Deepak Kumar Singh

Low velocity penetrating head injury with impacted foreign bodies in situ

Penetrating head injury is a potentially life-threatening condition. Penetrating head injuries with impacted object (weapon) are rare. The mechanism of low velocity injury is different from high velocity missile injury. Impacted object (weapon) in situ poses some technical difficulties in the investigation and management of the victims, and if the anticipated problems are not managed properly, they may give rise to serious consequences. The management practice of eight patients with impacted object in situ in context of earlier reported similar cases in literature is presented.

Cerebral astroblastoma: A radiopathological diagnosis.

Astroblastoma is a rare glial neoplasm whose histogenesis has been clarified recently. It primarily occurs in children and young adults. We are reporting a case of 12-year-old girl child who presented with features of raised intracranial tension and generalized tonic-clonic seizures. Brain magnetic resonance imaging revealed a large well-circumscribed, cystic lesion without perifocal edema, and enhancing mural nodule in right parietal region. A radiological differential diagnosis of pilocytic astrocytoma and cerebral astroblastoma was made. A complete excision was done and histologically the lesion turned out to be an astroblastoma. We review the histology, immunohistochemistry, and imaging features of astroblastoma and survey the current literature, treatment strategies, and prognostic aspects for the management of this rare neoplasm.

Multiple neural tube defects in a child: A rare developmental anomaly

Background: The presence of multiple neural tube defects (NTDs) is a rare entity. Published literature shows not more than 10 case reports. Such cases contradict the well-established “zipper model” of neural tube closure and support “multi-site closure model.” Case Description: We are reporting a unique case of multiple NTDs in a 5-month-o ld female child. Occipital encephalocele, dorsal meningomyelocele, Split cord malformation (SCM), and tethered cord were present in this case. Conclusion: This case report further substantiate the “multisite closure model,” however, more research work on human neuro-embryology is needed to overcome the controversies of neural tube closure.

Central pontine myelinolysis in a pediatric head injury patient.

Central pontine myelinolysis occurs inconsistently as a complication of severe and prolonged hyponatremia, particularly when corrected too rapidly. It is a concentrated, frequently symmetric, noninflammatory demyelination within the central basis pontis. We describe a head injury patient who suffered this clinical entity as a consequence of rapidly corrected hyponatremia. Clinical manifestation and radiological findings are described along with a review of the pertinent literature.

Intraoperative ventriculo-stomographic evaluation of endoscopic cerebrospinal fluid diversion and flow restoration procedures.

Purpose.u2003This prospective study was designed for intra-operative demonstration of cerebrospinal fluid (CSF) flow in ventricles and cisternal spaces before and after neuroendoscopic procedure. The aim of this study was to evaluate site of obstruction of CSF flow and subsequent stomal or aqueductal patency after endoscopic third ventriculostomy (ETV) or aqueductoplasty in patients with hydrocephalus of diverse aetiology. Method.u2003Seventeen patients with hydrocephalus due to diverse aetiology underwent ETV (nu2009=u200915) and aqueductoplasty (nu2009=u20092) or cysto-ventrticulostomy (nu2009=u20091) or transaqueductal removal of neurocysticercus cyst (NCC) (nu2009=u20091). Intra-operatively, radio-opaque contrast agent (iohexol) instillation into the third ventricle was used for qualitative evaluation of obstruction and post-procedure CSF flow across the stoma into cisternal spaces. Result:u200311 male and 6 female patients ranging from 3 to 50 years of age were included in the study. Post-procedure intra-operative ventriculo-stomography (IOVSG) showed free flow of dye across the endoscopic stoma (nu2009=u200913) or aqueduct (nu2009=u20092) into cisternal spaces. Diagnosis of fourth ventricular NCC was made in one patient with panventriculomegaly. In two patients of tuberculous meningitis hydrocephalus, poor flow of contrast in the prepontine area and basal cisterns was seen on IOVSG. They were subjected to ventriculoperitoneal shunt insertion in the same sitting. Cine MRI confirmed the patency of stoma or aqueduct in follow-up period in all patients with successful endoscopic procedure. Conclusion.u2003IOVSG is a simple and safe technique that helps in confirming the adequacy of endoscopic procedure during surgery and thereby facilitates intra-operative decision about further management.

Double Suboccipital Meningoencephalocele: A Unique Case Report

sac, separated by a small piece of scalp tissue ( fig. 2 ). There was no evidence of Arnold-Chiari malformation or hydrocephalus. The patient was operated on under general anesthesia in a prone position. A transverse skin incision was made and both sacs were dissected. Two separate sacs filled with cerebrospinal fluid and gliotic brain tissue were identified, with the left sac larger than the right one and with no communication between each other. The scalp tissue in between the two swellings was excised out and both sacs were converted into a single sac at the base. The dura was closed in a water-tight fashion and wound closure was done in layers. The patient was discharged on the 8th postoperative day without any neurological sequelae. Over the past few years, in-depth descriptive research has been conducted on brain and spinal cord development in human embryos to discover the embryological basis of such complex anomalies. Neural tube formation and closure involve complex cellular, extracellular and intercellular processes. Two primary theories exist regarding the neural tube closure. The widely accepted theory is that neural tube closure is a continuous, bidirectional process which begins in the midcervical region and progresses in a zipper-like fashion both rostrally and caudally, with the cranial and caudal neuropores being the Neural tube defects refer to congenital deformities involving the coverings of the nervous system. These can be classified, on the basis of embryological considerations and the presence or absence of exposed neural tissue, as open or closed types. The simultaneous occurrence of meningomyelocele and/or encephaloceles at multiple sites along the vertebral axis is extremely rare and accounts for <1% of cases. The presence of two meningocele at the same site has been reported only once [1] . Herein, we report a very unique case of a double meningoencephalocele in the suboccipital region. The patient, a 5-month-old male, the first child of healthy parents, presented with two cystic swellings in the occipital area since birth. The parents had a nonconsanguineous marriage. The child’s perinatal history was uneventful. The swellings were covered with skin and measured 7 × 6 × 6 and 4 × 3 × 3 cm in dimension, respectively. The swellings were soft and transilluminant and were adjacent to each other without any connection at the base ( fig. 1 ). The skin over the swellings was complete and normal. Developmental assessment revealed that normal milestones and growth parameters were within normal range. An MRI scan revealed two sacs filled with cerebrospinal fluid and brain parenchyma in the suboccipital region. The opening of the right sac was caudal to the left Received: October 24, 2012 Accepted after revision: February 11, 2013 Published online: July 6, 2013

