Devi Prasad Patra

Dural Tuberculoma Mimicking Meningioma: A Clinicoradiologic Review of Dural En-Plaque Lesions

BACKGROUNDnTuberculosis has long been a major health concern in developing countries and now has troubled developed world as well, owing to increase in patients with human immunodeficiency virus and immigration. Central nervous system tuberculosis accounts for approximately 1% of cases of tuberculosis. The pathologic presentation is varied, with intraparenchymal tuberculomas and pachymeningitis being the most common. Being a great mimicker, it simulates numerous diseases radiologically, and this is best realized when atypical forms are encountered. Here an atypical case of dural en-plaque tuberculoma is presented with comprehensive review of dural en-plaque lesions with their differentiating features.nnnCASE REPORTnA 20-year-old man presented with features of increased intracranial pressure. On imaging, there was an enhancing dural-based lesion in the left frontoparietal region. In view of herniation syndrome, urgent surgical decompression of the lesion was performed. Histopathology showed features of tuberculosis. The patient is now asymptomatic with antitubercular therapy without any residual lesion at 6 months of follow-up.nnnCONCLUSIONSnTuberculoma en-plaque is an unusual entity characterized by a plaque-like meningitic process without exudation. It is easily confused with meningiomas as can other dural-based lesions comprising benign to malignant neoplastic, infectious, and granulomatous lesions. A preoperative diagnosis is imperative to differentiate it at least from neoplastic lesions, which are usually curable with surgical intervention in contrast to tuberculosis, which needs only optimal chemotherapy in most of the cases. Knowledge of differentiating imaging features, in corroboration with clinical history and high index of suspicion, helps in a proper preoperative diagnosis and optimal patient treatment.

Olfactory region schwannoma: Excision with preservation of olfaction.

Olfactory region schwannomas are rare, but when they occur, they commonly arise from the meningeal branches of the trigeminal nerve and may present without involvement of the olfaction. A 24 year old lady presented with hemifacial paraesthesias. Radiology revealed a large olfactory region enhancing lesion. She was operated through a transbasal with olfactory preserving approach. This manuscript highlights the importance of olfactory preservation in such lesions.

Delayed cerebral vasospasm and systemic inflammatory response syndrome following intraoperative rupture of cerebral hydatid cyst

Dear Editor, Treatment for symptomatic cerebral hydatid cyst is usually surgical excision. Surgery for cerebral hydatid cyst remains tricky, as inadvertent rupture may cause dissemination and occasionally allergic shock [3]. We report an unusual complication of delayed cerebral vasospasm and systemic inflammatory response syndrome (SIRS) following intraoperative rupture of hydatid cyst. A twenty-two-year old male presented with bifrontal headache for 5 years that worsened over the last 4 months, along with vomiting and left brachio-facial weakness in the last 1 month. Radiology revealed multiloculated large cystic lesion in the right temporal lobe, with the cyst walls partly enhancing (Fig. 1a–d). The lesion was approached through middle temporal gyrus, and multiple white translucent cysts were encountered, adhered to the medial temporal lobe and tentorium. Though the cysts were excised completely, there was some spillage of fluid from the inadvertent rupture (due to adhesions) of the first cyst into the cisternal spaces. Thereafter, 10 % betadine-soaked gauze was put over the operative cavity for 30 min, followed by thorough saline lavage. The cyst fluid showed scolices of echinococcus granulosus with several protoscolices and hooklets. The immediate pos operative period was uneventful. Twenty-four hours later, the patient became drowsy and developed left grade 3/5 hemiparesis with low grade fever. Blood examination showed marked leucocytosis. CT scan of the head showed diffuse brain edema with no infarcts (Fig. 1e– g). In view of new focal neurological deficit after a day, vasospasm was suspected. Cerebral digital subtraction angiography (DSA) revealed diffuse vasospasm of bilateral vertebral, basilar posterior cerebral arteries and focal vasospasm of the right posterior communicating artery. Intraarterial nimodipine was infused in bilateral vertebral and internal carotid arteries that showed radiological improvement of vasospasm (Fig. 1i–l). However, there was no clinical improvement. Diagnostic lumbar puncture and cerebrospinal fluid (CSF) examination revealed cell count of 170/dl (55 % neutrophils) and normal sugar. CSF culture was sterile. His sensorium worsened over the next 2 days, alongwithworsening of hemiparesis to left hemiplegia. High grade fever had set in and leucocytosis persisted. Blood, urine and tracheal aspirate culture did not show any growth. Steroids were administered. On the fourth post-operative day, the patient became hemodynamically unstable. Haematological workup showed pancytopenia. He expired a day later. Repeat CT head showed no new findings (Fig. 1h). Unfortunately, an autopsy was not performed. Cerebral hydatidosis is often encountered in developing countries [3]. The intraparenchymal cysts are usually unilocular cysts and tend to occur in the middle cerebral artery territory. These are non-enhancing spherical cystic lesions without perilesional edema. With progressive neurological deficits and raised intracranial pressure (ICP), surgical excision remains the treatment of choice. A high index of suspicion is necessary as intraoperative cyst rupture is not desirable. The preoperative diagnosis, however, may be missed in case of multiple loculations and wall enhancement as in the index case. Besides, despite all attempts to avoid cyst Not presented at any conference.

