George Kaar

Extraskeletal myxoid chondrosarcoma of the cerebellopontine angle presenting during pregnancy

Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft-tissue sarcoma, which usually occurs in the lower extremities. It is often associated with chromosomal translocations. The clinical, radiological and pathological findings in extraskeletal myxoid chondrosarcoma, with an origin in the cerebellopontine angle, are described along with the issues associated with management of this tumour presenting acutely in a 26-year-old woman who was 20 weeks pregnant.

Dural AVM supplied by the ophthalmic artery

Dural arteriovenous malformations in the anterior cranial fossa are rare and are especially prone to haemorrhage. These lesions are usually treated by surgical excision. We report the embolization of an anterior cranial fossa DAVM using an endovascular approach via the ophthalmic artery.

Extradural haematoma--to evacuate or not? Revisiting treatment guidelines.

BACKGROUND We describe three cases of extradural haematomas (EDHs) and their management, focusing on operative and non-operative treatment. We also review the available literature from the past three decades as well as the guidelines for the management of EDH. An algorithm is formulated based on different factors, including the clinical course of the patients and their CT findings. METHODS The first patient presented to us after sustaining a fall with a GCS of 15/15 and a large parieto-occipital EDH with a volume of 90 cm3. He was treated non-operatively. Follow-up CT showed good resolution of the haematoma. The second patient presented with a GCS of 7/15, a posterior fossa EDH with a volume of 30 cm3, and obstructive hydrocephalus. Emergency ventriculostomy was performed, which was converted to a VP shunt. The third case was a patient presenting with a large hemispheric EDH, which was 130 cm3 in volume. The GCS at presentation was 14/15 but dropped to 6/15, following which he underwent craniotomy and evacuation of the EDH. RESULTS The Glasgow Outcome Scale (GOS) at three months was five for the first two cases and three for the third case with a dense right hemiplegia. CONCLUSION EDH, both supratentorial and in the posterior fossa, can be managed non-operatively. A large volume EDH (>30 cm3) can be managed non-operatively provided the GCS at presentation and follow up remains the same with symptomatic improvement. Prompt treatment of a large volume EDH may still result in a poor outcome.

Osteogenesis imperfecta presenting as aneurysmal subarachnoid haemorrhage in a 53-year-old man

The authors describe a case of aneurysmal subarachnoid haemorrhage in a 53-year-old man with background of osteogenesis imperfecta (OI). CT brain revealed diffuse subarachnoid haemorrhage (SAH) and cerebral angiogram subsequently confirmed vertebral artery aneurysm rupture leading to SAH. To the authors knowledge this is the first case of vertebral artery aneurysmal SAH described in OI. A previously undiagnosed OI was confirmed by genetic analysis (COL1A1 gene mutation). This aneurysm was successfully treated by endovascular route. Post interventional treatment patient developed stroke secondary to vasospasm. Communicating hydrocephalus, which developed in the process of management, was successfully treated with ventriculo-peritoneal shunt. The aetio-pathogenesis and management of this condition is described. The authors have reviewed the literature and genetic basis of this disease.

'Miracle baby': an outcome of multidisciplinary approach to neurotrauma in pregnancy.

Traumatic brain injury (TBI) warranting neurosurgical intervention in the pregnant population is a rarity. We describe a case of a 27-year-old woman who at 13 weeks of gestation presented with multiple traumas having been involved in a near fatal road traffic accident. Glasgow Coma Scale was 6/15. CT brain showed extensive haemorrhagic contusions, diffuse brain swelling and multiple skull and facial fractures. Decompressive craniectomy was performed to control her intracranial pressure during her management in the intensive care. A viable intrauterine pregnancy was confirmed and progressed as maternal stabilisation and rehabilitation continued. At 35+3 weeks a 2770 g male child was delivered via emergency caesarean section after spontaneous onset of labour. The child had no detectable abnormalities and is clinically well. Eight months post-TBI the patient continues to make gradual improvements but is left with severe cognitive impairment and currently undergoing rehabilitation. A multidisciplinary approach was adopted in the management of this patient.

