Laurence A. G. Marshman

Idiopathic spinal cord herniation: case report and review of the literature.

OBJECTIVE AND IMPORTANCE Idiopathic spinal cord herniation (ISCH) is a rare condition, reported in only 25 patients thus far, in which the thoracic cord is prolapsed through an anterior dural defect. It typically presents in middle age as either Brown-Sequard syndrome or spastic paraparesis. CLINICAL PRESENTATION A 55-year-old woman initially presented at the age of 41 years with Brown-Sequard syndrome at the T8 disc space level on the left side. Investigations, including primitive magnetic resonance imaging, were deemed negative at that time. After a stepwise deterioration over 14 years, she presented again with spastic paraparesis and double incontinence, in addition to her previous spinothalamic dysfunction. Magnetic resonance imaging at this stage suggested either ISCH or a dorsal arachnoid cyst. INTERVENTION Through a T7-T8 laminectomy, a left-of-midline ISCH was identified and easily reduced by gentle cord traction. No dorsal arachnoid cyst was identified. The anterior dural defect was repaired with a XenoDerm patch (LifeCell Corp., Woodlands, TX). After surgery, there was improved motor and sphincter function. However, there was continued sensory disturbance. CONCLUSION ISCH is rare cause of thoracic cord dysfunction. Despite prolonged diagnostic delay, significant clinical improvement may be obtained with ISCH reduction and anterior dural repair.

Significantly Improved Outcomes With a Less Invasive Posterior Lumbar Interbody Fusion Incorporating Total Facetectomy

Study Design. Original study. Objective. Prospective comparison of clinical outcomes after a standard posterior lumbar interbody fusion (ST-PLIF) and after a limited exposure PLIF incorporating total facetectomy (LI-PLIF). Summary of Background Data. Most groups have reported significantly improved clinical outcomes after ST-PLIF. To our knowledge, however, a comparison of outcomes between ST-PLIF and the LI-PLIF that we herein describe has not been reported before. Methods. Patients were included who had suffered chronic low back pain for a minimum of 2 years that was unresponsive to conservative treatment. N = 114 consecutive patients underwent ST-PLIF, whereas n = 209 underwent LI-PLIF. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). The minimum follow-up for either group was 2 years. Results. There was a significant improvement in the ODI (22.5 ± 1.0, P < 0.001), VAS for back pain (3.8 ± 0.1, P = 0.003), VAS for leg pain (4.0 ± 0.2, P = 0.002), and SF-36 for bodily pain (14.7 ± 0.9, P = 0.012) after ST-PLIF. However, there was a significantly greater improvement in all scores after LI-PLIF: ODI (28.8 ± 1.4 vs. 22.5 ± 1.0, P < 0.001), VAS for back pain (5.4 ± 0.2 vs. 3.8 ± 0.1, P = 0.001), VAS for leg pain (5.1 ± 0.2 vs. 4.0 ± 0.2, P < 0.001), and SF-36 for bodily pain (18.5 ± 0.8 vs. 14.7 ± 0.9, P = 0.003). There was a significantly shorter duration of hospital stay after LI-PLIF (2.24 ± 0.057 days) than after ST-PLIF (4.04 ± 0.13 days) (P = 0.005). Operative complications occurred in 19.3% of ST-PLIF and in 6.7% of LI-PLIF. Conclusion. Clinical outcomes were significantly improved after both ST-PLIF and LI-PLIF. However, outcomes were significantly better after LI-PLIF than after ST-PLIF. Significantly shortened hospital stay with LI-PLIF probably reflected the “less invasive” technique per se. Significantly better clinical outcomes with fewer complications after LI-PLIF, however, potentially reflected maneuvers singular to LI-PLIF: (1) preservation of posterior elements, (2) avoidance of far lateral dissection over the transverse processes, (3) bilateral total facetectomy, (4) fewer neurologic complications, and (5) avoidance of iliac crest autograft. LI-PLIF is therefore recommended over ST-PLIF.

The progression of an infundibulum to aneurysm formation and rupture: case report and literature review.

