Subgaleal dermoid cyst of the anterior fontanelle in a child

AbstractThe congenital inclusion dermoid cyst (CDIC) of the anterior fontanel is a benign, slow-growing lesion. Subgaleal location of dermoid cyst is extremely uncommon. We report a case of 14year old female who had subgaleal dermoid cyst of the anterior fontanel where the cyst could be excised completely with good outcome. Computed tomography scan is the investigations of choice as it will show the greater details of the lesion and its relation to the underlying structures. Characteristic scalloping of the outer table of cranium on radiographs can help to differentiate intracranial extension from extracranial location of the lesion

Intraventricular entrapment of shunt catheter causing shunt malfunction

Intraventricular septations can lead to compartmentalization of the ventricles that can result in “complex or loculated hydrocephalus”. We report a case of 7 year old female child who underwent multiple shunt revisions where there was intraventricular entrapment of shunt catheter leading to obstruction of the shunt and malfunction. In present case we placed the ventricular catheter in contra-lateral ventricle with good clinical outcome. With the recent advancements endoscopic guided removal of the old malfunctioning ventricular catheters is considered the safest option

Delayed neurological deterioration due to progressive pneumocephalus

Pneumocephalus can develop immediately following head trauma or clinical presentation may be delayed for days. We report a case of 35 year male whose initial CT scan brain plain small specks of pneumocephalus in left para-sellar region. However the next day he was complaining of severe headache and had multiple episodes of vomiting. Repeat CT scan showed increase in the size of pneumocephalus including appearance of intraventricular air with mild cerebral edema. The patient recovered well with conservative management. The present case is a gentle reminder that in a subgroup of head injury patients, intracranial air can produce significant mass effect leading to tension pneumocephalus which can can behave like other intracranial mass lesions and causes worsening of the neurological status of these patients

Massive infarction and cavernous sinus thrombosis: An uncommon complication of tooth extraction

Cavernous sinus thrombosis (CAST) is a rare and potentially fatal complication following tooth extraction. In present case of a 55 year old male known case of diabetes mellitus underwent tooth extraction. After 5 days, he noticed swelling around the cheek, high grade fever, and frontal headaches. Diagnosis of alveolar abscess after inspection was made, for which incision and drainage was done. Next morning, he noticed that the cheek swelling progressed to left eye and there was CT brain was performed which showed hyperdense areas in cavernous sinus on left side and left sylvian fissure with hemorrhagic venous infarct in left temporal and frontal lobes. More caudal sections revealed mucosal thickness in left maxillary and ethmoidal sinuses, edema over cheek, preseptal orbital swelling, retro-orbital fat stranding and axial proptosis. A diagnosis of rhino-orbital infection from dental source with cavernous sinus extension causing left temporo-frontal hemorrhagic venous infarction was made Emergency surgery for decompression was performed but the patient did not responded to the treatment and succumbed to the infection. This case is a reminder that in patients with uncontrolled diabetes, undergoing dental procedures should be carefully dealt with appropriate antibiotic cover. Early signs like unilateral facial edema, orbital chemosis, edema, and proptosis should raise high index suspicion of cavernous sinus thrombosis

Delayed deterioration following the evacuation of posterior fossa extradural hematoma

A missed or delayed detection of intracranial injuries can lead to progressive neuronal damage and secondary brain damage. We present a case of 45 year female presented 8 after the road traffic accident and had a large posterior extradural hematoma on left side with mass effect. In addition there was a small speck of right frontal contusion with localized cerebral edema. The patient initially improved after evacuation of the hematoma. However on 3rd post-operative day she was complaining of headache and became progressively drowsy. A follow up CT scan showed increase in peri-lesional edema around the right frontal contusion with squashing of the lateral ventricles suggestive of diffuse cerebral edema. The patient was shifted back to intensive care unit and responded well to further conservative management. In our patient the events could be collaborated well with existing evidence (presence of contrecoup contusion and on clinical deterioration at day 3)

Primary hypothyroidism masquerading pituitary macroadenoma

Diffuse and reactive pituitary gland enlargement secondary to primary hypothyroidism is an uncommon occurrence and that can masquerade many pituitary disorders. In present article, we report a case of 19 year female severe hypothyroidism presenting with diffuse enlargement of pituitary gland and hyperprolactinemia and review the clinical importance of this entity. Knowledge of this entity is very important to avoid unnecessary surgery and irreversible complications in this sub-group of patients

