Krishna Prabhu

Awake craniotomy and electrophysiological mapping for eloquent area tumours

OBJECTIVE An awake craniotomy facilitates radical excision of eloquent area gliomas and ensures neural integrity during the excision. The study describes our experience with 67 consecutive awake craniotomies for the excision of such tumours. METHODS Sixty-seven patients with gliomas in or adjacent to eloquent areas were included in this study. The patient was awake during the procedure and intraoperative cortical and white matter stimulation was performed to safely maximize the extent of surgical resection. RESULTS Of the 883 patients who underwent craniotomies for supratentorial intraaxial tumours during the study period, 84 were chosen for an awake craniotomy. Sixty-seven with a histological diagnosis of glioma were included in this study. There were 55 men and 12 women with a median age of 34.6 years. Forty-two (62.6%) patients had positive localization on cortical stimulation. In 6 (8.9%) patients white matter stimulation was positive, five of whom had responses at the end of a radical excision. In 3 patients who developed a neurological deficit during tumour removal, white matter stimulation was negative and cessation of the surgery did not result in neurological improvement. Sixteen patients (24.6%) had intraoperative neurological deficits at the time of wound closure, 9 (13.4%) of whom had persistent mild neurological deficits at discharge, while the remaining 7 improved to normal. At a mean follow-up of 40.8 months, only 4 (5.9%) of these 9 patients had persistent neurological deficits. CONCLUSION Awake craniotomy for excision of eloquent area gliomas enable accurate mapping of motor and language areas as well as continuous neurological monitoring during tumour removal. Furthermore, positive responses on white matter stimulation indicate close proximity of eloquent cortex and projection fibres. This should alert the surgeon to the possibility of postoperative deficits to change the surgical strategy. Thus the surgeon can resect tumour safely, with the knowledge that he has not damaged neurological function up to that point in time thus maximizing the tumour resection and minimizing neurological deficits.

Decompressive craniectomy in cerebral venous thrombosis: a single centre experience

Background Cerebral venous thrombosis (CVT) is an important cause for stroke in the young where the role for decompressive craniectomy is not well established. Objective To analyse the outcome of CVT patients treated with decompressive craniectomy. Methods Clinical and imaging features, preoperative findings and long-term outcome of patients with CVT who underwent decompressive craniectomy were analysed. Results Over 10 years (2002–2011), 44/587 (7.4%) patients with CVT underwent decompressive craniectomy. Diagnosis of CVT was based on magnetic resonance venography (MRV)/inferior vena cava (IVC). Decision for surgery was taken at admission in 19/44 (43%), within 12 h in 5/44 (11%), within first 48 h in 15/44 (34%) and beyond 48 h in 10/44 (22%). Presence of midline shift of ≥10 mm (p<0.0009) and large infarct volume (mean 146.63 ml; SD 52.459, p<0.001) on the baseline scan influenced the decision for immediate surgery. Hemicraniectomy was done in 38/44 (86%) and bifrontal craniectomy in 6/44 (13.6%). Mortality was 9/44 (20%). On multivariate analysis (5% level of significance) age <40 years and surgery within 12 h significantly increased survival. Mean follow-up was 25.5 months (range 3–66 months), 26/35 (74%) had 1 year follow-up. Modified Rankin Scale (mRs) continued to improve even after 6 months with 27/35 (77%) of survivors achieving mRs of ≤2. Conclusions This is the largest series on decompressive craniectomy for CVT in literature to date. Decompressive craniotomy should be considered as a treatment option in large venous infarcts. Very good outcomes can be expected especially if done early and in those below 40 years.

Clinical and radiological outcomes in 153 patients undergoing oblique corpectomy for cervical spondylotic myelopathy

Abstract Objective. To document the clinical and radiological outcomes in a large series of patients undergoing the oblique cervical corpectomy (OCC) for spondylotic myelopathy. Materials and methods. We retrospectively analyzed our series of 153 patients undergoing OCC for cervical spondylotic myelopathy (CSM) over the last 10 years. A mean clinical follow-up of 3 years was obtained in 125 patients (81.7%), while 117 patients (76.5%) were followed up radiologically. Neurological function was measured by the Nurick grade and the modified Japanese Orthopedic Association score (JOA). Plain radiographs and magnetic resonance images (MRI) were reviewed. Results. Ninety-two percent were men with a mean age of 51 years and a mean duration of symptoms of 18 months. Sixty-one had a single level corpectomy, 66 had a 2-level, 24 had a 3-level, and two had a 4-level OCC. There was statistically significant improvement (p < 0.05) in both the Nurick grade and the JOA score at mean follow-up of 34.6 ± 25.4 months. Permanent Horners syndrome was seen in nine patients (5.9%), postoperative C5 radiculopathy in five patients (3.3%), dural tear with CSF leak in one patient (0.7%), and vertebral artery injury in one patient (0.7%). Of the 117 patients who were followed up radiologically, five patients (4.3%) developed an asymptomatic kyphosis of the cervical spine while 22 patients (25.6%) with preoperative lordotic spines had a straightening of the whole spine curvature. Conclusions. The OCC is a safe procedure with good outcomes and a low morbidity for treating cervical cord compression due to CSM. This procedure avoids graft-related complications associated with the central corpectomy, but is technically demanding.