OBJECTIVE AND IMPORTANCE Infundibula (IFs) are funnel-shaped symmetrical enlargements that occur at the origins of cerebral arteries and are apparent on 7 to 25% of otherwise normal angiograms. They are frequently considered as normal anatomic variants of no pathogenic significance. CLINICAL PRESENTATION We report the case of a ruptured posterior communicating artery aneurysm that had developed at the site of a previously known IF in a 49-year-old hypertensive woman. She had a poor conscious level at admission, with widespread subarachnoid hemorrhage and obstructive hydrocephalus. INTERVENTION The patient was immediately ventilated, and an external ventricular drain was inserted. The aneurysm was successfully clipped; however, secondary hemorrhage occurred both before and during craniotomy. She developed marked hypernatremia and subsequently died. CONCLUSION This is the 11th case of IF-to-aneurysm progression reported. It suggests that in certain cases, serial investigations may be indicated with IFs to detect aneurysm formation and preempt rupture.

The implications of ISAT and ISUIA for the management of cerebral aneurysms during pregnancy

Both the International Subarachnoid Aneurysm Trial (ISAT) and the International Study on Unruptured Intracranial Aneurysms (ISUIA) have been widely extrapolated to influence the management of actual or anticipated aneurysmal subarachnoid hemorrhage (SAH). However, it remains possible that sub-groups exist for which such extrapolation might subsequently prove premature. In this review, we discuss the implications that such extrapolation may potentially have for one such SAH sub-group: the clinically rare scenario of SAH in pregnancy.

Primary intracerebral mesenchymal chondrosarcoma with rhabdomyosarcomatous differentiation: case report and literature review

Intracranial chondrosarcoma (Ch-S) is a slow-growing, locally recurrent, malignant cartilaginous tumour of the skull base. Intracranial mesenchymal chondrosarcoma (MsCh-S) is a rarer, more malignant variant associated with the supratentorial meninges. Only seven cases of Ch-S, and six of MsCh-S, that were primarily intraparenchymal in origin have been reported. Moreover, no case of intracranial Ch-S or MsCh-S has been reported in which rhabdomyosarcomatous differentiation was prominent. A 17-year-old Asian girl presented with a 4-week history of occipital headache, vomiting and paraesthesia in the left hand. She was drowsy with a left hemiparesis and had a dilated right pupil with bilateral papilloedema. CT demonstrated a large, partly calcified, contrast-enhancing mass in the right temporo-parietal region with oedema and midline shift. Through a large craniotomy, a tense brain was encountered with no apparent cortical abnormality. Despite a radical tumour excision, with excellent initial clinical recovery, a local recurrence rapidly occurred within weeks prior to the administration of any radiotherapy. Initial histopathological examination revealed a primary MsCh-S with osseous and rhabdomyosarcomatous differentiation, with an indistinct margin. After a second radical excision, a second recurrence rapidly occurred; however, this proved excessively vascular and inoperable. Radiotherapy was declined and death followed within 3 weeks. This is the seventh case of primary intracerebral MsCh-S to be reported and the first to demonstrate rhabdomyosarcomatous differentiation. It was characterized clinically by rapid, local recurrence with increased vascularity.

Primary Extradural Epithelioid Leiomyosarcoma of the Cervical Spine: Case Report and Literature Review

