Anita Jagetia

Brain stem infarction: a complication of microvascular decompression for trigeminal neuralgia.

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Endoscopic observations of blocked ventriculoperitoneal (VP) shunt: a step toward better understanding of shunt obstruction and its removal

Abstract Objectives. Most of our understanding of ventriculoperitoneal (VP) shunt blockage (ventricular end) is based on in vitro studies of blocked VP shunts. Not much information is available regarding the in vivo changes that occur in the tube and in the surrounding ventricle. The primary aim of our study was to observe and analyse these changes, directly, through the endoscope, in patients with blocked shunts undergoing an endoscopic third ventriculostomy (ETV). Based on these findings, we have also suggested criteria for safe removal of the VP shunt tube following ETV. Material and methods. ETV was performed with standard technique in patients with blocked VP shunt. The ventricular end of the shunt tube was inspected through the endoscope, for changes in ventricle linings as well as in the shunt tube. These changes were correlated with the age of the patient, etiology of HC, type or make of the shunt tube, duration of shunt placement to ETV and the CSF findings. Results. Fifty-three patients of blocked VP shunt underwent ETV from July 2006 to April 2010. Thirty patients had Chhabra (CH) V P Shunt (Surgiwear, India) and 23 had ceredrain (CD) shunt (Hindustan Latex, India). The age of the patients ranged from 2 months to 60 years (mean – 13.33 years.). Various causes of hydrocephalus (HC) included congenital hydrocephalus (aqueductal stenosis) in 18 patients, post-meningitis hydrocephalus (PMH) in 32 cases, neuro-cysticercosis (NCC) in 2 patients and intraventricular haemorrhagic (IVH) in 1 patient. Clinical and radiological improvement occurred in 33 (62.21%), and 24 (45%) patients, respectively. Freedom from shunt was attained in 20 (38%) patients. The changes around the shunt tube were seen in 41 (77%). Hyperaemia and neovascularised ependyma was seen in 20 (37%) and 15 (28%) patients. Encasement of the tube was seen in 41%. Ependymal growth and neovascularised shunt tubes were noticed in 15% each. Choroid plexus blocking the tube was seen in only four cases (7%). VP shunt was revised in 14 patients (26.4%). Patient with infective etiology had more changes (p < 0.005). Age, CSF findings and make of shunt tube had no relation with endoscopic observations (p< 0.02). Conclusions. ETV has a role in shunt failures. It can offer patient a chance of shunt free life. Endoscopic observation of shunt tube and ventricle can unfold several interesting in vivo findings pertaining to shunt obstruction. Shunt should only be removed if there are no adhesions and neovascularisation.

CSF rhinorrhea: An overview of endoscopic repair

Abstract CSF rhinorrhea can be diagnosed with more accurate localizations of the site of leak with the help of modern radiological methods. The repair involves surgical intervention, which has changed from open craniotomy to minimally invasive techniques. Endoscopic repair has gained popularity in last decade and is being practiced by many neurosurgeons either alone or with their ENT colleagues. The overall success rate of endoscopic repairs has triggered several centers to adopt endoscopic repair as first line of treatment of CSF rhinorrhea. However the inexperience of neurosurgeon to sinus anatomy may pose some difficulties with the young neurosurgeons. The article presents a review of the techniques for confirmation of a CSF leak as well as endocscopic repair of CSF fistula.

Saccular bilobed aneurysm of an azygos anterior cerebral artery

An azygos anterior cerebral artery is an anatomical variant in which the anterior communicating artery is absent and both the A1 segments unite to form a single A2 segment of the artery. This anatomical variant may be associated with holoprosencephaly and may predispose to aneurysm formation, however the association of such an anomaly with an aneurysm is rare. When associated with an aneurysm, it poses management difficulties due to the single distal anterior cerebral artery. Most of the reported aneurysms with such an anomaly are saccular and located in the distal part of the artery. We report a patient with a wide neck saccular multilobed aneurysm who presented after a grade 3 subarachnoid haemorrhage. A right pterional craniotomy and clipping of the aneurysm was performed following cerebral angiography. The mechanism of formation and difficulties in management of such an aneurysm is discussed.

Ventriculoperitoneal shunt tube infection and changing pattern of antibiotic sensitivity in neurosurgery practice: Alarming trends

INTRODUCTION Infection associated with a ventriculoperitoneal shunt is a severe complication with a high morbidity and substantial mortality. There are no guidelines to choose antibiotics in case of shunt infection. Most surgeons use antibiotics of their choice whereas limited centres follow their own antibiotic policy. An alarming increase in antibiotic resistance has led to rising morbidity and mortality. MATERIALS AND METHODS This was a retrospective analysis of patients who underwent ventriculoperitoneal shunt surgery between January 2010 and December 2015 at our institution. Shunt tubes and cerebrospinal fluid were sent for culture and sensitivity in patients who were suspected clinically of having shunt tube infections. The processing of the samples was done by standard techniques, and the identification of the organism along with its sensitivity pattern was performed using Vitek 2 system. RESULTS A total of 1186 ventriculoperitoneal shunt surgeries were performed during this period at our institute in patients of all age groups. There were 757 (63.8%) male and 429 (36.2%) female patients. A total of 156 samples of patients were sent for culture and sensitivity during this period, out of which 79 (50.6%) samples had growth of an organism either in the cerebrospinal fluid [36 (23.1%)], shunt tubing [16 (10.2%)], or in both [27 (17.3%)]. The most common organisms grown in the cultures were Staphylococcus aureus [65 (82.3%)] or coagulase-negative Staphylococcus [22 (25.3%)] in the Gram-positive group and Escherichia coli [17 (21.5%)] in the Gram-negative group. Over the last 6 years, the sensitivity pattern of both Gram-negative and Gram-positive bacteria has shown alarming decreasing sensitivity for various commonly used antibiotics. CONCLUSION Ventriculoperitoneal shunt infection has become an important concern in cases of hydrocephalus. Due to the development of a high proportion of antibiotic resistance, we recommend an empirical therapy of antibiotic therapy for prophylaxis and suspected infection in ventriculoperitoneal shunt surgery.

