Satish Kumar Verma

O-arm with navigation versus C-arm: a review of screw placement over 3 years at a major trauma center.

Abstract Introduction: There is a relatively high incidence of screw misplacement during spinal instrumentation due to distortion of normal anatomy following spinal trauma. The O-arm is the next-generation spinal navigation tool that provides intraoperative 3-D imaging and navigation for spine surgeries. Aims and objectives: To evaluate and compare the use of O-arm as compared to C-arm for spinal trauma in a Level I trauma center in India. Materials and methods: In this retrospective study over 3 years (July 2010–April 2013), All patients of spinal injury who underwent spinal instrumentation were divided into O-arm group and C-arm group. Accuracy of screw placement was assessed during each surgery in both groups. Results: A total of 587 patients were evaluated during the study period. There were 278 patients in O-arm group and 309 patients in C-arm group. Both groups were well matched in mean age (27.7 vs. 28.9 years), ASIA grades, and level of injury. The number of screws placed was significantly higher in the C-arm group as compared to the O-arm group (2173 vs. 1720). However, the O-arm group had significantly less screw malplacement rate of 0.93% (n = 16) as compared to malplacement rate in C-arm group of 8.79% (n = 191, p < 0.05). Conclusion: Use of O-arm imaging system ensures accurate screw placement and dramatically decreases screw malplacement rate, thus providing better patient safety. Its use is especially beneficial in academic and teaching centers where novice surgeons can attain results equivalent to that of experts in spinal instrumentation.

Fatal Superior Sagittal Sinus and Torcular Thrombosis After Vestibular Schwannoma Surgery: Report of a Rare Complication and Review of the Literature

BACKGROUND Cerebral venous sinus thrombosis (CVST) is a rare condition with the potential to cause severe morbidity and mortality. CVST can also occur after vestibular schwannoma (VS) surgery with the thrombosis of transverse and sigmoid sinus. However, there is not a single report of superior sagittal sinus (SSS) thrombosis after VS surgery reported in the literature. CASE DESCRIPTION A 45-year-old woman presented to our center with large left-sided solid cystic VS. On admission she was dehydrated, and after clinical stabilization, she underwent gross total excision of tumor through left retromastoid suboccipital craniotomy after cerebrospinal fluid drainage through an external ventricular drain. Surgery was uneventful, but postoperatively she had an episode of seizure. Immediate postoperative computed tomography (CT) brain scan was normal with good operative cavity. However, 24 hours later, she developed left-sided motor deficit, and a repeat CT scan showed right frontal parenchymal hemorrhage with intraventricular extension. On further evaluation, magnetic resonance venography showed entire SSS thrombosis, with patent bilateral transverse and sigmoid sinuses. She was not started on the anticoagulants in view of intracranial hemorrhage. Subsequently, she underwent right-sided decompressive craniectomy because there was progressive deterioration in her Glasgow Coma Scale, and she succumbed despite all efforts. Retrospectively, dehydration and intracranial hypotension could be likened to her sinus thrombosis. CONCLUSIONS This case underscores the significance of adequate optimization of the patients prior to surgery, besides adequate operative skills to avoid this rare but serious complication of SSS and torcular thrombosis after VS surgery.

Giant intradiploic arachnoid cyst for 13 years

A case of intradiploic arachnoid cyst is reported. The patient presented with a progressively enlarging swelling situated over left frontal region for approximately 13-years following blunt trauma to head. Magnetic resonance imaging showed an intradiploic fluid containing cyst having intensity like cerebrospinal fluid (CSF). He underwent craniotomy and successful surgical repair. Intraoperatively CSF cyst was located in the frontal pole with a large defect over inner table and large rent in the dura. It was lined with arachnoid membrane. Pertinent literature is reviewed in brief.

Giant calvarial cavernous hemangioma

Though hemangiomas of the bone are quite common, calvarial (skull) cavernous hemangiomas are relatively rare pathologies. Calvarial hemangiomas are usually small and asymptomatic. However, they may occasionally grow in size to achieve large sizes and can present as a palpable swelling. We present a child with massive temporo-parieto-occipital calvarial cavernous hemangioma, who was managed with a multimodal approach with excellent cosmetic and neurologic outcome.

Orbital roof intradiploic meningioma in a 16-year-old girl

Primary intraosseous or ectopic meningioma of the skull is a rare tumor accounting for about 1% of meningioma. Intradiploic meningioma is an extremely rare type of extraneuraxial meningiomas. Intradiploic meningioma of the orbit is extremely rare, and <8 such cases are reported till date in western literature occurring in the pediatric age group. Here the authors present a case of 16-year-old female, who presented with progressive proptosis, with normal vision and was managed successfully surgically. Clinical features, pathophysiology, and surgical management of this rare entity are discussed in the context of pertinent literature.

Giant choroid plexus papilloma of the lateral ventricle in fetus.

Choroid plexus papillomas (CPPs) are rare tumors having bimodal distribution. Pediatric CPPs are commonly present in supratentorial compartment and most commonly located in lateral ventricle and usually present at 16-18 months. Authors could find only one case report of fetal choroid plexus papilloma in the literature. In the present case, authors illustrate an unusual presentation of CPP with raised intracranial pressure (ICP) since birth, the need for proper preoperative planning, meticulous surgical technique, and intensive intra operative monitoring for normothermia, fluid-electrolyte balance, and blood replacement for achieving excellent results.

