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Intracranial arachnoid cyst is the most common cystic congenital anomaly in the brain. In this study, we discuss a pregnancy that had serial fetal ultrasound scans throughout the pregnancy and a fetal anomaly scan at 24 weeks of gestation that was normal. The child was born healthy with normal development, but 12 months onward the head began to enlarge. The magnetic resonance imaging of the brain showed a large posterior fossa arachnoid cyst with hydrocephalus. We discuss the postulation to explain this pathogenesis of the cyst. This case highlights that not all symptomatic arachnoid cysts are congenital despite the manifestation being as early as infancy.

Large thoracolumbar intradural cystic lesions are rare. The possible diagnosis would be a cystic nerve sheath tumour, dural ectasia or arachnoid cyst. We report the first case of a neglected giant thoracolumbar spinal cystic tumour that had resulted in progressive deleterious spinal column deformity due to bony erosion precluding any form of surgical remedy. In the same case, another fatal sequela of a neglected spinal cystic tumour is a spontaneous rupture resulting in an acute hydrocephalus and mortality. This case impresses the natural history of a spinal cystic lesion. The take home point would be these cases need early surgical intervention is indicated to prevent sequelae that has been described.

Multidisciplinary team meetings (MDTMs) are essential in the clinical management of pediatric central nervous system (CNS) tumors. Evaluations of the impact of MDTMs on childhood CNS tumors and clinicians’ perspectives on their effectiveness are scarce. We retrospectively reviewed the clinical data of pediatric patients (aged

Acute spontaneous spinal epidural hematoma without any identified etiology is a rare phenomenon and an uncommon cause of acute spinal cord compression. We report a case of acute spontaneous cervical spinal epidural hematoma, with sudden onset of acute neck pain and left-side body weakness during sleep which resembling of cervicle carotid dissection. The pain commenced suddenly, early in the morning while the patient was asleep. He had no previous history of any relevant medical disorder. Cervical Spine MRI revealed a cervical epidural haematoma at C3/C4, mainly on the left side, with spinal cord compression. Therefore, an emergent C3/C6 hemilaminectomy and evacuation of hematoma were carried out within 24 h of presentation. The patient's neck pain resolved after surgery and he was able to walk, though he required bladder catheterization on discharge after 1 week. He has nearly intact motor neurological examination in the second month of the operation.

Malignant astrocytomas are composed of heterogeneous cell populations. Compared to grade IV glioblastoma, low-grade astrocytomas have more differentiated cells and are associated with a better prognosis. Therefore, inducing cellular differentiation to alter the behaviour of high-grade astrocytomas may serve as a therapeutic strategy. The nuclear factor one (NFI) transcription factors are essential for normal astrocytic differentiation. Here, we investigate whether family members NFIA and NFIB act as effectors of cellular differentiation in glioblastoma. We analysed expression of NFIA and NFIB in mRNA expression data of high-grade astrocytoma and with immunofluorescence co-staining. Furthermore, we induced NFI expression in patient-derived subcutaneous glioblastoma xenografts via in vivo electroporation. The expression of NFIA and NFIB is reduced in glioblastoma as compared to lower grade astrocytomas. At a cellular level, their expression is associated with differentiated and mature astrocyte-like tumour cells. In vivo analyses consistently demonstrate that expression of either NFIA or NFIB is sufficient to promote tumour cell differentiation in glioblastoma xenografts. Our findings indicate that both NFIA and NFIB may have an endogenous pro-differentiative function in astrocytomas, similar to their role in normal astrocyte differentiation. Overall, our study establishes a basis for further investigation of targeting NFI-mediated differentiation as a potential differentiation therapy.

Background A higher incidence of pediatric intracranial germ cell tumors (iGCTs) in Asian countries compared with Western countries has been reported. In Malaysia, the literature regarding pediatric iGCTs have been nonexistent. The aim of this study was to review the management, survival, and long-term outcomes of pediatric iGCTs at a single tertiary center in Malaysia. Patients and methods We retrospectively reviewed data from patients aged below 18 years with iGCTs treated at the University Malaya Medical Center (UMMC) from 1998 to 2017. Results Thirty-four patients were identified, with a median follow-up of 3.54 years. Sixteen (47%) patients had pure germinoma tumors (PGs), and the remaining patients had nongerminomatous germ cell tumors (NGGCTs). The median age was 12 years, with a male:female ratio of 4.7:1. Abnormal vision, headache with vomiting, and diabetes insipidus were the commonest presenting symptoms. Twenty-eight patients received initial surgical interventions, 24 were treated with chemotherapy, and 28 received radiotherapy. Eight patients experienced relapses. The 5- and 10-year event-free survival rates were similar at 61.1%±12.6% and 42.9%±12.1% for PG and NGGCT, respectively. The 5- and 10-year overall survival rates were the same at 75.5%±10.8% and 53.3%±12.3% for PG and NGGCT, respectively. Four patients died of treatment-related toxicity. Most of the survivors experienced good quality of life with satisfactory neurological status. Conclusions The survival rate of childhood iGCTs in UMMC was inferior to that reported in developed countries. Late diagnosis, poor adherence to treatment, and treatment-related complications were the contributing factors. Although these results highlight a single institution experience, they most likely reflect similar treatment patterns, outcomes, and challenges in other centers in Malaysia.

