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A 33-year-old man with anti-phospholipid antibody syndrome associated with Budd Chiari syndrome and subdural hematoma. He developed venous thrombosis in his hepatic vein (stenting done) when laboratory studies demonstrated prolongation of activated partial thromboplastin time (APTT). Subdural hematoma demonstrated with Computed tomography (CT) of brain. Laboratory studies revealed thrombocytopenia, prolonged bleeding time and APTT, positive antinuclear antibody and positive test results for both lupus anticoagulant and an anti-cardiolipin antibody, namely antiphospholipid antibodies. Based on these findings, we consider that the tendency of this bleeding may have been due to antiphospholipid antibodies, attacking the platelet membranes and that the bridging veins in the subdural space may be the site at which the bleeding tendency easily appears. Antiphospholipid antibody syndrome accompanied by hemorrhagic complications had rarely been reported. We suggest that special attention should be given to hemorrhagic complications in patients with antiphospholipid antibody syndrome associated with fragility of the vessels and/or platelet dysfunction and on anticoagulant (warfarin).Pulse Vol.10 January-December 2017 p.25-28

Background : A meningioma is a tumor that arises from the meninges- the membranes that surround the brain and spinal cord. Objective : This is a retrospective analysis of the recorded data of patients managed for intracranial meningiomas between January 2007 and June 2015 at Apollo Hospital, Dhaka. Methodology : Demographic data was analyzed for all but only patients who had surgery and histological diagnosis were analyzed for outcome. Results : This study shows that meningiomas had female preponderance. Majority cases were above 50 years of age. Convexity is the most common anatomical location of meningioma. Most common symptoms were headache (70%) followed by seizure in 34.3% of patients. 90% of the cases were benign. Malignant meningioma was 1.4% and recurrence was found in 1.4% of cases. Six patients with histological grades I, II and III meningi- omas were sent for stereotactic radiotherapy after incomplete tumor resection or for residual tumour. Total removal was done in 80% cases and the mortality was 1.4%, in patient who had poor GCS score on admission. Pulse Vol.9 January-December 2016 p.22-26

Introduction: Cerebellopontine angle tumors are a surgical challenge to many neurosurgeons who want to operate in this space. Although most of these tumors are benign, they are a challenge because of the complex anatomy and important neurovascular structures that traverse this space. Most common cerebellopontine angle tumor is vestibular schwannoma. The management of these cases is essentially surgical. There has been a change in the surgical strategy over the years from simple intratumoral decompression to complete microsurgical excision, to radical excision with facial nerve and hearing preservation. Objectives: To study the clinical and radiological characteristics, know the pathological types and determine the surgical resectability and outcome of cerebellopontine angle tumor. Materials and Methods: It is a retrospective study done in the department of Neurosurgery, Apollo Hospitals Dhaka. 34 patients diagnosed with cerebellopontine angle tumor were recruited into the study. Results: Among 34 cases of cerebellopontine angle tumors vestibular schwannoma alone constituted 79%. Most of the tumors were large or giant tumors. Total resection was done in 25% of vestibular schwannoma and 50% of meningiomas. Anatomical preservation of facial nerve was achieved in 73% of patients. Facial nerve function as measured by the House Brackmann system. Postoperatively 61% had a score of 1 or 2; 29% had a score of 3 or 4; and 8% had a score of 5 or 6. Other complications included 2 cases of CSF leak, 3 cases of meningitis, 2 cases of lower cranial nerve palsy and 1 patient died. Conclusion: Cerebellopontine angle tumors show high incidence from 3rd to 5th decade with common symptoms being hearing loss and ataxia. Most of the patients presented at a delayed stage with large to giant tumors with no useful hearing. Sub total excision with keeping anterior part of tumor for preserving facial nerve function is the goal. Pulse Vol.8 January-December 2015 p.8-14

A 41 year old nondiabetic, non hypertensive male was admitted in AHD through neurosurgery OPD with the complaints of left eye watering and left sided weakness for 1 month. MRI examination revealed a mass / lesion in the left prepontine cistern, left CP angle with extension to left middle cranial fossa which was histologically found to be chondroma, an extremely rare tumour in the above mentioned location.Pulse Vol.8 January-December 2015 p.81-84

Objectives: The aim of this study was to test the hypothesis that decompressive hemicraniectomy (DHC), compared with craniotomy with evacuation of hematoma, and would improve clinical outcomes of patients with supratentorial intracerebral hemorrhage (SICH). Methods: We compared patients (November 2008–February 2014) with supratentorial ICH treated with DHC without hematoma evacuation and craniotomy with hematoma evacuation. DHC measured at least 150 mm and included opening of the dura. We analyzed clinical, radiological, and surgical characteristics. Outcome at 6 months was divided into good (modified Rankin Scale 0–4) and poor (modified Rankin Scale 5–6). Results: Fifteen patients (mean age 58 years) with ICH were treated by DHC. Median hematoma volume was 61 ml and mean preoperative Glasgow Coma Scale (GCS) was 7. Ten patients had good and five had poor outcomes. In hematoma evacuation group 29 patients were treated. Median hematoma volume was 55 ml and mean preoperative Glasgow Coma Scale (GCS) was 8. Seventeen patients had good and twelve had poor outcomes. Conclusions: DHC is more effective than hematoma evacuation in patients with SICH. Based on this small cohort, DHC may reduce mortality. Larger prospective study is warranted to assess safety and efficacy. Pulse Vol.7 January-December 2014 p.16-21