Rare Case of Cerebrospinal Fluid Proctorrhea Caused by Anterior Sacral Meningocele with Rectothecal Fistula

BACKGROUND Anterior sacral meningocele (ASM) leading to secondary rectothecal fistula is extremely rare, and to date only 5 such cases have been described in the world literature. CASE DESCRIPTION We describe an uncomplicated case of a 52-year-old female patient presenting with cerebrospinal fluid leak from the anus who was investigated and found to have an ASM with rectothecal fistula. The ASM and rectothecal fistula were subsequently repaired using a posterior approach. Pertinent literature review, clinical findings, neuroimaging, and surgical management are described for these rare lesions. CONCLUSION Early diagnosis and surgical disconnection of the fistulous tract led to satisfactory outcome in the present case and avoided the catastrophic complication of meningitis.

Medial sphenoid wing meningiomas: Experience with microsurgical resection over 5 years and a review of literature

BACKGROUND Medial sphenoid wing meningiomas are medially located tumors on the sphenoid wing with attachment over the anterior clinoid process. They represent a distinct entity. These medial sphenoid wing meningiomas present a more difficult problem for the neurosurgeons because in a majority of cases, they involve the anterior visual pathways and arteries of the anterior circulation and may invade the cavernous sinus (CS). Higher morbidity, mortality and recurrence rates have been observed in these tumors compared with meningiomas in other locations. The rate of recurrence for medial sphenoid wing meningiomas is reported as being one of the highest amongst intracranial meningiomas. MATERIAL AND METHODS The authors retrospectively analyzed 78 consecutive patients with the diagnosis of medial sphenoid wing meningioma who were operated in our department from January 2008 to December 2012. RESULTS These patients, having a meningioma of the medial sphenoid ridge, were divided into two types depending on the involvement of CS. Diplopia, internal carotid artery encasement, and postoperative visual deterioration were more common in Type 2 tumors. Similarly, extent of resection and postoperative morbidity were greater in Type 2 patients. CONCLUSIONS CS invasion confers an added risk to the surgical morbidity and outcomes. However, with proper surgical techniques, optimum outcomes can be achieved and overall surgical results at our center are found to be comparable to that of the current literature.

Glioblastoma multiforme presenting as a fungating mass extending through previous craniotomy site

325 Neurology India | May-Jun 2013 | Vol 61 | Issue 3 include headache and dizziness. High resolution CT scan of the posterior fossa with bony details of the foramen passing through is the neurodiagnostic procedure of choice. Histologically, Antoni type A schwannoma has elongated spindle cells in irregular streams and is compact in nature and type B schwannoma has a looser organization often with cystic spaces. Most of the hypoglossal schwannoma have a dumbbell shape and involve both intracranial and extracranial segment of the hypoglossal nerve.[3] However, pure intracranial hypoglossal schwannoma are unusual.[1] The most distinguishing clinical findings of patients with hypoglossal nerve schwannoma are unilateral tongue atrophy and fasciculations.[4] The differential diagnosis of tumor involving hypoglossal canal includes chemodectoma, chordoma, meningioma, lymphoma, and metastatic tumors. The symptom of slurred speech improved after the surgery. Hypoglossal neuropathy is frequently associated with adjacent cranial nerve involvement. Isolate hypoglossal neuropathy is rare. Tumor, infection, trauma of skull base, radiation, and vascular insult are the causes of isolated hypoglossal nerve palsy.[5] In conclusion, schwannoma of the hypoglossal nerve is very rare, can present with atrophy of the tongue, but they can also be asymptomatic initially.[5] Early diagnosis and surgical intervention can preserve the function of nerve.

Traumatic posterior fossa extradural hematoma: Experience at level I trauma center

Introduction: Posterior fossa extradural hematoma (PFEDH) is rare among the traumatic brain injury and represent about 4–7% cases of all EDHs. This rare condition is rapidly fatal unless identified and intervened timely. Because of limited space in posterior fossa, comparatively small volume can cause clinical deterioration. Early diagnosis by cranial computed tomography and emergent evacuation is vital for a good outcome. Materials and Methods: This study was conducted at Level I trauma center at All India Institute of Medical Sciences, New Delhi, India. Hospital medical records were reviewed from September 2007 to June 2015. There were 856 cases of acute EDHs and of these 69 cases had PFEDHs. Records of patients with PFEDHs were reviewed for the mode of injury, Glasgow Coma Scale (GCS) at admission, imaging, type of intervention, outcome, and follow-up. GCS was assessed at 6 months and 12 months follow-up. Pertinent literature is reviewed. Results: Of these 69 patients, 51 were males and 18 females. The mean age of patients was 28.6 years (range 4–43 years). Forty-three patients had GCS 15 at admission, and only 4 of them had admission GCS <8. Mean EDH volume was 29.2 ml. Sixty-six patients were operated, three managed conservatively. Sixty-seven patients were discharged, of which, 56 (81.1%) had GCS 15. Two patients died. Most common associated injuries were long bone fractures (18, 26.1%) followed by blunt injury thorax (11, 15.9%). Mean follow-up duration was 69.2 months (range 6–94 months). At 6 months follow-up, 61 (88.4%) patients had good recovery (Glasgow Outcome Score [GOS] 5) and at 12 months, 62 (89.8%) had GOS 5. Conclusion: PFEDH are rare. They are usually associated with occipital bone fractures and may also have a supratentorial hematoma. It may be rapidly fatal due to the expansion of hematoma and compromise of the posterior cranial fossa space leading to brainstem compression, tonsillar herniation, and/or obstructive hydrocephalus. Early diagnosis and emergent evacuation lead to good outcome.