Malignant bihemispheric cerebral edema after cranioplasty - An extension of the Monro-Kellie doctrine and predictive factors

Background

Several changes in normal pressure dynamics on the brain occur with a decompressive craniectomy and subsequent cranioplasty. Dead space volume is an important factor contributing to intracranial volume postcranioplasty. A decrease in this volume due to negative suction drain along with relative negative pressure on the brain with the loss of external atmospheric pressure may lead to fatal cerebral edema.

Case Description

A 52-year-old gentleman with a 210 mL volume and middle cerebral artery territory infarction underwent an emergency craniectomy and 6 months later a titanium mold cranioplasty. Precranioplasty computed tomography (CT) scan evaluation revealed a sunken skin flap with a 9 mm contralateral midline shift. Immediately following an uneventful surgery, the patient had sudden fall in blood pressure to 60/40 mmHg and over a few min had dilated fixed pupils. CT revealed severe diffuse cerebral edema in bilateral hemispheres with microhemorrhages and expansion of the sunken right gliotic brain along with ipsilateral ventricular dilatation. Despite undergoing a contralateral decompressive craniectomy due to the midline shift toward the right, the outcome was fatal.

Conclusion

Careful preoperative risk assessment in cranioplasty and close monitoring postprocedure is crucial, especially in malnourished, poststroke cases, with a sinking skin flap syndrome, and a long interval between decompressive craniectomy and cranioplasty. Elective preventive measures and a low threshold for CT scanning and removal of the bone flap or titanium mold are recommended.

Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia: A case report

BACKGROUND

Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid (CSF) blockade due to arachnoidal adhesions and bands. Although many of the techniques currently in use, namely, the theco-peritoneal, syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.

CASE SUMMARY

A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.

CONCLUSION

We present a novel technique aimed at correcting the primary cause of a post-arachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.

Bi-modal radiofrequency treatment for coexisting neuralgia and neuropathy in adjacent divisions of the trigeminal nerve

Trigeminal neuralgia and deafferentation neuropathic pain, or trigeminal neuropathy, are different symptomatologies, rarely reported to present together. The case of a 65-year-old gentleman suffering from trigeminal neuralgia of the maxillary and mandibular division is reported. He first underwent an infraorbital neurectomy that was complicated by deafferentation neuropathic pain, whilst his mandibular neuralgia continued. He was treated successfully for both the neuropathic and neuralgic symptoms in the same session using ultra-extended euthermic pulsed radiofrequency treatment for the maxillary division (V2) and radiofrequency thermocoagulation for the mandibular division (V3). This report is novel in describing the use of dual modalities in the same session for two distinct coexisting clinical entities in two different divisions of the same cranial nerve. The use of ultra-extended pulsed radiofrequency treatment for neuropathic pain in this case is also unique. Nearly 2years after the procedure, the patient continues to have complete pain relief.

Intraventricular tuberculoma

A 38-year-old female presented with headaches, fever, and malaise. Computed tomography showed an intraventricular peripheral ring-enhanced lesion with central necrosis. The lesion was totally excised. Histological examination revealed a tuberculoma. The patient was treated with antituberculous chemotherapy. The patient was asymptomatic at 9 months. Ventricular involvement in neurotuberculosis is rare, but should be considered in the presence of other indicators of tuberculous infection.

Flare up of tuberculous abscess following stereotactic aspiration--case report

A 16-year-old non-immunocompromised and otherwise healthy patient presented with a tuberculous brain abscess. The abscess was aspirated stereotactically. Following the aspiration the disease process flared up and multiple daughter abscess cavities were discovered. The daughter abscesses were removed via craniotomy. Stereotactic aspiration requires care to prevent such flare up of the disease.

Basilar invagination and Chiari malformation associated with cerebellar atrophy: report of two treated cases

We report two patients with an unusual complex of anomalies wherein the basilar invagination and Chiari malformation was associated with marked cerebellar atrophy. Both patients presented with relatively severe lower cranial nerve deficits and showed clinical improvement following a posterior foramen magnum bony decompression. The pathogenesis of the anomalies is discussed and the rationale of treatment is analysed.

Midline cerebellar cystic schwannoma : a case report

An extremely unusual case of a cystic schwannoma in the region of the inferior vermis and posterior to the fourth ventricle in a fifteen year old boy is reported. The cystic tumour caused partial obstruction to the outflow of cerebrospinal fluid from fourth ventricle and resulted in development of supratentorial hydrocephalus. On investigations, the schwannoma simulated a Dandy-Walker cyst. The boy presented with symptoms of increased intracranial pressure. On surgery, the lesion was not arising from any cranial nerve, nor was it attached to brain parenchyma, blood vessel or to the dura. The possible histogenesis of the cystic schwannoma in a rare location is discussed.

Spontaneous cerebrospinal fluid (CSF) rhinorrhoea in spongiform dysplasia of the cranium: an unusual presentation of neurofibromatosis

A 20-year-old woman with neurofibromatosis presented with CSF rhinorrhoea. Spongiform dysplasia of the cranium was found. The dysplastic bone contained CSF. The exact site of the CSF fistula into the calvarium and into the paranasal sinuses could not be detected on investigation but nasal packing of the ethmoid and sphenoid sinuses controlled the rhinorrhoea. The unique features of this case are presented along with a brief review of the literature.

Basilar invagination: a study based on 190 surgically treated patients

OBJECT

The authors analyzed the cases of 190 patients with basilar invagination that was diagnosed on the basis of criteria laid down in 1939 by Chamberlain to assess the appropriate surgical procedure.

METHODS

Depending on the association with Chiari malformation, the anomaly of basilar invagination was classified into two groups. Eighty-eight patients who had basilar invagination but no associated Chiari malformation were assigned to Group I; the remainder of the patients, who had both basilar invagination and Chiari malformation, were assigned to Group II. The principal pathological characteristic was observed to be direct brainstem compression due to odontoid process indentation in Group I and a reduction in posterior cranial fossa volume in Group II.

CONCLUSIONS

Despite the anterior concavity of the brainstem in both groups, transoral surgery was the most suitable procedure for those patients in Group I and decompression of the foramen magnum was found to be appropriate for patients in Group II. After surgical decompression, a fixation procedure was found to be necessary in most Group I cases, but only in a small minority of Group II cases.

Basilar invagination: a study based on 190 surgically treated patients

Object

The authors analyzed the cases of 190 patients with basilar invagination that was diagnosed on the basis of criteria laid down in 1939 by Chamberlain to assess the appropriate surgical procedure.

Methods

Depending on the association with Chiari malformation, the anomaly of basilar invagination was classified into two groups. Eighty-eight patients who had basilar invagination but no associated Chiari malformation were assigned to Group I; the remainder of the patients, who had both basilar invagination and Chiari malformation, were assigned to Group II. The principal pathological characteristic was observed to be direct brainstem compression due to odontoid process indentation in Group I and a reduction in posterior cranial fossa volume in Group II.

Conclusions

Despite the anterior concavity of the brainstem in both groups, transoral surgery was the most suitable procedure for those patients in Group I and decompression of the foramen magnum was found to be appropriate for patients in Group II. After surgical decompression, a fixation procedure was found to be necessary in most Group I cases, but only in a small minority of Group II cases.