Congenital dermoid inclusion cyst over the anterior fontanelle (CDIC) is an uncommon cystic lesion. It is a benign and curative lesion. In these two cases a soft, cystic mass located over the anterior fontanelle. The cyst had no intracranial extension and was easily excised intact. The clinical and image findings of the cysts were described and compared with the usual dermoids. Many different types of lesions over the children's skull exist and some are commonly diagnosed in daily practice. Congenital dermoid inclusion cyst over the anterior fontanelle (CDIC) is a rare and benign lesion.Pulse Vol.7 January-December 2014 p.42-45

Background Temporary occlusion of the proximal vessel is being increasingly used as an adjunct during aneurysm surgery for safer dissection, evacuation of the aneurysm, and to prevent intraoperative rupture. The guidelines regarding its practice are ambiguous. One of the major concerns is the safe time limit for temporary occlusion. Studies done so far have failed to reach a consensus on this issue. This study is an attempt to provide a practical, safe time period of intermittent occlusion of an artery in the anterior circulation, irrespective of vascular territory. Patients and Methods A total of 68 patients in whom elective, intermittent, temporary clipping of the proximal vessel was employed during aneurysm surgery were prospectively studied. They were divided into two groups, Group I with an occlusion period of less than 7 minutes and Group II with occlusion period of 10 minutes and above per episode. The incidence of complications in both groups, their relationship to the number of intermittent clippings, and the total duration of clipping were analyzed. Results The incidence of complications was more in Group II (23.5 vs. 8.8%). There was a reduction in the incidence of complications when the duration of occlusion per episode was reduced; this, however, was not reflected statistically (p = 0.1). The total duration of temporary occlusion, when compared, was significantly longer in Group II (p = 0.000). The total duration of clipping, however, was not significantly different between those who developed complications and those who did not (p = 0.86). The occurrence of complications did not correlate with the vascular territory, number of intermittent clippings, or the total duration of occlusion within their respective groups. Conclusion Our study supports the view that the proximal vessel can be safely occluded during aneurysm surgery. The total occlusion period could be safely prolonged when employed in an intermittent fashion with periods of reperfusion to attain the objective of safe dissection. The reduction in duration of each episode of occlusion, though resulted in fewer complications, did not reach statistical significance.

A 56 years old diabetic hypertensive male was admitted through neurosurgery OPD with the complaint of vision problems in the right eye for the last 1 and 1/2 years. Peri-metry reveals bilateral temporal field defects and MRI examination showed a sellar and suprasellar mass infiltrating the surrounding structures including cavernous sinus. Histomorphologically and inmmunohistochemically, a diagnosis of atypical pituitary adenoma was made.Pulse Vol.8 January-December 2015 p.66-68

Isolated cerebral mucormycosis without rhino-orbital focus is an extremely rare but life-threatening infection of central nervous system that most commonly found in intravenous drug abuser. We present a case of isolated cerebral mucormycosis diagnosed by open biopsy and treated with amphotericin B. DOI: http://dx.doi.org/10.3329/pulse.v5i2.20267 Pulse Vol.5 July 2011 p.54-57

Study design A retrospective descriptive assessment of the clinical and radiologic outcomes of 11 patients who underwent transpedicular decompression for thoracic spine tuberculosis. Objectives To study the neurologic and radiologic outcomes in patients who underwent transpedicular decompression for thoracic spine tuberculosis. Summary of background data Several approaches have been used in the management of thoracic spine tuberculosis to achieve the goals of decompression of the cord followed by immobilization and antituberculous therapy. These range from conservative regimens of computed tomography-guided biopsy followed by bed rest and drug therapy to radical surgeries that involve extensive debridement of the vertebral body followed by instrumentation. The authors report their experience with a "middle path" regimen of transpedicular decompression followed by external immobilization and antituberculous therapy. Methods The charts of 11 patients were reviewed retrospectively for clinical outcome, and kyphotic angle was measured on the follow-up radiographs to ascertain progression of kyphosis. Results There was no worsening of the neurologic status in any patient, and 10 of the 11 patients returned to functional activity. There was no significant progression of kyphosis. Conclusions Our results show that the transpedicular approach is a viable and safe surgical option for ventral decompression in thoracic spine tuberculosis, followed by chemotherapy for 18 months and immobilization in an alkathene shell for 3 months.

We report the results of a prospective randomized controlled trial, which looked at the incidence of postoperative diabetes insipidus (DI) following the use of three different hydrocortisone protocols, and the results of a study, on the incidence of DI and cortisol response in patients not given hydrocortisone. In study 1, 114 patients with pituitary macroadenoma were randomized into three groups: conventional dose (inj. hydrocortisone 100 mg IV 6-hourly for 3 days); intermediate dose (inj. hydrocortisone 100 mg IV 6-hourly on day 1, 100 mg IV 8-hourly on day 2, and 100 mg IV 12-hourly on day 3); low dose protocol (inj. hydrocortisone 25 mg IV 6-hourly on day 1, 25 mg IV 8-hourly on day 2 and 25 mg IV 12-hourly on day 3). Radical excision was achieved in 92 patients. The incidence of DI with the conventional dose was 52%, intermediate dose, 36% and low dose, 24% (p = 0.025). Study 2 included 16 consecutive patients with Hardy's grade A & B pituitary adenoma. These patients were randomized to receive (Group I) or not receive (Group II) hydrocortisone. Patients in Group II demonstrated normal cortisol response intraoperatively and no patient developed features of hypocortisolism; the incidence of DI in this group was 14%. The low dose hydrocortisone protocol reduced the incidence of DI by 46% when compared with the conventional dose hydrocortisone protocol. In patients with grade A and B tumour with normal preoperative cortisol levels, the use of perioperative hydrocortisone can be avoided.

