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Author(s): Zahra Khosravi (corresponding author) [1]; Katarzyna Minta [2]; Chandrasekaran Kaliaperumal [3] Sir, In the insightful article by Madhugiri and Venkatesan,[sup.[1]] the two authors ask the important question 'Does reader [...]

This article discusses the advancements in neurosurgery, particularly in skull base surgery, and the importance of anatomical knowledge in achieving successful outcomes and avoiding complications. The study focuses on the use of the zygomatic root as a tool for predicting the position of internal landmarks in the middle cranial fossa, which can aid in procedures such as trigeminal neuralgia treatment and epilepsy surgery. The article also highlights the potential benefits of virtual reality and haptic simulation in preoperative planning and training. The authors emphasize the importance of neuroanatomy in various neurosurgical specialties and suggest that the use of the zygomatic root can enhance surgical care for patients worldwide. [Extracted from the article]

Abstract Introduction The authors report a rare case of primary spinal ependymomatosis in a young adult man. Multiple primary ependymomatous lesions were seen on magnetic resonance imaging and no anaplasia was identified on the surgical-pathological analysis. The aetio-pathological mechanism and surgical significance of this rare occurrence is discussed. Case presentation A 26-year-old man of Polish origin presented with a ten-day history of pain in the left leg and lower back. This was followed by difficulty in urinating and a decrease in sensation in both legs. Examination revealed pyramidal signs and mild weakness in both lower limbs. He had early sphincter involvement requiring catheterization. Magnetic resonance imaging of the brain was normal. However, that of the spinal cord revealed multiple intradural spinal lesions, both intra- and extramedullary, extending from the cervical cord down to the cauda equina roots. T12-L1 laminectomy was performed. Multiple intradural, extra- and intra-medullary tumors were seen. After the operation, the patient deteriorated with a sensory level at T4. Post-operative cranio-spinal radiotherapy was administered but there was no clinical improvement in the lower limbs. Conclusion Primary spinal ependymomatosis is a rare phenomenon involving multiple spinal segments in the absence of a primary intracranial tumor. Radical excision is unrealistic in this condition. Biopsy followed by radiotherapy is the preferred method of treatment.

Abstract Introduction We present a case of herpes zoster infection (shingles) precipitated by surgical manipulation of the trigeminal nerve root during an attempted microvascular decompression procedure. The pathogenesis of this phenomenon, as well as the importance and role of prophylactic acyclovir in its management, are discussed. Case presentation A 54-year-old Caucasian man with a classical long-standing left-sided V2 and V3 division primary trigeminal neuralgia refractory to medical management, underwent posterior fossa exploration for microvascular decompression via a standard retromastoid craniectomy. The patient had immediate and complete relief from pain. Three days after the operation, he developed severely painful vesicles with V2 and V3 dermatomal distribution. Rather than the classical paroxysmal, lancinating type of trigeminal neuralgia, the pain experienced by the patient was of a constant burning nature. A clinical diagnosis of herpes zoster (shingles) was made after smear confirmation from microbiological testing. The patient was commenced on antiviral treatment with acyclovir. His vesicular rash and pain gradually subsided over the next two weeks. He remains asymptomatic one year later. Conclusions Postoperative shingles precipitated by trigeminal nerve manipulation during surgery for trigeminal neuralgia can be a distressing and demoralizing experience for the patient. A careful preoperative history, early recognition, and prompt antiviral therapy is necessary.

Background: Colloid cysts of third ventricle are rare lesions which may present with symptoms of acute hydrocephalus. We report a case of acute obstructive hydrocephalus secondary to third ventricular colloid cyst and its management during 1st trimester pregnancy. Case Description: A 31-years-old lady presented to the emergency department with reduced consciousness. Computed tomography head showed obstructive hydrocephalus and an obstructing lesion near foramen of Monro suggestive of third ventricle colloid cyst. She underwent endoscopic resection of colloid cyst. Her pregnancy was only confirmed after surgery and she delivered a healthy neonate at full term. She has remained clinically well and had resumed her work as a general practitioner. Case Description: A 31-years-old lady presented to the emergency department with reduced consciousness. Computed tomography head showed obstructive hydrocephalus and an obstructing lesion near foramen of Monro suggestive of third ventricle colloid cyst. She underwent endoscopic resection of colloid cyst. Her pregnancy was only confirmed after surgery and she delivered a healthy neonate at full term. She has remained clinically well and had resumed her work as a general practitioner. [ABSTRACT FROM AUTHOR]

