Virender K. Khosla

Spinal neurenteric cyst. Association with vertebral anomalies, diastematomyelia, dorsal fistula, and lipoma

A 50-year-old man was admitted with complaints of difficulty in walking, urinary incontinence, and a lump over the lumbosacral region. X-ray examination of the lumbosacral spine revealed bizarre vertebral anomalies, including a hole in the L-5 vertebral body. At operation an enterogenous cyst in association with diastematomyelia, cutaneous fistula, and a lipoma was encountered. Post-operatively, some improvement ensued. The case is discussed and pertinent literature reviewed with particular reference to the etiopathology of the cyst.

Nonaneurysmal nonperimesencephalic subarachnoid hemorrhage: is it a benign entity?

BACKGROUND Although the clinical profile of patients with PMN SAH is well documented, there are scarce data available for patients with nonaneurysmal n-PMN SAH. In the present study, the clinical characteristics of patients with n-PMN SAH were analyzed and compared with those of PMN SAH and aneurysmal SAH. METHODS Patients with spontaneous SAH, in whom the initial DSA or 3-dimensional CTA result was normal, underwent another investigation (CTA/DSA). If the results of both of these were negative, a second DSA was done after 4 to 6 weeks. Patients in whom even the second DSA failed to reveal an aneurysm or any other vascular abnormality were labeled as nonaneurysmal SAH. Within this group, 2 different types were identified: PMN SAH and n-PMN SAH. RESULTS There were 61 patients in whom the results of the first DSA and CTA were both negative. In 2 of these patients, an aneurysm was demonstrated at a second DSA. Seven patients died before a second DSA could be done. After excluding these, there were 18 patients with PMN SAH and 34 with n-PMN SAH. There was no mortality in these patients; and at a mean follow-up of 1.8 years, all patients with PMN SAH and 94.1% of patients with n-PMN SAH had a good outcome. Associated comorbid illnesses were more frequent in patients with PMN SAH and n-PMN SAH as compared with the aneurysmal SAH patients. CONCLUSIONS Once an aneurysm is definitely excluded, patients with n-PMN SAH have a good outcome, and like PMN SAH, have a benign clinical course. However, a second DSA is mandatory to avoid missing an aneurysm or any other vascular lesion.

Tuberculosis of the craniovertebral junction: is surgery necessary?

OBJECTIVE:Tuberculosis of the craniovertebral junction is an uncommon entity and its optimal management remains controversial. In this study, we present the evolution of management protocol of this disease in our institute in the past 3 decades. METHODS:A total of 51 patients with craniovertebral junction tuberculosis presenting as atlantoaxial dislocation from 1978 through 2004 were reviewed. The disease was rated from Stage I to Stage III, depending on the radiological findings. All patients received antitubercular treatment for 18 months. In the initial period of this study (1978–1986), all patients (n = 10) underwent surgery, usually a posterior fusion. In the second period (1987–1998), patients with less severe disease (Stages I and II, n = 14) were managed with external rigid immobilization, whereas patients with severe disease (Stage III, n = 11) underwent either a transoral decompression with or without posterior fusion or posterior fusion alone. More recently (1999–2004), all patients (n = 16) in all stages (Stages I–III) have been managed without surgery by a rigid external immobilization. RESULTS:Except for two patients who died (one because of miliary tuberculosis, the other because of acute hydrocephalus), clinical recovery occurred in all. Follow-up imaging demonstrated radiological healing as well, with regrowth of the destroyed bone. CONCLUSION:The mainstay of management of tuberculosis of the craniovertebral junction is prolonged antitubercular treatment with a rigid external immobilization. Surgery is not necessary, even in patients with advanced stages of disease. Complete clinical and radiological healing occurs in all patients with conservative treatment.

