[Show abstract][Hide abstract] ABSTRACT: Sir, Intrathoracic migration of the distal end of the ventriculoperitoneal shunt is extremely uncommon. We came across this rare complication, managed successfully by thoracocentesis and shunt revision. A nine-mo-old child underwent a right side ventriculoperitoneal shunt for tuberculous meningitis with hydrocephalus. Routine X-ray post surgery revealed the distal shunt tip below the dome of diaphragm. Three mo after discharge the child presented to the casualty with severe respiratory distress. X- ray chest revealed hydrothorax with coiled distal end of the tube in the thorax with no part below the diaphragm suggesting a supradiaphragmatic intrathoracic migration of the shunt (Fig. 1). Emergency pleural tap was done to relieve the respiratory distress Once the child’s clinical condition was stabilized, revision of the distal end done. Very few cases of intrathoracic migration of the distal end of the shunt presenting with symptomatic hydrothorax. 1-5 Infants are more prone to become symptomatic, as in infants and young children less than 5 yr, the pleura cannot absorb significant cerebrospinal fluid. The intrathoracic migration of the shunt can be either supradiaphragmatic or transdiaphragmatic. 6 In supradiaphragmatic migration the site of entry into the chest is probably incorrect subcutaneous passage. Doh et al, reported incorrect subcutaneous passage under ribs confirmed by CT scan in a case of supradiaphragmatic migration of the shunt. 2 The intrathoracic migration in the present case is supradiaphragmatic as the chest X- ray revealed whole of the shunt tube coiled in the chest with no part below the diaphragm which could be possibly due to the accidental passage into pleural cavity either by passage under the ribs or in the supraclavicular fossa during tunneling. Management requires revision of the lower end with repositioning the distal end back into the peritoneal cavity is required once the patient’s clinical condition stabilizes as was done in the present case. Temporary exteriorization may be required in very sick children. Meeker et al reported a case of intrathoracic migration of the shunt in a female presenting with dyspnea in her early pregnancy which was managed by serial thoracocentesis as a temporary measure and shunt revision after delivery. 5
Full-text · Article · Mar 2010 · The Indian Journal of Pediatrics
[Show abstract][Hide abstract] ABSTRACT: The authors report a case of intracranial tumor in a 60 year female, previously asymptomatic presenting with altered sensorium following a road traffic accident. Imaging showed a small left frontotemporal contusion along with a large right frontoparietal extra axial mass lesion suggestive of a meningioma. Patient improved significantly after craniotomy and tumour decompression. Histopathology with immunohistochemical analysis however revealed the presence of a solitary fibrous tumor of meninges. The case is reported in view of its rarity, atypical presentation and need to distinguish from meningiomas which they can mimic radiologically.
No preview · Article · Dec 2009 · Journal of neurosurgical sciences
[Show abstract][Hide abstract] ABSTRACT: Traumatic spinal epidural hematomas in children are uncommon. Early diagnosis and prompt surgical evacuation is critical in these patients. We report two children with traumatic thoracic spine epidural hematomas with remarkable neurological recovery after surgical evacuation. Epidural hematoma with significant cord compression requires early diagnosis and emergency evacuation. This is crucial to expedite neurological recovery.
No preview · Article · Aug 2009 · Journal of Clinical Neuroscience
[Show abstract][Hide abstract] ABSTRACT: The objective of this retrospective study was to study the outcome in patients with basal ganglia, thalamus and brainstem (central/deep) arteriovenous malformations (AVMs) treated with gamma knife radiosurgery (GKS) and to compare the results with that for AVMs at other intracranial locations.
The results of 53 patients with central AVMs and 255 patients with AVMs at other locations treated with GKS at our center between April 1997 and March 2005 with minimum follow-up of 1 year were analyzed. CENTRAL AVMS: Forty of these 53 AVMs were Spetzler-Martin grade III, 11 were grade IV, and 2 were grade V. The mean AVM volume was 4.3 cm(3) (range 0.1-36.6 cm(3)). The mean marginal dose given was 23.3 Gy (range 16-25 Gy). The mean follow-up was 28 months (range 12-96 months). Check angiograms were advised at 2 years after GKS and yearly thereafter in the presence of residual AVM till 4 years. Presence of a residual AVM on an angiogram at 4 years after radiosurgery was considered as radiosurgical failure. Complete obliteration of the AVM was documented in 14 (74%) of the 19 patients with complete angiographic follow-up. Significantly lower obliteration rates (37% vs. 100%) were seen in larger AVMs (>3 cm(3)) and AVMs of higher (IV and V) Spetzler-Martin grades (28% vs. 100%). The 3- and 4-year actuarial rates of nidus obliteration were 68% and 74%, respectively. Eight patients (15%) developed radiation edema with a statistically significantly higher incidence in patients with AVM volume >3 cm(3) and in patients with Spetzler-Martin grade IV and V AVMs. Five patients (9.4%) had hemorrhage in the period of latency. COMPARISON OF RESULTS WITH AVMS AT OTHER LOCATIONS: Patients with central AVMs presented at a younger age (mean age 22.7 years vs. 29 years), with a very high proportion (81% vs. 63%) presenting with hemorrhage. Significantly higher incidence of radiation edema (15% vs. 5%) and lower obliteration rates (74% vs. 93%) were seen in patients with central AVMs.
