Avinash Kumar Kanodia

Chiari II Malformation Mimicking Partial Rhombencephalosynapsis? A Case Report

Rhombencephalosynapsis is a rare congenital intracranial malformation with very few cases reported in literature. Partial rhombencephalosynapsis is a variation of this anomaly with fewer reported cases. We present the case of a patient with Chiari II malformation mimicking partial rhombencephalosynapsis.

Role of susceptibility-weighted imaging in demonstration of cerebral fat embolism

Cerebral fat embolism (CFE) is a rare but potentially lethal complication of long bone fractures. Many cases of CFE occur as subclinical events and remain undiagnosed. We report a case of a 22-year-old man, with multiple long bone fractures from a road traffic accident, who subsequently developed hypoxia, neurological abnormality and petechial rash. CT of the head was normal. MRI of the head confirmed the diagnosis with lesions markedly conspicuous and most widespread on susceptibility-weighted imaging as compared to all other sequences including diffusion-weighted imaging.

Herpes simplex encephalitis: unusual imaging appearances

Herpes simplex virus (HSV) is the most common non-epidemic and sporadic cause of viral meningoencephalitis with an incidence of approximately 1–3 cases per million.1 Ninety five per cent of fatal adult cases are a result of type 1 HSV (HSV-1) and typically follow latent viral reactivation in the trigeminal ganglion in immunocompetent patients.1 MRI is regarded as being the most sensitive radiological investigation, with changes usually visible within 2–3 days of onset of symptoms.1 Traditionally on MRI, Herpes simplex encephalitis (HSE) exhibits bilateral asymmetrical involvement of the limbic system, including the medial temporal lobes, insular cortices and inferolateral frontal lobes and cingulate gyri.1 Sparing of the basal ganglia is a key feature, which also helps in differentiating from middle cerebral artery infarction on diffusion-weighted imaging (DWI). Atypical patterns, if seen, usually affect the younger population with involvement of the cerebral hemispheres and rarely, the midbrain and pons.1 We present serial brain imaging of a 52-year-old woman who presented to the acute medical unit with a weeks history of lethargy, intermittent headaches and an episode of syncope prior …

Role of 3D FLAIR in Demonstration of Peripheral Lesions of Brainstem and Cranial Neuropathies

Aim: We present a pictorial review of 3D FLAIR images depicting its importance in demonstrating the peripheral lesions of brainstem particularly in relation to attachment of cranial nerves and cranial neuropathies and particularly in context of patients with multiple sclerosis (MS). Discussion: T2 axials and routine 2D FLAIR have drawbacks in depicting the lesions on the peripheral aspects of brainstem. Such lesions are commonly found in MS. The revised McDonald’s criteria (2010) put equal emphasis on periventricular, juxtacortical, infratentorial and cord lesions. Detection of peripheral lesions thus play important role in fulfilling the criteria of dissemination in space and also provide anatomic correlate in several cranial nerve palsies. In clinically isolated syndromes, demonstration of lesions at the site of affected cranial nerves increase diagnostic confidence and exclude other potential disease processes. Ability to show signal changes at cranial nerve attachment can also potentially prevent a false attribution of symptoms to neurovascular compression. Conclusion: We propose that 3D FLAIR sequence is extremely useful in detecting Review Article International Neuropsychiatric Disease Journal, 2(4): 167-174, 2014 168 abnormalities on the surface of brainstem and cranial nerve attachments and should be performed in all patients of MS and cranial nerve palsies.

Spontaneous Enlargement then Regression of a Colloid Cyst of the III Ventricle

Aim: We describe a case of a 22 year old pregnant female patient who was found to have a small colloid cyst that increased spontaneously, followed by spontaneous significant reduction in size. Presentation of Case: The patient’s colloid cyst was picked up incidentally in late pregnancy at 39 weeks. It showed spontaneous increase in size accompanied by deterioration of symptoms at 31 months post diagnosis and then showed significant spontaneous reduction in size at 38 months post diagnosis. Discussion and Conclusion: Spontaneous reduction of a colloid cyst of third ventricle is a very rarely described phenomenon. To our knowledge this is one of only 3 cases of spontaneous regression of an III ventricular colloid cyst. It may be reasonable to follow up cases, where there is a documented history of increase.

Transitional Meningioma with Intratumoural Bleed and Associated Subdural Haemorrhage: Case Report and a Review of Literature

Haemorrhage in intracranial tumours is usually associated with malignant primary brain tumours or metastases and rarely with grade 1 meningiomas. We present the case of a 64-year-old woman, who presented acutely and was found to have a convexity meningioma with intratumoral and subdural haemorrhage. A review of the literature has been performed to look at all published cases of meningiomas with haemorrhages, particularly in relation to their subtypes.The association of meningiomas with different types of intracranial haemorrhage has been discussed. Various factors potentially responsible for haemorrhage and association with subtypes has also been discussed.

Management of CSF Leak Following Incidental Durotomy during Lumbar Spinal Surgery: Is Flat Bed Necessary?