Background/Aim: Significant change has been happening in the introduction of technology in medical teaching all over the world. We aim to determine if the undergraduate medical students and teachers are open to incorporating changes in the current medical curriculum or if there is a need for the same in the Republic of Ireland. Materials and Methods: A cross-sectional study involving 202 participants of whom 152 were medical students and 50 medical professionals (teachers and hospital doctors) were carried out involving three different medical universities namely; University College Cork (UCC), University College Dublin (UCD), and National University of Ireland in Galway (NUIG). Participants were requested to answer a series of 15 questions designed incorporating various fields of technology necessary for the study. The data was collected and analyzed using Statistical Package for Social Sciences (SPSS) software to determine statistical significance. Results: The participants overall had a positive attitude toward the utility of modern technology and web-based applications in current medical curriculum. Ninety-one percent of the participants preferred the introduction of modern technology into medical education and 7% were against the idea and a further 2% of them remained undecided. Conclusion: There seems to be a "technology gap" in the current undergraduate medical curriculum in Ireland. A large-scale study involving more participants from all the medical schools in Ireland is recommended. We believe, changes can be brought into the current medical teaching and learning to make the process more fruitful and successful. [ABSTRACT FROM AUTHOR]

Ventriculoperitoneal (VP) shunt insertion is one of the most common neurosurgical procedures for the treatment of chronic hydrocephalus. Although regarded as a relatively benign procedure, several complications including obstruction, infection and mechanical failure can be seen during the postoperative stage. Symptomatic sterile cerebrospinal fluid (CSF) ascites and hydrothoracies are rare complications of VP shunt surgery. The paucity of cases makes identifying the aetiological factors difficult, particularly without catheter tip migration. It is most likely that several factors interact to reduce the absorption of CSF. The authors discuss the case of a 5-year-old girl who developed CSF ascites and a pleural effusion after starting chemotherapy for a suprasellar pilocytic astrocytoma, 2 years post-VP shunt insertion, due to a secondary obstructive hydrocephalus. After the initial management of the presenting symptoms, the child's VP shunt was subsequently changed to a ventriculo-atrial shunt and the patient made an unremarkable recovery. We also review the literature pertaining to this rare complication, assessing identifiable risk factors and surgical management options. [ABSTRACT FROM AUTHOR]

We describe a case of severe traumatic brain injury with multiple facial and skull fractures where CT angiogram (CTA) failed to yield a definite result of brain death as an ancillary test. A 28-year-old man was admitted following a road traffic accident with a Glasgow Coma Score (GCS) of 3/15 and fixed pupils. CT brain revealed uncal herniation and diffuse cerebral oedema with associated multiple facial and skull fractures. 72 h later, his clinical condition remained the same with high intracranial pressure refractory to medical management. Clinical confirmation on brain death was not feasible owing to facial injuries. A CTA, performed to determine brain perfusion, yielded a 'false-negative' result. Skull fractures have possibly led to venous prominence in the cortical and deep venous drainage system. This point needs to be borne in mind while considering CTA as an ancillary test to confirm brain death. [ABSTRACT FROM AUTHOR]

The authors describe a case of a giant intracranial mature cystic teratoma in a 16-year-old girl presenting acutely with a severe headache, vomiting and a complex generalised seizure with a background history of intermittent headaches for 3 years. CT and MRI brain demonstrated a ruptured large cystic teratoma encapsulating two large teeth within the diffusely dense fatty heterogeneous lesion. Surgical debulking of the cyst was performed and the calcific remnants were left behind owing to dense adhesion to the brain. The procedure was complicated by postoperative hydrocephalus and needed a ventricloperitoneal shunt. She is currently asymptomatic and undergoing rehabilitation. [ABSTRACT FROM AUTHOR]

The authors describe a case of L-asparaginase induced intracranial thrombosis and subsequent haemorrhage in a newly diagnosed 30-year-old man with acute lymphoblastic leukaemia who was successfully managed by surgical intervention. At presentation, he had a Glasgow Coma Score of 7/15, was aphasic and had dense right hemiplegia. Neuroimaging revealed an acute anterior left middle cerebral artery infarct with parenchymal haemorrhagic conversion, mass effect and subfalcine herniation. He subsequently underwent left frontal craniotomy and evacuation of large frontal haematoma and decompressive craniectomy for cerebral oedema. Six months postoperatively he underwent titanium cranioplasty. He had made good clinical recovery and is currently mobilising independently with mild occasional episodes of expressive dysphasia, difficulty with fine motor movement on the right side, and has remained seizure free. This is the first documented case of L-asparaginase induced haemorrhagic stroke managed by neurosurgical intervention. The authors emphasise the possible role of surgery in managing chemotherapy induced intracranial complications. [ABSTRACT FROM AUTHOR]

Spinal intramedullary epidermoid cyst is a rare condition. Recurrent epidermoid cyst in the spine cord is known to occur. The authors describe a case of recurrent conus medullaris epidermoid cyst in a 24-year-old female. She initially presented at 7 years of age with bladder disturbance in the form of diurnal enuresis and recurrent urinary tract infection. MRI lumbar spine revealed a 4 cm conus medullaris epidermoid cyst. Since the initial presentation, the cyst had recurred seven times in the same location and she underwent surgical intervention in the form of exploration and debulking. This benign condition, owing to its anatomical location, has posed a surgical and overall management challenge. This occurrence is better managed in a tertiary-care centre requiring multi-disciplinary treatment approach. [ABSTRACT FROM AUTHOR]

