Rama Chandra Deo

Quantitative analysis of variable extent of anterior clinoidectomy with intradural and extradural approaches: 3-dimensional analysis and cadaver dissection.

BACKGROUND: Drilling of the anterior clinoid process (ACP) is an integral component of surgical approaches for central and paracentral skull base lesions. The technique to drill ACP has evolved from pure intradural to extradural and combined techniques. OBJECTIVE: To describe the computerized morphometric evaluation of exposure of optic nerve and internal carotid artery with proposed tailored intradural (IDAC) and complete extradural (EDAC) anterior clinoidectomy. METHODS: We describe a morphometric subdivision of ACP into 4 quadrangles and 1 triangle on the basis of fixed bony landmarks. Computerized volumetric analysis with 3-dimensional laser scanning of dry-drilled bones for respective tailored IDAC and EDAC was performed. Both approaches were compared for the area and length of the optic nerve and internal carotid artery. Five cadaver heads were dissected on alternate sides with intradural and extradural techniques to evaluate exposure, surgical freedom, and angulation of approach. RESULTS: Complete anterior clinoidectomy provides a 2.5-times larger area and 2.7-times larger volume of ACP. Complete clinoidectomy deroofed the optic nerve to an equal extent as by proposed the partial tailored clinoidectomy approach. Tailored IDAC exposes only the distal dural ring, whereas complete EDAC exposes both the proximal and distal dural rings with complete exposure of the carotid cave. CONCLUSION: Quantitative comparative evaluation provides details of exposure and surgical ease with both techniques. We promote hybrid/EDAC technique for vascular pathologies because of better anatomic orientation. Extradural clinoidectomy is the preferred technique for midline cranial neoplasia. An awareness of different variations of clinoidectomy can prevent dependency on any particular approach and facilitate flexibility. ABBREVIATIONS: ACP, anterior clinoid process EDAC, extradural anterior clinoidectomy ICA, internal carotid artery IDAC, intradural anterior clinoidectomy MOB, meningo-orbital band ON, optic nerve SOF, superior orbital fissure

Intradural Spinal Arachnoid Cyst: A Long-Term Postlaminectomy Complication: A Case Report and Review of the Literature.

BACKGROUND Spinal arachnoid cysts are a rare cause of spinal cord compression. Intradural arachnoid cysts are rarer than extradural arachnoid cysts. Spinal arachnoid cysts are mostly congenital in origin. Arachnoid cysts due to trauma, lumbar puncture, or surgery are rarely reported. Most arachnoid cysts are located posterior to the spinal cord in the thoracic regions. The ideal treatment is laminectomy or laminoplasty with puncture, marsupialization, or excision. But the development of a cervico-thoracic spinal intradural extramedullary arachnoid cyst anteriorly located 28 years after laminectomy is a recognizable complication of laminectomy. CASE DESCRIPTION We report here a case of a 45-year-old man who underwent C6-T1 laminectomy at the age of 17 years for cervical intervertebral disc prolapse (C6/7, C7/T1) and compressive myelopathy. Twenty-eight years after laminectomy, he developed spastic quadriparesis and was diagnosed with a spinal intradural extramedullary anterior arachnoid cyst at the laminectomy site with compressive myelopathy. CONCLUSIONS So, although laminectomy with excision is usually practiced to treat spinal arachnoid cysts, laminectomy itself is a cause of development of intradural arachnoid cysts.

Practical guidelines for setting up neurosurgery skills training cadaver laboratory in India

Though the necessity of cadaver dissection is felt by the medical fraternity, and described as early as 600 BC, in India, there are no practical guidelines available in the world literature for setting up a basic cadaver dissection laboratory for neurosurgery skills training. Hands-on dissection practice on microscopic and endoscopic procedures is essential in technologically demanding modern neurosurgery training where ethical issues, cost constraints, medico-legal pitfalls, and resident duty time restrictions have resulted in lesser opportunities to learn. Collaboration of anatomy, forensic medicine, and neurosurgery is essential for development of a workflow of cadaver procurement, preservation, storage, dissection, and disposal along with setting up the guidelines for ethical and legal concerns.

