Bhawani Shanker Sharma

Tethered cord syndrome in adults.

BACKGROUND The tethered cord syndrome (TCS) is usually diagnosed in childhood and its symptomatic onset in adult life is not common. In the present study, we analyzed the data of patients who presented with TCS in adulthood with the aim of studying the clinical spectrum and management strategies. CLINICAL MATERIAL Over a 5-year period, 18 adult patients (more than 18 years of age) with TCS were investigated with MRI and were operated on. Patients with adult TCS could be divided into two groups. Group 1 included patients who were asymptomatic in childhood and presented for the first time in adult life (10 patients). The second group was comprised of patients with preexisting static skeletal/neurological deformities who presented in adult life with new or progressive symptoms (eight patients). Eleven patients had cutaneous stigmata, 15 had motor or sensory deficit, nine had back/leg pain, eight had leg atrophy, and six had sphincter disturbances. The most frequent MRI finding was a low lying cord with an intradural and/or extradural lipoma. The cord was detethered surgically and the tethering lesion excised. Pain was usually relieved after surgery (8 out of 9), but only a few patients (2 out of 6) had improvement of sphincter dysfunction. CONCLUSIONS The late presentation of TCS is possibly related to the degree of tethering and the cumulative effect of repeated microtrauma during flexion and extension. Adult patients with persistent back/leg pain and/or neurological or skeletal deformities should be investigated with MRI to establish an early diagnosis. Surgery should be performed in all adult patients with TCS, once the diagnosis is established.

Gliosarcoma With Cartilage Formation

A case of gliosarcoma with cartilaginous component is described. Immunohistochemical and electron microscopic studies confirmed the presence of glial and fibroblastic elements. A major part of the sarcomatous tissue was undifferentiated and not labeled by any of the markers used including those for endothelial cells. The cartilage cells also were not labeled either by antiglial fibrillary acidic protein or any other marker. The occurrence and histogenesis of cartilage in gliomas and gliosarcomas have been reviewed.

Intramedullary spinal cysticercosis. Case report and review of literature.

Intramedullary spinal cysticercosis is extremely uncommon; only 29 cases have been reported previously. A case of solitary intramedullary spinal cysticercosis is described. Factors accounting for the rarity of intramedullary cysticerci are reviewed and the probability of reaching a preoperative diagnosis is discussed. This is the fifth such case reported from India.

Congenital intramedullary spinal ependymal cyst

A rare case of congenital intramedullary ependymal cyst of the dorsal cord in a 7-year-old boy associated with kyphoscoliosis and rachidian malformations of the dorsal spine is reported. Myelography suggested an intramedullary lesion. The posterior location and presence of a clear plane of cleavage from the medullary tissue enabled total enucleation of the cyst. Histological differentiation from other similar intradural cysts is discussed and the relevant literature is reviewed. This is the fifth such case reported in the literature.

Vertebral cryptococcosis simulating tuberculosis

Infection with the fungus Cryptococcus neoformans is seen predominantly in two forms: (a) pulmonary and (b) cerebromeningeal. Skeletal cryptococcosis is uncommon. There have been only occasional case reports of thoracic vertebral cryptococcosis presenting as cord compression. A young female had cervical lymphadenopathy diagnosed as tuberculosis by fine needle aspiration cytology (FNAC) and was on antitubercular therapy (ATT) for 5 months. She developed rapidly progressive paraparesis and imaging demonstrated a destructive vertebral body lesion involving T2 – 3 with a paraspinal abscess producing cord compression. A costotransversectomy with excision of the diseased bone and bone grafting was done. Histopathological examination revealed cryptococcosis. The patient was put on antifungal medication, but expired 2 weeks after surgery. Radiological, magnetic resonance imaging and surgical finding of vertebral cryptococcosis can mimic tuberculosis. The definite diagnosis of cryptococcosis depends upon microscopic identification of the organism. A high index of suspicion leading to early surgical confirmation and institution of anti fungal therapy is necessary to reduce the mortality and morbidity.

Tension pneumocephalus following evacuation of chronic subdural haematoma.

Five cases of a rare complication of tension pneumocephalus following evacuation of chronic subdural haematoma are described. This occurred in 8% of all cases of chronic subdural haematoma treated following installation of a CT scanner. The chronically compressed brain contributes to the ingress of this intracranial air. The increase in the brain bulk and gradual re-expansion of the brain, in the early postoperative period, competes with the trapped subdural air resulting in a rise in intracranial pressure leading to neurological deterioration. Twist drill craniostomy and aspiration, using a brain cannula with a three-way connector, has produced excellent results.

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.

Actinomycotic brain abscess

A histologically confirmed actinomycotic brain abscess, in a previously healthy female, is reported. CT scan findings of a thick walled multiloculated ring enhancement with smooth inner margin and irregular nodular enhancement of outer margin, along with contiguous patchy enhancing lesion with circular low attenuation areas were suggestive of a chronic granulomatous abscess. Surgical excision and prolonged antibiotic therapy produced a good resolution.

Primary spinal epidural Ewing's sarcoma.

A rare case of Ewings sarcoma, originating primarily in the spinal epidural space is reported. Only five similar case reports are available in the English literature. Full recovery from a state of complete paraplegia, due to malignant compression, local recurrence without distant metastases and the longest survival of more than three years and six months, makes a unique combination. Pathology and therapy are briefly discussed and the pertinent literature reviewed.

Spontaneous Thrombosis of Giant Cavernous Internal Carotid Artery Aneurysm in a Neonate

Neonatal intracranial aneurysms are rare, with only 20cases being reported in the literature. No case of spontaneous resolution of a giant intracranial cavernous segment aneurysm in a neonate is reported till date. The authors describe a 3-week-old male child who presented with a left-sided tonic seizure episode and was diagnosed as having a right-sided giant cavernous internal carotid artery aneurysm. The aneurysm was found to be totally thrombosed on angiography done before planning definitive treatment. The child is doing well at 2 years of follow-up. Spontaneous thrombosis, an exceptionally rare but fortunate outcome in a rare case of giant neonatal internal carotid artery aneurysm, has led the authors to report this case. The need of repeat imaging or angiography should be considered to rule out this rare outcome, more so if there is any delay between the ictus and treatment.