Page 11 Incidental durotomy (ID) is a term used to describe unintentional opening of the dura mater during spinal surgery. Although, commonly referred to as dural tear; most recent scholars are circumventing the use of the latter term, as it could imply an element of carelessness when none were necessarily present. Therefore, ID, unintended durotomy, unintentional durotomy or simply just dural opening, have been recommended to replace the term dural tear.1,2

Audit of a Standard Operating Procedure to Prevent Wrong-Level Lumbar Spinal Surgery with Intra-Operative X-Ray

Introduction: One of the major errors that can be encountered by a spinal surgeon is operating at the wrong level/side. However, wrong-level spinal surgery is considered a ‘never-event’ and is under-reported. Many surgeons have traditionally adopted the technique of palpating or “counting” from L5-S1 to determine the operative level in lumbar spine procedures without necessarily the use of intraoperative X-ray control. Most surgeons these days; however, use X-rays or fluoroscopy during the surgery. There is no universal standard operating procedure (SOP) for the use of X-rays or fluoroscopy during spinal surgery and the compliance of the surgeons for any local SOP is unknown. Aim: The audit primarily intended to check the compliance with an established local SOP using X-ray to identify lumbar spinal level. We also determined the accuracy of lumbar spine level marking by palpation. We also tried to quantify the intra-operative error rate following pre-operative X-ray level marking. Overall, the optimum role of X-rays was determined for adequate level of lumber decompression. Methods: The audit was performed as a prospective clinical audit within a single neurosurgical department. Data collected from theatre logbook, medical notes and picture archive and communication system (PACS). An established local SOP for use of X-rays during spinal surgery was used as a benchmark to audit local practice. Cycle 1: Every lumbar discectomy and decompression from June to November 2015 (6 months) was obtained. The findings were presented in our local clinical effectiveness meeting with the aim check local practice and suggest improvements. Cycle 2: Re-audit a further 6 months, December 2015 to May 2016, to see the significance of the change implemented. Results: In the first cycle, one patient did not receive pre-operative X-ray. While all other patients received pre-operative X-rays, the number of exposures was available in only 71% of patients, out of which 39% required one exposure, 43% required two exposures, 16% required three exposures and 2% required four exposures. Twenty eight cases (13.9%) were recorded to have intra-operative X-ray level checked due to doubt, out of which 22 cases were found to be on an incorrect level. In the second cycle, all patients received pre-operative X-rays and the number of exposures was recorded for all, out of which 52% required one exposure, 32% required two exposures, 13% required three exposures and 3% required four exposures. Twenty cases (9.7%) were recorded to have intra-operative X-ray level checked due to an arising doubt, out of which only 7 were found to be on an incorrect level.

Chronic Subdural Haematoma: Systematic Review Highlighting Risk Factors for Recurrent Bleeds

Introduction: Chronic subdural haematoma (CSDH) is one of the commonest forms of intracranial haemorrhage. Surgical drainage of CSDH is a routine operation in the modern neurosurgical practice which has shown to be the most effective way in treating this entity; however, the incidence of recurrence of the haematoma post operatively remains as high as 26.5%. The risk factors for CSDH recurrence remains an area of ongoing research. Objective: We have conducted a systematic review to evaluate the available literature addressing the risk factors for CSDH recurrence, aiming to minimise or at least identify patients at higher risk of recurrence in order to decrease associated morbidity. Methods: Ovid via Medline, PubMed, and Google scholar databases were searched for eligible studies, search results were then limited to studies in English language, Humans and studies published within the last 5 years. The included studies were critically appraised using the Critical Appraisal Skills Programme (CASP) tool, and each study has then been ranked using the Harbour and Miller hierarchy of ranking. Results: Based on available evidence, we classified the risk factors associated with recurrence to patients’, radiological, and surgical factors. Patient factors include history of seizures, trauma, alcoholism, brain atrophy, and presence of CSF shunts, while the role of diabetes in relation to the recurrence is controversial. Radiologically the presence of air in the subdural space post-operatively, the width of the haematoma, and the presence of bilateral CSDHs are associated with increased risk of recurrence. While the predictive value of multiple membranes in the CSDH remains controversial. Surgically, the risk of recurrence was noted to be higher in patients with parietal or occipital compared to those who had frontal burr hole drainage, also placing a subdural drain decreases the chance of recurrence and some evidence showed better outcomes for frontally placed drains. The role of anti-inflammatory agents (including steroids) remains an area of ongoing debate. Conclusions: Risk factors for CSDH can be divided into patients’, radiological, and surgical factors. We encourage health care providers to minimize if not prevent potentially avoidable factors. Patients with increased risks for recurrence should be identified early by the treating team and when possible should be informed about their higher than usual risk of recurrence. Moreover this review highlights the general lack of a sufficiently powered class I evidence addressing this topic and that further research is required in this topic.

An Unusual Intracranial Inflammatory Process of Unknown Origin

1Department of Neurosurgery, Ninewells Hospital and Medical School, Dundee, UK 2Department of Neurology, Ninewells Hospital and Medical School, Dundee, UK 3Department of Radiology, Ninewells Hospital and Medical School, Dundee, UK 4Department of Endocrinology, Ninewells Hospital and Medical School, Dundee, UK *Corresponding author Avinash Kumar Kanodia, MD, DM, FRCR Department of Radiology Ninewells Hospital and Medical School Dundee, UK E-mail: avinash.kanodia@nhs.net