OBJECTIVE AND IMPORTANCE:No case of primary epithelioid leiomyosarcoma involving the spine has been reported previously. CLINICAL PRESENTATION:A 61-year-old Nigerian woman presented with progressive spastic quadriparesis and acute urinary retention. Her only medical history included a total abdominal hysterectomy for fibroids 10 years earlier in Nigeria. Results of the general examination were normal. Pyramidal spastic quadriparesis (3/5) with a sensory level at C5–C6 was found neurologically. Magnetic resonance imaging scans of the brain and spine revealed extradural cord compression at C3–C5 as the sole abnormality. This was caused by a large, soft tissue mass arising from the erector spinae muscles, which was predominantly isointense on T1-weighted images, of mixed intensity on T2-weighted images, and homogenously enhanced after gadolinium contrast agent administration. There was an associated signal change in the cord at C3–C4. Computed tomography confirmed the predominantly soft tissue involvement, but with bone erosion and infiltration within the posterior elements of C4. Systemic screening for cancer was negative. INTERVENTION:At decompressive laminectomy, urgently undertaken under corticosteroid cover, an excessively vascularized, soft tissue tumor was subtotally excised, after which independent walking and normal sphincter function were regained within 1 week. Four weeks later, a complete macroscopic tumor excision was undertaken, incorporating lateral mass (C3–C6) and C2 pedicle screw stabilization, along with iliac crest bone grafting. The patients neurological status continued to improve. However, while awaiting radical radiotherapy, the patient declined further treatment and returned to her native Nigeria. Histopathological findings were consistent with an epithelioid leiomyosarcoma. CONCLUSION:This is the first reported case of a primary craniospinal epithelioid leiomyosarcoma.

Unilateral fixed dilation of the pupil as a false-localizing sign with intracranial hemorrhage: case report and literature review.

OBJECTIVE AND IMPORTANCE Although other focal signs may prove “false localizing,” it is a neurosurgical axiom that unilateral fixed dilation of the pupil occurs ipsilateral to a supratentorial mass. CLINICAL PRESENTATION A 25-year-old man collapsed with a dense right hemiplegia and a Glasgow Coma Scale score of 6 (eye opening, 1; motor, 4; verbal, 1) after rupture of a left middle cerebral artery aneurysm associated with an intrasylvian hematoma. Initially, both pupils had remained equal-sized and reactive: however, within hours, the right (contralateral) pupil became fixed and dilated (i.e., false localizing). For some time, the left (ipsilateral) pupil remained small and reactive; at emergency craniotomy, this also became fixed and equally dilated. INTERVENTIONAfter evacuation of the clot and wrapping of the aneurysm, both pupils rapidly became equal-sized and reactive. Twenty-four hours later, concurrent with massive left hemispheric swelling and a midline shift, the left (ipsilateral) pupil became unilaterally fixed and dilated (i.e., false localizing). Eventually, the right (contralateral) pupil also became fixed and dilated, concurrent with cardiovascular collapse. Death occurred within 10 hours. CONCLUSIONUnilateral fixed dilation of the pupil in patients with hemispheric mass lesions may be false localizing. Furthermore, disparate “herniating mechanisms” can arise despite mass effect emanating from the same side. Because such mechanisms cannot be witnessed, their nature remains speculative. An extensive review is contained in this article.

Bacillus cereus meningitis complicating cerebrospinal fluid fistula repair and spinal drainage.

Non-anthrax Bacillus species are rare, but serious causes of bacterial meningitis in those either immunocompromised or treated with CSF diversion. Although resistant to first-line antibiotics, they usually respond to chloramphenicol. We report a case of fulminant Bacillus cereus meningitis that complicated lumbar spinal drainage which proved resistant to all first-line antibiotics including chloramphenicol.Non-anthrax Bacillus species are rare, but serious causes of bacterial meningitis in those either immunocompromised or treated with CSF diversion. Although resistant to first-line antibiotics, they usually respond to chloramphenicol. We report a case of fulminant Bacillus cereus meningitis that complicated lumbar spinal drainage which proved resistant to all first-line antibiotics including chloramphenicol.

Case report: Sylvian fissure meningioma without dural attachment in a 4-year-old child

We report a case of a Sylvian fissure meningioma in a young child that was demonstrated at angiography to have an intrinsic blood supply from the middle cerebral artery, and at operation was found to be without dural attachment. The site and the lack of dural attachment are very rare, although they may like other rare characteristics of meningiomas be features of childhood tumours.

MRI of a spinal intradural extramedullary sarcoid mass.

Sarcoidosis is a systemic disease characterised by the histopathological finding of non-caseating granulomata. Several large series have found clinical manifestations of nervous system involvement to be present in 5% of cases. Spinal syndromes are reported at clinical presentation in 6% - 28% of patients with neurosarcoid. Intradural, extramedullary masses represent a very rare complication of neurosarcoid and we illustrate the MRI findings for the first time.