Although the clinical and imaging features and behaviour of brain stem gliomas in children are well documented, similar data are not available, for adults. We have carried out a retrospective study, on 101 consecutive patients (71 children and 30 adults) with a histologically verified brain stem glioma. Duration of symptoms, clinical features, imaging characteristics, histopathology and outcome were specifically compared in children and adults with brain stem glioma. Peak incidence was in the first decade in children and in the third and fourth decades in adults. Mean duration of symptoms before admission was 9.7 months in adults and 3.6 months in children (P

Thirty two poor grade patients (grade 3, 20 patients and grade 4, 12 patients) with tuberculous meningitis and hydrocephalus were prospectively studied to evaluate the response to external ventricular drainage in predicting outcome after shunt surgery. All grade 3 patients underwent a shunt procedure irrespective of their response to external ventricular drainage, and an attempt was made to correlate the immediate response to external ventricular drainage to their long term outcome. Patients in grade 4 underwent shunt surgery only if there was clinical improvement by at least one grade after external ventricular drainage. Follow up (mean 23.1 months) was available for 30 patients (93%). Of the 20 patients in grade 3, seven underwent shunt surgery directly, 13 after an external ventricular drainage. In the group which underwent drainage, the immediate clinical response was improvement in six, no change in six, and death in one. Long term improvement or death occurred almost equally in all the subgroups. The immediate response to external ventricular drainage was not predictive of the long term outcome in grade 3 patients. All 12 patients in grade 4 underwent an external ventricular drainage and only one improved. The rest continued to deteriorate and succumbed to the disease. Grade at admission was the single most important predictor of good outcome (p=0.002) and severity of hydrocephalus had an adverse impact on outcome (p= 0.04). The rest of the variables studied (age, duration of illness, duration of altered sensorium, CSF cell count, and CSF protein concentrations) had no effect on long term outcome. All patients in grade 3 should be given the benefit of shunt surgery without a trial of external ventricular drainage. However, patients in grade 4 should undergo an external ventricular drainage in view of the high mortality in this group.

Tumours of the pineal region are rare. Between 1983 and 1997, 128 patients with pineal masses were treated in our institution. Forty-eight (38%) of these were benign. There were 13 patients with meningiomas, 11 with epidermoid tumours, 10 with cystic lesions, five with vascular lesions, five with infective pathology and four with mature teratomas. All patients were managed surgically. Ventriculo-peritoneal shunts were inserted preoperatively to relieve hydrocephalus. Open surgery thereafter was mostly done through the supracerebellar infratentorial approach. The occipital transtentorial route was preferred for meningiomas. Stereotactic biopsy was used in two patients only. Radical excision of tumours was achieved in 55% of operated cases, partial excision in 25%. Radiation therapy, which was the mainstay of treatment earlier, was used only in two patients. Stereotactic radiosurgery was used in one patient. All patients followed up were found to be in good or excellent condition.

Two patients with posterior fossa arachnoid cysts associated with syringomyelia are discussed adding to the five cases already reported in the literature. The formation and progression of syringomyelia secondary to a posterior fossa cyst and its possible pathophysiology by dynamic CSF flow studies using magnetic resonance (MR) imaging are discussed and reviewed.

Background Symptomatic pneumocephalus after transsphenoidal surgery, though reported, is a rare phenomenon. We report three cases of pneumocephalus in a series of 300 transsphenoidal operations for sellar/suprasellar mass lesions done over the past 12 years. Methods and Results Three cases of symptomatic pneumocephalus occurring after transsphenoidal surgery are presented to illustrate the causative factors, methods of prevention, and management. In case 1, an intraoperative cerebrospinal fluid (CSF) leak occurred and drainage of CSF through a lumbar subarachnoid drain resulted in pneumocephalus, in spite of repair of the sellar floor. In case 2, partial excision of tumor and subsequent reduction of intracranial pressure due to a ventriculoperitoneal (VP) shunt led to pneumocephalus. In case 3, radiotherapy-induced shrinkage of a partially excised tumor resulted in pneumocephalus. The sellar floor had not been repaired in cases 2 and 3 as there was no intraoperative CSF leak and only a partial excision had been done. Conservative management failed in the two patients in whom it was tried. Repair of the sella and sphenoid sinus had to be done in all three cases. Conclusions Repair of the sellar floor should be done after a transsphenoidal approach in all cases, even when no intraoperative leak has been identified and only a partial excision of tumor has been done. Once pneumocephalus has occurred, the sellar floor and sphenoid sinus should be repaired early before reducing the intracranial pressure (ICP) by tapping ventricular air and draining or diverting CSF.

BACKGROUND Empiric antibiotic therapy for multiple brain abscesses is not advised, as biopsy to rule out other causes and material for cultures can be obtained with minimal morbidity using computed tomography (CT)-guided stereotaxy. METHODS We report a good outcome following treatment of this 60-year-old nonimmunocompromised patient with six pyogenic cerebral abscesses. CT-guided stereotactic aspiration of two abscesses were done on the first occasion and appropriate antibiotics were administered. Serial CT scans were done and the abscesses that recollected or enlarged were again aspirated. RESULTS Group A beta hemolytic streptococci were grown from the pus. Two abscesses recollected and one enlarged during antibiotic therapy. These were aspirated on the second and third occasions, 1 week and 2 weeks after the first procedure. The abscess less than 3 cm resolved with antibiotics alone. Intravenous crystalline penicillin, chloroamphenicol, and metronidazole were given for 2 weeks followed by oral ampicillin and cotrimoxazole for 10 weeks. There was no morbidity related to the multiple procedures and the patient had a good outcome at the end of 16 weeks. CONCLUSIONS CT-guided stereotactic aspiration of multiple brain abscesses is known to have a low morbidity and mortality. We highlight the additional option of multiple, staged aspirations for those abscesses not readily responding to antibiotic therapy.

