Chinmaya Dash

Massive life-threatening bifrontal epidural hematoma following placement of an external ventricular drain.

Dear Editor: External ventricular drainage is a life-saving neurosurgical procedure for CSF drainage in acute hydrocephalus. External ventricular drain (EVD) was first described by Dandy [2]. Most common EVD-related complications include infection and hemorrhage; however, literature on hemorrhagic complications of EVD remains sparse [4, 5]. Epidural hematoma is a rare complication and can occur at site of placement or at a distant site due to sudden decompression and dural stripping from the overlying bone. A 17-year-old male patient, a diagnosed case of thalamic glioma who received primary radiotherapy, presented to us with complaints of headache, repeated vomiting, and drowsiness. On examination, his GCS was E1VtM2. Non-contrast CT (NCCT) scan of the head showed right thalamic tumor with hydrocephalus (Fig. 1a). An EVD was inserted through right frontal twist drill craniostomy, at the Kocher’s point. CSF was under high pressure, and the EVD bag was kept at a level of patient’s tragus. The patient became conscious (GCS E4VtM6) after the placement of the EVD. After 4 h of EVD placement , pat ient again became unresponsive (GCS E1VtM1), and the EVD had drained 50 ml of CSF by then. NCCT scan of the head revealed massive bifrontal epidural hematoma (EDH) and the EVD tip was in the frontal horn of the right lateral ventricle (Fig. 1b). A bicoronal scalp incision, bilateral frontal bone flap was elevated and EDH was evacuated. The superior sagittal sinus and the bifrontal dura were found stripped from the bone. Multiple central and peripheral dural hitches were applied and the bone flap was placed back. The patient regained consciousness after surgery and his sensorium improved following surgery to E4VtM6 with CT head showing complete evacuation of EDH (Fig. 1c). Eight hours after EDH evacuation, the patient again became E1VtM1. NCCT scan showed dilatation of ventricles, so a right parietal EVD was inserted. The patient again regained consciousness (GCS E4VtM6). The EVD was converted to a ventriculo-peritoneal shunt as a definitive measure of CSF diversion after 48 h (Fig. 2a, b). The patient was doing good at 3 months follow-up with a functioning shunt. External ventricular drainage is one of the life-saving procedures in neurosurgery, although tapping ventricle still can cause hemorrhagic complications due to injury to cortical vein or the subependymal vasculature. The reported hemorrhagic complications of an EVD include a parenchymal bleed, intraventricular bleed, and subdural or epidural hematomas [1, 3]. Intra-parenchymal and subdural hematomas are mostly due to direct trauma, whereas an EDH occurs as a result of direct trauma to the dural vessel, venous lacunae, and diploe or may be due to the sudden decompression of the ventricles, * Kanwaljeet Garg gargneuro@hotmail.com

Management of Choroid plexus tumors in infants and young children up to 4 years of age: An institutional experience

BACKGROUND Choroid plexus tumors (CPTs) are rare tumors characterized by papillary and intraventricular growth. The young age of presentation of such tumors, especially in infants, and the lack of consensus on adjuvant therapy in case of atypical choroid plexus papilloma (aCPP) and choroid plexus carcinoma (CPC) create dilemma for the management of such tumors. We discuss the presentation, management, complications, and outcome in 15 patients (children 4 years of age and younger) and review pertinent literature. METHODS We retrospectively analyzed the case records of all patients with CPTs who were operated in our institute from January 2010 to March 2018. We found 15 patients in the age group of 0-4 years of age. The variables analyzed include age, sex, presentation, location, surgical approach, extent of resection, intraoperative blood loss, percentage of blood loss, blood transfused, histopathology, postoperative complications, and outcome. Images were obtained from picture archiving and communication system, and patient details and follow-up were obtained from discharge summary, operative notes, and hospital records. RESULTS Ten patients had choroid plexus papilloma (CPP), 2 patients had aCPP, and 3 patients had CPC. The mean age was 15.2 months, whereas the median age was 8 months (range, 40 days-4 years). The mean blood loss was 329 mL, whereas the median blood loss was 175 mL. There were a total of 5 deaths, including 3 patients with CPC and 1 each with aCPP and CPP. CONCLUSIONS CPTs are challenging tumors in infants and very young children because of the potential for massive blood loss. CPP is associated with lesser blood loss and favorable outcome compared with aCPP and CPC. Massive blood loss in CPC and aCPP can be life threatening as has been shown in our series. CPC has a rapid proliferation potential as shown in one of our cases. Attempts at decreasing vascularization of such tumors should be made by various methods, including preoperative embolization and neoadjuvant chemotherapy; however, a consensus on this is lacking.