The authors describe a rare case of metastatic bronchogenic adenocarcinoma in a 55-year-old man presenting with concomittant solitary lytic skull lesion and ischaemic stroke. Metastatic bronchogenic carcinoma is known to present as lytic skull lesions. Primary brain tumours are also known to cause ischaemic brain injury. An underlying stroke risk may be exagerated by cranial tumour surgery. Patients with brain tumours are well known to be predisposed to an increased risk of developing thromboembolic disease. It is unusual to see metastatic bronchogenic adenocarcinoma presenting as ischaemic stroke with a background of concomittant cerebral metastasis. The aetio-pathogenesis of this rare occurrence is discussed with a review of literature. [ABSTRACT FROM AUTHOR]

The authors describe a case of aneurysmal subarachnoid haemorrhage in a 53-year-old man with background of osteogenesis imperfecta (OI). CT brain revealed diffuse subarachnoid haemorrhage (SAH) and cerebral angiogram subsequently confirmed vertebral artery aneurysm rupture leading to SAH. To the authors knowledge this is the first case of vertebral artery aneurysmal SAH described in OI. A previously undiagnosed OI was confirmed by genetic analysis (COL1A1 gene mutation). This aneurysm was successfully treated by endovascular route. Post interventional treatment patient developed stroke secondary to vasospasm. Communicating hydrocephalus, which developed in the process of management, was successfully treated with ventriculo-peritoneal shunt. The aetio-pathogenesis and management of this condition is described. The authors have reviewed the literature and genetic basis of this disease. [ABSTRACT FROM AUTHOR]

The authors describe an unusual case of metastatic thyroid follicular adenocarcinoma presenting with sciatica in a 79-year-old woman. The primary thyroid tumour was undiagnosed until this clinical presentation. The patient gave a short history of back pain and right-sided sciatica, which was progressive and nocturnal in nature. Neuroimaging revealed an enhancing intradural mass lesion, which was completely excised through a right L1-L3 hemilaminectomy. Histopathological examination of the excised tissue revealed a follicular thyroid carcinoma. Subsequent metastatic investigation revealed a heterogeneously attenuating mixed solid cystic mass in a retrosternal thyroid gland, with multiple solid pulmonary nodules suggestive of metastatic disease. She opted for palliative radiotherapy for the primary thyroid cancer and made remarkable postoperative improvement. The authors conclude that surgical treatment of solitary metastatic lesion may produce good symptomatic relief irrespective of patient's age and primary pathology, while emphasising the need for detailed clinical evaluation of patients with 'red flag' symptoms. [ABSTRACT FROM AUTHOR]

Parry-Romberg syndrome (PRS) or progressive hemi facial atrophy syndrome is a rare condition of unknown aetiology that is characterised by progressive unilateral facial and cranial atrophic changes of skin, subcutaneous tissues and bone. The authors describe a 37-year-old female with a history of PRS, who presented with a subarachnoid haemorrhage secondary to rupture of a 9 mm fusiform aneurysm of the posterior cerebral artery. There was an associated external carotid arterio-venous fistula noted with this aneurysm. The aneurysm was treated by endovascular route and was successfully coiled. Follow-up angiogram revealed spontaneous resolution of the fistula with good occlusion of the aneurysm. The aetio-pathogenesis of this rare occurrence, literature review and its management is discussed. [ABSTRACT FROM AUTHOR]

Haemangiopericytomas are a group of aggressive soft tissue sarcomas that originate from the pericytes in the walls of capillaries. Local invasion of the surrounding structures is not uncommon. Symptoms depend on the location, size and grade of tumour. Coexistence with a benign tumour in the same location is very rare. We report an interesting case of occipital scalp lipoma with an underlying torcular haemangiopericytoma and skull defect. [ABSTRACT FROM AUTHOR]

We describe a case of acute functional deterioration in a 13-year-old girl with severe spastic diplegia (GMFCS III) and a new diagnosis of diffuse intrinsic pontine glioma (DIPG). She presented with acute deterioration in mobility and motor function over 1 month, which was associated with dysarthria, dysphagia and behavioural change. Her mother had noticed subtle functional deterioration over the 2 months prior to this. Her physiotherapist who was concerned about her acute functional deterioration referred her for emergency review. Neurological imaging revealed a diffuse pontine lesion consistent with DIPG. She was subsequently referred to oncology. She deteriorated further, clinically, over the next few days and following discussion with the team; her family opted for palliative treatment, given the poor prognosis associated with DIPG. [ABSTRACT FROM AUTHOR]