Dumbell hydatid disease of spine with posterior paraspinal muscle involvement

Spinal hydatid disease is a rare form of hydatid disease caused by the larval form of Echinococcus granulosus (E. granulosus). Dogs are primarily the definitive hosts of E. granulosus with man and sheep serving as intermediate hosts. Spinal HD contributes to approximately 45 % of all skeletal hydatid disease cases. Spinal HD is perhaps the worst form of parasitic infestations associated with morbidity requiring surgical correction. Braithwaite and Lees have classified spinal hydatids into five types (1) intramedullary (2) intradural extramedullary (3) extradural intraspinal disease (4) vertebral hydatid (5) paravertebral hydatid. When hydatid disease from spinal canal extends into retroperitoneal space through the neural foramen, it gives dumbell formation (similar to nerve sheath tumors). Symptoms of hydatid are mainly due to compressive effects of the cyst, low back pain accompanying motor weakness, sensory disturbances, bowel and bladder disturbances and cauda equina syndrome. Extensive vertebral hydatidosis can cause fractures of vertebrae. Serology tests are used in diagnosing suspected cases of hydatid disease. MRI with soft tissue detail is more preferable than other modalities in diagnosing spinal hydatid. Successful treatment of spinal hydatid disease necessitates adequate neuroimaging evaluation, careful surgical removal without spillage of cystic components and adding adjuvant chemotherapy in few cases is the mainstay of treatment. Sometimes when it is difficult to retrieve all the cysts in toto, debulking is advised

Recurrent extraventricular anaplastic ependymoma with scalp metastasis

Extraneural metastasis from anaplastic ependymoma is uncommon. In a study from Memorial Sloan Kettering Cancer Center where the authors reviewed 81 ependymomas cases (between 1956 and 1989) there were only five (6.2%) cases had extraneural metastases. We present a case of anaplastic ependymoma with scalp metastasis and discuss the possible mechanism of spread. In majority most of the cases of metastatic extracranial ependymoma patients have underlying progressive intracranial disease. Although these patients receive standard treatment for the primary tumor (Gross total resection and radiotherapy) and the management options for recurrences includes re-excision, focal re-irradiation, stereotactic radiosurgery, or craniospinal radiotherapy for metastatic disease the long term outcome is not favorable

Commonly available CT characteristics and prediction of outcome in traumatic brain injury patients

Background: Acute Computerized Tomography (CT) characteristics are used widely and most accepted for prediction of outcome among Traumatic Brain Injury (TBI). The commonly available and simple combinations of existing and unexplored CT parameters may be more useful in prediction of outcome. The present study explores commonly available CT characteristics by possible combinations based on anatomical basics.Methods: Abnormal CT sign was considered with any cranial lesion. Based on anatomical locations of cortical lobes, nine possibilities were made that include individual and combinations of mentioned lobes. The laterality was either right or left or bilateral. The outcome was favourable or unfavourable based on discharge Glasgow Outcome Scale (GOS). Binary logistic regression was used to predict outcome.Results: 452 patients were recruited in the present study. There was significant risk of unfavourable outcome among patients with location of Sub Dural Haemorrhage (SDH) in Parietal + Temporal region (OR=10,p<0.001); Cerebral Contusion in Temporal region (OR=3,p=0.03), Frontal + Temporal region(OR=16,P=0.001), Frontal + Parietal + Temporal region (OR=18.7,p<0.001). Patients with four abnormal CT signs had worst outcome. Presence of SDH on right side (OR=4.5,p<0.001) and bilateral Cerebral Contusion (OR=4.5,p=0.003) was at the risk of unfavourable outcome.Conclusion: The present study based on anatomical classification has shown that location and laterality of lesion can significantly predict TBI outcome

Massive cerebellar infarction: a neurosurgical approach

Cerebellar infarction is a challenge for the neurosurgeon. The rapid recognition will crucial to avoid devastating consequences. The massive cerebellar infarction has pseudotumoral behavior, should affect at least one third of the volume of the cerebellum. The irrigation of the cerebellum presents anatomical diversity, favoring the appearance of atypical infarcts. The neurosurgical management is critical for massive cerebellar infarction. We present a review of the literature