Review of spinal neuroectodermal tumor

Abstract Primary spinal primitive neuroectodermal tumors (PNETs) are rare tumors. Most of these tumors occur in children and young adults. To date, 47 cases of primary spinal PNET have been reported in the literature. These tumors are highly aggressive with rapid growth. Review of the literature shows that the overall prognosis of PNETs of spinal cord is very poor even with adequate surgery, radiotherapy and chemotherapy. All the cases reported to date are reviewed in terms of surgical treatment, adjuvant therapy and outcome and the experience with two of these cases are described. Both cases were thoracic extradural ones with intrathoracic extension through intervertebral foramina resembling neurofibroma. Both cases underwent gross total removal of intraspinal and thoracic component. Post-operatively both underwent cranio-spinal radiotherapy. One patient died after a post-operative period of 4 months and the other one is still alive 8 months after surgery, radiotherapy and chemotherapy.

Intradiploic ossified giant cavernous hemangioma of skull with a dural tail sign mimicking primary calvarial meningioma.

250 Neurology India | Mar-Apr 2012 | Vol 60 | Issue 2 The case reported by Yilmazer et al.,[1] demonstrated a fusiform aneurysm of the left transverse sinus with bony erosion accompanied by internal jugular vein aneurysm. The patient was not treated and was followed up. Marco et al.,[2] described a case with a wide-necked venous aneurysm of the left transverse sigmoid sinus, and they treated it by endovascularly stent placement across the aneurysm neck and embolization of the aneurysm with Guglielmi detachable coils. Gologorsky et al.,[3] reported a widenecked venous aneurysm of the right transverse sigmoid sinus, and they treated it by surgically coagulation of aneurysmal neck and reconstruction of transverse sigmoid junction with a series of U-clips. In our patient both surgical and endovascular treatments were rather contraindicated, so palliative third ventriculostomy was done for obstructive hydrocephalus. This procedure helped the patient in attaining weight and growth. Perhaps use of fl ow diverters would also be useful in such cases. However, because we had little experience with the use of fl ow diverters in infants and as we also felt that the infant might grow out of it, we did not use this method.

Supratentorial extradural hematoma in children: An institutional clinical experience of 65 cases

Aim and Objective: To survey the epidemiology, management, and severity of extradural hematoma (EDH) in children. Materials and Methods: All patients of EDH (n = 65) in the age group of 0-16 years admitted to our department during the period of August 13 and July 14 were analyzed retrospectively from the hospital records. In all patients, age, sex, mode of injury, clinical presentation, site of EDH, management, duration of hospitalization, and outcome were evaluated. Observation and Results: Of 65 patients, males were 70.76% with a male to female ratio of 2.4:1, most of the victims (47.69%) were in the age group of 11-16 years. Mean duration of hospitalization was 4.32 days. The most common mode of injury was fall from height in 29 cases (44.61%) followed by road traffic accident (RTA) in 23 cases (35.35%). Temporoparietal EDH was the most common computed tomography finding present in 22 (33.84%) patients. 67.69% patients presented to casualty with minor head injury having Glasgow coma scale (GCS) between 14 and 15. Most common presenting feature was vomiting in 52 cases (80%) and next to it was altered sensorium. The mortality rate was 7.69% (n = 5). Conclusion: Extradural hematoma is a life-threatening entity encountered in pediatric head injury. Timely intervention and diagnosis decrease mortality to a great degree. Most of the mortality is encountered in patients who presented late at the neurosurgical unit with low GCS.

Anterolateral Transcavernous Extradural Petrosectomy Approach: 3-Dimensional Operative Video Demonstration in Cadavers

Kawase’s technique of extradural subtemporal transpetrosal, transtentorial approach is a popular middle cranial fossa approach for lesions of the petroclival region. This is one of the most commonly performed procedures because of surgeons’ familiarity and years of successful practice over the past 2 decades. Inappropriate handling may put several neurovascular structures at risk because the area around the petrous apex is densely crowded with the internal carotid artery (ICA), cranial nerves III through VIII, and the cochleovestibular complex. Lesions extending into anterior cavernous sinus demand additional dissection and exposure. The authors here describe an extradural technique of exposure of the anterior petrous apex with interdural dissection in the lateral wall of the cavernous sinus with medial mobilization of the trigeminal nerve. It provides a larger rhomboid at the petrous apex with greater exposure of the anterior and posterior cranial fossae. Extradural anterior clinoidectomy and anterior cavernous dissection is demonstrated for lesions with parasellar and orbital extension. The limitations of this approach are the increased operative time and unfamiliar anatomy, especially in the region of the cavernous sinus. Potential complications include increased blood loss, cerebrospinal fluid leak, and injury to cochlear apparatus and cranial nerves (III-VI). Skull-base approaches warrant high competence and proficiency of the treating surgeon because surgical risks are high and the margin of error is small. The complexities of skull-base anatomy and dissection must be mastered by cadaver dissection in the laboratory. This educational 3dimensional video of cadaver dissection and 3-dimensoinal animation graphics demonstrates the pertinent anatomy and an extradural approach to the anterior petrous apex and cavernous sinus exposure.

