Dattatraya Muzumdar

Trigeminal neuroma: analysis of surgical experience with 73 cases.

OBJECTIVEWe reviewed the clinical and radiological features of 73 cases of trigeminal neuromas treated with radical surgery. METHODSThe records for 73 patients with trigeminal neuromas who were surgically treated in the neurosurgery department of King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College (Mumbai, India), between 1989 and 2001, were retrospectively analyzed. The appropriateness of the selected surgical route was studied. The postoperative and follow-up data for the patients were analyzed, to determine the outcomes of radical surgery. RESULTSIn addition to the other presenting features of trigeminal neuromas, nine patients presented with the rarely reported symptom of pathological laughter. Three approaches were observed to be appropriate for treatment of these tumors, i.e., the infratemporal fossa interdural approach, the lateral basal subtemporal approach, and the retrosigmoid approach. In 51 cases (70%), total tumor excision was achieved. Two patients died during the postoperative period. With an average follow-up period of 38 months, there has been a recurrence in 1 case and 71 patients are leading independent and active lives. CONCLUSIONRadical surgery is associated with excellent clinical outcomes and long-term tumor control. A majority of tumors, even those that are large and multicompartmental, can be removed in a single surgical stage and exposure.

Brain abscess: An overview

Intracranial abscess is a formidable entity. Despite the advent of newer antibiotics and surgical strategies, the overall outcome and quality of life issues in brain abscess patients still remain a continuous challenge for the neurosurgical community. It is a direct interplay between the virulence of the offending microorganism and the immune response of the host. An analysis of our experience in the 289 cases of surgically treated pyogenic brain abscess is presented along with an overview of intra-cranial abscess of varied etiology and in different locations. The etiology, pathogenesis, radiological advances and treatment modalities of brain abscess are discussed in light of current literature.

Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients.

OBJECT This study is a retrospective analysis of 60 surgically treated patients with 64 peripheral nerve sheath tumors (PNSTs) at the second cervical (C-2) nerve root. The anatomical subtleties of these tumors and their implications for surgical strategy when compared with other spinal PNSTs and other tumors in the foramen magnum region are reviewed. METHODS Sixty patients with C-2 PNSTs treated surgically in the Department of Neurosurgery at King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College between 1992 and 2006 were studied. All patients underwent magnetic resonance imaging. Tumors were divided into 3 groups depending on their anatomical location identified during surgery. Those tumors located within or extending into the spinal dural tube were called Type A, those located within the dural tube of the C-2 ganglion were labeled as Type B, and tumors extending laterally into the paraspinal region were labeled as Type C. Follow-up durations ranged from 6 months to 15 years (mean 64 months). RESULTS There were 38 male and 22 female patients in the study, who ranged in age from 6 to 62 years (mean 28 years). Nine patients had clinical features indicative of neurofibromatosis (NF). The mean duration of symptoms at the time of presentation was 27 months (range 4 days-5 years). Two patients had no specific symptoms related to the C-2 PNST, 6 patients had only local symptoms such as neck pain or stiffness, and 52 patients had symptoms of varying degrees of myelopathy. There were 5 solely Type A tumors, 7 Type A + B tumors, 31 Type B tumors, and 21 Type B + C tumors. All Type A, A + B, and B tumors were totally resected. Seven of 21 Type B + C tumors were partially resected, and the remainder were completely resected. All patients postoperatively reported varying improvement in their preoperative symptoms. Except for patients with NF who were disabled by other tumors, the rest of the patients resumed their normal life style. There have been no cases of symptomatic tumor recurrence. CONCLUSIONS The majority of PNSTs located at the C-2 level in these patients probably arose from the large C-2 ganglion and are limited within the dural confines or are interdural in location. In contrast to other spinal PNSTs, the location of C-2 PNSTs is in most cases posterior to the lateral mass of the atlas and axis and the atlantoaxial joint and is exposed to the posterior without any bone cover. Radical tumor resection is safe, resolution of clinical symptoms is rapid, and recurrence rates are extremely low. In a selected number of cases, bone work for tumor exposure and resection can be entirely avoided.

Posterior Cranial Fossa Dermoid in Association with Craniovertebral and Cervical Spinal Anomaly: Report of Two Cases

Two patients, a 12-year-old girl and an 8-year-old boy, with congenital craniovertebral anomaly and Klippel-Feil syndrome also had a posterior cranial fossa dermoid. The association of these two discrete pathological lesions in the same individual is extremely rare. As both lesions are related to an embryological disorder, issues regarding the possible stage of dysgenesis are analyzed. The treatment options in such cases are discussed.