Butterfly C2 Vertebra: An Unusual Finding in a Case of Os Odontoideum

the remaining body was noticed ( fig. 1 a, d). The lateral masses were well formed. Of interest, there was associated midline sagittal radiolucency of both the anterior and posterior arch of the atlas. The patient was operated on through a posterior approach and atlantoaxial fusion in a reduced position was achieved with C1 lateral mass screws, C2 pedicle screws and rods. As the bony strut connecting the 2 halves of the body of the axis was thick and appeared to be strong, the adjacent vertebra (C3) was not included in the fusion. Postoperatively, the patient recovered well, with improvement in spasticity and power. A CT scan at the 6-month follow-up showed C1-2 lateral mass fusion. There was no splaying of the C2 body ( fig. 2 ). The development of the axis is complex. It usually develops from 5 ossification centers: paired centers for the neural arches, 1 basal center for the body, a dentate center for the odontoid, and 1 apical center [2] . The dens itself develops from bilateral ossification centers that usually unite at midline by birth. The apical center begins to ossify at 2 years of age and is usually complete by the age of 6, though occasionally it may not ossify till adolescence [2] . The development of C2 (or the axis) is distinctly different from the remaining cervical vertebra. The time course of the ossification and development of this vertebra is variable and may extend a few years after birth [1, 2] . These cartilaginous junctions may persist for a long time as radiolucent areas in a few, but a true anomaly like the nonfused or absent posterior arch of the axis is rare [3] . A posterior midline synchondrosis is occasionally seen in the dens as radiolucency [2, 4] . Though rare, clefts and nonfusion of the posterior arch (cervical spina bifida) have been reported with craniofacial anomalies like cleft lip and palate [5] . However, a midline cleft in the body of the axis (butterfly C2) has never been reported. We report a butterfly C2 in a young girl with os odontoideum. A 10-year-old female child presented with progressive spastic quadriparesis associated with bowel bladder involvement and recurrent nonhealing ulcers of the hands for 8 months. There was no craniofacial abnormality. Radiology revealed os odontoideum with atlantoaxial dislocation, causing compression of the cervicomedullary junction ( fig. 1 ). The body of the axis showed a peculiar abnormality. The lower posterior half constituted of 2 parts joining anterosuperiorly to a midline structure like wings of a butterfly joining its body. Additionally, a sclerotic sagittally oriented midline septum extending across Received: June 1, 2014 Accepted after revision: August 18, 2014 Published online: October 21, 2014

Louis Victor Leborgne (“Tan”)

Louis Victor Leborgne was a patient of Paul Broca. Monsieur Leborgne, as Broca would call him, was also known around in the hospital by the nickname Tan. His neurologic condition left him with difficulty in speaking, and he could only speak the word Tan. Leborgne spent nearly half of his entire life in the hospital. He was initially admitted into the psychiatry division of the hospital and was later transferred under the care of Broca toward the end of his life. The story of the Leborgne sits in the crossroads of human thoughts that led to the discovery of cerebral localization. It is the objective of this study to describe the circumstances associated with this patient, which led the great thinkers of that time to discover the language localization in the cerebral cortex. Leborgnes condition was the cornerstone in the evolution of this discovery. More than 150 years have passed since the death of Leborgne, yet Leborgnes brain continues to attract researchers investigating the mysteries of human speech.

