Sachin Baldawa

Spontaneous Resolution of Bilateral Chronic Subdural Hematoma.

A sixty five years old male had presented about two years back with progressive weakness of left upper and lower limb and altered mentation. On examination, as per the hospital records, he was in altered sensorium and had left hemiparesis grade 3/5. Computed tomography (CT) of the brain revealed a hypodense collection in the right frontotemporoparietal region with areas of hyperdensity posteriorly in the parietal region. This was suggestive of a predominant chronic subdural hematoma with an acute component in the parietal region (Figure 1). The hematoma was 1.5 cm in thickness and was causing significant mass effect resulting in compression of the ipsilateral ventricle. Midline shift of 8 mm was noted to the left side (Figure 1). Another hypodense collection was noted in left frontoparietal region with specks of hyperdensity in the left frontal region (Figure 1). Patient was advised surgical evacuation of bilateral subdural hematoma in order to reduce the mass effect and reverse the neurological deficit. However the patient’s relatives were not willing to undergo surgery and he was discharged on best possible medications. He was eventually lost to follow up. Two years later he presented to the emergency department with history of fall following an episode of giddiness. On examination he was conscious, oriented in time, place and person. His left hemiparesis had improved and he was ambulant without support. Brain CT revealed complete resolution of the left frontoparietal subdural hematoma (Figure 2). A thin rim of right subdural collection was noted with no evidence of midline shift or mass effect (Figure 2). He was symptomatically treated and discharged.

Surgical Outcome in Cystic Vestibular Schwannomas

Background: Cystic vestibular schwannomas (VS) form a rare subgroup that differs from the solid variant clinically, radiologically, and histopathologically. These tumors also vary in their surgical outcome and carry a different risk of post-operative complications. We analyzed our series of 64 patients with cystic VS and discuss the technical difficulties related to total excision of these tumors and focus on complication avoidance. Materials and Methods: A retrospective review of cystic VS surgically managed over a span of 11 years. The case records were evaluated to record the clinical symptoms and signs, imaging findings, surgical procedure, complications, and follow-up data. Post-operative facial nerve palsy was analyzed with respect to tumor size and tumor type. Results: Progressive hearing impairment was the most common initial symptom (76.6%). Atypical initial symptoms were present in 15 patients (23.4%). Preoperatively, 78% patients had good facial nerve function (HB grade 1, 2) and 22% had intermediate (HB grade 3, 4) to poor (HB grade 5 and 6) function. Mean tumor size was 4.1 cm. Complete tumor removal was achieved in 53 patients (83%). The facial nerve was anatomically intact but thinned out after tumor excision in 38 patients (59.4%). Ninety percent patients had either intermediate or poor facial nerve function at follow-up. Poor facial nerve outcome was associated with giant tumors and peripherally located, thin-walled cystic tumors. Conclusion: Resection of cystic VS is complicated by peritumoral adhesions of the capsule to the nerve. Extensive manipulation of the nerve in order to dissect the tumor–nerve barrier results in worse facial nerve outcome. The outcome is worse in peripherally located, thin-walled cystic VS as compared to centrally located, thick-walled cystic tumors. Subtotal excision may be justified, especially in tumors with dense adhesion of the cyst wall to the facial nerve in order to preserve nerve integrity.

An unusual association of classical Joubert syndrome with retrocerebellar arachnoid cyst