Objectives The Neural Tube Defects Research Group of University of Malaya was approached to analyze a tablet named TELSE, which may have resulted in a baby born with central nervous system malformation at the University of Malaya Medical Centre. In this animal experimental study, we investigated the content of TELSE and exposure of its contents that resulted in failure of primary neurulation. Results Liquid Chromatography Tandem Mass spectrophotometry analysis of the TELSE tablet confirmed the presence of trimethoprim as the active compound. The TELSE tablet-treated females produced significant numbers of embryos with exencephaly (n = 8, 36.4%, *P

The Glasgow Coma Scale (GCS), which classifies patients into mild, moderate or severe traumatic brain injury (TBI), is a system used to prioritize treatment and prognosticate the severity of head injury. In this study, sera of patients with various stages of TBI, as well as control subjects, were analyzed to screen for proteins that may be used to complement the GCS system. By subjecting pooled serum samples to iTRAQ analysis for quantitative comparison of protein abundance, and attesting their altered levels using ELISA, we have detected increased levels of serum amyloid A, C-reactive protein, leucine-rich alpha-2-glycoprotein, lipopolysaccharide-binding protein, fibronectin, vitronectin and alpha-1-antichymotrypsin in patients across all strata of TBI relative to the controls. However, kininogen was decreased only in moderate and severe TBI, whereas apolipoprotein E and zinc-alpha-2-glycoprotein were only increased in severe TBI. Hence, we propose a panel of serum biomarkers, which if analyzed within 24 h of the injury, can be used to diagnose patients with TBI into mild, moderate or severe stratification objectively, thus complementing the traditional GCS.

Tension pneumocephalus is rare but has been well documented following trauma and neurosurgical procedures. It is a surgical emergency as it can lead to neurological deterioration, brainstem herniation and death. Unlike previous cases where tension pneumocephalus developed postoperatively, we describe a case of intraoperative tension pneumocephalus leading to sudden, massive open brain herniation out of the craniotomy site. The possible causative factors are outlined. It is imperative to rapidly identify possible causes of acute intraoperative brain herniation, including tension pneumocephalus, and institute appropriate measures to minimize neurological damage. Resumo: O pneumoencéfalo hipertensivo é raro, mas foi bem documentado após trauma e procedimentos neurocirúrgicos. Trata-se de uma emergência cirúrgica porque pode levar à deterioração neurológica, herniação do tronco cerebral e morte. Ao contrário de casos anteriores nos quais o pneumoencéfalo hipertensivo se desenvolveu no pós-operatório, descrevemos um caso de pneumoencéfalo hipertensivo desenvolvido no período intraoperatório levando a uma herniação cerebral súbita, maciça e aberta para fora do local da craniotomia. Os possíveis fatores causais são destacados. É imperativo identificar rapidamente as possíveis causas da herniação cerebral aguda no intraoperatório, incluindo o pneumoencéfalo hipertensivo, e instituir medidas apropriadas para minimizar os danos neurológicos. Keywords: Intraoperative brain herniation, Tension pneumocephalus, Hydrogen peroxide, Brain amputation, Palavras-chave: Herniação cerebral no intraoperatório, Pneumoencéfalo hipertensivo, Peróxido de hidrogênio, Amputação cerebral

ResumoO pneumoencéfalo hipertensivo é raro, mas foi bem documentado após trauma e procedimentos neurocirúrgicos. Trata‐se de uma emergência cirúrgica porque pode levar à deterioração neurológica, herniação do tronco cerebral e morte. Ao contrário de casos anteriores, nos quais o pneumoencéfalo hipertensivo se desenvolveu no pós‐operatório, descrevemos um caso de pneumoencéfalo hipertensivo desenvolvido no período intraoperatório que levou a uma herniação cerebral súbita, maciça e aberta para fora do local da craniotomia. Os possíveis fatores causais são destacados. É imperativo identificar rapidamente as possíveis causas da herniação cerebral aguda no intraoperatório, incluindo o pneumoencéfalo hipertensivo, e instituir medidas apropriadas para minimizar os danos neurológicos.AbstractTension pneumocephalus is rare but has been well documented following trauma and neurosurgical procedures. It is a surgical emergency as it can lead to neurological deterioration, brainstem herniation and death. Unlike previous cases where tension pneumocephalus developed postoperatively, we describe a case of intraoperative tension pneumocephalus leading to sudden, massive open brain herniation out of the craniotomy site. The possible causative factors are outlined. It is imperative to rapidly identify possible causes of acute intraoperative brain herniation, including tension pneumocephalus, and institute appropriate measures to minimize neurological damage.

