G. Lakshmi Prasad

Coexistent Supratentorial and Infratentorial Subdural Hygromas with Hydrocephalus After Chiari Decompression Surgery: Review of Literature

BACKGROUND Foramen magnum decompression (FMD) is the standard procedure for Chiari I malformation. Although seemingly a straightforward procedure, recent articles have reported an increase in various complications. We describe a rare complication of coexistent supratentorial and infratentorial subdural hygromas (SDHs) with hydrocephalus noted after FMD and provide a detailed review of the literature on this topic. METHODS A 34-year-old woman presented with strain-related suboccipital headache and myelopathy for 6 months. Imaging revealed tonsillar herniation up to C2 level and cervical syringomyelia. A standard FMD, C1 posterior arch removal, and tonsillar reduction was performed. After an initial uneventful postoperative course, she had 2 readmissions with headache, vomiting, and ataxia. Imaging showed a tense pseudomeningocele and concomitant supratentorial and infratentorial (initially right-sided, followed by left-sided) SDHs with ventriculomegaly. She was conservatively managed with antiedema measures and had excellent relief of symptoms. For the literature review, only cases with concomitant supratentorial and infratentorial SDHs with hydrocephalus were searched online and analyzed. RESULTS Including ours, 10 cases have been reported. Mean age was 25.3 years. The male-to-female ratio was 1:2.3. Symptoms appeared an average of 12.6 days postoperatively. Treatment was with conservative management in 3 cases, and 3 cases required permanent cerebrospinal fluid diversions. Mean follow-up duration was 9.4 months (range, 1-27 months). CONCLUSIONS Coexistent supratentorial and infratentorial SDHs with hydrocephalus after Chiari decompression is a very rare occurrence. Treatment needs to be individualized based on the predominant symptomatic lesion, and surgical options need to be judiciously considered. Good prognosis is the rule in most cases.

Brain Metastasis with High Protein Content- An Extremely Rare Imaging Feature

Metastasis forms the most common brain malignancy. Solitary or multiple ring enhancing intra-axial lesions bordered on the gray-white matter junction with disproportionate edema is the usual pattern on imaging. No reports of high protein content parenchymal metastatic lesion can be found in literature till now. Authors here describe a case of 42 year old female presenting with features of intracranial hypertension and imaging suggestive of a high protein containing lesion. Gross total resection was performed and histopathological features were suggestive of metastatic papillary adenocarcinoma.

Delayed facial palsy after microvascular decompression: Report of two cases

Microvascular decompression (MVD) is a novel surgical procedure predominantly performed for treating trigeminal neuralgia (TN) and hemifacial spasm (HS). Multiple studies have proven the long-term success of MVD for both these conditions. The most common complications of MVD reported include chemical meningitis, facial hypesthesia, cerebrospinal fluid leak, facial paresis, and hearing loss. Delayed facial palsy (DFP) is an uncommon complication mostly noted in MVD for HS and after the removal of acoustic tumors. We report two cases of DFP occurring after performing MVD, one each for HS and TN. This is also the first case of DFP to be reported after MVD for TN. Both were young females who developed DFP 2 weeks after surgery. They were managed with oral steroids and acyclovir for 2–3 weeks and achieved excellent outcome at an average of 4.5 weeks from the onset. We conclude that although majority of the cases improve spontaneously, steroids and acyclovir might assist in faster recovery.

Neurogenic pulmonary oedema complicating traumatic posterior fossa extradural haematoma: Case report and review.

Abstract Introduction: Pulmonary oedema is accumulation of fluid in the lung air spaces and interstitia. Neurogenic pulmonary oedema (NPE) is a potentially life-threatening condition which has been noted in head injury, subarachnoid haemorrhage (SAH), intracerebral haemorrhage (ICH) and others. Timely management is crucial to achieve good outcome; however, no specific guidelines have been defined. Methods: A 33-year female involved in a motor vehicular accident had a GCS of 14/15 and CT scan showed a moderate-sized unilateral posterior fossa extradural haematoma (PFEDH). She had sudden deterioration in her haemodynamic status with drop in sensorium 2 hours after admission. There was a copious amount of frothy secretions noted on intubation and she was diagnosed as having NPE. Results: Sub-occiptial craneictomy (SOC) with haematoma evacuation was performed and was managed with PEEP mechanical ventilation post-operatively. Excellent outcome was obtained and was discharged with a GOS of 5. Conclusions: NPE is a poorly understood and uncommon complication of acute CNS injury and should be considered in any patient with acute respiratory distress in the setting of CNS injury. Reduction in ICP and supportive mechanical ventilation form the mainstay of management. Diagnosis of NPE remains challenging and more reliable diagnostic criteria need to be defined to identify such cases with greater frequency.