We hypothesized that when contrast-enhanced CT reveals a solitary cerebral cysticercus granuloma, MRI would not usually provide additional information that might assist in management. We retrospectively compared visualisation of solitary cysticercus granulomas on contrast-enhanced CT and MRI in 16 patients presenting with seizures; gadolinium (Gd) enhancement was used in 6 patients. The granuloma was delineated well on both CT and MRI in 15 patients; in one patient, in whom CT was performed with 10-mm slices, it was seen only on contrast-enhanced MRI, CT and unenhanced MRI revealing only the surrounding oedema. On CT the granuloma was seen best on thin (2-5 mm) contrast-enhanced sections (in 10 patients). On MRI, Gd-enhanced images showed the granuloma best, as a ring-enhancing lesion, in all 6 patients. In the other 10 patients, the granuloma was seen only on T2-weighted images in 8 and on both T1- and T2-weighted images in 2. On T2-weighted images a characteristic low-signal ring with a high-signal centre was seen in 12 patients. Sensitivity of the imaging techniques was: contrast-enhanced CT (5 and 10 mm slices) 93.8% (15/16); thin (2-5 mm) section contrast-enhanced CT 100% (6/6); unenhanced MRI 93.8% (15/16). MRI did not reveal additional granulomas or cysts in any patient. In patients strongly suspected to be harbouring this lesion, when 10-mm contrast-enhanced CT reveals only oedema, thin (2-5 mm) slice CT is a cost-effective alternative to MRI.

✓ Solitary cysticercus granulomas that produce seizures usually measure less than 20 mm in diameter and diminish in size spontaneously. Unlike live cysticercus cysts, they have not been known to increase in size. In a prospective follow-up study of 93 consecutive patients with epilepsy and small solitary lesions (< 20 mm in diameter) enhancing on computerized tomography (CT), 91 were found to have solitary cysticercus granuloma; of these, seven (7.7%) were diagnosed as having an enlarging cysticercus granuloma. Enlarging lesions were defined as those that, on follow-up CT, had increased by more than 50% of their original size but were still less than 20 mm in diameter (Group 1, three patients) or those that had increased to more than 20 mm (Group 2, four patients). Excision biopsy is recommended for Group 2 solitary lesions, regardless of the clinical progression, to eliminate the possibility of other pathologies. However, a trial of albendazole therapy with early CT re-evaluation (within 4 to 6 weeks) may be warranted in those with Group 1 lesions and in selected patients with Group 2 lesions. It is important to recognize the entity of enlarging solitary cysticercus granuloma to avoid mistaking it for a tuberculoma and treating the patient with empiric antituberculous therapy.

The main objective of our study was to evolve a practical management protocol for neurosurgical patients with hyponatremia and natriuresis, based on their blood volume status and hematocrit. Twenty-one patients with hyponatremia and natriuresis and 3 control patients were studied. Patients with hyponatremia were categorized on the basis of their hematocrit, central venous pressure, and total blood volume. Group A consisted of patients with hypovolemia and anemia (16 patients); Group B patients had hypovolemia but no anemia (5 patients); Group C included those with hypervolemia (0 patients). Patients in Groups A and B received isotonic saline (> 50 ml/kg/d) and oral salt (12 g/d). Additionally, those in Group A were transfused with 500 ml of whole blood. The end points in the study were 72 hours after entry or two consecutive serum sodium values of > 130 mEq/L, whichever was earlier. Hyponatremia was corrected in all the patients within 72 hours (1 patient, < 24 h; 13 patients, < 48 h; and 7 patients, < 72 h). We conclude that most neurosurgical patients with hyponatremia and natriuresis have hypovolemia, with or without anemia. Fluid and salt replacement and a blood transfusion rather than fluid restriction often results in the correction of the hyponatremia. Our findings offer indirect evidence to support the hypothesis that in most of these patients, hyponatremia is caused by cerebral salt wasting syndrome, rather than the syndrome of inappropriate secretion of antidiuretic hormone.

The brain stem is an unusual location for a pyogenic abscess. We report a case of a brain stem abscess in a 5-year-old boy with tetralogy of Fallot that was refractory to conservative medical therapy but was cured after a single computed tomographic-guided stereotactic aspiration and appropriate antibiotic therapy. The remarkable features in this case were the extremely large size of the abscess (3.2 cm in diameter), occupying the full vertical extent of the brain stem and containing 15 ml of pus. We believe this is the first report of a favorable outcome in a cardiogenic brain stem abscess. The value of computed tomographic-guided stereotactic surgery in the management of this lethal condition is documented with a review of the relevant literature.