The 21st-century challenge to neurocritical care: the rise of the superbug Acinetobacter baumannii. A meta-analysis of the role of intrathecal or intraventricular antimicrobial therapy in reduction of mortality

OBJECTIVE Neurosurgical infections due to multidrug-resistant organisms have become a nightmare that neurosurgeons are facing in the 21st century. This is the dawn of the so-called postantibiotic era. There is an urgent need to review and evaluate ways to reduce the high mortality rates due to these infections. The present study evaluates the efficacy of combined intravenous plus intrathecal or intraventricular (IV + IT) therapy versus only intravenous (IV) therapy in treating postneurosurgical Acinetobacter baumannii infections. METHODS The authors performed a meta-analysis of all peer-reviewed studies from the PubMed, Cochrane Library database, ScienceDirect, and EMBASE in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Five studies were finally included in the present analysis: 126 patients were studied who had postneurosurgical A. baumannii infection. The Cochrane collaboration tool was used to evaluate risk of bias, and a test of heterogeneity was performed. The I2 statistic was calculated. The patients were divided into 2 groups: the IV group received only intravenous therapy and the IV + IT group received both intravenous and intrathecal or intraventricular antimicrobial therapy. The outcome was mortality attributed specifically to A. baumannii infection in postneurosurgical cases. The pooled data were analyzed using the Cochran-Mantel-Haenszel method in a fixed-effects model. RESULTS The total number of patients in the IV-only group was 73, and the number of patients in the IV + IT group was 53. The mean duration of intravenous therapy was 27 days. The mean duration of intrathecal colistin was 21 days. The intravenous dose of colistin ranged from 3.75 to 8.8 MIU per day. The dose of intrathecal colistin ranged between 125,000 and 250,000 IU per day. The overall calculated odds ratio for mortality for the IV + IT group after pooling the data was 0.16 (95% CI 0.06-0.40, p < 0.0001). The patients who received IV + IT therapy had an 84% lower risk of dying due to the infection compared with those who received only IV therapy. CONCLUSIONS There is an 84% lower risk of mortality in patients who have been treated with combined intrathecal or intraventricular plus intravenous antimicrobial therapy versus those who have been treated with intravenous therapy alone. The intrathecal or intraventricular route should be strongly considered when dealing with postneurosurgical multidrug-resistant A. baumannii infections.

Primary Intracranial Extraskeletal Mesenchymal Chondrosarcoma: Clinical Mimicry as Glomus Jugulare.

Background: Extraskeletal mesenchymal chondrosarcoma (ESMCS) is an unusual pathologic variant of chondrosarcoma. There are no specific clinicoradiographic parameters to distinguish it from other intracranial pathologies. The diagnosis can be established only on the basis of histopathology, which may pose significant challenges in certain unusual locations. Purpose: In this case, we discuss the pitfalls in diagnosis, management, and major characteristics of ESMCS with a review of current literature. Methods and Results: A 47-year-old female patient presented with a jugular foramen tumor which was misdiagnosed as glomus jugulare tumor for which she received primary gamma knife radiosurgery at 2 instances. But unfortunately, the patient died because of the increase in size of the lesion associated with necrosis. Autopsy analysis revealed a highly cellular tumor, rich in sarcomatous cells, and well-differentiated cartilages consistent with ESMCS. Conclusion: A definite preoperative diagnosis of ESMCS is crucial though difficult especially when located at complex sites like jugular foramen and clinicoradiological mimicry. The most crucial step in the management of ESMCS is accurate diagnosis with critical evaluation of clinical, radiological, and histopathological parameters and realization of highly variable clinical course of the disease.

Redundant anomalous vertebral artery in a case of congenital irreducible atlantoaxial dislocation: Emphasizing on the differences from the first intersegemental artery and operative steps to prevent injury while performing C1-2 joint manipulation.

Anomalous vertebral artery (VA), commonly the persistent first intersegmental artery (FIA) is often seen with congenital atlantoaxial dislocations (AAD). An unusual redundant/ectatic loop of VA passing below the C1 (upside down VA) has been described below and appears to be different from FIA. The operative technique to protect it while C1-2 joint manipulation has been described. A 35 year old male presented with progressive spastic quadriparesis after trivial trauma. Radiology showed irreducible atlantoaxial dislocation with occipitalised C1 and C2-3 fusion. The left VA was anomalous passing beneath the C1 arch with a redundant loop lying posterior to the C1-2 joint. This was unlike the persistent first intersegmental artery (FIA) and was safeguarded while dissecting the C1-2 facet. The artery was dissected and safeguarded while performing C1-2 joint manipulation. A redundant/ectatic loop lying posterior to C1-2 joint is an unusual variant of anomalous VA. Evaluation of preoperative radiology helps in diagnosing such anomalous VA. Dissection of the entire redundant loop of the anomalous artery is important in opening the C1-2 joint required for reduction and placement of spacer/ bone grafts to achieve good bony fusion. Also mobilizing the loop allows safe insertion of lateral mass screw. Care needs to be taken while fastening screws to prevent compression of the loop.

