G Samson Sujit Kumar

Cerebrospinal fluid leak during cervical corpectomy for ossified posterior longitudinal ligament: incidence, management, and outcome.

Study Design. Retrospective. Objective. To study the incidence of intraoperative cerebrospinal fluid (CSF) leak in patients with ossified posterior longitudinal ligament (OPLL) undergoing central cervical corpectomy (CC) and to describe a reliable technique for treating the leak after CC. Summary of Background Data. The rate of dural tear after CC is higher in patients with OPLL compared to other causes of cervical spinal stenosis. Various techniques have been described to deal with dural tears with CSF leak in OPLL. We assessed the efficacy of the repair technique used to deal with this complication in our patients with OPLL who had undergone CC. Methods. A retrospective study was performed of all patients diagnosed with OPLL (n = 144) who had undergone CC between July 1992 and June 2007 (15 years). The dural defect was repaired with an onlay graft of crushed muscle/fascia and a layer of gelatin sponge. Bed rest and a lumbar subarachnoid drain were used for 5 days after surgery. Results. Intraoperative CSF leak was noted in 9 patients (6.3%). The dural defects ranged in size from a few mm to about 15 mm (10–75 mm2). All patients had a successful repair with no patient requiring reoperation for the CSF leak. Conclusion. Intraoperative CSF leak was encountered in 6.3% of patients undergoing CC for OPLL. A successful repair was achieved using fascial graft, gelatin sponge, lumbar CSF drainage, and bed rest.

Cranial melioidosis presenting as a mass lesion or osteomyelitis

OBJECT Melioidosis is caused by Burkholderia pseudomallei and causes multiple abscesses in different organs of the body. Cranial melioidosis, although uncommon, is sometimes confused with tuberculosis and is therefore under-recognized. The authors report on 6 cases of cranial infections caused by Burkholderia pseudomallei, presenting as mass lesions or cranial osteomyelitis, and review the literature. METHODS The authors performed a retrospective review of the records of patients with cranial melioidosis treated at their institution between 1998 and 2005 to determine the presentation, management, and outcome of patients with this infection. RESULTS Of the 6 patients diagnosed with cranial melioidosis during this period, 4 had brain abscesses and 2 had cranial osteomyelitis. All patients were treated surgically, and a diagnosis was made on the basis of histopathological studies. All patients were started on antibiotic therapy following surgery and this was continued for 6 months. One patient died soon after stereotactic aspiration of a brain abscess, and the other 5 patients had good outcomes. CONCLUSIONS Cranial melioidosis is probably more prevalent than has been previously reported. A high index of suspicion, early diagnosis, initiation of appropriate antibiotic therapy and treatment for an adequate period are essential for assuring good outcome in patients with cranial melioidosis. The authors recommend surgery followed by intravenous ceftazidime treatment for 6 weeks and oral cotrimoxazole for 6 months thereafter in patients with cranial melioidosis.

Acute graft extrusion following central corpectomy in patients with cervical spondylotic myelopathy and ossified posterior longitudinal ligament

We studied the influence of surgeon experience, number of levels operated and level of the lower mortise on acute graft extrusion in patients undergoing uninstrumented one-level to three-level central corpectomy (CC) for cervical spondylotic myelopathy (CSM) or ossified posterior longitudinal ligament (OPLL). Between 1992 and 2005, 410 consecutive patients underwent one-level to three-level CC with autologous iliac (in one-level and two-level corpectomy) or fibular (in three-level corpectomy) graft. The surgeons experience was divided into four eras (I-IV; three eras of 100 consecutive patients each and the fourth with the last 110 patients). Eight patients (1.95%) experienced acute graft migration and seven required re-exploration. The graft extrusion rate in the first era was significantly higher than in the other three eras (6%, 1%, 1%, 0%; p=0.01) implying a significant learning curve. The extrusion rates for one-level, two-level and three-level CC were not significantly different (3%, 1.6%, 0% respectively; p=0.3). The extrusion rate for grafts ending in the C7 body (3/230, 1.6%) was not significantly different from the data for grafts ending in other bodies (5/180, 2.8%) (p=0.23). There is a low incidence of acute graft migration in patients undergoing uninstrumented CC with autologous bone grafts with a significant learning curve in avoiding graft extrusion.

Intraoperative mapping of sacral nervous system (S2 – 4)

Electrophysiological mapping of the sacral nervous system was used during operations on 80 patients with conus and cauda equina lesions. At surgery, under controlled muscle relaxation, the sacral neural elements (S2 – 4) were mapped using direct mono-polar stimulation and recording of compound muscle action potentials (CMAPs) from the external anal sphincter (EAS). Responses were obtained in 86.25% (69/80) of the patients. In 33 (82.5%) out of 40 patients with preoperative deficits involving the S2 – 4 segments, CMAPs could be elicited. Identification of nerve roots was useful in dissection of lipomyelomeningocoeles, tumour excisions and untethering of filum terminale. In three patients, stimulation of the filum terminale elicited motor responses and, hence, it was not sectioned. Intraoperative mapping of the S2 – 4 nerve roots under controlled muscle relaxation is feasible in a majority of patients, including those with deficits involving S2 – 4. This method was useful in sparing viable nerve roots during surgery in conus and cauda equina regions, and identification of ‘functional’ filum terminale.

Deep sylvian meningioma: a case report and review of literature

Case reportA 6-year-old boy presented with seizures. Computed tomography and magnetic resonance imaging showed a large enhancing mass in the left temporo-parietal region.TreatmentHe underwent left temporo-parietal craniotomy and total excision of the lesion. At surgery, there was no dural attachment, and the tumor was mainly in the posterior part of left sylvian fissure. The biopsy was reported as WHO grade I meningioma.OutcomeAt 4-year follow-up, he was asymptomatic, and there was no tumor recurrence.

