Harsimrat Bir Singh Sodhi

Congenital atlantoaxial dislocation: a dynamic process and role of facets in irreducibility

OBJECT Patient age at presentation with congenital atlantoaxial dislocation (CAAD) is variable. In addition, the factors determining irreducibility or reducibility in these patients remain unclear. The facets appear to contribute to the stability of the joint, albeit to an unknown extent. The objective of this paper was to study the characteristics of C1-2 facets in these patients and their bearing on the clinicoradiological presentation and management. METHODS Twenty-four patients with CAAD were studied. Fifteen patients had irreducible CAAD (IrAAD); 3 of these patients experienced incomplete reduction after traction, and 9 had reducible CAAD (RAAD). The images (CT scans of the craniovertebral junction in a neutral position) obtained in the parasagittal, axial, and coronal planes were studied with respect to the C1-2 facets and were compared with 32 control scans. The inferior sagittal and coronal C-1 facet angles were measured. The lordosis of the cervical spine (cervical spine angle calculated on radiographs of the cervical spine, neutral view) in these patients was compared with normal. The management of these patients is described. RESULTS The inferior sagittal C-1 facet angle and at least one coronal angle in patients with IrAAD were significantly acute compared with those in patients with RAAD and the control population. A significant correlation was found between age and the acuteness of the inferior sagittal C-1 facet angle (that is, the more acute the angle, the earlier the presentation). The lordosis of the cervical spine was exaggerated in patients with IrAAD. Three patients with IrAAD who had smaller acute angles experienced a partial reduction after traction and a complete reduction after intraoperative distraction of the facets, thereby avoiding a transoral procedure. An inferior sagittal C-1 facet angle of more than 150° in the sagittal plane predicted reducibility. Drilling a wedge off the facet in the sagittal plane to make the inferior sagittal C-1 facet angle 150° can reduce the C1-2 joint intraoperatively by posterior approach alone. CONCLUSIONS The acuteness of the inferior C-1 sagittal facet angles possibly determines the age at presentation and reducibility. The coronal angles determine the telescoping of C-2 within C-1. Patients with IrAAD can be treated using a posterior approach alone with the exception of those with extremely acute angles or a retroflexed dens. The exaggerated lordosis of the cervical spine in these patients is a compensatory phenomenon.

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

BACKGROUND Tuberculosis 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. CASE REPORT A 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. CONCLUSIONS Tuberculoma 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.

Are C2 pars-pedicle screws alone for type II Hangman's fracture overrated?

BACKGROUND/OBJECT The recent trend for treatment of certain cases of type II Hangmans fracture has been towards motion preserving surgery. This is claimed to be achieved with placement of pedicle screws across the fracture fragments. However, the long term outcome in clinical scenario is not yet clear, neither are the factors determining suitability of such a technique. MATERIALS AND METHODS We have retrospectively analyzed the results of 11 patients of type II Hangmans fracture, according to the extent of translation. Nine patients underwent stabilization of fracture with C2 pedicle screws and 2 were managed with halo immobilization. The conservative management failed in one and this patient underwent internal fixation using pars-pedicle screw as well. The long term clinical and radiological (CT and dynamic X-rays) outcome was analyzed. RESULTS All patients including the one with halo immobilization, showed solid fusion across the fracture fragments. With the exception of one patient none had any clinical symptoms. This lone patient complained of restricted neck movements. Three different types of radiological results were observed. Two patients with translation >8mm showed C2-3 body fusion. Three of 6 patients with minimal translational (3-4mm) showed facet fusion. Three patients with moderate translational dislocation (4.5-5.5mm) showed persisting C2-3 angular instability. CONCLUSIONS The C2 pedicle screw is a good technique for osteosynthesis. However, the claimed long term advantage of motion segment preservation with this technique remains doubtful. It may be suitable for those fractures with minimal translation (<4mm), where the superiority of surgery, itself, over external immobilization is questionable. C2-3 fusion is preferable for those fractures with translation >4mm as these are unstable and C2 pedicle screws alone are likely to have less desirable results.