Craniovertebral junction evaluation by computed tomography in asymptomatic individuals in the Indian population

Background: The available literature on the anatomy and imaging of the craniovertebral junction (CVJ) focusses on the osteometric indices described for the detection of abnormal relationships between the components of CVJ. However, a knowledge of the normal osteometry of this region in the Indian population is critically important for the operating surgeon as it may influence the surgical technique as well as the choice, size and configurations of the implants. It is also important to determine whether critical differences exist between the osteometric data of Indians and the rest of the world for this part of the anatomy. Accordingly, the present study is an attempt to quantitate the osteometric indices for the anatomically normal CVJ in Indian subjects Materials and Methods: We retrospectively studied the imaging data of 49 consecutive adult patients (31 males, 18 females) who underwent a computed tomographic (CT) angiogram for suspected vascular conditions unrelated to the craniovertebral junction. Several parameters related to the atlanto-dental relationship, foramen magnum, atlas and axis vertebrae were recorded, including the dimensions of the commonly instrumented bony regions and also the indices related to the CVJ bony relationships. The data was also compared between the two genders, statistically through the Students t-test using the statistical program “R”. Results: No patient had an atlanto dens interval >2.5 mm. The mean distance of the odontoid tip from the McRae line in this series was 5.11 mm and no patient had the odontoid tip above the McRae line. Female subjects had significantly smaller diameters of C1 lateral masses and odontoid screw trajectory length when compared to males. Additionally, in the Indian population, the length range of odontoid screw trajectory and the thickness of the narrowest part of the C2 pedicles was smaller with respect to similar data from other geographical regions. However, the rest of the parameters resembled the data from studies conducted on populations with other ethnicities. Conclusion: The osteometric parameters of the CVJ in the Indian population are largely similar to those described globally. However, there are some important differences too which can influence the design of surgical implants suited to the Indian population.

Letter to the Editor: Whole-brain CT perfusion and subarachnoid hemorrhage

TO THE EDITOR: We read with keen interest the article by Malinova et al.3 (Malinova V, Dolatowski K, Schramm P, et al: Early whole-brain CT perfusion for detection of patients at risk for delayed cerebral ischemia after subarachnoid hemorrhage. J Neurosurg 125:128–136, July 2016). The authors have described the utility of wholebrain CT perfusion (CTP) in predicting the occurrence of delayed ischemic neurological deficits and delayed cerebral infarction in patients with acute subarachnoid hemorrhage (aSAH). We commend the authors for their study, which sheds light on the enigma of delayed ischemic neurological deficits and delayed cerebral infarction following aSAH. In days to come, CTP may become part of routine study in patients with aSAH. Global cerebral edema (GCE) occurs after aSAH and is associated with functional and cognitive dysfunction. It usually occurs during the early phase (0–3 days) after aSAH. GCE is identified on CT scan by the following characteristics: 1) effacement of hemispheric sulci and basal cisterns, and 2) bilateral and extensive disruption of the cerebral gray-white matter junction at the level of the centrum semiovale.1,2 Patients with GCE have global perfusion deficits when compared to patients without GCE.1 This may affect early CT perfusion studies, and it probably was not considered by the authors. The number of such patients and the CTP findings in such patients should be addressed. Acute hydrocephalus after aSAH is known to be associated with reduced cerebral blood flow in the deep gray matter and periventricular white matter.4 This could also have affected the results, and interpretation of this study and the number of patients with hydrocephalus have not been mentioned. The authors’ study has very few patients with Fisher Grade 2 SAH and no patient with Fisher Grade 1 SAH, and it may be very difficult to generalize the result of this study to patients in these two groups. Thus, a study with a larger patient population and one composed of these two groups needs to be done, considering the radiation and the use of contrast agents for CTP studies. We once again commend the authors for this study and concur with them that a larger study group is required to compare various subgroups and to analyze the effects of CTP on outcome of patients with aSAH.

