intact posterior lip of the internal auditory meatus as a fixed bony point. RESULTS In the 6 cases, the mean length of the posterior wall of the IAC measured on the preoperative high-resolution computed tomography scan was 10.79 mm±1.87. By using our technique, the percentage of total length of the posterior wall of IAC drilled was 75.3%±20.5%. No injury to the posterior semicircular canal or common crus was observed intraoperatively. Total excision was performed in 5 patients, and near-total excision was performed in 1 patient. Functional hearing was preserved in all patients; testing was done 1 month after surgery. CONCLUSIONS Adequate drilling of the posterior wall of the IAC could be achieved, and tumor excision with hearing preservation was obtained by meticulous intraoperative planning and measurements based on preoperative computed tomography scanning and by keeping the intact posterior lip of the internal auditory meatus as a landmark for safe drilling.

Primary myoepithelioma of the dorsal spine: a case report and review of literature.

Study Design. Case report and review of the relevant literature. Objective. To present a case of primary spinal myoepithelioma and discuss its clinical, radiological and histopathological characteristics. We report a long-term follow-up of 5 years. Summary of Background Data. Myoepithelial neoplasms, represent a diverse morphological and biological spectrum of tumors, composed of epithelial and myoepithelial elements. Primary myoepithelioma of the bone is extremely rare and very few cases of spinal myoepitheliomas have been reported till date. Methods. A 50-year male, presenting with complaints of paraparesis and difficulty in walking, was diagnosed to have an expansile lytic lesion involving the D10 vertebral body with paraspinal extension. The patient underwent D10 laminectomy and gross total resection of the tumor. Patients power improved postoperatively, and he returned to his full functional status. Results. Long-term follow-up of 5 years reveals 2 recurrences, despite gross total resection at the initial surgery followed by radiotherapy. Histopathology, at the third surgery, documents the transformation of myoepithelioma into myoepithelial carcinoma. Conclusion. Primary myoepithelioma of spine is very rare. Gross total resection with wide resection margins in the paraspinal region should be used to tackle this rare entity as the role of adjuvant therapy is doubtful. Long-term follow-up is a must. Level of Evidence: N/A

The clinical profile, management, and overall outcome of aneurysmal subarachnoid hemorrhage at the neurosurgical unit of a tertiary care center in India.

Background and Purpose: Several studies report good outcomes in selected patients of aneurysmal subarachnoid hemorrhage (aSAH). The purpose of our study is to project the clinical characteristics, management, and overall outcome of patients with aSAH presenting to a tertiary care center in India. Materials and Methods: A prospective study was conducted over a period of 10 months and all patients presenting with aSAH were studied. Patients presenting in all grades and managed with any type of intervention or managed conservatively were included to characterize their clinical and radiological profile at admission, during management, and at discharge. Outcome was assessed with the Glasgow Outcome Score (GOS) at 3 months follow-up. Results: Out of the 482 patients [mean age: 51.3 (±13.5); M: F = 1:1], 330 patients were fit to be taken up for intervention of the ruptured aneurysm, while 152 patients were unfit for any intervention. At 3 months follow-up, good outcome (GOS 4 and 5) was observed in 159 (33%), poor outcome (GOS 2 and 3) in 53 (11%), and death in 219 (45.4%) patients, while 51 patients (10.6%) were lost to follow-up. Most (95%) of the patients in the non-intervention group expired, and hence the high mortality rate, as we have analyzed the results of all patients of all grades, regardless of the treatment given. The predictors of poor outcome (GOS 1, 2, and 3) at 3 months follow-up, using multinomial regression model, were: World Federation of Neurological Surgeons (WFNS) grade IV and V (at admission and after adequate resuscitation) [odds ratio (OR): 35.1, 95% confidence interval (CI): 10.8-114.7] and presence of hypertension as a co-morbid illness [OR: 2.7, 95% CI: 1.6-5.6]. All patients showing acute infarction on computed tomography scan at presentation had a poor outcome. Conclusions: Despite recent advances in the treatment of patients with aSAH, the morbidity and mortality rates have failed to improve significantly in unselected patients and natural cohorts. This may be attributed to the natural history of aSAH, and calls for new strategies to diagnose and treat such patients before the catastrophe strikes.

Pediatric brainstem oligodendroglioma.

The authors present the first report of pediatric brainstem oligodendroglioma, infiltrating midbrain, and medulla oblongata. The report details clinical features, radiological findings, and surgical steps. As this entity is exceedingly uncommon, the overall epidemiology, prognosis, and long-term outcome remain far from established.