Neuronal cell damage following ischaemia is postulated to be due to free radical induced lipid peroxidation, and ascorbic acid is supposedly an important non-enzymatic scavenger of such free radicals. This study was undertaken to evaluate the protective effect of ascorbic acid on the brain in a primate model after focal cerebral ischemia. Consumption of ascorbic acid in the monkey brain following ischaemia and its effect on macroscopic infarct size as demonstrated by 2, 3, 5, Triphenyl tetrazolium chloride (TTC) staining were used as parameters. The monkeys in the treated group were given 1 gram ascorbic acid parenterally every day for six days. The mean level of total ascorbic acid in right basal ganglia was 35.1 +/- 4.2 micrograms/mg of protein in the treated group as opposed to 22.9 +/- 2.1 micrograms/mg of protein in the nontreated group both before ischaemia. After right middle cerebral artery occlusion to produce focal cerebral ischaemia, the total ascorbic acid in the right basal ganglia 2 hours post ischaemia was 13.3 +/- 3.1 micrograms/mg of protein in the treated group as opposed to 9 +/- 1.6 micrograms/mg of protein in the untreated group. The average consumption of total ascorbic acid was 21.8 micrograms/mg of protein in the treated group and 13.9 micrograms/mg of protein in the nontreated group. Macroscopic infarct size as determined by TTC staining in the right cerebral hemisphere was 11.7 +/- 6.9 in treated group whereas it was 24.4 +/- 4.4 (expressed as percentage of right hemisphere) in the non-treated group. There was significant reduction in the size of the infarct in the treated group.(ABSTRACT TRUNCATED AT 250 WORDS)

✓ It is commonly believed that differentiating solitary small cysticercus granulomas and small tuberculomas in patients with seizures is difficult without resorting to an excision biopsy. The aim of this study was to formulate clinical and computerized tomography (CT) criteria to distinguish these two entities in patients with epilepsy. Toward this end, clinical and CT data from six consecutive patients with histologically proven small solitary tuberculomas and 25 consecutive patients with histologically proven solitary cysticercus granulomas were compared. Evidence of raised intracranial tension and a progressive focal neurological deficit was seen only in patients with tuberculomas (two of six cases). All tuberculomas were greater than 20 mm in size and five of the six were irregular in outline. Only tuberculomas were associated with a midline shift on CT (four of six cases). All cysticercus granulomas were less than 20 mm in size and 24 (96%) of the 25 were regular in outline, conforming to one of two characteristic patterns. No cysticercus granuloma was associated with a midline shift. Based on the above clinical findings (evidence of raised intracranial tension and a progressive neurological deficit) and CT criteria (size, shape, and association with a midline shift), it is possible to separate these two entities in a majority of patients with seizures and with a single small lesion on CT.

Intracranial aspergillus granulomas over a 12-year period were studied retrospectively. Three distinctive types of presentations were seen, namely nine patients had the rhinocerebral form with primary involvement of the air sinuses and secondary involvement of the skull base, cranial nerves and brain, three patients with the apparently purely intracranial form presented like any other space occupying lesion and one patient who had a 'stroke-like' presentation had a parasellar lesion. None of these patients were immunocompromised. The clinical features, and the medical and surgical options are discussed together with outcome.

Central neurocytoma is a tumour showing neuronal differentiation. This tumour usually located in ventricles occurs at young age and carries favorable prognosis. For this, accurate diagnosis is essential. There is no published case report of central neurocytoma in Bangladesh. With these objectives, we have presented a case report of central neurocytoma in a 37 years old female. DOI: http://dx.doi.org/10.3329/pulse.v6i1-2.20351 Pulse Vol.6 January-December 2013 p.51-52

Five cases of incidentally detected pituitary macroadenomas are described. All five had suprasellar extensions, but none had visual field defects as tested by computed perimetry. One patient had sellar changes seen on an X-ray film taken following a head injury, while the others were detected by computed tomography performed for seizures, stroke and meningitis. Four patients underwent trans-sphenoidal surgery for suprasellar extensions with or without hypopituitarism, while one was managed conservatively as he had normal visual fields and pituitary function and there was a spontaneous decrease in size of the adenoma. The management of such incidental pituitary macroadenomas is discussed.

Intracerebral Schwannoma is a rare tumour which can mimic meningioma clinically, radiologically and morphologically. Immunohistochemical techniques are necessary to confirm the Schwann cell origin of the tumours. We report such a tumour in the posterior frontal parasagittal region. The origin of Schwann cells in the central nervous system is still speculative and various postulations are discussed.

We report a favorable outcome following a staged radical excision of an intramedullary low-grade astrocytoma involving the entire spinal cord in a pediatric patient. Although the preoperative neurological status was poor, the eventual outcome was good. This highlights the importance of a good tumor-cord interface that permitted a radical excision of an extensive tumor. Since partial excision followed by radiotherapy usually results in disease progression in patients with low-grade astrocytomas, radical excision and follow-up is probably the treatment of choice.

Thirty consecutive Indian patients with focal or generalised seizures and single, small (less than 10 mm), enhancing lesions on CT scans (SSECTL) were studied. Five patients (Group A) were treated with anticonvulsants alone and did not have a biopsy. In ten patients (Group B) a CT guided stereotaxic biopsy of the lesion was carried out and in the remainder (15-Group C) and excision biopsy of the lesion was carried out following CT guided stereotaxic localisation. In all patients in Group B the lesion were reported as "chronic nonspecific inflammation". In seven of 15 patients in Group C the lesions showed a cysticercus with a granuloma and in a further five the pathology was that of a "parasitic granuloma" but the parasite could not be identified. Biopsy did not reveal a tuberculoma or neoplasm in any of the patients. The lesions studied are the same as "disappearing" CT lesions reported in Indian patients, as in 12 of 15 patients in Groups A and B, who could be followed up for more than three months, the lesions had spontaneously disappeared or left calcific residues. It is concluded that in Indian epileptic patients with SSECTL cysticercosis is the commonest aetiology. A treatment protocol for these patients is suggested on the basis of the findings.

