Dattaraj Sawarkar

Fatal Superior Sagittal Sinus and Torcular Thrombosis After Vestibular Schwannoma Surgery: Report of a Rare Complication and Review of the Literature

BACKGROUND Cerebral venous sinus thrombosis (CVST) is a rare condition with the potential to cause severe morbidity and mortality. CVST can also occur after vestibular schwannoma (VS) surgery with the thrombosis of transverse and sigmoid sinus. However, there is not a single report of superior sagittal sinus (SSS) thrombosis after VS surgery reported in the literature. CASE DESCRIPTION A 45-year-old woman presented to our center with large left-sided solid cystic VS. On admission she was dehydrated, and after clinical stabilization, she underwent gross total excision of tumor through left retromastoid suboccipital craniotomy after cerebrospinal fluid drainage through an external ventricular drain. Surgery was uneventful, but postoperatively she had an episode of seizure. Immediate postoperative computed tomography (CT) brain scan was normal with good operative cavity. However, 24 hours later, she developed left-sided motor deficit, and a repeat CT scan showed right frontal parenchymal hemorrhage with intraventricular extension. On further evaluation, magnetic resonance venography showed entire SSS thrombosis, with patent bilateral transverse and sigmoid sinuses. She was not started on the anticoagulants in view of intracranial hemorrhage. Subsequently, she underwent right-sided decompressive craniectomy because there was progressive deterioration in her Glasgow Coma Scale, and she succumbed despite all efforts. Retrospectively, dehydration and intracranial hypotension could be likened to her sinus thrombosis. CONCLUSIONS This case underscores the significance of adequate optimization of the patients prior to surgery, besides adequate operative skills to avoid this rare but serious complication of SSS and torcular thrombosis after VS surgery.

Surgical management of odontoid fractures at level one trauma center: a single-center series of 142 cases.

INTRODUCTION Odontoid fractures constitute 9-20% of all adult cervical spine fractures. The present study was carried out to focus on the nuances involved in the surgical management of odontoid fractures. MATERIALS AND METHODS Patients with an odontoid fracture, admitted for surgical stabilization, between January 2008 and March 2014, were included in the study. RESULTS Among 142 patients [127 male and 15 female patients; median age: 28 years range 4-75 years], type II odontoid fractures were present in 111, type IIA fractures in 8, and type III fractures in 23 patients. 58.5% patients had been involved in a motor vehicular accident while 38.7% had sustained a fall. Eighty-five patients (59.9%) with a well-reduced fracture and an intact transverse ligament underwent anterior odontoid screw (OS) placement; the other 57 patients (40.1%) underwent posterior fixation (PF). The mean follow-up duration was 22 months (range: 6 months-5.4 years). OS placement was successful in 82 patients (96.5%) with a fusion rate of 95% (95.8% in type II, 100% in type III, and 75% in type IIA odontoid fractures). The procedure-related morbidity was 11.7%. One patient died of sub-arachnoid hemorrhage (SAH) that occurred during OS placement. The PF procedures had a better fusion rate (96.5%). The latter patients, however, had significant restriction of their neck movements and an overall morbidity of 8.7%. The revision surgery rates after OS placement and PF fixation were 7% and 3.5%, respectively. CONCLUSIONS Anterior OS fixation shows excellent fusion rates and should be the first-line management in reduced/non-displaced acute type II (including type IIA) and high type III odontoid fractures as it preserves cervical motion. PF, that has also been associated with an excellent fusion rate, should be reserved for patients where OS fixation has either failed or has not been feasible.

Rare Case of Cerebrospinal Fluid Proctorrhea Caused by Anterior Sacral Meningocele with Rectothecal Fistula

BACKGROUND Anterior sacral meningocele (ASM) leading to secondary rectothecal fistula is extremely rare, and to date only 5 such cases have been described in the world literature. CASE DESCRIPTION We describe an uncomplicated case of a 52-year-old female patient presenting with cerebrospinal fluid leak from the anus who was investigated and found to have an ASM with rectothecal fistula. The ASM and rectothecal fistula were subsequently repaired using a posterior approach. Pertinent literature review, clinical findings, neuroimaging, and surgical management are described for these rare lesions. CONCLUSION Early diagnosis and surgical disconnection of the fistulous tract led to satisfactory outcome in the present case and avoided the catastrophic complication of meningitis.

Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus—Case Report and Literature Review

Calcified chronic subdural hematomas are an occurrence rarely seen in neurosurgical clinical practice. And when they occur bilaterally, the radiologic image they present is fascinating, as is the clinical presentation, but their management may be challenging. They have been reported to present with a multitude of neurologic deficits but never with diabetes insipidus, which is described here. Due to the rarity of this pathology, the management protocol is not well defined, though there have been quite a few papers on this condition. This review article gathers information published over the years on this rare entity to suggest a treatment protocol.

Management of Pediatric Posterior Circulation Aneurysms—12-Year Single-Institution Experience

BACKGROUND Pediatric posterior circulation aneurysms are rare, complex, poorly understood lesions on which only limited literature is currently available. We report our 12-year experience of managing this condition to enhance knowledge of this rare entity. METHODS Patients <18 years old with posterior circulation aneurysms managed at our institution from January 2005 to April 2017 were included. Demographic, clinical, radiologic and management details were retrieved from hospital records and characteristics of the aneurysms and treatment were analyzed. RESULTS During this period, 20 pediatric patients (male-to-female ratio 15:6; mean age, 13.1 years) with posterior circulation aneurysms were treated. Most of the patients (75%) presented with subarachnoid hemorrhage. The most common location was the vertebrobasilar junction and vertebral artery (31.81%) followed by the basilar artery and the posterior cerebral artery (27.72% each). Dissecting (81.8%) and large (63.63%) aneurysms were the most common types noted. Of the15 patients with 22 aneurysms treated, 13 underwent endovascular management (parent vessel sacrifice in 8 aneurysms and parent vessel preservation in 5 aneurysms), 1 patient underwent surgery, and 1 patient received medical management for central nervous system tuberculosis. During follow-up, 1 patient had recurrence of aneurysm, and 1 patient died after discharge from the hospital. Overall good outcome was recorded in 90% of patients (Glasgow Outcome Scale score 4-5). CONCLUSIONS Vertebrobasilar junction and vertebral artery was the most common location for posterior circulation aneurysms and most were dissecting aneurysms. Endovascular treatment was the mainstay of management. Overall good outcome was observed at long-term follow-up.

Intracranial pressure (ICP) monitoring in diffuse brain injury: to do or not to do?

Dear Sir, We read with great interest the article in your journal by Vora et al. regarding the role of intracranial pressure (ICP) monitoring in diffuse brain injury titled “Intracranial pressure monitoring in diffuse brain injury-why the developing world needs it more?” [4]. We commend the authors for evaluating the role of ICP monitoring in long-term outcomes of patients with diffuse brain injury. It was indeed interesting to note that they found statistically significant improvement in the extended Glasgow outcome scale (GOS-E) at 1 month in the ICP monitoring group. Moreover, a better 2 weeks and 6 months mortality rates in the ICP-monitored group were observed, though it was not statistically significant. However, we would like to discuss a few shortcomings of the article as below: