Sanjiv Sinha

Hypophyseal tuberculoma: direct radiosurgery is contraindicated for a lesion with a thickened pituitary stalk: case report.

OBJECTIVE AND IMPORTANCE Hypophyseal tuberculomas are extremely rare lesions. The recognition of hypophyseal tuberculomas in the differential diagnosis of pituitary tumors is important, even with no evidence of systemic tuberculosis. CLINICAL PRESENTATION A 27-year-old female patient presented with continuous, dull, generalized headaches and amenorrhea, with no history of visual diminution, galactorrhea, or endocrinological abnormalities and no evidence of systemic tuberculosis. The patient exhibited a normal water balance, without polyuria or polydipsia. A gynecological examination, including an endometrial biopsy for amenorrhea, did not reveal any abnormalities. Perimetric and endocrinological examination results were normal. Contrast magnetic resonance imaging revealed a dense enhancing intrasellar mass, with thickening of the pituitary stalk. INTERVENTION Sublabial rhinoseptal transsphenoidal decompression of the lesion was performed. The histopathological features were consistent with a diagnosis of tuberculoma, and acid-fast bacilli were demonstrated in the surgically removed tissue with Ziehl-Neelsen staining. As soon as the histopathological features were known, the patient underwent a lumbar puncture for cerebrospinal fluid analysis, which indicated normal findings. An intradermal tuberculin test yielded negative results. The patient was treated with medical therapy for 18 months, and complete resolution of the lesion was observed in follow-up examinations. CONCLUSION Hypophyseal tuberculomas are often mistaken for pituitary adenomas. The finding of a thickened pituitary stalk in contrast magnetic resonance imaging scans may be useful for the differentiation of these lesions from pituitary adenomas. Direct radiosurgery is not an appropriate primary treatment method for pituitary adenomas and is principally restricted to elderly, medically unfit patients with microadenomas and patients with residual or recurrent tumors after microsurgery. It is contraindicated for patients who exhibit a thickened pituitary stalk in contrast magnetic resonance imaging scans.

Progressive multifocal leukoencephalopathy in a patient with idiopathic CD4+T lymphocytopenia.

Progressive multifocal leukoencephalopathy (PML) is demyelinating of central nervous system caused by JC virus infection and often occurs in immunodeficient individuals. We report progressive PML in a 30-year-old male with idiopathic severely depressed CD4+T lymphocyte count. He was sero-negative for human immunodeficiency virus (HIV) infection.

Brain stem infarction: a complication of microvascular decompression for trigeminal neuralgia.

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CSF rhinorrhea: An overview of endoscopic repair

Abstract CSF rhinorrhea can be diagnosed with more accurate localizations of the site of leak with the help of modern radiological methods. The repair involves surgical intervention, which has changed from open craniotomy to minimally invasive techniques. Endoscopic repair has gained popularity in last decade and is being practiced by many neurosurgeons either alone or with their ENT colleagues. The overall success rate of endoscopic repairs has triggered several centers to adopt endoscopic repair as first line of treatment of CSF rhinorrhea. However the inexperience of neurosurgeon to sinus anatomy may pose some difficulties with the young neurosurgeons. The article presents a review of the techniques for confirmation of a CSF leak as well as endocscopic repair of CSF fistula.

Saccular bilobed aneurysm of an azygos anterior cerebral artery

An azygos anterior cerebral artery is an anatomical variant in which the anterior communicating artery is absent and both the A1 segments unite to form a single A2 segment of the artery. This anatomical variant may be associated with holoprosencephaly and may predispose to aneurysm formation, however the association of such an anomaly with an aneurysm is rare. When associated with an aneurysm, it poses management difficulties due to the single distal anterior cerebral artery. Most of the reported aneurysms with such an anomaly are saccular and located in the distal part of the artery. We report a patient with a wide neck saccular multilobed aneurysm who presented after a grade 3 subarachnoid haemorrhage. A right pterional craniotomy and clipping of the aneurysm was performed following cerebral angiography. The mechanism of formation and difficulties in management of such an aneurysm is discussed.

Endovascular Occlusion of Cervical Internal Carotid Artery Pseudoaneurysm in a Child Treated by N-Butyl Cyanoacrylate: A Rare Case Report.

We report a rare case of spontaneous extracranial cervical internal carotid artery (ICA) pseudoaneurysm in a female child aged 3 years who presented with a swelling in the neck which had bled following an attempted incision as it had been thought to be an abscess. A CT angiogram and an MR angiogram were not very conclusive to diagnose the exact site of origin and the morphology of the aneurysm. Digital subtraction angiography revealed a dissecting pseudoaneurysm of the right extracranial cervical ICA. The right ICA was ending as a pseudosac, and the right cerebral circulation was filling up through the right posterior cerebral artery. To minimize the radiation exposure, a microcatheter was placed inside the diagnostic catheter. The aneurysm sac was occluded using N-butyl cyanoacrylate since there was no distal flow to the brain from the artery beyond the aneurysm. It was a safe, effective and cheaper alternative to open surgery or to other endovascular management options available. Not all neck swellings are abscesses, and they should be examined and evaluated to exclude a vascular cause.

