Devendra K. Chhabra

Intracranial aneurysms in patients 18 years of age or under, are they different from aneurysms in adult population?

SummaryBackground. Intracranial aneurysms are extremely uncommon in the first two decades of life. This study was undertaken to assess the clinicoradiological features and surgical outcome of intracranial aneurysms in patients less than or equal to 18 years of age; and, to highlight the differences between these and intracranial aneurysms seen in adult patients.Methods and material. Twenty-two patients, 18 years of age or under (male:female ratio=1.75:1; mean age 14.18±3.8 years, age range 5 to 18 years) and 451 adult patients aged older than 18 years (male:female ratio=1:1.05; mean age 48.21±12.71 years, age range, 19 to 81 years) were treated for intracranial aneurysms at our center between January 1991 and July 2003. The univariate statistical analysis was used to compare differences between the two groups.Findings. The patients under 18 years constituted 4.6% of the total patient population having intracranial aneurysms. The incidence of associated medical diseases was greater in patients under 18 years than in the adults (9% versus 0.26%, p<0.05). The incidence of seizures was more than double in patients under 18 years (36% versus 17%, p<0.05). The incidence of intracerebral haematoma (ICH; 41% versus 22.5%, p>0.05), intraventricular haemorrhage (IVH; 45% versus 34%, p>0.05), and hydrocephalus (36% versus 25%, p>0.05) were higher in patients under 18 years. In adult patients, anterior communicating artery (AcoA) and in children, ICA bifurcation were the most frequent sites of aneurysm formation respectively (p<0.05). The incidence of giant aneurysms was nearly double in children (13.6% versus 6.5%, p>0.05). The incidence of clinical vasospasm was almost the same in both groups. The overall outcome was favourable in 82% of patients under 18 years and 58.8% in adults. The management mortality in patients under 18 years was 9.1%, while in the adult patients, it was 19%.Conclusion. In patients under 18 years of age, there was a definite male predominance; a higher incidence of seizures; and, the ICA bifurcation formed the most frequent site of intracranial aneurysms. In adults, AcoA a was the commonest site. Rebleeding and delayed ischaemic deficits were the major causes of morbidity. Favorable outcome after surgery in young patients was better in comparison to their adult counterparts.

Occurrence of Split Cord Malformation in Meningomyelocele: Complex Spina bifida

Objective: To describe the clinical features and surgical outcome of a combined anomaly, i.e. split cord malformation (SCM) with meningomyelocele (MMC), and to propose an addition to Pang’s classification of SCM to accommodate a combined form of anomaly. Methods: We retrospectively analyzed 16 cases of such a combination, out of a total of 106 cases of spinal dysraphism treated and studied prospectively for outcome at our center. The clinical profile and outcome of these cases are described. Results: All cases had SCM and MMC. Nine patients were males, and the mean age of presentation was 3.9 years. Twelve patients had Pang’s type I SCM and the other 4 were of type II. The MMC sac was lumbar in 11 cases. In all the patients, SCM was present either at the same level as the MMC or one to two segments above it. Nine patients had motor weakness, 6 had hypoesthesia, 4 had urinary incontinence and 3 had trophic ulcers. Nine patients had neuroorthopedic syndrome. All cases, except 3 (who were operated on at birth, at which time ‘superficial surgery’ was performed without relevant imaging), underwent repair of the MMC and excision of the spur/septum at the same sitting. The 3 cases who had undergone superficial surgery, however, were operated on for SCM following investigation at our center, obviously at a second sitting. After an average follow-up of 7.2 months, 4 patients showed improvement in motor weakness, 5 in hypoesthesia and 3 in urinary symptoms, whereas trophic ulcers had healed in all cases. Conclusion: With respect to the occurrence of SCM at or above the level of an MMC, we feel it is apt to screen the entire spinal/neuraxis by MRI in children with MMC. We labeled this combined pathology ‘complex spina bifida’, and feel it is necessary to make a minor modification to Pang’s classification to accommodate the pure/combined anomalies together.

Intrinsic third ventricular craniopharyngiomas: report on six cases and a review of the literature

BACKGROUND Craniopharyngiomas constitute 2 to 4% of intracranial neoplasms. However, the purely intraventricular variety are rare. Their magnetic resonance imaging (MRI) characteristically shows an intact third ventricular floor, a patent suprasellar cistern, an intact pituitary stalk, and the absence of sellar abnormalities. METHODS Between 1994 and June 2002, 6 patients with purely intraventricular craniopharyngioma were surgically managed. There were 4 cystic and 2 solid lesions. The surgical approaches utilized included a frontal, parasagittal, transcallosal approach with the third ventricle being accessed using either the transforaminal or subchoroidal approach (n = 3); pterional, transsylvian (n = 1), and bifrontal interhemispheric (n = 2) approaches in which the third ventricle was accessed via the lamina terminalis. A ventriculoperitoneal shunt was required for one of the 3 patients with hydrocephalus. RESULTS Total excision was performed in 3 patients with cystic craniopharyngioma, while a small residual lesion was left adherent to the third ventricular floor in the others. There was one perioperative mortality because of septicemia. Two patients required thyroxine supplementation. Two patients developed transient and one other patient a sustained diabetes insipidus. The 2 patients with solid tumors received radiotherapy for the residual lesions. At follow up ranging from 8 to 36 months, neither tumor recurrence nor regrowth was observed in any of the patients. The symptoms of raised intracranial pressure, hypothalamic dysfunction or visual field defects had resolved. CONCLUSIONS Intraventricular craniopharyngiomas occur in an older population and present mainly with raised intracranial pressure. Visual and endocrinologic imbalances are much less in these lesions compared to the suprasellar craniopharyngiomas. They mainly attach to the third ventricular floor. The surgical approaches to the third ventricle, along with radiotherapy and hormone supplementation, were successful in the management of these rare tumors.

Primary intraosseous orbital hemangioma : a case report and review of the literature

Primary intraosseous orbital hemangiomas are rare tumors. Only 25 cases have been reported in the literature. Very few of them have multiple orbital bone involvement. We report a case with extensive involvement of the orbital roof, the medial and lateral walls of the orbit, and the lesser and greater wings of the sphenoid, and describe a unilateral extradural frontotemporal approach to excise the tumor and decompress the right superior orbital fissure and both optic nerves. A brief clinical and radiological review of the literature is presented.

Thoracic myelopathy secondary to ossified ligamentum flavum.

Summary.Summary.Background: Focal ossification of the ligamentum flavum (OLF) forms one of the rare causes of thoracic myelopathy. The lower thoracic spine is most frequently affected and the patients present with initial posterior column disturbances followed by progressively increasing spastic paraparesis. The pathogenesis of OLF has not been conclusively established.Method: Five patients with thoracic myelopathy due to OLF underwent decompressive laminectomy and excision of the ligamentum flavum. Their MRI delineated a linear or beak like excrescence, uniformly hypo-intense on T1 and T2 weighted images, situated posterior to the thecal sac. A comparison between the pre-operative neurological status and the status at follow-up was done using Harshs myelopathic grading.Finding: Decompressive laminectomy followed by the drilling of the OLF and its excision, occasionally along with the adherent outer layer of the dura, resulted in significant improvement in motor weakness and tingling sensations. However, at the last available follow-up, none of the patients had retained their ability to run briskly (grade I) and all of them had residual spasticity.Interpretation: OLF may significantly contribute to a spatial reduction of the thoracic spinal canal resulting in paraparesis. The T2 weighted sagittal image of the magnetic resonance imaging (MRI) is the modality of choice for screening of the longitudinal extent of the OLF. A rapid neurological improvement occurs following decompressive laminectomy and excision of the OLF. However, the persistence of residual spasticity at follow-up may be due to irreversible changes within the cord by the significant thecal compression and the delay between the onset of initial symptoms and signs and surgical decompression.

Intraventricular meningiomas: A surgical challenge

BACKGROUND Primary intraventricular meningiomas (IVM) pose a surgical challenge as they often remain asymptomatic until they become very large; have close proximity to vital intraventricular structures; and, their vascular supply is often encountered only after significant tumor debulking. In this study, the surgical management of IVM is discussed. METHODS Between 1989 and 2003, nine patients (7 with lateral and 2 with fourth ventricular) IVM, were operated upon. Raised intracranial pressure, gait ataxia, memory impairment, seizures (motor and sensory) were the main presentations. Four had hydrocephalus while five had either a sequestered temporal or occipital horn. All were large tumors with an average size more than 5.3 cm. The lateral ventricular IVM were accessed by the posterior middle temporal gyrus (n=5) or the superior parietal lobule (n=2) approach. A midline suboccipital craniectomy was used for the fourth ventricular IVM. RESULTS Total excision was achieved in eight and partial excision in one. Patients with lateral ventricular tumors required a postoperative intraventricular drain for a minimum period of 48 hours. The main morbidity included visual field defects and transient hemiparesis, seizure and meningitis. The one patient with partial excision died 6 weeks later due to transtentorial herniation as a result of intratumoral bleed and lateral ventricular sequestration. CONCLUSIONS An IVM, being initially asymptomatic, usually attains a large size before detection. During surgery, its devascularisation is usually achieved only after significant tumor debulking. Development of hydrocephalus or ventricular sequestration should be constantly monitored and may be avoided in the postoperative period by continuous external ventricular drainage.

Rhinological complications of sublabial transseptal transsphenoidal surgery for sellar and suprasellar lesions : prevention and management

Transseptal transsphenoidal surgery is the most widely accepted operative procedure for sellar and suprasellar lesions. About 35% out of fifty-four cases operated by this procedure at our centre had rhinological complications. Possible mechanism involved and their prevention and management is discussed herewith.