Paediatric craniomaxillofacial (CMF) surgery requires a multidisciplinary team approach to ensure the optimal and holistic management of children with craniofacial deformities. The aim of this retrospective study was to analyse the complications following functional interventions among 34 CMF deformity patients in a single multidisciplinary craniofacial centre. Electronic data including patient demographic characteristics and clinical entry were analysed. Inclusion criteria were all paediatric patients with CMF deformities who underwent various functional interventions. A total of 64 interventions (48 intermediate and 16 definitive) were conducted. Based on the Sharma classification of complications, 20.3% were type I, 4.7% were type II, 1.6% were type III, and 4.7% were type IV . Most complications were type I, which included local infection (3.1%) and premature opening of tarsorrhaphy (3.1%). More serious complications (types III and IV) included temporary visual loss (1.6%) and intraoperative haemorrhage (1.6%). Although a low complication rate was observed in intermediate interventions, a higher complication rate was observed in more complex definitive interventions such as monobloc distraction osteogenesis. Although most complications were manageable, effective prevention remains mandatory, as serious complications may lead to permanent damage and mortality. This analysis highlights the importance of a multidisciplinary team approach to optimize the outcomes in CMF patient management.

Purpose Pediatric medulloblastoma (MB) treatment has evolved over the past few decades; however, treating children in countries with limited resources remains challenging. Until now, the literature regarding childhood MB in Malaysia has been nonexistent. Our objectives were to review the demographics and outcome of pediatric MB treated at the University Malaya Medical Center between January 1994 and December 2013 and describe the challenges encountered. Methods Fifty-one patients with childhood MB were seen at University Malaya Medical Center. Data from 43 patients were analyzed; eight patients were excluded because their families refused treatment after surgery. Results Headache and vomiting were the most common presenting symptoms, and the mean interval between symptom onset and diagnosis was 4 weeks. Fourteen patients presented with metastatic disease. Five-year progression-free survival (± SE) for patients ≥ 3 years old was 41.7% ± 14.2% (95% CI, 21.3% to 81.4%) in the high-risk group and 68.6% ± 18.6% (95% CI, 40.3% to 100%) in the average-risk group, and 5-year overall survival (± SE) in these two groups was 41.7% ± 14.2% (95% CI, 21.3% to 81.4%) and 58.3% ± 18.6% (95% CI, 31.3% to 100%), respectively. Children younger than 3 years old had 5-year progression-free and overall survival rates (± SE) of 47.6% ± 12.1% (95% CI, 28.9% to 78.4%) and 45.6% ± 11.7% (95% CI, 27.6% to 75.5%), respectively. Time to relapse ranged from 4 to 132 months. Most patients who experienced relapse died within 1 year. Febrile neutropenia, hearing loss, and endocrinopathy were the most common treatment-related complications. Conclusion The survival rate of childhood MB in Malaysia is inferior to that usually reported in the literature. We postulate that the following factors contribute to this difference: lack of a multidisciplinary neuro-oncology team, limited health care facilities, inconsistent risk assessment, insufficient data in the National Cancer Registry and pathology reports, inadequate long-term follow-up, and cultural beliefs leading to treatment abandonment.

In severe syndromic craniosynostosis, distraction osteogenesis (DO) provides superior segmental advancement and allows progressive clinical monitoring to ensure that adequate skeletal expansion is achieved. We report two cases of Crouzon syndrome involving a 3-year-old boy and a 4-year-old girl, who were both treated with monobloc Le Fort III DO using a combination of external and internal distraction devices (Synthes, Oberdorf, Switzerland) to treat severe orbital proptosis and obstructed nasopharyngeal airway secondary to severe hypoplastic craniofacial skeletal components. Their skeletal segments were advanced in daily increments by 27 mm and 23 mm, respectively. Results at 18 months postoperatively showed successful outcomes, as evidenced by adequate eye protection, tracheostomy tube decannulation following objective evidence of patent nasopharyngeal airway, and acceptable facial appearance. Monobloc Le Fort III DO using a combination of external and internal devices produces favorable functional and clinical outcomes for the treatment of severe orbital and airway discrepancy in Crouzon syndrome.