Arachnoid cysts of the posterior fossa are rather uncommon compared with their supratentorial counterparts. Spontaneous disappearance of middle cranial fossa arachnoid cysts has been reported but there are none in the English literature on the spontaneous fluctuation in size of a posterior fossa arachnoid cyst. We present a 41-year-old male, with a midline posterior fossa arachnoid cyst, which appeared to lessen in size spontaneously with complete disappearance of symptoms and then enlarged with a worsening in neurological status.

A rare case of an extradural brucellosis granuloma in the thoracic region is presented. Medical treatment delayed surgical intervention and led to total paraplegia with sphincteric disturbance despite improving serum antibody titres. However, delayed neurosurgical intervention resulted in near-total clinical recovery. Early surgical intervention in cases of significant spinal cord compression due to an extradural brucellosis granuloma with a progressive neurological deficit is recommended.

A 62-year-old woman presented with raised intracranial pressure and features of a right cerebellopontine angle tumour with extension into the right middle cranial fossa. The patient died before a surgical excision could be performed. The autopsy revealed a primary esthesioneuroblastoma of the sphenoid sinus eroding the petrous bone and extending into the middle cranial fossa with metastatic tumour in the liver, and paratracheal and hilar lymph nodes. Although rare, esthesioneuroblastoma must be considered in the differential diagnosis of petrous-sphenoid lesions.

Sixty-eight patients with pituitary adenomas were classified into groups based on their invasiveness and functional status. Mean argyrophilic nucleolar organizer region proteins (AgNOR) counts obtained from 200 cells showed no correlation with the invasive status of pituitary adenomas. However, the functional tumours showed significantly higher AgNOR counts than non-functional tumours.

A study of the clinical, radiological, and pathological correlations in 43 patients with solitary cysticercus granuloma and epilepsy focused on factors that might help in predicting the presence of the parasite in the granuloma and those that might influence the formation of oedema around the granuloma. The duration of symptoms (< six months and > or = six months) and CT morphology of the granuloma (ring and disc, type A; nodular lesion, type B) were studied as factors that could possibly predict the presence of the parasite in the granuloma. The influence of sex of the patient and the presence of a neutrophilic response in the granuloma on the intensity of oedema around the lesion as seen on CT was also studied. The pathological features were studied in the excised granulomas. The intact or degenerated form of the cysticercus was evident in 22 of 43 specimens. Neither the duration of seizures (P = 0.17) nor the type of lesion on CT (P = 0.16) was predictive of the presence of the parasite in the granuloma. The sex of the patient (P = 0.51) and the neutrophilic response in the specimen (P = 0.73) did not correlate with the degree of oedema on CT indicating that neither of these host factors was a major determinant of oedema production. The findings point to the varied and unpredictable natural history of solitary cysticercus granulomas and the complex nature of host-parasite interactions in individual patients. The inability to predict the presence of the parasite in the granuloma on the basis of the clinical or radiological features precludes a selection of patients with such lesions for cysticidal drug treatment.

The goal of trans-sphenoidal pituitary adenoma surgery is radical excision of the tumour with preservation of endocrine function. Our hypothesis was that, even in macroadenomas extending into the suprasellar cistern, the 'capsule' of the tumour is the compressed normal pituitary gland. The biopsy material from 126 patients with pituitary macroadenomas were retrospectively reviewed to look for the presence of normal adenohypophysis. Fourteen patients with macroadenomas operated trans-sphenoidally were studied prospectively, sampling tissue from the periphery of the tumour for histopathology. From the retrospective data, we found that normal adenohypophysis was more often found at histopathology in the extracapsular excisions, rather than in the intracapsular excisions. In the 14 patients studied prospectively, normal adenohypophysial tissue was found histologically at all sites sampled except in areas where the tumour was invasive. In conclusion, while an extracapsular excision would offer the best chance for a surgical cure, preserving parts of the capsule may preserve normal and possibly functioning gland.

BACKGROUND While calcification of orbital hemangiomas has been reported previously, no reports exist of heterotopic ossifications occurring within the orbit. CASE DESCRIPTION A 30-year-old male presented with spontaneous onset of painless progressive proptosis of the left eye, with diplopia. The preoperative radiologic findings are presented. The lesion was excised completely. The pathologic features and probable causes are discussed. CONCLUSIONS Heterotopic ossification of the orbit should be considered in the differential diagnosis of an orbital lesion showing radiologic features of calcification or ossification.

We present here the results of our series of peri-insular hemispherotomy for intractable hemispheric epilepsy. There were 6 children in this series with a mean age of 10.2 years and mean duration of seizures of 7.2 years. The seizure results were excellent in all children and they also showed significant improvement in functional status. This procedure has significant advantages when compared to other forms of hemispherectomy. However, a larger experience with longer periods of follow-up is needed.