The clinical profile, management, and overall outcome of aneurysmal subarachnoid hemorrhage at the neurosurgical unit of a tertiary care center in India.

Background and Purpose: Several studies report good outcomes in selected patients of aneurysmal subarachnoid hemorrhage (aSAH). The purpose of our study is to project the clinical characteristics, management, and overall outcome of patients with aSAH presenting to a tertiary care center in India. Materials and Methods: A prospective study was conducted over a period of 10 months and all patients presenting with aSAH were studied. Patients presenting in all grades and managed with any type of intervention or managed conservatively were included to characterize their clinical and radiological profile at admission, during management, and at discharge. Outcome was assessed with the Glasgow Outcome Score (GOS) at 3 months follow-up. Results: Out of the 482 patients [mean age: 51.3 (±13.5); M: F = 1:1], 330 patients were fit to be taken up for intervention of the ruptured aneurysm, while 152 patients were unfit for any intervention. At 3 months follow-up, good outcome (GOS 4 and 5) was observed in 159 (33%), poor outcome (GOS 2 and 3) in 53 (11%), and death in 219 (45.4%) patients, while 51 patients (10.6%) were lost to follow-up. Most (95%) of the patients in the non-intervention group expired, and hence the high mortality rate, as we have analyzed the results of all patients of all grades, regardless of the treatment given. The predictors of poor outcome (GOS 1, 2, and 3) at 3 months follow-up, using multinomial regression model, were: World Federation of Neurological Surgeons (WFNS) grade IV and V (at admission and after adequate resuscitation) [odds ratio (OR): 35.1, 95% confidence interval (CI): 10.8-114.7] and presence of hypertension as a co-morbid illness [OR: 2.7, 95% CI: 1.6-5.6]. All patients showing acute infarction on computed tomography scan at presentation had a poor outcome. Conclusions: Despite recent advances in the treatment of patients with aSAH, the morbidity and mortality rates have failed to improve significantly in unselected patients and natural cohorts. This may be attributed to the natural history of aSAH, and calls for new strategies to diagnose and treat such patients before the catastrophe strikes.

Is ligation and division of anterior third of superior sagittal sinus really safe

BACKGROUND/OBJECT Ligation and division of anterior third (AT) of superior sagittal sinus (SSS) is presumed to be safe and is commonly used for approaching anterior skull base tumors and distal anterior cerebral artery aneurysms (DACA). Contrary to this belief we found complications secondary to this procedure more often than described and we have described them along with probable etiology. MATERIALS AND METHODS A total of 62 patients who underwent bifrontal or extended bifrontal craniotomies with ligation and division of the proximal end of SSS were studied retrospectively. The clinical profiles and postoperative CT scans were studied to look for venous edema and hemorrhages. Venogram (digital subtraction) was done in one of the patients who had developed this complication. RESULTS Five patients developed bifrontal venous hemorrhagic infarcts (4 patients with anterior skull base tumors and 1 with DACA aneurysm). These patients had a morbid postoperative hospital stay with memory disturbances and urinary incontinence in the follow up period. Two patients died. The venogram done in one patient revealed complete occlusion of the AT-SSS. The morbidity and mortality that can be attributed to ligation of AT-SSS was 8.06% and 1.6% respectively. CONCLUSIONS The safety of ligation and division of the AT-SSS is questionable, contrary to traditional teaching. Though only the proximal end of SSS is ligated, the occlusion extends upto the distal craniotomy edge possibly due to reflection of the dural leaf with AT-SSS that causes kinking and thrombosis. It is more often seen in patients with anterior skull base lesions, probably because of already compromised basal venous drainage. A preoperative venogram could possibly predict the safety of this procedure.

