Charles Marks

Subdural haemorrhage following endoscopic third ventriculostomy. A rare complication

SummarySubdural collections or hematomas are frequently observed after shunt placement [7–9, 13], but rarely after ETV [6]. A review of literature revealed 7 cases [1, 5, 6, 10, 12], of which only 1 was symptomatic [5]. We will discuss the causes, management, and methods of prevention of this complication and we will present a case of symptomatic subdural haematoma, following endoscopic third ventriculostomy for illustration.

Garré's chronic diffuse sclerosing osteomyelitis of the sacrum: a rare condition mimicking malignancy.

Garrés chronic diffuse sclerosing osteomyelitis (DSOM) is a rare disease that occurs most commonly in the mandible. We present a case of sacral DSOM that simulated an expanding destructive sacral tumour. Treatment was conducted on the basis of the available experience with the mandibular form of the disease, with partial symptomatic relief, but progressive sclerosis of the sacral lesion. To the best of our knowledge, this is the first case initially presenting in the sacrum. As an osteolytic expanding lesion simulating malignancy, it is important to recognize this entity in the sacrum.

Development of Intracranial Hypertension After Surgical Management of Intracranial Arachnoid Cyst: Report of Three Cases and Review of the Literature

OBJECTIVE To describe three cases of delayed development of intracranial hypertension (IH) after surgical treatment of intracranial arachnoid cyst, including the pathogenesis of IH and a review of the literature. METHODS A retrospective and prospective analysis of three male patients (two 18 years old and one 45 years old) was performed. All patients underwent surgical intervention for symptomatic intracranial arachnoid cyst in the form of fenestration of the cyst and a cystoperitoneal shunt. RESULTS All three patients presented at a later stage with new-onset headaches after the initial management of arachnoid cyst. Magnetic resonance imaging and magnetic resonance venography ruled out any intracranial vascular pathology. Lumbar puncture and intracranial pressure monitoring showed increased intracranial pressure suggestive of idiopathic IH. To manage IH, intracranial pressure monitoring, cystoperitoneal shunt, ventriculoperitoneal shunt, and lumboperitoneal shunt were performed. CONCLUSIONS The pathogenesis of delayed development of IH in this clinical setting is not clearly elucidated. When intracranial arachnoid cysts are treated, the possibility of future development of IH should be borne in mind. Delayed presentation with headaches in patients after treatment of intracranial arachnoid cysts should raise the possibility of IH.

Extradural haematoma--to evacuate or not? Revisiting treatment guidelines.

BACKGROUND We describe three cases of extradural haematomas (EDHs) and their management, focusing on operative and non-operative treatment. We also review the available literature from the past three decades as well as the guidelines for the management of EDH. An algorithm is formulated based on different factors, including the clinical course of the patients and their CT findings. METHODS The first patient presented to us after sustaining a fall with a GCS of 15/15 and a large parieto-occipital EDH with a volume of 90 cm3. He was treated non-operatively. Follow-up CT showed good resolution of the haematoma. The second patient presented with a GCS of 7/15, a posterior fossa EDH with a volume of 30 cm3, and obstructive hydrocephalus. Emergency ventriculostomy was performed, which was converted to a VP shunt. The third case was a patient presenting with a large hemispheric EDH, which was 130 cm3 in volume. The GCS at presentation was 14/15 but dropped to 6/15, following which he underwent craniotomy and evacuation of the EDH. RESULTS The Glasgow Outcome Scale (GOS) at three months was five for the first two cases and three for the third case with a dense right hemiplegia. CONCLUSION EDH, both supratentorial and in the posterior fossa, can be managed non-operatively. A large volume EDH (>30 cm3) can be managed non-operatively provided the GCS at presentation and follow up remains the same with symptomatic improvement. Prompt treatment of a large volume EDH may still result in a poor outcome.

Solitary intracranial myofibroma in a child

A rare case of solitary interhemispheric myofibroma with excellent outcome in a 20 month old boy is described. The clinicopathological features of this unusual condition are reviewed with emphasis on the CNS manifestations. A case of congenital fibrosarcoma was first diagnosed by William and Schrum1 and was subsequently renamed congenital generalised fibromatosis by Stout in 19542 as a distinct form of juvenile fibromatosis characterised by tumour-like nodules involving the skin, soft tissues, bones, and viscera. Based on the ultrastructural and immunohistochemical features of the cell of origin and the occurrence of this condition in infants, as well as congenitally, it was renamed infantile myofibromatosis by Chung and Enzinger in 1981.3 This disorder is considered to represent a hamartomatous myofibroblastic proliferation, although laboratory evidence suggests that it may arise secondary to oestrogen stimulation in utero . Infantile myofibromatosis represents the most common fibrous tumour of infancy and may present with solitary or multicentric lesions. When visceral involvement is present, the multilesional form is termed “generalised”. Cases with familial incidence,3spontaneous regression,4 5 and fatal outcome3 6 have all been described. Poor outcome has generally been associated with extensive visceral involvement and …

“Unusual brain stone”: heavily calcified primary neoplasm with some features suggestive of angiocentric glioma

This 40-year-old man presented with a 5-month history of progressive right-sided headache associated with visual blurring. He also had a history of epilepsy but had been seizure free with medication for the past 10 years. An initial CT scan of his brain performed 16 years previously had revealed a small area of calcification in the right parietal region. In the current presentation, he had a left-sided homonymous hemianopia but no other neurological deficits. A CT scan of his brain showed a much larger calcified, partly cystic lesion in the right parietal region. Because he was symptomatic, the lesion was excised and the cyst was drained. Histological examination of the excised tissue showed an unusual primary tumor that was difficult to classify but had some features of angiocentric glioma. The heavy calcification, mixed-density cell population, and regions with features of angiocentric glioma were most unusual. The patient remained asymptomatic 5 years after surgery, and follow-up scans did not show recurrence.

Pseudotumor cerebri following traumatic brain injury in a 29-year-old man

We describe a case of pseudotumor cerebri in a young man developing 4 years post-traumatic brain injury (TBI). A 29-year-old man was admitted after sustaining a fall with headache, and no clinical deficits were noted on examination. CT brain demonstrated an extradural hematoma. This was successfully evacuated after his symptomatic worsening. Following this, he developed bone flap infection and had the infected bone flap removed. He developed chronic mild-to-moderate headache following these procedures, which failed to respond to medical treatment. Pseudotumor cerebri was diagnosed. A lumboperitoneal (LP) shunt, ventriculo-peritoneal (VP) shunt, and bitemporal craniectomy were performed as a part of management at different stages. Post-TBI patients may present with chronic headache and in such circumstances, a possibility of pseudotumor cerebri must be considered. Investigations should include neuroimaging in the form of MRI/MRV and fundoscopy to look for papilledema. Management in the form of CSF flow diversion techniques (VP and LP shunt) with medical management results in good clinical outcomes

Headache during haemodialysis in a patient with shunt: a cause for concern?

A 20-year-old woman with a functioning ventriculoperitoneal (VP) shunt consistently reported unbearable vertex headaches and nausea during the last hour of her haemodialysis (HD) sessions. After one particularly severe episode, which was associated with vomiting, restlessness and blurred vision, her team suspected that she was developing dialysis disequilibrium syndrome. She improved fully on cessation of HD, requiring simple analgaesia only, and continued dialysis three times per week. Several more distressing episodes of nausea and headaches compelled us to give intravenous mannitol during HD, resulting in temporary improvement. Subsequently, shorter and more frequent dialysis sessions along with intravenous mannitol resulted in satisfactory clinical response.

Does surgical technique affect the incidence of spondylodiscitis post-lumbar microdiscectomy?: A retrospective analysis of 3063 patients

Study Design. Retrospective audit in a single center during a period of 7 years operated by 3 groups of surgeons after 3 different surgical techniques. Objective. Our study aimed to determine whether surgical technique had any influence on the incidence of spondylodiscitis in patients undergoing lumbar microdiscectomy and to compare this with published rate of incidence of spondylodiscitis. Summary of Background Data. The incidence of spondylodiscitis post–lumbar microdiscectomy ranges from 0.2% to 15%. There is limited evidence to compare different techniques and the incidence of spondylodiscitis. Methods. A total of 3063 patients were analyzed from 2005 to 2011 for discitis postoperatively. The first group followed a standard microdiscectomy technique, the second group used antiseptic (Savlon; Novartis Consumer Health UK Limited, Surrey, UK) irrigation at the end of the procedure to irrigate the disc space, and the third group followed standard microdiscectomy along with usage of a separate disc instruments when discectomy was performed. The number of patients operated in the individual groups was 559, 1122, and 1382. Results. The total number of patients who had postoperative discitis was 3 (0.10%), with a range of 0.07% to 0.18%. There was 1 case of discitis in each group. The incidence of spondylodiscitis in groups A, B, and C were 0.18%, 0.09%, and 0.07%, respectively. Conclusion. This study concluded that different techniques used for lumbar microdiscectomy revealed that standard microsurgical technique with usage of antiseptic irrigation for the disc space and usage of separate disc instruments had lesser incidence of spondylodiscitis in comparison with standard microdiscectomy. The overall incidence of postoperative discitis remains less in our series. So far, to our knowledge, this report involves the largest number of patients studied to determine the incidence of discitis in patients undergoing lumbar microdiscectomy. Level of Evidence: 3

What lies beneath.

Haemangiopericytomas are a group of aggressive soft tissue sarcomas that originate from the pericytes in the walls of capillaries. Local invasion of the surrounding structures is not uncommon. Symptoms depend on the location, size and grade of tumour. Coexistence with a benign tumour in the same location is very rare. We report an interesting case of occipital scalp lipoma with an underlying torcular haemangiopericytoma and skull defect.