The University of Malaya Medical Centre, Kuala Lumpur had acquired a intraoperative MRI (iMRI) brain suite via a public private initiative in September 2015. The MRI brain suite has a SIEMENS 1.5T system with NORAS coil system and NORAS head clamps in a two room solution. We would like to retrospectively review the cranial paediatric neuro-oncology cases that had surgery in this facility from September 2015 till December 2019. We would like to discuss our experience with regard to the clear benefits and the challenges in using such technology to aid in the surgery. The challenges include the physical setting up the paediatric case preoperatively, the preparation and performing the intraoperative scan, the interpretation of intraoperative images and making a decision and the utilisation of the new MRI data set to assist in the navigation to locate the residue safely. Also discuss the utility of the intraoperative images in the decision of subsequent adjuvant management. The use of iMRI also has other technical challenges such as ensuring the perimeter around the patient is free of ferromagnetic material, the process of transfer of the patient to the scanner and as a consequence increased duration of the surgery. CONCLUSION: Many elements in the use of iMRI has a learning curve and it improves with exposure and experience. In some areas only a high level of vigilance and SOP (Standard operating procedure) is required to minimize mishaps. Currently, the iMRI gives the best means of determining extent of resection before concluding the surgery.

Objectives We evaluated the feasibility of using chemical shift gradient-echo (GE) in- and opposed-phase (IOP) imaging to grade glioma. Methods A phantom study was performed to investigate the correlation of 1H MRS-visible lipids with the signal loss ratio (SLR) obtained using IOP imaging. A cross-sectional study approved by the institutional review board was carried out in 22 patients with different glioma grades. The patients underwent scanning using IOP imaging and single-voxel spectroscopy (SVS) using 3T MRI. The brain spectra acquisitions from solid and cystic components were obtained and correlated with the SLR for different grades. Results The phantom study showed a positive linear correlation between lipid quantification at 0.9 parts per million (ppm) and 1.3 ppm with SLR (r = 0.79–0.99, p

Monobloc Le Fort III distraction osteogenesis allows superior skeletal advancement in treating severe syndromic craniosynostosis. We report a rare orbital complication in a 3-year-old boy with Crouzon syndrome who developed right-eye exodeviation with limited abduction during the intradistraction period following this surgery. Images from a computed tomography scan confirmed direct impingement of the distracted right lateral orbital wall to the lateral rectus muscle. The impingement was surgically relieved via lateral orbital wall osteotomy. Ten months postdistraction, a review showed normal eye movement. A lateral orbital osteotomy cut for a monobloc Le Fort III distraction should be designed near the rim to prevent this complication.

This paper reports an unusual case of a transsphenoidal encephalocele and discusses our experience with a minimally invasive management. To the best of our knowledge, we present the first case of a combined endoscopic transnasal and transoral approach to a transsphenoidal encephalocele in an infant. A 17-day-old boy, who was referred for further assessment of upper airway obstruction, presented with respiratory distress and feeding difficulties. Bronchoscopy and imaging revealed a transsphenoidal encephalocele. At the age of 48 days, he underwent a combined endoscopic transnasal and transoral excision of the nasal component of the encephalocele. This approach, with the aid of neuronavigation, allows good demarcation of the extra-cranial neck of the transsphenoidal encephalocele. We were able to cauterize and carefully dissect the sac prior to excision. The defect of the neck was clearly visualized, and Valsalva manoeuvre was performed to exclude any CSF leak. As the defect was small, it was allowed to heal by secondary intention. The patient’s recovery was uneventful, and he tolerated full feeds orally on day 2. Postoperative imaging demonstrated no evidence of recurrence of the nasal encephalocele. Endoscopic follow-up showed good healing of the mucosa and no cerebrospinal fluid leak. The surgical management of transsphenoidal encephalocele in neonates and infants is challenging. We describe a safe technique with low morbidity in managing such a condition. The combined endoscopic transnasal and transoral approach with neuronavigation is a minimally invasive, safe and feasible alternative, even for children below 1 year of age.

Crouzon syndrome (CS) is the most common craniosynostosis syndrome and requires a comprehensive management strategy for the optimization of care and functional rehabilitation. This report presents a case series of 6 pediatric patients diagnosed with CS who were treated with distraction osteogenesis (DO) to treat serious functional issues involving severe orbital proptosis, an obstructed nasopharyngeal airway, and increased intracranial pressure (ICP). Three boy and 3 girls were 8 months to 6 years old at the time of the operation. The mean skeletal advancement was 16.1 mm (range, 10 to 27 mm) with a mean follow-up of 31.7 months (range, 13 to 48 months). Reasonable and successful outcomes were achieved in most patients as evidenced by adequate eye protection, absence of signs and symptoms of increased ICP, and tracheostomy tube decannulation except in 1 patient. Complications were difficult fixation of external stabilizing pins in the distraction device (n = 1) and related to surgery (n = 4). Although DO can be considered very technical and can have potentially serious complications, the technique produces favorable functional and clinical outcomes in treating severe CS.