Dear Sir, A 4-year-old male born of second degree consanguineous marriage was presented to the paediatric outpatient department with ataxia, mild intellectual impairment, motor and developmental delay, hypotonia and poor development of speech. He was born at term with no perinatal insults. There was no history of seizure, feeding or swallowing difficulty or abnormal breathing pattern at birth. On examination, the child had truncal ataxia and hypotonia in limbs. Eye movements were normal. There was no facial dysmorphism. Detailed evaluation of the eye did not reveal retinal dystrophy. Ultrasonography of the abdomen did not reveal renal cysts or liver involvement. Rest of the systemic examination was normal. Magnetic resonance imaging of the brain revealed a deep interpeduncular cistern and thickened horizontally elongated superior cerebellar peduncle on axial imaging consistent with the pathognomonic molar tooth sign of Joubert syndrome (Fig 1(A, 1B)). Hypoplasia of the vermis with CSF cleft between the two cerebellar hemispheres was evident (Fig 1(C, 1D)). The fourth ventricle was enlarged and distorted resulting in bat wing appearance (Fig 1(C)). The cerebellar hemispheres showed prominence of cerebellar folia suggestive of cerebellar hypoplasia (Fig 1(A, 1B, 1C, 1E)). The posterior fossa was enlarged with retrocerebellar cyst matching CSF signal intensity changes on all sequences suggestive of arachnoid cyst (Fig 1(A–E)). The cyst did not show any communication with the fourth ventricle. A thin cyst wall was evident between the superiorly placed retrocerebellar cyst and inferiorly widened retrocerebellar CSF space (Fig 1(E)). Except for mild dysgenesis of corpus callosum, no other intracranial abnormality was evident. Joubert syndrome (JS) is a rare genetic developmental anomaly of the brain involving under development or malformation of the brainstem and cerebellum [1]. It is an autosomal recessive disorder first described in 1969. JS is included in group of ciliopathies as approximately ten causative genes have been identified which encode the proteins of primary cilium [2]. Defect in the structure or function of primary cilium leads to clinical manifestations. The term classic JS is reserved for individuals who present with episodic hyperpnea or apnea in infancy, hypotonia, oculomotor apraxia, nystagmus, ataxia, intellectual disability, mild to severe motor and developmental delay [1–3]. The neuroimaging hallmark of this midbrain hindbrain malformation is molar tooth sign and vermian hypoplasia [1–3]. A deep interpeduncular cistern and abnormally thickened, horizontally elongated superior cerebellar peduncle gives the classical appearance of molar tooth sign [2, 3]. Lack of normal decussation of superior cerebellar peduncle leads to more horizontal perpendicular orientation of the peduncle to the midbrain and is also responsible for decreased anterior-posterior diameter of the brainstem [2]. Hypoplasia of the vermis leads to CSF cleft between both the cerebellar hemispheres and distorted, enlarged fourth ventricle resulting in bat wing shape on axial imaging [1]. However, the molar tooth sign is not specific for JS. The term Joubert syndrome and related disorder is used to describe all other disorders presenting with molar tooth sign on brain imaging [1]. Other features include progressive retinal dystrophy, coloboma, occipital encephalocele, microcystic renal disease, hepatic fibrosis, polydactyly, oral hamartomas and endocrine abnormalities. Hence, these disorders are classified into six phenotypic subgroups of classical JS, JS with * Sachin Baldawa sachin_baldawa@yahoo.co.in

Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury

Dear Sir, I read with great interest the article by Kim et al. [1] mentioning the risk factors for delayed surgical evacuation of acute subdural hematoma (SDH) in mild head injury patients who were initially treated by non-surgical means and would like to add a few comments. In patients with traumatic brain injury, the decision to evacuate acute SDH is based predominantly on the patient’s GCS score, pupillary examination, and CT scan findings. The guidelines laid down by the Brain Trauma Foundation in 2006 for the management of acute SDH are universally followed [2]. The Brain Trauma Foundation lays great emphasis on the thickness of acute SDH and the degree of midline shift in guiding surgery for patients with traumatic brain injury [2]. As per the Brain Trauma Foundation guidelines, acute SDHmore than 10 mm thick or a midline shift greater than 5 mm on imaging, irrespective of the patients GCS score, needs surgical evacuation [2]. However, volume of the hematoma has not been considered as a guiding parameter in patients with acute SDH. In fact, the Brain Trauma Foundation emphasizes calculating the volume of hematoma in order to decide surgical evacuation of extradural hematoma only [2]. Patients with mild head injury (GCS score of 13 to 15) having acute SDH are more likely to have hematoma thickness of less than 10 mm and midline shift of less than 5 mm [1]. By calculating the volume of hematoma in patients with mild head injury having acute SDH, neurosurgeons will be able to predict which hematomas are likely to enlarge and hence are likely to need evacuation. In the series published by Mathew et al. [3], 23 patients with mild head injury having acute SDH were initially subjected to non-operative management. In six of these patients who needed delayed surgical evacuation of the acute SDH, the volume of the hematoma was significantly larger than the group that was managed conservatively [3]. In the authors’ series, also the volume of the hematoma was an independent risk factor for the development of delayed hematoma enlargement [1]. The authors need to be commended for re-introducing volume of the hematoma as a decisive parameter in predicting hematoma enlargement apart from thickness of the hematoma and degree of midline shift in patients with acute SDH and good neurological status.

