Z. A. B. Jamjoom

Systemic metastasis of medulloblastoma through ventriculoperitoneal shunt: Report of a case and critical analysis of the literature

An unusual case of medulloblastoma metastasizing through a ventriculoperitoneal shunt to the scrotum in a child with a hydrocele is presented. A review of the literature disclosed 160 cases of medulloblastoma with systemic metastases, 30 (18.7%) of them having undergone systemic shunts. Analysis of the distribution patterns of the metastases in relation to the shunt type revealed that shunts had probably provided the route of systemic spread in no more than 11 cases (6.9%). Only one of these cases had no intracranial tumor at autopsy, suggesting that the outcome was probably worsened by the systemic metastases through the shunt. In contrast, five patients had intraaxial tumor recurrence that largely determined the outcome. In the remaining five cases, information concerning the tumor within the central nervous system was not available, and it remains speculative whether these patients could have survived longer without the shunts. It is concluded that the chance of medulloblastoma metastasizing through cerebrospinal fluid shunt is quite small and has an even smaller chance of adversely affecting the final outcome of the medulloblastoma patient. Consequently, in our opinion there should be no contraindication to precraniotomy shunting if required in such patients.

Orbito-cranial injury caused by penetrating metallic foreign bodies: report of two cases

Two cases of orbito-cranial injury caused by foreign bodies (FBs)penetrating the lateral wall and roof of the orbit are described.In the first patient, a long rusted nail acted as a missile andwas only detected by X-rays and CT scan. The nail penetratedthe orbit, the eyeball, the lateral orbital wall, and thetemporal lobe of the brain. Lodged partly in the orbit andpartly in the brain, this nail caused leakage of cerebrospinalfluid (CSF) through eye and led to orbital cellulitis andlocalized meningitis. The foreign body (FB) was removed throughan extradural pterional approach with rapid resolution oforbital cellulitis and meningitis. In the second patient,large metallic FB, having penetrated the orbital roof was lodgedintracranially above the chiasma. This was removed via frontalcraniotomy. Mechanism of such injuries and appropriatesurgical approaches are described as well.

Atypical forms of spinal tuberculosis: case report and review of the literature

OBJECTIVEnThe object of this report is to highlight some of the less known atypical features of spinal tuberculosis (TB) in the hope of facilitating early diagnosis. Pure neural arch and sacral TB is rare and the co-existence of these two as widely separated skip lesions in the same patient is even rarer.nnnCLINICAL PRESENTATIONnAn unusual case of tuberculous process affecting the sacrum as well as the neural arches of upper cervical vertebrae is presented. Neither the clinical features nor the imaging techniques, including radiography, bone scintigraphy, computed tomography, and magnetic resonance imaging, were helpful in establishing the diagnosis. The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block. Development of this second destructive lesion involving the posterior spinal elements (the neural arch) led to a diagnosis of malignant spinal metastasis. The true diagnosis was only revealed by the histology of the solid tumor-like extradural mass in the upper cervical region and demonstration of acid-fast bacilli (AFB) in the lesion. Anti-TB chemotherapy resulted in complete resolution of sacral and cervical lesions as well as the neurologic deficits.nnnCONCLUSIONnDifferential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases.

Bilateral Femoral Nerve Compression by Iliacus Hematomas Complicating Anticoagulant Therapy

An unusual case of bilateral femoral nerve compression caused by iliacus hematomas in a patient on anti-coagulant therapy is herein reported with special reference to the comparative diagnostic value of ultrasonography, computerized tomorgraphy, and magnetic resonance imaging. The importance of early surgical decompression is also emphasized.

Cranial and intracranial aspergillosis of sino-nasal origin

SummaryThis paper is an attempt at defining the most efficacious surgical and antifungal therapy for invasive cranial and intracranial aspergillosis, and is based on experience with nine non-immuno-compromised patients treated and followed-up by the authors between 1983 and 1994; as well as on the summary of previously reported cases and advances in therapy of this condition. Depending on the degree of aspergillar involvement of the cranial base and intracranial structures, a classification, with implications for treatment and prognosis, is also proposed.Two patients had extracranial skull base erosion; whereas relentlessly progressive granulomas, mimicking malignancy, invaded the skull base and intracranial contents in seven cases. Of these seven patients with cranial and intracranial invasion, two died of acute intracranial haemorrhage due to fungal invasion of cerebral blood vessels. In two patients, complete surgical eradication of the disease proved impossible due to cavernous sinus involvement, while residual aspergillomas are still present in orbit and paranasal sinuses (PNS) in a further two patients in spite of multiple surgical procedures and prolonged antifungal chemotherapy (AFC). What appears to be a cure has been effected in one patient only. Multiple therapeutic strategies were used. Biopsy plus systemic AFC was ineffective, surgical drainage and debridement plus systemic AFC resulted in long-term survivals but no cure. Radical surgery in conjunction with systemic and local (intracavitary) AFC should be considered to improve an otherwise poor prognosis.