Intramedullary Cervical Neurenteric Cyst Mimicking an Abscess

We describe a cervical intramedullary neurenteric cyst in a 12-year-old male patient who presented with gradual onset and progressively worsening neck pain, spastic quadriparesis and impaired sensation in the C2 dermatome. MR imaging revealed a well-defined peripherally enhancing cystic intramedullary lesion with a posteroinferior enhancing nodule at the C2–C3 level mimicking an abscess. There was no evidence of spinal dysraphism. The lesion was completely resected through a posterior approach and the patient showed radical improvement in his symptomatology. At follow-up after 3 years, he was asymptomatic and the MR imaging showed no evidence of any residual or recurrent cyst. The case presented here is unique, since a spinal neurenteric cyst showing intense peripheral contrast enhancement mimicking an abscess is unusual. The radiological features, pathogenesis and surgical considerations in cervical intramedullary neurenteric cysts are discussed and the relevant literature is briefly reviewed.

Glioblastoma Multiforme following Cranial Irradiation and Chemotherapy for Acute Lymphocytic Leukaemia

The most common secondary neoplasms which occur following cranial radiation therapy are sarcoma and meningioma. The occurrence of glioblastoma multiforme following radiation and chemotherapy in acute lymphocytic leukaemia (ALL) is rare. We report 3 cases of glioblastoma multiforme in children developing 11–72 months following completion of chemotherapy/radiotherapy for ALL. The exact cause for the development of glioblastoma multiforme following therapy for ALL is not clear. A genetic predisposition may be essential for the occurrence of such a highly malignant primary brain tumour in leukaemia patients, irrespective of radiation and/or chemotherapy. The pathogenesis and surgical management are discussed, and the literature on the subject is reviewed.

Anterior tentorium-based epidermoid tumours: results of radical surgical treatment in 96 cases.

A retrospective analysis of 96 surgically treated tentorium and anterior tentorial hiatus-based epidermoid tumours from 1997 – 2004 is presented. The most prominent symptoms were headache (53.1%) and ataxia (44.8%). The average tumour size was 4.4 cm. Surgical approaches included posterior cranial fossa route (85 cases), basal subtemporal middle fossa route (9 cases) and combined posterior fossa and subtemporal routes in two cases. Total tumour resection was performed in 46 patients. Eight and four patients developed transient and sustained postoperative neurological deficits respectively. There was mortality in two patients. There was non-symptomatic recurrence of the tumour in two cases. Ninety-four patients are leading active functional lives. Radical and safe resection of anterior tentorium-based epidermoid tumours is associated with symptomatic relief and lasting cure. Extensive drilling of the petrous bone can be avoided. Gentle dissection of the tumour and capsule from the critical neurovascular structures can limit post-operative morbidity.

One stage reduction and fixation for atlantoaxial spondyloptosis: Report of four cases.

We report four patients having an extremely rare and hitherto unreported clinical condition of spondyloptosis of the atlas over axis. Between the year 1999 and 2004, four patients with spondyloptosis were retrospectively analysed. The age of the patients ranged from 12 to 31 years. In three patients, the aetiology of spondyloptosis was probably congenital in nature and in one case it was secondary to rheumatoid disease. The patients presented with varying degrees of neck pain and spastic quadriparesis. All patients were successfully treated by atlantoaxial joint distraction, reduction of the dislocation and direct lateral mass plate and screw fixation by techniques described earlier by the senior author. Manipulation of the atlantoaxial joints and restoring the anatomical craniovertebral alignments is possible and probably an ideal treatment of cases with atlantoaxial spondyloptosis.

Endolymphatic sac carcinoma of the right petrous bone in Von Hippel-Lindau disease

A large endolymphatic sac papillary adenocarcinoma in a patient with Von Hippel-Lindau (vHL) disease is reported. A 31-year-old man was treated for a left eye retinal angioma 10 years previously and had been blind in that eye since. He was admitted with progressive tinnitus, lower cranial nerve paresis and ataxia. Investigations revealed a vascular and bone-eroding petrous tumour. The entirely extradural tumour involved a large part of the petrous bone and extended into the cerebellopontine angle. The vascular tumour was radically resected using a presigmoid approach after feeding vessel embolisation. The literature on this rare clinical entity is briefly discussed.

Plaster of Paris Mould for Stereotactic Frame Fixation

Stereotactic procedures have been prevalent in neurosurgical practice for a prolonged time period. With the advent of new custom-made frames designed for morphologic and functional neurosurgical procedures, its extended use in the pediatric population is becoming increasingly popular. However, there is still a need for sophistication in design and instrumentation. We describe a novel method of a plaster of Paris mould for stereotactic frame fixation, which can be a useful adjunct during frame fixation. It primarily accounts for a remarkable variation in skull shapes and sizes seen in the pediatric population undergoing stereotaxy besides many other advantages.