Letter to the Editor. Unilateral or bilateral drainage for chronic subdural hematoma

TO THE EDITOR: We read with keen interest the article by Andersen-Ranberg et al.1 (Andersen-Ranberg NC, Poulsen FR, Bergholt B, et al: Bilateral chronic subdural hematoma: unilateral or bilateral drainage? J Neurosurg [epub ahead of print July 8, 2016. DOI: 10.3171/2016.4.JNS152642]). In their study of 291 patients with bilateral chronic subdural hematoma (bCSDH), the authors identified 264 patients who underwent unilateral or bilateral surgery for chronic subdural hematoma (CSDH). They concluded that patients treated with unilateral surgery had twice the risk of retreatment as compared to patients who underwent bilateral surgery. The authors have added a valuable contribution to the management of bCSDH, the management protocol of which is not clearly defined. The authors have rightly pointed out that in cases of bCSDH, surgical intervention may be difficult and risky on the side with thin CSDH because the distance from the dural surface to the cortex may be small. Under such circumstances, we suggest surgical intervention for the side with the larger volume of hematoma for which the patient is symptomatic and a trial of steroids for the side with the lesser volume of hematoma, especially in patients with thin hematomas that may not be amenable to simultaneous surgical intervention. In their study of 26 patients, Thotakura and Marabathina5 were able to manage 11 cases successfully with steroids. Steroids act by decreasing or inhibiting the inflammatory pathway, which is believed to play a role in enlargement of CSDHs.4 A 2012 systemic review of the role of steroids in the management of CSDH found 5 observational studies that provided Class III evidence regarding the beneficial effects of steroids in the management of CSDH.2 In reporting on their randomized controlled trial (RCT) on the use of dexamethasone with surgical drainage for the reduction of recurrence with reoperation, Chan et al. concluded that steroid therapy with surgical drainage was associated with a lower rate of recurrence requiring reoperation, although the difference was not statistically significant.3 A study is warranted in order to explore this option, which can be of immense use in caring for patients with bCSDH.

Letter to the Editor: Reduced incidence of CSF leak following complete calvarial reconstruction of craniectomies.

TO THE EDITOR: We read with keen interest the article by Eseonu et al.2 (Eseonu CI, Goodwin CR, Zhou X, et al: Reduced CSF leak in complete calvarial reconstructions of microvascular decompression craniectomies using calcium phosphate cement. J Neurosurg 123:1476– 1479, December 2015) regarding the reduced incidence of CSF leaks following complete calvarial reconstruction of craniectomies done for microvascular decompression (MVD) using calcium phosphate cement. MVD is a very fruitful surgery and provides symptomatic relief in up to 95% of patients with trigeminal neuralgia.4,5 CSF leakage following MVD can be devastating. We commend the innovative idea of the authors in their efforts to reduce the incidence of CSF leaks following retrosigmoid craniectomy for MVD. The authors report on 221 patients who underwent retrosigmoid craniectomy for MVD to treat trigeminal neuralgia. Of 221 patients, 116 consecutive patients received polyethylene titanium mesh incomplete cranioplasty and the subsequent 105 patients received calcium phosphate for complete cranioplasty. They reported a statistically significant higher incidence of CSF leaks in the incomplete-cranioplasty group and no leaks in the calcium phosphate group. We would like to bring few important points in this article to the kind attention of the readers. Dural closure was augmented with a collagen dural substitute, which was sutured to the dura and reinforced with collagen matrix and fibrin sealant. However, the article did not mention the number of patients in whom dural substitute was required for dural closure (in patients in whom primary dural closure was not possible) in each group, and this could be a cause of bias.3 Other causes of poor wound healing like diabetes, steroid use, and malnutrition were not evaluated and can be a very important cause of bias and need to be accounted for. Moreover, the rate of CSF leak reported in one of the largest series of MVD was 1.5%.1 There might be some other factors responsible for a high CSF leakage rate in the patients who received polyethylene titanium mesh–augmented incomplete cranioplasty (CSF leakage rate 4.5%). Hence, a randomized study to remove the confounding factors would be ideal to determine the superiority of one method of cranioplasty over other.

Hyperplasia of Cervical Spinous Process Presenting as Subcutaneous Mass

A 7-y-old male child presented with complaints of neck pain for last 2 y. There was no history of neck trauma or any other significant history. Physical examination revealed a tender, bony hard midline posterior cervical mass elevating the skin (Fig. 1). On direct questioning patient’s father came up with history of noticing the swelling for the first time 2 years back, with no change in size since then. Neurological examination was unremarkable with no restriction of neck movements. Radiographs revealed hypertrophy of the C3 spinous process. Computed tomography (CT) revealed hypertrophied left lamina of C3 with enlarged and thickened spinous process (Fig. 2). In addition there was schisis of spinous process of C4