Intramedullary spinal cord metastasis arising from papillary thyroid carcinoma: A case report and review of literature.

Background: Intramedullary spinal cord metastases (IMSCM) are typically drop lesions from intracranial metastases and are a rare manifestation of systemic malignancy (8.5% of central nervous system metastases). They arise from primaries such as the lungs, breast, kidney, melanoma, or lymphoma. On the other hand, they arise very rarely from papillary thyroid carcinoma (PTC), even though it is the most common type of primary thyroid malignancy. Case Description: A 54-year-old male presented with pain in the lower back along with tingling, numbness, and weakness in the bilateral lower limbs. This was associated with urine incontinence for 1½ months. In the previous month, he developed a left-sided solitary thyroid nodule. Fine needle aspiration cytology and ultrasonography were suggestive of metastasis. Furthermore, the thoracolumbar magnetic resonance imaging showed T1-hypo and T2-hyper-intense D11-D12 level intramedullary lesion, with intense enhancement, which was consistent with an intramedullary lesion involving the conus. At surgery, a firm, brownish yellow, friable, vascular tumour was removed en toto. Upon discharge, the patient was neurologically intact except for residual bladder incontinence. Conclusion: In an extensive literature review (pubmed), IMSCM metastasis from PTC primary is confirmed as a rarity and this may be the fourth documented case. Moreover, this may be the first report of a case of PTC metastatic neurological deterioration “even before the treatment of the primary was undertaken.” Early diagnosis and microsurgical resection can result in improvement of neurological deficits and in the quality of life of patients with IMSCM.

Isolated thoracic (D5) intramedullary epidermoid cyst without spinal dysraphism: A rare case report

Spinal epidermoid cyst, congenital or acquired, is mainly congenital associated with spinal dysraphism, rarely in isolation. Intramedullary epidermoid cysts (IECs) are rare with less than 60 cases reported so far; isolated variety (i.e., without spinal dysraphism) is still rarer. Complete microsurgical excision is the dictum of surgical treatment. A 14-year-old boy presented with 4-month history of upper backache accompanied with progressive descending paresthesia with paraparesis with early bladder and bowel involvement. His condition deteriorated rapidly making him bedridden. Neurological examination revealed upper thoracic myeloradiculopathy probably of neoplastic origin with sensory localization to D5 spinal level. Digital X-ray revealed no feature suggestive of spinal dysraphism. Contrast magnetic resonance imaging (MRI) characteristics clinched the presumptive diagnosis. Near-total microsurgical excision was done leaving behind a small part of the calcified capsule densely adhered to cord. Histopathological features were confirmative of an epidermoid cyst. Postoperatively, he improved significantly with a gain of motor power sufficient to walk without support within a span of 6 months. Spinal IECs, without any specific clinical presentation, are often diagnosed based upon intraoperative and histopathological findings, however early diagnosis is possible on complete MRI valuation. Complete microsurgical excision, resulting in cessation of clinical progression and remission of symptoms, has to be limited to sub-total or near-total excision if cyst is adherent to cord or its confines.

Contrecoup extradural hematoma with coronal suture diastasis

Extradural hematoma (EDH) generally occurs in the site of impact, that is, coup injury site. EDH is associated with fracture of skull in many a times due to direct impact. However, EDH in counter coup site is a rare occurrence. Hardly, yet, 12 cases have been reported including this case. Here, we reported a case of a 22-year-old male of contrecoup acute EDH who had sustained head injury due to fall from bike. Physical examination revealed direct impact at the left occipito-parietal region with laceration of scalp and bruise with transient loss of consciousness at the time of injury. There was no evidence of impact on the right side of his head. Computed tomography scan revealed an EDH in the right fronto-temporal region without any bone fracture on bone windows. On intraoperative exploration, it is found that there was coronal suture diastasis with small subgaleal hematoma and right fronto-temporal extradural hematoma. The evacuation of EDH was done. The patient discharged on 3rd postoperative day. It can be concluded that direct impact on head causes exactly opposite hit of brain, and compensatory rebound causes a negative pressure in between the layers causing disruption of vessels and potential accumulation of blood. This mechanism mostly favors for acute subdural hematoma due to compact attachment of dura with cranium. However, in this case, diastasis of coronal suture due to transmitted force is the cause of accumulation of blood extradurally in relatively loosely adhered dura in fronto-temporal region where a potential negative pressure space is created by contrecoup injury.