Temporal aneurysmal bone cyst: cost-effective method to achieve gross total resection

Aneurysmal bone cyst (ABC) is a vascular benign bony expansile lesion. The treatment is gross total resection. Surgery for a skull base aneurysmal bone cyst poses a significant challenge because of its vascularity and the adjacent neurovascular structures. We present the case of a young male with a temporal aneurysmal bone cyst who underwent gross total resection of the lesion. The external carotid artery (ECA) was temporarily clamped to cut off the vascular supply. There was no intraoperative event, and the patient made a good postoperative clinical recovery. This technique was used as an alternative to subselective endovascular embolization of the ECA branches. This case represents a simple yet cost-effective surgical technique to control bleeding for a highly vascular lesion such as ABCs, especially in resource-deficient countries.

Posterior clinoid meningioma: A case report with discussion on terminology and surgical approach.

Background: Posterior clinoid process (PCP) meningiomas are rare lesions. In close proximity to these lesions are the perforators from internal carotid artery and the oculomotor nerve, which need to be considered while deciding the appropriate surgical approach. Case Description: We describe a basal frontotemporo-orbito-zygomatic approach with splitting of the sylvian fissure to resect an eccentrically placed PCP meningioma. Conclusion: A basal frontotemporo-orbito-zygomatic approach with splitting of the sylvian fissure is a safe approach to resect an eccentrically placed PCP meningioma.

Multiple glioblastoma: A diagnostic challenge and controversies in management.

449 Neurology India / May 2015 / Volume 63 / Issue 3 stenosis and rarely tracheo‐ arterial fistula have been reported.[1‐5] The brachiocephalic artery is most commonly involved in the fistulous communication followed by the carotid artery, brachiocephalic/innominate vein and aortic arch.[4] The incidence of tracheo‐vessel fistula is 0.6‐0.79%. It usually occurs due to performance of a low tracheostomy below the fourth tracheal ring or if there is a high riding vessel.[1,4] Various mechanisms have been proposed for the development of the fistula including a persistent cuff pressure causing tracheal necrosis along with the vessel exerting pressure on the same site due to its pulsations, the tip of tube rubbing against the tracheal wall, a piston like movement of the tracheostomy tube connected to the ventilator, local infection, neoplastic invasion or necrosis of the cartilage.[1,2,4,5] The method of prevention of this fistula is to not perform the tracheostomy below the third tracheal ring, achieving a periodic deflation of the cuff, avoidance of infection, and prevention of abnormal movement of the tracheostomy tube that is likely to erode the vessel wall. In the presence of active bleeding at that site, an overinflation of the tube to prevent aspiration and to control bleeding is advocated. The definitive management of this entity is to identify the bleeding point and perform an open repair of the vessel wall in case conservative measures are insufficient to stop the bleeding.

Bilateral posterior fossa and temporo-occipital extra-dural hematomas: A simple novel technique

Posterior fossa extra-dural hematoma is rare and early diagnosis and management is associated with good outcome. Twenty four year male presented with somnolence and soft tissue swelling of occipital region following road traffic accident. CT scan revealed bilateral posterior fossa with bilateral temporo-occipital Extradural Hematoma (EDH) with mass effect. He was operated through a trifoliate incision and craniotomies leaving a strip of bone over the transverse and occipital sinus. The blood loss with such technique was minimal and the control of sinus tear was easier as the dura on either sides of the sinus can to tied to each other to hitch the sinus up to the bone thereby, providing a good tamponade. Early diagnosis of posterior fossa EDH and prompt surgical evacuation especially in patients with mass effect provide excellent recovery. However, the surgery may be associated with significant blood loss due to venous sinus injury increasing the morbidity and mortality. We have described a novel technique that minimizes the blood loss for patients with PFEDH straddling across the venous sinuses.

Empirical antitubercular therapy even in endemic area should be started with caution: Missed case of calvarial epidermoid presenting with discharging sinus.