GKS is an effective modality of treatment for central AVMs, though relatively lower obliteration rates and higher complication rates are seen compared to AVMs at other locations.
No preview · Article · May 2009 · Acta Neurochirurgica
[Show abstract][Hide abstract] ABSTRACT: Although the effects of Gamma Knife surgery (GKS) on the risk of hemorrhage are poorly understood, a certain subset of patients does suffer bleeding after GKS. This study was undertaken to analyze the outcome of patients sustaining hemorrhage after GKS; it is the most feared complication of radiosurgical management of cerebral arteriovenous malformations (AVMs).
Between May 1997 and June 2006, 494 cerebral AVMs in 489 patients were treated using a Leksell Gamma Knife Model B, and follow-up evaluations were conducted until June 2007 at the All India Institute of Medical Sciences in New Delhi. Fourteen patients who sustained a hemorrhage after GKS formed the study group. In most of these patients conservative management was chosen.
The mortality rate was 0% and there was a 7% risk of sustaining a severe deficit following rebleeding after GKS. None of the patients sustained rebleeding after complete obliteration. Patients with Spetzler-Martin Grade III or less had increased chances of hemorrhage after GKS (p < 0.002). The presence of deep venous drainage, aneurysm, venous hypertension, or periventricular location on angiography was common in patients with hemorrhage after GKS.
The risk of hemorrhage that remains following GKS for cerebral AVMs is highest in the 1st year after treatment. The present study showed a relatively good outcome even in cases with hemorrhage following GKS, with no deaths and minimal morbidity, further substantiating the safety and efficacy of the procedure.
No preview · Article · May 2009 · Journal of Neurosurgery
[Show abstract][Hide abstract] ABSTRACT: Radiosurgery has been widely adopted for the treatment of cerebral AVMs. However radiosurgical treatment of patients with hemorrhagic presentation is fraught with risk of rebleed during latency period. The present study intends to analyze the obliteration rate, time to obliteration and chances of rebleed in patients with hemorrhagic versus non-hemorrhagic clinical presentation in cerebral arteriovenous malformations (AVMs) treated with gamma knife radiosurgery (GKS).
Of all the patients with cerebral AVMs treated from May 1997 to June 2006, 157 patients with neuroimaging follow up with digital subtraction angiography harboring 160 AVM nidii formed the study group. The mean age of presentation was 28 years (range, 6-58 years); mean nidus volume being 3.64 cm3 (range, 0.011-36.6 cm3). The mean follow up period was 70 months (range, 13-121 months). All the patients were treated predominantly by primary GKS with use of adjunctive pre-GKS embolization in selected patients.
A total of 103 (64%) patients presented with hemorrhage. There was no difference in the obliteration rate (69% versus 67%, p=0.672), mean latency period to obliteration (30 months versus 32 months, p=0.1989) and chances of hemorrhage (4.8% versus 3.5%, p=0.690) in patients with hemorrhagic as compared to non-hemorrhagic presentation.
Prior hemorrhage does not affect the outcome after GKS in terms of obliteration rate, latency to obliteration as well as chances of hemorrhage during latency period. Gamma knife appears equally efficacious irrespective of the mode of clinical presentation in the management of cerebral AVMs; a concomitant use of pre-GKS embolization/surgery may be needed in patients with hemorrhagic presentation in selected cases, however.
No preview · Article · Jul 2008 · Clinical Neurology and Neurosurgery
[Show abstract][Hide abstract] ABSTRACT: Craniopharyngiomas with a large posterior fossa extension beyond the level of the foramen magnum are very rare and usually removed in two stages. The objective of this paper is to report that such rare cases of giant cystic predominantly retrochiasmatic retroclival craniopharyngiomas can be completely excised by an anterior transpetrous approach in a single stage.
The first case was a 6-year-old boy who presented with a 1-year history of recurrent episodes of seizures, headache, and vomiting. The second case was a 10-year-old girl who presented with history of headache, visual deterioration, and left-side hemiparesis for one and half years. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) in both these patients revealed a giant sellar suprasellar cystic lesion with areas of calcification and the lesion was predominantly retrochiasmatic with a huge retroclival posterior fossa extension down to the level of the C1 vertebra and laterally to the cerebellopontine angle. Gross total excision of both suprasellar and posterior fossa extensions could be done in both the patients through an anterior transpetrous transtentorial approach (Kawase's approach).
Postoperative imaging (MRI/CT) revealed no obvious evidence of residual tumor. The first patient had right hemiparesis from which he recovered completely. The second patient died suddenly on postoperative day 4 after initial uneventful postoperative period, and the exact cause of death is not known.
Giant cystic craniopharyngiomas, which are predominantly retrochiasmatic and associated with huge retroclival posterior fossa extensions, can be removed in single stage by Kawase's approach.