Intramedullary Spinal Cord Abscess—a rare Entity in Pediatric Age Group

Dear Editor: The article entitled BIntramedullary dermoid cyst infection mimicking holocord tumor: should radical resection be mandatory?-a case report^ authored by Karaaslan et al. was read with great interest [1]. Authors report a case of a 1-year boy with rapidly progressive quadriparesis and bladder dysfunction. He was febrile and probably toxic with elevated markers of acute infection. MRI spine was suggestive of a holocord intramedullary abscess. A limited L5 laminectomy was done, and an infected dermoid was found during surgery which was sampled for examinations. The child received prolonged antibiotics and was able to stand with support and follow-up (FU) MRI showed regression of the abscesses at 3 months. Intramedullary spinal cord abscesses (IMSCA) are rare entities, first described by Hart in 1830 and fewer than 100 cases have been reported till date, of which less than 50 are in pediatric age group [1–5]. In children, the most common cause is a congenital dermal sinus (CDS), while hematogenous spread (genitourinary and pulmonary infections, infective endocarditis) is the commonest etiology in adults [3, 4]. In one review, Chan et al. noted that most of the recent cases of IMSCAwere cryptogenic in origin [4]. An acute presentation of IMSCA includes fever, back pain, and a transverse myelitc picture while chronic ones present similar to an intramedullary neoplasm. Accompanying fever may or may not be present [4]. Thoraco-lumbar region is the most common affected while holocord involvement is rare [2, 3]. MRI is the best imaging modality for diagnosis of these lesions. Since, CDS is the commonest etiology in children, prevention of IMSCA relies on prompt detection and early treatment of CDS [4]. Surgical drainage and decompression with prolonged antibiotic therapy is the standard management. With use of effective antibiotics, the outcomes have significantly improved as compared to pre-antibiotic era; however, a delay in the proper diagnosis from the onset of symptoms may prevent optimal recovery [3, 5]. A minimum of 6–8 weeks of antibiotics (rarely up to 12 weeks) is recommended bymost of the authors [3]. Different surgical techniques have been reported for managing such abscesses including limited myelotomy and aspiration, multilevel laminectomy and drainage, and others [2, 3, 5]. In cases of holocord involvement, irrigation through a feeding tube has been reported with good outcomes. The inclusion tumor should be removed simultaneously but these tumors adhere tightly to the surrounding cord and radical removal may endanger the nervous tissue. Hence, a more conservative excision will suffice in most cases [3, 5]. Outcome is usually good but in one review, the authors noted that, although survival has improved in recent times, persistent neurological deficits were noted in majority of survivors [4]. As a genuine reader of your journal, I would like to raise a few points regarding this article. Firstly, the imaging is suggestive of a dorso-lumbar abscess with meningeal inflammation extending up to the medulla and the entire cerebral hemispheres and not a pure holocord abscess (Figs. 1 and 4). This is because holocord involvement is rarely reported, especially in children in the absence of a dermal sinus. The signal changes in the cervical cord appear to be reactive edema and inflammation secondary to the infectious process. Secondly, according to the intra-operative findings, only the dermoid cyst was aspirated and sent for necessary tests, while the intramedullary abscess was not * G Lakshmi Prasad lakshmi.prasad@manipal.edu

Remote site hemorrhage after intracranial surgeries: is it really benign?