Sir, Spontaneous discharging sinus due to a bony lesion is not an unknown entity. When encountered in endemic areas or developing countries, tubercular osteomyelitis is found to be a leading cause. Occasionally, some bony lesions may mimic tubercular osteomyelitis.[2] We present an unusual case of intradiploic epidermoid of sphenoid ridge that was initially misdiagnosed and treated as tuberculosis. An 11-year-old child presented with complaint of intermittent whitish discharge from right anterior temporal area [Figure 1a] for 4 years without any history of trauma or fever. The pus culture was sterile. Cytology of discharge showed only inflammatory cells but no granuloma. Computed tomography (CT) scan showed a lytic lesion in the sphenoid ridge [Figure ​[Figure1b1b and ​andc].c]. Patient was empirically treated with antitubercular therapy (ATT) drugs as calvarial tuberculosis was suspected clinically. The patient did not respond to ATT and the discharge persisted even after 6 weeks. Figure 1 (a) Whitish discharge from the wound. (b) Computed tomography scan showing hypodense lesion in the right sphenoid ridge intra diploic space. (c) Bone window computed tomography shows expanded lytic lesion of the sphenoid ridge Magnetic resonance image (MRI) acquired at this time showed sharp well-defined margin and uniform diffusion restriction [Figure ​[Figure2a2a–c] that raised suspicion of other lesion. Sinus track was excised completely through a frontotemporal flap. The track was in continuity with the well-defined bony lesion and underneath the bone extradurally [Figure ​[Figure3a3a and ​andbb]. Figure 2 (a) Magnetic resonance axial T2-weighted images depict widening of the intradiploic space with hyperintense soft tissue lesion within it. Small similar signal intensity lesion is seen in the overlying subgaleal tissue, adjacent to the bony lesion which ... Figure 3 (a) Intraoperative image showing subgaleal sinus track and whitish caseous material seen inside the lesion (b). (c) Completely healed lesion at 6 month follow-up The initial histopathology showed inflammatory cells with some stratified squamous epithelium. On careful evaluation, keratin was seen confirming the diagnosis to be epidermiod. ATT was stopped. The child improved, wound healed completely [Figure 3c] and there is no recurrence at 6 months follow-up. Spontaneous discharging sinus from the calvaria has been reported in infections such as tuberculosis, mycetomas, or posttraumatic osteomyelitis and occasionally in epidermoid.[1,2,3] It is important to establish the diagnosis as management differs in each case. The diagnostic dilemma increases as all of them appear as lytic lesion on radiology with subtle differences. Calvarial tuberculosis usually appears as a cone-shaped lytic bony lesion, wider at the inner table or diffuse hypodensity with peripheral enhancement on CT imaging. Enhancing extradural inflammatory collection may be found in some cases.[2] In posttraumatic osteomyelitis, the involved bone is sclerotic with sequestrum. Fungal lesions such as mycetoma appear as punched out lytic lesion with intradural enhancing mass.[1] Calvarial epidermoid commonly appears as a lytic lesion with sclerotic margin on CT scan often eroding the inner table.[3] In our case, the diagnosis was clinched on MRI which showed uniform hyperintense signal on diffusion-weighted images and hypointense on apparent diffusion coefficient map corresponding to restricted diffusion [Figure 2b] and c. Tubercular osteomyelitis shows patchy restriction and lacks uniformity. The modality of treatment differs in each case. In our case, the initial cytological evaluation suggested infection and empirical ATT was started. As the lesion did not respond to ATT, radiology was reevaluated including MRI and complete surgical excision was planned. After thorough discussion with the pathologist, a careful evaluation of the slides showed stratified squamous epithelium with keratin. Therefore, discharging sinus from the calvaria may not necessarily be tubercular even in an endemic area and should be properly evaluated. Cautious evaluation of radiology and histopathology helps establish the correct diagnosis, else the patient may receive unnecessary ATT. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial Support and Sponsorship Nil. Conflicts of Interest There are no conflicts of interest.