Internal Carotid Artery Bifurcation Aneurysms: Microsurgical Strategies and Operative Nuances for Different Aneurysmal Directions

BACKGROUNDnInternal carotid artery bifurcation aneurysms (ICAbifAs), comprising approximately 5% of intracranial aneurysms, are characterized clinically by their tendency to occur at a younger age and surgically by the technical difficulties posed by their domes being adherent to the frontal lobe, their location at the apex of the sylvian fissure, and their relation to myriad perforator complexes.nnnOBJECTIVEnTo review the nuances of technique and operative strategy specific to aneurysmal direction in the light of our experience with ICAbifAs.nnnMETHODSnICAbifAs managed at our institute from January 2001 to July 2016 were analyzed. Detailed analysis of clinical data, pre- and postoperative radiology, operative notes and videos, and clinical outcome was done.nnnRESULTSnFifty-one patients with ICAbifAs were treated in the study period out of which 40 patients underwent microsurgical clipping. The median age was 48 yr (range 14-68 yr). Nearly 95% of the patients presented in a good clinical grade (World Federation of Neurological Surgeons grade 1 and 2). At 6-mo follow-up, 36 patients (90%) had good clinical outcome (Glasgow Outcome Scale 4 and 5). According to their direction, ICAbifAs were grouped as anteriorly directed (10 cases), superiorly directed (23 cases), and posteriorly directed (7 cases). Operative techniques and nuances utilized depend on aneurysmal direction and are presented here.nnnCONCLUSIONnAn appropriate surgical strategy based on the direction of ICAbifAs as per the preoperative radiology, meticulous dissection of aneurysmal wall from adjacent perforators, and clip application with the aim of remodeling the ICA bifurcation are integral to achieving a good outcome.

A comparison of the techniques of direct pars interarticularis repairs for spondylolysis and low-grade spondylolisthesis: a meta-analysis

OBJECTIVE Spondylosis with or without spondylolisthesis that does not respond to conservative management has an excellent outcome with direct pars interarticularis repair. Direct repair preserves the segmental spinal motion. A number of operative techniques for direct repair are practiced; however, the procedure of choice is not clearly defined. The present study aims to clarify the advantages and disadvantages of the different operative techniques and their outcomes. METHODS A meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following databases were searched: PubMed, Cochrane Library, Web of Science, and CINAHL ( Cumulative Index to Nursing and Allied Health Literature). Studies of patients with spondylolysis with or without low-grade spondylolisthesis who underwent direct repair were included. The patients were divided into 4 groups based on the operative technique used: the Buck repair group, Scott repair group, Morscher repair group, and pedicle screw-based repair group. The pooled data were analyzed using the DerSimonian and Laird random-effects model. Tests for bias and heterogeneity were performed. The I2 statistic was calculated, and the results were analyzed. Statistical analysis was performed using StatsDirect version 2. RESULTS Forty-six studies consisting of 900 patients were included in the study. The majority of the patients were in their 2nd decade of life. The Buck group included 19 studies with 305 patients; the Scott group had 8 studies with 162 patients. The Morscher method included 5 studies with 193 patients, and the pedicle group included 14 studies with 240 patients. The overall pooled fusion, complication, and outcome rates were calculated. The pooled rates for fusion for the Buck, Scott, Morscher, and pedicle screw groups were 83.53%, 81.57%, 77.72%, and 90.21%, respectively. The pooled complication rates for the Buck, Scott, Morscher, and pedicle screw groups were 13.41%, 22.35%, 27.42%, and 12.8%, respectively, and the pooled positive outcome rates for the Buck, Scott, Morscher, and pedicle screw groups were 84.33%, 82.49%, 80.30%, and 80.1%, respectively. The pedicle group had the best fusion rate and lowest complication rate. CONCLUSIONS The pedicle screw-based direct pars repair for spondylolysis and low-grade spondylolisthesis is the best choice of procedure, with the highest fusion and lowest complication rates, followed by the Buck repair. The Morscher and Scott repairs were associated with a high rate of complication and lower rates of fusion.