A 13-year-old male with Type 1 Chiari malformation presented with progressive limb weakness for 2 months. He had a high stepping, unsteady gait with grade 4/5 motor strength in all extremities and increased reflexes. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated Arnold–Chiari malformation type I with basilar invagination, worsening syringomyelia and tonsillar herniation (Fig. 1a). There was no evidence of hydrocephalus. He underwent an occipitocervical instrumentation and fusion followed by endoscopic transnasal odontoidectomy in the same operative setting.

OBJECTIVE: To evaluate the survival outcomes in patients diagnosed with intracranial germ cell tumours (iGCT). METHODS: Retrospective review of all patients with iGCT treated in a single center from July 1996 to Jun 2017. Three treatment regimens were used: MSKCC, SIOP CNS GCT 96 and SIOP CNS GCT II. RESULTS: Thirty patients were identified with a median follow-up of 4.04 years (range 0.17–19.10). The mean age was 10.23 years. Male: female ratio was 5:1. Visual impairment (50%), endocrinopathy (30%) and precocious puberty (20%) were the commonest presenting symptoms. Duration of symptoms prior to presentation ranged from 1 to 108 weeks. Pure germinomas (n=15) and non-germinomatous germ cell tumours (NGGCT) (n=15) were equally distributed. Tumour location was pineal in 15 (50.0%), suprasellar in 8 (26.7%), hypothalamic in 2 (6.7%) and other sites (basal ganglia, thalamus, frontal lobe) in 5 (16.7%) patients. Eight patients (26.7%) had metastatic disease at diagnosis. Four cases underwent surgical debulking, 14 were biopsied and 7 had complete resection. Fifteen patients received chemo-radiotherapy, 7 had chemotherapy only and 8 underwent radiotherapy only. Elevated levels of serum alpha-fetoprotein and beta-human chorionic gonadotropin normalised after 2 courses of chemotherapy in all NGGCT cases. The 5-year event-free survival (EFS) and overall survival (OS) were 61.3 ± 14.1% and 78.3 ± 11.1% for pure germinoma, respectively. For NGGCT, the 5-year EFS and OS were 36.0 ± 13.3% and 41.3 ± 13.7%. Eleven recurrences occurred within a median duration of 11 months following diagnosis and 8 of them died within 10 months. CONCLUSION: Compared to pure germinoma, NGGCTs have poor prognosis.

The aims of the present study were to undertake gene expression profiling of the blood of glioma patients to determine key genetic components of signaling pathways and to develop a panel of genes that could be used as a potential blood-based biomarker to differentiate between high and low grade gliomas, non-gliomas and control samples. In this study, blood samples were obtained from glioma patients, non-glioma and control subjects. Ten samples each were obtained from patients with high and low grade tumours, respectively, ten samples from non-glioma patients and twenty samples from control subjects. Total RNA was isolated from each sample after which first and second strand synthesis was performed. The resulting cRNA was then hybridized with the Agilent Whole Human Genome (4x44K) microarray chip according to the manufacturer's instructions. Universal Human Reference RNA and samples were labeled with Cy3 CTP and Cy5 CTP, respectively. Microarray data were analyzed by the Agilent Gene Spring 12.1V software using stringent criteria which included at least a 2-fold difference in gene expression between samples. Statistical analysis was performed using the unpaired Student's t-test with a p

Objective To compare the extent of persistent neuropsychological impairment in patients with complicated mild traumatic brain injury (mTBI) and those with uncomplicated mTBI. Methods Sixty-one patients with mTBI (Glasgow Coma Scale score 13–15) were recruited prospectively, categorized according to baseline computed tomography findings, and subjected to neuropsychological assessment at initial admission (n = 61) as well as at a 6-month follow-up (n = 30). The paired t test, Cohen's d effect size calculation, and repeated-measures analysis of variance were used to establish the differences between the 2 groups in terms of neuropsychological performance. Results A trend toward poorer neuropsychological performance among the patients with complicated mTBI was observed during admission; however, performance in this group improved over time. In contrast, the uncomplicated mTBI group showed slower recovery, especially in tasks of memory, visuospatial processing, and executive functions, at follow-up. Conclusions Our findings suggest that despite the broad umbrella designation of mTBI, the current classification schemes of injury severity for mild neurotrauma should be revisited. They also raise questions about the clinical relevance of both traumatic focal lesions and the absence of visible traumatic lesions on brain imaging studies in patients with milder forms of head trauma.