Endoscopic transsphenoidal approach to petrous apex cholesterol granulomas

Cholesterol granulomas of the petrous apex are inflammatory reactions due to obstruction of air cells within the petrous apex. We report two cases of petrous apex cholesterol granulomas that were treated via the endoscopic transsphenoidal route. The transsphenoidal approach is minimally invasive, preserves hearing and drains these cysts into the sphenoid sinus. We consider this approach to be the technique of choice for a cholesterol granuloma that abuts sphenoid sinus.

Endoscopic transsphenoidal excision of a GH-PRL-secreting pituitary macroadenoma in a patient with McCune-Albright syndrome.

Abstract We describe an endoscopic transsphenoidal excision of a GH-PRL-secreting pituitary adenoma and remodeling of frontotemporal fibrous dysplasia in a patient with McCune–Albright syndrome. Sphenoid dysplasia rendered transsphenoidal surgery challenging, but a study of the radiological anatomy and good surgical planning made this feasible. Medical therapy and radiation was required for persistent acromegaly after surgery.

Dermoid tumor with diastematobulbia

BACKGROUND Dermoid tumors are rare congenital lesions and account for 0.2% to 1.8% of all intracranial tumors. Dermoid tumor with diastematobulbia is very rare. CASE DESCRIPTION We report a dermoid tumor in an adult female with an unusual location and morphology. The lesion had 2 major components with different material within the cysts. The posterior part of the dermoid had presented on the floor of the fourth ventricle and had split the pons into 2 distinct halves. The anterior part of the lesion was situated in the prepontine cistern and encircling the anterior half of the brainstem. The lesion was radically excised, and the postoperative images showed return of the 2 halves of the pons to appose each other in the midline. CONCLUSION This case report demonstrates the anatomical peculiarities of this extremely unusual presentation of a dermoid cyst with diastematobulbia. Total excision of the lesion through a dorsal approach resulted in a good outcome.

Optic nerve haemangioblastoma mimicking a planum sphenoidale meningioma

Haemangioblastomas are rarely seen in the suprasellar region, arising from the optic apparatus or pituitary stalk, mimicking meningiomas on the preoperative MRI scan. They may be suspected in the presence of large flow voids and the absence of a dural tail. Intraoperatively, the extreme vascularity and compressibility of the tumour with no dural attachment should alert the surgeon to the diagnosis. A complete resection with preservation of vision may be successfully attempted because of the well-demarcated tumour-nerve interface.

Posttraumatic subgaleal and orbital hematoma due to factor XIII deficiency

The authors report on a 6-year-old boy who presented with a tense subgaleal hematoma and proptosis 2 weeks after a minor head injury that were successfully managed by continuous closed-system drainage and blood transfusion. At evaluation he was found to have a transient mild factor XIII deficiency.

Synovial sarcoma mimicking a thoracic dumbell schwannoma- a case report*

Abstract Introduction: Synovial sarcoma is a rare mesenchymal malignant neoplasm that accounts for less than 10% of soft tissue sarcomas. About 95% of the sarcomas occur in the extremities. Primary synovial sarcomas of the spine are a rare tumor arising from the paravertebral regions, paraspinal muscles or epidural spaces. Purpose: To report an atypical radiological presentation of synovial sarcoma of the thoracic spine mimicking a nerve sheath tumor in an elderly adult and describe the management with review of the literature. Clinical presentation: A forty-six-year-old lady presented with clinical features of a thoracic intradural extramedullary cord compression at T7 level. She was Nurick grade 4 at presentation. MRI of the Thoracic spine with whole spine screening showed a contrast enhancing intradural extramedullary tumor at the T7-8 level; the tumor was exiting out through the left T7-8 neural foramina with foraminal widening. The possibility of a schwannoma was considered. Intervention: She underwent a T7-8 laminectomy and total excision of the tumor followed by posterior fusion. The biopsy was reported as synovial sarcoma. She subsequently underwent radiation and chemotherapy. She had marked improvement in her Neurological status and remained disease free at six months follow-up. Conclusion: Synovial sarcoma of the spine is a rare mesenchymal malignant neoplasm. One needs to consider Synovial sarcoma as one of the differential diagnosis of intradural tumors of the spine.

Schwannoma of supraorbital nerve presenting as a subfrontal tumor

diameters vary in size and the blood fl ow is slow. The vascular spaces are separated by a matrix of fi brous collagenous tissue without glial.[4,5] Extra-cerebral CMs are mainly located in the middle cranial fossa, more so in the parasellar region and occasional at the clivus. Literature review showed report of seven cases of intrasellar CMs and fi ve cases with imaging fi ndings.[6-9] The clinical presenting features of intrasellar CMs is similar to pituitary adenomas.[8] Parasellar CMs with intrasellar extension are different from intrasellar CMs with cavernous sinus extension and this can be determined by measuring the major portion of the tumor mass. In this case, the major part of the tumor was located in the sellar fossa with left and upward extension.