Case report: Thrombosed giant cavernous carotid artery aneurysm secondary to cervical internal carotid artery dissection: An unusual entity

Spontaneous thrombosis of a giant intracranial aneurysm with parent artery occlusion is known. The exact mechanism is however unclear and various theories have been proposed. We present an unusual case of an angiographically documented cervical internal carotid artery (ICA) dissection, which led to total occlusion of the ICA distal to the dissected site, with acute cessation of forward blood flow. This resulted in acute upstream thrombosis of the giant cavernous carotid artery aneurysm and an acute cavernous sinus syndrome-like presentation.

Giant saccular distal azygos artery aneurysm: Report of a case and review of literature

An azygos anterior cerebral artery (ACA) is a rare variant of normal embryogenesis in which confluence of two A1 segments results in a single A2 segment with the absence of anterior communicating artery. The occurrence of an aneurysm at the bifurcation of azygos ACA is rare with few cases reported in the literature. We report a case of a 40-year-old lady who presented with subarachnoid hemorrhage following rupture of a giant, saccular distal azygos ACA aneurysm. Bifrontal craniotomy and clipping of an aneurysm was performed. The clinical significance of azygos ACA and surgical strategies in clipping these aneurysms are discussed with a review of literature.

Comments on the article titled "Endoscope-assisted, minimally invasive evacuation of sub-acute/chronic epidural hematoma: Novelty or paradox of Theseus?" by Ansari et al.

Dear Sir, I read with great interest the article by Ansari et al. BEndoscope-assisted, minimally invasive evacuation of subacute/chronic epidural hematoma: Novelty or paradox of Theseus?^ DOI 10.1007/s00701-016-2851-z. The authors need to be congratulated for performing this extremely unconventional but minimally invasive approach for evacuation of subacute or chronic epidural hematoma measuring 20 to 50 ml in volume. With the increasing trend to perform neurosurgical procedures minimally invasive using endoscope, it was only a matter of time before attempts were made to evacuate extradural hematoma through an endoscope. Conventional craniotomy for evacuation of symptomatic acute or subacute epidural hematoma still remains the gold-standard method. The standard surgical principles taught to neurosurgical residents and aptly described in most neurosurgical textbooks for evacuation of epidural hematoma are (1) Adequate exposure and proper visualization, (2) Control of bleeding source either arterial or venous, and (3) Multiple dural hitches after hematoma evacuation. Based on the first principle, adequate exposure and proper visualization, in the conventional method, craniotomy should be wide enough to expose the underlying hematoma. In the author’s case series using the minimally invasive technique, the exposure is bare minimumwith a single burr hole placed at the summit of the hematoma. A single burr hole with its limited space eventually leads to undermining of the bone edge, widening the burrhole to facilitate entry of the endoscope in the extradural space. This prevents bone edges of the burrhole from hitting the endoscope during insertion into the extradural space. The limited exposure in the present technique has been circumvented by adequate visualization of the periphery of the hematoma using a 30 or 70° endoscope. Control of the bleeding source is technically challenging using the minimally invasive method as agreed by the authors. Venous bleeding can easily be controlled using a gels ponge or oxidized cellulose. It is the arterial bleeder at the periphery of the hematoma that can prove to be a nuance using the endoscope as the surgical field gets flooded with blood. With the limited entry of bipolar diathermy, coagulation of arterial bleeder using the endoscope can indeed prove to be a nightmare for the surgeon. Failure to control bleeding may eventually lead to conversion to conventional craniotomy. The authors have described using a bent metal suction cannula to reach the arterial bleeder and coagulate the bleeder with monopolar cautery placed over the suction cannula. This method, though commonly used by general surgeons, is seldom used in neurosurgical practice. It is indeed remarkable that none of the seven surgeries performed by the authors were converted to conventional craniotomy for want of achieving hemostasis. Bleeding from the fracture site, which can easily be controlled using bone wax, may be difficult to control using the endoscope through a single burrhole. The essential and final step performed after evacuating epidural hematoma is application of multiple dural stitches and tenting the dura up against the bone edge to prevent further dural stripping and recollection. In the present case series by the authors, dural hitch was applied only at the burrhole site, leaving behind significant persistent epidural space where the dura is not opposed to the overlying bone. Yet, none of the patients in the authors’ series developed recollection of hematoma. Conventional craniotomy offers the best chance of recovery to the patient with minimal risk of recollection when all * Sachin Baldawa sachin_baldawa@yahoo.co.in