Delayed brain abscess after embolization of arterio-venous malformation: Report of two cases and review of literature

Infections of central nervous system are rare complications of endovascular procedures. Review of literature revealed only four reported cases of brain abscesses after embolization of intracranial arteriovenous malformations (AVMs). We report two new cases of delayed brain abscess after embolization of AVM. In one of the patients, it was due to an unusual organism, Burkholderia caeci.

Perioperative complications in endovascular neurosurgery: Anesthesiologist's perspective

Background: Endovascular neurosurgery is known to be associated with potentially serious perioperative complications that can impact the course and outcome of anesthesia. We present here our institutional experience in the anesthetic management of various endovascular neurosurgical procedures and their related complications over a 10-year period. Methods: Data was obtained in 240 patients pertaining to their preoperative status, details of anesthesia and surgery, perioperative course and surgery-related complications. Information regarding hemodynamic alterations, temperature variability, fluid-electrolyte imbalance, coagulation abnormalities and alterations in the anesthesia course was specifically noted. Results: Among the important complications observed were aneurysm rupture (2.5%), vasospasm (6.67%), thromboembolism (4.16%), contrast reactions, hemodynamic alterations, electrolyte abnormalities, hypothermia, delayed emergence from anesthesia, groin hematomas and early postoperative mortality (5.14%). Conclusion: Awareness of the unique challenges of endovascular neurosurgery and prompt and appropriate management of the associated complications by an experienced neuroanesthesiologist is vital to the outcome of these procedures.

Meningeal alveolar soft part sarcoma masquerading as a meningioma: a case report

Alveolar soft part sarcoma (ASPS) is a rare soft-tissue neoplasm with an incidence rate of 0.5–0.9%. It frequently occurs in the head, neck and extremities of young children, adolescents and young adults. A 32-year-old woman presented with headache, vomiting and double vision for 1 month. Magnetic resonance imaging (MRI) showed right parietal mass, hypointense on T1 and hyperintense on T2 (Fig. 1a). Neurosurgical resection was carried out for suspected meningioma. Microscopy showed a tumour composed of polyhedral cells arranged in nests and alveolar pattern. The cells had abundant eosinophilic, granular cytoplasm, vesicular nucleus with prominent nucleoli (Fig. 1b-d). Periodic acid Schiff (PAS) with diastase stain was positive. Immunohistochemistry were non-contributory. A diagnosis of ASPS was made. Further clinico-radiological investigations failed to reveal any primary site. ASPS is thought to arise from displaced paraganglionic mesoderm and may have a close homology with paragangliomas of the carotid body. Other studies indicate myogenic origin. The cells contain crystals composed of protein monocarboxylase transporter 1 and CD 147. The absence of crystals on PAS with diastase stain and on ultra-structure does not rule out ASPS, but their presence is of diagnostic importance. Cytogenetically, there is fusion of the ASPL gene on chromosome 17 to the TFE3 gene on chromosome X [der(17)t(X;17)(p11; q25)]. ASPS with solely meningeal involvement is rare; only single case has been reported of a 39-year-old man with seizures, left temporal meningeal-enhancing lesion with brain oedema on MRI. Features of ASPS without any primary lesion was reported. The present case is the second such case of meningeal lesion clinically suspected to be a meningioma. ASPS has a gradually progressive course. Surgical excision alone or in combination with radiotherapy is the recommended mode of treatment in patients with intracranial metastases who are not terminally ill.

Endovascular Occlusion of Cervical Internal Carotid Artery Pseudoaneurysm in a Child Treated by N-Butyl Cyanoacrylate: A Rare Case Report.

We report a rare case of spontaneous extracranial cervical internal carotid artery (ICA) pseudoaneurysm in a female child aged 3 years who presented with a swelling in the neck which had bled following an attempted incision as it had been thought to be an abscess. A CT angiogram and an MR angiogram were not very conclusive to diagnose the exact site of origin and the morphology of the aneurysm. Digital subtraction angiography revealed a dissecting pseudoaneurysm of the right extracranial cervical ICA. The right ICA was ending as a pseudosac, and the right cerebral circulation was filling up through the right posterior cerebral artery. To minimize the radiation exposure, a microcatheter was placed inside the diagnostic catheter. The aneurysm sac was occluded using N-butyl cyanoacrylate since there was no distal flow to the brain from the artery beyond the aneurysm. It was a safe, effective and cheaper alternative to open surgery or to other endovascular management options available. Not all neck swellings are abscesses, and they should be examined and evaluated to exclude a vascular cause.

Fatal epistaxis from the fetal posterior communicating artery--a delayed complication of trans-sphenoidal surgery.

Vascular complications following trans-sphenoidal surgery can occur due to injury of the cavernous segment of the internal carotid artery, external carotid artery and its branches or an aneurysm rupture. The incidence of vascular complications in trans-sphenoidal surgery is 0.4% to 1.4%. Vascular injury was encountered in a patient with giant pituitary adenoma who underwent staged trans-sphenoidal tumour removal. Following his third surgery, he had delayed fatal epistaxis. An angiogram revealed a fetal type posterior communicating artery with a blow out of the junction of the posterior communicating artery with the posterior cerebral artery. The diagnosis and management of this condition are discussed.