Surgical Management of Remote, Isolated Type II Odontoid Fractures with Atlantoaxial Dislocation Causing Cervical Compressive Myelopathy

OBJECTIVE:The remote (more than 6 mo after injury) and isolated (not associated with any other cervical spinal fractures) Type II fractures of the odontoid (RI IIO) are unique in being inherently unstable and prone to malunion or nonunion, leading to cervical compressive myelopathy. The present study discusses their surgical management. METHODS:Nineteen patients with RI IIO with atlantoaxial dislocation (AAD) causing compressive myelopathy were treated. Their preoperative disability was graded as Grade I: neurologically intact (presented with hyperreflexia and mild spasticity; n = 3); Grade II: independent with minor disability (n = 7); Grade III: partially dependent for daily needs (n = 6); and Grade IV: totally dependent (n = 3). They were classified as irreducible AAD caused by 1) malunited fracture of the odontoid (n = 2), 2) fixed anterolisthesis of the anterior arch of a C1-fractured odontoid complex (n = 3), and 3) fixed retrolisthesis of the anterior arch of a C1-fractured odontoid complex (n = 1); and reducible AAD caused by 1) mobile AAD (n = 11) and 2) hypermobile AAD (n = 2). The patients with irreducible AAD underwent a transoral decompression and posterior fusion; those with a malunited fracture underwent surgery immediately, whereas those with fixed anterolisthesis or retrolisthesis were initially placed in cervical traction. The patients with reducible AAD underwent a direct posterior fusion. In the patient with “hypermobile” AAD, a proper alignment of the fractured segment of the odontoid relative to the body of the axis in a neutral position of the neck was ensured before the posterior fusion was performed. RESULTS:At follow-up (mean, 15.37 ± 9.67 mo), three patients in Grade I maintained their neurological status. Of the seven patients in Grade II and six in Grade III, five had improved to Grade I, and eight were in Grade II. The three patients in Grade IV improved to Grade I, II, and III, respectively. CONCLUSION:The patients with RI IIO may be divided into five groups on the basis of their differing management protocols. There is a considerable risk of delayed myelopathy unless surgical reduction and stabilization are performed. Posterior stabilization is the preferred option in dealing with these fractures. Despite the presence of severe neurological deficits and the prolonged duration of symptoms, a significant neurological improvement usually occurs after surgery.

Multiple infected extradural parasellar hydatid cysts

BACKGROUND Intracranial hydatid disease constitutes 1%-2% of all cases of hydatid disease. Multiple, infected, extradural, parasellar hydatid cysts in a patient constitutes an extremely rare presentation. CASE REPORT This 21-year-old man presented with a progressive left supraclavicular swelling of 3 years duration and raised intracranial pressure of 6 months duration with a past history of left-sided chronic suppurative otitis media that had resolved with antibiotics. On neurologic examination, he had bilateral deterioration of vision with optic atrophy; right temporal field defect; left III, IV, VI, VI, and V2 cranial nerves palsy; and left ear conductive deafness. The patients E.S.R was raised. His computed tomography (CT) scan showed a hypodense, lobulated lesion in the middle cranial fossa with a hypodense, nonenhancing rim, septations, and focal calcification without perifocal edema. A purulent fluid was aspirated from the left supraclavicular swelling, which did not reveal any organism on staining and culture. Aspiration of the left temporal swelling showed whitish watery fluid, the cytology of which revealed an infected hydatid cyst. Excision of the left temporal extradural, hydatid cysts was done, except the portion of the capsule adherent to the dura, and albendazole was started. One month later, the supraclavicular hydatid cysts were removed. Six months later, a left mastoidectomy was performed for chronic suppurative otitis media. A repeat CT scan showed complete resolution of the hydatid cysts. There was no recurrence at 1 year follow-up. CONCLUSIONS A rare case of multiple infected extradural hydatid cysts of the parasellar region is reported. The unusual CT picture of a hypodense lobulated mass with septations and a hyperdense rims is presented. The difficulties in its complete excision and successful management with long-term albendazole therapy are discussed.

Surgery of vestibular schwannomas: An institutional experience

AIMS To report management results of vestibular schwannomas (VS) treated surgically in our institute, with particular reference to completeness of tumor excision, facial nerve and hearing preservation and complications of surgery. STUDY DESIGN AND SETTINGS Retrospective study of 259 patients treated during the years 1988 to 2002. MATERIALS AND METHODS The facial nerve function and hearing assessment was done according to House-Brackmann [HB] grading and pure tone audiometry (PTA) respectively. All patients were operated by retro-mastoid sub-occipital approach. RESULTS Most patients had large tumors and had no useful hearing (90%), had disabling cerebellar ataxia (88%) and presented with features of raised intra-cranial pressure (45%). Large sized tumors were in 41.3% and giant sized tumors were in 56% cases. Complete tumor excision was carried out in 96.5% and anatomical preservation of facial nerve was achieved in 79.2% cases. Hearing preservation was achieved in 8 patients. Cerebrospinal fluid leak with or without meningitis and transient lower cranial nerve paresis were common complications. The mortality was 6%. CONCLUSIONS With experience, complete tumor excision with good facial nerve preservation can be achieved in large tumors. Hearing preservation is difficult in bigger tumors. Prevention and control of infection was a major concern.