In this article, we review the English literature of calcified pseudomeningoceles in the lumbar region.A systematic review using the Medline Database using the varied nomenclature for pseudomeningoceles, as well as reviewing the reference lists of relevant article found.We discuss the different pathological theories on formation of a pseudomeningocele, the formation of a calcified wall and the optimal management for this entity. To date, 17 cases have been described, of which 13 are reviewed here. Calcification of pseudomeningocele is a rare entity and in the lumbar spine this occurs postsurgically. The only predisposing factor is prior surgery to the lumbar spine. Computer tomography, magnetic resonance imaging (MRI) and MRI myelography in combination are the preoperative investigations of choice. The radiological work-up can be preoperatively diagnostic and is important in the surgical planning.The treatment is surgicel removal and the decision to treat is based on patient symptoms and correlating these with imaging. There is an average reported follow-up of 1.7 years postoperatively for these patients and the reported outcome after surgery is good.

✓ The patient in this report had a parasagittal meningioma with an intrasinus extension that presented with features of benign intracranial hypertension and no focal neurological deficit or seizure. The meningioma was managed with a combination of endovascular stent placement and radiotherapy. The authors describe the investigation and technical aspects of stent placement for the stenosed sinus. Good symptomatic relief in the patient was achieved.

Establishing standardized methods to assess outcome is needed to measure the effectiveness of surgery in relieving symptoms and improving quality of life. We prospectively studied 203 patients undergoing primary lumbar discectomy. Data was collected before surgery, at 3 months postoperatively and at long-term follow-up (12 – 60 months, median 24) using both disease-specific (visual analogue scores, Roland – Morris disability scales, and Hospital Anxiety and Depression scales) and generic (SF-36) instruments. Continued significant symptomatic benefit was observed to long-term assessment and the health gains in this patient group compared favourably with other elective surgical procedures. We have used this data to validate the SF-36 for use in this context and we recommend that SF36 should be used as a sole measure of outcome in routine practice, as well as in future studies.

Purpose The aim of the present study was to establish the incidence of maxillofacial (MF) injury accompanying mild traumatic brain injury (mTBI) and the associated neurocognitive deficits and white matter changes. Materials and Methods A prospective review of 41 patients with mTBI and maxillofacial injury (with or without intracranial lesion) due to motor vehicle accidents who had admission computed tomography (CT), neurocognitive evaluation, and quantitative diffusion tensor imaging available was performed during admission and at 6 months of follow-up. Descriptive statistics were used for the demographic data, and a paired t test and repeated measure analysis of variance were used to establish the intergroup differences and susceptibility. Results The included patients were relatively young adults, with a mean age of 27.3 ± 8.8 years and 11.3 ± 2.1 years of education. Of the 41 patients, 20 (48.8%) had maxillofacial injuries involving the soft tissue and muscles, 18 (43.9%) had facial bone fractures, and 3 (7.3%) had mixed injuries. Of the 41 patients with MF injuries, 28 (68.3%) had intracranial abnormalities found on the admission CT scan. Executive function and attention were significantly altered across the time points, with patients with both MF injury and an intracranial lesion doing poorly at baseline but with improvement 6 months later. In contrast, the patients with no visible intracranial lesion but with MF injuries remained impaired, with signs of a slowed recovery. The fractional anisotropy of the genu of the corpus callosum, anterior limb of the internal capsule, and cingulum for patients with MF injuries but without an intracranial lesion showed trends of reduced integrity over time. Conclusions The presence of MF injury without any intracranial traumatic lesions in patients with mTBI increases the risk of short- and long-term neurocognitive derangement compared with patients with mTBI, MF injury, and intracranial traumatic lesions.

© Mary Ann Liebert, Inc. 2015. We explored the prognostic value of diffusion tensor imaging (DTI) parameters of selected white matter (WM) tracts in predicting neuropsychological outcome, both at baseline and 6 months later, among well-characterized patients diagnosed with mild traumatic brain injury (mTBI). Sixty-one patients with mTBI (mean age=27.08; standard deviation [SD], 8.55) underwent scanning at an average of 10h (SD, 4.26) post-trauma along with assessment of their neuropsychological performance at an average of 4.35h (SD, 7.08) upon full Glasgow Coma Scale recovery. Results were then compared to 19 healthy control participants (mean age=29.05; SD, 5.84), both in the acute stage and 6 months post-trauma. DTI and neuropsychological measures between acute and chronic phases were compared, and significant differences emerged. Specifically, chronic-phase fractional anisotropy and radial diffusivity values showed significant group differences in the corona radiata, anterior limb of internal capsule, cingulum, superior longitudinal fasciculus, optic radiation, and genu of corpus callosum. Findings also demonstrated associations between DTI indices and neuropsychological outcome across two time points. Our results provide new evidence for the use of DTI as an imaging biomarker and indicator of WM damage occurring in the context of mTBI, and they underscore the dynamic nature of brain injury and possible biological basis of chronic neurocognitive alterations.