Solitary brainstem abscess successfully treated by microsurgical aspiration

A case of pyogenic pontine abscess detected by computerized tomography scan in a 10-year-old boy is presented. While on broad-spectrum antimicrobial treatment, he deteriorated and developed new symptoms of respiratory distress. Microsurgical exposure of the abscess and aspiration of pus resulted in rapid improvement in his neurological state and radiological resolution of the lesion. The aim of this article is to emphasize the importance of prompt diagnosis and the role of surgical drainage of pus in the management of brainstem abscesses.

Neural arch tuberculosis: radiological features and their correlation with surgical findings

Radiological features of 17 cases of neural arch tuberculosis (NAT), treated surgically by the authors, are reviewed and correlated with the operative and histopathological findings. The diagnostic accuracy of different imaging modalities in the evaluation of this rare, atypical form of spinal tuberculosis was found to be very low. Thus, the initial diagnosis was in error in 15 out of 17 of our cases. Recognition of the radiological diagnostic features of NAT is important, not only because they may mimic primary or metastatic spinal neoplasms, but also because of the surgical implications. Computed tomography (CT) and magnetic resonance imaging (MRI) features correlated most closely with the surgical findings, whereas plain spinal radiographs and myelograms were found to be non-specific and non-diagnostic.

Lumbosacral dural anomalies in von Recklinghausen neurofibromatosis

SummaryThe lumbosacral dural abnormalities in two patients with von Recklinghausen neurofibromatosis (vRNF) are described. Analysis of 18 previously reported cases revealed considerable morphological variations of the lumbosacral dural lesions associated with vRNF, but three basic forms may be distinguished. The pathogenesis of these lesions is still controvesial. The contrast studies in our patients, especially the computed tomographic myelography (CTM), suggest that the meningocoeles in vRNF are, in fact, abnormally dilated and elongated nerve root sleeves and should, therefore, be distinguished from other types of meningeal cysts occuring in the lumbosacral region. The clinical significance of these dural anomalies are discussed.

Management strategies for acute brain lesions presenting during pregnancy: a case series

Background.u2003The management of brain lesions diagnosed during pregnancy is challenging to both obstetricians and neurosurgeons. In this study, a series of nine pregnant women were admitted to neurosurgery presenting with different acute brain lesions. Objective. To establish guidelines for the management of acute brain lesions that present during pregnancy. Patients and methods.u2003Retrospective review of the medical records of all pregnant women admitted for urgent care to King Khalid University Hospital (KKUH) from 1995 to 2009. Results.u2003Eight patients were multiparous, and one was primigravida, two were in the first trimester, and seven were in the second or third trimester. The mean age was 30.5 years. Six patients had brain tumours, while one patient had tuberculoma, and two had aneurismal subarachnoid haemorrhages (SAH). Three patients completed a full term pregnancy following surgery. Two patients had emergency caesarean section (CS) immediately followed by neurosurgery in the same session. Two patients completed their pregnancies to full term and had craniotomies after delivery. Two patients had therapeutic abortions followed by neurosurgery. No maternal or foetal complications were recorded in this series. Conclusion.u2003The management of pregnant patients with acute brain lesions should be individualised and multidisciplinary. As it is difficult to allocate a single, general treatment protocol to pregnant patients with brain lesions, we suggest the following guidelines: for patients in the second and early third trimesters, it is safe to perform a craniotomy first and allow the patient to complete a full term pregnancy. For patients at 34 weeks or more of gestation, emergency CS followed by a craniotomy is recommended. For patients in the 1st trimester, it is advisable to terminate the pregnancy to allow safe management, although the laws governing this will vary from country to country. For patients with benign tumours who respond to corticosteriods, it is possible to complete the pregnancy and postpone surgery until after delivery.

Paraganglioma of the cauda equina: case report and review of the literature

A rare paraganglioma of the cauda equina is reported. The clinical, radiological and histological features of this neoplasm are described. Diagnosis was resolved by the absence of glial fibrillary acid protein and electron microscopic evidence of neurosecretory features. Relevant literature is reviewed.