Occipital Encephalocele and Spinal Meningomyelocele in Same Patient: New Theories Hold True?

A 3 d-old girl presented with history of two swellings on back of head and thoracic region since birth. Child was born to consanguineous marriage. Mother had not visited any ante-natal clinic and the baby was delivered at her home in a village. There was no other significant maternal or family history. On examination two swellings measuring approximately 5×5×5 cm were present on suboccipital area and back of thoracic region, respectively. Both swellings were cystic, compressible and non tender to touch (Fig. 1). Presence of neural elements was noted on trans-illumination. Skin overlying both swellings was dysraphic. Baby was moving her both lower limbs and the anal tone was normal. There was no other congenital deformity. A diagnosis of occipital encephalocele and thoracic meningomyelocele with impending rupture was made. A MRI scan was done to confirm the diagnosis and patient was operated subsequently in view of threatened rupture. Multiple neural tube defects (NTD) in same patient have been reported very rarely. The search of literature revealed only 17 cases, in form of various combinations [1, 2], but such a classical case having occipital encephalocele and thoracic meningomyelocele has never been reported. The popular theory [3] of primary and secondary neurulation depicts that; there can only be two sites of NTDsthe anterior and posterior neuropores. The pathogenesis of multiple NTDs can be understood by multisite neural tube closure model [4], in which five closure sites have been shown to exist in the neural tube of human embryo. The multisite neural tube closure model suggests the existence of five separate closure points, or “zippers,” in normal neural tube in humans. Nakatsu et al. [5] examined human embryos in which the neural tube was closing grossly and histologically and observed that closure initiates at three sites: First site is future cervical region, widely accepted as an initiation site of neural tube closure; Second site is the mesencephalicrhomboncephalon boundary and Third site is the rostral end of neural groove over the procencephalon where anterior neuropore closes. Some authors have suggested that fusion at cephalic level (second site) can be in two separate tracts in a Yshaped manner [6]. This case is unique as it clearly holds the concept of zipper or at least three sites closure D. K. Singh (*) Department of Neurosurgery, Dr. RML Institute of Medical Sciences, Lucknow, India e-mail: gkp.deepak@gmail.com

Disseminated cysticercosis: rare manifestation of a common disease.

We are presenting a case of disseminated cysticercosis involving the brain, spinal cord, orbit, muscles, subcutaneous tissues, liver and spleen of an immunocompetent man. Although cysticercosis is a common tropical disease, such widespread dissemination is an uncommon manifestation. Imaging studies are described with emphasis on hepatic and splenic involvement which has been described only rarely in the published literature.

The transparaspinal approach: A novel technique for one-step removal of dumb-bell-shaped spinal tumors

Complex dumb-bell spinal tumors are challenging surgical lesions. Combined antero-posterior exposures have traditionally been used in their management. This combined exposure has the disadvantage of a two-stage operation with transthoracic or retroperitoneal dissection. With better understanding of biomechanics of spine and evolution of microsurgical technique, there has been resurgence of single stage surgeries, among which the transparaspinal exposure provides the simplest and the most direct route for resection of dumb-bell tumors. A 16-year-old male was admitted with history of back pain with radiation to left lower limb for 6 months, progressive weakness of both lower limbs for two months, and hesitancy of micturition for 1 month. A clinical diagnosis of cauda-conus lesion was made. Radiological investigations revealed a complex dumb-bell spinal tumor extending from lower part of L2-L4 vertebra, with large paraspinal extension through left L3 intervertebral foramina. Tumor was successfully removed in one step using a transparaspinal approach. We discuss technical details of this novel approach along with limitations and possible complications.

Unilateral hydrocephalus: atypical presentation of intracranial tuberculoma.

A 43-year-old male presented with 3-month history of low-grade fever and headache. Radiological investigations revealed unilateral hydrocephalus. Unilateral obstruction of the foramen of Monro due to chronic tubercular ependymal inflammation was suspected and endoscopic septostomy was planned. Though ventriculo-peritoneal shunt is a simple method to treat hydrocephalus, complications related to this procedure are numerous. Neuroendoscopy is a safe method to treat hydrocephalus in selected cases, and also provides access to biopsy the lesion in question. An isolated tuberculoma obstructing the foramen of Monro was seen during endoscopy. Presentation and management of this unusual tuberculoma is reported along with a review of the pertinent literature.