Osteoradionecrosis (ORN) is a rare yet well-recognized complication following radiotherapy to the head and neck. We illustrate the only case of a spontaneous extrusion of the sequestered C1 arch through the oral cavity and discuss our experience with a combined endoscopic transnasal and transoral approach for cervical ORN.A 56-year-old female presented with a 3-month history of blood-stained nasal discharge. She had been treated with radiotherapy for nasopharyngeal carcinoma 25 years earlier. Flexible nasal endoscopy demonstrated an exposed bone with an edematous posterior nasopharyngeal mass. Computed tomography showed a pre-vertebral mass with destruction of C1 and C2. She underwent occipito-cervical fusion followed by a combined transnasal and transoral endoscopic debridement of non-viable bone in the same perioperative setting. Healing of the raw mucosa was by secondary intention and reconstruction was not performed.Histopathological examination reported ulcerated inflamed granulation tissue with no evidence of malignancy. During follow-up, she remained neurologically intact with no recurrence.Using both nasal and oral spaces allows placement of the endoscope in the nasal cavity and surgical instruments in the oral cavity without splitting the palate. Hence, the endoscopic transnasal and transoral approach has vast potential to be effective in carefully selected cases of cervical ORN.

Central nervous system melioidosis is an unusual infection in humans. This article reports a case of melioidosis presenting as an acute spinal epidural abscess. A discussion of this case and its management together with a brief review of melioidosis of the central nervous system is presented.

This is a rare case of synchronous pituitary adenoma and PNET in an adult and first of this sort in the literature. The MR appearances suggest a single pathological entity causing the changes in the different anatomical location which can occur in cases of germ cell tumours, PNET and glioblastoma. In certain cases, histological confirmation may be warranted for the different lesions. Both pathologies have different treatment strategy and outlook depending on the age, extent of the disease and Karnofsky score.

Introduction Cystic meningiomas are rare variants of meningiomas; they can pose a radiological diagnostic dilemma. Case presentation We present a rare case of a 30-year-old Chinese woman with a histopathological diagnosis of infratentorial cystic meningioma (World Health Organization Grade 1) in which the features in imaging modalities were suggestive of a hemangioblastoma. Intraoperatively, however, the gross macroscopic features were more in keeping with a pilocytic astrocytoma. Conclusion In benign cystic meningiomas, particularly the infratentorial variety, radiological findings utilizing the various imaging modalities and intraoperative impressions may not be reflective of or in keeping with the final histopathological diagnosis.

This study aims to describe the presence and severity of extracranial concomitant injuries in traumatic brain injury (TBI) patients and to ascertain their effect on long-term functional outcome.A retrospective cohort study was performed in a single-center recruiting patients with first episode of TBI. The types and severity of extracranial concomitant injuries were documented for patients who fulfilled the inclusion criteria. Injuries with Abbreviated Injury Scale (AIS) grade 3-6 were considered to be high grade. A cross-sectional functional assessment was conducted at 18 months post-injury using Glasgow Outcome Scale.A total of 100 patients were included in the analysis. Extracranial concomitant injuries were seen in 78% of the patients. Three commonest injuries were facial (44%), lower extremity (20%) and upper extremity (12%) injuries. Among the AIS grade ≥ 3, injury involving the chest was most common (41%). Presence of extracranial concomitant injuries AIS grade ≥ 3 was significantly associated with disability in TBI patients at 18 months (OR 12.74, 95% CI 2.39-67.95, p = 0.003).Presence of extracranial concomitant injuries was high. In TBI survivors, extracranial concomitant injuries AIS grade ≥ 3 influenced the long-term functional outcome at 18 months, causing moderate and severe disabilities.Concomitant injuries should be suspected in patients with traumatic brain injury, especially in a high-speed trauma mechanisms as the incidence can be as high as 78% as in this study and may interfere with the long term rehabilitation and outcome. This study shows that severe extra cranial concomitant injuries are associated with a poor long term functional outcome even in the mild traumatic brain injury patients and therefore need to be addressed early in the rehabilitation of this group of patients. Early diagnosis and management of severe concomitant injuries is warranted and may improve the functional gains in the long term after traumatic brain injury.