Aim and Objective: Dysembryoplastic neuroepithelial tumour is an unusual brain tumour with varied incidence commonly occured in younger age group. We report a 16-year old female diagnosed as a case of dysembryoplastic neuroepithelial tumour. Clinical presentation: A 16 year old female was examined for headache and convulsion for two months. MRI revealed a brain tumour which was later confirmed as dysembyroplastic neuroepithelial tumour by histopathological examination.DOI: http://dx.doi.org/10.3329/pulse.v4i1.6968Pulse Vol.4 January 2010 p.43-44

Fifty four cases of single small (

Although infection is the commonest central nervous system complication following renal transplantation, brain abscess is uncommon. Over the last 11 years, five renal transplant recipients who had brain abscesses were treated by computed tomography (CT)-guided stereotactic aspiration. Three patients had a fungal abscess, one a tuberculous abscess and the other had a methicillin-resistant Staphylococcus aureus abscess. One patient required a craniotomy for the excision of a fungal abscess which was persistent after two CT-guided stereotactic aspirations. The survivors in this group are the patient with a tuberculous abscess who is alive and well 5 years after diagnosis, and another with a dematiaceous fungal abscess (phaeohyphomycosis). CT-guided stereotactic surgery is minimally invasive, and can safely be performed in these patients. It often leads to an aetiological diagnosis in renal transplant recipients with brain abscesses. Specific antibiotic management directed towards the causative organism rather than empirical treatment can be instituted following the procedure. Although the ultimate prognosis in these patients is bleak even with specific antibiotic therapy, an occasional patient might have a good outcome with prompt and appropriate therapy. Keywords: brain abscess; computed tomography guided stereotaxy; renal transplant recipients

A small posterior fossa volume has been thought to lead to hind brain herniation. The resultant obstruction to the CSF pathways at the level of the foraman magnum has been implicated in the development and subsequent progression of syringomyelia. This report highlights the gradual development of a small posterior fossa due to fibrous dysplasia of the occipital bone with consequent tonsillar herniation resulting in syringomyelia.

Objectives To evaluate (1) the clinical profile, treatment, and outcome of adult and pediatric patients presenting with intracranial abscess of otogenic origin and (2) the advantages of concurrent craniotomy and mastoidectomy. Design A prospective case series. Setting An academic tertiary referral center in India. Patients Thirty-six patients clinically diagnosed as having intracranial abscess that was secondary to suppurative otitis media and confirmed by computed tomographic scanning. Intervention Concurrent craniotomy and mastoidectomy. Results Children were more commonly affected than adults, and there was a male preponderance. All patients had cholesteatoma at surgery, although one third of the children had only granulation tissue on otoscopy. More than two thirds of the patients in both the groups presented with more than one intracranial complication and definitive surgical intervention was done later than 24 hours. Meningitis was the most frequent intracranial complication, followed by cerebellar abscess. There was no significant intraoperative or postoperative morbidity, mortality, recurrence of intracranial complications, or residual neurological deficits. Three children (14%) showed evidence of recidivism cholesteatoma requiring revision surgery. Conclusions In suppurative otitis media with intracranial complications, it is accepted practice to treat the neurosurgical complication first, followed by mastoidectomy at a later date after the patient has been stabilized. Craniotomy with concurrent mastoidectomy is not only safe, but it also removes the source of infection at the same time the complications are being treated, thus avoiding reinfection while the patient is awaiting the ear surgery. In addition, the treatment is completed with a single, shorter hospital stay, which is more economical for the patient.

Temporary occlusion of major cerebral blood vessels occasionally becomes necessary during surgical procedures. Ascorbic acid (Vitamin C) is an important non-enzymatic scavenger of free radicals and its protective effect on the brain in permanent focal cerebral ischaemia has been proven in a primate model of focal cerebral ischaemia [16]. Additional damage caused by reperfusion of the infarcted area has been shown in the rat model [22]. This study was undertaken to study the efficacy of ascorbic acid in decreasing infarct size in ischaemic reperfused brain. Maccaca radiata monkeys in the treated group were given two grams of ascorbic acid, parentally immediately before clipping the middle cerebral artery and the control group was given placebo. Reperfusion was done after four hours. Mean infarct size in all the three brain slices in the ascorbic acid pretreated group was 7.3% +/- 2.7 and in the placebo group 22.1 +/- 6.7 under similar conditions. The mean infarct size in the ascorbic acid pretreated group of monkeys was significantly lower when compared with the placebo group (p = 0.0003).

Patients with parenchymatous mass lesions in the perirolandic area as seen by CT or MRI are unique in that identification of the central sulcus (CS) intraoperatively is crucial in determining the surgical strategy. Somatosensory-evoked potential (SEP) responses were used under general anaesthesia for the intraoperative identification of the central sulcus (CS). Sixty-five patients with parenchymatous mass lesions were included in the study and a phase reversal in the hand area across the central sulcus was used to identify this sulcus. Based on the clinical findings the patients were classified into three groups: Group A were patients with predominant motor deficits, Group B, patients with predominant sensory deficits; and Group C were patients with gross sensory and motor deficits. This study shows that in patients with predominant motor deficits a phase reversal with good amplitude was obtained in all cases. In patients with predominant sensory deficits a phase reversal could be obtained, but their amplitudes were markedly decreased. In patients with predominant sensorimotor deficits no phase reversal could be obtained. The central sulcus could not be located accurately by somatosensory evoked potentials in these cases (group C).