We read with interest the article by Stuart et al. ‘Remote cerebellar haemorrhage from site of craniotomy: A report of two cases’ published in your esteemed journal. The authors report two cases, 53-year and 56-year old, both females, operated for anterior circulation aneurysms and subsequently developed hemorrhages in the cerebellar parenchyma and temporal lobe in the immediate post-operative period after an uneventful surgery. The first case had to undergo an external ventricular drain (EVD) insertion for hydrocephalus and had residual mild cerebellar signs at 3 months follow-up, while the remote cerebellar hemorrhage (RCH) was entirely benign in the second case. They conclude that the outcomes of these hemorrhages are most frequently benign but multiple foci of hemorrhage (particularly bilateral RCH) increase the risk of morbidity requiring neurosurgical intervention. We recently managed one such case of RSH in our department. A 22-year male was operated for a right-sided acute subdural hematoma around 6 hours after sustaining a motor vehicle accident. His admission GCS score was 5/15 (E1V1M3). Postoperatively, he showed deterioration in GCS score and CT showed a large posterior fossa extradural hematoma (EDH) with adjacent supratentorial extension. He underwent craniotomy and evacuation of EDH (Figures 1(a–c)). He had showed modest improvement at time of discharge. Firstly, we are of the opinion that the term remote site hemorrhage (RSH) aptly suits rather than the term RCH, since the bleed can be present in the supratentorial (ST) compartment in addition to infratentorial (IT) compartment, as seen in this case and other reports. As the authors have stated, this is a well-recognized complication, occurring predominantly in supratentorial surgeries. Literature review reveals many major studies being published on this rare complication. After analyzing all these reports, a total of 143 cases were identified. A quarter of these RSH occurred after infratentorial procedures, which were predominantly tumor resections (90%). Aneurysm clipping was the predominant supratentorial surgery responsible for RSH, while tumor resections and epilepsy surgery (predominantly temporal lobectomy) constituted the rest (a quarter each). Around 10% of them were related to miscellaneous surgeries (cysts/burr-hole drainage for subdural hygromas/traumatic brain injury). The ratio of IT:ST bleed was 1.3:1. Secondly, the outcome is not very benign as described by these authors. Among the reported cases, outcomes were not described in around 5% cases. Analyzing the remaining ones, the mortality rate was noted to be 18%, 60% of which was related to IT hematomas and remaining 40% for ST ones. Apart from death, RSH was associated with equally significant morbidity, with moderate to poor disability seen in 18% of cases. Multiple site hemorrhages, however, portend a poorer outcome than solitary ones, as 37% of them were dead or had poor outcome. In terms of locations, parenchymal and deep locations are associated with poor outcome than subdural or extradural hematoma (EDH). This highlights the fact that RSH is indeed not a benign condition as described by many authors, as the combined morbidity and mortality is seen in one-third of cases. The pathophysiology of RSH is not well defined, although many postulates have been proposed. The loss of substantial CSF volume during surgery appears to play a central role. Cerebellar ‘sag’ as a result of CSF hypovolemia, causing transient occlusion of superior bridging veins within the posterior fossa and consequent hemorrhagic venous infarction, is one of the most likely pathophysiological cause of RCH. However, the CSF loss theory may not explain all instances of RSH. A few degrees of head tilt in ST craniotomies may result in occlusion of the ipsilateral internal jugular vein by the transverse process of C1 resulting in hemorrhages due to venous hypertension. Other plausible

Spinal Intramedullary Abscess Secondary to Dermal Sinus in Children

Introduction Congenital dermal sinuses (CDS) are uncommon lesions. They are most often noted in lumbosacral region and may lead to meningitis or spinal abscess. Intramedullary spinal cord abscess (IMSCA) due to CDS is rare and often co‐exists with an inclusion tumor such as dermoid/epidermoid cyst. Materials and Methods Literature review was done to analyze all cases of pediatric IMSCA secondary to CDS by searching online databases starting from the oldest case reported. Results Only 50 cases have been reported and were analyzed. Mean age was 22.6 months (range 1 month‐15 years). Fever, acute flaccid lower limb weakness, and urinary disturbances were the most common presenting features. Dermal sinus was commonest in lumbosacral region. Inclusion cysts were observed in 50% of cases. Staphylococcus aureus was the most the common organism. Mean follow‐up duration was 18.2 months (range 1 week‐156 months). Majority of the cases underwent multilevel laminectomy with myelotomy and drainage of abscess. Outcome was good‐to‐excellent in around 60% cases with four deaths. Presence of fever and limb weakness was significantly associated with poor outcomes. Conclusion Intramedullary abscess secondary to CDS is very rare. Complete sinus tract excision, myelotomy and drainage of abscess, and decompression of co‐existent inclusion cysts with prolonged antibiotic therapy remain the standard treatment. Approximately 60% cases achieve good outcomes. Fever and limb weakness portend poorer outcomes than those without.