The predictability of neurocognitive outcomes in patients with traumatic brain injury is not straightforward. The extent and nature of recovery in patients with mild traumatic brain injury (mTBI) are usually heterogeneous and not substantially explained by the commonly known demographic and injury-related prognostic factors despite having sustained similar injuries or injury severity. Hence, this study evaluated the effects and association of the Brain Derived Neurotrophic Factor (BDNF) missense mutations in relation to neurocognitive performance among patients with mTBI. 48 patients with mTBI were prospectively recruited and MRI scans of the brain were performed within an average 10.1 (SD 4.2) hours post trauma with assessment of their neuropsychological performance post full Glasgow Coma Scale (GCS) recovery. Neurocognitive assessments were repeated again at 6 months follow-up. The paired t-test, Cohen’s d effect size and repeated measure ANOVA were performed to delineate statistically significant differences between the groups [wildtype G allele (Val homozygotes) vs. minor A allele (Met carriers)] and their neuropsychological performance across the time point (T1 = baseline/ admission vs. T2 = 6th month follow-up). Minor A allele carriers in this study generally performed more poorly on neuropsychological testing in comparison wildtype G allele group at both time points. Significant mean differences were observed among the wildtype group in the domains of memory (M = -11.44, SD = 10.0, p = .01, d = 1.22), executive function (M = -11.56, SD = 11.7, p = .02, d = 1.05) and overall performance (M = -6.89 SD = 5.3, p = .00, d = 1.39), while the minor A allele carriers showed significant mean differences in the domains of attention (M = -11.0, SD = 13.1, p = .00, d = .86) and overall cognitive performance (M = -5.25, SD = 8.1, p = .01, d = .66).The minor A allele carriers in comparison to the wildtype G allele group, showed considerably lower scores at admission and remained impaired in most domains across the timepoints, although delayed signs of recovery were noted to be significant in the domains attention and overall cognition. In conclusion, the current study has demonstrated the role of the BDNF rs6265 Val66Met polymorphism in influencing specific neurocognitive outcomes in patients with mTBI. Findings were more detrimentally profound among Met allele carriers.

Intraventricular haemorrhage is the most common cause of hydrocephalus in a pre-term baby and may require surgical intervention depending on severity. This case illustrates foraminal septae as a subtle cause of progressive quadriventricular hydrocephalus in a child born pre-term with a history of grade III intraventricular haemorrhage. The septae within the fourth ventricular exits were clearly demonstrated with 3D-FIESTA (fast imaging employing steady-state acquisition) MRI acquisitions and assisted in differentiation from communicating hydrocephalus. This finding guided the decision to a successful endoscopic third ventriculostomy. 3D-FIESTA sequence is recommended for investigating children with hydrocephalus secondary to intraventricular haemorrhage due to its diagnostic potential and implications on surgical technique.

Background . The purpose of this study was to validate and assess the accuracy and usefulness of sending short video clips in 3gp fi le format of an entire scan series of patients, using mobile telephones running on 3G-MMS technology, to enable consultation between junior doctors in a neurosurgical unit and the consultants on-call after offi ce hours. Method. A total of 56 consecutive patients with acute neurosurgical problems requiring urgent after-hours consultation during a 6-month period, prospectively had their images recorded and transmitted using the above method. The response to the diagnosis and the management plan by two neurosurgeons (who were not on site) based on the images viewed on a mobile telephone were reviewed by an independent observer and scored. In addition to this, a radiologist reviewed the original images directly on the hospital ’ s Patients Archiving and Communication System (PACS) and this was compared with the neurosurgeons ’ response. Results . Both neurosurgeons involved in this study were in complete agreement with their diagnosis. The radiologist disagreed with the diagnosis in only one patient, giving a kappa coeffi cient of 0.88, indicating an almost perfect agreement. Conclusion. The use of mobile telephones to transmit MPEG video clips of radiological images is very advantageous for carrying out emergency consultations in neurosurgery. The images accurately refl ect the pathology in question, thereby reducing the incidence of medical errors from incorrect diagnosis, which otherwise may just depend on a verbal description.

Summary Background Chronic subdural haematoma causes serious morbidity and mortality. It recurs after surgical evacuation in 5–30% of patients. Drains might reduce recurrence but are not used routinely. Our aim was to investigate the effect of drains on recurrence rates and clinical outcomes. Methods We did a randomised controlled trial at one UK centre between November, 2004, and November, 2007. 269 patients aged 18 years and older with a chronic subdural haematoma for burr-hole drainage were assessed for eligibility. 108 were randomly assigned by block randomisation to receive a drain inserted into the subdural space and 107 to no drain after evacuation. The primary endpoint was recurrence needing redrainage. The trial was stopped early because of a significant benefit in reduction of recurrence. Analyses were done on an intention-to-treat basis. This study is registered with the International Standard Randomised Controlled Trial Register (ISRCTN 97314294). Findings Recurrence occurred in ten of 108 (9·3%) people with a drain, and 26 of 107 (24%) without (p=0·003; 95% CI 0·14–0·70). At 6 months mortality was nine of 105 (8·6%) and 19 of 105 (18·1%), respectively (p=0·042; 95% CI 0·1–0·99). Medical and surgical complications were much the same between the study groups. Interpretation Use of a drain after burr-hole drainage of chronic subdural haematoma is safe and associated with reduced recurrence and mortality at 6 months. Funding Academy of Medical Sciences, Health Foundation, and NIHR Biomedical Research Centre (Neurosciences Theme).