Full-text · Article · Apr 2008 · Child s Nervous System
[Show abstract][Hide abstract] ABSTRACT: Neonatal intracranial aneurysms are rare, with only 20 cases being reported in the literature. No case of spontaneous resolution of a giant intracranial cavernous segment aneurysm in a neonate is reported till date. The authors describe a 3-week-old male child who presented with a left-sided tonic seizure episode and was diagnosed as having a right-sided giant cavernous internal carotid artery aneurysm. The aneurysm was found to be totally thrombosed on angiography done before planning definitive treatment. The child is doing well at 2 years of follow-up. Spontaneous thrombosis, an exceptionally rare but fortunate outcome in a rare case of giant neonatal internal carotid artery aneurysm, has led the authors to report this case. The need of repeat imaging or angiography should be considered to rule out this rare outcome, more so if there is any delay between the ictus and treatment.
No preview · Article · Feb 2008 · Pediatric Neurosurgery
[Show abstract][Hide abstract] ABSTRACT: This retrospective study was designed to study the outcome in children with intracranial arteriovenous malformations (AVMs) treated with Gamma Knife surgery (GKS).
One hundred and forty-two children were treated with GKS at the authors' institution between April 1997 and March 2006; of these, 103 patients with a mean follow-up of 26.4 months (range 6-96 months) were included. The mean age at presentation was 13.9 years (range 3-18 years). Eighty-six (83%) patients presented with hemorrhage. In 57 children the AVMs were Spetzler-Martin Grade I or II, and in 46 the AVMs were Grades III, IV, or V. The mean volume of the AVMs was 2.4 ml (range 0.04-23.3 ml). The mean marginal dose administered was 24.4 Gy (range 15-27 Gy). Follow-up angiography was advised at 2 years after GKS and yearly thereafter. In patients with residual AVMs, follow-up angiography was advised yearly until 4 years after GKS. If residual AVM was present, even on a follow-up angiogram obtained 4 years postsurgery, the GKS was considered a failure.
Complete obliteration of the AVM was documented in 34 (87%) of the 39 patients with complete angiographic follow-up. The 3- and 4-year actuarial rates of nidus obliteration were 66 and 86% respectively. Three patients (2.9%) experienced bleeding during the latency period, and symptomatic radiation-induced edema was noted in four patients (3.8%). A significantly higher incidence of radiation edema was noted in patients with AVM volumes greater than 3 ml and in patients with Spetzler-Martin Grade IV and V AVMs.
Gamma Knife radiosurgery is an effective modality for the treatment of intracranial AVMs in children, yielding high obliteration rates and low complication rates.
No preview · Article · Jan 2008 · Journal of Neurosurgery
[Show abstract][Hide abstract] ABSTRACT: Eumycetoma in the cerebellopontine angle region is extremely uncommon with no case being reported as per an extensive review of the literature by the authors. The authors report a case of cerebellopontine angle eumycetoma in a young female managed by subtotal decompression and antifungal treatment. The pre-operative diagnosis of eumycetoma in this location is extremely difficult and the role of histopathology is very important to characterize this uncommon lesion. The prognosis of this bizarre pathology is dismal despite all treatment modalities as compared to the usual tumors of the cerebellopontine angle that generally have a favorable outcome.
No preview · Article · Aug 2007 · Clinical Neurology and Neurosurgery
[Show abstract][Hide abstract] ABSTRACT: Significant numbers of patients with spinal tuberculosis (TB), especially in developing countries, still present late after disease onset with severe neurological deficits. The authors conducted a study to assess the outcome in these patients.
Fifty-nine patients with spinal TB and severe motor deficits underwent surgery at the authors' center during the past 10 years. Data obtained in 48 patients with a minimum of 3 months of follow up (mean follow-up period 12.8 months) were analyzed. The disease in 34 patients was characterized by Frankel Grade A/B (Medical Research Council Grade 0/5) and in 14 patients by Frankel Grade C (unable to walk even with support) at admission. Thirty (88%) of the 34 patients with Frankel Grade A/B status and 13 (92.8%) of the 14 patients with Frankel Grade C status at admission experienced improvement to Frankel Grade D/E (walking with or without support) at the last follow-up examination 3 or more months after surgery. The degree of improvement exhibited by patients with a Frankel Grade A/B spinal cord injury was comparable to that shown by patients with Frankel Grade C status. Even patients with flaccid paraplegia, gross sensory deficit, prolonged weakness, spinal cord signal changes demonstrated on magnetic resonance imaging, and bladder involvement have experienced dramatic improvement in motor function since surgery. A significant number of the patients have shown remarkable improvement in other symptoms such as pain (91.6%), spasticity (88%), and bladder symptoms (88%).
A significant proportion of patients with spinal TB and severe motor deficits experience remarkable improvement after surgical decompression and hence should undergo surgery even though they may be suffering from paraplegia of considerable duration.
No preview · Article · May 2007 · Journal of Neurosurgery Spine