Facial Nerve Localization and Functional Preservation in Vestibular Schwannomas

LETTER: The article by Mastronardi et al 1 published in your esteemed journal was read with great interest. The authors investigated the variation in the position and course of the facial nerve (FN) in 100 vestibular schwannoma (VS) cases operated over a 5-year period by the keyhole retrosigmoid approach and the relationship between FN position and postoperative facial results. The average maximum diameter of tumor was 2.41 cm (range, 0.5e5.8 cm). In 96 cases (96%), the tumor extended into the internal auditory canal (IAC). The FN position was confirmed by direct stimulation and was classified into 4 patterns: anterior surface of the tumor, anterosuperior (AS), anteroinferior, and dorsal. The AS pattern was most common, and none had a dorsal pattern. Total and nearly total removal was possible in 68 patients (68%), subtotal removal was possible in 25 patients, and partial removal was possible in 7 patients. In all patients, the IAC was opened using a 4-mm diamond burr or an ultrasonic aspirator. FN function was assessed preoperatively, at 1 week and 6 months or greater postoperatively using House-Brackman (HB) classification (HB I, normal; HB VI, total paralysis). At 6-month follow-up, HB I patients accounted for 90 cases (91.8%). In 15 patients (15%), the tumor had one or more cystic components, and 100% of cystic cases were HB I versus 90.4% of solid cases at 6-month follow-up, although not statistically significant. There were no significant differences between FN displacement and the maximal tumor diameter, mean age, and difficulties in nerve location. However, the anterior pattern had significantly worse results in terms of longterm facial nerve function as compared with AS and anteroinferior patterns. In addition, in patients with strong adhesion between the FN and tumor capsule, the HB-I FN function was observed in 33 (80.5%) of 41 strongly adherent cases versus 100% of patients with low adherence. Furthermore, the hearing preservation was less in patients with strong adhesion. The authors suggested performing a “near total” (99%) removal in large VSs with severe adhesion between tumor and a stretched and flattened FN, which is more difficult to preserve, leaving a millimeter-sized remnant of the capsule along the course of the nerve. The authors concluded that attempts should be made to preserve hearing acuity (if socially useful before surgery) and to identify the position and course of the FN for preserving its function. Because accurate identification of the course of the FN on preoperative magnetic resonance imaging is unreliable, surgical manipulation must be careful and precise, using appropriate microinstruments, frequent intraoperative nerve stimulations, and continuous electromyographic monitoring.

Outcome of Traumatic Brain Injury in the Elderly Population: A Tertiary Center Experience in a Developing Country

BACKGROUND The growing elderly population has contributed to an increasing incidence of traumatic brain injury (TBI) in this cohort worldwide. Here we describe our institutional experience in the management of TBI in elderly Indian patients. METHODS This was a 3-year retrospective analysis of 73 consecutive patients age ≥65 years admitted to our university hospital with TBI. Exclusion criteria included a history of concussion injury, chronic subdural hematoma (SDH), discharge against medical advice, and declared dead within 6 hours after arrival. Mode of injury, clinicoradiologic features, management, and outcomes were analyzed. The Glasgow Outcome Scale (GOS) was used to assess outcome. RESULTS Our cohort was predominately male (82%). The mean patient age was 72.1 years (range, 65-97 years), and 20 were age ≥75 years. Head injuries (HIs) were mild in 37 patients, moderate in 18, and severe in 18. The majority of injuries were contusions. Fifty-five patients (75%) were managed conservatively, and 18 (25%) underwent surgery. There were 7 deaths (9.5%). The rate of poor outcome was 26% overall, and 45% in patients age ≥75 years. Poor outcome in severe HI was seen in 83% (15 of 18) of the entire cohort but in 100% (7 of 7) of the very elderly patients. On univariate analysis, age ≥75 years, severe HI, acute SDH, and surgical management were significantly associated with poor outcome while acute SDH and surgical management were significant on multilogistic regression analysis. CONCLUSIONS Age ≥75 years, severe HI, and acute SDH are poor prognostic factors in patients with TBI. The benefit of surgery in these patients is unlikely, and surgery needs to weighed judiciously, keeping in mind the economics involved and the fate of caregivers, especially in developing countries.

Neurosurgery at Kasturba Medical College: Past, present and future

Kasturba Medical College (KMC), Manipal, is the oldest and one of the most reputed medical institutes in coastal Karnataka, catering to a population of over 4 million, spanning a stretch of over 350 kms along the southwest coast of India from Mangalore to Goa. The Department of Neurosurgery at KMC, established in 1968, continues to be the leading and most preferred referral center providing high quality neurosurgical services in this region. The article provides an insight into the origin of the department, its infancy and teething troubles, its continuous growth and landmark achievements over the years. This brief review also highlights the current area of focus and describes the plans for its future development.