Cerebral phaeohyphomycosis presenting as an intraventricular mass

Cerebral phaeohyphomycosis presenting as an intraventricular mass Sir, Phaeohyphomycoses are subcutaneous and systemic infections caused by dematiaceous fungi with dark walled hyphae due to the presence of melanin in the cell wall.Cerebral phaeohyphomycosis presents most commonly as a cerebral abscess and Cladophialophora bantiana accounts for the majority of the reported cases thus far. A 20-year-old woman presented with headache, vomiting and progressive weakness of right upper and lower limbs for three months. Physical examination revealed bilateral papilloedema, right sided hemiparesis and spastic gait. Magnetic resonance imaging (MRI) of the brain showed an enhancing lesion in the left lateral ventricle causing dilatation of the ipsilateral lateral ventricle. The choroid plexus of the ipsilateral ventricle was thickened [Figure 1]. She underwent a left frontal craniotomy and subtotal excision of the mass. At surgery the mass was intraventricular and was attached to the choroid plexus and had papillary projections. Anteriorly the mass was adherent to the caudate nucleus and the thalamostriate vein. The histopathological examination showed a circumscribed nodule in the choroid plexus consisting of several discrete necrotising granulomata composed of multinucleated giant cells, histiocytes and lymphocytes. Pigmented branching hyphae were seen within the necrotic centers of the granulomata and within some of the giant cells [Figure 2]. The biopsy was reported as necrotising granulomatous Figure 1: Magnetic resonance imaging (MRI) of the brain, T1W post gadolinium image showing an enhancing lesion in the left lateral ventricle causing dilatation of ipsilateral lateral ventricle. Figure 2: Photomicrograph showing the hyphae within the giant cells of the granuloma (H/E, 90x) inflammation consistent with phaeohyphomycosis. Species identification was not possible, as cultures had not been submitted. She was advised systemic antifungal treatment with amphotericin B, but was discharged at request on oral ketoconazole. Two weeks later she presented with symptoms of raised intracranial pressure. A computed tomogram of the brain showed an increase in the dilatation of the left lateral ventricle. She underwent an emergency left ventriculoperitoneal shunt. CSF fungal and mycobacterial cultures done at this point were negative. She was started on intravenous Amphotericin B and a cumulative dose of 1.5 gms was given. She was discharged on a six-month course of oral itraconazole. Cerebral phaeohyphomycosis was first reported in 1952 by Binford and since then several cases have been reported. Apart from Cladophialophora bantiana other agents responsible are Cladophialophora bantiana is neurotropic in nature and may cause brain abscess in both normal and immunosuppressed …

Intracranial actinomadura granuloma.

368 CMYK neurological deficits and nocturnal recrudescence are quite valuable in differential diagnosis. We suggest that the anxiety because of stress-elevated intra-arterial blood pressure triggers the radiating pain in our case. An axial MR is a valuable scan as evaluation of loop formation. If MRI findings suggest any possible VA tortuosity and migration, then MR angiography should be performed to confirm these findings. In treatment modalities, it has been experienced that most patients require surgical procedures in spite of they were treated conservatively initially. The traditional surgical procedures are anterolateral microvascular decompression and anterolateral cervical vascular reconstruction of the loop vertebral artery. Mild sedatives relieved symptoms. Surgery has been advised as preventive for further progressive disturbances. However she refused the surgical procedure. The onset of analgesia with tricyclic anti-depressants ranges from 3 to 7 days for radicular pain. Pain relief in this patient showed us that within 2 days sedation (one of common side effects of amitriptyline) was effective to relieve the stress of patients as well as the stress related to hypertension. In our further investigations, we saw that she was calm, and her blood pressures were at normal levels. This case is, the youngest and only case with a pain aggravated by anxiety as far as we have seen in vertebral artery compression syndromes. Loop compression has some characteristics, which differentiate it from other cervicobrachialgia syndromes. The MR with MR angiography is the preferred modality in diagnostic work-up. Conventional angiography may be indicated only if the vascular reconstruction is planned for the compressive evaluation, which includes the balloon occlusion test.

Multiple extracranial metastases from intradiploic meningioma

Spontaneous internal carotid artery dissection (SICAD) has classically been associated with a good prognosis and many clinicians treat it conservatively.[1] However, a recent study reiterates the very poor recanalization rates in SICAD with complete occlusion.[2] Moreover, collateral flow is critically important in maintaining cerebral perfusion in such patients. Hence our case highlights the option of primary stenting in selected cases of SICAD with ischemic stroke, especially those with complete occlusion of the ICA and poor collateralisation. Prior case reports have shown the importance of considering primary stenting over intraarterial thrombolysis in selected cases of ischemic stroke.[3,4] Intravenous or intra-arterial thrombolysis was unlikely to have provided any benefits in this instance.

An unusual cause of "dropped head syndrome"

The most common presenting symptom in children with GBS is weakness; pain, however, is the most salient.[3] Patients also report other sensory complaints such as numbness or paresthesia. A true sensory level, which would be concerning for spinal cord injury, is usually absent. The aforementioned symptoms are rapidly followed by symmetric weakness of the extremities over a 24-hour period; these may continue to worsen for up to four weeks before reaching a plateau. Proximal muscle weakness, as described in this case, is the primary complaint in only 15-20% of patients. The physical exam of patients with GBS reveals diminution or loss of deep tendon reflexes. Autonomic dysfunction such as abdominal pain, postural hypotension, cardiac dysrrhythmia, bowel and bladder incontinence are not uncommon. GBS is potentially a lethal condition; patients should be monitored for respiratory insufficiency and cardiac arrhythmia in hospital.[1] Patients need to remain hospitalized until symptom progress halts.