Superior cerebellar aneurysm causing subarachnoid haemorrhage in a 17-year-old with alagille syndrome

Abstract Alagille syndrome is a rare autosomal dominant condition characterised by mutation in Jagged1 gene. Intracranial aneurysms may be seen in this condition and may present as subarachnoid hemorrhage. We describe the first case of superior cerebellar aneurysm rupture causing WFNS grade 1 subarachnoid haemorrhage in a 17-year-old girl. The clinical condition and management of this rare occurrence is discussed with a review of literature.

A neurosurgical presentation of patent foramen ovale with atrial septal aneurysm

We describe a case of cerebral abscess in a 53-year-old lady with a background of congenital heart defect. She has an atrial septal defect with atrial septal aneurysm, which remained undiagnosed until this clinical presentation. She presented with a short history of right-sided hemiplaegia and neuroimaging revealed a heterogeneous lesion in the left frontoparietal region. Neuronavigation-guided left frontoparietal craniotomy was performed to debulk the lesion and preoperatively frank pus was drained, which grew Streptococcus constellatus. She was successfully treated with antibiotics for 6 weeks and her clinical condition improved. We believe that the patients’ previous dental extraction has possibly resulted in a paradoxical embolism through the atrial septal defect bypassing the pulmonary circulation. The MRI scan picture was misleading, as it was initially thought to be a high-grade brain tumour.

Interdural Spinal Cyst: A Rare Clinical Entity.

BACKGROUND For more than 2 decades, dural spinal cysts have been broadly classified as extradural and intradural. CASE DESCRIPTION A 40-year-old woman presented with radicular thoracic pain. Intraoperative findings showed the cyst to be present within the dura itself. CONCLUSIONS We suggest a revised classification of spinal dural cysts. This case highlights that, during surgery for spinal meningeal cysts, surgeons should bear in mind the possibility of an interdural cyst. This may help avoid inadvertent tears in the deep layers of such cysts, thus maintaining dural patency.

Brain dead or not? CT angiogram yielding false-negative result on brain death confirmation.

We describe a case of severe traumatic brain injury with multiple facial and skull fractures where CT angiogram (CTA) failed to yield a definite result of brain death as an ancillary test. A 28-year-old man was admitted following a road traffic accident with a Glasgow Coma Score (GCS) of 3/15 and fixed pupils. CT brain revealed uncal herniation and diffuse cerebral oedema with associated multiple facial and skull fractures. 72 h later, his clinical condition remained the same with high intracranial pressure refractory to medical management. Clinical confirmation on brain death was not feasible owing to facial injuries. A CTA, performed to determine brain perfusion, yielded a ‘false-negative’ result. Skull fractures have possibly led to venous prominence in the cortical and deep venous drainage system. This point needs to be borne in mind while considering CTA as an ancillary test to confirm brain death.

Dyskalaemia following diffuse axonal injury: case report and review of the literature

Traumatic brain injury, and its management, commonly causes derangements in potassium balance. There are a number of recognised causative factors including head trauma, hypothermia and iatrogenic factors such as pharmacological agents and permissive cooling. We describe a case of a 19-year-old man with a severe traumatic brain injury. In a 36-h period, his intracranial pressure increased despite maximal medical therapy and he developed refractory hypokalaemia. Immediately following a decompressive craniectomy, the patient was noted to be profoundly hyperkalaemic; this led to the development of ventricular tachycardia and cardiac arrest, from which the patient did not recover. The effects of brain injury on potassium balance are not well appreciated; the effect of decompressive craniectomy on potassium (K+) balance has not been described previously. We would like to emphasise the potential effect of diffuse axonal injury, a severe form of brain injury and decompressive craniectomy on potassium balance.