Embolization in high-flow arteriovenous malformations of the face

Five patients with arteriovenous malformations of the face (4 males and 1 woman; age range, 11-38 years) were treated by selective embolization through the feeding arteries with polyvinyl alcohol particles. Immediate gross angiographical obliteration was obtained in 4 patients, with pronounced reduction of the arteriovenous shunt in the fifth. Clinical symptoms including bleeding, swelling, pulsations, bruit, and disfigurement improved in all the patients followed up for a period of 6 to 21 months. Polyvinyl alcohol particle embolization, without surgical resection, though palliative could be useful in select patients. The classification and diagnosis of congenital vascular malformations is briefly reviewed and treatment discussed.

Giant basal prolactinoma extending into the nasal cavity

An unusual case of a giant prolactinoma extending to the nasopharynx and nasal cavity is presented. A 35-year-old man admitted for nasal obstruction and visual disturbances was found to have bilateral anosmia, right homonymous hemianopsia, and a right hemiparesis. The serum prolactin level was 13,300 ng/mL. Radiological examination revealed a large mass invading the skull base and extending into the suprasellar region and the left frontal lobe superiorly and into the nasopharynx inferiorly. Subtotal removal was done through a bilateral orbitofrontal craniotomy, which was followed by radiotherapy and bromocriptine administration. Immunohistochemical analysis confirmed a prolactinoma. The rarity of such a tumor, its location and extension, and the usefulness of magnetic resonance imaging and immunohistochemistry are stressed. Pertinent literature is reviewed.

Invasive intracranial aspergillosis: the management dilemmas

BACKGROUND Invasive intracranial aspergillosis remains a disease with high morbidity and mortality. The rapid increase in the incidence of this disease led us to review the literature and formulate a treatment protocol for such patients. METHODS An analysis of 46 patients with invasive intracranial aspergillosis is presented and the subgroups of extradural and intradural variety are evaluated with different treatment strategies. RESULTS Patients with extradural form of disease had 100% survival, whereas antifungal chemotherapy preloading tends to provide a better outcome. CONCLUSIONS Extradural aspergillosis does not need chemotherapy preloading, whereas intradural variant may have improved survival chances after preloading. Liposomal formulation has an advantage of shortened time duration for preloading, because the daily administration dose is 6 times higher than conventional preparation.

Measurements of the skull base for transpetrosal surgery

To understand the anatomy and the surgical approaches to the petrous, 19 adult human skulls (38 specimens) were studied. The foramen spinosum, groove for greater petrosal nerve, superior and posterior margins of the internal auditory meatus, fissure for the endolymphatic sac, and anterior margin of the groove for sigmoid sinus were the constant, easily identifiable bony landmarks located strategically; they served as guides during the transpetrosal approach. Measurements between various points helped both to understand the local anatomy better and to decide the degree and direction of safe bony removal during transpetrosal surgery.

Long-term outcome in surviving patients after clipping of intracranial aneurysms.

OBJECTIVE The quality of life and functional outcome may be significantly impaired in patients of aneurysmal subarachnoid hemorrhage. The purpose of the present study was to assess the status of patients undergoing surgical clipping of intracranial aneurysms in a long-term follow-up and to identify factors affecting outcome. METHODS 494 patients who underwent clipping of their intracranial aneurysms with a minimum follow-up of 1 year after their discharge were studied. Preoperative factors such as age, Hunt and Hess grade, Fisher grade, time interval between ictus and surgery, and site of aneurysm were recorded. The long-term status was assessed using Glasgow Outcome Scale (GOS), Modified Rankin Scale (MRS), Barthel index (BI), and Mini-Mental State Examination (MMSE). RESULTS Site of aneurysm and ictus-surgery interval did not have any effect on any parameter at long-term follow-up. Majority of patients who were discharged continued to improve as measured by GOS, Modified Rankin Scale, and Barthel index. However a significant proportion of patients had impaired MMSE at long-term follow-up. Multivariate analysis showed a significant effect of age on MMSE and also a positive correlation between number of aneurysms and GOS. CONCLUSIONS Most patients who survived and were discharged continued to improve in the postoperative period even though the immediate postoperative outcome was not favorable in many. However, a substantial subset had impaired cognitive function.