Comments on the article entitled "The Geriatric Scoring System (GSS) in meningioma patients-validation" by Cohen-Inbar O, Sviri GE, Soustiel JF, Zaaroor M. Acta Neurochir (2011) 153:1501-1508.

Dear Sir, We read with great interest the article entitled “The Geriatric Scoring System (GSS) in meningioma patients— validation” by Cohen-Inbar O, Sviri GE, Soustiel JF, Zaaroor M. Acta Neurochir (2011) 153:1501–1508 [3]. Meningiomas are the most common primary intracranial tumor. These benign tumors, when located in a surgically accessible location, are amenable to surgical resection providing a long-term cure. However, the complexity of these tumors increases in certain locations like the cavernous sinus, foramen magnum, as well as with advancing age [5]. With increasing life expectancy and easy availability of advanced imaging modalities, even in developing countries, the occurrence of intracranial meningioma is more likely to be diagnosed in patients older than 65 years. Also, the incidence of meningioma tends to increase with advancing age. Meningiomas in the elderly are considered to be a distinct clinical entity [2, 3]. Often elderly patients suffer from other systemic illness, which makes them poor surgical candidates. In such a scenario, neurosurgeons are often faced with the dilemma of deciding whether surgical intervention in the form of total resection will lead to an overall improvement in recovery and functional outcome, or tumor resection is likely to result in worse quality of life as compared to the elderly patient’s preoperative status. However, age alone should not be considered as a contraindication for surgery if risk factors are appropriately managed [1, 4]. A scoring system like the Geriatric Scoring System (GSS), which includes patient factors and imaging findings, enables risk stratification of the elderly subpopulation who are likely to benefit from surgical intervention and those who are unlikely to benefit [2, 3]. Evidence-based decisionmaking is possible. Unlike the CLASS algorithm [5] and SKALE grading system [6], GSS incorporates tumor factors such as size and location, patient factors such as neurological deficits and Karnofsky score, associated comorbidities like diabetes, hypertension, and lung disease, and imaging findings like peritumoral edema [2, 3]. Though validation of this scoring system is based on retrospective data analysis, GSS provides sound scientific knowledge in guiding neurosurgeons to decide in which subpopulation of elderly patients to surgically intervene [2, 3]. We agree with the authors that prospective evaluation of this scoring system is essential not only for meningiomas but for all other primary brain tumors as well as for all age groups [3]. It will be prudent, here, to remember that biologic behavior of other primary intracranial tumors differ significantly from meningioma. Hence, an individual case-based approach will be more appropriate. This scoring system will enable neurosurgeons to walk the fine line in identifying elderly patients with meningioma where the benefits from surgical resection far outweigh the risks.