Fatal epistaxis from the fetal posterior communicating artery--a delayed complication of trans-sphenoidal surgery.

Vascular complications following trans-sphenoidal surgery can occur due to injury of the cavernous segment of the internal carotid artery, external carotid artery and its branches or an aneurysm rupture. The incidence of vascular complications in trans-sphenoidal surgery is 0.4% to 1.4%. Vascular injury was encountered in a patient with giant pituitary adenoma who underwent staged trans-sphenoidal tumour removal. Following his third surgery, he had delayed fatal epistaxis. An angiogram revealed a fetal type posterior communicating artery with a blow out of the junction of the posterior communicating artery with the posterior cerebral artery. The diagnosis and management of this condition are discussed.

Occiput/C1–C2 fixations using intra-laminar screw of axis – A long-term follow-up

Abstract Background. The surgical management of the craniocervical junction is challenging. Rigid posterior fixation of occiput/C1–C2 can be performed using a variety of surgical techniques including C2 pedicle/pars interarticularis, transarticular and intralaminar screw fixations. Methods. Forty-one patients were treated with occipital plate/C1 lateral mass and C2 intra-laminar screw fixations for basilar invagination and congenital atlantoaxial subluxation, post-traumatic instability, tuberculous and rheumatoid arthritis-associated atlantoaxial dislocation. Out of forty-one, thirty-six patients had bilateral crossing intra-laminar screws and five had ipsilateral laminar screw fixation bilaterally. Results. Follow-up was done in thirty-nine patients from 6 months to 8 years (mean: 21 months) and solid osseous fusion could be achieved in all (100%). One patient was lost to follow-up and another patient died of a cause unrelated to surgical technique. Pre-operative and post-operative Neurosurgical Cervical Spine Scale showed improvement in all patients having features of myelopathy. There were no neurological or vascular complications. However, nine patients had posterior laminar breach, eight had anterior laminar penetrations and three had wound infections. One patient had transient bulbar palsy and one patient had hardware failure in the form of avulsion of the midline occipital plate. Conclusions. Intra-laminar screw fixation is a safe alternative to transarticular and transpedicular/pars interarticularis fixation of C2 with advantage of having no risk of injury to vertebral artery and comparable biomechanical and pull-out strength.

C2 intralaminar (crossing/ipsilateral) fixation as a bailout procedure for failed transpedicular/pars interarticularis screw placement.

Craniocervical and atlantoaxial disability may be treated with variety of craniovertebral/C1-C2 constructs. Craniovertebral junction posterior stabilization is technically demanding due to presence of numerous bony anatomical variations and the course of the vertebral artery. C2 transpedicular/pars interarticularis screw placement further increases the risk of injury to vertebral artery [1, 2, 4]. We have utilized intralaminar fixation of axis in 19 patients as a bailout technique in failed C2 pedicle/pars interarticularis screw fixation of a total of 42 patients who were planned for occipito-C2 pedicle/pars interarticularis and 21 for C1 lateral mass and C2 pedicle/pars interarticularis instrumentation over a period of 7 years (July 2002–August 2009). Thin-cut computed tomography with multiplanar reconstruction was characteristic in determining detailed bony anatomy of C2, transverse foramen, location of vertebral artery, size of pars interarticularis, diameter of pedicle, and thickness of lamina. All 19 patients had occipitocervical pain, 11 had features of myelopathy, and five each had unsteadiness of gait and torticollis. There was aberrant vertebral artery in five cases, inadequate size of pars interarticularis and/or small size of pedicle in 13 patients, and destruction of body and pedicle in one patient prevented safe transpedicular/ pars interarticularis screw insertion in these 19 patients.

Extravasation of contrast medium resembling hematoma following iatrogenic vascular trauma: Case report

Abstract The complication rate of cerebral angiography is 0.4 to 12.2% and stroke patients are at increased risk. Non-contrast CT head done for deterioration following angiographic procedures may show hyperdensity. This hyperdensity usually suggests the presence of a procedure induced hematoma. Rarely, it may be due to contrast extravasation. A high index of suspicion is needed in the latter group of patients to avoid unnecessary surgery. Two cases showing hyperdense lesions on non-contrast CT following iatrogenic vascular trauma during angiography and related procedures are presented with special emphasis on features which help to differentiate contrast extravasation from procedure induced hematoma.