Objective - To evaluate a set of clinical and computed tomographic (CT) criteria (previously described by us) to predict the diagnosis of a solitary cerebral cysticercus granuloma (SCCG) at initial presentation, in patients presenting with seizures. Material and methods - The diagnostic criteria were applied prospectively to patients presenting with seizures and solitary lesion on the CT scan. The clinical diagnostic criteria were as follows: seizures should be the presenting complaint; there should be no evidence of persistent raised intracranial pressure, progressive neurological deficit or an active systemic disease. The CT diagnostic criteria were: evidence of a solitary contrast enhancing lesion measuring 20 mm or less in its maximal dimension without a shift of the midline structures due to the surrounding oedema. A diagnosis of SCCG was made only when all the clinical and CT criteria were fulfilled. Over a period of 36 months, we managed 401 patients presenting with seizures and a solitary mass on the CT scan; 215 met the criteria for the diagnosis of an SCCG. Results - Of the 215 patients initially diagnosed to have an SCCG, 197 were ultimately determined to have that diagnosis (true positive diagnosis) while 16 were excluded because of lack of follow-up CT assessment. Two of the 215 patients with the initial diagnosis of an SCCG subsequently had histological diagnosis of a secondary metastasis and a pyogenic abscess (false positive diagnosis). Our set of diagnostic criteria for SCCG had a sensitivity of 99.5%; specificity of 98.9%; a positive predictive value of 99%; and a negative predictive value of 99.5%. The likelihood ratios for the positive and negative tests were 92.99 and 0.005 respectively. Conclusions - Our diagnostic criteria help in not only accurately identifying an SCCG but also in differentiating it from a solitary tuberculoma and other brain masses. However, confirmation of the diagnosis of an SCCG is only obtained at follow-up evaluation and therefore careful clinical and CT re-evaluation is essential in all patients initially diagnosed to have an SCCG.

We document the clinical presentation, management and outcome of histologically verified, solitary, intrinsic brain stem tuberculomas in six patients. The neurological symptoms and signs in these patients did not distinguish their lesions from other intrinsic masses of the brain stem. On contrast-enhanced computed tomography (CT), the tuberculomas appeared as ring enhancing lesions in three patients and nodular contrast enhancing lesions in the other three. Diagnosis was established on the basis of CT-guided stereotactic biopsy in all patients. All patients were treated with antituberculous drugs for 18 months. Steroid therapy of 2-8 weeks duration was also used in four patients. At a median follow-up period of 20 months (range 9-51 months), three patients were asymptomatic and the other three were functioning independently with mild disability. Although isolated, intrinsic brain stem tuberculoma is an uncommon entity, it should be suspected in patients presenting with features of an intrinsic brain stem mass and a contrast-enhancing lesion on CT. CT-guided stereotactic biopsy usually provides evidence of the inflammatory nature of the mass although an aetiological diagnosis is often elusive. Early diagnosis and appropriate therapy with antituberculous drugs and steroids usually results in an excellent or good outcome in most instances.

We had previously suggested a protocol for the management of neurosurgical patients with hyponatremia and natriuresis that was based on their volume status as determined by actual blood volume measurements. All patients in that study were found to be hypovolemic or normovolemic and responded, within 72 hours, to salt and fluid replacement. In the present study, the validity of that protocol was tested using central venous pressure as the sole measure of volume status of patients with hyponatremia and natriuresis.Twenty-five consecutive patients (26 cases) who fulfilled the inclusion criteria typically used to diagnose the syndrome of inappropriate secretion of antidiuretic hormone were included in the study. Central venous pressure was used to classify patients as hypovolemic (5 cm of water), normovolemic (6-10 cm of water), or hypervolemic (11 cm of water). Hypovolemic patients were given fluids (50 ml/kg/d) and salt (12 g/d). Normovolemic patients were given normal fluid with 12 g of salt per day. In addition, patients with anemia (hematocrit,27%) were administered whole blood. The end point was a serum sodium of more than or equal to 130 mEq/L measured in two consecutive samples 12 hours apart or 72 hours after entry into the study. If the serum sodium was less than 130 mEq/L at the end of 72 hours, the clinical condition of the patient determined further management.Nineteen of 25 patients (26 cases) were hypovolemic, the rest were normovolemic. No patient was hypervolemic. Nineteen of 25 patients (26 cases) attained normal serum sodium values within 72 hours, and an additional 3 responded within the next 36 hours (108 h after entry into the study). One patient who was discharged on request had normalized her serum sodium a week later. Among the three nonresponders, who were severely hypovolemic, as revealed by blood volume measurement, and responded to increased fluid and salt administration. One was normovolemic and responded to increased salt administration. There were no complications related to the therapy.Hyponatremia with natriuresis in the neurosurgical setting responds to salt and fluid replacement guided by the patients' volume status as determined by the central venous pressure. This study also offers further indirect evidence to suggest that the syndrome of hyponatremia with natriuresis is most often caused by "cerebral salt wasting" rather than by the syndrome of inappropriate secretion of antidiuretic hormone.

BACKGROUND Parenteral administration of narcotics has been the mainstay for postoperative pain relief in patients undergoing lumbar laminectomy. However, this may lead to respiratory depression and nausea, which may be hazardous in these patients. METHODS We evaluated the efficacy of wound infiltration with bupivacaine in 45 consecutive patients undergoing elective single-level lumbar laminectomy for intervertebral disc prolapse in a prospective, double-blind, randomized controlled trial. Prior to wound closure, the muscle and subcutaneous tissues were infiltrated with bupivacaine 0.375% or sterile physiologic saline. Postoperatively, the patients were assessed hourly for pain and an analgesic administered if the patient had moderate or severe pain. RESULTS All the 21 placebo recipients required analgesics in the first 9 hours postoperatively, compared to only 11 of 24 patients who received bupivacaine (p < 0.001). The mean (standard deviation) time before administration of the first dose of analgesic postoperatively in the bupivacaine and placebo recipients was 807.7 (567.6) minutes and 181.4 (110.1) minutes, respectively (p < 0.001). No adverse effects of local wound infiltration were noted. CONCLUSIONS Local wound infiltration with bupivacaine is a safe and effective method for providing postoperative pain relief and reducing narcotic use in patients undergoing lumbar laminectomy.